European Journal of Plastic Surgery

, Volume 31, Issue 1, pp 15–20

Surgical correction of pectus excavatum deformity and hypomastia

Authors

    • Department of Plastic SurgeryStrasbourg University Hospital
    • Service de Chirurgie plastique et Reconstructrice
  • C. Bruant-Rodier
    • Department of Plastic SurgeryStrasbourg University Hospital
  • A. Wilk
    • Department of Plastic SurgeryStrasbourg University Hospital
  • J. M. Wihlm
    • Department of Thoracic SurgeryStrasbourg University Hospital
Original Paper

DOI: 10.1007/s00238-007-0210-2

Cite this article as:
Bodin, F., Bruant-Rodier, C., Wilk, A. et al. Eur J Plast Surg (2008) 31: 15. doi:10.1007/s00238-007-0210-2
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Abstract

Female patients occasionally present with major pectus excavatum and hypomastia. The aim of this study was to investigate the clinical outcome of female patients who had combined surgical correction of both deformities. Since 1990, 12 young female patients underwent correction using a modelling sternochondroplasty with osteosynthesis using Borrelly’s slide fastener-handle. After 1 year, the material was removed, and the breast implants were placed in the subpectoral plane. Our investigation was based on functional, morphological, aesthetic and psychological criteria. Despite nonsignificant pulmonary function tests (p < 0.05), we noted a subjective improvement of physical capacity during exercise following pectus excavatum repair. Correction of thorax deformity increased the sternovertebral distance by a mean of 3.2 cm (range 1.5–5.5 cm) thus treating mediastinal compression. As for aesthetic results, all patients were satisfied or very satisfied. The psychological benefit was considered as phenomenal after surgical treatment. Repair of pectus excavatum by sternochondroplasty combined with correction of hypomastia for female patients suffering from a double deformity is possible with only two different operations.

Keywords

FemaleFunnel chestHypomastiaModelling sternochondroplastyBreast implant

Introduction

The funnel chest is the most frequent of the congenital anterior chest-wall deformities. It occurs in every 400 births and is often associated with female hypomastia. Implant correction of this hypomastia without prior correction of the pectus excavatum produces unsatisfactory aesthetic results. Two different operations exist for pectus excavatum. Silicone implant correction was introduced by Murray [16]. The modelling sternochondroplasty described by Ravitch [19, 20] was improved by the use of Borrelly’s slide fastener-handle [2]. For more than 10 years, plastic and thoracic surgery departments have been working together to treat female patients suffering from hypomastia and the funnel-chest syndrome. The aim of this study is to investigate the clinical outcome of combined surgical correction of both deformities.

Materials and methods

We have carried out a retrospective study over the last 14 years from 1990 to 2004. Twelve female patients suffering from hypomastia and major funnel-chest deformity have been treated. The mean age was 27 years, ranging from 17 to 43. Mean size of patients was 168 cm, mean weight was 52 kg. Mammary hypoplasia was bilateral in 11 cases and unilateral in 1 case. The funnel chest is always classified as three different types after Chin [4] (Fig. 1):
  • Type I: The narrow and symmetrical deformity is not overstepping the nipple line.

  • Type II: The large and symmetrical deformity is overstepping the nipple line.

  • Type III: The deformity is asymmetrical or unilateral.

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Fig. 1

Chin classification. a Type I. b Type II. c Type III

In our study, we had three patients with type I deformity, four patients had a funnel-chest type II, and five patients had a funnel-chest deformity type III.

The first operation consists in a modelling sternochondroplasty using a modified Ravitch technique:
  • Bilateral inframammary cutaneous incision through natural groove.

  • Exposure of the whole sternocostochondral chest-wall deformity: it is carried out through step-by-step upward section of pectoralis major costal attachments. This step respects pectoralis minor muscle.

  • Bilateral subperichondral double chondrotomy from the third to the seventh rib, located in parasternal position on the edges of the deformity.

  • High transverse cuneiform sternotomy at the superior limit of the funnel (usually second or third intercostal space) combined with, if necessary, a median inferior sternotomy to correct the anterior sternal convexity.

  • The sternocostal chest-wall remodelling is then stabilized using osteosynthesis using two or three retrosternal slide fastener-handles of Borrelly which are attached to the anterior costal arches.

  • In the case of inferior costal protrusion, an additional chondroplasty is performed after rectus abdominis muscle section.

  • Median suture of pectoralis muscles provides cushioning of the central deformity. Reattachment of rectus abdominis muscles with four retromuscular suction drains follows. Subcutaneous repair is by subcuticular suture.

This operation was always carried out by the same thoracic surgeon, whilst the mean period of hospital stay was 10 days.

After 1 year, the material was removed, and the breast implants were placed in the subpectoral plane at the same time. The mean interval between the two operations was 16 months (range 10–24 months). The choice of the type of prosthesis was shared with the patient. In seven cases saline implants and in five cases silicone implants were placed. Mean duration of hospital stay for the second operation was 5 days. The postoperative follow-up was 5 years and 8 months (range 2–12 years).

Our investigation was based on:
  • Functional criteria: questioning and pulmonary function tests (vital capacity and total pulmonary capacity)

  • morphological points of view: thoracic computed tomography (CT) with measure of vertebral–sternal distance and CT index (internal transverse distance divided by vertebral–sternal distance at most depressed portion; Fig. 2)

  • Aesthetic criteria: evaluation on a scale of 1 to 10 from the point of view of both surgeons and patients

  • Psychological point of view

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Fig. 2

CT scan. The CT-index is derived by dividing the transverse distance of the thorax (X) by the vertebral–sternal distance at the most depressed portion (y)

The results of functional and morphological parameters were statistically evaluated and Student’s t test was applied. p Values less than 0.05 were considered to be significant.

Results

Functional results

The functional impacts of thoracic deformities were always low. Nine dyspnea and two palpitations were noticed on exertion. Preoperative pulmonary function tests revealed seven restrictive syndromes and one obstructive syndrome (patient with asthma). After treatment, seven patients had subjective exercise capacity improvement, while two patients had their palpitations relieved, and six others had decreased exercise dyspnea. However, postoperative pulmonary function test were not improved. We observed a reduction of mean vital capacity (−4.75%) and total pulmonary capacity (−2.57%). These results were not significant: p = 0.33 for the vital capacity and p = 0.38 for the total pulmonary capacity (Table 1).
Table 1

Functional results

 

Before operation

After operation

Evolution

Exercise dyspnea

9

3

−6

Exercise palpitation

2

0

−2

Restrictive syndrome

7

7

0

Obstructive syndrome

1

1

0

Mean vital capacity (%)

94.29

89.57

−4.72 (p = 0.33)

Total pulmonary capacity (%)

89.57

94.57

−2.57 (p = 0.38)

Morphological results

CT scan revealed cardiac and pulmonary repercussion in ten cases with cardiac compression, cardiac deviation and/or trachea deviation. The preoperative mean vertebral sternal distance was 4.67 cm (range 2–8 cm) and the mean CT-index was 6.32 (range 3.25–12.5; Fig. 2). Correction of thorax deformation significantly increased vertebral sternal distance by a mean of 3.2 cm (range 1.5–5.5 cm), p = 1.73 10−5, relieving mediastinal compression. The postoperative CT-index showed a mean of 3.15 (range 2.48–3.69) with a significant decrease of the mean of 3.18 (range 0.77–9.17), p = 0.0012 (Fig. 2; Table 2).
Table 2

Morphological results

 

Before operation

After operation

Evolution

Number of cardiac, tracheal deviation and compression

10

0

−10

Vertebral sternal distance in centimeter (range)

4.67 (2–8)

7.92 (6.5–10.5)

+3.25 (p = 1.73 E-5) (1.5–5.5)

CT-index (range)

6.32 (3.25–12.15)

3.15 (2.48–3.69)

−3.18 (p = 0.0012) (0.77–9.17)

Aesthetic results

All patients were satisfied or very satisfied with the aesthetic results (Figs. 3 and 4). They gave a mean grade of 8.7 (range 7.0–10.0) on the evaluation scale.
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Fig. 3

Funnel chest type I. ac Before operations. df Result after operations

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Fig. 4

Funnel chest type III. ac Before operations. df Result after operations

The aesthetic evaluation by a group of plastic surgeons came to a mean grade of 7.7 (range 5.0–9.0). Five patients had a very good result, four had a good result, and three results were considered as fair (Table 3; Figs. 3 and 4).
Table 3

Aesthetic results

 

Patients

Surgeons

Very bad (1 and 2)

0

0

Bad (3 and 4)

0

0

Fair (5 and 6)

0

3

Good (7 and 8)

4

4

Very good (9 and 10)

7

5

Psychological results

The psychological repercussions of the deformities were considered to be very important and gave patients a significant complex from childhood onward. In the teenage years, the feeling of insufficiency was increased by the appearance of mammary hypoplasia. Young girls tried to hide their deformity by choosing suitable clothing. Therefore, they withdrew into themselves, which led to social and sentimental repercussions. After surgical correction, the benefit obtained was spectacular. Most of the patients clarified that the operation has changed their life. The disappearance of the deformity gave the patients more self-confidence and cleared the uncomfortable feeling towards their body.

Complications

Complications occurred in three cases:
  • An infection of the osteosynthesis material that required bar removal at 10 months instead of 12 months.

  • A periprosthesis seroma requiring multiple aspirations.

  • The risk of prosthesis extrusion required further surgical treatment.

No major cardiac, pulmonary or bone complication occurred. The most frequent complaint was chest-wall pain between surgeries. It appeared in 75% of all cases and was treated with paracetamol.

Discussion

Regarding severe deformities, pectus excavatum is frequently associated with a minor restrictive syndrome. Functional consequences are especially present during physical exercise but have no other effect on daily life. We did not notice any significant results concerning the progression of the restrictive syndrome in our study. From a subjective point of view, modelling sternochondroplasty modifies physical exercise capacity by diminishing dyspnea and palpitations. This improvement seems to be a secondary effect of decompression and relief of mediastinal deviation.

Varying results have been reported on the functional changes after surgical correction. Fonkalsrud and Bustorff-Silva [7] corrected 375 funnel chests with modelling sternochondroplasty. They described an improvement in the respiratory function with an increase in the vital capacity of 11%. Haller and Loughlin [11] did not observe any changes in vital capacity. However, they compared preoperative and postoperative cardiac and respiratory functions and found an improvement of tolerance during vigorous physical exercise. Recently, Malek et al. [13] studied the effects of pectus excavatum in 21 patients during physical exercise in terms of cardiac and pulmonary responses. He confirmed that there is a decrease in effort capacity in relation to the cardio-pulmonary deficit and not to the ventilatory limitation. Thus, it seems to be more interesting to carry out exercise tests rather than static tests for functional evaluation.

Aesthetically, 100% of the patients were satisfied or very satisfied. After surgical evaluation, there were, we report, good or even very good results in 75% of the cases. These results are similar to those found in the literature for chest-wall deformities [6, 9].

These deformities cause so much psychological trauma that this becomes a significant reason to operate on pectus excavatum [5]. The patients suffer from dysmorphia caused by funnel chest and the associated mammary hypoplasia. Overall, it is mainly psychological and aesthetic motivations that lead patients to seek surgical correction.

In the present study, there were only minor complications. The modelling sternochondroplasty was always carried out by one experienced thoracic surgeon. As described in literature, the technique resulted in low morbidity and no mortality [10, 14]. However, the first step of the procedure is significant and involves a 10-day hospital stay. The presence of slide fastener-handles of Borrelly is associated with moderate pain over several months in 75% of the cases. This surgery should only be proposed to patients who are motivated and aware of these drawbacks.

Surgeons using silicone implants to correct thoracic deformities consider it to be a relatively minor procedure with a short hospital stay [3, 21]. However, this technique has several disadvantages:
  • The edges of the prosthesis may be visible and palpable. This problem seems to be less frequent when the prosthesis is placed in a subpectoral position and undermining is less extensive than in the past [3].

  • Chronic fluid collection around the implant is frequent (about 30 to 65%) [12, 21] and requires serial needle aspiration.

  • Large-sized thoracic prostheses may be uncomfortable and may cause mechanical problems on certain movements. In some cases, they may even have to be removed [12, 15].

Moreover, we do not know exactly what will happen to the implants after 10 years. Some questions remain unanswered for now, e.g. about life persistency and long-term tolerance. Furthermore, could they be placed in conjunction with mammary prosthesis without any problems? How could prosthesis be placed to avoid rubbing, wearing and displacement? Several authors described displacement of breast implants in front of the sternum [1, 15].

Modelling sternochondroplasty leads to definitive long-term results and correct functional disorders [8]. We prove that this technique can be associated with the placement of mammary implants. The inframammary approach is very useful for the two steps of the procedure. The scar is nearly invisible, as it is concealed in the inframammary crease. The primary correction of the thoracic deformity is indispensable to place the mammary prosthesis correctly and to ensure a satisfactory aesthetic result. Bar removal at the same time as placing subpectoral breast implants does not create any technical problems and reduces the number of general anaesthetic sessions.

Modeling sternochondroplasty is a significant procedure. The minimal invasive technique of Nuss et al. [17] seems to have a low complication rate with excellent long-term results. This is mainly practiced in pediatric surgery, but it might also be efficient in adults [18]. This procedure may be an interesting alternative.

To our knowledge, there are no further studies concerning the combined treatment of funnel-chest deformities and mammary hypoplasia. We proved that correction of this double deformity could be achieved by two different operations only. This procedure is a reliable surgical technique giving excellent aesthetic and psychological results with a low complication rate. In comparison with another technique used frequently for pectus excavatum repair using a silicone prosthesis, the modelling sternochondroplasty gives good and lasting results, corrects functional disorders and is perfectly compatible with placement of breast implants. However, this is a significant intervention and should only be used in patients with major funnel-chest deformities and with strong motivation.

Copyright information

© Springer-Verlag 2007