Technical Considerations in the Surgical Management of Pectus Excavatum and Carinatum

THE ANNALS OF THORACIC SURGERY Journal of The Society of Thoracic Surgeons and the Southern Thoracic Surgical Association VOLUME 18 - NUMBER 6 - DECEMBER 19 74 Technical Considerations in the Surgical Management of Pectus Excavatum and Carinatum Francis Robicsek, M.D., Harry K. Daugherty, M.D., Donald C. Mullen, M.D., Norris B. Harbold, Jr., M.D., Donald G. Hall, M.D., Robert D. Jackson, M.D., Thomas N. Masters, Ph.D., and Paul W. Sanger, M.D.* ABSTRACT During the past 25 years, 650 operations have been performed on 608 patients for anatomically significant pectus excavatum or carinatum deformities of the anterior chest wall. There were no deaths in this series, and serious complications were very rare. We conclude that repair of pectus excavatum and carinatum deformities should include the following operative steps: (1) adequate mobilization of the sternum and correction of its abnormal angulation by transverse osteotomy; (2) adequate bilateral removal of the involved costal cartilage; and (3) securing the corrected position of the sternum with the patient s own living tissue, retaining its blood supply and using it as an internal support. Using these principles, new surgical procedures were developed for the correction of: symmetrical pectus excavatum, asymmetrical pectus excavatum, pectus carinatum with xiphoid angulation, pectus carinatum without xiphoid angulation, asymmetrical pectus carinatum, chondromanubrial prominence with chondrogladiolar depression, and recurrent pectus excavatum. We recommend surgical correction for patients in whom the deformity is significant and no contraindication exists. The ill effects of this condition should not be underestimated. From the Department of Thoracic and Cardiovascular Surgery, Heineman Medical Research Center, Charlotte Memorial Hospital, Charlotte, N.C. Presented at the Tenth Anniversary Meeting of The Society of Thoracic Surgeons, LOS Angeles, Calif., Jan. 28-30, 1974. *Deceased. Address reprint requests to Dr. Robicsek, Department of Thoracic and Cardiovascular Surgery, Heinemann Medical Research Center, Charlotte Memorial Hospital, Charlotte, N.C. 28207. 549

ROBICSEK ET AL. P ectus excavatum and carinatum are pathological conditions in which the indication for operative correction is controversial, the surgical technique debatable, and the postoperative results incapable of being objectively measured. It is fortunate indeed that at least establishing the diagnosis does not cause undue difficulties. During the 25 years our group has had a special interest in this subject, we have learned that even though many patients reach adulthood and may live a life seemingly unaffected by their condition, pectus excavatum and carinatum are not as innocuous as has been thought. The ill effects of this disease may manifest themselves early as well as late, and psychologically as well as physiologically. These considerations induced us to take an active surgical approach for the management of anterior chest deformities. We have applied several different surgical techniques in a wide variety of patients and have found most of them less than satisfactory, especially in pectus excavatum and carinatum. We have concluded that repair of these anomalies should include the following important operative steps: (1) the sternum should be adequately mobilized, its abnormal angulation being corrected by transverse osteotomy; (2) adequate bilateral removal of the involved costal cartilages is essential; (3) the corrected position of the sternum should be secured by using the patient s own living tissue, undeprived of its blood supply, as an internal support. Following these principles, new operative procedures were developed for correcting the different types of anterior chest deformities [25, 26, 28-30] (Fig. 1). These procedures incorporated some of the elements described and utilized by other authors [l-24, 27, 31-35]. The purpose of this paper is to present the techniques that proved to be the most effective in our clinical trials and have been used with only a few minor changes during the past decade. Material During the years 1949 to 1974,650 operations were performed altogether on 608 patients with deformities of anatomical or functional significance (or both) of the anterior bony thorax. According to the anatomical features of their deformity, these patients were divided into the categories shown in Table 1. The group included 398 male and 210 female patients; their ages at the time of operation are given in Table 2. Techniques The techniques we have developed are based on the principle that the abnormal anatomy in pectus excavatum and carinatum is not limited to the sternum alone but includes elongation and distortion of the costal cartilages, displacement and sometimes compression of the heart, and abnormalities in the anterior attachment of the diaphragm and the attachment of the rectus 550 THE ANNALS OF THORACIC SURGERY

Pectus Excavatum and Carinatum a 45 C d e FIG. I. The different forms of the most common anterior chest deformities: (a) symmetrical pectus excavatum; (b) asymmetrical pectw excavatum; (c) symmetrical pectus carinatum; (d) unilateral pectus carinatum; (e) bilateral costal prominence; and (f) chondromanubrial prominence with chondrogladiolar depression. muscles. In the development of pectus anomalies the sternum is usually regarded as the culprit. The advocates of this hypothesis believe that displacement of the sternum occurs first, followed by changes in the costal cartilages, which have no option but to follow the sternum in its displaced position. This deduction reminds us of the reasoning that the giraffe s neck is as long as it is because otherwise it could not reach the animal s head. After resecting the elongated and distorted cartilages, we cannot help agreeing with those who believe that the sternal displacement is secondary, due to overgrowth of the costal cartilages. If the sternum is pushed inward, the result is pectus excavatum. If it is pushed outward, pectus carinatum develops. It is the same disease. PECTUS EXCAVATUM Symmetrical Pectus Excavatum (Chondrosternal Depression, Chonechondrosternon, Funnel Chest). A funnel-shaped depression of the sternum and adjacent cartilages exists in this anomaly. The depression is circular in advanced cases and oval in the less accentuated deformity. The retrosternal space is narrowed, and the heart is more or less displaced into the left hemithorax. The sternal depression usually begins at the junction of the manubrium and gladiolus and becomes progressively deeper toward the xiphoid process. The costal cartilages are elongated, distorted, and sometimes fused together. The method we use for correction of the symmetrical variety of pectus excavatum is shown in Figure 2. The steps are as follows: Under f VOL. 18, NO. 6, DECEMBER, 1974 551

ROBICSEK ET AL. TABLE 1. ANATOMICAL FEATURES OF PECTUS DEFORMITIES IN 608 OPERATED PATIENTS Type of Deformity No. of Patients Pectus excavatum Symmetrical 391 Asymmetrical 67 Pectus carinatum With xiphoid angulation 92 Without xiphoid angulation 31 Asymmetrical 20 Chondromanubrial prominence with chondrogladiolar depression 7 Recurrent pectus deformity 42 Total number of operations 650 endotracheal anesthesia, a slightly upward, convex, transverse incision is made over the midsternum. The pectoralis muscles are detached on both sides of the sternum, then stripped and retracted laterally. Thereupon all involved cartilages are exposed, and with progressively longer segments being removed from the lower ones, they are resected subperiosteally. A transverse, cuneiform osteotomy of the sternum is performed next at the beginning of its abnormal downward curve. Care is taken to do the osteotomy in a line that falls to an intercostal space rather than to a chondrosternal junction and to leave the costal cartilages above the level of the osteotomy unresected. The xiphoid process is then grasped with a forceps, separated from the sternum, and mobilized. This mobilization includes division of the bands connecting it with the diaphragm, incision of the rectus sheath, and detachment of part but not all of the rectus fibers. This maneuver allows the xiphoid process to be dislocated and stretched under the lower edge of the sternum. In patients in whom the xiphoid process is very small, its size is augmented by leaving a small portion of the sternum attached to it. The tip of the sternum is then lifted with a towel clip, and with blunt and sharp dissection it is freed of its mediastinal perichondrial and intercostal attachments. The sternum is bent forward, and the pectus excavatum deformity disappears into a slightly overcorrected position. TABLE 2. AGES OF 608 PATIENTS AT TIME OF INITIAL OPERATION FOR PECTUS DEFORMITIES < 1 1-2 2-6 6-12 12-16 16-25 > 25 No. of Patients 4 61 142 164 146 66 25 552 THE ANNALS OF THORACIC SURGERY

Pectus Excavatum and Carinaturn, FIG. 2. Operative repair of symmetrical pectus excavatum. The involved cartilages are resected, and the corrected position of the sternum i.r secured with the support of the suspended xiphoid process. The overcorrection of the breastbone is secured with the aid of the xiphoid process, a maneuver which makes this procedure different from the original operation recommended by Ravitch [23]. The process is grasped again with a forceps or towel clip and suspended with two heavy stainless steel wire sutures to the lowest, most unresected costal cartilages on both sides. Tying the sutures pulls the xiphoid into a substernal position. Care is exercised not to pull the process too high, but only high enough to offer a firm support on which the lower edge of the sternum may rest. In this position the xiphoid process serves as an internal support that makes the corrected position of the sternum permanent. The pectoralis muscles are reattached to the sternum, and the subcutaneous tissues and skin are closed. When we first applied this procedure, special care was taken not to enter either of the pleural cavities. At the same time, however, we have also experienced a dismayingly large number of complications with the wound. These mishaps occurred primarily because of blood and serum collecting under the skin flaps, which could not be eliminated by draining the wound with a Penrose drain or by Hemovac suction. In the few patients in whom one of the pleural cavities was inadvertently entered, such complications were very rare. Consequently, during the last few years we have entered the right pleural cavity as part of the operative plan, connected it widely with the operative field, and drained it through an intercostal water-sealed catheter. This way, even after the chest tube is removed, the large absorbing VOL. 18, NO. 6, DECEMBER, 19 74 553

ROBICSEK ET AL. surface of the pleural space continues to suck up fluid that otherwise might have collected in the wound. Asymmetrical Pectus Excavatum. The asymmetrical type of pectus excavatum differs from the usual symmetrical form of the anomaly by the fact that there is also an axis deviation of the sternum, so its anterior surface is turned toward the smaller, usually the right, hemithorax. In some cases this deformity is associated with absence of a few ribs or the ipsilateral pectoralis muscle. The surgical management of such a deformity is by and large identical to that of symmetrical pectus excavatum, but it also requires correction of the axial torsion of the sternum. This is accomplished by placing a figure-ofeight wire suture at the edge of the upper osteotomy on the side toward which the sternum is rotated (Fig. 3). The tilting action of this suture corrects the costal cartilages more extensively on the side toward which the abnormal rotation of the sternum occurred. Another problem that the surgeon may face during correction of this anomaly is what we call the cross-eyed breast. In this situation the nipples remain in an unequal position after repair of asymmetrical pectus excavatum, the one on the involved side looking toward the midline. This condition can be eliminated easily by removing a full-thickness triangle of skin at the edge of the incision on the involved side (Fig. 4). PECTUS CARINATUM Pectus Carinatum with Xiphoid Angulation (Chondrosternal Prominence, Chondrogladiolar Prominence, Pigeon Breast). The anomaly commonly called pectus carinatum is characterized by protrusion of the sternum and symmetrical prominence of the involved costal cartilages. The sternum itself is elongated and joins the xiphoid process in an abnormal sharp angle that makes the sternal protrusion even more evident. The lower portion of the breastbone as well as the sternal ends of the costal cartilages show hyperostosis and bony proliferation. The lower costal cartilages or even the osseous portion of the ribs may be distorted and fused, and the Harrison grooves are frequently accentuated. Our method for correcting this anomaly, shown in Figure 5, is as follows: The sternum and the involved costal cartilages are exposed as FZG. 3. Axial correction of the sternum in usymmetrical pectus excavatum by osteotomy and Jigiire-of-eight wire sutures. 554 THE ANNALS OF THORACIC SURGERY

Pectus Excavatum and Carinatum FIG. 4. Correction of asymmetrical position of the nipples following pectus excauatum repair. described before. Retrosternal dissection and detachment of the perichondrium or intercostal muscle strips are not required. A transverse osteotomy is performed at the upper end of the abnormal forward curvature of the sternum, usually just below the angle of Louis. The sternum is then forcefully bent backward, breaking its posterior lamina and thus correcting its abnormal forward position. The xiphoid process is detached from the sternum, but its connections with the diaphragm and rectus muscles are left intact. A portion measuring 2 to 4 cm. is resected from the lower end of the corpus sterni. The newly created FIG. 5. Surgical repair of pectm carinatum with xiphoid anplation. The involved costal cartilages as well as the lower portion of the sternum are resected, and the corrected position of the sternum is secured by the pulling action of the reattached xiphoid process. VOL. 18, NO. 6, DECEMBER, igpj 555

ROBICSEK ET AL. distal end of the breastbone is smoothed, molded, and reunited with the xiphoid process using 2 to 4 stainless steel sutures. This way the sternum is pulled down by the action of the rectus muscles, and its corrected position is secured. The operation is completed by suturing the edges of the pectoralis muscles back to the sternum or suturing the detached muscles together over the sternum. The latter method results in a more even appearance: however, it requires the creation of somewhat larger skin flaps. Pectus Carinatum without Xiphoid Angulation. This form of carinatum deformity is usually not as extensive as the one previously described. The lower end of the sternum and xiphoid process protrudes with the axis pointing upward. In such cases, after resection of the costal cartilages and performance of the transverse sternal osteotomy, the breastbone is maintained in its proper position simply by approximating the pectoralis muscle over it (Fig. 6). Asymmetrical Pectus Carinatum. The operation for repair of the lateral varieties of pectus carinatum has to be tailored to the extent of the deformity. If the anomaly consists of only overgrowth of a few cartilages on one side, an incision is made directly over them, and the procedure can be limited to subperiostal removal of the unsightly protuberance. If more than two or three ribs are involved, a more radical procedure might be necessary. In general, it is advisable to be more radical than conservative in removal of cartilages, for only after closure of the incision will it become apparent that part of the protrusion still persists. In unilateral costal protuberance the position of the sternum is usually unaltered, thus making osteotomy unnecessary; the cartilages at the sternal junction are frequently overgrown, however, and need to be shaved off. It seems -paradoxical, but we have learned rather painfully that if a unilateral FIG. 6. Lateral view of operatiue correction of pectus carinatum without xiphoid angulation. Following asteotomy the corrected Position of the sternum is maintained by suturing the pectoral muscle above it. 556 THE ANNALS OF THORACIC SURGERY

Pectus Excavalum nnd Carinaturn FIG. 7. The unwanted sequela of untlateral resection of costal cartilages. If the cartilages on the contralateral side are not resected, their action flips the sternum forward. protrusion is significant enough to necessitate resection of several costal cartilages, the apparently normal cartilages on the opposite side should be resected too. Otherwise, the unbalanced action of these nonresected costal cartilages tilts the sternum to their side, and a worse deformity may develop (Fig. 7). CHONDROMANUBRIAL PROMINENCE WITH CHONDROGLADIOLAR DEPRESSION This infrequently seen anomaly consists of protrusion of the manubrium sterni and the adjacent two pairs of costal cartilages and a typical excavatum deformity involving the lower part of the sternum. The operation for this deformity requires correction of both components (Fig. 8). To accomplish this, it is necessary to resect all but the first costal cartilages. In addition, the protruding portion of the sternum and the first chondrosternal junctions are molded with a chisel. A transverse sternal osteotomy is performed at the level of the sternomanubrial junction and also at the level of the fourth rib. The sternum is bent forward and its corrected position secured by supporting the lower end of the sternal body by the detached and suspended xiphoid process, just as has been described in connection with pectus excavatum. REPAIR OF RECURRENT PECTUS DEFORMITY Most of the patients who were reoperated upon because of poor results had excavatum deformities. The first few reoperations proved quite difficult FIG. 8. Surgical correction of chondromanutwial prominence with chondrogladiolar depression. The procedure involves removal of the protruding portion of the sternum, performance of two osteotomies, and support of the depressed sternum by the suspended xiphoid cartilages. VOL. 18, NO. 6, DECEMBER, 1974 557

ROBICSEK ET AL. because of the extensive scarring and disappearance of the normal anatomical structure. The resected costal cartilages regenerated into a rigid, platelike structure, which made performance of the usual reconstructive procedure practically impossible. To overcome these difficulties, a new operative technique was developed for repair of recurrent deformities. The skin scar is excised. The sternum is exposed from the second chondrosternal junction to the xiphoid process. The pectoralis muscle is detached from the sternum on both sides and retracted laterally. A transverse osteotomy is carried out on the sternum at the beginning of the depression. If the xiphoid process is still in continuity with the sternum, it is detached. The sternum is dissected free posteriorly, and the fibrous lamina as well as the remnants of the intercostal muscles and regenerated cartilages are severed from their attachment to the sternum. The sternum is then bent anteriorly into a corrected position. This corrected position is made permanent by lifting the sternum above and securing it to the lateral fibrous plate consisting of the regenerated cartilages and intercostal structures (Fig. 9). This can be accomplished in two ways: (1) If the depression is not very wide, the sternum can be rested without difficulty on the top edge of the fibrous plates and attached to them with simple or figure-of-eight wire sutures (Fig. 10). (2) If the depression is very wide, the sternum is split longitudinally in the midline up to the groove of the transverse sternotomy. The divided sternum is elevated and spread, and the two halves are pulled sideways, placed on the lateral fibrous lamina, and attached to it with stainless steel wire sutures (Fig. 11). Regardless of which method is used, the pectoralis muscles are sutured together over the sternum to give the repair a smooth and equal appearance. FIG. 9. One method for surgical repair of recurrent pectus excauatum. Following osteotomy the freed-up sternum is rested on and sutured to the fibrous plate composed of remnants of costal cartilages and intercostal muscles. 558 THE ANNALS OF THORACIC SURGERY

Pectus Excavalum and Carinalum FIG. 10. Correction of recurrent pectus excavatum. The sternum is detached and the fibrous cartilagenous plate moved upward and supported in the corrected position by stainless steel wire sutures. In the few patients with recurrent pectus carinatum deformity, the poor result was usually due to conservative surgical repair rather than to true recurrence. They were handled by removing the protuberant portions of the sternum, ribs, and costal cartilages left behind during the primary repair. All our patients were encouraged to maintain proper posture after operation and to engage in physical activities, especially sports that lead to the development of chest muscles such as swimming or weight lifting. Results There were no deaths in this series, and the incidence of serious complications was limited to a single case of severe infectious mediastinitis that cleared with antibiotics and drainage. Other minor complications consisted of superficial wound infections and formation of keloid in the surgical scar. The degree of anatomical and cosmetic correction was evaluated during FIG. 11. An additional method for surgical repair of recurrent pectus excavatum. The sternum is freed up and rested on the fibrous plate composed of remnants of the costal cartilages and intercostal muscles. Because the depression is very wide in this case, the sternum is split and spread in its midline. VOL. 18, NO. 6, DECEMBER, 1974 559

ROBICSEK ET AL. the follow-up period, ranging from 1 to 25 years. The appearance of the anterior chest after primary repair is detailed in Table 3. Analyzing the case histories, it was evident that a significant number of the unsatisfactory results occurred in patients operated upon in the early period with techniques other than those described in this paper. Unsatisfactory results, however, continued to plague us, even if less frequently, after these new methods were introduced; this was especially true in teen-agers and young adults with asthenic corporal build; long, flat chest; and Marfanoid characteristics. The most pleasing results were obtained in the youngest patients. Forty-two of the 73 patients with unsatisfactory results were reoperated upon. In 36 a satisfactory result was obtained. The degree of psychological impairment which was eliminated by the repair of pectus deformities certainly deserves to be mentioned. Patients with pectus deformities are usually shy, thin individuals who are very selfconscious and unhappy about their anomaly. To conceal their deformity they walk and sit slightly bent forward, with stooped shoulders. As school children and young adults they are exposed to mockery, which causes them to avoid swimming and other outdoor activities. All these factors lead to an abnormal posture and tend to further aggravate their anomaly. Our patients responded most favorably to the elimination of these handicaps. The degree of physiological improvement after operation was much more difficult to measure. The reason for this is that the physiological disadvantages of pectus deformities are readily apparent only in the rare forms. The patient may be in serious difficulty at a very early age. These infants manifest rapid, paradoxical respiration, sometimes with outright gasping. The-y retain secretions, have tachycardia, and are cyanotic to varying degrees. Infants in such condition responded promptly and very satisfactorily to operation. In adults the decompensated form of pectus deformities is seen less frequently. It may manifest itself in syndromes similar to cor pulmonale or severe emphysema. The few patients we have seen were thought to be past the limits within which significant improvement could be expected from surgical therapy. Two young adults, however, were operated upon because of TABLE 3. RESULTS OF REPAIR OF PECTUS DEFORMITIES IN 608 PATIENTS Deformity No. of Result Patients Good Acceptable Unsatisfactory Pectus excavatum 458 353 44 61 Pectus carinatum 143 121 10 12 Chondrogladiolar prominence with chondrogladiolar depression 7 7...... Total 608 48 1 54 78 560 THE ANNALS OF THORACIC SURGERY

Pectus Excauatuin and Carinaturn disability thought to be caused by cardiac compression from the sunken sternum. Their response to operation was gratifying. Objective evaluation of cardiopulmonary impairment in an average patient with pectus excavatum or carinatum and possible improvement after surgical repair was very difficult, since the clinical symptoms in these conditions are rather uncertain and ill-defined. Pulmonary function and hemodynamic studies were not fruitful, primarily because of the wide range of normal values, from which only patients with severe deformities deviated. We have also found that most patients were only vaguely conscious of their limitations, since naturally they had never known what it was to be without them and did not become aware of them until an operation had improved their status. The ill-defined symptoms may vary from retarded growth and recurrent upper and lower respiratory tract infections in children to exertional dyspnea and asthmatic attacks and palpitation in adults. It was our general impression that when difficulties had existed before operation, they improved or disappeared afterward. Respiratory infections became less frequent; the growth rate picked up in children, and dyspnea improved in young adults. Especially impressive was the case of one of a pair of twins, who had retarded growth and a pectus deformity and who rapidly caught up with his sibling after surgical correction. References 1. Adkins, P. C., and Gwathmey, 0. Pectus excavatum: An appraisal of surgical treatment. J. Thorac. Surg. 36:714, 1958. 2. Alexander, J. Traumatic pectus excavatum. Ann. Surg. 93:489, 1931. 3. Ballinger, W. F., 11. In J. H. Gibbon, D. C. Sabiston, and F. C. Spencer (Eds.), Surgery of the Chest (2d ed.). Philadelphia: Saunders, 1969. 4. Bauhinus, I. Sterni cum costis ad interna reflexis spirandi dificultatis causa. Frankfurt: Schenk & Frankenberg, 1600. 5. Brodkin, H. A. Congenital chondrosternal prominence (pigeon breast): A new interpretation. Pediatrics 3:286, 1949. 6. Brodkin, H. A. Congenital costosternal depression (funnel chest): Its treatment by phrenicosternolysis and chondrosternoplasty. Dis. Chest 19:288, 1951. 7. Brodkin, H. A. Pigeon breast-congenital chondrosternal prominence. Arch. Surg. 77:261, 1958. 8. Brown, A. L. Pectus excavatum (funnel chest). Anatomic basis: Surgical treatment of the incipient stage in infancy; Correction of the deformity in the fully developed stage. J. Thorac. Surg. 9:164, 1940. 9. Carr, J. G. The cardiac complications of trichterbrust. Ann. Intern. Med. 6:885, 1933. 10. Chin, E. F. Surgery of funnel chest and congenital sternal prominence. Br. J. Surg. 186:360, 1957. 11. Flesch, M. Ueber eine seltene Missbildung des Thorax. Virchows Arch. Pathol. Anat. 57:289, 1873. 12. Hansen, F. N. The ontogeny and phylogeny of the sternum. Am. J. Anat. 26:241, 1919. 13. Hofmeister, W. Operation der angeborenen Trichterbrust. Beitr. Klin. Chir. 141:215, 1927. 14. Howard, R. Pigeon chest (protrusion deformity of the sternum). Med. J. Aust. 28:664, 1958. VOL. 18, NO. 6, DECEMBER, 1974 561

ROBICSEK ET AL. 15. Keeley, J. L., Schairer, A. E., and Brosnan, J. J. Failure of sternal fusion: Bifid sternum. Repair of approximation of sternal bars. A.M.A. Arch. Surg. 81:641, 1960. 16. Lester, C. W. The etiology and pathogenesis of funnel chest, pigeon breast and related deformities of the anterior chest wall. J. Thorac. Surg. 19:810, 1950. 17. Lester, C. W. Pigeon breast (pectus excavatum) and other protrusion deformities of the chest of developmental origin. Ann. Surg. 137:482, 1953. 18. Lester, C. W. Surgical treatment of protrusion deformities of the sternum and costal cartilages (pectus carinatum, pigeon breast). Ann. Surg. 153:441, 1961. 19. Meyer, L. Zur chirurgischen Behandlung der angeborenen Trichterbrust. Verh. Berlin Med. Ges. 42364, 1911. 20. Ochsner, A., and DeBakey, M. Chone-chondrosternon: Report of a case and review of the literature. J. Thorac. Surg. 8:469, 1939. 21. Peiper, A. Ueber die Erblichkeit der Trichterbrust. Klin. Wochenschr. 1: 1647, 1922. 22. Perrot, A. Discussion du rapport de M. Ch. Garnier sur le traitement chirurgical du thorax en entonnoir. Rev. Orthofi. 21:615, 1934. 23. Ravitch, M. M. The operative treatment of pectus excavatum. Ann. Surg. 129:429, 1949. 24. Ravitch, M. M. The operative correction of pectus carinatum (pigeon breast). Ann. Surg. 151:706, 1960. 25. Robicsek, F., Sanger, P. W., Taylor, F. H., and Stam, R. E. Xiphoid interposition: A technical modification for the repair of pectus excavatum. Am. Surg. 26:529, 1960. 26. Robicsek, F., Sanger, P. W., Taylor, F. H., and Thomas, M. J. The surgical treatment of chondrosternal prominence (pectus carinatum). J. Thorac. Cardiovasc. Surg. 45:691, 1963. 27. Sainsbury, S. K. Congenital funnel chest. Lancet 2615, 1947. 28. Sanger, P. W., Robicsek, F., and Daugherty, H. K. The repair of recurrent pectus excavatum.,j, Thorac. Cardiovasc. Surg. 56: 141, 1968. 29. Sanger, P. W., Taylor, F. H., and Robicsek, F. Deformities of the anterior chest wall. Surg. Gynecol. Obstet. 116:215, 1963. 30. Sanger, P. W., Robicsek, F., and Taylor, F. H. Surgical management of anterior chest deformities: A new technique and report of 153 operations without death. Surgery 48:510, 1970. 31. Sauerbruch, F. Die Chirurgie der Brustorgane. Berlin: Springer, 1920. Vol. 1, p. 347. 32. Sauerbruch, F. Operative Beseitigung der angeborenen Trichterbrust. Dtsch. Z. Chir. 234:760, 1931. 33. Seaberry, J. H. In W. A. Sodeman and W. A. Sodeman, Jr. (Eds.), Pathologic Physiology (4th ed.). Philadelphia: Saunders, 1967. 34. Sweet, R. H. Pectus excavatum: Report of two cases successfully operated upon. Ann. Surg. 119:522, 1944. 35. Truesdale, P. E. A new method of dealing with funnel chest. N. Engl. J. Med. 218:102, 1938. Discussion DR. DAVID J. DUGAN (Oakland, Calif.): The authors have presented fine evidence of an acceptable operation for what has been for years considered a nonsurgical condition in many instances. Seven hundred eighty patients with chest wall deformity subjected-and I use the term advisedly-to operative correction is a representative series and would seem to justify such an aggressive approach. However, I would question the justification of a major operation for a problem which in many cases can be solved by psychological treatment. 562 THE ANNALS OF THORACIC SURGERY

Pectus Excavatum and Carinaturn Since the original work done by Sanger and by Brown of San Francisco, Dailey of Texas, and others, the popularity of the operation has fluctuated. Also, the surgical indications have been largely cosmetic, since in most patients there is little physiological reason for surgical aggression. Perhaps now with our sophisticated calibrated means of physical examination, the complications that unoperated individuals experience in later life will be more apparent. We are all surgeons, and as such we are at our best when we are operating. I would only caution that the operating technique so ably presented by the authors be used with extreme caution and would recommend this type of operation only in the most extreme situation, in which physiological and occasionally psychological improvement can be expected. With this type of operative procedure, perhaps something pertaining to marriage could be cited to good advantage: What God has joined together, let no man put asunder. DR. IRVING M. MADOFF (Brookline, Mass.): At the second annual meeting of this Society in Denver, I indicated in discussion that the sternal deformity in pectus carinatum or pectus excavatum is easily corrected by removing the sternum, leaving the periosteum in situ. The general operative plan consists of removal of adequate lengths of costal cartilages subperichondrially as well as the deformed sternum. Since then I have continued to remove the sternum in the same manner without complications and with good late postoperative results. We had a patient with pectus carinatum in whom a satisfactory correction of the deformed sternum could not be obtained until it was removed subperiosteally. The postoperative roentgenogram 2 years later demonstrated good bone replacement and an excellent cosmetic effect. Following the described operative procedure, another young patient with a severely depressed sternum showed good bone replacement with excellent position of the sternum. No internal struts or external support were necessary. Four to six weeks after operation the sternal area was still quite firm. DR. DAVID H. WATERMAN (Knoxville, Tenn.): I would like to congratulate the authors on a well-presented paper and a very impressive series numerically. Maybe this demonstrates that a higher percentage of congenital deformities occur below the Mason-Dixon Line, because we seem to have seen many of them too. We think in Tennessee we still have a higher percentage of two-headed babies, however. I consider the psychological indication for this operation very important. Many of these patients come to us in their early teens, when they begin to be conscious that they are not the same as their playmates. We have seen striking psychological improvement in these young people after their deformities have been corrected; hence I think this is a perfectly valid indication. The operation is not a dangerous one. The youngest patient in our series was 1 year old, the oldest 45. Incidentally, I would like to ask the authors what they consider the ideal age for operating. For some of our patients with pectus excavatum we have inserted a metal bar underneath the sternum above, and to correct the flare we have lately put in a second bar below. As you know, these children have a rib flare at the bottom that is a deformity in itself, and leaving the lower bar in place longer than the upper bar has corrected this in a number of our patients. In closing I would like to comment on a rather attractive young lady patient of ours with pectus excavatum. She declined a pectus operation but asked to be sent to a plastic surgeon because of her small breasts. The surgeon put in silicone transplants and corrected her cross-eyed look. She also has a very impressive cleavage. *Discussion of J. L. Ehrenhaft, N. P. Rossi, and M. S. Lawrence, Developmental chest wall defects. Ann. Thoruc. Surg. 2:384, 1966. VOL. 18, NO. 6, DECEMBER, 1974 563

ROBICSEK ET AL. DR. RICHARD KING (Atlanta, Ga.): Our technique for correcting carinatum was described at the Society meeting in 1966,* and I believe it is a better approach than Dr. Robicsek s. I would like to describe its application in 2 patients. The first was a boy 18 years old whose pectus excavatum was so severe that it was necessary to do two wedge osteotomies in order to lift the sternum anteriorly to a satisfactory position. In a case this severe one should use two Rush nails instead of one. I find that I can obtain at least another?l2 to s/4 inch in anterior projection by using one of the braces I described at the Society meeting in 1966 in discussing Dr. Ehrenhaft s paper. The second patient also could not be corrected by Dr. Robicsek s technique. He was operated upon elsewhere at 3 years of age for pectus excavatum, and it resulted in an infection with partial loss of the sternum which produced complete separation of the gladiolus for 1;/2 inches. Through the same incision a 4-inch segment of the right fourth rib was resected, leaving the anterior periosteum. The rib was cut in half and both segments were used to bridge the separation, fixing them to the gladiolus above and below. Two Rush nails were also used for support, as in the first patient, and anterior projection of the gladiolus was maintained by the previously described brace. An excellent result was obtained. DR. ROBICSEK: First, I would like to thank Dr. Dugan for his discussion. His wise words were well taken, and I can use his advice in my surgical practice as well as my marital life. As far as Dr. Madoff is concerned, I had to cut my presentation quite short. I cannot state, naturally, that with different surgical methods we never fail. Recurrence, unfortunately, is not rare, regardless of what method somebody may use; and the surest indication that we don t have a perfect operation is the fact that so many different techniaues are recommended for this disease. We think our method might be the most &table, but again we cannot look objectively on our own child. I disagree with Dr. Madoff on the principle of the operation he is using, primarily because it is not radical enough. We used it at the beginning, but our results were very disappointing. Regarding Dr. Waterman s discussion, the number of patients we have operated on is certainly large. However, I should point out again that this represents the experience of 5 surgeons ranging as far back as 1945. As far as the psychological effects of this disease are concerned, I certainly agree with him. These patients, especially the ones with excavatum deformities, are usually shy, thin individuals who are very self-conscious and unhappy about their condition. They don t participate in sports, they avoid swimming pools, and this vicious circle makes the deformity even worse. As far as the correction is concerned, however, I disagree with the recommendation just to correct the cosmetic deformity, and I would certainly argue with anybody who tried to use a silicone transplant to hide the sternal depression. Compression of the heart and paradoxical breathing are factors which predispose these people to emphysema and cor pulmonale. I believe the anomaly should be corrected and not just painted over. As far as the ideal age for correction is concerned, we do it as early as possible. The operation is simplest on the very young. The older the child, the higher the rate of recurrence, which makes the technique more difficult. Concerning Dr. King s comments, I don t believe these patients need external or internal support, but again I would not quarrel with anyone who gets good results with those techniques. *Discussion of J. L. Ehrenhaft, N. P. Rossi, and M. S. Lawrence, Developmental chest wa.11 defects. Ann. Thoruc. Surg. 2:384, 1966. 564 THE ANNALS OF THORACIC SURGERY