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Treatment of flaring of the costal arch after the minimally invasive pectus
excavatum repair (Nuss procedure) in children

Article  in  Journal of Pediatric Surgery · September 2010

DOI: 10.1016/j.jpedsurg.2010.05.037 · Source: PubMed

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Remko P Bosgraaf Daniel C Aronson

Radboud University University Children's Hospital Zürich, Switzerland
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Journal of Pediatric Surgery (2010) 45, 1904–1906

www.elsevier.com/locate/jpedsurg

Treatment of flaring of the costal arch after the minimally

invasive pectus excavatum repair (Nuss procedure)
in children
Remko P. Bosgraaf ⁎,1 , Daniel C. Aronson2
Pediatric Surgical Center of Amsterdam, Emma Children's Hospital AMC, Amsterdam, PO Box 22660,
1100 DD Amsterdam, The Netherlands

Received 24 January 2010; revised 16 May 2010; accepted 30 May 2010

Key words:
Abstract Flaring of the costal arch may be part of the pectus excavatum deformity. This aspect will in
Nuss procedure;
rare cases be even worsen after the Nuss repair. This remaining deformity can be treated with a minimal
Costal arch;
subperichondral partial resection of the costal arch cartilage. In 5 patients, this additional technique
Flaring;
regained good to excellent results.
Reconstruction
© 2010 Elsevier Inc. All rights reserved.

Pectus excavatum (PE) is the most common congenital of the sternum; and correction of the funnel chest by using
chest wall deformity in children, occurring in approxi- the ribs as pressure countering [2]. However, in a small
mately 1 in every 700 births [1]. Flaring of the costal arch proportion of patients, the flaring of the costal arch
may be part of the deformity. In 1998, Donald Nuss remains and sometimes even increases. Usually, the final
described a minimally invasive procedure for PE repair, result of the minimally invasive procedure on the flaring
which has now replaced the open or classic “Ravitch”’ or cannot be predicted.
“Welch” repair in most cases and has become the standard This report presents 5 patients out of a series of 231 in
procedure for PE in children and is also applied in adults whom, after a previous Nuss repair, one or more concave
[1-10]. The procedure includes the insertion of a stainless lower costal cartilages and/or outward protrusion (flaring) of
steel bar retrosternally through the patient's chest, which is the costal arch remained present and who therefore
left in place for 2 1/2 years and is then removed; elevation underwent an additional minimal subperichondral partial
resection of the costal arch cartilage to correct this remaining
aspect of the deformity.
⁎ Corresponding author. Department of Gynecology and Obstetrics,
Onze Lieve Vrouwe Hospital, PO Box 95500, 1090 HM Amsterdam, The
Netherlands. Tel.: +31 0 6 17 58 72 73.
1. Patients
E-mail addresses: remkobosgraaf@hotmail.com, r.p.bosgraaf@olvg.nl
(R.P. Bosgraaf). In 1999, the Nuss procedure was introduced as the
1
Currently: Department of Gynecology and Obstetrics, Onze Lieve treatment of choice for PE in our center. Between March
Vrouwe Hospital, PO Box 95500, 1090 HM, Amsterdam, The Netherlands.
2
Currently: Department of Surgery/Pediatric Surgery, Radboud
1999 and June 2008, 5 children (3 boys) underwent a
University Nijmegen Medical Center, PO Box 9101, 6500 HB Nijmegen, minimal resection of the costal arch cartilage to correct the
The Netherlands. remaining flaring, after a previous Nuss repair (Table 1). The

0022-3468/$ – see front matter © 2010 Elsevier Inc. All rights reserved.
doi:10.1016/j.jpedsurg.2010.05.037
Flaring of the costal arch after Nuss procedure 1905

Table 1 Demographics and results 2. Surgical technique

Patient no. Sex Age at Hospital Complications
surgery (y) stay (d) Under general anesthesia and endotracheal intubation,
the costal arch was exposed through a small skin incision.
1 Male 17 5 None
2 Female 14 3 None
At the highest point of the costal arch, the perichondrium
3 Female 13 3 None was incised and peeled off the flaring part of the cartilage
4 Male 18 2 None (s). Usually, 1 to 3 partial rib cartilages were involved.
5 Male 20 4 None These segments of cartilage (5-10 cm) were then resected,
taking all flaring rib cartilages and, if necessary, the
connections between the cartilages into account, carefully
median age at operation was 17 years (range, 13-20 years). preserving the perichondrium. Absorbable PDS sutures
Cosmetic complaints of the remaining flaring were the were used to close the muscle fascia. The skin was then
indication for the operation in all patients. closed with absorbable intracutaneous sutures supported

Fig. 1 Photographs of patient 3 at 4 time points: (A) before Nuss procedure, (B) 6 months after Nuss procedure, (C) before Nuss bar removal
(=10 months after costal arch cartilage resection), and (D) 6 months after Nuss bar removal (=22 months after costal arch cartilage resection).
1906 R.P. Bosgraaf, D.C. Aronson

by Steri-Strips (Academic Medical Center, Amsterdam, curve. Because the morbidity has been minimal and the
The Netherlands). postoperative pain hardly necessitates the use of intravenous
morphine, this procedure may very well be done in a “day
care surgery” or “surgical short stay” environment. It could
3. Results thus be very well combined with the removal of the Nuss bar.
It will be obvious that this treatment of flaring of the
The postoperative analgesia administered was intravenous costal arch should not be combined with a Nuss procedure.
morphine during the first 24 hours, combined with oral After all, it cannot be predicted in which patients the flaring
paracetamol and diclofenac. The median hospital stay was will or will not disappear after placement of the Nuss bar; and
3 days (range, 2-5 days). No complications occurred. In all not all patients will seek for its additional treatment.
patients, good to excellent results were achieved. Before the
operation and during follow-up, results were documented References
with photographs in all (Fig. 1). All operations were
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[3] Welch KJ. Satisfactory surgical correction of pectus excavatum
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