Pectus excavatum, which is the most common chest deformity, is characterized by a depression of the sternum and adjacent costal cartilages. Pectus excavatum may go unrepaired in childhood or adolescence because physicians often dismiss such patients as having an inconsequential problem instead of a cosmetic deformity5. Especially in women pectus excavatum, because of the special meaning of breasts for women as a symbol of femininity, cosmetic deformities are more problematic than in men. Many methods have been reported to correct them, such as augmentation with breast implants6,7, customized silastic implanting8, lipofilling9, cartilage chips grafting10, or local flaps11. These methods are used to provide cosmetic improvement. However, these procedures may not always achieve a sufficiently pleasing aesthetic result. Many women pectus excuvatum patients present with symptoms of cardiopulmonary dysfunction due to depressed anterior chest wall compressing the intrathoracic organs, such as the heart and lungs, in relation to the degree of deformity12. These symptoms also increased psychosocial stress, which can limit social activities13. Physiologic and cardiopulmonary symptoms have been the primary reason for pectus excavatum surgery in the majority of women pectus excuvatum patients, although cosmesis is also important to them14. It has been recommended to correct chest wall deformity in pectus excavatum patients rather than to correct aesthetic deformity. Various techniques, such as the Ravitch procedure15, Nuss procedure16, and their modifications17, had been used to correct pectus excavatum. In this study, the authors have performed needlescope-assisted three-point fixation18, with or without quadrangular fixation19 of the pectus bars which was a technique invented to avoid bar displacement, a common and serious complication of the Nuss procedure.
Schwabegger et al. named the symptom that normally developed breasts in puberty20 were slanting medially along the slope of distorted ribs in women pectus excavatum patients as breast strabismus21–23. By remodeling the anterior thoracic wall with Nuss procedure, the slaning breasts were relocated to their orthotopic position, resulting in a more naturally breast projection23. The author's experience also shows the same above-described pattern (Fig. 3).
Because the breast strabismus causes a diminished intermammary distance with strabismus of the nipple-areola complexes, reposition of the breasts to an aesthetically acceptable position in women pectus excavatum patients following Nuss procedure is seemed to show increasing the intermammary distance. However, there have been no studies of properly quantified intermammary distance changes before and after pectus excavatum repair in women pectus excavatum patients. Because the breast is a three-dimensional structure, that shape can be expressed with a variety of indicators. Although simple numerical values are insufficient as a means of the breast shape expression, the authors quantified the pre- and postoperative changes in the distance between nipples by measuring the distance between them on the chest CT sections (Fig. 3).
This study had several limitations. First, the study compared the distance between the nipples of patients with pectus excavatum using only CT images. Second, various parameters that affect intermammary distance were not assessed. Further research through indicators and means that can express three-dimensional changes more accurately will be required.
Our results demonstrate that the skeletal correction with pectus excavatum repair with modified Nuss procedure results in an increased distance between nipples, demonstrating breast strabismus correction. This also suggests that skeletal correction alone, without breast surgery, might be useful for aesthetic improvement of medially slanting breast deformity in women pectus excavatum patients.