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Repair of Pectus Excavatum by Sternal Eversion
Repair of Pectus Excavatum by Sternal Eversion John A. Hawkins, M.D., J . L. Ehrenhaft, M.D., and Donald B. Doty, M.D. ABSTRACT Pectus excavatum was repaired by the sternal eversion (turnover) technique in 26 patients over a 7-year period. Vascular supply to the sternal graft was maintained by preservation of one internal mammary vascular pedicle. Good results were obtained in 21 (81%) patients followed for periods ranging from 2 to 76 months (mean, 32 months) postoperatively. Four patients (15%) had fair results; 2 patients with Marfan’s syndrome had partial recurrence, as did 1 patient with skin necrosis and 1 with hypertrophic scar. One patient (4‘%) had a poor early result due to wound infection and distal sternal necrosis requiring reoperation. Other complications were minor: superficial wound seroma in 2 patients and pneumothorax in 1. The sternal eversion technique for repair of pectus excavatum utilizes the concave shape of the sternum when turned over to create a cosmetically acceptable convex anterior chest wall contour. Judicious tailoring of the costal cartilages and shaping of the anterior sternum corrects asymmetrical deformities. The chest wall is very stable after repair. Since no prosthetic struts or pins are used, a second operation for removal is avoided. Preservation of the vascular supply to the sternum should allow normal growth of the anterior chest wall. The results have been sufficiently encouraging for us to recommend sternal eversion as the primary method for repair of pectus excavatum.
The history of operative repair of pectus excavatum extends over a period of nearly 60 years. Principles of surgical correction established by Ochsner and DeBakey [l] and developed by Lester [2] and Ravitch [3] include subperichondrial resection of involved costal cartilages, transverse sternal osteotomy, and elevation of the depressed sternal segment. Modifications of these basic techniques have been designed to maintain the corrected position of the sternum through the use of metal struts or pins [4, 51, prosthetic material [6], or autologous tissue [7-lo]. These methods for repair of pectus excavatum have yielded satisfactory early results and remain popular, even though there is a tendency for the appearance of the chest wall to deteriorate with time [ll-131.
From the Division of Thoracic and Cardiovascular Surgery, Department of Surgery, the University of Iowa Hospitids and Clinics, Iowa City, IA. Presented at the Twentieth Annual Meeting of The Society of Thoracic Surgeons, San Antonio, TX, Jan 23-25, 1!384. Address reprint requests to Dr. Ehrehift, Division of Thoracic and Cardiovascular Surgery, The University of Iowa Hospitals and Clinics, Iowa City, IA 52242.
368
The sternal eversion or turnover technique for repair of pectus excavatum differs substantially from the more commonly employed techniques. The sternal eversion repair involves transverse division of the sternum, division of costal cartilages, total mobilization of the plastron allowing 180-degree axial rotation of the bone and muscle graft (sternal turnover), and, finally, reattachment of the sternum and costal cartilages by suture. The operation is straightforward and the technique successful in achieving good cosmetic and functional results [14, 151. Experience with the sternal turnover repair, however, has been limited [14, 151. This article reports the results of experience using a modification of the sternal turnover or eversion repair of pectus excavatum in which one internal mammary vascular pedicle is preserved to assure the viability of the sternum and costal cartilages in the everted position. Results of the sternal eversion technique over a 7-year period have been sufficiently encouraging to recommend it as the primary method of repair for nearly all pectus excavatum deformities.
Material and Methods Twenty-six patients had repair of pectus excavatum using a sternal eversion technique at the University of Iowa Hospitals during a 7-year period from July, 1976, through June, 1983. The patients ranged from 22 months to 32 years old (mean, 9 years old); there were 17 male and 9 female patients. The primary indication for surgical correction of pectus excavatum was cosmetic in 24 of the 26 patients. Five of the patients reported having exertional dyspnea. In 2 patients, the primary indication for operation was repair of a cardiac defect requiring cardiopulmonary bypass. One of these patients underwent replacement of the ascending aorta and aortic valve for an ascending aortic aneurysm associated with Marfan’s syndrome, and the other underwent aortic valvotomy for congenital aortic stenosis. One other patient had Marfan’s syndrome, 6 had thoracic scoliosis, and 1 had limb length inequality as an associated defect. The operative technique in all patients was similar to the method described by Wada and colleagues [15] with the modification of preservation of one internal mammary vascular pedicle, which was possible in 24 of the 26 patients. In 2 patients, preservation of the vascular pedicle was not possible and the sternum and attached cartilages were treated as a free graft and simply turned over and sutured into place, exactly as described by Wada and associates. All of the patients were examined by the attending surgeon at return clinic visits. Satisfaction with results of the operation was evaluated by recent (1983) telephone contact with the patients or their parents.
369 Hawkins, Ehrenhaft, and Doty: Repair of Pectus Excavatum by Sternal Eversion
- Transverse sternotomy
Costal cartilages divided
\
Fig 1 . Sternal eversion technique for repair of pectus excavatum. The sternum is divided transversely in the second intercostal space, just above the beginning of the sternal deformity. The costal Cartilages and intercostal muscles (not shown) are divided vertically, just lateral to the beginning of the cartilage deformity.
Operative Technique A midline or submammary incision provides equally satisfactory exposure. The pectoralis muscle attachments to the ribs and costal cartilages are divided to expose the anterior chest wall laterally to the junction of the costal cartilages and osseous ribs. The redus abdominus and diaphragmatic muscle attachments are freed from the xiphoid process and costal margins. The sternum is divided transversely in the second or third intercostal space using an oscillating saw, at a point above the origin of the sternal deformity. The costal cartilages and intercostal muscles are transected vertically, lateral to the internal mammary vessel at the point the cartilage deformity begins, usually near the junction of the osseous and cartilaginous ribs (Fig 1).The sternum and costal cartilages are separated from the pericardium and anterior mediastinal tissues beginning inferiorly at the xiphoid and costal margins. The dissection proceeds superiorly; the sternal graft is elevated while both internal mammary vascular pedicles are preserved (Fig 2). One of the internal mammary vascular pedicles is chosen (usually the right) and mobilized proximally to its origin from the subclavian vessels. Substantial pleura and chest wall tissue is left surrounding the vessels to strengthen the vascular pedicle and to prevent kinking. The internal mammary vessels on the opposite side are ligated and divided, or mobilized if the primary vascular pedicle has been damaged. The sternum and attached cartilages are everted by turning the graft 180 degrees axially with the graft based on one internal mammary vessel. A path for the vascular pedicle is created between the two most proximal ipsilatera1 costal cartilages after removal of all intercostal muscle in the interspace. Usually the vascular pedicle must
Convexity now anterior
Fig 2 . Elevation of the sternal graft in sternal eversion repair of pectus excavatum. The internal mammary vessels are preserved as the sternum and attached costal cartilages are separated from mediastinal tissues. The sternal graft is based on one internal mammary pedicle and rotated 180 degrees axially so that the convexity is anterior.
be further mobilized distally off the sternum to relieve tension on the vessel that could compromise patency and to allow the vascular pedicle to tuck into the interspace channel created between the two most proximal cartilages. Patency of the preserved internal mammary artery in its new position is confirmed by Doppler ultrasound velocity probe. Costal margin flaring, which is usually present in varying degrees of severity, is corrected by placing a No. 3 or 5 wire suture through the perichondrium of the costal margin at the point of maximal anterior deformity on both sides. This is ordinarily at the anterior axillary line. The suture is tightened until the costal flaring is minimized. An anteriorly beveled osteotomy on the proximal sternum is usually necessary to ensure proper position of the graft sternal segment when the ends of the sternum are approximated. The sternum is then joined using two or three loops of No. 4 or 5 stainless steel wire. The wire loops are not tied at this point to allow continued mobility of the graft while maintaining position of the sternal ends. The costal cartilages on the graft are shortened with a scalpel at correct length and angles to precisely approximate the ends of the costal cartilages and ensure proper position and contour of the new anterior chest wall (Fig 3). The costal cartilages are reattached to lateral ribs using figure-of-eight No. 1wire to achieve a stable chest wall. Some shaping of the new anterior surface of the sternum and costal cartilages is usually necessary to achieve symmetry and the best cosmetic result. A scalpel is used
370 The Annals of Thoracic Surgery Vol 38 No 4 October 1984
,,-Internal Mammary Vascular Bundle
-Sternal fixation
,/‘
v\ Costal cartilages fixated
Excess cartilage resected
Fig 3 . Reapproximation of the sternal graft in sternal eversion repair of pectus excavatum. After the sternum has been repaired with wire, the costal cartilages are trimmed. This allows precise reapproximation of the costal cartilages to the ribs laterally and helps in correcting asymmetrical deformities.
to shave thin layers of cartilage or bone off protruding areas until an acceptable contour is obtained (Fig 4). The rectus abdominus muscles and fascia are reattached to the costal margin using interrupted size 0 polyglycolic acid suture. The pectoralis major muscles are reattached to the sternum in the midline sternum using interrupted 3-0 polyglycolic acid suture. The subcutaneous tissues are closed, and the skin is reapproximatedby subcuticular suture. No drains are left in the subcutaneous space; the mediastinum is allowed to drain to a thoracostomy tube, which is placed in the appropriate hemithorax if the pleura has been entered during sternal mobilization.
Results All patients survived the operation and were discharged from the hospital within six days, except for the 2 patients who underwent open-heart procedures [16]; these 2 patients were discharged at nine and twenty days postoperatively. The chest wall was stable in all patients, and none required ventilation beyond the anesthetic period except for those with combined cardiac procedures. Operative morbidity was minimal, with easily correctable complications occurring in 5 patients. The most common complication was superficial fluid collection, which occurred in 2 patients and was treated simply by opening a small portion of the incision. One patient had a wound infection (Staphylococcusepidermidis), that progressed to distal sternal necros,isand required reoperation. A pneumothorax occurriqg in 1patient was treated with tube thoracostomy. One patient had necrosis of a portion of a skin flap that healed by secondary wound closure.
I
K9
‘=,Reshape sternal contour
b;\
Fig 4 . Final shaping of the sternal graft in sternal eversion repair of pectus excavatum. The costal cartilages have been sutured to the lateral ribs using wire. The internal mammary vessels can now be seen coursing on the anterior surface of the turned-over sternum through the interspace channel to their origin from the subclavian vessels. A scalpel is used to shave thin layers of cartilage and bone to achieve a symmetrical contour of the anterior chest wall.
Follow-up ranged from 2 to 76 months (mean, 32 months). A good result was defined as a satisfactory appearance of the healed incision, correction of any costal flaring, and no recurrence of deformity. A good result was obtained in 21 of the 26 patients (81%).One of the patients included in the group with a good result did require removal of a bothersome sternal wire, which in no way affected the cosmetic or functional outcome of the repair. The operative result was classified as fair in 4 of the 26 patients. In both of the patients with Marfan’s syndrome, the operative result was less than desirable because of partial recurrence of the pectus excavatum deformity. The recurrence was not sufficient to require reoperation in either patient. Another patient had a fair result because of formation of marked hypertrophic scar, but the sternal contour is excellent and there is no residual costal flaring. The patient with partial necrosis of a skin flap also had a fair result because of hypertrophic scarring after secondary wound closure was complete. The patient with a wound infection was classified as having a poor result because of necrosis of a portion of the distal sternum. This required reoperation 1 year postoperatively with repair of the sternal defect using Marlex mesh.
Comment The most common current technique for repair of pectus excavatum is the method described by Ravitch [3]. The basic principles of the operation include subperichondrial resection of abnormal costal cartilages; freeing of the sternum from intercostal, pericardial, and mediastinal attachments; and elevation of the depressed sternal segment. A large number of modifications and additions to this basic procedure have been made over the years. Most of these technical modifications were designed to
371 Hawkins, Ehrenhaft, and Doty: Repair of Pectus Excavatum by Sternal Eversion
maintain the correct position of the sternum after elevation of the depressed sternum. This has been accomplished by using metal struts [4], Kirschner wires [5], autologous rib struts [7], Marlex mesh [6], tripod fiiation [9], and autologous perichondrium [lo]. The outcome using these techniques has generally been good, with 80 to 90% of patients having acceptable early results. Since most of these operations are performed during early childhood for cosmetic indications, long-term evaluation of results into adult life is especially important. Reports of follow-up of at least 20 years after repair of pectus excavatum using the Ravitch technique or variations on it are few, even though good operations have been available for nearly 40 years. The few reports that analyze results 20 years after repair suggest that there is deterioration in the appearance of the chest wall with time [ll-131. A satisfactory result was obtained in 31 to 54% of patients who were followed for at least 20 years after undergoing a Ravitch procedure [lo] or a modified repair [HI. While we did not tabulate our results with a standard repair of pectus excavatum, our clinical impression suggested that some results were less than satisfactory with the passing of time, thus prompting a trial of a different technique. The sternal eversion or turnover technique for repair of pectus excavatum differs substantially from the commonly employed techniques. Nissen [17] was among the first to report the use of sternal turnover in 1944. He described detaching the sternum and costal cartilages, turning the plastron over, and resuturing it to the anterior chest wall after rotating it 90 degrees. In 1956, Judet and Judet [18] reported their method, which has been popularized by Wada [19]. This technique involves transecting the sternum and costal cartilages, excising the sternum and attached cartilages from the chest wall, turning the sternum over as a free graft, and resuturing the sternum and costal cartilages. Satisfactory results using this technique of sternal turnover were obtained in 97% of the 199 patients in the 15-year experience of Wada’s group [15]. Similar results have been obtained in smaller series [14, 201. Despite the excellent results and the appeal of such a direct method of repair, experience with sternal turnover has been limited. Considerable concern has been expressed regarding potential for chest wall growth and for infection after reimplantation of the large devascularized sternal graft. These problems apparently were not observed in the younger patients in the series of Wada’s group [15]. However, patients more than 15 years old who underwent sternal turnover had a 46% incidence of complications attributable to devascularization of the sternum. The most serious complications included necrosis of bone and muscle and formation of fistula [21]. In 1956, Jung [22] reported a sternal turnover procedure with preservation of the blood supply. He described a sternal turnover that left the rectus abdominus muscles attached. Adequacy of this technique was documented by Scheer [23], who found normal histological
status of the bone after the Jung turnover procedure. Taguchi and associates [21] reported a sternal turnover procedure that maintained vascular supply using a technique of preservation of both internal mammary arteries. This technique seemed very attractive, and we reasoned that it could be simplified by preservation of only a single vascular pedicle to the sternal graft. Concern about vascular integrity of the sternum must also be expressed for the more standard techniques based on perichondrial resection of cartilage and elevation of the sternum [3-lo]. These techniques involve extensive mobilization of the sternum from surrounding tissues and blood supply, essentially converting it to a free bone graft. Infection has not been a major problem, but deterioration of the cosmetic appearance of the anterior chest wall with time suggests that interference with the blood supply to the sternum could have affected growth of the sternum. Techniques involving the use of prosthetic materials [6] could seriously affect growth of the anterior chest wall in the area of the prosthetic implant. The sternal eversion technique has several attractive features when compared to other, more commonly used methods. Sternal eversion directly addresses the deformity of the depressed sternum by utilizing the shape of the sternum to create an anterior contour of the chest wall. Cosmetic results are predictable. Contrary to the opinions of other authors (12, 131, we have found that asymmetrical deformities can be treated with the sternal eversion technique by using judicious tailoring of the costal cartilages and shaping of the anterior sternum. Chest wall stability is impressively maintained during the postoperative period, obviating the need for assisted ventilation. Since no prosthetic material is used and blood supply to the sternum is preserved, future growth should proceed normally. By avoiding the use of metal struts or pins, a second operation for removal is avoided. In sum, the technique we have described to repair pectus excavatum utilizing sternal eversion with preservation of vascular supply has yielded good cosmetic results with a low incidence of serious complications. Preservation of vascular supply to the sternum should provide excellent long-term results with continued maintenance of normal growth potential of the anterior chest wall. We recommend this procedure as the primary technique for repair of pectus excavatum.
References 1. Ochsner A, DeBakey M Chone-chondrosternon:report of a case and review of the literature. J Thorac Surg 8469,1939 2. Lester CW The surgical treatment of funnel chest. Ann Surg 123:1003,1946 3. Ravitch MM: The operative treatment of pectus excavatum. Ann Surg 129:429, 1949 4. Adkins PC,Blades B A stainless steel strut for correction of pectus excavatum. Surg Gynecol Obstet 113:111, 1961 5. Griffin EH, Minnis JF:Pectus excavatum: a survey and a suggestion of maintenance and correction. J Thorac Cardiovasc Surg 33:625, 1957
372 The Annals of Thoracic Surgery Vol 38 No 4 October 1984
6. Robicsek F: Marlex mesh support for the correction of very severe and recurrent pectus excavatum. Ann Thorac Surg 26:80, 1978 7. Dailey JE: Repair of funnel chest using substernal 0steoperiosteal rib graft strut: report of a case with four year follow-up. JAMA 150:1203, 1952 8. Sanger PW, Robicsek F, Taylor FH: Surgical management of anterior chest deformities: a new technique and report of 153 operations without a death. Surgery 48:510, 1969 9. Haller JA Jr, Shermeta DW, Tepas JJ, et a1 Correction of pectus excavatum without prostheses or splints: objective measurement of severity and management of asymmetrical deformities. Ann Thorac Surg 26:73, 1978 10. Holcomb GW Jr: Surgical correction of pectus excavatum. J Pediatr Surg 12295, 1977 11. Humphreys GH, Jaretzki A: Pectus excavatum: late results with and without operation. J Thorac Cardiovasc Surg 80:686, 1980 12. Howard R Funnel chest: results and description of an improved operative technique. Med J Aust 2134, 1978 13. Moghiss K Long-term results iin surgical correction of pectus excavatum and sternal prominence. Thorax 19:350,1964 14. Davis MV, Shah HH: Sternal turnover operation for pectus excavatum. Ann Thorac Surg l7268, 1974 15. Wada J, Ikeda K, Ishida T, Hasegawa T: Results of 271 funnel chest operations. Ann ‘l’horac Surg 10526, 1970 16. Doty DB, Hawkins JA: A turnover operation for pectus excavatum at the time of correction of intracardiac defects. J Thorac Cardiovasc Surg 86:787, 1983 17. Nissen R Osteoplastic procedure for correction of funnel chest. Am J Surg 64:169, 1944 18. Judet J, Judet R Sternum en entonnoir par resection et retournement. Mem Acad Chir (Paris) 82250, 1956 19. Wada J: Surgical correction of the funnel chest, “sternoturnover.” West J Surg Obstet Gynecol 69:358, 1961 20. Pouliguen JC, Benew J, Pasteyer J, Rigault P: Le retournement du plastron stemo-costad dans le traitement chirurgical du thorax en entonnoir. Ann Chir Infant 14:245,1973 21. Taguchi K, Mochizuki T, Nakagaki M, Kato K: A new plastic operation for pectus excavatum: sternal turnover surgical procedure with preserved internal mammary vessels. Chest 67606, 1975 22. Jung A: La traitement du thoiw en entonnoir par le “retournement pediacule” de la curvette sterno-chondrale. Mem Acad Chir (Paris) 82242, 1956 23. Scheer R ijber eine neue Method der Chirurgischen Behandlung der Trichterbrust die ”gestielte Umwendungsplastik.” Chirurg 28:312, 1957
Discussion (Charlotte, NC): I congratulate Dr. Hawkins and his colleagues on their wry nice paper and results. I am against turnover operations, not because they are bad operations or create bad results but because I think they are too much. I further postulate that the sternum will probably act in these operations as a free graft even with a preserved blood supply. The authors found two pedicles obstructed in their patients, and in the absence of angiographic proof I strongly suspect that later on they will find more. The sternal eversion technique presents a liability because the mammary graft procurement makes the operation a much larger procedure. It also leaves a large hunk of muscle and cartilage attached to the graft; therefore, the danger of tissue necrosis is higher. Even if the attached cartilages are shaved off, DR. FRANCIS ROBICSEK
there is a danger of cartilage overgrowth. Thus, it is even possible that you start off with a patient who has pectus excavatum and in a few years end up with a patient with pectus carinatum. That reminds me of the ill-fated Hungarian saint who performed a miracle by making a deaf person blind. Turnover operations try to correct the anatomical deformity of the sternum, and this is a fallacy. The sternum is not deformed in pectus excavatum; it is the cartilages that are deformed and overgrown. If the overgrown cartilages push the sternum down, an excavatum deformity exists; if they push the sternum up, a carinatum. To blame the poor sternum for the deformity is similar to stating that the head of a giraffe is so high because the neck is so long. The cartilages are the culprit, and if they are removed, you end up with a straight sternum on both sides. You do not have to turn the sternum over; you just have to maintain it in a correct position. We currently use an alternative method. The sternum is mobilized and an osteotomy performed. Then, the sternum is simply rested on a Marlex mesh plate, which is attached to the cartilages. We have used this method in more than 80 patients with good cosmetic results. I wish to call attention to the chest tube. We do not regard pneumothorax as a complication but a necessity. There is no better way to drain the mediastinal or the subcutaneous “pocket” than to connect it widely with the right pleural cavity and drain it through a chest tube. This assures very smooth wound healing. I found this paper very interesting, and I enjoyed learning about the technique used by Dr. Hawkin’s group. However, my views on pectus excavatum repair have not changed. DR. LYMAN A . BREWER, 111 (Loma Linda, CA): Because little cardiopulmonary impairment is found on intensive exercise testing, in most instances repair of pectus excavatum deformity is a cosmetic operation. Potentially dangerous and heroic procedures are therefore not warranted. The common method of repair includes elevation of the sternum, tailoring of the cartilages, and provision of internal support, which prevents recurrence. Because of fear concerning the fate of a large, devitalized piece of bone in the anterior mediastinum, reversal of the sternum is rare in the United States, though common in Japan. The authors’ technique of presenring the internal mammary blood supply and checking with the Doppler probe is ingenious. Dr. Hawkins, how long does this pedide remain patent? When the sternum is twisted, the internal mammary vessels are twisted as well. Can you tell us in what percentage of patients these vessels are patent, and have you used angiography to assess patency? The question of the viability of the pedicle must be answered and the end results in a large series evaluated before this operation replaces the successful techniques in current use. DR. JURO WADA (Tokyo, Japan): I enjoyed the paper presented by Dr.Hawkins. In treating funnel chest deformity, the sternal turnover technique I proposed in 1957 has proved to be an excellent surgical method. Lack of blood supply to the plastron has little to do with the long-term results. I can state this from my 25-year experience in treating more than 1,578 cases of funnel chest deformity (455 at Sapporo from 1957 to 1977 and 1,123 at Tokyo from 1978 to 1983). For patients with flat upper chest or unilateral deep funnel chest, I recommend sternal turnover overlapping. The plastron is sutured anterior to the manubrium, or to the unilateral ribs,
373 Hawkins, Ehrenhaft, and Doty: Repair of Pectus Excavatum by Sternal Eversion
or to both areas. We have had beautiful results with this technique. For patients less than 15 years of age in whom bone and cartilages are soft and malleable, I have exclusively recommended in recent years a much simpler operative method called sternocostal elevation. Deformed or overgrown cartilages are removed, and the sternum and ribs are united by Tevdek sutures. A perfect cosmetic result is obtained. Moire topography is recommended in appreciating or evaluating the results of operation. I wish to ask Dr. Hawkins two questions. First, why have you proposed a new term, sternal eversion, instead of sternal turnover? Second, how can you prove growth of the turned-over sternum? DR. MILTON v. DAVIS (Dallas, TX): Following the lead of Dr. Wada and Dr. Joe Gordon of Albuquerque, who, to my knowledge, started doing this operation before anyone else in the United States, I began performing sternal turnover for pectus excavatum repair more than 15 years ago. I do not have anything like the numbers in Dr. Hawkins's series, but I have done about 30 procedures. It has been a very happy experienceas far as the results go, but they still are not as good as they might be. I am learning as I go along because every one of these patients has a different sternal configuration. It is misleading to suggest that the anatomical defect of all patients with pectus excavatum is alike. In fact, each is very peculiarly different. Like Dr. Wada, I do not try to preserve the vascular pedicle; I do not know that you need to. And like Dr. Brewer, I am interested in whether or not the late patency of the vessels has been demonstrated. My results with this procedure have been good in patients of all ages, but the outcome really depends more on the anatomy than on the technique. Some anatomical conditions in this defect are very difficult. They are nearly all asymmetrical; it is just a matter of degree. I agree with Dr. Robicsek and many others that the basic deformity is an overgrowth of the cartilages. I probably have achieved my best results in younger patients because the sternum tends to be a little softer. At times, I put a grooved Steinmann pin in the sternal bone marrow and leave it in as permanent internal fixation to obtain a very nice proximal anterior curve to the sternum. I do want to raise a point that I think is important, and in so doing I find myself in respectful disagreement with the other discussants and maybe with just about everybody who has reported on this subject. I think it is a very serious mistake to look
on pectus excavatum as purely a cosmetic deformity. Those of us who have operated on patients with this conditionespecially those of us who have taken the sternum out and looked at this exceptional exposure in a live patient-have seen how the posterior wall of the sternum presses on the anterior surface of the heart. Without any question, this interferes with cardiac filling and cardiac output. When you examine these children when they are young, you find that their exercise tolerance is not all that different from other kids. But when you examine them before and after repair, their exercise tolerance in comparison with preoperative values is notably improved. DR. HAWKINS:I thank all of
the discussants for their remarks. In response to Dr. Robicsek's comment that sternal eversion or sternal turnover is too much of an operation, I think the classic Ravitch repair in which the cartilages are resected and the sternum is elevated is just as involved a procedure as sternal eversion. If this type of repair is done according to the way Ravitch described it, the sternum is completely devascularized, and often during the dissection the internal mammary vessels can be damaged. So the Ravitch technique and its variations completely devascularize the sternal segment. We have not seen the development of a pectus carinatum defect in any of our patients. It is true that the sternum is sometimes too prominent after it is turned over, but this is taken care of by tailoring the costal cartilages and shaving the anterior sternum with a scalpel. We cannot really answer Dr. Brewer's question about late patency of the internal mammary vessel because we have not specifically examined this. In 24 of our 26 patients, however, we were able to document with intraoperative Doppler ultrasound that the internal mammary artery was patent. Often it is necessary to extensively free the vascular bundle proximally and distally to ensure there is no torsion or kinking of the vessels. This dissection is guided by Doppler probe to document patency. Angiography to document patency of the internal mammary artery has not been done. To answer Dr. Wada's questions, it is very difficult for me to argue with a series of 1,500 patients. I realize that he does not preserve the internal mammary vessels and still has achieved excellent results, so it is difficult to disagree with his comments. We have had no problems with the growth of the anterior sternum, as illustrated by our late results. We believe that the preservation of the vascular supply will help maintain the potential for growth of the anterior chest wall, but there is no way to determine if this is absolutely necessary.
The history of operative repair of pectus excavatum extends over a period of nearly 60 years. Principles of surgical correction established by Ochsner and DeBakey [l] and developed by Lester [2] and Ravitch [3] include subperichondrial resection of involved costal cartilages, transverse sternal osteotomy, and elevation of the depressed sternal segment. Modifications of these basic techniques have been designed to maintain the corrected position of the sternum through the use of metal struts or pins [4, 51, prosthetic material [6], or autologous tissue [7-lo]. These methods for repair of pectus excavatum have yielded satisfactory early results and remain popular, even though there is a tendency for the appearance of the chest wall to deteriorate with time [ll-131.
From the Division of Thoracic and Cardiovascular Surgery, Department of Surgery, the University of Iowa Hospitids and Clinics, Iowa City, IA. Presented at the Twentieth Annual Meeting of The Society of Thoracic Surgeons, San Antonio, TX, Jan 23-25, 1!384. Address reprint requests to Dr. Ehrehift, Division of Thoracic and Cardiovascular Surgery, The University of Iowa Hospitals and Clinics, Iowa City, IA 52242.
368
The sternal eversion or turnover technique for repair of pectus excavatum differs substantially from the more commonly employed techniques. The sternal eversion repair involves transverse division of the sternum, division of costal cartilages, total mobilization of the plastron allowing 180-degree axial rotation of the bone and muscle graft (sternal turnover), and, finally, reattachment of the sternum and costal cartilages by suture. The operation is straightforward and the technique successful in achieving good cosmetic and functional results [14, 151. Experience with the sternal turnover repair, however, has been limited [14, 151. This article reports the results of experience using a modification of the sternal turnover or eversion repair of pectus excavatum in which one internal mammary vascular pedicle is preserved to assure the viability of the sternum and costal cartilages in the everted position. Results of the sternal eversion technique over a 7-year period have been sufficiently encouraging to recommend it as the primary method of repair for nearly all pectus excavatum deformities.
Material and Methods Twenty-six patients had repair of pectus excavatum using a sternal eversion technique at the University of Iowa Hospitals during a 7-year period from July, 1976, through June, 1983. The patients ranged from 22 months to 32 years old (mean, 9 years old); there were 17 male and 9 female patients. The primary indication for surgical correction of pectus excavatum was cosmetic in 24 of the 26 patients. Five of the patients reported having exertional dyspnea. In 2 patients, the primary indication for operation was repair of a cardiac defect requiring cardiopulmonary bypass. One of these patients underwent replacement of the ascending aorta and aortic valve for an ascending aortic aneurysm associated with Marfan’s syndrome, and the other underwent aortic valvotomy for congenital aortic stenosis. One other patient had Marfan’s syndrome, 6 had thoracic scoliosis, and 1 had limb length inequality as an associated defect. The operative technique in all patients was similar to the method described by Wada and colleagues [15] with the modification of preservation of one internal mammary vascular pedicle, which was possible in 24 of the 26 patients. In 2 patients, preservation of the vascular pedicle was not possible and the sternum and attached cartilages were treated as a free graft and simply turned over and sutured into place, exactly as described by Wada and associates. All of the patients were examined by the attending surgeon at return clinic visits. Satisfaction with results of the operation was evaluated by recent (1983) telephone contact with the patients or their parents.
369 Hawkins, Ehrenhaft, and Doty: Repair of Pectus Excavatum by Sternal Eversion
- Transverse sternotomy
Costal cartilages divided
\
Fig 1 . Sternal eversion technique for repair of pectus excavatum. The sternum is divided transversely in the second intercostal space, just above the beginning of the sternal deformity. The costal Cartilages and intercostal muscles (not shown) are divided vertically, just lateral to the beginning of the cartilage deformity.
Operative Technique A midline or submammary incision provides equally satisfactory exposure. The pectoralis muscle attachments to the ribs and costal cartilages are divided to expose the anterior chest wall laterally to the junction of the costal cartilages and osseous ribs. The redus abdominus and diaphragmatic muscle attachments are freed from the xiphoid process and costal margins. The sternum is divided transversely in the second or third intercostal space using an oscillating saw, at a point above the origin of the sternal deformity. The costal cartilages and intercostal muscles are transected vertically, lateral to the internal mammary vessel at the point the cartilage deformity begins, usually near the junction of the osseous and cartilaginous ribs (Fig 1).The sternum and costal cartilages are separated from the pericardium and anterior mediastinal tissues beginning inferiorly at the xiphoid and costal margins. The dissection proceeds superiorly; the sternal graft is elevated while both internal mammary vascular pedicles are preserved (Fig 2). One of the internal mammary vascular pedicles is chosen (usually the right) and mobilized proximally to its origin from the subclavian vessels. Substantial pleura and chest wall tissue is left surrounding the vessels to strengthen the vascular pedicle and to prevent kinking. The internal mammary vessels on the opposite side are ligated and divided, or mobilized if the primary vascular pedicle has been damaged. The sternum and attached cartilages are everted by turning the graft 180 degrees axially with the graft based on one internal mammary vessel. A path for the vascular pedicle is created between the two most proximal ipsilatera1 costal cartilages after removal of all intercostal muscle in the interspace. Usually the vascular pedicle must
Convexity now anterior
Fig 2 . Elevation of the sternal graft in sternal eversion repair of pectus excavatum. The internal mammary vessels are preserved as the sternum and attached costal cartilages are separated from mediastinal tissues. The sternal graft is based on one internal mammary pedicle and rotated 180 degrees axially so that the convexity is anterior.
be further mobilized distally off the sternum to relieve tension on the vessel that could compromise patency and to allow the vascular pedicle to tuck into the interspace channel created between the two most proximal cartilages. Patency of the preserved internal mammary artery in its new position is confirmed by Doppler ultrasound velocity probe. Costal margin flaring, which is usually present in varying degrees of severity, is corrected by placing a No. 3 or 5 wire suture through the perichondrium of the costal margin at the point of maximal anterior deformity on both sides. This is ordinarily at the anterior axillary line. The suture is tightened until the costal flaring is minimized. An anteriorly beveled osteotomy on the proximal sternum is usually necessary to ensure proper position of the graft sternal segment when the ends of the sternum are approximated. The sternum is then joined using two or three loops of No. 4 or 5 stainless steel wire. The wire loops are not tied at this point to allow continued mobility of the graft while maintaining position of the sternal ends. The costal cartilages on the graft are shortened with a scalpel at correct length and angles to precisely approximate the ends of the costal cartilages and ensure proper position and contour of the new anterior chest wall (Fig 3). The costal cartilages are reattached to lateral ribs using figure-of-eight No. 1wire to achieve a stable chest wall. Some shaping of the new anterior surface of the sternum and costal cartilages is usually necessary to achieve symmetry and the best cosmetic result. A scalpel is used
370 The Annals of Thoracic Surgery Vol 38 No 4 October 1984
,,-Internal Mammary Vascular Bundle
-Sternal fixation
,/‘
v\ Costal cartilages fixated
Excess cartilage resected
Fig 3 . Reapproximation of the sternal graft in sternal eversion repair of pectus excavatum. After the sternum has been repaired with wire, the costal cartilages are trimmed. This allows precise reapproximation of the costal cartilages to the ribs laterally and helps in correcting asymmetrical deformities.
to shave thin layers of cartilage or bone off protruding areas until an acceptable contour is obtained (Fig 4). The rectus abdominus muscles and fascia are reattached to the costal margin using interrupted size 0 polyglycolic acid suture. The pectoralis major muscles are reattached to the sternum in the midline sternum using interrupted 3-0 polyglycolic acid suture. The subcutaneous tissues are closed, and the skin is reapproximatedby subcuticular suture. No drains are left in the subcutaneous space; the mediastinum is allowed to drain to a thoracostomy tube, which is placed in the appropriate hemithorax if the pleura has been entered during sternal mobilization.
Results All patients survived the operation and were discharged from the hospital within six days, except for the 2 patients who underwent open-heart procedures [16]; these 2 patients were discharged at nine and twenty days postoperatively. The chest wall was stable in all patients, and none required ventilation beyond the anesthetic period except for those with combined cardiac procedures. Operative morbidity was minimal, with easily correctable complications occurring in 5 patients. The most common complication was superficial fluid collection, which occurred in 2 patients and was treated simply by opening a small portion of the incision. One patient had a wound infection (Staphylococcusepidermidis), that progressed to distal sternal necros,isand required reoperation. A pneumothorax occurriqg in 1patient was treated with tube thoracostomy. One patient had necrosis of a portion of a skin flap that healed by secondary wound closure.
I
K9
‘=,Reshape sternal contour
b;\
Fig 4 . Final shaping of the sternal graft in sternal eversion repair of pectus excavatum. The costal cartilages have been sutured to the lateral ribs using wire. The internal mammary vessels can now be seen coursing on the anterior surface of the turned-over sternum through the interspace channel to their origin from the subclavian vessels. A scalpel is used to shave thin layers of cartilage and bone to achieve a symmetrical contour of the anterior chest wall.
Follow-up ranged from 2 to 76 months (mean, 32 months). A good result was defined as a satisfactory appearance of the healed incision, correction of any costal flaring, and no recurrence of deformity. A good result was obtained in 21 of the 26 patients (81%).One of the patients included in the group with a good result did require removal of a bothersome sternal wire, which in no way affected the cosmetic or functional outcome of the repair. The operative result was classified as fair in 4 of the 26 patients. In both of the patients with Marfan’s syndrome, the operative result was less than desirable because of partial recurrence of the pectus excavatum deformity. The recurrence was not sufficient to require reoperation in either patient. Another patient had a fair result because of formation of marked hypertrophic scar, but the sternal contour is excellent and there is no residual costal flaring. The patient with partial necrosis of a skin flap also had a fair result because of hypertrophic scarring after secondary wound closure was complete. The patient with a wound infection was classified as having a poor result because of necrosis of a portion of the distal sternum. This required reoperation 1 year postoperatively with repair of the sternal defect using Marlex mesh.
Comment The most common current technique for repair of pectus excavatum is the method described by Ravitch [3]. The basic principles of the operation include subperichondrial resection of abnormal costal cartilages; freeing of the sternum from intercostal, pericardial, and mediastinal attachments; and elevation of the depressed sternal segment. A large number of modifications and additions to this basic procedure have been made over the years. Most of these technical modifications were designed to
371 Hawkins, Ehrenhaft, and Doty: Repair of Pectus Excavatum by Sternal Eversion
maintain the correct position of the sternum after elevation of the depressed sternum. This has been accomplished by using metal struts [4], Kirschner wires [5], autologous rib struts [7], Marlex mesh [6], tripod fiiation [9], and autologous perichondrium [lo]. The outcome using these techniques has generally been good, with 80 to 90% of patients having acceptable early results. Since most of these operations are performed during early childhood for cosmetic indications, long-term evaluation of results into adult life is especially important. Reports of follow-up of at least 20 years after repair of pectus excavatum using the Ravitch technique or variations on it are few, even though good operations have been available for nearly 40 years. The few reports that analyze results 20 years after repair suggest that there is deterioration in the appearance of the chest wall with time [ll-131. A satisfactory result was obtained in 31 to 54% of patients who were followed for at least 20 years after undergoing a Ravitch procedure [lo] or a modified repair [HI. While we did not tabulate our results with a standard repair of pectus excavatum, our clinical impression suggested that some results were less than satisfactory with the passing of time, thus prompting a trial of a different technique. The sternal eversion or turnover technique for repair of pectus excavatum differs substantially from the commonly employed techniques. Nissen [17] was among the first to report the use of sternal turnover in 1944. He described detaching the sternum and costal cartilages, turning the plastron over, and resuturing it to the anterior chest wall after rotating it 90 degrees. In 1956, Judet and Judet [18] reported their method, which has been popularized by Wada [19]. This technique involves transecting the sternum and costal cartilages, excising the sternum and attached cartilages from the chest wall, turning the sternum over as a free graft, and resuturing the sternum and costal cartilages. Satisfactory results using this technique of sternal turnover were obtained in 97% of the 199 patients in the 15-year experience of Wada’s group [15]. Similar results have been obtained in smaller series [14, 201. Despite the excellent results and the appeal of such a direct method of repair, experience with sternal turnover has been limited. Considerable concern has been expressed regarding potential for chest wall growth and for infection after reimplantation of the large devascularized sternal graft. These problems apparently were not observed in the younger patients in the series of Wada’s group [15]. However, patients more than 15 years old who underwent sternal turnover had a 46% incidence of complications attributable to devascularization of the sternum. The most serious complications included necrosis of bone and muscle and formation of fistula [21]. In 1956, Jung [22] reported a sternal turnover procedure with preservation of the blood supply. He described a sternal turnover that left the rectus abdominus muscles attached. Adequacy of this technique was documented by Scheer [23], who found normal histological
status of the bone after the Jung turnover procedure. Taguchi and associates [21] reported a sternal turnover procedure that maintained vascular supply using a technique of preservation of both internal mammary arteries. This technique seemed very attractive, and we reasoned that it could be simplified by preservation of only a single vascular pedicle to the sternal graft. Concern about vascular integrity of the sternum must also be expressed for the more standard techniques based on perichondrial resection of cartilage and elevation of the sternum [3-lo]. These techniques involve extensive mobilization of the sternum from surrounding tissues and blood supply, essentially converting it to a free bone graft. Infection has not been a major problem, but deterioration of the cosmetic appearance of the anterior chest wall with time suggests that interference with the blood supply to the sternum could have affected growth of the sternum. Techniques involving the use of prosthetic materials [6] could seriously affect growth of the anterior chest wall in the area of the prosthetic implant. The sternal eversion technique has several attractive features when compared to other, more commonly used methods. Sternal eversion directly addresses the deformity of the depressed sternum by utilizing the shape of the sternum to create an anterior contour of the chest wall. Cosmetic results are predictable. Contrary to the opinions of other authors (12, 131, we have found that asymmetrical deformities can be treated with the sternal eversion technique by using judicious tailoring of the costal cartilages and shaping of the anterior sternum. Chest wall stability is impressively maintained during the postoperative period, obviating the need for assisted ventilation. Since no prosthetic material is used and blood supply to the sternum is preserved, future growth should proceed normally. By avoiding the use of metal struts or pins, a second operation for removal is avoided. In sum, the technique we have described to repair pectus excavatum utilizing sternal eversion with preservation of vascular supply has yielded good cosmetic results with a low incidence of serious complications. Preservation of vascular supply to the sternum should provide excellent long-term results with continued maintenance of normal growth potential of the anterior chest wall. We recommend this procedure as the primary technique for repair of pectus excavatum.
References 1. Ochsner A, DeBakey M Chone-chondrosternon:report of a case and review of the literature. J Thorac Surg 8469,1939 2. Lester CW The surgical treatment of funnel chest. Ann Surg 123:1003,1946 3. Ravitch MM: The operative treatment of pectus excavatum. Ann Surg 129:429, 1949 4. Adkins PC,Blades B A stainless steel strut for correction of pectus excavatum. Surg Gynecol Obstet 113:111, 1961 5. Griffin EH, Minnis JF:Pectus excavatum: a survey and a suggestion of maintenance and correction. J Thorac Cardiovasc Surg 33:625, 1957
372 The Annals of Thoracic Surgery Vol 38 No 4 October 1984
6. Robicsek F: Marlex mesh support for the correction of very severe and recurrent pectus excavatum. Ann Thorac Surg 26:80, 1978 7. Dailey JE: Repair of funnel chest using substernal 0steoperiosteal rib graft strut: report of a case with four year follow-up. JAMA 150:1203, 1952 8. Sanger PW, Robicsek F, Taylor FH: Surgical management of anterior chest deformities: a new technique and report of 153 operations without a death. Surgery 48:510, 1969 9. Haller JA Jr, Shermeta DW, Tepas JJ, et a1 Correction of pectus excavatum without prostheses or splints: objective measurement of severity and management of asymmetrical deformities. Ann Thorac Surg 26:73, 1978 10. Holcomb GW Jr: Surgical correction of pectus excavatum. J Pediatr Surg 12295, 1977 11. Humphreys GH, Jaretzki A: Pectus excavatum: late results with and without operation. J Thorac Cardiovasc Surg 80:686, 1980 12. Howard R Funnel chest: results and description of an improved operative technique. Med J Aust 2134, 1978 13. Moghiss K Long-term results iin surgical correction of pectus excavatum and sternal prominence. Thorax 19:350,1964 14. Davis MV, Shah HH: Sternal turnover operation for pectus excavatum. Ann Thorac Surg l7268, 1974 15. Wada J, Ikeda K, Ishida T, Hasegawa T: Results of 271 funnel chest operations. Ann ‘l’horac Surg 10526, 1970 16. Doty DB, Hawkins JA: A turnover operation for pectus excavatum at the time of correction of intracardiac defects. J Thorac Cardiovasc Surg 86:787, 1983 17. Nissen R Osteoplastic procedure for correction of funnel chest. Am J Surg 64:169, 1944 18. Judet J, Judet R Sternum en entonnoir par resection et retournement. Mem Acad Chir (Paris) 82250, 1956 19. Wada J: Surgical correction of the funnel chest, “sternoturnover.” West J Surg Obstet Gynecol 69:358, 1961 20. Pouliguen JC, Benew J, Pasteyer J, Rigault P: Le retournement du plastron stemo-costad dans le traitement chirurgical du thorax en entonnoir. Ann Chir Infant 14:245,1973 21. Taguchi K, Mochizuki T, Nakagaki M, Kato K: A new plastic operation for pectus excavatum: sternal turnover surgical procedure with preserved internal mammary vessels. Chest 67606, 1975 22. Jung A: La traitement du thoiw en entonnoir par le “retournement pediacule” de la curvette sterno-chondrale. Mem Acad Chir (Paris) 82242, 1956 23. Scheer R ijber eine neue Method der Chirurgischen Behandlung der Trichterbrust die ”gestielte Umwendungsplastik.” Chirurg 28:312, 1957
Discussion (Charlotte, NC): I congratulate Dr. Hawkins and his colleagues on their wry nice paper and results. I am against turnover operations, not because they are bad operations or create bad results but because I think they are too much. I further postulate that the sternum will probably act in these operations as a free graft even with a preserved blood supply. The authors found two pedicles obstructed in their patients, and in the absence of angiographic proof I strongly suspect that later on they will find more. The sternal eversion technique presents a liability because the mammary graft procurement makes the operation a much larger procedure. It also leaves a large hunk of muscle and cartilage attached to the graft; therefore, the danger of tissue necrosis is higher. Even if the attached cartilages are shaved off, DR. FRANCIS ROBICSEK
there is a danger of cartilage overgrowth. Thus, it is even possible that you start off with a patient who has pectus excavatum and in a few years end up with a patient with pectus carinatum. That reminds me of the ill-fated Hungarian saint who performed a miracle by making a deaf person blind. Turnover operations try to correct the anatomical deformity of the sternum, and this is a fallacy. The sternum is not deformed in pectus excavatum; it is the cartilages that are deformed and overgrown. If the overgrown cartilages push the sternum down, an excavatum deformity exists; if they push the sternum up, a carinatum. To blame the poor sternum for the deformity is similar to stating that the head of a giraffe is so high because the neck is so long. The cartilages are the culprit, and if they are removed, you end up with a straight sternum on both sides. You do not have to turn the sternum over; you just have to maintain it in a correct position. We currently use an alternative method. The sternum is mobilized and an osteotomy performed. Then, the sternum is simply rested on a Marlex mesh plate, which is attached to the cartilages. We have used this method in more than 80 patients with good cosmetic results. I wish to call attention to the chest tube. We do not regard pneumothorax as a complication but a necessity. There is no better way to drain the mediastinal or the subcutaneous “pocket” than to connect it widely with the right pleural cavity and drain it through a chest tube. This assures very smooth wound healing. I found this paper very interesting, and I enjoyed learning about the technique used by Dr. Hawkin’s group. However, my views on pectus excavatum repair have not changed. DR. LYMAN A . BREWER, 111 (Loma Linda, CA): Because little cardiopulmonary impairment is found on intensive exercise testing, in most instances repair of pectus excavatum deformity is a cosmetic operation. Potentially dangerous and heroic procedures are therefore not warranted. The common method of repair includes elevation of the sternum, tailoring of the cartilages, and provision of internal support, which prevents recurrence. Because of fear concerning the fate of a large, devitalized piece of bone in the anterior mediastinum, reversal of the sternum is rare in the United States, though common in Japan. The authors’ technique of presenring the internal mammary blood supply and checking with the Doppler probe is ingenious. Dr. Hawkins, how long does this pedide remain patent? When the sternum is twisted, the internal mammary vessels are twisted as well. Can you tell us in what percentage of patients these vessels are patent, and have you used angiography to assess patency? The question of the viability of the pedicle must be answered and the end results in a large series evaluated before this operation replaces the successful techniques in current use. DR. JURO WADA (Tokyo, Japan): I enjoyed the paper presented by Dr.Hawkins. In treating funnel chest deformity, the sternal turnover technique I proposed in 1957 has proved to be an excellent surgical method. Lack of blood supply to the plastron has little to do with the long-term results. I can state this from my 25-year experience in treating more than 1,578 cases of funnel chest deformity (455 at Sapporo from 1957 to 1977 and 1,123 at Tokyo from 1978 to 1983). For patients with flat upper chest or unilateral deep funnel chest, I recommend sternal turnover overlapping. The plastron is sutured anterior to the manubrium, or to the unilateral ribs,
373 Hawkins, Ehrenhaft, and Doty: Repair of Pectus Excavatum by Sternal Eversion
or to both areas. We have had beautiful results with this technique. For patients less than 15 years of age in whom bone and cartilages are soft and malleable, I have exclusively recommended in recent years a much simpler operative method called sternocostal elevation. Deformed or overgrown cartilages are removed, and the sternum and ribs are united by Tevdek sutures. A perfect cosmetic result is obtained. Moire topography is recommended in appreciating or evaluating the results of operation. I wish to ask Dr. Hawkins two questions. First, why have you proposed a new term, sternal eversion, instead of sternal turnover? Second, how can you prove growth of the turned-over sternum? DR. MILTON v. DAVIS (Dallas, TX): Following the lead of Dr. Wada and Dr. Joe Gordon of Albuquerque, who, to my knowledge, started doing this operation before anyone else in the United States, I began performing sternal turnover for pectus excavatum repair more than 15 years ago. I do not have anything like the numbers in Dr. Hawkins's series, but I have done about 30 procedures. It has been a very happy experienceas far as the results go, but they still are not as good as they might be. I am learning as I go along because every one of these patients has a different sternal configuration. It is misleading to suggest that the anatomical defect of all patients with pectus excavatum is alike. In fact, each is very peculiarly different. Like Dr. Wada, I do not try to preserve the vascular pedicle; I do not know that you need to. And like Dr. Brewer, I am interested in whether or not the late patency of the vessels has been demonstrated. My results with this procedure have been good in patients of all ages, but the outcome really depends more on the anatomy than on the technique. Some anatomical conditions in this defect are very difficult. They are nearly all asymmetrical; it is just a matter of degree. I agree with Dr. Robicsek and many others that the basic deformity is an overgrowth of the cartilages. I probably have achieved my best results in younger patients because the sternum tends to be a little softer. At times, I put a grooved Steinmann pin in the sternal bone marrow and leave it in as permanent internal fixation to obtain a very nice proximal anterior curve to the sternum. I do want to raise a point that I think is important, and in so doing I find myself in respectful disagreement with the other discussants and maybe with just about everybody who has reported on this subject. I think it is a very serious mistake to look
on pectus excavatum as purely a cosmetic deformity. Those of us who have operated on patients with this conditionespecially those of us who have taken the sternum out and looked at this exceptional exposure in a live patient-have seen how the posterior wall of the sternum presses on the anterior surface of the heart. Without any question, this interferes with cardiac filling and cardiac output. When you examine these children when they are young, you find that their exercise tolerance is not all that different from other kids. But when you examine them before and after repair, their exercise tolerance in comparison with preoperative values is notably improved. DR. HAWKINS:I thank all of
the discussants for their remarks. In response to Dr. Robicsek's comment that sternal eversion or sternal turnover is too much of an operation, I think the classic Ravitch repair in which the cartilages are resected and the sternum is elevated is just as involved a procedure as sternal eversion. If this type of repair is done according to the way Ravitch described it, the sternum is completely devascularized, and often during the dissection the internal mammary vessels can be damaged. So the Ravitch technique and its variations completely devascularize the sternal segment. We have not seen the development of a pectus carinatum defect in any of our patients. It is true that the sternum is sometimes too prominent after it is turned over, but this is taken care of by tailoring the costal cartilages and shaving the anterior sternum with a scalpel. We cannot really answer Dr. Brewer's question about late patency of the internal mammary vessel because we have not specifically examined this. In 24 of our 26 patients, however, we were able to document with intraoperative Doppler ultrasound that the internal mammary artery was patent. Often it is necessary to extensively free the vascular bundle proximally and distally to ensure there is no torsion or kinking of the vessels. This dissection is guided by Doppler probe to document patency. Angiography to document patency of the internal mammary artery has not been done. To answer Dr. Wada's questions, it is very difficult for me to argue with a series of 1,500 patients. I realize that he does not preserve the internal mammary vessels and still has achieved excellent results, so it is difficult to disagree with his comments. We have had no problems with the growth of the anterior sternum, as illustrated by our late results. We believe that the preservation of the vascular supply will help maintain the potential for growth of the anterior chest wall, but there is no way to determine if this is absolutely necessary.