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J Thorac Cardiovasc Surg 2006;131:762-763
© 2006 The American Association for Thoracic Surgery

Letter to the Editor

Reply to the Editor

Department of Surgery, University Hospital and Children's Hospital Zurich, Zurich, Switzerland

The comment made by Dr Nagarajan finally comes down to an evaluation of the benefit of thoracic incisions on overall cosmesis and patient acceptance of the incision. His statement that anterolateral thoracotomy does not lead to significant breast deformation is correct only when the incision is applied in adults. In this age group, the breasts are developed and the inframammary fold is delineated. An anterolateral thoracotomy, however, in a prepubescent girl does lead to breast and chest asymmetry. Because full thoracic development requires more than a decade, and because troubles related to the private sphere are difficult to express, the cosmetic and psychological results of the anterolateral thoracotomy have been poorly evaluated and often ill-estimated. The fact that most patients—even the dissatisfied ones—never actively expressed complains regarding the incision (something that appears futile in view of the correction that was performed on the heart) was put to the credit of the approach. Bleiziffer and coworkers ¹ convincingly demonstrated that significant impairment (more than 20% of volume difference) in the development of the right breast occurred in 61% of the female patients after an anterolateral thoracotomy, yet only a minority of them expressed their discontentment. The asymmetry was the consequence of damage not only to the breast gland but also to the pectoralis muscles (which need be disinserted from the rib) and sometimes to the rib and costochondral junction. This also explains the suboptimal results achieved in boys. Interestingly, in this study, women with anterolateral thoracotomy and asymmetrical breasts had a better psychological acceptance of their image than those with a classic sternotomy and symmetrical breasts, evidencing the burden played by the visibility of the incision. Even if the subxiphoid approach, which leaves the upper part or "décolleté" of the thorax free, will be better accepted than a full sternotomy, the visibility of the incision will remain a nuisance for some young people. ² The posterolateral approach requires division of the latissimus dorsi and sometimes part of the serratus anterior muscle. ³ The cosmetic appearance of the scar is certainly comparable with our axillary incision. Stature problems and weakness of the shoulder are, however, possible consequences of this incision. In our opinion, the axillary incision, because it is located in a muscle-free area and because it spreads more than it divides muscles, leads to yet incomparable cosmetic and functional results in children. Schreiber and coworkers ⁴ recently reported similar results with the same incision (using a central cannulation) in an older population. To us, the anterolateral incision as advocated by Nagajaran is indicated in adults only, especially if the cardiac repair can be performed endoscopically. ⁵

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1. Bleiziffer S, Schreiber C, Burgkart R, Regenfelder F, Kostolny M, Libera P, et al. The influence of right anterolateral thoracotomy in prepubescent female patients on late breast development and on the incidence of scoliosis. J Thorac Cardiovasc Surg 2004;127:1474-1480.[Abstract/Free Full Text]
   
2. Nicholson IA, Bichell DP, Bacha EA, del Nido PJ. Minimal sternotomy approach for congenital heart operations. Ann Thorac Surg 2001;71:469-472.[Abstract/Free Full Text]
   
3. Houyel L, Petit J, Planche C, Sousa-Uva M, Roussin R, Belli E, et al. Right postero-lateral thoracotomy for open heart surgery in infants and children. indications and results. Arch Mal Coeur Vaiss 1999;92:641-646.[Medline]
   
4. Schreiber C, Bleiziffer S, Kostolny M, Horer J, Eicken A, Holper K, et al. Minimally invasive midaxillary muscle sparing thoracotomy for atrial septal defect closure in prepubescent patients. Ann Thorac Surg 2005;80:673-676.[Abstract/Free Full Text]
   
5. Casselman FP, Dom H, De Bruyne B, Vermeulen Y, Vanermen H. Thoracoscopic ASD closure is a reliable supplement for percutaneous treatment. Heart 2005;91:791-794.[Abstract/Free Full Text]
   

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): René Prêtre Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Prêtre, R. Search for Related Content PubMed Articles by Prêtre, R. Related Collections Congenital - acyanotic Related Article