The deformities of the anterior chest wall known as pectus carinatum or " pigeon breast " and pectus excavatum or " shoemaker chest " are very common, but remain hidden from society because people who have these deformities are usually ashamed of their chest aspect. The size and contour of the chest is associated with virility in the male, beauty in the female, and sex appeal in both, so it is not surprising that people with chest deformities avoid clothing and activities that make these deformities noticeable. The psychological impact of a pectus deformity can be devastating on a patient and, in our experience, this impact is not always related to the extent of the deformity. Medical knowledge is not wide in this field and instructions that are not ideal can be transmitted to the patient. The psychological problem is sometimes transferred to the parents who feel guilty for the deformity of their son or daughter. Feelings of frustration can increase with medical orientation to accept the deformity or just look for a way of solving it through surgery.
Based on clinical and imaging studies of over 3850 patients seen since 1977, and in the development of an experimental model that resulted in reproduction of pectus deformities in animals (for the first time in history of Medicine) we concluded that the deformities occur due to a disproportional growth of the sternum (chest bone) and/or costal arches (ribs). Many factors may be involved in its formation: heredity, respiratory disturbances like asthma, and spine mal alignment like an increased thoracic kyphosis and/or scoliosis. Cardiac problems may eventually be present.
The vast majority of pectus deformities are IDIOPATHIC in nature, i.e., they occur without a previous pathology in children and adolescents who are in good general health. We have noted two other forms of occurrence: the PATHOLOGIC, that occurs in the presence of diseases with growth disturbances in general, like Marfan's Syndrome, Bone Dysplasias, Rickets, Osteogenesis Imperfecta, etc..., and the IATROGENIC, that may develop after medical action in pediatric cardiac surgery, due to lesion and anatomic disarrangement of the sternal growth plates. Some medical publications have mentioned sutures in the sternum, not helping the understanding of the anterior chest wall growth. Endochondral ossification and growth plates in the sternum and costal arches are concepts that have important implications not only for the correct approach to pectus deformities of children and adolescents, but also to prevent an iatrogenic deformity.
In the 1950's and 60's decades surgery was reported as the only option of treatment for pectus deformities and any trial of conservative treatment condemned as ineffective. Doubts and critics about surgical results have occurred since the 70's, with reports of complications of high morbidity such as wound infection, wound hematoma, pneumothorax, atelectasis, ugly scars, keloid, decrease in pulmonary function and death. Surgeons disagree about methods and modifications continue to be advocated. Reports on the existence of >40 different operative techniques raise suspicion that an ideal operation has not yet been devised. On the other hand, in 1969, Lange and Müller described some success when bracing with belts small children with pectus carinatum. Despite the fact that the sternum is attached to the spine by the costal arches, contemporary orthopaedics has paid attention almost only to the back part of the human thorax. Just in 1993 a case of one pectus carinatum adolescent successfully treated with plaster cast followed by bracing was reported by others.
On the other hand, since 1979 we have reported good results of a conservative treatment for pectus carinatum deformities, the ones with protrusion of the sternum, for adolescents, through a method that involves the use of an orthosis or brace, the Dynamic Chest Compressor I or DCC I, and appropriate exercises. A variation of such an orthosis, called DCC II, and appropriate exercises have been used for pectus excavatum deformities, the ones with depression of the sternum, since 1988. Pectus deformities occur due to growth disturbances of the sternum and ribs, and they may get worse or better during the growing period, depending on the forces that will act on the chest. During the growing period the thoracic cage presents more flexibility and remodeling capacity. Nevertheless, even in adults bone and cartilage remodeling can occur.
For pectus carinatum with components of depression and flaring of the ribs both CDT I and II can be used together with exercises. We call this method the Dynamic Remodeling Method or DR method.
So, our approach is exclusively NON-SURGICAL! The initial stages of the treatment are: 1. first consultation and, if there is indication for immediate treatment, a cast mold of the deformity is made; 2. the orthosis (brace) is manufactured based on the mold and on detailed medical prescription according to the deformity of the patient; 3. another consultation for receiving instructions on how to use and to take care of the brace and prescription of appropriate exercises; 4. practice of therapeutic exercises in use of the orthosis under the supervision of a properly trained physical therapist; 5. periodic revisions, every two or three months when possible. For patients who do not live nearby our clinic, instructions are given on what may happen and what can be done for the adequate maintenance of the treatment until a revision consultation can be done.
We have classified the Pectus Carinatum , according to the apex of the protrusion, in three basic types: Superior (PCS), Inferior (PCI) and Lateral (PCL). The Pectus Excavatum deformities, the ones with pure sternal depression, are classified into Wide (PEW) and Localized (PEL). (See figure below). MIXED types can also occur.
The FLEXIBILITY of the anterior chest wall is more important than the severity of the deformity for prognosis of treatment using our method.
For assessment of the flexibility of pectus carinatum deformities, a manual compression test is done by compressing the protrusion area of the chest with the palm of one hand while the thoracic spine is supported by the other hand. If the protrusion decreases, it is still flexible.
For assessment of the flexibility of pectus excavatum deformities, an increased intrthoracic pressure test needs to be done as well. In a standing position, the patient takes a deep breath while actively contracts the abdominal muscles and holds the air simulating a blow to promote an increase of the intrthoracic pressure. Simultaneously, the examiner manually compresses the bilateral flaring of the inferior ribs. The deformity is considered flexible if an improvement of the depression is noted.
The treatment can be used to correct, partially or totally, any severity of pectus depending on the flexibility, the correct use of the orthosis, the exercises done, the instructions followed and the adjustments made during the treatment. It is not the simple use of a brace that improves and consolidates correction of an anterior chest wall deformity; it is a treatment done by the patient combined with experienced medical assessment and supervision. Many months or even years of treatment may be necessary to consider a correction stable.
The PCS is a rigid and less common type, and good results can be seen only when the orthotic treatment starts during CHILDHOOD, or at the beginning of adolescence when it is more likeable to be flexible, according to the residual amount of cartilage in the (chest bone) sternum.
The PCI and PCL are flexible types, and can usually be treated until the end of the growing period. EXCELLENT results have been observed for these two types of flexible deformities when patients follow medical instructions. The PCI and PCL are flexible types, and can usually be treated until the end of the growing period and even in adults. We normally recommend starting the orthotic treatment for PCI/PCL during the growth spurt of ADOLESCENCE, around 13 years of age, but we have been treating successfully even ADULTS with residual flexible deformities. Depressed areas of the ribs are also expected to be corrected through prescribed exercises. A continuous wearing of the orthosis is recommended at the beginning of treatment, first two or three months for flexible PCI and PCL, when reduction of the protrusion is usually obtained, but treatment can not be abruptly discontinued due to risks of recurrence. Correction of depressed areas of the rib cage may take much longer, generally from one to two years. Weaning from the orthosis must be done gradually according to the stage of treatment under medical supervision. As a stable improvement is observed, the amount of daily hours can be decreased: if the patient is already used to sleep with the DCC, he can decide if he prefers to wear it during day time or night time. The responsibility for a successful treatment in a shorter or longer time also depends on the patient.
A continuous wearing of the DCC is recommended at the beginning of treatment, first two or three months for flexible PCI/PCL. Correction of the protrusion is seen soon in these cases; but, to avoid recurrence, treatment can not be abruptly interrupted. Depressed costal cartilages usually take longer than one year to improve. Weaning from the orthosis must be done under an expert professional supervision. The amount of cartilage in the sternum, the bone age of the patient and the manual compression test are important to determine indication and prognosis for treatment. The older the patient the harder to tolerate the DCC I wearing. On the other hand, very young children with PCI and PCL tolerate well the orthosis, but they should only receive orthotic treatment when the deformity is severe or associated with asthma or other respiratory disturbance. As the deformed thoracic cage is corrected simultaneous improvement of the respiratory condition is usually observed. Parents of very young children should be aware of eventual recurrence and need of repeating treatment during adolescence. If the child has a small and flexible protrusion and he/she has not reached the growth spurt of adolescence, we recommend waiting a little bit longer before starting the orthotic treatment. If correction is obtained in an early phase of life and recurrence occurs, the patient may reject going through the orthotic treatment again. On the other hand, BONE REMODELING OF THE THORACIC CAGE DURING GROWTH SPURT OF ADOLESCENCE IS KEPT FOR LIFE.
The increased intrathoracic pressure test needs to be done to check flexibility. If the deformity is flexible, it can be treated.
For young children with pectus excavatum only backstroke swimming and blowing balloons are recommended to keep the flexibility of the chest. To very young children learn how to blow balloons, we recommend parents to teach them to blow using a straw to make bubbles in a liquid for 15 minutes every day. We have followed-up a baby who was born with a large PE deformity and after 9 years following our recommendations, presented a total correction of the deformity without using the brace. Maintaining the flexibility of the anterior chest wall of a child with pectus is important for the success of the orthotic treatment during adolescence. If prominence's of the inferior ribs are present, the orthotic treatment may eventually be started during late childhood or adolescence.
During ADOLESCENCE, exercises that increase the intrathoracic pressure in an apparatus called "peck deck" found in weight lifting gyms, are prescribed ALONG WITH the use of the DCC II. These exercises are done with the elbows raised and opened at the level of the shoulders, and the forearms and hands in a vertical position. The patient pushes the elbows to the midline against the apparatus' resistance. A forward movement of the sternum can usually be observed in excavatum patients. Depressed areas of the sternum and ribs are expected to be corrected through these exercises, done along with the use of the DCC. In the adolescence the remodeling of the anterior chest wall occurs in a way that will be kept for life.
ADULTS usually have rigid chest walls so, any brace (orthosis) wearing during adulthood must be seen as an experimental condition. An eventual successful treatment will depend on residual flexibility of the chest and on the patient tolerance and perseverance in wearing the orthosis. Flaring of the inferior ribs usually presents total correction and the central depression partial correction. We have some adults patients with PEL and PEW who persisted with treatment for more than one year and had a good improvement of their condition. A 49 year old PEL patient who was under treatment for more than 18 months had a surprisingly good result. He described the treatment as a painful transformation that made him feel as if he was being born again (See his pre and post-treatment photographs in Treated Cases). So, the method may eventually work in a long term period for adults despite some sacrifice to wear the brace as recommended.
Nicolas Andry, the man considered the "Father of Orthopaedics," in his book L'orthopédie ou l'art de prev'enir et de corriger dans les enfants, les difformités du corps , published in Paris in 1741, observed that limb deformities could be corrected through conservative methods of treatment. Later, Julius Wolff described what is accepted as a law in Orthopaedics: "The bone tissue is a dynamic structure that can be remodeled according to external forces."
What we have been doing is using these concepts to correct pectus deformities. Despite being solid, bone and cartilage are live substances that have the capacity of remodeling. The younger the patient the greater is his/her potential for osteocartilaginous remodeling, but such a remodeling occurs throughout life. Endochondral ossification and growth plates in the sternum and ribs are also concepts that have important implications for the correct approach to pectus deformities. We have paid attention to the fact that the bones and cartilages of the anterior chest wall also suffer the Wolff's law effects, and that the flexibility presented in the chest allows the use of external forces to improve or cure a pectus deformity. Corrective forces can change the stress history of skeletal tissues to beneficially alter subsequent patterns of growth and ossification. So, we use external forces to modify the growth and promote the remodeling of deformed structures of the anterior chest wall. Such therapeutic options, based on orthopaedic principles, have been proven effective in patients with flexible deformities.
So, we use to combine external forces (orthoses) and internal forces (increased intrthoracic pressure due to the exercises while wearing the orthoses) to modify the growth and promote the remodeling of deformed structures of the anterior chest wall. Such therapeutic options, based on orthopaedic principles, have been proven effective, mainly in patients with flexible deformities. An example of such a remodeling is shown in Figure number 9 of Treated Cases section, and below.
Regarding surgery during the growing period, the following reports are found in the medical literature: "More than 40 different operative techniques have been described to deal with Pectus Excavatum " (Isakov et al) "indicating that an ideal method has not yet been discovered"(Haje). "Operative techniques are controversial and a perfect result is not obtained with every procedure" (Heydorn et al). "Surgeons who recognize increasingly poor results as their patients grow older, blame the technique and seek a better one" (Humphreys and Jaretzki). "Bad results occur in children who are operated on before they are 12 years of age" (Milovic and Oluic) and "a poor long term outcome" (Ellis, Humphreys and Jaretzki) "have been reported without any explanation of why these failures occur. Current surgical methods do not refer to the GROWTH PLATES of the sternum and costal cartilages, and operation may produce secondary growth disturbance.." (Haje). And many other operative complications also exist in the literature, including decrease in pulmonary function.
The conservative procedure for pectus deformities is a unique treatment option for avoiding surgery and good results are observed mainly, but not only, during the growing period of life. We believe we can better help children and adolescents with these clinical conditions by giving them the opportunity of first trying a conservative method based on the principles of the Orthopaedic (DCC+exercises). The biological support for the conservative approach can be found in the medical papers we have published on this subject (see bibliography). For patients who have already had surgery, our method may also help if correctly applied.
Examples of long-term surgical results:
Adolescent after one year of osteocartilaginous corrective surgery for pectus excavatum.
See longitudinal scar. Total recurrence occurred a few months later.
Forty-two-year-old adult, five years after plastic surgery for correction of pectus excavatum.
Aspect of the chest after removal of subcutaneous silicone.
Note: the results above are not an expression of all surgeries. They are examples of something that may occur.
When the scoliosis is slight, sometimes only the DCC wearing can help. When the scoliosis is moderate, with a curvature higher than 20º, we associate a spine brace appropriated for the case. Usually, in this situation, we recommend wearing of the DCC from 4 to 6 hours a day and practice of the prescribed exercises in that period of the day; the brace for the spine should be worn for the rest of the day. The spine brace that we most often adopt is a bending brace that is made after a plaster cast mold (see example below).
Yes. Skin rash where the pads make pressure usually occurs during treatment. The intensity of skin rash varies from patient to patient. Wearing the brace over a clean T-shirt or using removable clean covers made of cotton jersey over the pads decreases the intensity of the rash. Topic medicine may eventually be required but should never be left under the pads. After some hours, remove the medicine with alcohol before wearing the brace again. Eventual skin marks go away with time at the end of the treatment. Over correction can also occur during treatment and should be controlled by an adequate medical supervision. It is more common to occur in pectus carinatum and very rare in pectus excavatum deformities. For a better understanding on this eventual complication we suggest medical doctors to read the scientific article: Haje SA, Haje DP (2006) Over correction during treatment of pectus deformities with DCC orthoses: experience in 17 cases. International Orthopaedics (SICOT). To see the abstract of the article, click http://www.springerlink.com (and search for: pectus+haje). The article can be requested online to the publisher. Written orientation and prescription regarding brace wearing should be provided to the patient when he/she receives the brace.
Yes, you should take it off for bathing, swimming, in special occasions, or playing sports with physical contact. You have just to remember to put it on as soon as any of these activities is over. Remember that the longer you stay without it, beyond the recommended time for each stage of treatment, the longer the total treatment period is. Keep in mind that the treatment performance is a patients responsibility. The Physicians role is to provide the patient with correct instructions, based on his personal experience.
Absolutely not! The DCC correctly built does not interfere with breathing. Indeed, we have observed that patients with respiratory problems, like asthma, improve the clinical condition with the remodeling of their chest wall through the orthotic treatment.
It must be considered that any strange object on the body may bother for some time until the patient gets adapted to it. Adjustments and repairs as treatment progress are usually necessary for comfort and efficiency.