The deformities of the anterior chest wall known as pectus carinatum or "pigeon breast" and pectus excavatum or "shoemaker chest" are very common, but remain hidden from society because people who have these deformities are usually ashamed of their chest aspect. The size and contour of the chest is associated with virility in the male, beauty in the female, and sex appeal in both, so it is not surprising that people with chest deformities avoid clothing and activities that make these deformities noticeable. The psychological impact of a pectus deformity can be devastating on a patient and, in our experience, this impact is not always related to the extent of the deformity. Medical knowledge is not wide in this field and instructions that are not ideal can be transmitted to the patient. The psychological problem is sometimes transferred to the parents who feel guilty for the deformity of their son or daughter. Feelings of frustration can increase with medical orientation to accept the deformity or just look for a way of solving it through surgery.

On the other hand, since 1979 we have reported good results of a conservative treatment for pectus carinatum deformities, the ones with protrusion of the sternum, for adolescents, through a method that involves the use of an orthosis or brace, the Dynamic Chest Compressor I or DCC I, and appropriate exercises. A variation of such an orthosis, called DCC II, and appropriate exercises have been used for pectus excavatum deformities, the ones with depression of the sternum, since 1988. Pectus deformities occur due to growth disturbances of the sternum and ribs, and they may get worse or better during the growing period, depending on the forces that will act on the chest. During the growing period the thoracic cage presents more flexibility and remodeling capacity. Nevertheless, even in adults bone and cartilage remodeling can occur.

For pectus carinatum with components of depression and flaring of the ribs both CDT I and II can be used together with exercises. We call this method the Dynamic Remodeling Method or DR method.

We have classified the Pectus Carinatum, according to the apex of the protrusion, in three basic types: Superior (PCS), Inferior (PCI) and Lateral (PCL). The Pectus Excavatum deformities, the ones with pure sternal depression, are classified into Wide (PEW) and Localized (PEL). (See figure below). MIXED types can also occur.

The FLEXIBILITY of the anterior chest wall is more important than the severity of the deformity for prognosis of treatment using our method.

For assessment of the flexibility of pectus carinatum deformities, a manual compression test is done by compressing the protrusion area of the chest with the palm of one hand while the thoracic spine is supported by the other hand. If the protrusion decreases, it is still flexible.

For assessment of the flexibility of pectus excavatum deformities, an increased intrathoracic pressure test needs to be done as well. In a standing position, the patient takes a deep breath while actively contracts the abdominal muscles and holds the air simulating a blow to promote an increase of the intrathoracic pressure. Simultaneouly, the examiner manually compresses the bilateral flaring of the inferior ribs. The deformity is considered flexible if an improvement of the depression is noted.

The PCS is a rigid and less common type, and good results can be seen only when the orthotic treatment starts during CHILDHOOD, or at the beginning of adolescence when it is more likeable to be flexible, according to the residual amount of cartilage in the (chest bone) sternum.

The PCI and PCL are flexible types, and can usually be treated until the end of the growing period. EXCELLENT results have been observed for these two types of flexible deformities when patients follow medical instructions.  The PCI and PCL are flexible types, and can usually be treated until the end of the growing period and even in adults. We normally recommend starting the orthotic treatment for PCI/PCL during the growth spurt of ADOLESCENCE, around 13 years of age, but we have been treating successfully even ADULTS with residual flexible deformities. See example of an adult under treatment in Treated Cases. Depressed areas of the ribs are also expected to be corrected through prescribed exercises. A continuous wearing of the orthosis is recommended at the beginning of treatment, first two or three months for flexible PCI and PCL, when reduction of the protrusion is usually obtained, but treatment can not be abruptly discontinued due to risks of recurrence. Correction of depressed areas of the rib cage may take much longer, generally from one to two years. Weaning from the orthosis must be done gradually according to the stage of treatment under medical supervision. As a stable improvement is observed, the amount of daily hours can be decresead: if the patient is already used to sleep with the DCC, he can decide if he prefers to wear it during day time or night time. The responsibility for a successful treatment in a shorter or longer time also depends on the patient.

The increased intrathoracic pressure test needs to be done to check flexibility. If the deformity is flexible, it can be treated.

For young children with pectus excavatum only backstroke swimming and blowing balloons are recommended to keep the flexibility of the chest. To very young children learn how to blow balloons, we recommend parents to teach them to blow using a straw to make bubbles in a liquid for 15 minutes every day. We have followed-up a baby who was born with a large PE deformity and after 9 years following our recommendations, presented a total correction of the deformity without using the brace. Maintaining the flexibility of the anterior chest wall of a child with pectus is important for the success of the orthotic treatment during adolescence. If prominences of the inferior ribs are present, the orthotic treatment may eventually be started during late childhood or adolescence.

During ADOLESCENCE, exercises that increase the intrathoracic pressure in an apparatus called "peck deck" found in weight lifting gyms, are prescribed ALONG WITH the use of the DCC II. These exercises are done with the elbows raised and opened at the level of the shoulders, and the forearms and hands in a vertical position. The patient pushes the elbows to the midline against the apparatus' resistance. A forward movement of the sternum can usually be observed in excavatum patients. Depressed areas of the sternum and ribs are expected to be corrected through these exercises, done along with the use of the DCC. In the adolescence the remodeling of the anterior chest wall occurs in a way that will be kept for life.

Nicolas Andry, the man considered the "Father of Orthopaedics," in his book L’orthopédie ou l’art de prev’enir et de corriger dans les enfants, les difformités du corps, published in Paris in 1741, observed that limb deformities could be corrected through conservative methods of treatment. Later, Julius Wolff described what is accepted as a law in Orthopaedics: "The bone tissue is a dynamic structure that can be remodeled according to external forces."

What we have been doing is using these concepts to correct pectus deformities. Despite being solid, bone and cartilage are live substances that have the capacity of remodeling. The younger the patient the greater is his/her potential for osteocartilaginous remodeling, but such a remodeling occurs throughout life. Endochondral ossification and growth plates in the sternum and ribs are also concepts that have important implications for the correct approach to pectus deformities. We have paid attention to the fact that the bones and cartilages of the anterior chest wall also suffer the Wolff’s law effects, and that the flexibility presented in the chest allows the use of external forces to improve or cure a pectus deformity. Corrective forces can change the stress history of skeletal tissues to beneficially alter subsequent patterns of growth and ossification. So, we use external forces to modify the growth and promote the remodeling of deformed structures of the anterior chest wall. Such therapeutic options, based on orthopaedic principles, have been proven effective in patients with flexible deformities.
So, we use to combine external forces (orthoses) and internal forces (increased intrthoracic pressure due to the exercises while wearing the orthoses) to modify the growth and promote the remodeling of deformed structures of the anterior chest wall. Such therapeutic options, based on orthopaedic principles, have been proven effective, mainly in patients with flexible deformities. An example of such a remodeling is shown in Figure number 9 of Treated Cases section, and below.

1994

Regarding surgery during the growing period, the following reports are found in the medical literature: "More than 40 different operative techniques have been described to deal with Pectus Excavatum" (Isakov et al) "indicating that an ideal method has not yet been discovered"(Haje). "Operative techniques are controversial and a perfect result is not obtained with every procedure" (Heydorn et al). "Surgeons who recognize increasingly poor results as their patients grow older, blame the technique and seek a better one" (Humphreys and Jaretzki). "Bad results occur in children who are operated on before they are 12 years of age" (Milovic and Oluic) and "a poor long term outcome" (Ellis, Humphreys and Jaretzki) "have been reported without any explanation of why these failures occur. Current surgical methods do not refer to the GROWTH PLATES of the sternum and costal cartilages, and operation may produce secondary growth disturbance..." (Haje). And many other operative complications also exist in the literature, including decrease in pulmonary function.

The consevative procedure for pectus deformities is a unique treatment option for avoiding surgery and good results are observed mainly, but not only, during the growing period of life. We believe we can better help children and adolescents with these clinical conditions by giving them the opportunity of first trying a conservative method based on the principles of the Orthopaedic (DCC+exercises). The biological support for the conservative approach can be found in the medical papers we have published on this subject (see bibliography). For patients who have already had surgery, our method may also help if correctly applied.

Examples of long-term surgical results:

Adolescent after one year of osteocartilaginous corrective surgery for pectus excavatum. See longitudinal scar. Total recurrence occured a few months later.

Forty-two-year-old adult, five years after plastic surgery for correction of pectus excavatum. Aspect of the chest after removal of subcutaneous silicone.

In addition, the Dynamic Chest Compressor (DCC) is an orthosis that must be manufactured according to each individual deformity for a successful treatment. We always make a plaster cast mold of the chest of the patient for the construction of a correctly fitted orthosis. The pads of the DCC needs to be exactly as the ones shown in the treated cases and method sections of this site: the shape and the position of the anterior pad vary according to the type of deformity; the posterior pad should have a cross (DCC I) or a rectangular form (DCC II) with round corners and should be fixed horizontally in the interior side of the rod and placed on the spine and paravertebral muscles. The use of screws is mandatory; velcro straps do not work as a dynamic way of compression. The prescription of exercises along with the brace wearing should be made according to the skeletal maturation of the patient.

The rate of success depends if the patient follows the instructions for wearing the orthosis and performing the exercises correctly. All cases of flexible carinatum types (PCI and PCL) treated in the appropriate age of adolescence, who followed the instructions for the orthosis wearing, presented a good or excellent result. Good results have also been observed in the other types of deformity treated under the same conditions.

Absolutely not! The DCC correctly built does not interfere with breathing. Indeed, we have observed that patients with respiratory problems, like asthma, improve the clinical condition with the remodeling of their chest wall through the orthotic treatment.

We have already treated without surgery hundreds of out-patients who came from all parts of Brazil, a country almost as large as the United States of America, and from other countries like Canada, England, the USA, Australia, Costa Rica, Colombia, Norway, Spain, Austria, Finland, Israel, Republic Dominican, Ireland, Macedonia, Uruguay, Italy, Germany, Slovenia, Portugal, Scotland, Japan, Argentina, Sweden, Denmark, Romania, Peru, Malta, Hong Kong, Ecuador, Chile, China, Mexico and Venezuela. The period of time between the first and the last medical visit is usually around FOUR WEEKDAYS. You should try to arrive on a Sunday. You could be seen and have the plaster cast mold done in the following Monday afternoon. Two days are necessary for construction of the brace and two more days for exercise teaching sessions and final medical check. You could leave on Friday or Saturday of the same week.

• the flight from Toronto to São Paulo took about 10 hours and from São Paulo to Brasília, an hour and a half;

• she said some people at the airports speak very good English, shop attendants do speak a little English, those who do not speak any English always try to find someone who does it and she managed to do many things by herself based on a Portuguese phrase book and by guessing similar words (retorno/return, hamburguer/hamburger, restaurante/restaurant, etc) and because Brazilians do use a lot of written words in English (sale, hot dog, milk shake, shopping, etc);

• taxis are everywhere, about half the price of those in the USA or Canada;

• hotels and shops accept main credit cards like Visa, American Express, etc. street stands, taxis, cinemas, hospitals, etc. only accept cash;

• dollars can be exchanged by Brazilian currency (Real) at the airport, in banks and hotels;

• she thinks Brazilian people are very warm hearted and friendly; in Brasília you can go sightseeing, shopping, swimming, jogging, watch cable TV, etc; clothes are fashionable and not very expensive;

• the weather is nice, around 23ºC (it gets hotter, up to 28ºC, in summer and colder, around 14ºC, in winter, specially at night; it is very dry from June to September and sometimes very wet during summer time);

• for other information, she recommends searching a website regarding travelling in Brazil, you can find out almost anything you want to know.

Appointments can be scheduled by e-mail. If you need information about how to organize your trip to Brazil, please contact the manager of our clinic, Mrs. Karla Haje, phone 0xx-55-61-910-78158 (day time) or 0xx-55- 61-3248-6292 (from 10:00 to 11:00 PM, Brazilian time), e-mail clinic@orthopectus.com.br. She can book a hotel and give information on transportation services that our clinic provides for the patient in Brasília. We make sure you are well assisted.

We can give a two-hour lecture in English or Portuguese to medical services in other countries. A practical course can also be added and its focus is to train doctors, orthotists and physical terapists in treating patients of their service. Such practical course lasts from four to five days. In this case, the medical service must provide an orthopaedic workshop, material and orthotists to manufacture the orthoses. All details must be worked out by e-mail clinic@orthopectus.com.br or by the phone 55-61-9107-8158, six months in advance.