Technique de Nuss

Nuss, Ravitch, 3D implants: which technique to choose ?

Author : Pr Jean-Pierre Chavoin, ex-Head of Plastic Surgery Department of Toulouse University Hospital

There are several surgical techniques to treat Pectus Excavatum. These techniques include those that involve filling (3D implants, lipofilling), which try to fill the morphological deformation, and orthopaedic techniques (Nuss, Ravitch), which aim to remodel the rib cage and alleviate any functional problems.

In the absence of verified functional problems, the 3D custom-made implant technique enables highly satisfactory, immediate morphological results at minimal patient risk.

Body

Filling techniques

Filling techniques do not affect the rib cage itself. Instead, implants are designed to fill the sunken chest from a morphological point of view. In no way are filling techniques intended to alleviate functional problems. If anything is unclear, cardiorespiratory tests are required to determine the most appropriate surgical technique. 3D implants and lipofilling are two filling technique options. Conversely, filling Pectus Excavatum with silicone gel breast implants is not indicated because it can cause the breast to appear convergent or divergent.

Drawing of an implant filling a Pectus Excavatum hole

3D Implants

Computer-aided designed 3D custom-made implants enable the treatment of any type of Pectus, including asymmetric cases, regardless of the patient's age. The risks are minimal and the results immediate. Only a single surgery is required. This technique has been around since 2008. Previously, implants were performed by casting plaster onto the patient's skin, which actually produced less accurate results.

Drawing illustrating fat syringes for Pectus lipoffiling

Lipofilling

Lipofilling or autologous fat grafting involves taking fat from the patient's body and reinjecting it in the appropriate place. It is a minimally invasive technique, used for very mild cases and for patients with sufficient fat reserves (uncommon among young people). Several injections are necessary to achieve the expected result, which can vary over time.

Reconstructive techniques

Reconstructive orthopaedic techniques, such as the Nuss or the Ravitch procedures, seek to rectify the rib cage to correct the morphological defect and free up space for the heart and lungs.

Drawing of the Ravitch technique drawing

Ravitch procedure

The Ravitch technique is an "open" technique that involves costal cartilage shortening and sternum fracturing to correct the deformation. The structure is stabilised using metal bar(s) attached to the ribs. The bar(s) must be removed after 6–12 months.

Drawing of the Nuss technique surgery with flipped bars

Nuss procedure

The Nuss procedure is a "closed" technique, also called mini-invasive technique. Using a small incision, a curvilinear bar is inserted laterally, following the internal convexity of the chest wall and passing close to the heart. The bar is then rotated 180 degrees to push the sternum out. The bar is removed after two or three years. This procedure may involved several bars.

 

Disadvantages and risks of reconstructive techniques

Reconstructive orthopaedic techniques, such as the Nuss and the Ravitch procedures, seek to rectify the rib cage to correct the morphological defect and free up space for the heart and lungs.

Disadvantages

Risk of residual Pectus Excavatum after Ravitch surgery

  • Two surgeries (at least)
  • Adapted for young patients (under 30yo)
  • Serious post-operative pain that can become chronic
  • Lengthy recovery times. Heart massage cannot be performed while the bars are in place
  • Long scar (Ravitch)

Risks

Risk of bar movement from Nuss technique on Pectus Excavatum

  • Cardiac or vascular injury when the bar is inserted (Nuss) during the operation
  • Bar migration, displacement or rupture
  • Allergy (loosened metal particles)
  • Haemorrhaging during bar removal (Nuss)
  • Unsatisfactory results or recurrence (particularly in asymmetric cases)

Consult the Ravitch and Nuss complications' bibliography

Revision of Nuss or Ravitch procedure using 3D implants

If the Nuss or the Ravitch procedure fails (unsatisfactory results, recurrence, complications etc.), the 3D custom-made implant technique is fully indicated.

This technique enables high-quality morphological results, with minimum complicating risks. Patients who need a bar removed urgently or are dissatisfied with the morphological results can benefit from the 3D custom-made implant technique.

Advantages of these revisions

  • Filling the deformation immediately,
  • Just one surgery, minimal risk,
  • Moderate pain, fast recovery,
  • Possible reuse of existing scars.

 

3D Implants treatment

Results

The 3D custom-made implant technique enables to correct Nuss or Ravitch technique failure with an immediate result.

Nuss review result on woman

Ravitch review result on man

More Results

Testimonials

Surgeon

The advantage of the filling technique through 3D implant is the simplicity compared to other orthopedic techniques like Ravitch or Nuss. This really is a minimally invasive surgery where no bones are touched, less painful and with an immediate final result.

Pr Assouad, Dr Debrosse, thoracic surgeons, Tenon Hospital (Paris)

Patient

I have asymmetric Pectus Excavatum. I was told by a specialist in Bordeaux that the Nuss technique seemed to be the best one to go for. The first procedure caused me a lot of suffering and the aesthetic result did not live up to my expectations.

Melissa, 19 years old, Charente-Maritime (France)