Congenital Thoracic Wall Deformities: Diagnosis, Therapy and Current Developments PDF
Preview Congenital Thoracic Wall Deformities: Diagnosis, Therapy and Current Developments
€l SpringerWienNewYork Anton H. Schwabegger Editor Congenital Thoracic Wall Deformities Diagnosis, Therapy and Current Developments SpringerWienNewYork Anton H.Schwabegger, MS, MSc, Assoc.Prof. DepartmentofPlastic,ReconstructiveandAestheticSurgery InnsbruckMedicalUniversity,Innsbruck,Austria Thisworkissubjecttocopyright. Allrightsarereserved,whetherthewholeorpartofthematerialisconcerned,specifically those of translation, reprinting, re-use of illustrations, broadcasting, reproduction by photocopyingmachinesorsimilarmeans,andstorageindatabanks. ProductLiability:Thepublishercangivenoguaranteeforalltheinformationcontained in this book. This does also refer to information about drug dosage and application thereof. In every individual case the respective user must check its accuracy by consulting other pharmaceutical literature. The use of registered names, trademarks, etc.inthispublicationdoesnotimply,evenintheabsenceofaspecificstatement,that suchnamesareexemptfromtherelevantprotectivelawsandregulationsandtherefore freeforgeneraluse. (cid:2)2011Springer-Verlag/Wien PrintedinAustria SpringerWienNewYorkispartof SpringerScience+BusinessMedia springer.at Typesetting:ThomsonPress(India)Ltd.,Chennai,India Printing:HolzhausenDruckGmbH,1140Wien,Austria Printedonacid-freeandchlorine-freebleachedpaper SPIN:12034987 With421(mostlycoloured)Figures LibraryofCongressControlNumber:2011921593 ISBN 978-3-211-99137-4 SpringerWienNewYork Preface Several publications, case reports, reviews, and new This work is dedicated to all the authors for their surgical techniques, either as modifications or new valuable and precious contributions to the further de- developments of the pectus excavatum or carinatum velopmentandpromotionofdiagnosticandtherapeutic surgery have inundated the literature databases over optionsinthetreatmentofpatientssufferingfromsuch the past decade. The shear quantity of individual strains. publicationsonthemostvariedtechnologiesimpedes Wearealsoexceptionallygratefultothephotographers theappropriateflowofinformationfromtheprimary KarinLangertandAngelikaFeichterfortheirdistinctive therapist to the patient and his or her parents, and artandhigh-quality photodocumentation. sometimes is even confusing for the physician or Equally we have to express our thanks to Professor surgeon himself/herself. To date, no comprehensive Werner Jaschke and his team from the Department of work with an overview of the current surgical, com- Radiology,MedicalUniversityInnsbruckforthegener- paratively rare or non-surgical alternative treatment ation of sophisticated radiologic imaging and their possibilities is available. Therefore, with this inter- readinesstoprovideuswiththisartworkthatenriches disciplinary work we made it our task, while making thebook soenormously. no claims to completeness, to create an overview of Without this comprehensive support this book would diagnostic measures, therapeutic options and the definitely nothaveits appealing vividness. follow-up treatment of congenital thoracic wall deformities. Anton H.Schwabegger, MD,MSc Foreword Duringthefirstdecadeofthe21stcentury,itishighly even during the 1950 polio epidemics, patients who educationaltolookbackandobservetheprogressthat developed respiratory paralysis were placed in iron wasmadeinthoracicsurgeryduringthe20thcentury. lungs not unlike Sauerbruch’s differential pressure Infact,the20thcenturycouldbecalledastheCentury chambers.theninthe1960s,ventilatorsweredeveloped of thoracic Surgery! Ira Rutkow in his book: Surgery: whichopeneduptheeraofIntensiveCareUnitsand AnIllustrativeHistorystatesthroughthelastdecades ever-largeroperationsonever-sickerpatientsuptoand ofthenineteenthcentury,operativeinterventioninthe includingheart–lungtransplants.Wideresectionofthe heart, lungs and other organs in the mediastinum and anterior wall structure for the treatment of chest wall thoracic cage usually had fatal results. Accordingly, deformitieswasadvocatedbyallmajormedicalcenters littleinterestwasexpressedintheestablishmentofsuch –eveninveryyoungchildren.Inthe1980s,therewasa surgery as a specialty. As more and more papers on hugeparadigmshiftwiththeintroductionoffiberoptics thoracic surgery were being presented during the first intothefieldofsurgery.Suddenlytheemphasischan- 20 years of the 20th century, however, this attitude gedfromever-largerincisionstoever-smallerincisions changed. starting with 10-mm thoracoscopes down to 2-mm Even at the beginning of the 20th century, anesthesia thoracoscopes. It is with this historical background in was administered by face-mask and the lungs would mind that this textbook reviews the present day man- collapse as soon as the chest was opened. It is not agement of congenital and acquired thoracic wall de- surprising, therefore, that early attempts at chest formities. the management of the two most common wall reconstruction were designed to approach the chestwallanomalies–pectusexcavatumandcarinatum problemexternallytoavoidopeningthepleuralcavity. – have undergone equally dramatic paradiagm shifts Sauerbruch even went further to design a differential from wide or radical resection of anterior chest wall negative pressure chamber, which encompassed the structures to minimally invasive procedures and even patient’s body from the neck down and was large non-surgical approaches including suction cups and enough to admit the surgeon as well. According to pressurebraces. Meade in his book: A History of thoracic Surgery, it As recently as 1990, anterior chest wall surgery was wasnotuntilafterthefirstWorldWarthatRowbotham considered to have matured with no new innovations. and Magill used a simple wide bored rubber tube in- Suddenlythishasbecomeanexcitinganddynamicarea serted into the upper trachea. A cuffed endotracheal of surgery with new ideas and innovations being pre- tubedidnotbecomeavailableuntil1932.Thisfinally scribed at conferences and in medical journals almost allowed thoracic surgery to expand to the point of onamonthly basis. permittingwideresectionofchestwallstructures,lung resections,andlaterevenopen-heartsurgery.However Donald Nuss,MB,ChB Contents Preface . . . . . . . . . . . . . . . . . . . . . . . v 3.3 Radiologicdiagnostics Foreword . . . . . . . . . . . . . . . . . . . . . vii MichaelRieger . . . . . . . . . . . . . . . . . . . . 68 3.3.1 Conventionalradiographs. . . . . . . . . . . 68 3.3.2 CT-scan. . . . . . . . . . . . . . . . . . . . . 68 1 Introduction 3.3.3 Three-dimensionalvolumerendering Anton H. Schwabegger. . . . . . . . . . . . . . 1 CTreconstruction . . . . . . . . . . . . . . . 71 3.4 Hallerindex,pectus-severity-index AntonH.Schwabegger . . . . . . . . . . . . . . . . 73 2 Deformities of the anterior thoracic wall 3.5 Cardiopulmonalinvestigation 2.1 Functionalanatomyofthethoraciccage BarbaraSemenitz . . . . . . . . . . . . . . . . . . . 75 BernhardMoriggl. . . . . . . . . . . . . . . . . . . 3 3.5.1 Conclusion. . . . . . . . . . . . . . . . . . . 77 2.1.1 Introduction . . . . . . . . . . . . . . . . . . 3 3.6 Psychologicalinvestigation 2.1.2 Developmentalaspects . . . . . . . . . . . . 3 GerhardRumpold,MartinLair. . . . . . . . . . . . 79 2.1.3 Mobilityandmotion. . . . . . . . . . . . . . 5 3.6.1 Psychosocialeffectsofafunnelorkeel 2.1.4 Pearlsoftopographicalanatomy. . . . . . . 9 breastdeformity. . . . . . . . . . . . . . . . 79 2.2 Geneticsofchestwalldeformities 3.6.2 Psychologicaltestdiagnostics . . . . . . . . 80 DieterKotzot . . . . . . . . . . . . . . . . . . . . . 14 3.6.3 Conclusion. . . . . . . . . . . . . . . . . . . 81 2.2.1 Pectusexcavatumandcarinatum . . . . . . 14 2.2.2 Summary. . . . . . . . . . . . . . . . . . . . 22 2.3 Classification/definition/description 4 Aspects of indication setting for selection oftypicalandraredeformities of individual therapy and informed consent BarbaraDelFrari,AntonH.Schwabegger . . . . . . 24 Anton H.Schwabegger . . . . . . . . . . . . . 83 2.3.1 Funnelchest/pectusexcavatum andsubgroups BarbaraDelFrari,AntonH.Schwabegger. . . 28 5 Therapy 2.3.2 Keelchest/pectuscarinatum andsubgroups 5.1 Basicsurgicaltechniqueswithspecial BarbaraDelFrari,AntonH.Schwabegger. . . 33 considerationsonskinincisions 2.3.3 Pectusarcuatum AntonH.Schwabegger. . . . . . . . . . . . . . . . 87 AntonH.Schwabegger . . . . . . . . . . . . 38 5.2 Positioningofpatientsduringsurgery 2.3.4 Polandsyndrome AntonH.Schwabegger. . . . . . . . . . . . . . . . 92 FazelFatah,AntonH.Schwabegger . . . . . 41 5.2.1 Positioningduringfunnelchest 2.3.5 Cleftsternumandotheranomalies surgery. . . . . . . . . . . . . . . . . . . . . . 92 BarbaraDelFrari . . . . . . . . . . . . . . . 47 5.2.2 Positioningduringkeelchestsurgery . . . . 93 2.3.6 Syndromal,mixed,andotherdeformities 5.2.3 Positioningduringsurgeryofother BarbaraDelFrari,AntonH.Schwabegger. . . 51 deformities. . . . . . . . . . . . . . . . . . . 93 5.3 Specialanestheticconsiderationsinthoracic wallsurgery:epiduralanesthesia,lungseparation, 3 Diagnostics andpostoperativeanalgesia 3.1 Photography Gu€nterLuckner,GottfriedMitterschiffthaler, AntonH.Schwabegger. . . . . . . . . . . . . . . . 57 MartinW.Du€nser . . . . . . . . . . . . . . . . . . 94 3.2 Thorax-caliper 5.3.1 Introduction . . . . . . . . . . . . . . . . . . 94 AntonH.Schwabegger . . . . . . . . . . . . . . . 63 5.3.2 Pre-anestheticconsultation. . . . . . . . . . 94 3.2.1 Techniqueofmeasurement. . . . . . . . . . 64 5.3.3 Anesthesia. . . . . . . . . . . . . . . . . . . 95 3.2.2 Conclusion. . . . . . . . . . . . . . . . . . . 67 5.3.4 Postoperativepatientmanagement . . . . . 99 x Contents 5.4 Video-assistedthoracoscopy(VATS) 6.6.2 Lipofillingforfunnelchestandsimilar PaoloLucciarini,AntonH.Schwabegger, oradjacentanteriorthoracicwalldeformities ThomasSchmid. . . . . . . . . . . . . . . . . . . 101 MonikaMattesich,AntonH.Schwabegger. . . 159 5.4.1 Introduction . . . . . . . . . . . . . . . . . 101 6.6.3 Localflaps 5.4.2 Surgicaltechnique. . . . . . . . . . . . . . 101 AntonH.Schwabegger . . . . . . . . . . . 165 5.4.3 Conclusion. . . . . . . . . . . . . . . . . . 104 6.6.4 Microvascularflaps ChristophPapp,WolfgangMichlits . . . . . 169 6.6.5 Freemicrovascularsternumturnoverflap 6 Special techniques in the funnel chest AntonH.Schwabegger,MilomirNinkovic. . . 176 deformity 6.7 Combinedsurgerywithassociatedanomalies 6.1 TheRavitchprocedure ordisease Anton H. Schwabegger. . . . . . . . . . . . . . 107 AntonH.Schwabegger. . . . . . . . . . . . . . . 185 6.1.1 SurgicaltechniqueoftheRavitch 6.8 VacuumbellprocedureaccordingtoEckartKlobe procedure . . . . . . . . . . . . . . . . . . 108 (nonsurgical) 6.2 ModificationsoftheRavitchprocedure MichaBahr. . . . . . . . . . . . . . . . . . . . . 190 andsimilarmethods 6.8.1 Introduction . . . . . . . . . . . . . . . . . 190 AntonH.Schwabegger. . . . . . . . . . . . . . . 112 6.8.2 Thevacuumbellaccording 6.2.1 Surgicaltechnique. . . . . . . . . . . . . . 113 toEckartKlobe . . . . . . . . . . . . . . . 190 6.2.2 Conclusion. . . . . . . . . . . . . . . . . . 115 6.8.3 Vacuumbellprocedure . . . . . . . . . . . 191 6.3 Thoracicwalldeformities 6.8.4 Patients . . . . . . . . . . . . . . . . . . . 192 AnnM.Kuhn,DonaldNuss . . . . . . . . . . . . 116 6.8.5 Complications . . . . . . . . . . . . . . . . 193 6.3.1 Introduction . . . . . . . . . . . . . . . . . 116 6.8.6 Intraoperativeuseofthevacuumbell. . . . 193 6.3.2 Surgicalrepair. . . . . . . . . . . . . . . . 118 6.8.7 Preoperativeuseofthevacuumbell. . . . 194 6.3.3 Surgicaltechnique. . . . . . . . . . . . . 118 6.8.8 Conclusion. . . . . . . . . . . . . . . . . . 194 6.3.4 Postoperativemanagement. . . . . . . . . 121 6.9 Pectus-barremovaltechnique 6.3.5 Techniqueofbarremoval(2–4yearsafter AntonH.Schwabegger. . . . . . . . . . . . . . . 196 insertion). . . . . . . . . . . . . . . . . . . 122 6.3.6 Results. . . . . . . . . . . . . . . . . . . . 122 7 Special techniques in the keel chest deformity 6.3.7 Operativeprocedure,analgesia,andlength ofstay . . . . . . . . . . . . . . . . . . . . 123 7.1 TheRavitchprocedure 6.3.8 Complications . . . . . . . . . . . . . . . . 123 AntonH.Schwabegger. . . . . . . . . . . . . . 201 6.3.9 Conclusion. . . . . . . . . . . . . . . . . . 126 7.1.1 Surgicaltechnique . . . . . . . . . . . . . . 201 6.4 SpecialconsiderationsinadultswithMIRPE 7.2 ModificationsoftheRavitchtechnique andMOVARPEtechniques forcorrectionofpectuscarinatumwithsplit AntonH.Schwabegger . . . . . . . . . . . . . . . 127 muscle,bioabsorbableosteosyntheticmaterial, 6.4.1 Surgicaltechniquewiththemodifiedhybrid andbrace:theInnsbruckconcept accessinadolescentsandadults, AntonH.Schwabegger,BarbaraDelFrari . . . . 206 theMOVARPE(MinorOpen 7.2.1 Introduction . . . . . . . . . . . . . . . . . 206 VideoendoscopicallyAssistedRepair 7.2.2 Methods . . . . . . . . . . . . . . . . . . . 206 ofPectusExcavatum)technique . . . . . . 132 7.2.3 Discussion . . . . . . . . . . . . . . . . . . 211 6.4.2 Discussion . . . . . . . . . . . . . . . . . . 138 7.2.4 Conclusion. . . . . . . . . . . . . . . . . . 215 6.4.3 Finalcomments . . . . . . . . . . . . . . . 139 7.3 Cartilagechipsforrefinementafterkeelchest 6.5 Custom-madesiliconeimplants remodeling AntonH.Schwabegger,BarbaraDelFrari . . . . 143 AntonH.Schwabegger. . . . . . . . . . . . . . . 218 6.5.1 Introduction . . . . . . . . . . . . . . . . . 143 7.4 Specialafter-treatment,thekeelchestdevice 6.5.2 Fabricationoftheimplant . . . . . . . . . 145 BarbaraDelFrari,AntonH.Schwabegger . . . . 220 6.5.3 Surgicaltechnique. . . . . . . . . . . . . . 147 6.5.4 Complications . . . . . . . . . . . . . . . . 149 8 Special techniques in pectus arcuatum 6.6 Autologoustissue. . . . . . . . . . . . . . . . . 154 and mixed deformities 6.6.1 Cartilagechipsfortreatmentorrefinement Anton H. Schwabegger. . . . . . . . . . . . . 225 infunnelchestdeformity AntonH.Schwabegger . . . . . . . . . . . 154 8.1 Conclusion . . . . . . . . . . . . . . . . . . . . . 230 Contents xi 9 Special aspects in females 12.1.1 Peri-andpostoperativeaswell Anton H. Schwabegger. . . . . . . . . . . . . 231 aslong-termcomplicationsinthecorrection ofpectusexcavatumdeformity 9.1 Surgicaltechniqueofthepectusexcavatum (inalphabeticorder) . . . . . . . . . . . 277 deformityinfemaleswithchestwall 12.1.2 Peri-andpostoperativecomplications remodeling . . . . . . . . . . . . . . . . . . . . . 233 inthekeelchestsurgery. . . . . . . . . 294 9.2 Discussion. . . . . . . . . . . . . . . . . . . . . 241 12.1.3 Conclusion. . . . . . . . . . . . . . . . . 296 9.3 Conclusion . . . . . . . . . . . . . . . . . . . . . 244 12.2 Hypertrophicscarsandkeloids DoloresWolfram-Raunicher . . . . . . . . . . . 298 10 Special technique in the Poland syndrome 12.2.1 Background/introduction. . . . . . . . . 298 12.2.2 Differentialdiagnosisofhypertrophic 10.1 SurgeryofPoland’ssyndrome scarversuskeloid. . . . . . . . . . . . . 298 FazelFatah. . . . . . . . . . . . . . . . . . . . . 247 12.2.3 Etiology . . . . . . . . . . . . . . . . . . 298 10.1.1 Principlesofsurgicalcorrection . . . . . 247 12.3 Siliconeimplantsandtheirfeatures 10.1.2 CorrectionofmalePoland’schestwall DoloresWolfram,EvelynRabensteiner. . . . . . 303 deformity . . . . . . . . . . . . . . . . . 248 10.1.3 CorrectionoffemalePoland’schestwall deformity . . . . . . . . . . . . . . . . . 251 13 Actual technical improvements, future aspects 10.1.4 CorrectionofPoland’schestwall deformityinchildren . . . . . . . . . . . 254 13.1 Thoracicwalldeformities:3-Dscanning 10.2 SpecialmicrovascularflapforthePoland andcomputerizedremodeling syndrome,theTMG-flap LaszloKovacs,MaximilianEder, ThomasSchoeller . . . . . . . . . . . . . . . . . 257 ChristianBrossmann,AntonH.Schwabegger. . . 307 10.2.1 Introduction. . . . . . . . . . . . . . . . 257 13.1.1 Background . . . . . . . . . . . . . . . . 307 10.2.2 Surgicaltechnique . . . . . . . . . . . . 257 13.1.2 3-Dquantificationofthebodysurface 10.2.3 HarvestingoftheTMG-flap . . . . . . . 258 geometry . . . . . . . . . . . . . . . . . 308 10.2.4 Preparationofthedonorside . . . . . . 259 13.1.3 Computer-aidedsurgicalplanning. . . . 310 10.2.5 Discussion. . . . . . . . . . . . . . . . . 260 13.1.4 Clinicalapplication . . . . . . . . . . . . 314 10.3 SpecialmicrovascularflapforthePoland 13.1.5 Conclusion. . . . . . . . . . . . . . . . . 315 syndrome,thelatissimusdorsi-flap 13.2 Specialinstruments,technicalrefinements AntonH.Schwabegger . . . . . . . . . . . . . . 262 AntonH.Schwabegger . . . . . . . . . . . . . . 318 10.3.1 Introduction. . . . . . . . . . . . . . . . 262 13.2.1 Roundtunnelizer . . . . . . . . . . . . . 318 10.3.2 Surgicaltechnique . . . . . . . . . . . . 263 13.2.2 Angledoscillatingsaw . . . . . . . . . . 319 10.3.3 HarvestingoftheLDM-flap 13.2.3 Extrapleuralpectusbar. . . . . . . . . . 320 andpreparationofthedonorside. . . . 264 13.2.4 Pectusbarfixation . . . . . . . . . . . . 320 10.3.4 Discussion. . . . . . . . . . . . . . . . . 265 13.2.5 Hybridrepair . . . . . . . . . . . . . . . 322 13.2.6 Absorbableplatesandscrews . . . . . . 322 13.2.7 Absorbablelateralstabilizer . . . . . . . 322 11 Surgery of other congenital anomalies 13.2.8 Klobe’svaccumbell. . . . . . . . . . . . 323 of the anterior thoracic wall 13.2.9 Endoscopicandthoracoscopicrepair inpectuscarinatum. . . . . . . . . . . . 324 11.1 Isolatedribdeformities 13.2.10 Lipofilling. . . . . . . . . . . . . . . . . 324 AntonH.Schwabegger . . . . . . . . . . . . . . 267 11.1.1 Summary. . . . . . . . . . . . . . . . . . 272 11.2 Cleftsternumrepair 14 Final conclusions . . . . . . . . . . . . . . . 327 AntonH.Schwabegger,BarbaraDelFrari . . . . 273 11.2.1 Discussion. . . . . . . . . . . . . . . . . 274 11.2.2 Conclusion. . . . . . . . . . . . . . . . . 275 12 Complications, special problems Syllabus . . . . . . . . . . . . . . . . . . . . . . 329 12.1 Complications,specialproblems,tips,andtricks List of contributors . . . . . . . . . . . . . . . . 331 AntonH.Schwabegger . . . . . . . . . . . . . . 277 Index. . . . . . . . . . . . . . . . . . . . . . . . 335 Introduction 1 Anton H. Schwabegger Congenital wall defects, if no functional deficit by quested to be corrected as rather aesthetic cardiac or pulmonary impairment exists in marked interventions. deformities,predominatelyencumberpatientsbecause Since the publication of Donald Nuss about the of their unsightly aesthetically unpleasant stain. The success of the minimally invasive repair of pectus appearance of such a deformity is not concealable excavatum(MIRPE)in1998thedemandforcorrection unclothedandevenclothedinthekeelchestdeformity ofallsortsofthoracicwalldeformitiesboomedalmost may not be camouflaged due to its prominent bulge. all over the world. The procession of the minimally During not only puberty but also during adolescence invasive pectus-bar, a modification of formerly more andlatersuchdeformities leadtoshunbehaviour and invasivesurgicalmethodsisstillongoing.Thisabove- social retreat. mentionedpublicationbyNusswasareportofexperi- Notonlyforleisure-timeactivities,whichareincreas- encespredominatelyinchildren,butafterafollow-up ingly focused on life-style and body constitution, but of10yearsthough,itwasverywellsuitableforreliable also for the process of partnership initiation such a evaluation.Neverthelessinmanyinstitutionsthisreport deformitystainrepresentsasignificantsocialhandicap. gaverisetoaeuphoricapplicationtoallsortsoffunnel The more seldom, true cardiopulmonal problems, chest deformities and even up to late adulthood. It causedbydeepthoracicwalldepressionswithdisplace- seemedtodevelopintoamethodofcorrectionforall ment or even compression of heart and lungs, usually seasons. Ensuing to that a myriad of publications areanexceptionforindicationsettingtothoracoplasty. appearedinthemedicalliteraturedatabases.However, Inmostcaseshowever,theneedforcorrectionisbased mostofthesequiteearlyconsecutivepublicationsjust on evidentsocial adaptive difficulties andimpairment described more or less small series of application and of worth living sense. merelyclinicalobservationswithoutadequateorinad- In former times and even a few decades ago thoracic equatefollow-up.Therewereonlyafewreportsabout deformities without or with only minor functional im- theevaluationofdistinctlong-termresultsindifferent pairment were settled as a simple non-aesthetic stains, ages and genders or potential intricate complications. notatallconsideringtheneedforcorrection,thusthey That is why, caused by euphoric presentation through werescarcelycorrectedbysurgicalinterventions.Here- all kinds of media in many places at times led to withthepsychicstateofderangementofaffectedpatients uncriticalemploymentforallkindsofdeformitieseven wasnotadequatelyconsideredorevenneglected. in aged adults with already rigid thoracic cages. The Potentiallybecauseofignoranceorlackofknowledge following and subsequent failures and rebounds in about therapeutic options and thus embarrassment, particularcases,althoughrarelypublished,inducedthe inappropriate medical counsels or advices were given development of modified and combined techniques or to the patient like it will resolve by time and body ledtoreminiscence toestablished older methods. growth,onecancamouflageitbyclothing,muscle However, the development is still going on and the training cures the deformity or surgery is much too MIRPEfocusesonadefinedbutbroadentityoffunnel risky. chestexpressionsandindications,whereastheongoing Nowadays patients and parents, usually by means of discussionandconfrontationwithalternativemethods electronic media, are much better informed about the definedspecialindicationsfortheapplicationofother available therapeutic options, occasionally even more availableandoccasionallymoresuitabletechniquesin indetailthansomephysiciansandthusaremuchmore children, adolescents andadults aswell. demanding for correction of their unpleasant stain. Nevertheless,manyofthetechniquesdescribedinthe Furthermore all available minor or major invasive following chapters should be performed only at methodsofsurgicalandalternativesupportiveactions specialized centres, which fulfil the requirements of aremoredevelopedbytechnicalandsurgicalmethods broad experience by sufficient numbers of cases nowadays. Increasingly minor deformities are re- treated. On the basis of the complexity of a broad
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