Pectus deformities affect about 1% of the population [1]. The hallmark of pectus excavatum is the caved-in appearance of the anterior chest. The severity of the defect and the asymmetry of the chest are quite variable. Patients may present with a very mild form of pectus excavatum or a very severe form with impairment of cardiopulmonary function because of the constricted pleural space or compromised venous return resulting from displacement of the cardiac base [2].

The use of autologous fat transplantation for the management of pectus deformity has not been previously described. We present a case of mild pectus excavatum and its correction by fat grafting.

Case Report

A 27-year-old woman presented with a mild funnel chest deformity (Fig. 1). Scleroderma had been diagnosed 10 years previously. She had been unresponsive to topical and systemic treatment with corticosteroids.

Fig. 1
figure 1

Preoperative views of the patient with pectus excavatum and scleroderma

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At physical examination, a mild pectus excavatum deformity and various sclerotic, atrophic, pigmented plaques all over her body were noted. Plain anteroposterior and lateral chest radiographic views were obtained. Echocardiography and a complete blood count were performed. There was no evidence of cardiopulmonary dysfunction. The choice was made to perform autologous fat transfer. The areas to be aspirated and grafted were previously marked. Appropriate perioperative sedation was administered. A solution containing 2% of xylocaine with adrenaline was infiltrated into the subcutaneous tissue of the abdominal area.

After a period of 15 min, syringe-assisted liposuction was performed with a small-bore cannula. The preparation of fat to be injected was accomplished in a manner that produced a clear, pale substance consisting mainly of viable fat cells, which is considered most adequate for grafting [3]. Fat transplantation was performed using the small-bore cannula through a stab incision placed in the anterior thorax after induction of appropriate local anesthesia (Fig. 2).

Fig. 2
figure 2

Marking of the sternal irregularity and autologous fat transplantation

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Using the same incision, different trajectories were created, and the fat was injected, starting from the deeper aspect and progressing to the surface. At the first intervention, 35 ml of fat was injected (Fig. 3). The patient was evaluated 6 months later, and a second procedure was performed because partial absorption of the injected fat had occurred (Fig. 4). Using the same incision, 18 ml of prepared fat was inserted. Figure 5 shows the final result 2 years after of the initial procedure.

Fig. 3
figure 3

Views of the preoperative and immediate postoperative results after the first intervention

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Fig. 4
figure 4

Postoperative views 6 months after the first intervention

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Fig. 5
figure 5

Postoperative views 18 months after the second intervention

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The patient was able to resume her normal activities within 3 days after each intervention. She was satisfied with the final result obtained, reporting a considerable gain in her quality of life and a significant improvement in her social activities.

Discussion

Breast and chest wall disfiguration attributable to a funnel chest is an aesthetically and sometimes functionally debilitating deformity requiring correction. For severe deformities caused by pectus excavatum malformations, the standard operative procedures generally are based on either sternal elevation or turnover [4]. Although, the minimally invasive procedures, such as endoscopic correction and Erlangen repair, seem to show both optimized cosmetic results and maximized functionality, the possible secondary sequelae of these surgical approaches cannot be overlooked [5].

In an important group of pectus excavatum cases, the funnel chest is limited to the sternal plate and represents an isolated aesthetic defect. Such a defect can be corrected by insertion of a customized one-piece silicon implant, resulting in an aesthetic correction with a low complication rate [6]. Whereas the use of prefabricated silicone implants yields good cosmetic results, the safety of their use in morphea patients is highly controversial.

Morphea or scleroderma is a disorder characterized by thickening and induration of the skin and subcutaneous tissue due to excessive collagen deposition [7]. The etiology of localized scleroderma may involve genetic factors causing abnormalities in the immune system, vascular tissue, and extracellular matrix [8]. The reported trigger factors include implantation of silicon prosthesis and trauma as well as bacterial, viral, and toxic factors [9–11].

The choice of autologous fat grafting seemed to be a more appropriate and less invasive procedure for the reported specific patient. She was asymptomatic from a functional standpoint, but highly concerned about her aesthetic image. It is known that partial fat graft resorption is encountered in autologous adipose tissue transfer [12]. Overcorrection of the defect was performed because it partially compensated for fat absorption. Although the patient had to undergo a secondary intervention, she highly appreciated the cosmetic final result and the relief from the psychological consequences of such disfigurement.

No complications were observed. Although there was no further evidence of graft resorption during a 2-year follow-up period, the long-term results of fat grafting in the sternal area are yet to be determined.

Conclusion

Patient satisfaction and improved quality of life show that the described method of autologous fat transfer could be a new option in the armamentarium of techniques for correction of mild pectus deformities.