Chest wall deformities and corrective procedures: A closer look at Funnel Chest(pectus excavatum) and Pigeon Chest (pectus carinatum)
MBBS, MS, MCh, FRCPS, FRCS, FRCSCTh
One afternoon during a busy clinic, I saw a young 18-year-old man with his mother. He was tall and slim and appeared extremely shy. His mother, who looked very worried, handed me a letter from his GP which described him as having pectus excavatum. I asked him to remove his shirt so that I could examine his chest, but he was extremely reluctant to do so. His mum said that she would leave the room and told me that he had never removed his shirt in front of any of his family members. When she left the room, I examined him and found him to have quite a deep depression of the sternum. He told me that this made him feel like a ‘freak’ and that he would remain covered up during the summer on the beach and even when he went swimming. His mother later told me that he had few friends and was also surprised that he had not yet had a girlfriend.
What is pectus excavatum and how is it treated?
Pectus excavatum is an anterior chest wall structural deformity characterised by sternal (breast bone) depression. The condition is developed after birth due to an unequal growth of cartilage supporting the sternum. This presses the sternum inwards onto the cardiopulmonary system, creating a classical defect.
Initially, pectus excavatum was treated in the form of the Ravitch procedure, an extensive surgery involving the removal of cartilage, breaking of the sternum and re-joining it together. Following this procedure, the patient would remain in hospital for up to seven days with a recovery period lasting up to six weeks.
The new approach (the Nuss procedure), introduced by Dr Donald Nuss from the USA for children adopts a keyhole technique. We currently offer treatment in the form of the minimally invasive Nuss procedure at our centre. During this procedure, a metal bar, which is pre-designed for a patient’s particular defect, is passed under the sternum through a tiny incision of half a centimetre. It is fixed on the other side with a stabiliser and the sternum is instantly pushed forward to correct the defect. The bar stays in place for up to three years. Following this three-year period, the bar is typically removed during another short procedure. The Nuss procedure is performed under general anaesthesia and takes approximately half an hour from start to finish. The patient will then stay in hospital for one night and can usually return to an office job within a week. Pain control is sometimes needed for patients in the post-operative period. In hospital, we would offer patient controlled analgesia.
This surgery has revolutionised the outlook and recovery time for patients and we are receiving an increased number of referrals from all over the UK and abroad. We set up our unit in collaboration with Professor Pilegaard from Denmark who has extensive experience in minimally invasive pectus correction surgery. We can offer this surgery to anybody from 16 to 40 years of age. From 40 years upwards, the cartilage become calcified and the bar may not correct the defect sufficiently.
Below are pictures of the patient described in the above case study. He is now a confident 19-year-old who is happy to go swimming and now has his first girlfriend!
After: The depression from pectus excavatum after correction by the Nuss procedure (described above).
Before: An image showing the extent of the chest wall depression from pectus excavatum.
Before ———after braces
Before ———after braces
Pectus carinatum (or pigeon chest) is a deformity of the chest wall caused by abnormal growth, and subsequent protrusion, of the sternum (breast bone) and adjacent ribs. Traditionally, pectus carinatum has been treated surgically. In many centres, the modified Ravitch procedure has been adopted for surgical correction. This involves a vertical incision at the area of most severe deformity. This incision allows surgeons access to the sternum and adjacent ribs. Multiple rib cartilage resections are made to shorten the length of deformity and a wedge osteotomy of the sternum is performed. The newly created space at the osteotomy line is filled and the sternum is stabilised with a titanium bar (Scarci, M et al., 2016).
Alternatively, pectus carinatum can be treated with the use of orthotic braces. Compressive orthotic places offer a non-invasive solution. These braces take advantage of the malleable nature of the chest wall in adolescents and, therefore, younger patients are typically more amenable to successful correction with orthotics.
Our centre uses a T-Joe bracing system for all pectus deformities. This is a flat-profile brace that can be used during physical activities as it allows unrestricted arm motion. The T-Joe brace can also be worn overnight in bed. Each brace is custom-fit for each patient (Pectus Services, 2019).