There are many modifications and innovations to the Nuss procedure, notably for handling more complex cases of pectus excavatum.
Dr. Hyung Joo Park has detailed many treatments addressing patients with more complicated, deep, or eccentric forms of a deformity.
One of them is the sandwich procedure for treating patients with more severe and asymmetric forms of deformity.
Doctors reconstruct the entire chest wall using the sandwich approach, commonly known as the press-molding technique. In addition to treating pectus carinatum, it is also helpful in more complicated cases like the excavatum/carinatum mixture ones.
Complex excavatum/carinatum deformities appear to respond well to the sandwich approach using the external and internal bars.
When to do Non-Surgical TREATMENT
For non-complicated cases, brace therapy or vacuum bell can be the primary strategy for treating the malformation.
Asymmetrical chest wall deformities and mixed excavatum/carinatum deformities that surgeons cannot correct with any non-surgical device are of indications for surgery.
It would be best if you spoke with your doctors whenever it is a severe form to determine what surgical treatment is necessary for you.
Doctors have developed the idea of press-molding the entire front chest wall while sandwiching exterior and internal bars for mixed-type (combined) chest abnormalities.
The sandwich technique for combined pectus cases
The chest wall protrusion is reduced by simple external compression of the chest wall during pectus carinatum correction of the patient's chest.
Because of the unwanted reduction of the chest wall near the carinated part, the chest wall will not be restored uniformly. Therefore, asymmetric deformities or coupled excavatum/carinatum should not be treated with simple external compression.
According to surgeons' theories, to repair the pectus carinatum properly, the chest wall must be press-molded.
The carinated part must be externally compressed with the pectus bar while the chest wall is internally supported to rebuild the wall.
Step by step
It is time for surgery when all necessary preparations and examinations are done. On the day of the surgery, you need to have an anesthetic. Then you will be placed in a neutral laying position on the operating table before the treatment begins.
For this surgery, two bars are needed, internal and external.
- First, your surgeon will mark the target points on the chest wall.
The point of compression for the external bar is at the top of the carinatum.
The depressed area (excavatum part) of the chest wall is the secondary target for the internal bar.
- First is the insertion of the internal bar, followed by the exterior bar compression (the sandwich one technique).
- The internal bar's shape must fit the chest wall.
- The medical scope is introduced through a small chest incision to create the internal bar's path.
- The external bar has a flat segment that meets the carinated part to increase compression.
- With the "through-the-skin suture technique," the external bar is secured to the matching ribs.
- While compressing the carinatum part using the table-mounted compressor, the pericostal wires are attached to the end holes of the bar.
- The internal bar is threaded through the previously installed guide and rotated to raise the depressed portion of the chest wall.
- The last step is connecting the external and internal bars to the bridge plate.
Before and after the operation, the medical team in charge of you and your surgeon must give you proper guidance. After your surgery, you will receive specific instructions on what you can and cannot do during the critical post-operative period.
This procedure is challenging for any patient, but it has the potential to improve your life. That is why you must be emotionally and physically prepared.
Is this approach successful?
Doctors initially use this sandwich press-molding method for severe chest wall abnormalities involving a carinatum/excavatum complex.
Starting to be used by surgeons in 2007, this technique successfully approached these extreme and rare chest deformations.
With other modifications to the method, doctors can treat any form of chest malformation with this kind of surgery, which is a promising and good thing for any of us with this deformation.
Studies showed that the sandwich approach is the best way to repair all sorts of chest wall protrusions after achieving an excellent result in a case with an extreme combined excavatum/carinatum complex deformity.
But on the other hand, you can find other articles on the internet that say this sandwich technique may only sometimes be the best solution for complicated chest deformities and will not necessarily produce the best results.
To address protrusion and depression simultaneously, some surgeons suggest a minimally invasive procedure using one or two metal bars and say that early clinical results are promising with this method.
From a neutral point of view, it would be best to decide which procedure is most suitable for your deformity with your doctor's help—knowing that everyone's deformity need customized treatment methods.
I want to constantly remind you that the desire for change in people with deformities is critical for recovery.
Solutions exist. What matters is how big our motive is, so we can find the right way to correct our deformation.
Please consult a doctor who will monitor your condition and with whom you will decide what is best for you and the severity of the deformity.
The amount of information regarding this technique still needs to be increased, so any additional information is welcome.
If you have such an operation, please share it with us so that we can gather as much knowledge as possible on this topic.
I hope this post was helpful to you. Thank you for reading.
- Park HJ, Kim KS. The sandwich technique for repair of pectus carinatum and excavatum/carinatum complex. Ann Cardiothorac Surg. 2016 Sep;5(5):434–9.
- Wang W. Minimally invasive operation for costal arch deformity [Internet]. Science Repository OÜ; 2018 Jul [cited 2023 Feb 4]. Available from: https://www.sciencerepository.org/minimally-invasive-operation-for-costal-arch-deformity_SCR-2-104