Other procedures

Weights/suspension - historically the excavatum defect was treated by attachment of the sternum via a surgically implanted screw, to a system of weights suspended from a gantry. The weights are gradually increased over a period of weeks till the deformity corrects. The procedure is no longer used.

Sternal Turnover - the sternum and its attached cartilages can be excised en bloc. After complete excision it is turned over and wired in place. I would have reservations about the viability of the rotated sternum and its ability to grow satisfactorily in children. It is an unnecessarily complex procedure.

Peri-chondrial sling - a modification of the Ravitch procedure involves suturing the peri-chondrial sheaths behind the sternum to maintain its elevation. This practice is to be avoided as it can lead to bony constriction of the chest cavity which is not amenable to any surgical correction- a disastrous result.

Marlex sling - like our own procedure this is a modification of the Ravitch procedure but uses a sling of non-absorbable Marlex to hold the sternum. This seems a perfectly reasonable procedure. We choose to use a slowly absorbable PDS suture to avoid late effects ot infection, erosion and migration.

Nuss procedure - recently popularised as a minimally invasive procedure,this procedure involves the passage of a gull-wing metal bar under the sternum. It is then rotated with a robust handle forcing the sternum out. The bar is then wired to the ribs. It suffers all the drawbacks of metal bar insertion - loosening, fracture, migration and infection. The risk of blind passage of a bar between the right ventricle and the sternum can be reduced by observing its passage with a thoracoscope. Hopefully this will avoid the complication of cardiac laceration which has been described. Fracture of the bar is less common due to the use of a stronger modern alloy. I must say that the results as presented I would not regard as acceptable in my practice

Poland’s syndrome is best treated by plastic surgery involving, breast reconstruction, latissimus transfer and prosthesis,and sometimes reduction mammoplasty of the contra-lateral breast.

For sternal agenesis, slide chondroplasty of individual cartilages accompanied by longitudinal osteotomies of the sternal bars will usually bring the two halves together. Skin cover may require omental or pectoral flaps.

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