Dr Patrick Treacy shares some his most challenging cases. This month he talks about treating pectus excavatum medically with hyaluronic acid filler.

1. B O D Y
67Aesthetic Medicine • February 2015
SPONSORED BY CASE FILESwww.aestheticmed.co.uk
Dr Patrick Treacy shares some his most challenging
cases. This month he talks about treating pectus
excavatum medically with hyaluronic acid filler
Dr Treacy’s
CASEBOOK
DR PATRICK TREACY
is chairman of the Irish
Association of Cosmetic
Doctors and Irish regional
representative of the British
College of Aesthetic Medicine
(BCAM). He is European medical
advisor to Network Lipolysis
and Consulting Rooms and
holds higher qualifications in
dermatology, laser technology
and skin resurfacing. In 2012
and 2013 he won awards for
‘Best Innovative Techniques’
for his contributions to
facial aesthetics and hair
transplants. Dr Treacy also
sits on the editorial boards
of three international
journals and features regularly
on international television and
radio programmes. He was a
faculty member at IMCAS
Paris 2013, AMWC Monaco
2013, EAMWC Moscow 2013
and a keynote speaker for
the American Academy of
Anti-Ageing Medicine in
Mexico City this year.
>>
A
28-year-old Irish female presented with pectus excavatum and no
previous assessment or corrective surgery. She denied any breathing
problems but had a possible cardiac anomaly (a displaced central beat on
cardiac auscultation). CXR showed base lung capacity decreased. ECHO
showed some mitral redundancy but no regurgitation.
The patient had been previously assessed and deferred surgical intervention
as the condition was not bothering her medically but in later years it was having a
psychologicalimpactonherlife.Shewantedtopursueaminimallyinvasivetechnique
andweconsideredthepossibilityofusingBioAlcamidorMacrolane.Itwasdecidedto
use Macrolane as a test procedure as it would wear off over period of a year and could
be replaced if required. This compound is a body-contour filler launched by Q-Med
in the UK in early 2008. The treatment involves injecting stabilised hyaluronic acid
into the breast and then moulding to the desired shape. More recently, Q-Med has
discontinuedpromotingMacrolaneasabreastenhancerduetothelackofconsensus
amongst radiologists regarding how to examine breasts that have been injected
with filler.1
Discussion
Pectus excavatum is characterised by a depression of the anterior chest wall
(sternum and lower costal cartilages) and is the most frequently occurring chest
wall deformity. The prevalence ranges from 6.28 to 12 cases per 1,000 around the
world. Generally pectus excavatum is present at birth or is identified after a few
weeks or months; however, sometimes it becomes evident only at puberty. The
consequence of the condition on a individual’s life is variable, some live a normal
life and others have physical and psychological symptoms such as: precordial pain
after exercises; impairments of pulmonary and cardiac function; shyness and
social isolation.2
PLEASE ADVISE ON IMAGE USE
AS SIX FURTHER PICS WERE SUPPLIED
BUT THERE IS NO ROOM FOR MORE

2. 68 Aesthetic Medicine • February 2015
SPONSORED BYCASE FILES www.aestheticmed.co.uk
B O D Y
TREATMENT OPTIONS
Surgical repair
Surgical repair is typically performed in the teenage
years. If repair is done during childhood, there is a risk of
recurrence during adolescence. There are two types of
surgical correction, open repair (Ravitch Procedure) and
minimally invasive repair (Nuss Procedure). The majority
of the patients with pectus excavatum are candidates for
the Nuss Procedure.
Open repair (Ravitch Procedure)
Open repair, called the Ravitch procedure, is done through
a horizontal incision across the mid chest. In this repair
the abnormal costal cartilages are removed, preserving
the lining of cartilage, thus allowing the sternum to move
forward in a more normal position. This procedure takes
approximately four to six hours.3 4
Minimally Invasive Repair (Nuss Procedure)
From 1997 a new surgical repair called, minimally
invasive surgery, became available. This less invasive
surgical option consists of the retrosternal placement
of a curved metal bar, without resections of the costal
cartilages or sternum osteotomy, and is performed by
videothoracoscopy. Repair with a metal pectus bar, called
the Nuss Procedure, is achieved by bending a stainless
bar to fit the chest wall. The bar is then inserted and
secured through a small incision under each arm using
the aid of an endoscope to monitor and avoid injury to
the heart during insertion. The bar goes over the ribs and
under the sternum, to push the sternum forward into the
new position. The ends of the bar are secured to the chest
wall. This procedure takes between one to two hours. 5 6
inserted and a space created centrally between the muscle
and mammary gland prior to injection of the product. When
in position, and whilst withdrawing the cannula, the NASHA
gelwasinjectedinthedirectionswherevolumewasdesired.
The bevel of the cannula was held away from the pectoralis
muscle, to avoid injection into tissue with low resistance.
There is a potential for NASHA gel to migrate below the
pectoralis muscle. The breast was then massaged carefully
to aid contouring of the gel with the surrounding tissues. A
maximum of 150 ml of NASHA gel was injected per breast.
The patient was reviewed after three weeks to check for
any unevenness or asymmetry. A minor touch-up procedure
was required with an injection of about 10 ml of NASHA gel
per breast.
The main exclusion criteria to Macrolane are an
unreasonable expectation regarding increase in breast
volume,pathologicalfindingsonmammography/ultrasound,
asymmetrical breasts, ptosis, hereditary risk of breast
cancer, and previous breast augmentation or surgery.
CONCLUSION
Historically, pectus excavatum was considered as a
cosmetic defect, although some children can suffer from
heart and breathing difficulties as the condition restricts
the volume of the chest and reduces cardiac function.7
Although many patients are able to live comfortably and
happily with the deformity, many other patients struggle
with negative body image, low self-esteem, and social
awkwardness. This is especially true for teenagers as
the pectus defect often worsens during the adolescent
years, a time when the child may be seeking peer
acceptance. Treatment modalities over the past decade
have largely favoured surgical techniques, including
sub-perichondrial resection of the costal cartilages,
transverse osteotomy of the sternum and placement
of a sub sternal support. From 1997, minimally invasive
surgery, became available by retrosternal placement
of a curved metal bar, without resections of the costal
cartilages or sternum osteotomy. However, many aspects
that relate to the benefits and harms of both techniques
have not been defined. This paper looks at the feasibility
of evaluating the effectiveness and safety of using
hyaluronic acid filler instead of conventional surgery for
treating people with pectus excavatum. AM
REFERENCES
(1) AnnChirPlastEsthet.2011Jun;56(3):171-9.doi:10.1016/j.anplas.2011.04.002.Epub
2011Jun2.[Macrolane(®),atooprematureindicationinbreastaugmentation.
(2) Surgicalinterventionsfortreatingpectusexcavatum.deOliveiraCarvalhoPE,da
SilvaMV,RodriguesOR,CataneoAJ.CochraneDatabaseSystRev.2014Oct29;10:
(3) RecurrentPectusExcavatumRepairviaRavitchTechniqueWithRibLockingPlates.
PasrijaC,WehmanB,SinghDP,GriffithBP.Eplasty.2014Dec2;14:ic46.eCollection
2014.Noabstractavailable.
(4) ModificationoftheNussProcedure:TheSingle-incisionTechnique.AizawaT,
TogashiS,DomotoT,SasakiK,KiyosawaT,SekidoM.PlastReconstrSurgGlob
Open.2014Dec5;2(11):e256.
(5) ANext-GenerationPectusExcavatumRepairTechnique:NewDevicesMakea
Difference.ParkHJ,KimKS,LeeS,JeonHW.AnnThoracSurg.2014Dec6.pii:
S0003-4975(14)01727-5.
(6) http://www.pedsurg.ucsf.edu/conditions--procedures/pectus-excavatum.aspx
(7) Astudyaboutthecostoclavicularspaceinpatientswithpectusexcavatum.
KimJJ,ParkH,ParkJ,ChoD,MoonS.JCardiothoracSurg.2014Dec6;9(1):189
Nuss Procedure Bar Placement Nuss Procedure Bar Flipped
Non-invasive correction with hyaluronic acid
NASHA gel was injected under sterile conditions following
administration of local anesthesia via entry in the lower
lateral pole of the breast in the region of the mammary
fold. We also used a modified procedure allowing NASHA
injections to the upper pole (anterior to the axillary line and
adjacent to the pectoral muscle) to optimize the result in
patients who were atrophic there. Each breast was lifted
beforeintroductionofthecannulatominimiseinjectioninto
glandular tissue. A 12G (15 cm length) blunt cannula was then
Nuss Bar X-ray of Nuss bar in place