Natural history and timing of surgery
If left unoperated the deformity increases in size, most markedly in the years of the pubertal growth spurt. As it becomes more severe, the rib ends are drawn in and the deformity of the ribs becomes permanent if correction is not performed before growth finishes. Many clinicians leave surgery “till growth has stopped”, hoping they will grow out of the deformity or that muscle growth will obscure it. Neither is the case in truth. At this stage the rib deformity cannot be corrected and the results cannot be satisfactory.

Young children are hardly aware of the diagnosis and have no interest in having it corrected. The easily embarrassed teenager however, will avoid taking his shirt off and will avoid swimming, changing in front of his mates for football and so on. In his late teens the self-conscious youth will be embarrassed by his appearance when dealing with the fairer sex.

There is no need to operate on the pre-school child when he is exposed to all the paediatric anaesthetic risks. I usually operate at about 8 years of age when anaesthesia is safer, there is plenty of time for the deformed ribs to refashion themselves and a few weeks off school will not affect his academic progress. At this stage the deformity is mild and he is usually not worried by the condition. However, at this age he is still not conscious of the deformity, though his parents may be, and it will be difficult to convince him that, by the time he is conscious of it (at age 15) it will be too late to get a good result. This then is the dilemma facing the advising surgeon.

Indications for operation
The indication for the operation is cosmesis. It is a cosmetic operation only. Concerns about asthma and pressure on the heart are unfounded.

However cosmesis is important to the full development of a child. I know I am exposing my Australian sport-loving bias when I say it is important for a young man to go swimming and to play football without worrying about his appearance. If my operation allows him to fully develop socially and in sport, I feel it is worthwhile. One must of course remember that this is an operation with all its attendant risks and it is being performed purely for cosmetic reasons.

Having said that, where there is a severe deformity at a relatively young age I do suggest strongly to the parents that they should consider surgery. While there is little evidence for it I find it hard not to imagine some restriction of cardiac filling on exertion when there is severe displacement of the heart.

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