Surgery of thoracic malformations: the experience of Percy Army Hospital

Since 1988, 113 patients have undergone repair of pectus chest deformities in our institution: there were 93 with pectus excavatum (PE)(82%), 18 with pectus carinatum (PC)(16%), and 2 with pectus arcuatum (PA) (2%). All patients underwent sternochondroplasty procedure with a variation of modified Ravitch repair technique. Ninety-two percent of patients considered the result after repair to be perfect. This procedure needs an anterior thoracic approach, with a sufficient mobilization of the skin and the pectoralis muscles up to the angle of Louis, and with the removing of abdominal muscles from lower costal cartilage and xiphoid. Chondrotomies on ribs and even sternotomies with partial resection of sternocostal cartilages were performed to obtain the correction of the deformity. We obtain a real "puzzle" that needs to be stabilized with specific ostheosynthesis material: The Martin and Borelly's kit. These bars are placed under the sternum on his back face with PE and placed across on the anterior of the sternum with PC if necessary. With PA (PE+PC), the material is placed alternatively on the posterior and anterior part of the sternum. Since few years, the pectoralis muscles were reconstructed with an accentuated medialization to cover the middle line in association with costal and cartilaginous repair. All patients underwent a physical preparation with preoperative and postoperative muscular training. Some patients considered initially very longineal and sometimes like "frangible" individual became sportsman and real athletes. In only 4 % of patients, we considered the persistence or recurrent minimal deformities from sternal concavity, generally in patients who didn't practice enough sport. All of them, had new repair using an accentuated medialization of pectoralis muscles, and sometimes we realized a "lipofeeling". Also, 4 patients presented early rupture of the Martin and borelly's material, which was removed generally during few months after intervention. Indeed, broken material retained under posterior part of the sternum, remain certainly a danger for the heart. Also, skin necrosis localized in front of the incision has occurred in 2 patients. They required a healing by granulation. We will remind that nowadays in France an American technique described by Doctor NUSS is also developed. This will be shortly described by our friend Gilles Grosdidier from NANCY. This procedure seems to be particularly adapted for young patients with PE.