Chest Wall Deformities

Chest Wall Deformities

They are generally seen as non-life-threatening deformities. This condition should be investigated because it is accompanied by scoliosis (slippage of the spine) in approximately one quarter. Patients should also be examined for various congenital heart diseases and other diseases.

Pectus Excavatum

It is also known as a shoemaker’s chest or a sunken chest. It is the inward collapse of the rib cage.

It is the most common chest wall deformity, seen in 1 in 300-400 live births. It is not as rare as it is thought. These children have very typical appearances: narrow and thin chest, hooked shoulder, externally rotated ribs and poor posture. A shoemaker’s chest usually appears at birth or in the first years of life, and is noticed by the mother and relatives. Although it rarely regresses, the collapse will most likely worsen in adolescence. It is seen 4 times more frequently in men than in women. Although the cause of the collapse is excessive growth of the cartilage ribs, the etiology is not known for sure. Irregularly growing cartilage ribs push the breastbone backwards. There is an increased familial predisposition. In 37% of cases, there is a family history of chest collapse (a shoemaker’s chest).

This deformity is tolerated in childhood. As age increases, pain may occur in the deformed cartilage rib after exertion and pain in the left breast area. Palpitations and heart rhythm disorders may be observed after exertion. A murmur may be heard in the heart after short exercise. Electrocardiographic changes may occur due to the displacement of the heart. When the deformity in the chest wall is corrected, improvement in lung functions is observed. This improvement is a bit difficult to achieve in delayed corrections (after the age of 40).

The chest wall causes a depression, especially in the anterior wall of the right heart ventricle, with its posterior displacement. With the correction of the depression, the depression in the heart ventricle is also corrected. In the simplest terms, the volume as much as the depression steals space from the heart and lungs. In my personal words, I always warn patients that “this deformity will not cause you problems in youth, but in old age”. Because in old age, there will be more need for the stolen heart and lungs due to the deformity. In addition, posture disorders due to the deformity will lead to pain and movement restriction symptoms in old age.

For respiratory and heart-related problems, the greater the preoperative collapse, the more correction should be expected. Many researchers have linked the symptomatic disorder in pectus excavatum to a decrease in volume in the chest cavity. Even in normal individuals, it is difficult to prove this relationship since there is a wide range between cardiopulmonary function limits. This depends entirely on physical work and body habits.

In addition, even if it does not cause any functional impairment, the patient’s unhappiness with this deformity alone requires correction. This is also accepted in the literature. Because there are quite a few patients who state that they never go swimming without taking off their T-shirts and express their unhappiness with this. Psychiatrists have conducted many studies on this issue since 1960 and have used the term “psychological deformity” for this condition. Because in one study, 82% anxiety, motivational disorder, labeling anxiety, 78% lack of self-confidence and timidity, 72% indecisiveness, and 66% aggression were detected.

Treatment

There are surgical or non-surgical treatment options for chest depression.

There are two most commonly applied surgical methods. We will try to explain the surgery of Nuss (MIRPE- Minimally Invasive Surgery) and Ravitch methods.

In the Ravitch Method, the rib cage is opened from end to end and the deformed cartilage ribs are removed except for the 2nd rib. Then, a wedge-shaped piece is removed from the back of the most sunken part of the breast bone and stitched with wire stitches. The procedure is completed by placing a wire behind the breast bone. Unfortunately, this procedure is not as short as we described, it takes about 3 hours and there is bleeding and 2 drains are placed to drain the blood. The wire is removed after about 10 days. The patient’s hospital stay and the time to return to actual life are long. He/she cannot do sports for at least 6 months. For these reasons, it has lost its popularity today (especially in the last 15 years). However, it can still be used as an option in deformities that cannot be corrected with the minimally invasive method.

Another method has been reported to be raising the bone with a bar behind the sternum. The minimally invasive procedure, now known as the Nuss Procedure, has been developed and perfected over the years. Complications of this minimally invasive procedure are quite rare. The recovery period is on average 4-5 days. Attention is paid to postoperative pain control, respiratory physiotherapy, and patient/parent education. The pectus bar is removed within two to four years after it is placed. The procedure is performed under general anesthesia. When looking at long-term results, the probability of recurrence is less than 5% on average. If the deformity is to be corrected with a single bar, this method is applied with a total of 3 2 cm surgical incisions, 1 on the left and 2 on the right. In addition to all these advantages, although very rare, cases of heart injury have been reported while the bar is being placed and sometimes removed with this method.

The non-surgical treatment method is the application of the vacuum bell. In individuals up to the age of 14-17, when bone development and hardening have not yet occurred, negative pressure is applied to the deformity with the help of the Vacuum Bell on a daily basis and the deformity is corrected within approximately 1 year. It may not be suitable for wide oval type defects or plateau type defects. The correct treatment choice is determined by the physician together with the patient. In addition to the Vacuum Bell treatment, exercises performed with the physiotherapist and nutritional support performed with the dietician provide great benefits in correcting the deformities of the patients more quickly and effectively.

Pectus Carinatum

Deformities where the chest wall is not collapsed inward but protrudes outward are called pectus carinatum deformities. This deformity is much rarer than pectus excavatum. It does not usually cause a decrease in heart or lung functions. The greatest need for treatment is that the patient is unhappy with this appearance.

Treatment

The treatment is surgical, just like in pectus excavatum deformity. Similarly, with the minimally invasive MIRPE method (Abramson Procedure), a steel bar placed under the skin can collapse the chest wall and bring it to its normal position, and with the Ravitch Method, a large incision is made to cut the connection between the sternum bone and the cartilage, and if necessary, the cartilage length can be shortened. The difference between the Abramson procedure and the Nuss procedure applied to patients with pectus excavatum is that the chest cavity is not entered, the bar is sent over the bone. For this reason, serious complications such as heart injury are not observed.

Below are the pre- and post-operative images of a patient who underwent surgery using the Abramson method.

Below, the pre- and postoperative appearance of a pectus carinatum case corrected with the Ravitch Method is shared.

In non-surgical treatment, the use of orthosis is prominent. By applying continuous pressure to the dislocated area with the orthosis, the deformity is corrected with the development of other parts. There are treatment approaches where orthosis treatment is applied for 23 hours, 18 hours, 12 hours or 6 hours per day. The longer the daily approach is chosen, the earlier the results can be obtained. However, this depends on the social life of the patient. In terms of choosing the appropriate orthosis, making it made of the appropriate material, and the need for close monitoring of the patient to prevent possible pectus excavatum while using the orthosis, it would be correct to apply it in centers that are experienced and do this job in large numbers. Patients should be monitored with periodic examinations in terms of how long the treatment will continue and, if necessary, the use should be interrupted from time to time until the bones harden and the repeatability of the treatment should be considered.

Images of a patient who underwent orthosis due to pectus carinatum deformity before, during and after 10 months of treatment

In selecting a suitable patient for orthosis treatment, the chest wall must not have hardened yet. Therefore, it is applied to patients under the age of 17. It should be measured how much pressure the patients’ deformities are corrected with, and surgical methods should be chosen without applying orthosis for patients whose pressure level is above a certain value. In addition, even if the images of patients who come for check-ups with pressure measurement do not show any results yet, when the pressure value required for correction decreases compared to the value measured in the previous examination, it can be determined that the patient is on the right track in his treatment, and visual results can be obtained if the treatment is continued. This prevents unnecessary abandonment of the treatment.

Correction pressure measurement in a case with pectus carinatum deformity

Poland Syndrome

It is quite rare compared to pectus excavatum and carinatum deformities. In those with this syndrome:

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Small or absent breast tissue or head

• Underdevelopment or absence of chest wall muscles on the affected side

• Underdevelopment of subcutaneous fat tissue

• Absence of axillary hair on the affected side

• Thoracic deformity due to absence or underdevelopment of ribs

• Short arm or forearm on the affected side, shortened fingers (brachydactyly) and fusion of fingers (syndactyly)

One or more of the symptoms and signs may be observed.

Appearance of absence of chest muscle in a case with Poland Syndrome

For Poland Syndrome treatment, see for details.

Sternal Cleft

The sternum bone (the board of faith) is formed by the union of two leaves in the middle. If this union does not occur due to a developmental disorder in the embryonic period, a sternal cleft is observed. The sternum may be completely cleft or partial depending on the point at which the fusion ends.

Rib Flare

The ribs are protruding. In this type of deformity, the patient is quite complaining about the appearance. In the past, rib removal surgery was performed in all cases. Today, in addition to surgery, bandage treatment is also applied in the treatment of these deformities. In addition, with the Ribella Procedure, which is a painless, sutureless and incision-free method developed and patented by Dr. Hasan Ersöz, patients can get rid of Rib Flare deformity in a short time with a very simple procedure. For details, you can visit our DR CURVER website, which belongs to our Dr. Curver