Reconstruction of pectus excavatum with silicone implants

An Open, Prospective Study to Evaluate the Effectiveness and Safety of Hyaluronic Acid for Pectus Excavatum Treatment

Background

Pectus excavatum (PE) is sometimes associated with psychological and physiological difficulties influencing a patient’s quality of life. Treatment with a hyaluronic acid (HA)-based gel may benefit patients and be an alternative to other more invasive treatments.

Objectives

The authors sought to evaluate the effectiveness in terms of satisfaction, duration, and safety of HA gel treatment for PE including impact on quality of life.

Methods

Males ≥18 years having PE without functional problems received HA gel injections (50 – 150 mL) at the site of deformity and in some cases at the medial pectoralis muscle borders to optimize the aesthetic result. Follow-up visits were performed after 1, 3, 6, 12, and 24 months with optional retreatment at the 24-month visit including a 1-month follow-up. Evaluations included Pectus Excavatum Evaluation Questionnaire, patient satisfaction, magnetic resonance imaging, and safety assessments.

Results

The treatment significantly improved patients’ self-esteem (P < 0.001) and psychosocial function (P ≤ 0.038) throughout the study, as assessed by Pectus Excavatum Evaluation Questionnaire. Patients were satisfied with the aesthetic outcome and considered the treatment mild in terms of level of pain during injection. Treatment effects were maintained up to 24 months and 58% of the HA gel remained at this visit, shown by Magnetic Resonance Imaging measurements. The treatment was well tolerated.

Conclusions

Treatment of PE with HA gel improved patient quality of life related to self-esteem and psychosocial functioning including aesthetically pleasing results. The treatment may also offer benefits in terms of safety and tolerability compared with other treatments.

Level of Evidence: 4

[Contribution of computer-aided design for the conception of custom-made implants in Pectus Excavatum surgical treatment. Experience of the Nantes plastic surgery unit]

INTRODUCTION

Pectus excavatum is the most common congenital chest malformation and is a common reason for consultation in plastic surgery. Our attitude is most often a filling of the depression with a custom-made silicone prosthesis. The objective of this work was to evaluate the interest of computer-aided design (CAD) of implants compared to the conventional plaster molds method.

PATIENTS AND METHODS

We have collected all the cases of custom-made silicone implants to treat funnel chests in our plastic surgery department. The quality of the results was evaluated by the patient, and in a blind manner by the surgical team using photographs and standardized surveys. The pre-operative delays, the operating time and length of hospital stays, the number of surgical recoveries, and the post-operative surgical outcomes were recorded.

RESULTS

Between 1990 and 2016, we designed 29 silicone thoracic implants in our department. Before 2012, implants were made from plaster chest molds (n=13). After this date, implants were designed by CAD (n=16). Patients rated their results as "good" or "excellent" in 77% and 86% of cases respectively in the plaster and CAD groups. The surgical team's ratings for CAD implant reconstructions were better than in the plaster group: 8.17 versus 6.96 (P=0.001). CAD implants were significantly less detectable than the plaster group implants. The operating time was reduced in the CAO group: 60.2 compared to 74.7minutes in the plaster group (P=0.04), as was the length of hospitalization: 3.5 versus 5.3 days (P=0.01). There were no significant differences between the two groups in terms of post-operative complications.

CONCLUSION

The management of pectus excavatum by a custom-made silicone implant is a minimally invasive method that provides good cosmetic results. The design of these implants is facilitated and qualitatively improved by CAD.

Periareolar Access for Pectus Excavatum Correction with Silicone Implants: A New Method to Minimize Postoperative Scars-Review of the Literature, Considerations and Statistical Analysis of Clinical Outcomes

BACKGROUND

Pectus excavatum (PE) is one of the most frequent thoracic malformations. Generally, the malformation is not associated with functional disorders and often constitutes an aesthetic alteration with significant psychological distress.

OBJECTIVES

To reduce the visibility of the residual scarring produced by corrective surgery and to improve the aesthetic outcome, the authors propose a new prosthetic implant technique through a periareolar access.

METHODS

From January 2005 to January 2015, 11 patients affected with PE underwent the surgical procedure with a sternal prosthesis implanted through a periareolar access with the help of a fiberscope. The preoperative evaluation of the perception of the malformation and postoperation results were made using different questionnaires. The data collected in our series were compared with that reported in 4 different papers where other forms of access were used: sternal, inframammary and transumbilical.

RESULTS

No major complications or dislocation of the implants were reported. Among the complications, 6 postoperative seromas were reported. The patients' perception of improvement through the use of 2 questionnaires and an evaluation scale showed substantial improvement in all the aesthetic outcomes.

CONCLUSIONS

The periareolar technique provides excellent cosmetic results compared to the sternal one. This access causes fewer complications and necessitates a shorter average hospital stay than the sternum access. To conclude, according to what is shown in the literature, periareolar access seems to be a quicker procedure, requiring a shorter stay in hospital, and results in scars that can more easily be hidden and are more accepted by patients.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Male Pectoral Implants: Radiographic Appearance of Complications

There has been a significant surge in aesthetic chest surgery for men in the last several years. Male chest enhancement is performed with surgical placement of a solid silicone pectoral implant. In the past, male chest correction and implantation were limited to the treatment of men who had congenital absence or atrophy of the pectoralis muscle and pectus excavatum deformity. But today, the popularization of increased chest and pectoral size fostered by body builders has more men desiring chest correction with implantation for non-medical reasons. We present a case of a 44-year-old, male with a displaced left pectoral implant with near extrusion and with an associated peri-implant soft tissue mass and fluid collection. While the imaging of these patients is uncommon, our case study presents the radiographic findings of male chest enhancement with associated complications.

Challenging Breast Augmentations: The Influence of Preoperative Anatomical Features on the Final Result

BACKGROUND

Achieving satisfactory results may be difficult in augmentation mammaplasty patients in the presence of breast, chest wall, or vertebral deformities. These deformities have not been classified previously, and the impact of each deformity or combination of deformities has not been defined.

OBJECTIVES

The aims of this study are to determine the complicating factors in augmentation mammaplasty, to classify these factors according to their influence on surgical outcome, and to develop an identification system for simplifying the recognition of challenging cases.

METHODS

We retrospectively analyzed photographs and records of 100 consecutive patients who underwent augmentation mammaplasty. We observed suboptimal results in 18 cases. Preoperative deformities of the breast, chest wall, and vertebra were recorded in order to determine which factor or factors had complicated the surgeries. Eventually, the relationship between suboptimal surgical results and complicating factors was evaluated.

RESULTS

We observed that some deformities alone caused suboptimal results, whereas others did not. Deformities that caused suboptimal results alone were called major complicating factors, and any others were called minor complicating factors. We observed that suboptimal results were also obtained in patients who had four minor complicating factors. Patients who had suboptimal results because of major or minor complicating factors were considered challenging cases.

CONCLUSIONS

In this study, complicating factors for augmentation mammaplasty were defined and classified as major or minor depending on their effect on the surgical outcome. We suggest an identification system that simplifies the recognition of challenging cases in breast augmentation.

Pectus excavatum with delayed diagnosis of implant tear on MRI apparently causing recurrent postoperative seromas: A case report

Seroma formation is the most common early postoperative complication after pectus excavatum repair, but later seromas are rare. While many seromas eventually resorb or decrease in size after aspiration, our case demonstrates recurrent seroma formation as a late complication of pectus excavatum repair in a patient with an implant tear. Postoperative seromas can result in prolonged chest wall pain, large chest wall masses, and increased mass effect on the heart with potential risk for resultant right ventricular outflow obstruction. This case report illustrates a solid silicone implant tear. Though rare, early recognition may help to decrease the likelihood of recurrent postoperative seromas.

Customized silicone implant for the correction of acquired and congenital chest wall deformities: A valuable option with pectus excavatum

BACKGROUND

Surgical remodeling and correction of congenital and acquired chest wall deformities (CWD) is undertaken many times for cosmesis. Although reportedly minimally invasive, commonly used Nuss procedure for correction of pectus excavatum (PE) is not without complications. Nuss procedure is also not suitable for complex deformities and Poland syndrome cases. Insertion of custom-made silicone implants for the reconstruction of defects has been adopted from adult plastic reconstructive surgery as primary repair of CWD or rescue procedure for recurrence of PE after recurrence or residual deformity.

METHODS

We present our experience with CWD reconstruction in children with customized silicone prosthesis made from a surgically implantable liquid silicone rubber (NuSil MED-4805, Ca).

RESULTS

Since 2006 we treated 26 patients with CWD: six were children (age <17years, median 14.6) with PE. Implants were custom made for each patient's chest. The implants were inserted under general anesthesia. Postoperatively all patients were fully satisfied with the cosmetic result and subjective patient satisfaction remained excellent at follow-up in all the children. Only one child developed postoperative complications (seroma).

CONCLUSIONS

Customized silicone implant for PE in the pediatric age is an alternative therapeutic method, as primary or rescue treatment, with equally good cosmetic outcome, fewer significant complications, less postoperative pain and a faster recovery.

Systematic review of surgical treatment techniques for adult and pediatric patients with pectus excavatum

This compares outcome measures of current pectus excavatum (PEx) treatments, namely the Nuss and Ravitch procedures, in pediatric and adult patients. Original investigations that stratified PEx patients based on current treatment and age (pediatric=0-21; adult 17-99) were considered for inclusion. Outcome measures were: operation duration, analgesia duration, blood loss, length of stay (LOS), outcome ratings, complications, and percentage requiring reoperations. Adult implant patients (18.8%) had higher reoperation rates than adult Nuss or Ravitch patients (5.3% and 3.3% respectively). Adult Nuss patients had longer LOS (7.3 days), more strut/bar displacement (6.1%), and more epidural analgesia (3 days) than adult Ravitch patients (2.9 days, 0%, 0 days). Excluding pectus bar and strut displacements, pediatric and adult Nuss patients tended to have higher complication rates (pediatric - 38%; adult - 21%) compared to pediatric and adult Ravitch patients (12.5%; 8%). Pediatric Ravitch patients clearly had more strut displacements than adult Ravitch patients (0% and 6.4% respectively). These results suggest significantly better results in common PEx surgical repair techniques (i.e. Nuss and Ravitch) than uncommon techniques (i.e. Implants and Robicsek). The results suggest slightly better outcomes in pediatric Nuss procedure patients as compared with all other groups. We recommend that symptomatic pediatric patients with uncomplicated PEx receive the Nuss procedure. We suggest that adult patients receive the Nuss or Ravitch procedure, even though the long-term complication rates of the adult Nuss procedure require more investigation.

Correction of asymmetric pectus excavatum using a virtually designed silicone implant

BACKGROUND

An extended asymmetric funnel chest deformity with the breast gland located in the thoracic mold can lead to a fictitious aplasia of the breast. The authors termed this condition "pseudo-Amazon syndrome" because the breast tissue and the pectoralis muscle are fully developed.

METHODS

This report presents a detailed technical approach to the fabrication of a precise-fitting custom-made silicone implant. The design of the implant was achieved using a computed tomography (CT) data set and rapid prototyping. The volumes of the "hidden" and the normal breasts measured preoperatively by processing the CT data were similar. These volumes were compared with the breast volumes measured by three-dimensional photography 4 years postoperatively to assess the predictability of the volume congruency. The silicone implant was surgically placed in the epicostal plane and extended almost over the right hemithorax.

RESULTS

The implantation was performed without the necessity of further trimming. Both the surgeon and the patient rated the aesthetic and functional long-term result as good in terms of symmetry and the possibility of exercise without restrictions. The final breast volume of the surgically treated side was 95 % of the volume of the normal contralateral breast.

CONCLUSION

The described method reduces the operation time and the operative trauma by primary implant fit. However, the method is rather elaborate and the production process is expensive. This in turn reduces the generation of proceeds to a minimum.

LEVEL OF EVIDENCE V

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Patient satisfaction and clinical results 10 years after modified open thoracoplasty for pectus deformities

PURPOSE

Indications for surgical treatment for patients with pectus excavatum and carinatum are psychosocial issues, pulmonary or cardiac limitations or pain. When surgery is indicated in our institution, patients are treated with a modified thoracoplasty according to the Ravitch technique. In order to stabilize pectus excavatum, an allogenic bone strut is transplanted which does not require removal.

PATIENT AND METHODS

Seventy-one patients with a mean age of 17 years who were treated for pectus deformities between 1997 and 2007 were evaluated retrospectively.

RESULTS

The average period of follow-up was 5.3 years. Sixty-six percent of the patients suffered from pectus excavatum, 34% from pectus carinatum. One osseous revision had to be performed after overcorrection of pectus carinatum into pectus excavatum. Six minor complications occurred. At follow-up, the mean patient satisfaction score was 4.3 (scale 1-5). The Manchester Scar Scale resulted in 96% cosmetically well-healed scars. Clinically, 93% of the surgical results were rated good.

CONCLUSIONS

This study retrospectively shows that this modification of the Ravitch approach is a safe and effective treatment option for pectus deformities with long-term satisfactory results for the patients without the need for bar removal.

How to perform breast augmentation safely for a pectus excavatum patient

BACKGROUND

Pectus excavatum is the most common chest wall deformity. Women with pectus excavatum may have associated hypoplastic breasts and often desire breast augmentation. This report describes how to perform breast augmentation safely for a pectus excavatum patient.

METHODS

In the past 5 years, the authors have treated 11 women with hypoplastic breasts and pectus excavatum. Their ages have varied from 21 to 39 years. The women generally were healthy without cardiovascular function impairment. Four of the women had breast asymmetry, with a smaller right breast. It was decided to use wide silicone implants to augment the breast and to camouflage the chest wall deformity. The implants were placed under the pectoralis major muscle in all cases.

RESULTS

The follow-up period varied from 10 months to 4.5 years. No acute or late complications related to the breast augmentation were encountered. All the patients were satisfied with the result, and none desired further surgical treatment for pectus excavatum. For two patients, a small depression in the upper part of the breast was persistent after surgery due to insufficient implant coverage.

CONCLUSION

Most women with pectus excavatum desire to have the deformity corrected with minimal or no scarring. The chest is known to be an area prone to hypertrophic or keloid scars. The reported approach is simple and safe, easily camouflaging the deformity. It is a short procedure that results in high satisfaction.

Aesthetic breast augmentation and thoracic deformities

To ensure the best results from aesthetic breast augmentation, preoperative evaluation and adequate patient information are essential. However, assessment of the underlying thoracic shape often is neglected. Patients with obvious deformities are aware of the problematic reconstruction, whereas patients with mild or moderate deformities often are not aware of their condition and fail to see that standard breast augmentation will lead to unsatisfying results. The authors reviewed their charts for patients with breast augmentation and mild to moderate thoracic deformities, then compiled the therapeutic possibilities and the outcome. Of the 548 patients who underwent breast augmentation, 7.1% (n = 39) exhibited low- or midgrade thoracic wall deformities. Almost none of the patients were aware of their deformity. The patients were augmented with silicone-filled, textured round implants. Placement and volume were adapted to the anatomic situation. A reoperation was not performed in any case, and both patient and physician satisfaction was high. The percentage of patients with thoracic deformity in this group was high compared with an overall incidence of less than 2%. This emphasizes the need for cautious physical examination and preoperative documentation. By individualized surgical planning and diligent implant selection, optimal results and patient satisfaction can be achieved.

[Postoperative complications in plastic surgery]

Plastic surgery covers a broad spectrum of diseases and conditions in the areas of reconstructive surgery, hand, burn and aesthetic surgery. Besides acquired defects or malformations an increasing number of patients are being treated for surgical or multimodal complications. In a considerable number of patients plastic and reconstructive surgery remains the only therapeutic alternative after other therapy has failed. Therefore complication management in plastic surgery is of utmost importance for a successful outcome. In addition patient expectations in the results of plastic surgery as a discipline of invention and problem solving are steadily increasing. This challenge is reflected in clinical patient management by intensive research in tissue engineering and regenerative medicine. Patients in plastic surgery are recruited from all age groups of either gender, involving traumatic and oncologic as well as congenital and aesthetic disorders. The demographics of aging, multimorbidity and obesity pose new challenges to plastic surgery. Although age over 70 years is not an independent risk factor per se for complications in plastic surgery, e.g. for complex free flap transfer, medical problems are present at a higher rate, which is to be expected in this age group. Risk factors such as alcoholism and coronary heart diseases seem to be independent predictors of perioperative complications. Therefore older patients can also benefit from plastic surgery and recurrent operations by the corresponding risk and complication management. Complication management necessitates careful patient selection, estimation of operative risks and patient-adapted selection of procedures. In addition to expertise in plastic surgery a thorough knowledge of non-surgical and surgical back-up procedures for technical incidents as well as vascular circulatory and wound healing disorders is required to deal successfully with complications in plastic surgery. This article presents these specific aspects of postoperative complication management in plastic surgery.

Pectus excavatum reconstruction with silicone implants: long-term results and a review of the english-language literature

Pectus excavatum, or funnel chest, is an anterior chest wall deformity, characterized by a depressed sternum. Frequently used techniques for pectus excavatum repair are extensive thoracic surgical corrections at a young age. At an adult age, custom-made silicone implants can be used as a less extensive surgical option. Thus far, there are only a limited number of reports in the English-language literature concerning this treatment modality. We evaluated our series of 16 patients treated with custom-made silicone implants, assessing complications, patient satisfaction, and aesthetic outcome. Seven patients (44%) had complications, mostly seroma formation (31%). Ten of 12 patients (83%), who were evaluated at the long-term, reported improved patient satisfaction and 9 of 13 patients (69%), in whom aesthetic results were assessed, had a good or excellent aesthetic outcome.Our study, combined with a review of the English-language literature, demonstrates that there is a place for custom-made silicone implants in the treatment of pectus excavatum, especially in less severe cases at an adult age. Preoperative counseling with emphasis on the likelihood of seroma formation is advocated.

Child pectus excavatum: correction by minimally invasive surgery

INTRODUCTION

Pectus excavatum (PE) is a congenital deformity essentially responsible for an unattractive aspect, much more rarely for compression problems. The classical treatments consist either in filling the excavation or in open thoracic reconstruction (the Ravitch technique). Alternatively, the treatment described by Nuss raises the sternum with a retrosternal metallic bar placed under thoracoscopic guidance. We present the preliminary results of a series of 25 children operated on using this technique.

HYPOTHESIS

The minimally invasive procedure described by Nuss is a valid surgical strategy to treat PE.

MATERIALS AND METHODS

Twenty-five patients were operated on between February 2004 and April 2007 by the same surgeon. Nineteen of these patients presented a purely cosmetic indication. The six other patients were considered to have a more severe form of PE, with cardiorespiratory repercussions. In this group, there were two cases of Marfan syndrome and two patients presenting a history of previous cardiothoracic surgery. The technique has always consisted in placing a retrosternal bar through two lateral incisions. The surgery was always performed with right lung exclusion and was guided by thoracoscopy in 21 cases. In four particularly severe cases, a subxiphoid approach was required, making endoscopic guidance unnecessary. The severity of the lesion was evaluated by the Haller Index. All the patients had regular clinical follow-up (at three weeks, three months, and then every six months); assessment of pain, satisfaction with the cosmetic results, and perceived improvement in respiratory function were the criteria used for this follow-up.

RESULTS

The cosmetic result was judged to be positive by 24 patients. One patient was dissatisfied (because of the asymmetrical shape resulting from the use of a single implant). Five patients presented minor complications with no repercussions on the cosmetic or functional result. One case of secondary bar displacement required revision on day 15. Following this revision evolution was uncomplicated (discharge on day 7 and activities resumed at three weeks). Finally, the hardware was removed at a delay after implantation ranging from one to two years. As of today, 13 patients have had their hardware removed with no complications or loss of the initial result.

DISCUSSION

The original indication of the Nuss technique remains symmetrical PE in seven to 14-year-old children. The insubstantial scarring makes the technique valuable in the purely cosmetic forms of the condition. Based on this series, our technique has evolved toward certain adjustments depending on the severity and the etiology of the lesion. The most reported complication in the literature is secondary displacement of the bars. This problem is easily controlled by attaching the bar to a rib. Over the years, we have modified the implant design so as to improve its tolerance and stability. In asymmetrical forms of PE, implanting two bars has provided better efficacy. When a major form is present or when there is a history of cardiorespiratory problems, we recommend a short subxiphoid incision to release the pleural and pericardial adherences, precluding the need for thoracoscopic guidance. With these simple adjustments, this technique gains in reliability for cosmetic indications and its use can be extended to specific forms such as collagenosis or postoperative deformities.

LEVEL OF EVIDENCE

Level IV. Therapeutic Study.

Minimally Invasive Repair for Treating Pectus Excavatum — Early Results

Minimally invasive repair of pectus excavatum (MIRPE) is the preferred technique for repair of funnel chest deformity. The aim of this study is to evaluate our initial postoperative results, to identify factors related to postoperative complications and to examine the acceptability of MIRPE by the patients.

Patients, Materials and Methods:

25 MIRPE patients (20 male and 5 female) were operated on between November 2002 and February 2007 at the Department of Pediatric Surgery, Turku University Central Hospital. The median age of the patients was 14 years (range from 5 to 23 years). One patient had undergone previously open Sulamaa reconstruction and one had a history of intrathoracic lymphoma. The remaining 23 patients had primary pectus excavatum. A right thoracoscopy was performed to every patient.

Results:

Operative mortality was zero and there were no clinically significant bleeding complications. Epidural analgesia was necessary for adequate pain control. Small symptomless residual pneumothoraxes and pleural effusions were common after the operation but neither required intervention. One patient had a hemothorax 7 months postoperatively, which was cured with a single puncture. Bar displacement took place in 2 patients but required correction in only one of these patients. There were 2 wound infections, one superficial and one which led to removal of the bar was 6 months after the operation. This may have been unnecessary. Two patients had pneumonia, one probably unrelated to the operation. One patient required psychiatric ward treatment, and 3 patients had mild psychological symptoms not requiring specific therapy. The preliminary cosmetic results were good or excellent in 90% of the cases, but a longer follow-up is needed for information on the final outcome.

Conclusions:

MIRPE is a safe operation and gives a cosmetically good result. Thoracoscopy is needed during the operation. The early postoperative period in hospital is painful and there the patients need intensive care. We found the high epidural analgesia beneficial and safe during early period of pain treatment. The bar is removed not earlier than 3 years after the operation as a day care surgical procedure.

Free fat transplantation for the aesthetic correction of mild pectus excavatum

Pectus excavatum is a common type of congenital chest wall abnormality. The defect ranges in severity from mild to severe, and can lead to cardiopulmonary impairment caused by the caved-in chest. The case of a 27-year-old woman with mild pectus excavatum and a diagnosis of scleroderma is reported. Cosmetic correction of pectus excavatum malformation with the use of autologous fat transplantation has never been reported. The individual achievement of relief from the psychological consequences of such disfigurement and the improvement in quality of life are high. Autologous fat transfer could be a new option in the armamentarium of techniques for correction of mild pectus deformities.