Interactive Cardiovascular and Thoracic Surgery 3:95-98(2004)
© 2004 European Association of Cardio-Thoracic Surgery
Institutional report - Thoracic general |
A new approach to pectus deformity in females
Tamer Okay*,
Murat Yasaroglu,
Mehmet Yildirim,
Oya Imamoglu Uncu,
Bülent Aydemir,
Ilgaz Dogusoy and
Alper Findikçioglu
Siyami Ersek Thoracic and Cardiovascular Surgery Center, Recep Peker cad. 27/1, Kiziltoprak-Kadikoy, Istanbul, Turkey
Received December 10, 2002;
received in revised form August 13, 2003;
accepted August 27, 2003
Supplementary data associated with this article can be found, in the online version, at doi:10.1016/S1569-9293(03)00211-1.
Presented at the 10th Annual Meeting of the European Society of Thoracic Surgeons, Istanbul, Turkey, October 26–28, 2002.
* Corresponding author. Tel.: +90-216-414-6282; fax: +90-216-414-6276
tamerokay{at}hotmail.com
 |
Abstract
|
|---|
One of the most preferred procedures for correction of pectus deformities is the modified Ravitch procedure. The main aim is cosmetic for many patients, especially in females. Two types of skin incisions have been described for this operation in the literature: midsternal and transversal. Both incisions leave a skin scar on the sternum and result in unacceptable cosmetic results. As a way of concealing the ugly skin incision scar under the breasts after puberty, we describe and discuss the use of bilateral inframammarian separated skin incisions. We have used our method for correction of pectus deformity in 12 female cases in our clinic since 1991. Two 4–5 cm incisions were localized as 1/3 medially and 2/3 laterally below both breasts. With this incision we performed the modified Ravitch technique. In spite of technical difficulties of exposure, correction of the deformity was satisfactory in all patients. Only one patient had seroma and one had perioperative pneumothorax. The patients were followed up for from 3 months to 9 years. No recurrence was observed. Breast development and sensitivity was found to benormal at follow-up. The new approach was found to be effective and more cosmetically acceptable than the other approaches for correction of pectus excavatum in female patients.
Key Words: Pectus excavatum; Submammarian incision; Sternoplasty; Chest wall deformity
|
1. Introduction
|
|---|
Pectus is a deformity of the sternum and costal cartilage with depression or protrusion of varying degree. Usually it is first noted in infancy and does not warrant any operative procedure. Cardiorespiratory symptoms are very rare but occur occasionally [1]. Generally, pectus deformity is not associated with other anomalies except for cardiac malformations [2]. If the deformity is deep or progressing obviously or it is a cause of respiratory disturbance, an operation for correction can be advisable at any age. Especially in females, for many cases the indication is purely cosmetic or psychological. There is no contraindication to operation except some systemic illness [3]. Many operation techniques, of which Ravitch's procedure is one of the most popular among thoracic surgeons, have been offered so far. Two types of skin incisions have been described for Ravitch's technique, i.e. midsternal and transverse [1–4]. A midsternal incision provides wider exposure than the transversal type. Although the transverse inframammarian incision may be more cosmetic, both incisions leave a skin scar on the sternum, which can be cosmetically undesirable. In order to avoid such a skin scar on the sternum we devised and performed a new approach, bilateral separated inframammarian incisions for Ravitch's repair.
|
2. Material and methods
|
|---|
Between 1991 and 2002, bilateral separated inframammarian skin incisions have been performed to conceal the bad skin scar under the breast for correction of pectus excavatum in 12 girls ranging from 7 to 15 years of age. All patients had pectus excavatum in varying degrees. We examined all patients in terms of lung capacity, cardiac functions (transthoracic echocardiography) and routine blood tests. The fifth ribs and/or inframammarian folds were found and marked on both sides before operation. All patients were placed in supine position. The skin was incised just on the submammarian fold or on the 5th intercostal space on both sides. Each incision began 2–3 cm far from the sternal edge. The length of each incision was 4–5 cm and they were placed 1/3 medially and 2/3 laterally of the nipple line. Using retractors, the apertures of incisions were carried easily over all the deformed cartilages. The skin, the pectoralis major, the pectoralis minor and the serratus anterior muscle flaps on the deformed cartilage were dissected by electrocautery from 1 cm above the beginning of the deformity superiorly and to the xyphoid inferiorly (Video 1). Because development and sensitivity of the breast may be affected negatively, the breast tissue was not dissected from the pectoralis major muscle [5]. Subperichondrial resection was performed for deformed costal cartilage as required. We did not need to remove the 2nd costal cartilage because none of the upper borders of the deformities were above the 3rd rib in our patients. Outer and inner layers of the sternal cortex were cut with a saw or an electrocautery just at the beginning of the deformity (Video 2). When it was necessary, a third cortical osteotomy was performed on the distal concavity of the sternal deformity to keep the sternum straight. Because we removed all cartilage of the arcus costarum, the xyphoid and rectus muscles were so flexible that they did not resist correction of the deformity. So rectus abdominis muscles were not cut and were not separated from the xyphoid. Then the deformity could be corrected easily and one or two steel bars were placed under the sternum transversely (Fig. 1). Both ends of the bar(s) were placed on the bony ribs. The bar was stabilized on the 3rd or 4th ribs using 2/0 absorbable suture (Dexon or Vicryl). We did not need to suture the edges of the osteotomy to each other. After bleeding control, the operation was terminated with one or two Hemovac drains in the mediastinum. Skin was sutured using 2/0 polypropylene intradermally. Between the 3rd and 6th postoperative months, the steel bar was removed under local anesthesia with a small incision on top of the previous incision in order to avoid a new skin scar. All patients were followed up for 3 months to 9 years. Mean follow-up time was 23±3 months. In order to discuss our results duration of operations, pain control, hospital stays, complications, satisfaction of patients and/or parents, and breast development were noted.
View larger version (110K):
[in this window]
[in a new window]
|
Fig. 1 After removal of deformed cartilage and correction of the sternum, a stainless steel bar was placed under the sternum for internal support.
|
|
|
3. Results
|
|---|
Although all patients’ parents were suffering from postural, psychological or cardiac problems, in all patients echocardiographic findings, lung capacities and blood analysis findings were normal. So we were able to perform our new approach in all patients. In spite of difficulties of operating with this incision, the sternum was corrected satisfactorily in all patients. We did not abandon the procedure for any reason. Only in one case was a 1–2 mm skin necrosis line seen at the wound edge perioperatively due to overtension of skin with retractors. We excised and sutured this area during the operation and no problem was observed throughout the postoperative period. All cases were treated with metamizol for pain control. Neither atelectasis nor hypoxia was seen during the postoperative period. No wound infection was discovered. Only one case of seroma and another of perioperative pneumothorax developed. Both were treated successfully with tube drainage. The operation time varyied from 1 h 25 min to 3 h (mean 1 h 58 min). All patients were discharged from hospital between 4 and 8 (mean 4.91±1.37) days and returned to normal life 4–6 weeks after the operation. Four patients had been operated on at puberty and five reached puberty after operation. In the other three patients breast tissue had begun to develop but they had not yet reached puberty. During long-term follow-up in all cases breast tissue development was satisfactory and sensitivity was normal. The incisions were hidden just below the breasts. Although we did not suture the edges of the sternal osteotomy, no recurrence has been observed during the postoperative follow-up.
|
4. Discussion
|
|---|
Although surgical indications for pectus repair are the physiological, orthopedic postural, psychological or cosmetic effects of the deformity [2], the main aim especially for many female patients is cosmetic or psychological. Our of all patients had pectus excavatum but this approach can be performed for pectus carinatum as well. Because midsternal or transverse skin incisions may cause ugly scar tissue on the sternum, the results of the operation can be found to be unacceptable to both patients and parents. In females, to avoid such a complication modified the Ravitch procedure should be performed with our new approach, bilateral separated inframammarian incisions. In this way skin scars are concealed below the breast tissue and they are not seen in the upright position after breast tissue development [6] (Fig. 2). Skin on the sternum remains intact. In our cases all patients and/or parents found the results satisfactory (Fig. 3A,B). Currently almost all modern techniques are based on the modified Ravitch procedure, except the Nuss procedure [2]. Some organ injuries have been published with the Nuss procedure but no similar complication has been published with the Ravitch technique. Although some authors believe that internal fixation does not give better results [3] many others have proposed internal support with a steel bar or bioabsorbable materials to avoid recurrence [2,6,7]. We preferred using a stainless steel bar for internal support. In our approach, removal of the bar can easily be done under local anesthesia. Compared to other approaches our incision does not require an additional incision for removal of the bar. This is an advantage for patients and surgeons. Due to the bar being sutured onto bony ribs bilaterally, no bar displacement occurred. Some meshes (Marlex, propylene, etc.) can also be used for internal support and their removal may not be required. Because our approach does not require entering the thoracic cavity for placement of the bar, the probability of intrathoracic complications such as fluid accumulation, infection and atelectasis occurring can be lessened [8–13]. Satisfactory control of pain with metamizol also affected the absence of atelectasis and hypoxia. In our series suprasternal seroma in one case and pneumothorax in another were acceptable complications [13]. The mean operating time was 1 h 58 min (1 h 25 min–3 h) and because of the learning curve, it is getting shorter as time goes on; even this time is not much longer than the Nuss procedure (1 h 32 min). Hospital stay was almost the same as the Nuss procedure (4 days vs. 4.91±1.37 days) [14]. The length of incisions is longer than thos in the Nuss procedure and of course has some more disadvantages such as infection risk. Breast development and sensitivity were found to be normal at follow-up. Developed breasts covered the incision scar tissue in the upright position, the skin on the sternum was kept intact and our aim was achieved. One patient got married 3 years after her operation and breast-fed her baby. We have noted no recurrence during follow-up. In conclusion, in females this new approach has been found to be more cosmetically acceptable than the other incision procedures and is preferred by us.
View larger version (84K):
[in this window]
[in a new window]
|
Fig. 3 Patients and parents found the results satisfying, as we did. (A) Before surgery. (B) After surgery.
|
|
|
Appendix A
|
|---|
ICVTS on-line discussion
Author: Dr. Ravindranath Tiruvoipati, Clinical Research Fellow, Glenfield Hospital, ECMO, 66, Glenfrith Close, Leicester LE3 9QQ, UK
Date: 17-Dec-2003
Message: The article by Okay et al, about the new approach for the correction of pectus deformity in females is interesting.
I would like to know whether this approach has been used in any male patients. The age of the patients in this study ranged from 7 to 15 years. Is there any particular age where the authors prefer to perform this operation for prevention of recurrence as well as impairment in the growth of chest wall?
Technically would this approach be difficult in older patients as compared to the younger patients?
Response
Author: Dr. Tamer Okay, Dr. Siyami Ersek Hospital, Thoracic Surgery, Recep Peker Cad. 27/3 Kiziltoprak, Istanbul, Turkey
Date: 17-Dec-2003
Message: I will try to answer the questions posed:
All of our patients were female. Because the main aim of this approach was to hide skin incisions under breasts after puberty, we did not perform it in male patients.
We do not prefer to perform the pectus repair in those younger than 4-5 years old because we use a steel bar for internal support. Any dislocation of the bar may be very dangerous for the patients. They must try to avoid trauma or accidents for 3-6 months and it can be very hard to do that for young, energetic, playing children.
If the deformity is appropriate, our approach can be performed easily in adult patients as well.
|
References
|
|---|
- Shamberger RC. Chest wall deformities. Shields TW. General thoracic surgery. 4th ed. Malvern, PA: Williams and Wilkins; 1994. p. 529–534
- Landolfo KP, Sabiston DC Jr. Disorders of the sternum and the chest wall. Sabiston DC Jr, Spencer FC. Surgery of the chest. 6th ed. Philadelphia, PA: Saunders; 1991. p. 494–498
- Hood RM. Techniques for funnel chest. Hood RM. Techniques in general thoracic surgery. 6th ed. Philadelphia, PA: Saunders; 1985. p. 183–185
- Hougaard K, Arendrup H. Deformities of female breasts after surgery for funnel chest. Scand J Thorac Cardiovasc Surg. 1983;17:171–174[Medline]
- Massiha H. Reconstruction of the submammary crease for correction of postoperative deformities in aesthetic and reconstructive breast surgery. Ann Plast Surg. 2001;46:275–278[Medline]
- Lansman S, Serlo W, Linna O, Pohjonen T, Tormala P, Waris T, Ashammakhi N. Treatment of pectus excavatum with bioabsorbable polylactide plates: preliminary results. J Pediatr Surg. 2002;37:1281–1286[Medline]
- Gurkok S, Genc O, Dakak M, Balkanli K. The use of absorbable materials in correction of pectus deformities. Eur J Cardiothorac Surg. 2001;19:711–712[Abstract/Free Full Text]
- Hosie S, Sitkiewicz T, Petersen C, Gabel P, Schaarschmidt K, Till H, Noatnick M, Winiker H, Hagl C, Schmedding A, Waag KL. Minimally invasive repair of pectus excavatum – the Nuss procedure. A European multicentre experience. Eur J Pediatr Surg. 2002;12:235–238[CrossRef][Medline]
- Hebra A, Swoveland B, Ebgert M, Tagge EP, Georgeson K, Othersen HB Jr, Nuss D. Outcome analysis of minimally invasive repair of pectus excavatum: review of 251 cases. J Pediatr Surg. 2000;35:252–257[Medline]
- Engum S, Rescorla F, West K, Rouse T, Scherer LR, Grosfeld J. Is the grass greener? Early results of the Nuss procedure. J Pediatr Surg. 2000;35:246–251[CrossRef][Medline]
- Willekes CL, Backer CL, Mavroudis C. A 26-year review of pectus deformity repairs, including simultaneous intracardiac repair. Ann Thorac Surg. 1999;67:511–518[Abstract/Free Full Text]
- Nuss D, Kelly RE Jr, Croitoru DP, Katz ME. A 10-year review of a minimally invasive technique for the correction of pectus excavatum. J Pediatr Surg. 1998;33:545–552[CrossRef][Medline]
- Moss RL, Albanese CT, Reynolds M. Major complications after minimally invasive repair of pectus excavatum: case reports. J Pediatr Surg. 2001;36:155–158[Medline]
- Coln D, Gunning T, Ramsay M, Swygert T, Vera R. Early experience with the Nuss minimally invasive correction of pectus excavatum in adults. World J Surg. 2002;26:1217–1221[CrossRef][Medline]
|
|
Top
Abstract
1. Introduction