Q: Dr. Eppley, I have an indented lower end of my sternum, I think it is called pectus excavatum. I have read about implants to fix but I don’t want a scar on my chest to put it in nor do I ever want any problems with an implant down the road. I was wondering if I was a good candidate for an injectable method of pectus excavatum repair. That seems perfect to me for my chest problem. I have attached some pictures.
A: Thank you for sending your pictures. You have a very discrete lower tail of the sternal depression or a limited pectus excavatum deformity. It’s size and location is deal for an injectable form of pectus excavatum repair or sternal augmentation, the question is one of which material to use. The options include your own fat, hydroxyapatite granules or an hydroxyapatite cement. Having used all three for an injectable sternoplasty approach, I would opt for hydroxyapatite granules or fat. While I love injectable fat (and yes even you as a thin guy have enough to harvest) as it is both natural and will never created an abnormal contour problem, it is very prone to partial or complete resorption due to the tight attachment of the sternal tissues. The pressure of the tight overlying skin is the cause of fat atrophy/resorption. How much of the fat will take can not be precisely predicted before surgery. Hydroxyapatite granules can be injected, are very moldable (as they are granules), will not resorb, and have low risk of any contour/shape issue. Any of the bone cements (composed of hydroxyapatite) are great space fillers and are permanent but are very prone to being overfilled or having an irregular shape (as they set as a hard mass), thus requiring a revisional procedure for adjustment should that occur.
Dr. Barry Eppley
Q: Dr. Eppley, For an injectable sternoplasty approach for a minor pectus proble on one side, is it possible to apply the hydroxyapatite granules in layers in order to avoid over correction? Can a mold of my good side be done, using it to fix the deformed side. I am asking all these questions because I wouldn’t want to proceed with the operation knowing it will not result in a positive outcome.
A: Obviously no patient or doctor wants to do a procedure that does not have a good chance of a positive outcome. But the reality is that there is no precise method to figure out how much hydroxyapatite to apply in an inejctable sternoplasty approach. A mold of the size of the defect would be done before surgery to estimate the volume of the material needed. And, at surgery, it is always better to place less material rather than too much as more can always be added later and too much would be problematic to remove. I have found that using these guidelines is very helpful in getting the best outcomes, but the limited approach of a small site injection delivery method always introduces variables that do not exist when operations are done in a more open incisional approach. (which is not an advised option due to the scar in your case)
Dr. Barry Eppley
Q: Dr. Eppley, I have a cosmetic issue with one side of my chest. My right pectoral bone/cartilage formation is good but my left inner pec seems to be either missing the inner bone or it may be indented like a minor pectus excavatum. What are my options for fixing this cosmetuc chest issue. I have attached a picture so you can see the area I am referring to.
A: Thank you for sending your picture. I do think it is a very minor manifestation of a pectus excavatum. I think given its very minor cosmetic issue and its location, I would only an injectable sternoplasty technique. One option is fat injections which can be precisely placed and are not a foreign material. While its volumetric survival can not be assured and there certainly is a question of whether you have any fat to donate at all, but that would be my first choice. (although lack of a donor site may make it not an option) The other reasonable option would be injecting hydroxyapatite (HA) granules onto the sternum. These granules can be mixed with PRP (platelet-rich plasma) to form an injectable gel that can be molded once placed into the defect area.
Dr. Barry Eppley
Q: Dr. Eppley, I am a 55 year-old male that underwent a pectus excavatum correction for a severe deformity. Although initially thrilled with the results, I have experienced a disappointing recurrence as is evidenced by the photos. I would do about anything at this point to have a normal looking chest. I am active and healthy, I box and lift weights. I take medication for high blood pressure, which is controlled, and I take synthroid for hypothyroidism. I do not smoke or drink, and aside from the scripts I am drug free. I would appreciate any and all information you may have on an injectable sternal procedure to help build it up.
A: Injectable sternoplasty is a concept that comes from injecting a moldeable bone cement into small lower sternal pectus excavatum defects. A pocket for the material was initially made through a small incision to receive the material which was molded into shape after it as placed, After having done a handful of cases, the bone cement material (which was intended for use for other skeletal issues) was withdrawn from the commercial market due to economic issues of the manufacturer. (not any material problems) That not leaves us with having to consider to use other materials that can be placed either through injection or a small incision. Fat injections remain as the best current method because it is truly injectable and is a natural material. And most everybody has some fat to donate. The biggest and well known problem with fat injections is that its survival is variable and can not be precisely predicted. This is why it is always overdone/overfilled. Other more material-assured results are injectable hydroxyapatite granules or beads. Which although very simple, safe and uses a well known biocompatible material, I have yet to do that just yet.
Dr. Barry Eppley
Q: I have a minor case of pectus excavatum on the bottom of my sternum, although I do not believe it is causing me any physical problems such as breathing. I find its indentation to be very disturbing and affects my self-image. I was reading about the case study: Injectable Sternoplasty with Kryptonite Cone Cement on one of your websites and was wondering if this is the treatment would be good for me as I have about the same level of severity as shown in that person. I have had quite a difficult time researching any relevant plastic surgery options for treating this problem.
A: It is no surprise that you have had a difficult time finding any treatment options for minor to moderate sternal contour deformities as they really don’t exist. Short of treatment for more significant cases of pectus excavatum with the Nuss procedure or the older radical method of rib resection, there is no reported methods for sternal ‘augmentation’. In the past, plastic surgeons have occasionally used custom or carved implants for sternal augmentation but these required large incisions to place and were often associated with postoperatuve problems of seromas, infection or implant mobility. Whatever is placed on the sternum, it must be fixed and adhere to the bone to prevent these problems. This is why I have applied a cranioplasty approach to the sternum, specifically a Kryptonite injection approach. This material bonds to the bone and can flow through a very small tube for placement. In my experience with it I have learned that it takes less material than one thinks to fill a lower sternal indentation, usually less than 5 grams due to the expansion of the material
Q: I read in Dr. Eppley’s blog about using Kryptonite Bone Cement for pectus excavatum. I had the Nuss procedure done 5 years ago and breast implants done 4 years ago. I got very good results with the procedure and implants with the lower part of my ribs; however, the upper area (below the collarbone) is still indented. I would like to inquire about this procedure and whether or not I would be a viable candidate.
A: Kryptonite bone cement is a new type of bone filler/replacement that works well as an onlay, meaning to build out a bone surface to create a better contour. Currently it is approved in the United States for cranioplasty, the filling in or building out of skull bone contours. While it has never been formally tested for use on the sternum, there is no reason to think that it would not work just as well there as on the skull. What makes Kryptonite a possibility in the sternum is that it can be injected after it is mixed before it sets up into a hard mass. This is a very unique characteristic of a bone cement and no prior ones have ever had this physical property. As valuable as that material property is in the skull, it becomes a critical material characteristic in the sternum as incisions of any size are easily seen there.
For an upper sternal problem, a small incision inside the sternal notch can be used to develop the subperiosteal/supraperiosteal pocket. It is into this pocket that the material is injected and molded. The critical step in injectable sternoplasty, like injectable cranioplasty, is to make a good recipient pocket that matches the external outline of the contour defect.