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Archive for the ‘sternoplasty’ Category

OR Snapshots – Custom Sterno-Pectoral Implants in Pectus Excavatum

Thursday, November 16th, 2017

 

The chest is exposed to a variety of deformities of its bony and cartilaginous structures. The curve of the ribs around the chest and their attachment to the sternum create an architecture that can become disturbed. One of the most recognized of these deformities is pectus excavatum. This chest wall deformity is most typified with the sunken appearance of the lower end of the sternum. This is associated an outerward flare of the lower ribs and a broader concavity of the upper rib cartilages. Despite the basic anatomic components of pectus excavatum, it comes in a wide range of presentations. It is not always symmetric and can appear just one side.

Surgery for correction of pectus excavatum has been around for decades. It has evolved from open rib resections to the placement of metal bars behind the sternum to create an outward push for a chest wall reshaping effect. But many of these procedures are helpful they rarely provide a perfect correction. And the invasiveness of surgery, particularly in younger patients who have a lot of growth to undergo, can led to their own chest wall abnormalities as well.

In adults residual sterno-pectoral chest wall deformities can be treated by the placement of implants to improve their contours. While in the past such chest wall implants have been made by a variety of different methods and materials, a custom approach is used today. This can be done by either a direct moulage on the patient’s chest from which the implant is made or the implant can be made directly from a design done on the patient’s 3D CT scan of their chest.

Because of better design methods, more complete sternal or larger sterno-pectoral implants are now possible. Bigger designs of course requirer larger incisions to insert. But often pre-existing scars make this less of an aesthetic concern.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – Custom Sternal Implant

Thursday, November 3rd, 2016

 

There are numerous types of congenital chest wall deformities. In many such deformities the central sternum is affected. One of the most common of these deformities is pectus excavatum. The sternum is indented or depressed as the attached ribs are abnormally bent inward. There are many manifestations of this chest wall disorder from more minor sternal contour abnormalities to the entire anterior chest being sunken in.

The repair of pectus excavatum has evolved over the years with the greatest innovation being the Nuss procedure. Placing a rigid bar under the sternum and attaching it to the ribs remarkably bends the sternum and central chest wall outward. Once the metal bar is removed years later much of the chest wall shape improvement is maintained even in older adult patients.

But as effective as the Nuss procedure may be for many patients, it can often still leave the central sternum suboptimally projected. This manifests as a deeper valley or groove in the central chest. Such sternal depressions, whether after a Nuss procedure or from untreated more minor pectus excavatum deformities, can still be aesthetically bothersome for many patients.

There are numerous treatment options for sternal augmentation from fat injections to implants. The tight tissues of the sternum are a poor recipient site for injected fat persistence. The best sternal augmentation method, in my opinion, is that of an implant placed on the bone. This will have a permanent augmentation effect and can be custom made from the patient’s 3D CT scan or intraoperatively hand carved from silicone contoured carving blocks.

custom-sternal-implant-replacement-dr-barry-eppley-indianapolisThis patient had a prior Nuss procedure for pectus excavatum followed by the placement of a silicone sternal implant. While the implant provided some good improvement, it did not cover the full vertical length of the sternal defect and had a hump shape to it. It had originally been placed through a long vertical substernal incision. (which was unnecessary, a much smaller horizontal incision works just fine) I removed the old sternal implant, which turned out to be a modified silicone calf implant, and replaced it with a hand carved custom sternal implant from a contoured carving block.  A side by side comparison of the two sternal implants showed the differences in their shape. The hump deformity from the prior implant occurred because the curved surface of the modified calf implant was facing upward and its flat surface was facing downward. (the exact opposite from how its shape should be positioned.

You may note the many holes placed in my custom sternal implant design. These are called perfusion holes and are placed during surgery prior to placement by a 3 or 4mm dermal punch. This allows for the rapid ingrowth of soft tissue through the implant. This creates firm implant fixation by many soft tissue anchors and creates a form of soft tissue ingrowth through the implant.

Dr. Barry Eppley

Indianapolis, Indiana

Custom Pectus Excavatum Implants

Monday, May 16th, 2016

 

Pectus excavatum is a common congenital thoracic deformity that occurs in about 1:500 births. Males are more frequently affected than females. In severe cases it may be associated with pulmonary impairment but many pectus excavatum cases are cosmetic deformities. Given the importance of the appearance of the male chest it is no surprise that such thoracic deformities carry with them a significant psychological impact.

Nuss procedure for pectus excavatumThe most common surgical technique for the treatment of pectus excavatum are invasive and range from the historic radical cartilage resection to the contemporary Nuss procedure. While invasive the use of the Nuss bar does not remove rib cartilages and uses a metal bar to reshape the chest internally. But the bar does need to be removed secondarily and the degree of correction can often be incomplete. Better results are in the youngest patients where the rib cartilages are most malleable.

In the May 2016 issue of the journal Plastic and Reconstructive Surgery, an article  was published ‘Correction of Pectus Excavatum by Custom-Made Silicone Implants: Contribution of Computer-Aided Design Reconstruction. A 20-Year Experience and 401 Cases.’  In this paper, the authors report on their experience with a large number of silicone implants to treat funnel chests. Prior to 2007, implants were made from plaster chest molds. Since 2007 three-dimensional reconstructions were made from CT scans by computer-aided design. Only one infection and three hemtomas occurred. All implants developed some degree of periprosthetic seroma. Patients rated the appearance of computer-designed implants as much better than that of the plaster molds. The degree of correction of the chest deformity was also better corrected with  the computer-designed implants. A Medical Outcomes survey showed significant social and emotional improvements.

Custom Pectus Excavatum ImplantA custom pectus excavatum implant made from a 3D CT scan can be a very good option for chest reshaping if one is opposed to any form of invasive thoracic surgery. While it is still surgery it done on top of the chest or from an extrathoracic location. Using a computer-aided design for the implants is superior to an external silastic elastomer mold because it is based on the actual shape of the underlying ribs and sternum. External molds are based on the shape of the external skin which does not have the detail of the underlying supportive cartilage and bone anatomy.

In this incredibly large clinical series in this paper, undoubtably the largest ever reported and probably done in the entire world, there were a surprising very low number of any complications. They did not report the need to remove any implants over the study period which is remarkable. This is a testament to how well the tissues tolerate an implant in an area of relatively low motion and stress exposure.

Dr. Barry Eppley

Indianapolis, Indiana

Custom Sternal Implants

Thursday, May 5th, 2016

 

The sternum, often referred to as the breastbone, is a long bone running down the middle of the chest. It connects to the ribs through a cartilaginous connection. The most common aesthetic deformity of the sternum is pectus excavatum. This is where the sternum and, to some degree, the attached ribs grow abnormally inward. This produces a well known sunken in appearance to the chest.

Pectus excavatum presents in a wide variety of manifestations. It can present as a relatively minor and isolated sternal depression to a much larger and even functionally limiting central chest concavity. While there are well known invasive treatments for pectus excavatum if significant enough (e.g., Nuss procedure), treatments for more minor sternal depressions are not as well chronicled.

Treatment options for lower sternal depressions include injectable fat grafting, injectable bone cements and custom sternal implants. While there are a large number of advocates for fat grafting, the sternum is a challenging area for fat survival due to the extreme tightness of the overlying soft tissues and the lack of natural fat in them. Multiple fat injection treatments would certainly be needed. Injectable bone cements are less well known and having used them, they offer permanent volume enhancement. But if any irregular contours develop or over correction occur, they can be hard to revise successfully.

Custom Sternal Implant result Dr Barry Eppley IndianapolisCustom Sternal Implant incision placement Dr Barry Eppley IndianapolisA sternal implant composed of a solid but flexible silicone material offers a precise shape that is also easily reversible. Such sternal implants can be made by two different methods.    A silicone elastomer moulage can be made by direct shaping on the patient. From this moulage the silicone custom sternal implant is made. The key to its design is to prevent an over correction or the appearance of a sternal ‘hump’. Its design should be to lessen the sternal depression to that of a more natural concavity that exists between the pectoralis muscles. Therefore, the moulage design should not have a flat top appearance but still maintain an inward curve to it across its outer surface. Because of its narrow shape it can be introduced through a small 1.5 cm incision at the level of the xiphoid process in a horizontal skin crease.

3D Ct scan pectus excavatumThe other technique for fabrication of custom sternal implants is through a computer design from a 3D CT scan of the patient’s chest. This allows a custom fit to the underlying sternum but does not account for the overlying soft tissue and the adjoining cartilages in its design. For smaller sternal defects, the added cost may not justify any increased aesthetic benefit in some cases.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Custom Sternal Implant

Friday, April 1st, 2016

 

Background: The breastbone or sternum is a central long flat bone located in the center of the chest. It serves as a connection point for the ribs which creates a strong breastplate of protection for the heart and lungs. The sternum is shaped like a necktie which consists of three parts, the upper manubrium, the sternal body and the lower xiphid process.

The most common congenital malformation of the sternum is that of pectus excavatum. This is a well known funnel-shaped appearance of the chest which has its greatest depth over the lower end of the sternum. The hollow at the lower part of the sternum is caused by a backward displacement of the xiphoid cartilage. While the definitive treatment for pectus excavatum is sternal elevation by the placement of a pectus bar (Nuss procedure), older patients or patients with more minor variants of sternal depression may not choose to undergo this procedure.

Augmentation of an isolated lower end sternal depression can be done using one of two approaches. Injection fat grafting can be done provided the patient has enough fat to harvest. But in the tight sternum tissues, the survival of injected fat is not predictable and often takes poorly…or requires multiple injection sessions. Sternal implants can also be sued but there are few reports of this sternal augmentation method.

Sternal Defect (minor pectus excavatum)Case Study: This 40 year-old male was bothered the inward depression of the lower end of his sternum. He was very muscular and had developed significant pectoral muscle enlargement. However this did not improve the appearance of his sternal concavity. He choose to have it treated by a custom sternal implant. Using a silicone elastomer material, the design and shape of the implant was made by fashioning the material into the sternal depression until set. From this moulage a silicone sternal implant was fabricated.

Custom Strernal Implant placement Dr Barry Eppley IndianapolisCustom Sternal Implant incision placement Dr Barry Eppley IndianapolisUnder general anesthesia in the supine position, a 3 cm horizontal skin incision was made at the lower end of the sternum. A tissue pocket was made along the bone from the lower end of the sternum superiorly. The custom sternal implant had multiple 3mm perfusion holes placed throughout its length. it was inserted and secured to the bone with sutures. The incision was closed in multiple layers with dissolveable sutures.

Custom Sternal Implant result intraop below view Dr Barry Eppley IndianapolisCustom Sternal Implant result intraop oblique viewCustom Sternal Implant result intraop side view Dr Barry Eppley IndianapolisHis immediate surgery results showed a complete leveling of his sternal depression. The implant was designed to lessen the sternal concavity but was not made too big so that it created an unnatural ridge or elevation.

A custom sternal implant provides an augmentation solution that is both permanent and has a minimal recovery. The key is in the design of the implant so that it looks natural and not overdone.

Highlights:

1) Sternal depressions or indentations are common expressions of pectus excavatum deformities.

2) Augmentation of the depressed or V-shaped sternum can be done with a custom sternal implant.

3) A custom sternal implant can be made from a silicone elastomer moulage fashioned from the patient.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study: Injectable Sternoplasty with Kryptonite Bone Cement

Thursday, February 10th, 2011

Background:  The chest deformity, pectus excavatum (funnel chest) is seen as a deep depression of the sternum, usually involving the lower half or two thirds of the sternum. Its deepest indentation is at the junction of the chest and the abdomen. The lower four to six rib cartilages dip backward abnormally to increase the deformity or depression and push the sternum posterior or backward toward the spine.

In most significant cases, pectus deformities are treated surgically with excellent success. The most popular surgical technique today is the Nuss procedure where a rigid titanium bar is placed behind the sternum and pushes it forward. But not all pectus problems are significant enough to either warrant surgery or would pass insurance criteria for it. These more minor pectus deformities are limited to just the very end of the sternum and the xiphoid process.

Treatment options for these more limited pectus deformities are few. Solid types of implants can be hand carved intraoperatively or preformed prior to surgery off of 3-D CTs and inserted. But this requires a resultant visible incision which may not be a good trade-off form a small sternal indentation. In addition, such sternal implants do have a history of potential problems such as mobility and seromas. (fluid collections)

Case Study: This is an 18 year-old male who wanted cosmetic improvement of his sternal deformity. He had been evaluated by a pediatric surgeon who felt his problem was not significant enough to justify sternal recontouring/repositioning. He had no pulmonary problems or limitations with exercise. The lower sternal indentation measured 7cms in height and 5 cms in width. It was a well-defined indentation that measured by water displacement of 10 mls.  

He opted for a new injectable sternoplasty approach which had not been previously done. The concept was to place Kryptonite Bone Cement through an injectable technique and allow it to be set and molded as it cured. This calcium carbonate-based material has the flow properties to be mixed and then injected through a small plastic tube. Once set, the material is very adherent to bone and becomes as rigid as the bone to which it attaches. Its porosity (a feature that develops as it sets) allows the potential for bone ingrowth over time.

Prior to surgery, the sternal defect was measured in volume and with a playdoh cast to get an idea of the material to be injected. During surgery, a 5mm incision was made over the lower end of the sternal at the edge of the indentation. An elevator was used to make a pocket at the bone level with an effort to be subperiosteal. Then using 5 grams of Kryptonite powder, it was mixed with its two liquid components and mixed for two  minutes. It was then transferred to a syringe which was attached to a 12 French plastic catheter and injected. The material was allowed to cure to a doughy state for 15 minutes and then molded by external pressure on the overlying skin. A lightly compressive circumferential chest wrap was then placed.

The entire procedure took 45 minutes. The results were immediate with elimnination of the lower sternal indentation. He was discharged as an outpatient. He reported no pain afterwards.  

Case Highlights:

1)      Pectus excavatum presents as a whole range of sternal deformities. More minor manifestations of it affect just the lower third of the sternum and do not usually qualify for surgical repair.

 

2)      Injectable augmentation of the lower third of the sternum can be easily and successfully done with Kryptonite Bone Cement. Its firm adherence to the sternal bone and its high impact resistance make it a good material for use in the chest.

 

3)       This injectable sternoplasty technique may also be useful for secondary revision of pectus excavatum repair in which the ideal contour has not been obtained.

Dr. Barry Eppley

Indianapolis, Indiana

Injectable Sternoplasty (Pectus Excavatum Repair) – Kryptonite Bone Cement as a Sternal Augmentation Material

Wednesday, August 18th, 2010

Pectus excavatum, also known as funnel chest, is a defect characterized by differing levels of sternal depression. The deepest area of the sternal depression is always on the lower third of the sternum near the upper abdominal area. The lower costal or rib cartilages dip backward to increase the deformity or depression and push the sternum posterior backward towards the spine.

Significant pectus deformities are treated when the patient is young, usually between 12 to 18 years of age. At this age, the plasticity of the cartilages make this age group the ideal period for repair. While extensive cartilage resection (Ravtich approach) has been the historic approach. This radical operation has been replaced by the Nuss Procedure which involves the placement of a large curved bar through incisions on the chest wall. The bar is rotated into position and kept in place for 2 to 3 years.

But not all sternal reconstructive surgery leaves a perfectly flat or well curved sternum. In addition, some patients have very small sternal depressions that were either not recognized for early treatment or were not significant enough for any form of sternal reshaping and respositioning. Such cosmetic sternal deformities have been traditionally treated with onlay implants usually composed of preformed or custom carved silicone. Gore-tex blocks and sheets have also been used as sternal inserts.

But these synthetic materials have not been without their complications including infection, seroma formation, and capsular contracture. This has resulted in either their need for removal or the outcome of a hard and unnatural feeling implant. This is largely because these synthetic materials are not intended to be bone substitutes or replacements so they never integrate and become an extension of the natural sternal bone. Better sternal onlay materials would be an asset and could provide a better option for smaller sternal depressions that don’t warrant invasive bone reshaping.

The ideal sternal onlay augmentation material would adhere to the bone surface, have bone-like firmness and fracture resistance, and be injectable. The need to be delivered into the sternal site by injection is critical as any incision across the sternum is a cosmetic deformity by itself. Of all available bone substitute materials historically used, none fulfill all of these criteria. Most are hydroxyapatite-based which are neither injectable or fracture-resistant.

The recent commercial introduction of Kryptonite bone cement has the potential to fulfill these sternal criteria. Kryptonite Bone Cement is a non-toxic, porous, adhesive bone substitute material that possesses bone-like mechanical properties. It is composed of naturally occurring fatty acids and calcium carbonate. It’s three ingredients are mixed together at the time of surgery to create an initial liquid material that converts into a firm putty within minutes. It is Kryptonite’s liquid phase after mixing that makes it injectable.

Kryptonite bone cement has been shown experimentally to be an easily injectable material for limited incision or minimal access cranioplasty. It can flow through small diameter (3mms) plastic tubing, can be easily molded through the skin by outward digital molding pressure, adheres to the bony pocket created, and does not stick to the overlying skin. Its success for a cranial surface suggests that it would work equally well on the sternum, which represents just another flat bone surface. Through a small (< 10mm) lower sternal incision, a subperiosteal pocket can be easily created and injected. The material can be molded to fill a sternal defect and harden in 15 minutes. Once set, it will feel like natural bone and will encapsulate with the underlying sternum

Kryptonite bone cement represents a viable sternal augmentation material. Its ability to be placed by injection opens up treatment possibilities for those with sternal depression deformities that would not otherwise merit more extensive surgical reconstruction. 

Dr. Barry Eppley

Indianapolis, Indiana


Dr. Barry EppleyDr. Barry Eppley

Dr. Barry Eppley is an extensively trained plastic and cosmetic surgeon with more than 20 years of surgical experience. He is both a licensed physician and dentist as well as double board-certified in both Plastic and Reconstructive Surgery and Oral and Maxillofacial Surgery. This training allows him to perform the most complex surgical procedures from cosmetic changes to the face and body to craniofacial surgery. Dr. Eppley has made extensive contributions to plastic surgery starting with the development of several advanced surgical techniques. He is a revered author, lecturer and educator in the field of plastic and cosmetic surgery.

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