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legwengw
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[*] posted on 9-9-2011 at 08:33 PM
Modified Ravitch or Nuss?


Hi, I am new to this site, and I was hoping to get some questions answered and maybe some suggestions to help me make my decision.

My name is Walker, 23 years old, and I am going to get the pectus excavatum surgery in December by Dr. Robert Strange in Portsmouth, Va. I have a 3.75 haller index, and i don't have much rib flaring, and my chest is pretty symetrical. My left pec is a little more developed than my right, so maybe the surgery will fix that. From talking to him, I gathered that the Ravitch is a much shorter recovery time, and recommended since I'm not in the teenage bracket anymore. But I have heard that the Nuss is the preferred method by most people, at least from reading the stories on this site, and other ones. I know how both procedures are done, but I'm not sure how to decide. The Nuss seems more painful, due to the bars constantly straining against the sternum (he told me I'd get 2), and a much longer recovery time, since they are in for 2-3 years. But the Ravitch seems like more cutting, a "band" permanently placed in my chest that the cartilage will eventually grow around, and I heard there is no chance of excercising during the 6 months recovery. Can anyone with personal experience with either one give me some pros/cons on them? I'm glad to be finally be able to use something like this site for help and helping others. I'm putting up some pictures as well for more guidance. Thanks in advance to you guys/girls!

Pectus(1).JPG - 17kBPectus(2).JPG - 22kB
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[*] posted on 9-9-2011 at 11:52 PM



Welcome leg!

There was a recent thread on this topic:

http://www.pectusinfo.com/board/viewthread.php?tid=8935

Its hard to tell from your pics, but your chest looks pretty good. If you have a procedure at all I think you would be good candidate for the nuss but only by a highly experienced nuss surgeon. I would do your homework, read lots of journals and ask lots of questions. I had the nuss at 56 by Dr J so you are certainly not too old. I couldn't be happier with my result. I was back at the gym within two months, my pain was very manageable and no big scar. Now I mostly forget the bars are there.

OBY

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[*] posted on 9-10-2011 at 08:07 AM


legwendw, there seems to be more than one method of doing the modified Ravitch. What I had at the end of June involved placing a steel bar behind my sternum and pulling it forward. Also the rib cartilage was partially removed with the outer layer (like casing) left in place so it could grow back. I was told the bar will be removed in about a year and a half. He recommended this method because I'm 52. My son is 16 and he had the Nuss the day before me. Being a teen he bounced right back. He has to be careful not to over do the upper body exercises or he gets sore on the incision spots. I don't know for sure but I think it would be almost impossible to flip the bar at this point, but I don't want him to push it. I can tell you that my Ravitch bar is definitely uncomfortable. I think there are also different types of bars in use for this procedure. Mine is flat with some sawtooth looking ends. If I'm inactive it's no problem, but when I bend over the darn thing feels like it jabs me in my flared ribs. I wonder if maybe the bar was a bit wide for me, since I'm a small woman. I'm fine with it though, as long as it doesn't fail when they remove the bar... Anyway, my son's pectus was mild like yours, and he's doing great with the Nuss. I think it's not as painful when the pectus is mild. I'd find out which kind of modified Ravitch your doctor would perform, and take a look at the bar he'd be using. And there is pressure from the Ravitch bar as well as with the Nuss. I have some cellulitis on the left side (red streaky rash). My surgeon says he thinks it's from the pressure of the bar, harmless but annoying.
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[*] posted on 9-10-2011 at 08:22 AM


In my very HO. I think you would be perfect candidate for 1 Nuss bar. One bar would set you nicely. After the Nuss, the bar would go away. After the Ravitch, the metal plate would stay in you forever.
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[*] posted on 9-10-2011 at 08:31 AM


I agree in his case I think the Nuss would be great, and have no idea why he'd need more than 1 bar. However, I'm puzzled about the metal plate you're talking about. All I have is a flat bar and I get it removed in a year and a half.
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[*] posted on 9-10-2011 at 08:56 AM


Some people here reported that they had modified Ravitch and that they have some plate in their chest, which would have to be removed only for heart surgery.
I guess there is lots of variations and modifications of Ravitch. I just read about this plate on this board yesterday :)
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[*] posted on 9-11-2011 at 06:26 AM


I just checked a map to see where Portsmouth is - as you know, you are very close to Norfolk.

May I suggest that you call CHKD and schedule a consultation with one of their Nuss surgeons? If nothing else, it would give you more information to make your decision.

You are not too old for CHKD and I can't say enough great things about their pectus program. Our daughter had her redo at the age of 21 with Dr. Ann Kuhn.

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[*] posted on 9-11-2011 at 10:19 AM


Thanks everyone for all the replies. The reason he said I may need 2 bars, is due to my height (6'2'') But I should be more specific regarding details on where I'm getting it done at. I'm in the military, and Dr. Strange has performed the surgery (Nuss and Ravitch) multiple times, but he is a military doctor. I doubt I could be sent to CHKD when they have a doctor out of the Portsmouth hospital that can perform it. Another reason that sways my choice is the time I would be out of work. The nuss seems more beneficial in my case, and I heard after a couple months, you can return to the gym, and excercise, and go back to work. That's a big factor, even though I would be taking it very slow to measure my progress. Obviously, I won't be doing contact sports and lifting large amounts of weight until after the bars came out. But I feel as if after getting the surgery, after recovery, running and cardio will come much more easily. I have shortness of breath, and chest pain when doing those sorts of things, but I try to ignore them most of the time. And I will also feel a lot more comfortable about taking my shirt off in public, and in front of the mirror.
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[*] posted on 9-11-2011 at 01:07 PM


Thank you for serving our country!
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[*] posted on 9-12-2011 at 08:24 AM


I had a modified Ravitch procedure in 1998 at age 34. My case was pretty severe. At that time the Nuss method really hadn't been tried yet on adults very much, so my options were limited. Overall my procedure was successful. Mine was done by Dr. Leonard in Minnesota who had his own version of the Ravitch which used an external brace (albeit cumbersome) that was worn for 6 to 8 weeks following the surgery that had a wire loop that went under the relocated sternum. After that, the brace came off the wire was removed and you were done. No permanent hardware whatsoever. Mine worked, I know there were people who did not have successful results. The drawbacks are a frontal scar, which by now is faded greatly and no correction in the high part of the chest (I had a small implant added later to improve that appearance). The advantages were that I was backto my sport of gymnastics after six months. You can read some of my other posts on the board for more details. If I was in the position to consider correction today, I'd no doubt opt for the Nuss to avoid the frontal scar even in spite of the bars being in for several years.
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[*] posted on 9-13-2011 at 04:58 PM


Hi there, my ravitch surgery is going to be Oct 3. My surgeon will be using a titanium orthopedic plate shaped like a "t", super thin, I won't feel it under my skin unless I press real hard. It will be affixed to my straightened sternum with screws to hold it that way. I am glad it will stay forever because I fear that if they take it out, the sternum may cave back in again. Obviously before the plate goes on, they straighten the sternum. He is going to take a couple notches out of mine. I am 34 and out of 4 surgeons I talked to, 2 recommended Nuss, 2 recommended Ravitch. It depends on the individual which one you do and what your surgeon is most experienced with and what you would rather have. With the ravitch, they will cut away the deformed cartilage and you have to wait for it to grow back. It is a longer healing process compared to the Nuss. The Ravitch has been out a long time and as you see they have different options with it.
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[*] posted on 9-13-2011 at 05:26 PM


Either way you do it you wake up with a flat beautiful sternum. It just depends on many things. Do you want to have a second surgery to remove a Nuss bar, or a ravitch bar. Would you be happy with one surgery with a plate that remains in forever. Would you want to have cartilage removed. Or would you want to keep your cartilage and just force your bones to learn its new position with the Nuss and hope it stays that way after the Nuss hardware gets removed. Are you interested in cardio and tons of movement or are you more of a sedentary person? You don't want the Ravitch if you plan to be active immediately. If you don't want bars interfering with your lung space, maybe the Nuss isn't the best option if you are looking to take deep breaths and dont want to feel the bar poking you when you bend the wrong way.
Just keep researching and you will come to a conclusion you are confident in. Much love, Mandy
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[*] posted on 9-14-2011 at 01:29 PM


I had a Ravitch in 2005. I had a short titanium bar in for 11 months. However my chest caved back in a bit and one of the ribs failed to grow back fully and so was "floating" afterwards. I could feel it moving around when I moved a certain way--mostly at the gym. I was so disappointed with the result that I had a Nuss in 2007 almost exactly 2 years after the original Ravitch.

At your age, the difference in the recovery should not really be a significant consideration. It may be a couple of weeks difference at most. I was back in the gym exactly 8 weeks after my Nuss (I was 46 at the time). Your main concern should be the quality of the correction and risk of recurrence. If you read old posts on this board you will see many many more people are disappointed in Ravitch results down the road due to recurrence than with a Nuss. So much so that they get a Nuss redo. There was one case last year of an Australian teenager where his entire chest caved in post-ravitch to a position worse than before the surgery. There are very few cases of Nuss patients getting a Ravitch redo. But if your surgeon will leave some hardware in permanently, then perhaps the chance of recurrence is diminished.

The other consideration is what will be cut. I have never heard of a Ravitch where the sternum was straightened, because that means the entire sternum must be cut away from all of the ribs, which will leave the chest wall very unstable during healing. Usually it is cut some ways down, and then angled outward. But since you will have some permanent hardware, perhaps he intends to cut away the entire sternum. Ask your surgeon if this is what he intends to do. If he intends to cut the sternum in half and angle the bottom part outwards, you will never have a normal looking chest, because a normal sternum does not go this way. As with my case there is also a chance the ribs will not grow back as hoped. You will not know this until months afterwards when it does or does not grow, regardless of what your surgeon hopes.

If I had it to do all over again, I would NOT have had the Ravitch, and would have gone straight to the Nuss. I would have saved a lot of time and trouble and gotten a better correction. Once you chop up our chest with a Ravitch, your future options are limited... you can never go back, so you'd better hope your surgeon gets it perfectly right the first time.

But every case is different, so its up to you to get all the facts and decide for yourself, then hope for the best!

Here are a couple of my pics for comparison:

Before any surgery:


2 years AFTER RAVITCH:


2 years AFTER NUSS:


Good luck with whatever you decide!
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[*] posted on 9-14-2011 at 07:53 PM


Once again, great info as usual on here. I really appreciate the help you all provide, because it gives me the confidence to stick with it. I think I'm going to go with a Nuss. I was originally considering that before, but the doctor said consider getting the Ravitch. Dr. S was trying to explain to me its similar to teeth, as in forcing them outward is going to be more painful than the Ravitch, which is just cutting the deformed cartilage and letting your sternum free float. I would like to work out and return to work somewhat soon though, because I don't want to be out of work too long. I know I can't really assume too much or place too much strain on my body, but I am going to try and speed my recovery up as fast as possible if I can. I have seen my fair share of malingerers in the Navy, and I don't want to be one of them. I think that Nuss is the way to go for me, even if I have to put up with the pain, and the feeling of bars in my chest. I don't think I could handle it if my chest caved back in or stayed the same afterwards. I've been waiting my whole life it feels like to get this done. I'm both excited and very nervous about it. Good luck and congrats on the surgery l8ter; I know everything will go well for you. And edgey, thanks for the input as well; your pics help me me keep my eyes on the goal. Going to start a journal on this site here soon, I think. So glad I got onboard with this support group. :D
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[*] posted on 9-16-2011 at 06:09 PM


Thanks legwengw. It sounds like you considered everything. How many surgical opinions did you seek? Are you scheduled for surgery with Dr. S already?

I know what you mean about worrying with the sternum caving in. Nobody wants that. I worry about the healing process, I don't want to miss tons of work either. I hope your surgery goes well. It will be a speedier recovery than mine!

Cheers L8r
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[*] posted on 9-16-2011 at 06:33 PM


In regards to the longer Nuss recovery time, I really wouldn't let that play a major roll in your decision making. It's good to hear that you're leaning towards the Nuss procedure, but maybe this will just be some words of reassurance.

You're roughly six years older than I am, so take everything I say with a grain of salt, but I honest to god did not/am not finding the Nuss recovery that terrible. The first two weeks are a living hell, but I'd assume the same can be said with the Ravitch.

It's been a month and a few days since I had my surgery, and I can tell you I feel great. I'm going to school for 8 hours a day. My pain management is down to 600mg of Ibuprofen twice a day at most. I'm driving. I get myself into and out of bed. I'm driving. On Oct 1 I'll be heading back to work, and by then I've received the all clear to begin lifting around 20lbs.

I rarely feel "pain." I'm just often sore or achey, but it quickly just becomes part of life. I don't even think about it.





Nussed by Dr. Thomas Sato on 8/9/11

My Journal with pics: http://www.pectusinfo.com/board/viewthread.php?tid=8951
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[*] posted on 12-17-2011 at 10:27 PM


Ok so i had the nuss procedure on the 13th and now im off the epidural and on oral meds. Ive had a hard time adjusting to everything. The pain is vey bad most days now and its hard to do everything now. Ive got some more pics but i need to resize them on my home computer. Im trying to stay positive but right now all i want to do is go back in time before surgery. Im currently in the Portsmouth naval hospital, and ive been here since Tuesday. I had one bar put in, but i can feel it all the time. The days arent so bad, but nights have been unbearable. Extra pain meds into my epidural and even then i had all sorts of pain. But since the epidural came out ive had constant pain in my chest, and its hard not to think about it. I just want to ask a couple questions to you guysa who have been nussed or currently are. When does the breathing pain go away? Does anyone have have any suggestions for sleeping? And finally, i feel bloated and swollen since surgery. Is that how everyone feels or looks like when they are discharged?
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[*] posted on 12-18-2011 at 03:36 AM


Leg,
I hope things turn around for you soon. Some people recover very quickly from this surgery and experience little pain while others tend to have a lot of pain and recover much slower. How quickly you will recover is going to be different than everyone else. Sleeping is a real pain in the ass the first few weeks. A lot of people have used wedge pillows, others have just placed like 7 or 8 pillows behind them while sleeping to prop themselves up. I slept in a recliner the first few weeks after surgery and it worked fine. But it wasn't much fun. In fact, many times I would regret having the surgery because the pain, especially at night, but looking back on it now I'm very, very glad I had it done.

Right now you are in the thick of your darkest times. Don't expect to be able to see the light at the end of the tunnel yet. You are too far away. Just focus on walking, deep breathing and sleeping the best you can. Check with your doctor and see if he's ok with you taking an extra pain pill at bedtime, or even two extra. That may help alleviate some of the problem. However, sleeping well is usually one of the last luxuries we get back.

Also, it's very normal to feel bloated and swollen because, well, you are bloated and swollen. Don't sweat it. Just keep breathing and walking.

Keep us updated please.




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