Pectus excavatum is a deformity which is much more common in men than women and consists of a depression of the sternum (breast bone) along with the attached ribs creating a depression of the central portion of the chest. There are many variations of the deformity which may involve only the ribs, or, the sternum and ribs only on one side. The individual affected may not recognize the presence of a deformity until the onset of puberty when the skeletal structures begin to enlarge and assume adult configuration. At that time the sternum and ribs begin to show a depression and angulation that may not have been evident before. (There is another chest deformity called Pectus carinatum (PC or pigeon chest) which produces the reverse problem, that is, a projection of the sternum and attached ribs. This deformity is much less common that Pectus excavatum and requires a different type of surgical correction.) Women may notice that the breast on the side most affected does not enlarge to match to opposite side.
In my practice, the majority of patients with this problem are seen as adults. It is unfortunate that teens who are exhibiting PE are frequently told that it will just go away as they mature. The same statement is made with persistent gynecomastia. Neither is true. Persistent gynecomastia, and PE as well as PC are probably genetic problems that manifest during puberty. They are not going to resolve without surgery and teens along with their parents should be told the truth.
During your consultation, the chest will be examined and a determination made as to whether there is a physical impact to body functions or whether the condition is visual only. Most PE cases do not impact the function of the heart and lungs and therefore correction is “cosmetic”. If there is significant cardiac or pulmonary dysfunction due to the sternal/rib deformity, then correction of the bone deformity is required. However, the vast majority of cases are corrected with a silicone implant to elevate the depressed soft tissue leaving the bones intact. In Pectus excavatum, until the skeleton is mature in the mid to late teens, surgery is best delayed. Should the bones need to be elevated due to compromised physiology, this will be done as soon as the dysfunction is diagnosed. Again, the latter is rare.
All PE cases that are to be corrected with a silicone implant will require that a moulage is done to make an exact casting of the chest and its deformity. The process is simple if lengthy. A two layer cast of the chest is made using dental alginate and common plaster of Paris. This takes about an hour. The result is a negative impression of the chest. The cast is removed and a second layer of plaster is poured into the mold which, when hardened, will product a exact duplicate of the chest and its deformity. At that point, the deformity is corrected with a sculpted wax model that will exactly fill the void and correct the depression of the chest. This wax model will be shipped to a custom silicone implant manufacturer who will produce a sterile silicon implant that will be used at surgery to fill the deformity.
Women frequently find that the developing breasts help to hide this condition if the deformity is slight.
As with all surgery, smoking, certain medicines and most supplements along with alcohol and recreational drugs must be stopped for several weeks prior to surgery. Anabolic steroids including large-dose testosterone should be stopped at least 6 weeks or more prior to surgery. Many drugs and supplements can cause blood not to clot leading to a number of complications. Follow the surgeon’s orders exactly. Be sure to ask ALL of your questions at the initial consultation.
The operation is done usually under a general anesthesia as an outpatient. With a properly shaped and constructed implant ready, a 2 inch incision is made in the midline of the upper abdomen. A pocket is developed under the skin and fascia and above the bones in the area of the chest defect to receive the implant. Implants can be large covering as much as 50% of the chest, or, much smaller depending on the size of the defect. Frequently, breast augmentation is done at the same time to help camouflage the area. A suction drain is usually left in place to assure evacuation of any blood or tissue fluid in the pocket. A compression dressing is placed and the patient sent to the Recovery Room until awake.
Post Surgery and Recovery
Outpatient surgery allows the patient to leave the surgery unit shortly after the operation is complete but that does not mean that he is free to do whatever. Postoperatively the patient should remain in bed for the 24 hours after surgery, getting out of bed only to use the bathroom. Snoozing the first 24 hours is the best thing you can do as it allows the body to begin the healing process immediately and keeps the blood pressure normal so as not to produce bleeding. Pain is usually minimal in PE surgery as no bone or muscle is involved. You will be prescribed something for pain, swelling, muscle spasm and antibiotics usually. Use only as directed and do not take any other medicines or supplements not prescribed. For the first week, you activity will be severely restricted, especially the use of your arms. When pain, swelling and stiffness of surgery decline, your activity level will be increased. Remember, while the incision will heal within 14 days, the area about the implant does not heal for 6 weeks. You do not want to stress that area too early which may result in complications. You may usually return to work in about 2 weeks. Complications can significantly lengthen this recovery time. You will be seen 2-3 days after your surgery, then weekly for 2-3 times, then at 6 weeks, 3 months, 6 months and a year postop.
Risk and Complications
Complications are possible with any surgical procedure. And, while the complication rate with a pectus implant is minimal, you cannot just will them away by refusing to face the possibilities. However, you can reduce their rate of occurrence by following the pre- and post-operative instructions exactly. Most complications of cosmetic surgery procedures are not surgical errors but healing complications that are frequently the results of hematoma (bleeding), seroma (collection of tissue fluid), delayed wound healing, implant dislocation due to excessive early activity, or undesirable results due to miscommunication between doctor and patient (too large, too small, wrong shape).
When budgeting for correction of Pectus excavatum surgery, remember there is the fee for the surgeon, the fee for the moulage, the fee for the implant manufacturer, the cost of the surgery facility and the fee for the anesthesiologist. There are miscellaneous other costs such as lab tests, medications, preop physical, etc. Once you are seen in consult and all factors evaluated, a final cost will be quoted for you. If you would like to get a general range of fees, please call the office at 404-252-3672 and ask for the patient coordinator as she will be able to ascertain your general needs and give you a baseline average cost.