Sir:
We read with great interest the article entitled “Correction of Pectus Excavatum by Custom-Made Silicone Implants: Contribution of Computer-Aided Design Reconstruction. A 20-Year Experience and 401 Cases” by Chavoin et al.1 We wish to discuss some points that we consider important in current practice.
The authors were able to show the efficiency and good tolerance of their pectus excavatum correction procedure in a large series of patients. They reported a lower reoperation rate than that of traditional surgical reconstruction (1.5 percent versus 3.3 percent for the Ravitch procedure and 5.3 percent for the Nuss procedure)2 with good cosmetic results. This series highlights the importance of offering this strategy as a first-line treatment for all patients without functional impairment, which is the majority of patients. Indeed, it would have also been advisable to present the results of all of the functional tests for different patients, which might provide information for discussing the inconstant functional impairment related to intermediate to deep pectus excavatum. The authors resolved the problem of silicone implant luxation, which was the main reported complication,3 and this led to the decreased complication rate. It would also be good to know how the authors manage inferior rib flaring that is not corrected on introduction of the implant.
We also believe in the many benefits of computer-aided design in the development of these implants, particularly for lateralized or asymmetric pectus excavatum (chin 3), and more particularly in women in whom the plaster technique is unsuitable. We believe that readers would have benefited from a more thorough explanation of the technique used to design the implants from computed tomography data, including how the authors obtained the referential judged as normal that allows the design of the superficial surface of the implant called the “anatomical plane.”
Like the authors, we frequently observe postoperative seromas, which sometimes persist and require up to 10 weeks of treatment, despite wearing pressure garments and weekly aspiration. At the end of the procedure, we suggest the use a biological fibrin glue spray to avoid seromas, and our preliminary results appear encouraging, although a controlled study is required.
For nearly 5 years, we have used fat grafting with very good results in centered shallow pectus (chin 1), in the secondary correction of the asymmetric pectus (chin 3) after a sternochondroplasty, and for correcting the shape and volume of the breasts after thoracic repair.4 This option has multiple advantages: autologous material, ambulatory surgery, absence of scarring, and little risk of infection. The use of intraoperative ultrasound (Fig. 1) allows intramuscular injection in some very asymmetric shapes, which enables the surgeon to redraw the contours and maintain the fat graft in a more localized area.
;)
Fig. 1.: (Above) Intraoperative view of a lateral infraclavicular fat injection guided by ultrasound. (Below) Outcome during the intramuscular injection. The fat is dispersed in the muscle or under the fascia (arrowheads) based on intraoperative ultrasound findings.
We are convinced that there are many cases in which sternochondroplasty, the Nuss procedure, and implants5 are all good choices that can benefit from correction with fat grafting. This highlights the importance of treating patients with pectus excavatum with a multidisciplinary team to allow patients to choose the most suitable technique based on various factors. The collaboration between plastic and thoracic surgeons allows combined treatments with customized filling and remodeling that enhances the results and decreases morbidity.
DISCLOSURE
The authors have no financial interest to declare in relation to the content of this communication.
Christian Herlin, M.D., Ph.D.
Farid Bekara, M.D.
Plastic and Reconstructive Surgery and Burns Unit, and
Plastic and Craniofacial Pediatric Surgery Unit
CHU Montpellier
Montpellier, France
Jean Philippe Berthet, M.D., Ph.D.
Thoracic Surgery Department
CHU Montpellier
Montpellier, France
Swany Dast, M.D.
Plastic, Reconstructive, and Aesthetic Surgery
CHU Picardie
Amiens, France
Audrey Michot, M.D.
Plastic, Reconstructive, and Aesthetic Surgery
CHU Bordeaux
Bordeaux, France
Nicolas Bertheuil, M.D.
Plastic, Reconstructive, and Aesthetic Surgery
CHU Rennes
Rennes, France
REFERENCES
1. Chavoin JP, Grolleau JL, Moreno B, et al. Correction of pectus excavatum by custom-made silicone implants: Contribution of computer-aided design reconstruction. A 20-year experience and 401 cases. Plast Reconstr Surg. 2016;137:860e871e.
2. Johnson WR, Fedor D, Singhal S. Systematic review of surgical treatment techniques for adult and pediatric patients with pectus excavatum. J Cardiothorac Surg. 2014;9:25.
3. Snel BJ, Spronk CA, Werker PM, van der Lei B. Pectus excavatum reconstruction with silicone implants: Long-term results and a review of the English-language literature. Ann Plast Surg. 2009;62:205209.
4. Ho Quoc C, Delaporte T, Meruta A, La Marca S, Toussoun G, Delay E. Breast asymmetry and pectus excavatum improvement with fat grafting. Aesthet Surg J. 2013;33:822829.
5. Ho Quoc C, Chaput B, Garrido I, André A, Grolleau JL, Chavoin JP. Management of breast asymmetry associated with primary funnel chest (in French). Ann Chir Plast Esthet. 2013;58:5459.
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