Pectoralis Muscle Transposition in Association with the Ravitch Procedure in the Management of Severe Pectus Excavatum

Pectus excavatum (PE) is the most common congenital chest wall deformity, affecting 1 to 8 in 1,000 live births.1 Indications for the surgical correction of congenital chest wall deformities include functional/physiological, cosmetic, and psychosocial reasons. Palpitations, exertional dyspnea, fatigue, and chest pain are commonly reported symptoms attributed to pectus deformities.2 Many patients report exercise intolerance and increasing limitations in physical activity, which they attribute to their chest deformity. Some patients with PE have been shown to suffer a dynamic restrictive pulmonary process.3 Pectus deformities are often associated with body image issues, especially in patients in their teenage years, and these issues can predispose patients to psychological distress. Surgical repair of pectus deformities was shown to improve both physical limitations and psychosocial well-being in children.3–5 The most common surgical approaches for PE treatment are the modified Ravitch technique and the minimally invasive Nuss technique.4–6 The first technique for PE repair was proposed by Ravitch in 1949 and is an open technique that requires partial resection of the costal cartilage, xiphoid excision, and osteotomy of the sternum.6 Multiple modifications to this procedure have been proposed over time, such as the placement of a metal strut to support the sternum, which is removed within 6 months to 1 year. It was not until nearly half a century later that an alternative surgical option was devised and published.7,8 The goal of the Ravitch procedure is to remove abnormal rib cartilage while preserving the perichondrium, allowing regrowth of the rib cartilage to the sternum in a more anatomic fashion. Other key elements in the operation include performing a sternal osteotomy to allow redirection of the sternum and stabilization of the sternum with a metal bar, when necessary. A modification of the established Ravitch procedure, which is applied to treat symmetric as well as asymmetric forms of PE and carinatum, was established. It requires exposure of the sternum and ribs, removal of abnormal cartilage, and fixation of the sternum in a proper anatomical position with 2 metal bars, 1 inserted into the sternum (Kirschner nail) and 1 perpendicularly (Rush wire) fixed between the bilateral corresponding ribs and the xiphoidal process. The metal bars are left in place for at least a year and then are removed with a second operation. Results have shown this technique to be effective in correcting the deformity but at the expense of a quite invasive and long-lasting surgical procedure associated with 7–10 days of hospitalization and resulting in a long scar on the anterior portion of the chest. Physical activity is also severely restricted for several months as the costal cartilage slowly grows back together. Furthermore, this procedure is associated with a 15%–20% complication rate according to different series.9 A number of complications that can be classified as immediate and late-stage may affect open sternochondroplasty. These complications include hemothorax and pneumothorax, infection, seroma, hardware dislocation, exposure, and eventually inadequate correction or deformity recurrence.9 Early complications may be prevented or solved in most instances (at the expense of a reoperation); however, late complications, such as soft tissue thinning, skin breakdown with hardware exposure, hardware dislocation, and inadequate sternocostal healing, may severely compromise the outcome, posing a relevant clinical challenge (Table ​(Table11). Table 1. Complications of Open Sternochondroplasty