0
1992 The British Association of Plamc Surgeons
Improved chest wall fixation for correction of pectus excavatum M. L. Bentz and J. W. Futrell Dirkion
of Plastic and Reconstructive
Surgery,
Unkersity
of Pittsburgh
School of Medicine,
Pittsburgh,
USA
SUMMARY. Pectns excavatnm, the most common congenital chest wall abnormality, is manifested by deformity of the costal cartilages resulting in a depressed and often rotated sternum. Although there are conflicting data to support and reject the concept that physiologic improvement can be a consequence of surgical repair, correction is frequently indicated for aesthetic improvement alone. The most popular current repair involves resection of abnormal costal cartilages, sternal osteotomy and mobilisation, followed by fixation of the sternum in the corrected position. Improved fixation techniques have evolved, but generally have not employed current concepts of rigid fixation. The correction of pectns excavatnm using reconstruction plates incorporates the benefits of rigid fixation, while allowing custom chest wall contouring and sternal reorientation. Reconstruction plate fixation of the sternum should be considered during correction of pectns excavatnm in adult and adolescent patients.
Electrocardiography documented a sinus arrhythmia. He underwent operative correction without further preoperative evaluation. Intraoperatively, a vertical midsternal incision was made, followed by bilateral pectoralis major muscle elevation. Bilateral subperichondral resection of the abnormal costal cartilages of ribs four to seven was then performed. Following posterior monocortical sternal osteotomy and anterior sternal mobilisation, placement of an autogenous rib bone graft into the osteotomy site was accomplished.
Plastic surgeons should play a more active role in the surgery of congenital chest wall deformities. Principles and techniques of reconstructive plastic surgery form the essence of the surgical correction of pectus deformities. Reconstruction of these challenging anomalies involves mobilisation of muscle flaps, resection of abnormal cartilagenous and occasionally osseous structures, restoration of normal anatomic contour. and sternal fixation in the correct anatomic position. Correction of pectus excavatum, the most common congenital chest wall deformity (Ravitch, 1977) incorporates all of these for the improvement of form and possibly function. Although there are multiple surgical approaches to the abnormal costal cartilages responsible for pectus excavatum, the most popular repair involves subperichondral resection of abnormal costal cartilages, anterior sternal mobilisation, sternal osteotomy, and sternal fixation in the corrected position (Ravitch, 1977). Improved fixation techniques should incorporate the benefits of rigid plate fixation, allowing custom chest wall contouring and precise sternal reorientation. Reconstruction plate fixation of the sternum should be considered during correction of pectus excavatum in older adolescent and adult patients.
Rigid sternal fixation in the corrected position was then achieved using three dimensional mandibular reconstruction plates (Howmedica-Luhr, Rutherford, NJ). One plate was placed vertically in the upper midline to maintain the corrected sagittal orientation. Two other plates were contoured and placed transversely from rib to sternum to span the deficit created by cartilage resection (Fig. 3). The pectoralis muscles were re-inset over closed suction drainage catheters, following which the incision was closed. A postoperative chest radiograph demonstrated no pneumothorax, but did identify the baseline orientation of the reconstruction plates (Fig. 4). At 10 postoperative months, he maintains an excellent chest wall contour (Fig. 5) with unrestricted activity, including bench pressing 225 pounds.
Discussion Most patients with the congenital deformity of pectus excavatum eventually seek medical attention due to awareness and concern about their appearance. Therefore, correction is usually indicated for aesthetic improvement. Though some investigators suggest that operative attention to pectus excavatum results in improved physiologic function (Beiser et al., 1972; Cahill et al., 1984), there are also data to refute significant physiologic improvement (Peterson et al., 1985). Reported surgical correction has been achieved by extrathoracic silicone mould placement (Lavey et al., 1982; Marks et al., 1984) costal cartilage sculpting (Spear et al., 1987). transsternal metal strut placement without sternal osteotomy (Wesselhoeft and DeLuca,
Case report A 27-year-old male weight lifter presented for evaluation
of a pectus excavatum deformity, after having unsuccessfully attempted to improve his chest wall contour by weight training. He noted no exercise limitation and was asymptomatic from a cardiovascular standpoint, but requested correction for aesthetic improvement. Physical examination revealed a moderately severe pectus deformity with slight sternal rotation (Fig. 1). Cardiopulmonary examination was unremarkable. A chest radiograph demonstrated cardiac displacement into the left hemithorax, while computerised tomography defined sternal rotation, costochondral deformity. and mediastinal displacement (Fig. 2). 367
368
British Journal
Fig. 1
Fig. 2
Figure l--Oblique preoperative view of the pectus excavatum deformity. Figure 2-Computerised rotation, cardiac displacement into the left hemithorax, and abnormal costal cartilage segments.
1982), pedicled sternal eversion (Hawkins et al., 1984), and free sternal rotation with microsurgical revascularisation (Hirayama et al., 1985). The most popular correction involves subperichondral resection of the abnormal costal cartilages, posterior monocortical sternal osteotomy, placement of an autogenous bone graft into the osteotomy site, anterior sternal mobilisation, and sternal fixation in the corrected position. The chest wall can be approached through a vertical midsternal incision, or through an inframammary incision. The inframammary incision is ideal for female patients as the scar is more easily concealed (Bentz and Dunn, 1987). However, in patients with undeveloped or developing breasts, the inframammary incision must be carefully designed to avoid injury to the breast parenchyma (Hougaard and Arendrup, 1983). Techniques of sternal fixation, after the restoration of normal chest wall contour, include the use of wires (Rehbein and Wernicke, 1957), rib struts (Haller et al., 1989), metal struts (Adkins and Blades, 1961; Wesselhoeft and DeLuca, 1982), Steinmann pins (Davies, 1986), synthetic mesh, and plates. Although less popular, correction without sternal fixation has also been described (Hecker rt al., 1981). Plate fixation using osteosynthetic plates was originally described by Gotzen (1979), and later by Watanabe (Watanabe and Takashi, 1984) and Takagi (Takagi and Yamaga, 1986). Gotzen reported the first four patients with pectus excavatum who were surgically corrected by A0 plate fixation of the sternum. Watanabe subsequently employed A0 plate fixation in 31 patients, removing the plates 12-18 months later. Takagi incorporated a Zimmer osteosynthetic plate in 12 patients. and similarly removed all of the plates. In this case, three mandibular reconstruction plates were employed, allowing custom chest wall contouring. One was placed in the vertical upper midline to stabilise the posterior osteotomy that permitted anterior sternal mobilisation. Two were fixed trans-
of Plastic Surgery
tomography
reveals the extent of sternal
versely, after three-dimensional contouring, to fix the mobile sternum to the intact lateral ribs. We believe that this approach offers the optimal available fixation for the correction of pectus excavatum and other chest wall anomalies. The ability to contour these plates in multiple dimensions is advantageous, as the pectus deformities represent three-dimensional reconstructive problems. In addition, current technology has evolved to provide strong, rigid, bony fixation with a low profile and minimally palpable plate. There are limited disadvantages to the use of reconstruction plate fixation. Infection problems associated with the use of synthetic material are at least a theoretical disadvantage. Infection complications and plate exposure should be minimal, with careful layered closure. including pectoralis major muscle coverage of the plates. In an older adolescent or adult patient, expansion of the chest wall is not impeded by the presence of transversely oriented plates, and thoracic growth inhibition is not an issue. However, potential growth inhibition is an indication to apply other means of transverse fixation for paediatric patients with growing thoracic cages. Vertical plate fixation, however, should be applicable for any age patient. One issue that remains unresolved is the fate of reconstruction plates after the chest wall is healed and stable. Plastic surgeons should become more involved in the care of patients with congenital chest wall deformities. The reconstruction of these interesting anomalies involves principles and techniques that are basic to plastic and reconstructive surgery. The repair of pectus excavatum is based on the resection of abnormal costal cartilage segments followed by rigid sternal fixation to maintain the corrected chest wall contour. Current reconstruction plate technology provides the ability to fix the sternum rigidly in three dimensions using a low profile system, and should be considered in the correction of pectus excavatum in adolescents and adults.
Improved
Chest
Wall
Fixation
for Correction
of Pectus
369
Excavatum
Fig. 4
Fig. 3
Fig. 5 Figure 3-Vertically oriented reconstruction plate stabilises the sternum over the osteotomy site after anterior mobilisation. Horizontally oriented reconstruction plates rigidly fix the inferior sternum and lateral chest wall. Figure &Postoperative chest radiograph identifies plate of pectus excavatum, positions and excludes pneumothoraces. Figure %Oblique postoperative view, six months after correction demonstrates the improved aesthetic chest wall contour which is maintained in spite of weight training.
References Adkins, P. C. and Blades, B. (1961). A stainless steel strut for correction of pectus excavatum. Surgery. Gynecology and Obsrerrics,
113, 1 I I.
Beiser, G. D., Epstein, S. E., Stampfer, M. Goldstein, R. E., Noland, S. P. and Levitsky, S. (1972). Impairment of cardiac function in patients with pectus excavatum. with improvement after operative correction. New England Journal qf Medicine, 287, 267. Bentz, M. L. and Dunn, J. (1987). The inframammary incision for median sternotomy in pediatrics. Journal qf CardiacSurgery. 2. 499.
209, 578.
Hawkins, J. A., Ehrenhaft, J. L. and Doty, D. B. (1984). Repair of pectus excavatum by sternal eversion. Annals qf Thorucic Surgery. 38. 368.
Cahill, J. L., Lees, G. M. and Robertson, H. T. (1984). A summary of preoperative and postoperative cardiorespiratory performance in patients undergoing pectus excavatum repair. Journal of Pediarric
Steinmann pin strut technique. Delaware Medical Journal. 58, 733. Gotzen, L. and Dragojevic, D. C1979). Funnel chest correction by use of A0 implants and instruments. Thorrccic and Cordiocmwhr Surgery, 27, 6 1. Hailer, J. A., Scherer, L. R., Turner, C. S. and Colombani. P. M. (1989). Evolving management of pectus excavatum based on a single institutional experience of 664 patients. Annals of Surgery.
Surgery,
19, 430.
Davies, A. L. (1986). Repair ofpectus
excavatum
employing
internal
Hecker, W. C., Percher, G. and Dietz, H. G. (1981). Ergebnisse operativer korrektur von keilund trichterbrust nach einer modifizierten operation-stechnik von Ravitch und Hailer. Zeitschrifi ,fi‘r Kinderchirurgie. 34, 220. Hirayama, T., Nozaki, M. and Wakamatsu, S. (1985). A new surgical
370 method for repair of funnel chest. Anr~uls oJ Plustic Surgery. 14, 213. Hougaard, K. and Arendrup, H. (1983). Deformities of the female breast after surgery for funnel chest. Scandinaoia~ Journal q/ Thoracic and Cardiorlascular Surgery. 17. 171. Lavey, E. L., Apfelberg, D. B., Lash, H., Maser, M. R., Laub, D. R. and Gosain, A. (1982). Customized silicone implants of the breast and chest. Plastic and Reconstructioe Surgery, 69, 646. Marks, M. W., Argenta, L. C. and Lee, D. C. (1984). Silicone implant correction of pectus excavatum : indications and refinements in technique. Plastic and Reconstructire Surgery, 74, 52. Peterson, R. J., Young, C., Godwin, J. D., Sahiston, D. C. and Jones, R. H. (I 985). Noninvasive assessment of exercise cardiac function before and after pectus excavatum repair. Journal ofThoracicand Cardiorascular Surgery. 90. 25 1. Ravitch, M. M. (1977). Congenital deformities of the chest wall and their operalive correction. Philadelphia, Saunders, p. 708. Rehbein, F. and Wernicke, H. H. (1957). The operative treatment of the funnel chest. Archives ofDiseases in Childhood, 32, 5. Spear, S. L., Romm, S., Hakki, A. and Little, J. W. (1987). Costa1 cartilage sculpting as an adjunct to augmentation mammaplasty. Plastic and Reconstructire Surgery. 79. 921. Takagi, K. and Yamaga, M. (1986). A new modified operation for funnel chest using Zimmer osteosynthetic plate. Archioes of Orthopaedic arld Traumatic Surgery, 105. 154.
British
Journal
of Plastic
Surecrv
Watanabe, Y. and Takashi, I. (1984). Surgical correction of pectus excavatum for adults and adolescents. Japanese Journal c!f Surgery, 14, 472. Welch, K. J. and Shamberger, R. C. (1987). Surgical repair of anterior chest wall deformities. Surgical Rounds, August, 19. Wesselhoeft, C. W. and DeLuca, F. G. (1982). A simplified approach to the repair of pediatric pectus deformities. Annuls qf Thoracic Surgery, 34. 640.
The Authors Michael L. Be&, MD, Assistant Professor of Surgery J. William Futrell, MD, Professor and Chief
(Plastic)
Division of Plastic and Reconstructive Surgery, University of Pittsburgh School of Medicine, Pittsburgh. Pennsylvania, USA Requests for reprints to: Dr M. L. Bentz, MD, Division of Plastic and Reconstructive Surgery, University of Pittsburgh, Scaife Hall 662. Pittsburgh, Pennsylvania 15261. USA Paper received 12 December 199 I. Accepted 11 February 1992. after revision.
1992 The British Association of Plamc Surgeons
Improved chest wall fixation for correction of pectus excavatum M. L. Bentz and J. W. Futrell Dirkion
of Plastic and Reconstructive
Surgery,
Unkersity
of Pittsburgh
School of Medicine,
Pittsburgh,
USA
SUMMARY. Pectns excavatnm, the most common congenital chest wall abnormality, is manifested by deformity of the costal cartilages resulting in a depressed and often rotated sternum. Although there are conflicting data to support and reject the concept that physiologic improvement can be a consequence of surgical repair, correction is frequently indicated for aesthetic improvement alone. The most popular current repair involves resection of abnormal costal cartilages, sternal osteotomy and mobilisation, followed by fixation of the sternum in the corrected position. Improved fixation techniques have evolved, but generally have not employed current concepts of rigid fixation. The correction of pectns excavatnm using reconstruction plates incorporates the benefits of rigid fixation, while allowing custom chest wall contouring and sternal reorientation. Reconstruction plate fixation of the sternum should be considered during correction of pectns excavatnm in adult and adolescent patients.
Electrocardiography documented a sinus arrhythmia. He underwent operative correction without further preoperative evaluation. Intraoperatively, a vertical midsternal incision was made, followed by bilateral pectoralis major muscle elevation. Bilateral subperichondral resection of the abnormal costal cartilages of ribs four to seven was then performed. Following posterior monocortical sternal osteotomy and anterior sternal mobilisation, placement of an autogenous rib bone graft into the osteotomy site was accomplished.
Plastic surgeons should play a more active role in the surgery of congenital chest wall deformities. Principles and techniques of reconstructive plastic surgery form the essence of the surgical correction of pectus deformities. Reconstruction of these challenging anomalies involves mobilisation of muscle flaps, resection of abnormal cartilagenous and occasionally osseous structures, restoration of normal anatomic contour. and sternal fixation in the correct anatomic position. Correction of pectus excavatum, the most common congenital chest wall deformity (Ravitch, 1977) incorporates all of these for the improvement of form and possibly function. Although there are multiple surgical approaches to the abnormal costal cartilages responsible for pectus excavatum, the most popular repair involves subperichondral resection of abnormal costal cartilages, anterior sternal mobilisation, sternal osteotomy, and sternal fixation in the corrected position (Ravitch, 1977). Improved fixation techniques should incorporate the benefits of rigid plate fixation, allowing custom chest wall contouring and precise sternal reorientation. Reconstruction plate fixation of the sternum should be considered during correction of pectus excavatum in older adolescent and adult patients.
Rigid sternal fixation in the corrected position was then achieved using three dimensional mandibular reconstruction plates (Howmedica-Luhr, Rutherford, NJ). One plate was placed vertically in the upper midline to maintain the corrected sagittal orientation. Two other plates were contoured and placed transversely from rib to sternum to span the deficit created by cartilage resection (Fig. 3). The pectoralis muscles were re-inset over closed suction drainage catheters, following which the incision was closed. A postoperative chest radiograph demonstrated no pneumothorax, but did identify the baseline orientation of the reconstruction plates (Fig. 4). At 10 postoperative months, he maintains an excellent chest wall contour (Fig. 5) with unrestricted activity, including bench pressing 225 pounds.
Discussion Most patients with the congenital deformity of pectus excavatum eventually seek medical attention due to awareness and concern about their appearance. Therefore, correction is usually indicated for aesthetic improvement. Though some investigators suggest that operative attention to pectus excavatum results in improved physiologic function (Beiser et al., 1972; Cahill et al., 1984), there are also data to refute significant physiologic improvement (Peterson et al., 1985). Reported surgical correction has been achieved by extrathoracic silicone mould placement (Lavey et al., 1982; Marks et al., 1984) costal cartilage sculpting (Spear et al., 1987). transsternal metal strut placement without sternal osteotomy (Wesselhoeft and DeLuca,
Case report A 27-year-old male weight lifter presented for evaluation
of a pectus excavatum deformity, after having unsuccessfully attempted to improve his chest wall contour by weight training. He noted no exercise limitation and was asymptomatic from a cardiovascular standpoint, but requested correction for aesthetic improvement. Physical examination revealed a moderately severe pectus deformity with slight sternal rotation (Fig. 1). Cardiopulmonary examination was unremarkable. A chest radiograph demonstrated cardiac displacement into the left hemithorax, while computerised tomography defined sternal rotation, costochondral deformity. and mediastinal displacement (Fig. 2). 367
368
British Journal
Fig. 1
Fig. 2
Figure l--Oblique preoperative view of the pectus excavatum deformity. Figure 2-Computerised rotation, cardiac displacement into the left hemithorax, and abnormal costal cartilage segments.
1982), pedicled sternal eversion (Hawkins et al., 1984), and free sternal rotation with microsurgical revascularisation (Hirayama et al., 1985). The most popular correction involves subperichondral resection of the abnormal costal cartilages, posterior monocortical sternal osteotomy, placement of an autogenous bone graft into the osteotomy site, anterior sternal mobilisation, and sternal fixation in the corrected position. The chest wall can be approached through a vertical midsternal incision, or through an inframammary incision. The inframammary incision is ideal for female patients as the scar is more easily concealed (Bentz and Dunn, 1987). However, in patients with undeveloped or developing breasts, the inframammary incision must be carefully designed to avoid injury to the breast parenchyma (Hougaard and Arendrup, 1983). Techniques of sternal fixation, after the restoration of normal chest wall contour, include the use of wires (Rehbein and Wernicke, 1957), rib struts (Haller et al., 1989), metal struts (Adkins and Blades, 1961; Wesselhoeft and DeLuca, 1982), Steinmann pins (Davies, 1986), synthetic mesh, and plates. Although less popular, correction without sternal fixation has also been described (Hecker rt al., 1981). Plate fixation using osteosynthetic plates was originally described by Gotzen (1979), and later by Watanabe (Watanabe and Takashi, 1984) and Takagi (Takagi and Yamaga, 1986). Gotzen reported the first four patients with pectus excavatum who were surgically corrected by A0 plate fixation of the sternum. Watanabe subsequently employed A0 plate fixation in 31 patients, removing the plates 12-18 months later. Takagi incorporated a Zimmer osteosynthetic plate in 12 patients. and similarly removed all of the plates. In this case, three mandibular reconstruction plates were employed, allowing custom chest wall contouring. One was placed in the vertical upper midline to stabilise the posterior osteotomy that permitted anterior sternal mobilisation. Two were fixed trans-
of Plastic Surgery
tomography
reveals the extent of sternal
versely, after three-dimensional contouring, to fix the mobile sternum to the intact lateral ribs. We believe that this approach offers the optimal available fixation for the correction of pectus excavatum and other chest wall anomalies. The ability to contour these plates in multiple dimensions is advantageous, as the pectus deformities represent three-dimensional reconstructive problems. In addition, current technology has evolved to provide strong, rigid, bony fixation with a low profile and minimally palpable plate. There are limited disadvantages to the use of reconstruction plate fixation. Infection problems associated with the use of synthetic material are at least a theoretical disadvantage. Infection complications and plate exposure should be minimal, with careful layered closure. including pectoralis major muscle coverage of the plates. In an older adolescent or adult patient, expansion of the chest wall is not impeded by the presence of transversely oriented plates, and thoracic growth inhibition is not an issue. However, potential growth inhibition is an indication to apply other means of transverse fixation for paediatric patients with growing thoracic cages. Vertical plate fixation, however, should be applicable for any age patient. One issue that remains unresolved is the fate of reconstruction plates after the chest wall is healed and stable. Plastic surgeons should become more involved in the care of patients with congenital chest wall deformities. The reconstruction of these interesting anomalies involves principles and techniques that are basic to plastic and reconstructive surgery. The repair of pectus excavatum is based on the resection of abnormal costal cartilage segments followed by rigid sternal fixation to maintain the corrected chest wall contour. Current reconstruction plate technology provides the ability to fix the sternum rigidly in three dimensions using a low profile system, and should be considered in the correction of pectus excavatum in adolescents and adults.
Improved
Chest
Wall
Fixation
for Correction
of Pectus
369
Excavatum
Fig. 4
Fig. 3
Fig. 5 Figure 3-Vertically oriented reconstruction plate stabilises the sternum over the osteotomy site after anterior mobilisation. Horizontally oriented reconstruction plates rigidly fix the inferior sternum and lateral chest wall. Figure &Postoperative chest radiograph identifies plate of pectus excavatum, positions and excludes pneumothoraces. Figure %Oblique postoperative view, six months after correction demonstrates the improved aesthetic chest wall contour which is maintained in spite of weight training.
References Adkins, P. C. and Blades, B. (1961). A stainless steel strut for correction of pectus excavatum. Surgery. Gynecology and Obsrerrics,
113, 1 I I.
Beiser, G. D., Epstein, S. E., Stampfer, M. Goldstein, R. E., Noland, S. P. and Levitsky, S. (1972). Impairment of cardiac function in patients with pectus excavatum. with improvement after operative correction. New England Journal qf Medicine, 287, 267. Bentz, M. L. and Dunn, J. (1987). The inframammary incision for median sternotomy in pediatrics. Journal qf CardiacSurgery. 2. 499.
209, 578.
Hawkins, J. A., Ehrenhaft, J. L. and Doty, D. B. (1984). Repair of pectus excavatum by sternal eversion. Annals qf Thorucic Surgery. 38. 368.
Cahill, J. L., Lees, G. M. and Robertson, H. T. (1984). A summary of preoperative and postoperative cardiorespiratory performance in patients undergoing pectus excavatum repair. Journal of Pediarric
Steinmann pin strut technique. Delaware Medical Journal. 58, 733. Gotzen, L. and Dragojevic, D. C1979). Funnel chest correction by use of A0 implants and instruments. Thorrccic and Cordiocmwhr Surgery, 27, 6 1. Hailer, J. A., Scherer, L. R., Turner, C. S. and Colombani. P. M. (1989). Evolving management of pectus excavatum based on a single institutional experience of 664 patients. Annals of Surgery.
Surgery,
19, 430.
Davies, A. L. (1986). Repair ofpectus
excavatum
employing
internal
Hecker, W. C., Percher, G. and Dietz, H. G. (1981). Ergebnisse operativer korrektur von keilund trichterbrust nach einer modifizierten operation-stechnik von Ravitch und Hailer. Zeitschrifi ,fi‘r Kinderchirurgie. 34, 220. Hirayama, T., Nozaki, M. and Wakamatsu, S. (1985). A new surgical
370 method for repair of funnel chest. Anr~uls oJ Plustic Surgery. 14, 213. Hougaard, K. and Arendrup, H. (1983). Deformities of the female breast after surgery for funnel chest. Scandinaoia~ Journal q/ Thoracic and Cardiorlascular Surgery. 17. 171. Lavey, E. L., Apfelberg, D. B., Lash, H., Maser, M. R., Laub, D. R. and Gosain, A. (1982). Customized silicone implants of the breast and chest. Plastic and Reconstructioe Surgery, 69, 646. Marks, M. W., Argenta, L. C. and Lee, D. C. (1984). Silicone implant correction of pectus excavatum : indications and refinements in technique. Plastic and Reconstructire Surgery, 74, 52. Peterson, R. J., Young, C., Godwin, J. D., Sahiston, D. C. and Jones, R. H. (I 985). Noninvasive assessment of exercise cardiac function before and after pectus excavatum repair. Journal ofThoracicand Cardiorascular Surgery. 90. 25 1. Ravitch, M. M. (1977). Congenital deformities of the chest wall and their operalive correction. Philadelphia, Saunders, p. 708. Rehbein, F. and Wernicke, H. H. (1957). The operative treatment of the funnel chest. Archives ofDiseases in Childhood, 32, 5. Spear, S. L., Romm, S., Hakki, A. and Little, J. W. (1987). Costa1 cartilage sculpting as an adjunct to augmentation mammaplasty. Plastic and Reconstructire Surgery. 79. 921. Takagi, K. and Yamaga, M. (1986). A new modified operation for funnel chest using Zimmer osteosynthetic plate. Archioes of Orthopaedic arld Traumatic Surgery, 105. 154.
British
Journal
of Plastic
Surecrv
Watanabe, Y. and Takashi, I. (1984). Surgical correction of pectus excavatum for adults and adolescents. Japanese Journal c!f Surgery, 14, 472. Welch, K. J. and Shamberger, R. C. (1987). Surgical repair of anterior chest wall deformities. Surgical Rounds, August, 19. Wesselhoeft, C. W. and DeLuca, F. G. (1982). A simplified approach to the repair of pediatric pectus deformities. Annuls qf Thoracic Surgery, 34. 640.
The Authors Michael L. Be&, MD, Assistant Professor of Surgery J. William Futrell, MD, Professor and Chief
(Plastic)
Division of Plastic and Reconstructive Surgery, University of Pittsburgh School of Medicine, Pittsburgh. Pennsylvania, USA Requests for reprints to: Dr M. L. Bentz, MD, Division of Plastic and Reconstructive Surgery, University of Pittsburgh, Scaife Hall 662. Pittsburgh, Pennsylvania 15261. USA Paper received 12 December 199 I. Accepted 11 February 1992. after revision.
