What does it imply to have a sunken chest or ‘pectus excavatum’?

Pectus excavatum, also known as “sunken chest” or “funnel chest”, is the most common congenital deformity of the chest wall. It consists of a concave depression of the sternum with greater or lesser depth that can be associated with sternal rotation, differentiating between symmetrical and asymmetrical pectus excavatum.

The incidence of this pathology is 1/300-400 births, being more frequent in males, with a 4:1 ratio. Although this deformity becomes more evident over the years, especially in adolescence, it is described that in 86% of patients it was present during the first year of life. It has been shown that hereditary transmission may be present in up to 30% of cases.

Symptoms

Most patients have no physical symptoms (98%). When they present physical affectation this corresponds to a limitation when performing intense physical exercise and to a lesser extent alterations in the cardiac rhythm or limitation in the respiratory functional capacity.

As there is a frequent association of this pathology with others such as asthma, scoliosis or Marfan syndrome, it is not uncommon for symptoms to be confused, as in the case of wheezing or heart murmurs.

The main reason why patients undergo surgery for pectus excavatum is because of its psychosocial impact. Most patients present a deterioration in self-perception that in very severe cases can lead to changes in their character and even limit social activities, especially those involving public display of the thorax. Hence the greater frequency of this type of intervention in coastal areas.

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It has been shown that after surgery there is a significant improvement in patients’ self-perception, with improvement in psychosocial functions and a favorable impact on their quality of life.

What are the causes?

The exact cause is currently unknown. There are several hypotheses, being currently the most accepted the existence of an anomalous growth of the costal cartilages in its sternal union that give rise to a depression of the sternum.

This would justify that the deformity is accentuated at the time of greatest growth of the patient (adolescence).

Is there any treatment?

The best treatment is prevention, but unfortunately there are no preventive measures for this pathology.

When it comes to treatment, there are different options. The most effective are the surgical ones, within which we will be able to differentiate two groups; those that modify the thoracic wall versus those that do not. There is a non-surgical treatment with a vacuum bell.

Orthotic treatment

Vacuum bell. By means of a device a vacuum is applied in the area of the sagging that will gradually reduce it. Indicated in children (requires a lot of flexibility), requires a long treatment time so it requires a lot of perseverance.

Surgical treatment

In this case, two types of surgical treatment are differentiated according to whether or not the chest wall is modified. The techniques that modify the thoracic wall are:

  • Ravitch technique

Classical or conventional technique for the treatment of pectus excavatum. Through an incision in the central region of the thorax, the surgeon proceeds to remove the excess cartilaginous tissue associated with a partial sternal section to place the sternum in its new position. Occasionally, osteosynthesis material is used as a support.

  • Nuss Technique
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Also known as MIRPE (Minimally Invasive Repair of Pectus Excavatum) or minimally invasive technique. It consists of elevating the deformity by placing a substernal bar, using at least two small lateral incisions. The surgeon needs a small thoracoscopy camera to monitor the procedure at all times. This bar will be removed in 2-3 years.

See video of the technique.

  • Taulinoplasty or Pectus-Up

Technique of recent appearance (2015) with very good aesthetic results. It consists of sternal traction by placing a small subpectoral bar, thus achieving the correction of the aesthetic defect without entering the pleural cavity. This bar is removed after 3-4 years.

See video of the technique.

As for the techniques that do not modify the thoracic wall, we find:

  • Individualized 3D silicone prosthesis

Based on the data obtained from the patient’s CT scan, a virtual copy of the defect is made in three dimensions. With this copy, a silicone model is built that fits perfectly to the patient’s anatomical defect. It is implanted subpectoral and pre-sternal, so it does not need to enter the pleural cavity.

Just as no two people are alike, no two defects are alike, and each case must be individualized.

Not all therapeutic options are suitable for all types of pectus, so it is important that a thorough assessment of the defect is carried out by a qualified professional, who will determine the technique or techniques most recommended for the patient, achieving the highest possible degree of satisfaction after surgery.