title: Pectus excavatum breast and chest deformity: indications for aesthetic plastic surgery versus thoracic surgery in a multicenter experience.
abstract: BACKGROUND
  Breast and chest wall disfiguration attributable to a funnel chest is an aesthetically and sometimes functionally debilitating deformity requiring surgical correction. Whereas extensive and combined deformities of the ventral chest wall are classically corrected using a so-called minimally invasive repair of the pectus excavatum, a modified Ravitch repair, or the minimized Erlangen repair, plastic surgeons are mostly challenged with alloplastic implant corrections of mild funnel chests. The authors have introduced an endoscopic method for placement of customized implants to restore the visible and nonfunctionally disturbing deformation of mild funnel chests when only the sternal plate is involved. This study compared these different plastic surgical and thoracic surgical approaches in a multicenter experience to develop a clinical algorithm and to identify those patients not requiring bony correction but rather alloplastic endoscopic implant correction alone.
  
  
  METHODS
  Patients with deformed rib cages and sternal plates were treated with the Erlangen minimally invasive procedure or a modified Ravitch procedure. For deformities involving the sternal bones only, endoscopically assisted minimally invasive implantation of silastic implants was performed.
  
  
  RESULTS
  Between 1987 and 2003, 599 patients with a pectus excavatum deformity were treated surgically by the authors' group. Between 1999 and 2003, 515 patients underwent surgery using the Erlangen minimally invasive repair technique at Friedrich-Alexander University-Erlangen. In addition, 84 patients underwent surgery at the Freiburg University Medical Center. In the current series, 79 patients underwent surgery using the modified Ravitch method. The mean patient age was 20.5 years (range, 3-54 years), and the rate of postoperative relapses was 5%. The findings showed that 73% of the patients judged the aesthetic result as excellent to good, and 20% were satisfied. In contrast, only five patients were suitable for soft tissue augmentation only. Two of these patients in the initial period received custom implants presternally via classical transverse skin incisions, whereas three patients were treated with endoscopic customized implant tissue augmentation.
  
  
  CONCLUSIONS
  Whereas with combined deformity of the sternal plate and the rib cage, a modified Ravitch repair yields good results, the endoscopic soft tissue correction with customized implants helps to avoid unsightly scars, allows for safe hemostasis in the dissection pocket, and leads to enhanced patient satisfaction. In the case of major chest wall deformity with orthopedic and functional relevance, a combination of the minimally invasive procedures (e.g., endoscopic correction and Erlangen repair) seems to show both optimized cosmetic results and maximized functionality.
authors.affiliation: Department of Plastic and Hand Surgery, Friedrich - Alexander-University, Erlangen-Nürnberg, Krankenhausstrasse 12, Erlangen, Germany. Raymund.horch@chir.imed.uni-erlangen.de
authors.forename: Raymund E
authors.initials: RE
authors.lastname: Horch
authors.forename: Erich
authors.initials: E
authors.lastname: Stoelben
authors.forename: Roman
authors.initials: R
authors.lastname: Carbon
authors.forename: Alaa A
authors.initials: AA
authors.lastname: Sultan
authors.forename: Alexander D
authors.initials: AD
authors.lastname: Bach
authors.forename: Ulrich
authors.initials: U
authors.lastname: Kneser
mesh_terms: D000293:Adolescent; D000328:Adult; D000465:Algorithms; D002648:Child; D002675:Child, Preschool; D004724:Endoscopy; D005260:Female; D005660:Funnel Chest / Q000601:surgery*; D006801:Humans; D021621:Imaging, Three-Dimensional; D008297:Male; D008875:Middle Aged; D019736:Prostheses and Implants; D019651:Plastic Surgery Procedures / Q000379:methods*; D013518:Surgery, Plastic; D013903:Thoracic Surgery; D014057:Tomography, X-Ray Computed