View 3D of a Pectus Excavatum with implant

What is Pectus Excavatum?

Author : Pr Jean-Pierre Chavoin, ex-Head of Plastic Surgery Department of Toulouse University Hospital, ex-President and General Secretary of French Plastic Surgery Society

Pectus Excavatum is a malformation of the thorax characterised by a median or lateral depression of the sternum. Funnel chest occurs in 1 to 2% of the population. The deformity get more obvious during the growth.

It is the most common deformity of the thorax (95% to 97% of cases [1]) with between 1/300 to 1/1000 births concerned per year worldwide [2].

Population, symptoms and causes of Pectus Excavatum 

Anyone can be affected by the condition. The scientific literature estimates that men are four times more likely to develop the condition than women. Pectus Excavatum is characterised by insufficient or excessive growth of the bony and/or cartilage structures of the rib cage. It affects the second part of the sternum and invades the cartilages from the third rib to the eighth rib. Scoliosis is often associated with the deformation.

Its aetiology has not allowed the causes and origin of the condition to be determined. The hereditary nature of the deformation is clear, as some 40% of those affected have a family member with the same condition[3].

Classification of Pectus Excavatum

The Chin classification categorizes the different types of Pectus Excavatum according to their morphological characteristics.

  • CHIN 1: the malformation is symmetrical, deep and focused on the sternum.

Type 1 Pectus Excavatum draw

Haller index of a type 1 Pectus Excavatum

3D view of a type 1 Pectus Excavatum

Type 1 Pectus Excavatum on a woman

Type 1 Pectus Excavatum on a man

3D view of a type 1 Pectus Excavatum with implant

  • CHIN 2: the malformation is symmetrical, shallower and extends to the pectoral regions.

Type 2 Pectus Excavatum draw

Haller index of a type 2 Pectus Excavatum

3D view of a type 2 Pectus Excavatum

Type 2 Pectus Excavatum on a woman

Type 2 Pectus Excavatum on a man

3D view of a type 2 Pectus Excavatum with implant

  • CHIN 3: the malformation is asymmetrical and extends to the pectoral regions. The deviation is most often on the right side.

Type 3 Pectus Excavatum draw

Haller index of a type 3 Pectus Excavatum

3D view of a type 3 Pectus Excavatum

Type 3 Pectus Excavatum on a woman

Type 3 Pectus Excavatum on a man

3D view of a type 3 Pectus Excavatum with implant

 

There are other types of Pectus Excavatum not defined in the Chin Classification.

  • Pectus Arcuatum: Congenital chest malformation that lifts the upper part of the sternum transversely. An arch is formed by the protrusion of the upper part of the sternum and the adjacent costal cartilages, which induces a medial trough called the sternal trough.
  • Mixed Pectus Excavatum: Pectus Excavatum mixing several types of Chin's classification. For example, the right side with a Chin 1 and the left side with a Chin 3 because it is more extended on the pectoral region. 

The Haller index allows measurement of the defect and Pectus Excavatum depth especially in women where the deformation is hard to evaluate because of the breast volume. The higher the Haller index, the deeper the Pectus Excavatum.

Does Pectus have a functional impact?

List of tests to measure Pectus Excavatum functional impact

Various studies have been conducted to determine whether this chest deformation affects patients' lung and heart capacities. While some researchers such as Malek MH, Berger DE and Marelich WD [4] have demonstrated a cardiovascular impact, others discount the hypothesis on the same bases (Guntheroth WG, Spiers PS)[5].

The works of Louis Daussy[6] (pulmonary) and Samir Shah[7] (cardiovascular) indicate that a sunken chest does not prevent a person from having a normal life. This is because the body and its organs develop alongside the condition and adapt to the malformation during growth.

Normally, the condition has no repercussion on cardiac or respiratory function, although this may be due to a restriction on physical activity caused by an altered body image.

If anything is uncertain during the clinical exam, a series of cardiopulmonary tests can determine the most appropriate surgical technique.

Psychological impact of Pectus Excavatum

Funnel chest is often difficult to accept both physically and psychologically. It also affects the patient's self-confidence and causes discomfort – sometimes profound – which can result in a complex. The psychological repercussions are especially important during adolescence, disrupting self-image and social relationships, and sometimes directly affecting the patient's ability to play sport.

The complex affects both men and women, regardless of the degree to which the condition causes the chest to sink. Patients limit activities and pastimes that involve exposing their chest, such as swimming, group sports and going to the beach...

Treatment

Cas clinique

Correction d'une asymétrie mammaire due au Pectus par le Dr Bettex

Cas clinique du Dr Bettex

Diagnostic et Correction d’un thorax en entonnoir et d’une asymétrie mammaire chez une jeune fille par le Dr Bettex à Marseille.

La patiente, une jeune fille de 17 ans, lycéenne et sportive, présente une asymétrie mammaire qui a un impact psychologique sur elle. L'examen clinique permet d'identifier un Pectus de type 3 avec une sévère dépression thoracique droite.

Elle n'a pas besoin d'implant mammaire pour compenser son asymétrie de la poitrine mais plutôt d'un implant de comblement au niveau du thorax pour combler la dépression sternale induite par la pathologie.

Après avoir évoqué la technique du lipofilling, elle opte finalement pour la solution de l'implant 3D sur-mesure pour corriger son défaut.

Lire la suite

Interview

Interview des Pr Assouad & Dr Debrosse sur le Pectus Excavatum

"[...] les patients éligibles pour lesquels on propose d’utiliser la technique de l’implant sur-mesure il faut impérativement leur faire un bilan fonctionnel cardiaque et respiratoire complet, il faut aller jusqu’au test d’effort parce que on ne peut pas confirmer la pose de l’implant sans vérifier qu’il n’y a pas de retentissement même s’ils sont sportifs"

"Jusqu’à l’arrivée de cette technique, on remettait le sternum à sa place avec une chirurgie osseuse où il fallait couper les cartilages, couper les côtes et relever le sternum. C’était donc une chirurgie lourde et douloureuse. Il y a une autre technique qui consiste à mettre une barre dans le thorax, représentant aussi une chirurgie lourde et désagréable."

"On est vraiment dans une chirurgie pour le coup peu invasive où on ne va pas du tout toucher au thorax osseux et donc source de beaucoup moins de douleur en post-opération et avec un résultat définitif quasiment immédiat."

"Je pense qu’il faut peut-être remettre en question ce qu’on dit sur l’impact fonctionnel des Pectus Excavatum : personnellement jusqu’à maintenant je n’en ai pas vu malgré les bilans qu’on a pu faire. Alors pourquoi vouloir corriger un thorax osseux que les patients ont eu pendant 20, 30 voire même parfois 40 ans, pourquoi vouloir les casser, provoquer des douleurs quand, avec une technique simple, on peut les corriger."