We appreciate the comments from Dr. de Beer and his team. We had great interest in their publication [1] on the cases of “sternocostal instability after Ravitch repair,” but we omitted to mention this important work in our recent report illustrating a new approach for post-Ravitch chest wall repair [2].
We completely agree with their statements on the risk of extensive cartilage resection in young patients undergoing pectus excavatum or carinatum repair. In the worst-case situation, insufficient chest wall growth has been linked to thoracic dystrophy and a chest cage that is small and restrictive [3,4]. The following are the author’s observations of post-Ravitch repair patients: (1) failure to grow led to a cone-shaped, narrow upper chest cage; (2) the conglomerated frozen chest wall structures caused acquired restrictive thoracic dystrophy; (3) the loss of costal structure resulted in a chest wall defect, leaving the heart unprotected, lying only beneath the skin; and (4) the pectus excavatum deformity recurred.
In the case we reported [2], multiple unsuccessful repair attempts made us frustrated. These included the Ravitch repair, which was done elsewhere, and then the pectus bar repair. We needed to devise a new approach, such as implanting a 3-dimensional (3D)-printed artificial chest wall. We could not obtain permission to use 3D-printed materials for compassionate reasons, and we decided to use sophisticated chest wall support with plate-screw reconstruction of the anterior defective chest wall and semi-permanent pectus bar support.
Unlike a case by de Beer and van Heurn [1], ours seems more complicated because the chest wall was significantly depressed and the cartilage around the half-missing sternal body was completely lost. Due to recurrent failures in the past, we required a durable and long-lasting metal support for the sunk and deficient chest wall deformities. We were satisfied with how the chest wall was fixed and how stable the sternum was in this case, but ultimately, we hope to use 3D-printed artificial chest wall reconstruction in such patients in the near future.
The authors’ policy for repairing congenital pectus deformities with pectus excavatum/carinatum/arcuatum has been to use pectus bars to preserve the costal structures and remodel the chest wall in a minimally invasive manner. We do not resect the chest wall; instead, we remodel it. However, for recurrent pectus excavatum after the Ravitch operation, mediastinal adhesion and a conglomerated frozen chest wall made the repair difficult and incomplete. First and foremost, loss of the cartilage around the sternum led to the lack of a sufficient skeleton for remodeling. As a result, the long-term maintenance of the chest wall deficiency was lost when the pectus bar support was removed.
We congratulate Dr. de Beer’s group on their successful repair of complicated cases involving floating sternum and a deficient chest wall, using their unique strut and mesh support technique. It is crucial to disseminate the information that excessive costal cartilage injury hinders chest wall growth and jeopardizes structural integrity.
Footnotes
Conflict of interest
No potential conflict of interest relevant to this article was reported.
References
- 1.de Beer SA, van Heurn EL. Sternocostal instability after Ravitch repair in adolescents; 3 case-reports and a review of surgical techniques in the literature. Plast Reconstr Surg Glob Open. 2020;8:e2720. doi: 10.1097/GOX.0000000000002720. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Rim G, Park HJ. Repair of recurrent pectus excavatum with a huge chest wall defect in a patient with a previous ravitch and pectus bar repair: a case report. J Chest Surg. 2022;55:246–9. doi: 10.5090/jcs.21.085. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Haller JA, Jr, Colombani PM, Humphries CT, Azizkhan RG, Loughlin GM. Chest wall constriction after too extensive and too early operations for pectus excavatum. Ann Thorac Surg. 1996;61:1618–25. doi: 10.1016/0003-4975(96)00179-8. [DOI] [PubMed] [Google Scholar]
- 4.Robicsek F, Fokin AA. How not to do it: restrictive thoracic dystrophy after pectus excavatum repair. Interact Cardiovasc Thorac Surg. 2004;3:566–8. doi: 10.1016/j.icvts.2004.06.007. [DOI] [PubMed] [Google Scholar]
