Defect-Oriented Versus Back Scar-Oriented Flap Design in Breast Reconstruction with Latissimus Dorsi Musculocutaneous Flap: A Patient-Reported Satisfaction Outcome Comparison Using BREAST-Q.

BACKGROUND: The design of the latissimus dorsi musculocutaneous flap in breast reconstruction has several options. To date, there have been no reports on the surgical outcomes with flap designed based on the defect shape of the mastectomy site and flap shape of the donor site. To compare patient satisfaction according to the flap design, we designed and conducted independent three sub-studies targeting fifty-three breast reconstruction patients using BREAST-Q© scale. METHODS: In study 1, there was no difference in patient satisfaction between the group with the flap designed according to the shape of mastectomy defect (defect-oriented group) that with the flap designed according to patient's wish regardless of defect shape (back scar-oriented group). In study 2, comparing the results based on the shape of the flap, vertically designed flap showed a statistically significant difference in the psychosocial well-being. In study 3, comparing the results based on the shape of the defect, no significant difference was noted. RESULTS: Even though designing a donor flap based on the shape and orientation of the mastectomy defect has no statistical significance in patient satisfaction or quality of life compared with that based on the patient preference in placement of the donor site scar, the group with the vertical donor design showed better psychosocial well-being than the group with other shapes of the donor flap. By considering the advantages and disadvantages of each flap design, enhanced patient satisfaction and durability and natural aesthetic goal can be achieved. This is the first study to compare the differences in results according to the flap design method during breast reconstruction. Patient satisfaction according to the design of the flap was investigated in the form of a questionnaire survey, and the results were displayed. In addition to breast shape, donor scars and complications were also investigated. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Orbital Reconstruction Using a Polyetheretherketone Patient-Specific Implant After Removal of a Mucocele Developing After Orbital Fracture Repair.

A few mucoceles developing secondary to facial bone fractures have been reported. Mucocele formation is thought to be attributable to displacement of the respiratory mucosa with obstruction of the sinus opening, especially if untreated. Accurate diagnosis and management are required; a growing mucocele will gradually destroy adjacent bony structures and cause irreversible complications. The authors describe a patient who presented with diplopia and mild discomfort when gazing upward. She had undergone reconstruction of medial and inferior orbital fractures 20 years previously. The patient was diagnosed with a mucocele developing after orbital fracture repair. The patient underwent mucocele removal and orbital reconstruction using a polyetheretherketone patient-specific implant. In a patient with orbital symptoms but without acute trauma, a mucocele should be among the differential diagnoses if history-taking reveals past orbital trauma and surgery. A polyetheretherketone patient-specific implant was effective for orbital reconstruction after mucocele removal.

Angioleiomyoma of the Parotid Gland Fed by the Superficial Temporal Artery.

Angioleiomyoma in the head and neck area is rarely observed. This report introduces 2 cases of angioleiomyoma discovered in the parotid gland, particularly with the superficial temporal artery (STA) as the feeding vessel. Each patient was evaluated preoperatively by clinical manifestation and computed tomography scan, but the difficulty was encountered due to nonspecific radiologic features of angioleiomyoa. Surgical intervention was performed for precise diagnosis and treatment. The tumors were fed from the STA, with the diagnosis of venous type parotid angioleiomyoma. To our knowledge, there have been only one previous report of angioleiomyoma of the parotid gland fed from STA in the literature. Once parotid tumor is discovered, although rare, the possibility of angioleiomyoma should be considered, and the authors recommend prompt surgical excision for accurate diagnosis and treatment.

Aesthetic Reconstruction of an Old Burr Hole Defect Using a Cancellous Bone Chip and a Porous Polyethylene Implant.

Burr hole trephination is a minimally invasive procedure but can leave a depressed scar at the surgical site. Various materials have been studied to fill such defects; however, to the best of our knowledge, there are no reports of reconstructing old, depressed scars from burr hole surgery. This report presents a patient with depressed scarring near the anterior hairline of the frontal bone on both sides due to burr hole trephination for a subdural hematoma 27 years prior. Computed tomography scans revealed bony defects under the scar. Reconstruction of the bony defect was performed by debriding the bony bed, filling it with hydrated alloplastic cancellous bone, and covering it with a porous SynPOR polyethylene titanium-reinforced implant. During 1 year of follow-up, the reconstruction was maintained without complications. The patient was satisfied with the esthetic outcome. Thus, old bony defects can be repaired using the appropriate materials and techniques.

Angiotensin-Converting Enzyme Inhibitor, Captopril, Improves Scar Healing in Hypertensive Rats.

Pathological cutaneous scars, with aberrant extracellular matrix accumulation, have multiple origins. Antihypertensive medications, such as calcium channel blockers, have been used to treat pathological scars. However, a relationship between angiotensin-converting enzyme (ACE) inhibitors, pathological scars, and blood pressure (BP) has never been reported. Here, we aimed to compare the differences in scar development and the effects of the administration of systemic ACE inhibitor on scar tissue in a normotensive rat, the Wistar Kyoto rat (WKY), a hypertensive rat, and the spontaneously hypertensive rat (SHR). Using an 8-mm punch, we created two full-thickness skin defects in a total of 32 rats (16 WKY and 16 SHR) to obtain a total of 64 wounds. We established control WKY (n = 16), captopril-treated WKY (n = 16), control SHR (n = 16), and captopril-treated SHR (n = 16) groups and started captopril (100 mg/g per day) treatment on day 21 in the appropriate groups. The BP of all groups was measured at 0, 3, and 5 weeks. The scar area was measured by histopathological examination, and scarring was expressed in terms of scar area and fibroblast and capillary counts. The expression of heat shock protein (HSP) 47, type I and III collagens, alpha-smooth muscle actin (α-SMA), Ki67, and vascular endothelial growth factor (VEGF) was investigated using immunohistochemistry. The scar area and fibroblast count were significantly higher in control SHR than in control WKY. The scar area, fibroblast count, and capillary count were significantly smaller in captopril-treated SHR than in control SHR. Immunostaining for α-SMA, Ki67, and VEGF also showed a noticeable decrease in scarring in the treated SHR compared with that in control SHR. Thus, BP affects scar development in a rat model, and an ACE inhibitor is more effective at reducing scars in hypertensive rats than in normotensive rats.

Antihelical Auricular Reconstruction With Adipoperichondrial Turnover Flap and Full-thickness Skin Graft.

ABSTRACT: Reconstruction of the antihelical area can be challenging because the cartilage can be easily exposed due to the thin overlying soft tissue, and it has a lack of tissue mobility. Skin graft can be hesitant to perform in antihelical defects where the bare cartilage is exposed.A 70-year-old male with squamous cell carcinoma of the antihelix of the left ear was referred to our department for surgical excision. Wide excision with tumor-free margins resulted in a defect of 2.0 × 1.0 cm with exposed bare cartilage. The authors covered the defect using adipoperichondrial turnover flap from cephalic portion of the earlobe followed by full thickness skin graft. The skin graft took well with no complication. Aesthetic result was satisfactory with no auricular deformity.This adipoperichondrial turnover flap is simple, easy, can be performed in one stage, and produces good esthetic results with no disfiguration of the ear shape.

Verapamil-containing silicone gel reduces scar hypertrophy.

A hypertrophic scar is a common dermal fibroproliferative lesion usually treated with topical silicone. Verapamil, a type of calcium channel blocker, is considered a candidate drug for the treatment of hypertrophic scars. Here, we report that the addition of verapamil to topical silicone gel enhances treatment outcomes of hypertrophic scars. Upon creation of hypertrophic scars with the rabbit ear model, varying concentrations of verapamil-added silicone gel (0.1, 1, and 10 mg/g) were applied daily for 28 days. After the animals were euthanised, microscopic measurement was performed for (a) scar elevation index (SEI), (b) fibroblast count, and (c) capillary count. On gross analysis, features of hypertrophic scars were significantly alleviated in the verapamil-added groups. On histologic examination, verapamil-added groups showed (a) reduced SEI (1.93 (1.79-2.67) for control vs 1.34 (1.21-1.51) for silicone only and 1.13 (1.01-1.65) for verapamil-added silicone), (b) fibroblast count 700.5 (599.5-838.5) for control, 613.25 (461-762.5) for silicone only, and 347.33 (182.5-527) for verapamil-added silicone), and (c) capillary formation (52 (35.5-96.5) for control, 46 (28-64.5) for silicone only, and 39.83(24-70) for verapamil-added silicone) (Kruskal-Wallis test, P < .05). On western blot, expression levels of collagen I protein was lower in the 1 mg/g and 10 mg/g verapamil-added silicone compared with control. Therefore, we suggest a therapeutic concentration of verapamil-added silicone gel of at least over 1 mg/g. Further study regarding maximally effective concentration and deeper insight into the mechanism of action should follow.

Quadrangular Fixation of Pectus Bars to Prevent Displacement in Nuss Procedure.

BACKGROUND: Double pectus bars are sometimes inserted to correct pectus excavatum. Method of double-bar fixation to prevent bar displacement has been rarely reported. We have used quadrangular fixation of the double pectus bars. The objective of this study was to compare results of the quadrangular fixation procedure with those of the classic separate fixation procedure. METHODS: From September 2011 to January 2016, 86 patients underwent Nuss procedure with double-bar insertion. In 44 patients, each bar was fixed separately (group A). In 42 patients, quadrangular fixation of the bars was performed with metal plates (group B). Patient demographics, Haller index (HI), bar displacement index (BDI), and reoperation rate were compared between the two groups. RESULTS: The mean patient age was 17.2 years (range: 3-40 years) in group A and 17.8 years (range: 4-30 years) in group B. There was no significant difference in preoperative or postoperative HIs between the two groups (all p >0.05). Early complication rates were 15.9% in group A and 9.5% in group B (p > 0.05). In group A, three patients underwent surgery to correct bar displacement (6.8% of reoperation rate), whereas there was no corrective surgery in group B. BDIs of the two groups were significantly different (p < 0.01). CONCLUSIONS: When quadrangular fixation was performed with upper and lower pectus bars bilaterally fixed by connecting each bar with plates, bar displacement was prevented more effectively than separate fixation, thus minimizing reoperation.

Identifying Preoperative Factors Associated with the Volume Discrepancy in Patients Undergoing Breast Reconstruction with the Extended Latissimus Dorsi Musculocutaneous Flap Coverage.

BACKGROUND: The latissimus dorsi (LD) flap is a versatile option for breast reconstruction. However, the indications are limited because of volume discrepancy between the breast and the flap. We conducted this study to identify preoperative factors associated with the volume discrepancy in patients undergoing breast reconstruction with the extended LD flap. METHODS: A retrospective study was performed in 69 patients (69 breasts) who underwent breast reconstruction with the extended LD flap between March 2015 and March 2018. We evaluated age, body weight, height, preoperative body mass index (BMI), postoperative BMI, breast skin defect size, breast volume, flap volume, and volume discrepancy [breast volume - flap volume]. RESULTS: Mean age, height, body weight, preoperative BMI, postoperative BMI, skin defect size, breast volume, flap volume, and volume discrepancy were 45.6 ± 7.1, 157.8 ± 0.1, 59 ± 8.1, 23.7 ± 3.2, 23.5 ± 3.3, 16.5 ± 9.3, 252.2 ± 107.1, 229.4 ± 95.6, and 32.6 ± 31.4, respectively. Spearman's rank correlation coefficients indicated significant positive linear correlations between volume discrepancy and preoperative BMI (correlation coefficient = 0.267, P = 0.027), volume discrepancy and breast volume (correlation coefficient = 0.472, P < 0.001), and between volume discrepancy and skin defect size (correlation coefficient = 0.609, P < 0.001). Stepwise multiple regression analysis yielded the following formula: predicted log volume discrepancy (ml) = 1.2891 + 0.0639 × skin defect size + 0.0025 × breast volume (R2 = 0.421). CONCLUSION: Skin defect size and breast volume were preoperative factors associated with volume discrepancy in patients who have undergone breast reconstruction with the extended LD flap. Considering these factors, we can predict the lack of volume and plan any necessary secondary procedures. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Emerging Fixation Technique to Prevent Pectus Bar Displacement: Needlescope-Assisted 3-Point Fixation.

BACKGROUND: Bar flipping displacement is one of the most common complications after the Nuss procedure for pectus excavatum. We evaluated the results of a modified Nuss procedure with needlescope-assisted bar fixation. METHODS: The records of 41 patients with pectus excavatum who underwent single pectus bar insertion with the Nuss procedure between July 2011 and August 2014 were retrospectively reviewed. The patients were divided into two groups: those who did not undergo 3-point fixation (group A) and those who did undergo 3-point fixation (group B). RESULTS: There were 36 male patients and 5 female patients with a mean age of 10.7 ± 8.3 years (range: 3-36 years). The postoperative Haller index (HI) (2.61 ± 0.42) was significantly lower than the preoperative HI (3.91 ± 1.07; p < 0.01). The angle of the initial bar position was 5.59 ± 7.37 degrees in group A and 8.52 ± 9.61 degrees in group B, with no significant difference between the groups (p > 0.05). The rate of reoperation to correct bar displacement was lower in group B (3.3%) than in group A (9.1%). CONCLUSION: Needlescope-assisted 3-point fixation of the bar was performed without an additional skin incision and showed a low rate of reoperation to correct displacement of the pectus bar.

Bioabsorbable plates and screws fixation in mandible fractures: clinical retrospective research during a 10-year period.

We present the basic guidelines for the safe fixation of a mandible fracture using a bioabsorbable system with less strength than the metallic system based on our 10 years of experience.We conducted a retrospective review of 75 patients who had undergone fixation using a bioabsorbable system for a mandible fracture. We analyzed the method of fixation and the size and thickness of the plates and screws that were selected depending on the mandible's fracture site.Minor complications including intraoral wound disruptions and infections occurred in 12 (16%) patients, and 2 (2.7%) patients among 10 patients who presented with infections had nonunion; therefore, they underwent replacement of the absorbable system with the titanium system. Bone resorption that was caused by the absorbable plate occurred in 12 (16%) patients.The bioabsorbable system also may be able to replace the metallic system in the fixation of comminuted mandible fractures if further research on the development of the system is supported.

Volume Measurement of Various Tissues Using the Image J Software.

Various methods have been introduced to assess the tissue volume because volumetric evaluation is recognized as one of the most important steps in reconstructive surgery. Advanced volume measurement methods proposed recently use three-dimensional images. They are convenient but have drawbacks such as requiring expensive equipment and volume-analysis software. The authors devised a volume measurement method using the Image J software, which is in the public domain and does not require specific devices or software packages. The orbital and breast volumes were measured by our method using Image J data from facial computed tomography (CT) and breast magnetic resonance imaging (MRI). The authors obtained the final volume results, which were similar to the known volume values. The authors propose here a cost-effective, simple, and easily accessible volume measurement method using the Image J software.

Endotine Midface for Soft Tissue Suspension in Zygoma Fracture.

Treatment of zygomatic fractures necessitates dissection beneath the soft tissues of the cheek. Inadequate resuspension may lead to deformities, including cheek ptosis, lower lid ectropion, and lateral canthal dystopia. The authors present their experience using a biodegradable suspension device for cheek flap resuspension. Patients who received open reduction for unilateral zygomatic fracture between January, 2006 and December, 2013 at a single center were included in the study. Patients could choose whether or not to have Endotine midface inserted. Patients rated satisfaction on facial symmetry. Computed tomography (CT) at 15 months was assessed for soft tissue thickness at the level of the midpoint of the nasolabial fold on each side. Photographs at 15 months were viewed by 3 blinded plastic surgeons and rated for cheek drooping. The results for all 3 parameters were compared between the Endotine group and the control group. A total of 83 patients were included (43 in the Endotine group and 39 in the control group). Patient satisfaction scores were statistically higher (P = 0.03) in the Endotine group (3.70 ±â€Š0.76) than the control group (2.85 ±â€Š0.96). Computed tomography soft tissue thickness score ratio between affected and unaffected side was significantly lower (P < 0.001) in the Endotine group than the ratio in the control group. Photography evaluation score difference between affected and unaffected side for the Endotine group (0.70 ±â€Š0.77) was significantly (P = 0.041) smaller than the control group (1.92 ±â€Š1.24). Endotine midface is easy to apply and effective in repositioning the elevated cheek flap in zygomatic fracture patients.

Identifying preoperative factors associated with the postoperative nasal synechia in patients undergoing closed reduction of the nasal bone fracture.

We conducted this study to identify preoperative factors that are associated with the postoperative nasal synechiae in patients with nasal bone fracture who underwent closed reduction.In the current single-center, retrospective study, we evaluated the fracture type, septal deviation angle (SDA), synechia scores (SSs) and visual analog scale (VAS) scores through a retrospective review of the medical records and computed tomography scans of 42 patients (n = 42) who had undergone closed reduction for nasal bone fracture at our medical institution during a period ranging from April to August 2013.The mean SS was significantly lower in the plane I group (n = 25) as compared with the plane II group (n = 17) (1.28 ± 1.77 vs 2.76 ± 1.89, P = 0.013). There was a significant positive correlation between the SDA and the SS with a formula of SS = 0.216SDA - 0.322 (r(2) = 0.532, P < 0.001) and between the SS and the VAS with a formula of VAS = 1.280SS + 0.612 (r(2) = 0.648, P < 0.001). Both the SS and VAS were significantly higher on the convex side as compared with the concave side of the nasal cavity.Our results indicate that patients with higher SDA or combined septal fractures might be at increased risks of developing the postoperative synechiae. Further large-scale, prospective studies are warranted to establish our results.

Treatment of mallet fracture using a percutaneous fixation technique with an 18-gauge needle.

The purpose of this paper is to introduce a simple and intuitive treatment method using an 18-gauge needle for mallet fractures that involve more than one-third of the articular surface. We performed a retrospective review of 17 patients who underwent closed reduction using an 18-gauge needle with transfixation of Kirschner wire between March 2007 and October 2013. According to the Wehbe and Schneider classification, 15 cases were type IB, 1 was type IIB, and 1 was type IIC. The mean size of bony fragments at the time of injury was 53 percent of the articular surface of the distal phalanx. According to Crawford's criteria, 6 of 17 patients had an excellent result, 9 had a good result and 2 had fair results. Our method of percutaneous reduction using an 18-gauge needle with transfixation of Kirschner wire is minimally invasive and is useful for the fixation of mallet fractures.

Reconstruction of Orbital Wall Fractures with a Combination of Resorbable Plates and Antibiotic-Impregnated Collagen Sheets.

(1) Background: Orbital wall fractures are common in maxillofacial trauma, and artificial implants are often used for reconstruction. However, there has always been concern about infection because implants are directly exposed to the airway. This study was conducted to determine the effectiveness of a combination of resorbable plates and antibiotic-impregnated collagen sheets in reconstructions of orbital fractures and to determine whether it had an effect in reducing postoperative antibiotic use. (2) Methods: The retrospective study was conducted on 195 patients who underwent orbital wall reconstruction from March 2019 to August 2022. The 176 patients in the control group underwent reconstruction using only resorbable plates and were administered postoperative antibiotics for 5 to 7 days. On the other hand, the 19 patients in the experimental group underwent reconstruction using a combination of resorbable plates and antibiotic-impregnated collagen sheets and only received antibiotics once before surgery. The occurrence of ocular complications, the length of hospitalization, the infection incidence rate, and the adverse effects of antibiotics were investigated. (3) Results: significant ocular complications were observed in the experimental group during a follow-up period of more than 1 year. Regarding postoperative infections, there were two cases of infection in the control group (infection rate: 1.14%), while no infection was found in the experimental group. The hospitalization period of the experimental group was significantly shorter than that of the control group (p < 0.01), and the incidence of total adverse effects of antibiotics, especially nausea, was lower in the experimental group (p = 0.02). (4) Conclusions: The combined use of resorbable plates and antibiotic-impregnated collagen sheets allows effective orbital wall reconstruction without infection, with a shorter hospital stay, and with fewer antibiotic adverse effects.

Orbital dystopia due to orbital roof defect.

We performed a retrospective review of patients who presented with delayed dystopia as a consequence of an orbital roof defect due to fractures and nontraumatic causes to search for a correlation between orbital roof defect size and surgical indications for the treatment thereof. Retrospective analyses were performed in 7 patients, all of whom presented with delayed dystopia due to orbital roof defects, between January 2001 and June 2011. The causes of orbital roof defects were displaced orbital roof fractures (5 cases), tumor (1 case), and congenital sphenoid dysplasia (1 case). All 7 patients had initially been treated conservatively and later presented with significant dystopia. The sizes of the defects were calculated on computed tomographic scans. Among the 7 patients, aspiration of cerebrospinal fluid, which caused ocular symptoms, in 1 patient with minimal displaced orbital roof and reconstruction with calvarial bone, titanium micromesh, or Medpor in 6 other patients were performed. The minimal size of the orbital roof in patients who underwent orbital roof reconstruction was 1.2 cm (defect height) x 1.0 cm (defect length), 0.94 cm(2). For all patients with orbital dystopia, displacement of the globe was corrected without any complications, regardless of whether the patient was evaluated grossly or by radiology. In this retrospective study, continuous monitoring of clinical signs and active surgical management should be considered for cases in which an orbital roof defect is detected, even if no definite symptoms are noted, to prevent delayed sequelae.

The changes of distance between nipples following correction of women pectus excavatum.

The breasts in women pectus excavatum patients frequently appear to be slanting medially along the inclination of the distorted ribs. This study aims to evaluate changes in the distance between the nipples and to find out whether medially slanting breasts are corrected in women pectus excavatum patients following modified Nuss procedure. This case series analysis enrolled 22 young women patients with pectus excavatum between October 2011 and September 2020. We measured all the patients' distances from the sternal midline to the right and left nipples, based on chest computerized tomography. We calculated the distances between nipples as being the sum of the right and left distances. The mean age of patients was 16.50 ± 4.73 years, and the follow-up periods were 35.59 ± 20.23 months. The postoperative Haller indices (2.89 ± 0.43) were significantly lower than the preoperative Haller indices (5.14 ± 1.96) (p = 0.000). The distances between the nipples before and after Nuss procedure were 145.17 ± 17.73 mm and 172.29 ± 19.11 mm, which is a significant increase following surgery. (p = 0.000). Our results demonstrated that skeletal correction with modified Nuss procedure in pectus excavatum increased the distance between nipples, indicating that medially slanting breasts had been corrected.

Acellular dermal matrix (Insuregraf) in the prevention of Frey's syndrome and surgical site depression after parotidectomy.

BACKGROUND: Parotidectomy is the treatment of choice in many parotid tumors. Due to the extensive nature of the procedure, unfavorable complications such as gustatory sweating, surgical site depression are common. Various techniques using fascia, muscle or AlloDerm have been developed but debate still remains regarding its availability and affordability. We applied a newly developed acellular dermal matrix (Insuregraf) to the parotidectomy field to act as a physical barrier and to provide adequate filling effect for prevention of functional and aesthetic complications. METHODS: From March 2010 to March 2017, 30 patients with parotid tumors underwent superficial parotidectomy. Twenty patients underwent only superficial parotidectomy. Ten patients had Insuregraf applied to the surgical site after superficial parotidectomy. We evaluated the incidence of Frey's syndrome, surgical site depression, and patient satisfaction rate in both groups. RESULTS: The incidence of Frey's syndrome was lower in the Insuregraf group (0 vs. 2). Surgical site depression was also lower in the Insuregraf group (2 vs. 20). Satisfaction score for facial contour in Insuregraf group was 9.2 out of 10, which was comparable to 6.2 out of 10 in the control group. CONCLUSION: Application of Insuregraf after superficial parotidectomy is an effective surgical procedure to prevent complications such as Frey's syndrome and surgical site depression. This technique is affordable and safe with no immune reactions. Above all this surgical method should be considered as an option for patients who are concerned about the contour of the face after surgery.

Changes in thoracic cavity dimensions of pectus excavatum patients following Nuss procedure.

BACKGROUND: Using a simple and intuitive method, we evaluated changes in the dimensions of the thoracic cavity of pectus excavatum (PE) patients following the Nuss procedure. METHODS: We performed a retrospective review of 141 patients who had undergone the Nuss procedure. The thoracic cavity was visualized using computed tomography (CT) scans and its dimensions determined by measuring the anteroposterior (AP) and transverse (T) diameters at three anatomical landmarks (the jugular notch, and manubriosternal and xiphisternal joints). The Wilcoxon signed-rank test was used to compare differences between preoperative and postoperative parameters. Kruskal-Wallis tests were performed to compare differences among groups in patient age, type of PE, and number of inserted bars. RESULTS: Of the 141 patients (115 men, 26 women), 87 had symmetric and 54 had asymmetric defects. The postoperative AP diameters at the manubriosternal and xiphisternal joints were significantly higher than their preoperative values, whereas the Haller indices and T diameters at the three anatomical landmarks were significantly lower than their preoperative values. In the multiple bars group, the postoperative AP diameters increased significantly compared with their preoperative values. In the multiple bars group, and in patients aged above 13 years, the postoperative T diameters at all three anatomical landmarks decreased significantly compared with their preoperative values. CONCLUSIONS: Correction of anterior depression of the sternum and compensatory narrowing of the chest width were observed in PE patients following the Nuss procedure. Further research will be necessary to determine the relationship between these observations and postoperative changes in chest volume.