Chest Wall Anomalies (Deformities)

Chest wall deformities refer to structural disorders of the chest wall. The most common types of deformities are shoemaker's chest (Pectus excavatum) and pigeon chest (Pectus carinatum).

What is Shoemaker's Chest (Pectus Excavatum)?

The shoemaker's chest refers to the collapse of the faith board and ribs into the rib cage. It is the most common of the chest wall anomalies (deformities). Although it is seen in both children and adults, it is more noticeable in early adolescence.

 

What Causes Shoemaker's Chest (Pectus Excavatum)?

It is a growth incompatibility at the junction of the ribs with the bone (sternum), popularly known as the sternum. The main problem is the incompatibility of growth and development at the cartilage ends of the ribs, i.e. overgrowth. The real cause of this mismatch is not fully known. As a result of this incompatibility, the sternum is pulled backwards and a hollow is formed.

Is Shoemaker's Chest (Pectus Excavatum) Genetic, Inherited?

It occurs in every 300-400 live births. It is 3-4 times more common in men. There is a familial predisposition in the incidence of the disease, meaning that up to 40% of patients with this disease may also have this disease. Severe collapse of the chest wall towards the back may cause heart and lung problems.

What are the Symptoms of Shoemaker's Chest (Pectus Excavatum)?

Symptoms usually become more pronounced at an age of rapid growth and development, but can begin as early as infancy. The most common complaints are chest and back pain and psychological problems.

Physical Symptoms

• Difficulty breathing during exercise
• Lack of strength compared to peers
• Fatigue
• Chest pain
• Irregular heartbeat

Psychological Symptoms

• Embarrassment about the appearance of the breast
• Decreased self-esteem
• Depression

Those who suffer from the above symptoms should be examined by a Pediatric Surgeon or Thoracic Surgeon who deals with this disease.

How is Shoemaker's Chest (Pectus Excavatum) Diagnosed?

The diagnosis of shoemaker's chest is based on the patient's complaints and the physician's physical examination. However, methods such as X-rays to determine the degree of the disease and possible additional disorders, computed tomography and magnetic resonance imaging to examine whether it is pressing on the heart and lungs, and echocardiography to evaluate heart function are used.

There are no specific blood tests etc. However, sometimes radiologic imaging (X-rays) can help to determine the severity of the disease and to detect other related problems, such as scoliosis of the spine. The most useful radiologic imaging method for problems with the heart is a CT scan of the chest. This allows a more precise examination of the displacement of the heart, as well as the degree of sternal rotation (the severity of the depression) caused by pectus asymmetry. This is especially important for patients who are scheduled for surgery.

Does Shoemaker's Chest (Pectus Excavatum) Have Associated Anomalies?

Pectus excavatum may be accompanied by other diseases. The collapse is more severe in cases of Marfan syndrome. In particular, boys with scoliosis should be evaluated in this respect. In addition, Tetralogy of Fallot (a hereditary heart disease) and Mitral Valve Prolapse (prolapse of the mitral valve) may rarely be associated. Pectus excavatum is actually more common in children with musculoskeletal diseases and developmental abnormalities.

How to Treat Shoemaker's Chest (Pectus Excavatum)?

It can be treated with Vacuum Bell and Surgical method (with surgery).

What is Vacuum Bell Therapy and Who is it applied to?

Vacuum Bell; It is the process of pulling the chest wall outward by creating an air cavity with a negative pressure system. It is possible to correct chest deformity without surgery, especially in children. A specially developed Vacuum Bell device is used for this purpose.

The vacuum device, shaped like a rubber bell, is connected to a pump. First, the device is placed in front of the chest, then the air is drawn out of the device with the help of the pump. This creates a suction or vacuum environment that pulls the chest and breastbone forward.

When this device is used regularly over a long period of time, the deformity corrects over time and the chest wall and breastbone begin to stand on their own in the plane they should be in.

Vacuum Bell can be applied to patients of all ages. However, its success may vary depending on the severity of the disease, the age of the patient, the duration of the application and the patient's compliance.

 

What is the Application Method of Vacuum Waist?

The method of application to the device is decided together with the patient's physician, the patient and the family according to the patient's age, compliance, the degree of the disease and the patient's time allocation.

It is usually started with 15 minutes twice a day and usually continued with 45-60 minutes twice a day. However, especially in adult patients and if time is available, it can be applied 2-3 times a day for a few hours.

The patient is called for follow-up at the end of the first month and the patient's compliance with the application and any problems are evaluated. One should not expect a rapid improvement at the end of the first month.

It should be known that the treatment will last at least a year and will usually be completed between 18-24 months. Keeping in touch with your doctor during this period, determining the duration of use and adhering to them will increase the chances of success in treatment.

Is Vacuum Bell Application a Painful Procedure?

No, it is not.

Does Vacuum Bell Therapy Restrict the Social Activity of the Patient?

During the application, the patient must be in a sitting or lying position, otherwise they can continue their normal life and social activities.

What are the Side Effects of Vacuum Bell Therapy?

Initially, there may be some temporary redness on the skin due to the vacuum effect. These also improve with the appropriate cream and continuing the procedure, otherwise no additional side effects are observed.

What is the Success Rate of Vacuum Bell Therapy?

It varies depending on the age of the patient, the degree of the disease and whether the application is performed regularly. In general, success is around 70% in patients under 12 years of age.

To Which Patients Is Surgical Treatment Applied?

In general, unless the patient refuses, Vacuum Bell should be the initial treatment in every patient. In patients with no improvement despite 6 months of treatment, surgical treatment should be performed in patients who do not want Vacuum Bell treatment.

Which Surgical Methods are Applied in Pectus Excavatum?

Many surgical methods have been applied in the historical process. Today, the Nus method, which has the lowest morbidity and mortality and the best success rate, is applied.

What is Nus Surgery and How Is It Performed?

This method is a method of lifting the sternum forward by supporting the back of the depression with a metal bar, without the need to cut or divide the ribs and cartilages.

In appropriate cases, the Nuss operation is the approach to be preferred because it is much less invasive with the thoracoscopic method compared to the classical Ravitch operation, which takes at least 4 hours, is completed in as little as 30 minutes, the incision is aesthetic, postoperative patient comfort is increased and the discharge time is fast.

 

What is the Process After NUS Surgery?

After the shoemaker's breast surgery, patients are hospitalized in the hospital for an average of 3-5 days depending on their condition. Pain is normal for the first 3 days. However, this can be minimized with intravenous painkiller treatment. Patients discharged from the hospital are asked to rest at home for 2-3 weeks.

What is the Recovery Process After NUS Surgery?

• Sudden movements should be avoided to prevent any displacement of the inserted rod.
• In the first 1 month, the patient should not bend at the waist and should not turn sideways at the waist.
• When getting out of bed or standing up, you should be assisted by someone, and no weight should be placed on the chest.
• For the first month, you should sleep on your back.
• Light walks can be done to gain strength.
• Light sportive activities can be started from the third month. It is recommended to start sports such as running, tennis and swimming after the sixth month.

When are the bars removed?

This depends on the age of the patient and the condition of the chest wall. Accordingly, removal of the bars is possible within 2-4 years. This procedure takes about 30 minutes and is performed under general anesthesia.

When Does the Patient Return to Normal Social Life After NUS Surgery?

Patients are hospitalized for an average of 4-5 days after surgery. No intervention is required except for relieving the pain that may occur during this period. After discharge, they may need family support at home for another 2-3 weeks. It may take 1-1.5 months to fully return to school/work.

What is the Best Age for Pectus Excavatum Surgery?

The ideal age range for surgical correction of the shoemaker's breast is 7-14 years. It is important to perform the surgery before puberty, as the rib cage can take its normal shape more easily during the rapid growth period.

Pigeon Chest (Pectus Carinatum);

Pigeon breast refers to the outward protrusion of the breastbone and ribs. It is the opposite deformity of the shoemaker's chest. It occurs when the cartilages that connect the ribs to the sternum deteriorate.

Pigeon breast, which is more common in men than women, usually begins to manifest itself after puberty and increases in severity with age. Although it is not known exactly why pigeon breast occurs, genetic predisposition is important.

 

 

What are the Symptoms of Pigeon Chest?

The symptoms of pigeon breast can vary from person to person, depending on the level of the disease.

These include

• Fatigue
• Difficulty breathing
• Chest pain
• Rapid heartbeat
• Recurrent respiratory infections

How is Pigeon Chest (Pectus Carinatum) Diagnosed?

As with shoemaker's chest, pigeon breast can be diagnosed by physical examination. In addition, frontal and lateral X-rays, computed tomography and magnetic resonance imaging can be added to the diagnostic process.

In addition to pigeon chest, echocardiography may also be ordered if an irregular heartbeat is detected during the diagnostic process.

What are the Treatment Methods for Pigeon Chest?

In the treatment of pigeon breast, two forms of treatment come to the fore depending on the severity of the disease and the patient's condition. These are corset treatment and surgical treatment.

What is Corset Treatment, How is it Applied?

The function of the corset used in pigeon breast treatment is similar to that of dental aligners. Worn over the chest, the corset presses on the ribs and the bone of faith from both the back and the front. Thus, over time, the breast bones return to their normal position.

The patient is recommended to wear the corset for 18-20 hours a day for 2 years. The corset can be removed only when taking a shower, doing sports or other activities.

In order to increase the success of the treatment, it is important to pay attention to the duration of corset use and to follow the doctor's recommendations.

 

What is the Success Rate of Corset Treatment?

It varies depending on the age of the patient, the severity of the disease and the patient's compliance with the treatment. In general, with regular corset use for 2 years, it is possible to cure pigeon breast in 70 percent of cases.

What are the Surgical Treatment Methods for Pigeon Chest?

Tarih boyunca birçok cerrahi yöntem kullanılmıştır. Ancak günümüzde yaygın olarak Modifiye Ravitch Ameliyatı, Abramson Ameliyatı yapılır.

Modified Ravitch Surgery;

For this procedure, an incision is made in the middle chest area. The abnormal cartilage is removed and the rib cage is pushed downwards. In addition, if necessary, a temporary metal bar is placed over the chest to keep the rib cage in the desired plane.

The length of hospital stay after this painful procedure varies depending on the patient's condition and pain control.

Abramson Surgery

Abramson surgery is a minimally invasive procedure performed through small incisions. It takes about 30-45 minutes and general anesthesia is applied.

During the operation, small incisions are made on both sides of the chest, as in Nuss surgery. Through these incisions, the lorenz bar, previously prepared specifically for the patient, is inserted between the faith board and the muscle tissue and pressed down. The operation ends when the bar is fixed to the ribs on both sides of the chest wall.

After Surgery

1. Patients are usually asked to stay in hospital for 4-5 days. During this time, the aim is to control the pain.
2. It is important to avoid sudden movements.
3. Routine life can be resumed within 2-3 weeks, and children can start school after two weeks.
4. In consultation with the doctor, only walking may be allowed for the first month; sports such as swimming, running and tennis between 1-3 months; and other professional sports after 6 months.

When to Remove the Lorenz Bar?

The surgically placed Lorenz bar;

• 2-3 years later in people younger than 18 years,
• 3-4 years later in people older than 18 years,

is removed in a 30-45 minute procedure under general anesthesia.

***The information provided here, the content of the website is organized for the purpose of informing the visitor, especially the families, and no information should be considered as advice by the visitors and should not lead to any decision or action. Families should definitely have their patient examined by a pediatric surgery specialist, consult with him/her and make a decision by consulting his/her one-on-one information.