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Reconstruction of pectus excavatum with silicone implants
Journal of Plastic, Reconstructive & Aesthetic Surgery (2006) 59, 1082e1086
Reconstruction of pectus excavatum with silicone implants Alexander Margulis a,*, Mordechai Sela b, Rami Neuman a, Anat Buller-Sharon b a
Department of Plastic Surgery, Hadassah Medical Center of Hebrew University, P.O. Box 12000, Jerusalem il-91120, Israel b Department of Maxillofacial Rehabilitation, Hadassah Medical Center of Hebrew University, Jerusalem, Israel Received 1 November 2005; accepted 8 December 2005
KEYWORDS Pectus excavatum; Silicone implants; Chestwall reconstruction
Summary The pectus excavatum deformity is characterised by a deep depression usually involving the lower one-half to two-thirds of the sternum. The indications for surgery are often aesthetic. Extensive procedures, requiring fracturing and remodelling of the chest wall skeleton are associated with high morbidity and high rate of complications. In this article we describe our renewed experience with reconstruction of mild and moderate pectus excavatum deformities with custom made prefabricated silicone implants. The fabrication of the implant and the surgical technique are described in detail. An excellent aesthetic correction of the deformity was achieved in all of the patients in our series, with high patient satisfaction rate. We conclude that with careful patient selection, artistic implant fabrication and meticulous surgical technique, this approach achieves excellent aesthetic correction with minimal morbidity and a low complication rate and therefore should maintain its place in the armamentarium of surgical techniques for reconstruction of pectus deformities. ª 2006 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All rights reserved.
The pectus excavatum deformity is characterised by a deep depression usually involving the lower one-half to two-thirds of the sternum, with the most recessed or deepest area at the junction of * Corresponding author. Fax: þ972 2 6418868. E-mail address: [email protected] (A. Margulis).
the chest and the abdomen. In many of these deformities, the sternum is asymmetric and courses to the right or left (Fig. 1A).1e3 The incidence of pectus excavatum is one in every 500e1000 children. The deformity shows shortly after birth and then progresses to its maximum severity in adolescence. Spontaneous
1748-6815/$ - see front matter ª 2006 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2005.12.035
Silicone implants in pectus excavatum
1083
Figure 1 A: A 22-year-old female with a severe asymmetric pectus deformity. B, C: Impression of the defect: irreversible hydrocolloid, enforced with plaster of Paris. D: The custom made silicone implant. E: The ‘try on’ of the silicone on the patient before the insertion. F: Intraoperative views after the implantation through bilateral submammary incisions.
regression or improvement rarely occurs. Front and lateral view chest x-rays demonstrate the deformity and may show displacement of the heart to the left of the midline as well as compression of the right ventricle. Different techniques were described to correct this deformity. In Ravtich procedure a sternal bar (called Adkin’s strut) is placed behind the sternum after mobilising the deformed cartilages around the sternum. The bar is removed approximately 12
months after the initial repair.2,3,5 Nuss described placement of a large curved bar under the deformed chest wall through percutaneous incisions.2 The bar is rotated upward and kept in place for a prolonged period of time during which the cartilages reform in their new position. Herein, we describe our renewed experience with reconstruction of mild and moderate pectus excavatum deformities with custom made prefabricated silicone implants. We believe this technique
1084 to be effective, minimally invasive and safe, with reproducible good aesthetic results and high patient satisfaction.
Materials and methods Patients Seven consecutive patients (four females and three males) with mild to moderate deformities were operated from 2003 to 2005. The age of the patients ranked from 20 to 30 years (average 24). The medial follow up period was 1.4 years. A custom made silicone implant was fabricated by the Department of Maxillofacial Prosthetics. Average operating time was 1 h and 12 min. The patients stayed in one night after the procedure and discharged on the following day.
Fabricating technique of the implant An impression of the defect with irreversible hydrocolloid (Alginate Impression Material Fast
A. Margulis et al. Set, GC Europe, Leuven, Belgium) is taken (Fig. 1B,C). The impression is reinforced by plaster of Paris as a second layer. Then, a master cast stone (Microstone Golden; Whip Mix Corp., Louisville, KY, USA) is prepared out of the impression. On the cast model of the sternal area, a model of the prosthesis is waxed with pink wax (Dentaria Baseplate Wax, Hashava Dental and Chemical Mfg., Israel) matching the required shape and size. Then, the wax prosthesis is placed on the patient chest wall for an initial evaluation. Corrections, if needed, are done at this stage. The waxed master cast is flashed, the wax boiled out, and the mold packed with pink silicone (polydimethylsiloxane, Silastic MDX4-4210, medical grade elastomer, Dow Corning Corp., Medical Materials, Midland, MI, USA) and pressed up to 8000 psi. The silicone is processed in the oven for 2 h at 100 C. Upon completion of processing, the silicone is removed from the stone and the prosthesis trimmed to its final size (cut by seizures or trimmed by drills) (Fig. 1D).
Figure 2 A, B: Preoperative views of a 22-year-old patient with a severe asymmetric pectus deformity. C, D: Postoperative views one year after the correction of the deformity with a custom made silicone implant. The patient did not desire repair of the breast asymmetry.
Silicone implants in pectus excavatum The silicone prosthesis is ‘tried’ on the patient before the insertion (Fig. 1E). Minor corrections of the prosthesis edges are done at this stage. The prosthesis is sterilised by gas (ethylene oxide) prior to delivery.
Surgical technique The implantation technique is straightforward. A meticulous antiseptic measurement and prophylactic antibiotics (Cefazoline 1 g intravenously) are routine. We use standard breast augmentation inframammary line incision in females (Fig. 1F) and upper abdominal 4 cm median incision in males. With smaller implants, transumbillical approach may be used. The implant is placed on top of the skin and its borders are marked on the skin. We aim to make the surgical pocket at the exact size of the implant, to avoid seroma formation with potential displacement of the implant and internal scarring. The flap is elevated right on top of the muscle
1085 fascia with care taken to preserve all the subcutaneous fat in the flap. A thick flap is the key to avoiding postoperative show of the implant. Careful haemostasis is achieved and the pocket is irrigated with dilute bacitracin solution. The implant is introduced and carefully seated in the pocket. Two suction drains are placed. The skin is closed in layers and the wound dressed with bacitracin, xeroform gauze and a soft fluffy bandage. The drains are removed around postoperative day five, depending on drainage.
Results An excellent correction of the deformity was achieved in all of the patients in this series (Figs. 2 and 3). A minimal implant ‘show’ was seen in one patient who was very thin. The satisfaction rate with the procedure was high. We did not have any
Figure 3 A, B: Preoperative views of a 20-year-old patient with a moderate asymmetric pectus deformity and a midline chest scar from a previous surgery. C, D: Postoperative views 1.2 years after the correction of the deformity with a custom made silicone implant and two months after augmentation of the right breast with a silicone gel breast prosthesis.
1086 other immediate or late complications in this small series. None of the patients required blood transfusion.
Discussion Congenital chest wall deformities may present as skeletal disorders, defects of sternal fusion, pectus carinatum (pigeon chest), pectus excavatum (funnel chest), and Poland’s Syndrome.1,4,6 The last two represent the vast majority of the congenital deformities of the chest wall.1,3,5,6 The indications for surgery in pectus excavatum are often cosmetic and psychological.1,2 Extensive procedures, requiring fracturing and remodelling of the chest wall skeleton are associated with high morbidity and high rate of complications such as recurrence of the funnel, scars, and cartilage nodules.3e5 These procedures should be probably preserved for children with severe deformities carrying the risk for secondary cardiac and pulmonary disease. The properties of silicone make it the perfect selection for implant material in this indication. The fabrication of the soft custom made implant is simple, cheap, reproducible and easy to teach. The wax model can be ‘measured’ on the patient’s chest prior to surgery, and needed corrections and touchups can be made. The implant can be easily sterilised. A connective tissue capsule is formed around the implant and it can be easily explanted in case of infection or patient dissatisfaction. A careful patient selection is mandatory. Thin patients with paucity of subcutaneous fat in the area of implantation are prone to implant ‘show’ after the surgery. A well developed inframammary crease will hide the scar well. On the other hand, male patients or female patients with underdeveloped inframammary crease need to be informed
A. Margulis et al. on visible scar which may show some hypertrophy in this area. Small implants can theoretically be placed through a periumbillical incision, but this approach makes the pocket dissection very challenging. Patients with preexisting secondary pulmonary or cardiac disease need to be informed that the procedure is purely aesthetic and will not improve their illness. The keys for achieving a stable implant that sits precisely in the desired location are dissection of a precise pocket exactly in the size of the implant and suction drains that stabilise the implant until an initial scar tissue forms. With the advancement of reconstructive techniques in surgery for pectus excavatum, correction of the deformity with implantable prosthesis has fallen out of grace. In our experience, with careful patient selection, artistic implant fabrication and meticulous surgical technique, this approach achieves excellent aesthetic correction with minimal morbidity and a low complication rate and therefore should maintain its place in the armamentarium of surgical techniques for reconstruction of pectus deformities.
References 1. Marks MW, Iacobucci J. Reconstruction of congenital chest wall deformities using silicone onlay prostheses. Chest Surg Clin N Am 2000 May;10(2):341e55 [vii]. 2. Lacquet LK, Morshuis WJ, Folgering HT. Long term results after correction of anterior chest wall deformities. J Cardiovasc Surg (Torino) 1998 Oct;39(5):683e8. 3. Willital GH. Indication and operative technique in chest deformities. Z Kinderchir 1981 Jul;33(3):244e52. 4. Fonkalsrud EW. Management of pectus chest deformities in female patients. Am J Surg 2004 Feb;187(2):192e7. 5. Shamberger RC, Welch KJ. Surgical repair of pectus excavatum. J Pediatr Surg 1998 Jul;23(7):615e22. 6. Chavoin JP, Dahan M, Grolleau JL, et al. Funnel chest: filling technique with deep custom made implants. Ann Chir Plast Esthet 2003 Apr;48(2):67e76.
Reconstruction of pectus excavatum with silicone implants Alexander Margulis a,*, Mordechai Sela b, Rami Neuman a, Anat Buller-Sharon b a
Department of Plastic Surgery, Hadassah Medical Center of Hebrew University, P.O. Box 12000, Jerusalem il-91120, Israel b Department of Maxillofacial Rehabilitation, Hadassah Medical Center of Hebrew University, Jerusalem, Israel Received 1 November 2005; accepted 8 December 2005
KEYWORDS Pectus excavatum; Silicone implants; Chestwall reconstruction
Summary The pectus excavatum deformity is characterised by a deep depression usually involving the lower one-half to two-thirds of the sternum. The indications for surgery are often aesthetic. Extensive procedures, requiring fracturing and remodelling of the chest wall skeleton are associated with high morbidity and high rate of complications. In this article we describe our renewed experience with reconstruction of mild and moderate pectus excavatum deformities with custom made prefabricated silicone implants. The fabrication of the implant and the surgical technique are described in detail. An excellent aesthetic correction of the deformity was achieved in all of the patients in our series, with high patient satisfaction rate. We conclude that with careful patient selection, artistic implant fabrication and meticulous surgical technique, this approach achieves excellent aesthetic correction with minimal morbidity and a low complication rate and therefore should maintain its place in the armamentarium of surgical techniques for reconstruction of pectus deformities. ª 2006 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All rights reserved.
The pectus excavatum deformity is characterised by a deep depression usually involving the lower one-half to two-thirds of the sternum, with the most recessed or deepest area at the junction of * Corresponding author. Fax: þ972 2 6418868. E-mail address: [email protected] (A. Margulis).
the chest and the abdomen. In many of these deformities, the sternum is asymmetric and courses to the right or left (Fig. 1A).1e3 The incidence of pectus excavatum is one in every 500e1000 children. The deformity shows shortly after birth and then progresses to its maximum severity in adolescence. Spontaneous
1748-6815/$ - see front matter ª 2006 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2005.12.035
Silicone implants in pectus excavatum
1083
Figure 1 A: A 22-year-old female with a severe asymmetric pectus deformity. B, C: Impression of the defect: irreversible hydrocolloid, enforced with plaster of Paris. D: The custom made silicone implant. E: The ‘try on’ of the silicone on the patient before the insertion. F: Intraoperative views after the implantation through bilateral submammary incisions.
regression or improvement rarely occurs. Front and lateral view chest x-rays demonstrate the deformity and may show displacement of the heart to the left of the midline as well as compression of the right ventricle. Different techniques were described to correct this deformity. In Ravtich procedure a sternal bar (called Adkin’s strut) is placed behind the sternum after mobilising the deformed cartilages around the sternum. The bar is removed approximately 12
months after the initial repair.2,3,5 Nuss described placement of a large curved bar under the deformed chest wall through percutaneous incisions.2 The bar is rotated upward and kept in place for a prolonged period of time during which the cartilages reform in their new position. Herein, we describe our renewed experience with reconstruction of mild and moderate pectus excavatum deformities with custom made prefabricated silicone implants. We believe this technique
1084 to be effective, minimally invasive and safe, with reproducible good aesthetic results and high patient satisfaction.
Materials and methods Patients Seven consecutive patients (four females and three males) with mild to moderate deformities were operated from 2003 to 2005. The age of the patients ranked from 20 to 30 years (average 24). The medial follow up period was 1.4 years. A custom made silicone implant was fabricated by the Department of Maxillofacial Prosthetics. Average operating time was 1 h and 12 min. The patients stayed in one night after the procedure and discharged on the following day.
Fabricating technique of the implant An impression of the defect with irreversible hydrocolloid (Alginate Impression Material Fast
A. Margulis et al. Set, GC Europe, Leuven, Belgium) is taken (Fig. 1B,C). The impression is reinforced by plaster of Paris as a second layer. Then, a master cast stone (Microstone Golden; Whip Mix Corp., Louisville, KY, USA) is prepared out of the impression. On the cast model of the sternal area, a model of the prosthesis is waxed with pink wax (Dentaria Baseplate Wax, Hashava Dental and Chemical Mfg., Israel) matching the required shape and size. Then, the wax prosthesis is placed on the patient chest wall for an initial evaluation. Corrections, if needed, are done at this stage. The waxed master cast is flashed, the wax boiled out, and the mold packed with pink silicone (polydimethylsiloxane, Silastic MDX4-4210, medical grade elastomer, Dow Corning Corp., Medical Materials, Midland, MI, USA) and pressed up to 8000 psi. The silicone is processed in the oven for 2 h at 100 C. Upon completion of processing, the silicone is removed from the stone and the prosthesis trimmed to its final size (cut by seizures or trimmed by drills) (Fig. 1D).
Figure 2 A, B: Preoperative views of a 22-year-old patient with a severe asymmetric pectus deformity. C, D: Postoperative views one year after the correction of the deformity with a custom made silicone implant. The patient did not desire repair of the breast asymmetry.
Silicone implants in pectus excavatum The silicone prosthesis is ‘tried’ on the patient before the insertion (Fig. 1E). Minor corrections of the prosthesis edges are done at this stage. The prosthesis is sterilised by gas (ethylene oxide) prior to delivery.
Surgical technique The implantation technique is straightforward. A meticulous antiseptic measurement and prophylactic antibiotics (Cefazoline 1 g intravenously) are routine. We use standard breast augmentation inframammary line incision in females (Fig. 1F) and upper abdominal 4 cm median incision in males. With smaller implants, transumbillical approach may be used. The implant is placed on top of the skin and its borders are marked on the skin. We aim to make the surgical pocket at the exact size of the implant, to avoid seroma formation with potential displacement of the implant and internal scarring. The flap is elevated right on top of the muscle
1085 fascia with care taken to preserve all the subcutaneous fat in the flap. A thick flap is the key to avoiding postoperative show of the implant. Careful haemostasis is achieved and the pocket is irrigated with dilute bacitracin solution. The implant is introduced and carefully seated in the pocket. Two suction drains are placed. The skin is closed in layers and the wound dressed with bacitracin, xeroform gauze and a soft fluffy bandage. The drains are removed around postoperative day five, depending on drainage.
Results An excellent correction of the deformity was achieved in all of the patients in this series (Figs. 2 and 3). A minimal implant ‘show’ was seen in one patient who was very thin. The satisfaction rate with the procedure was high. We did not have any
Figure 3 A, B: Preoperative views of a 20-year-old patient with a moderate asymmetric pectus deformity and a midline chest scar from a previous surgery. C, D: Postoperative views 1.2 years after the correction of the deformity with a custom made silicone implant and two months after augmentation of the right breast with a silicone gel breast prosthesis.
1086 other immediate or late complications in this small series. None of the patients required blood transfusion.
Discussion Congenital chest wall deformities may present as skeletal disorders, defects of sternal fusion, pectus carinatum (pigeon chest), pectus excavatum (funnel chest), and Poland’s Syndrome.1,4,6 The last two represent the vast majority of the congenital deformities of the chest wall.1,3,5,6 The indications for surgery in pectus excavatum are often cosmetic and psychological.1,2 Extensive procedures, requiring fracturing and remodelling of the chest wall skeleton are associated with high morbidity and high rate of complications such as recurrence of the funnel, scars, and cartilage nodules.3e5 These procedures should be probably preserved for children with severe deformities carrying the risk for secondary cardiac and pulmonary disease. The properties of silicone make it the perfect selection for implant material in this indication. The fabrication of the soft custom made implant is simple, cheap, reproducible and easy to teach. The wax model can be ‘measured’ on the patient’s chest prior to surgery, and needed corrections and touchups can be made. The implant can be easily sterilised. A connective tissue capsule is formed around the implant and it can be easily explanted in case of infection or patient dissatisfaction. A careful patient selection is mandatory. Thin patients with paucity of subcutaneous fat in the area of implantation are prone to implant ‘show’ after the surgery. A well developed inframammary crease will hide the scar well. On the other hand, male patients or female patients with underdeveloped inframammary crease need to be informed
A. Margulis et al. on visible scar which may show some hypertrophy in this area. Small implants can theoretically be placed through a periumbillical incision, but this approach makes the pocket dissection very challenging. Patients with preexisting secondary pulmonary or cardiac disease need to be informed that the procedure is purely aesthetic and will not improve their illness. The keys for achieving a stable implant that sits precisely in the desired location are dissection of a precise pocket exactly in the size of the implant and suction drains that stabilise the implant until an initial scar tissue forms. With the advancement of reconstructive techniques in surgery for pectus excavatum, correction of the deformity with implantable prosthesis has fallen out of grace. In our experience, with careful patient selection, artistic implant fabrication and meticulous surgical technique, this approach achieves excellent aesthetic correction with minimal morbidity and a low complication rate and therefore should maintain its place in the armamentarium of surgical techniques for reconstruction of pectus deformities.
References 1. Marks MW, Iacobucci J. Reconstruction of congenital chest wall deformities using silicone onlay prostheses. Chest Surg Clin N Am 2000 May;10(2):341e55 [vii]. 2. Lacquet LK, Morshuis WJ, Folgering HT. Long term results after correction of anterior chest wall deformities. J Cardiovasc Surg (Torino) 1998 Oct;39(5):683e8. 3. Willital GH. Indication and operative technique in chest deformities. Z Kinderchir 1981 Jul;33(3):244e52. 4. Fonkalsrud EW. Management of pectus chest deformities in female patients. Am J Surg 2004 Feb;187(2):192e7. 5. Shamberger RC, Welch KJ. Surgical repair of pectus excavatum. J Pediatr Surg 1998 Jul;23(7):615e22. 6. Chavoin JP, Dahan M, Grolleau JL, et al. Funnel chest: filling technique with deep custom made implants. Ann Chir Plast Esthet 2003 Apr;48(2):67e76.