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Page 4 of 5 Ewbank et al. Mini-invasive Surg 2018;2:5 I http://dx.doi.org/10.20517/2574-1225.2017.51

also noted the width of the chest increased as the anterior to posterior chest wall distance decreased from
compression. This is an expected result since the circumference of the chest will distribute laterally as the
forced is applied from front to the back of the chest. Since the binder conforms to the shape of the chest, the
lateral displacement of the chest is not hindered.

The criteria for using a compressive orthotic brace on patients with pectus carinatum are two-fold: patient is
willing to wear the brace for at least 8 h a day, and patient wants to improve the chest cosmesis. If the chest
is extremely stiff, in particular for older patient, the force of initial correction may be too high to compress
the chest. For these patients, the failure rate for brace compression therapy is high. For patients who have
a very hard “knuckled” carinatum, brace therapy may not work since the force needed to compress the
knuckle is too high. An excision in this case would be preferred. Index of severity for pectus carinatum is
not well established unlike the index used for pectus excavatum. The most common index of severity used
for pectus excavatum is the Haller index. The Haller index concept can be applied to pectus carinatum but
it is not often used as an index to describe pectus carinatum. Due to the absence of optimal index for pectus
carinatum, the severity of the pectus carinatum is usually defined as mild, moderate or severe. This is a
subjective index. A better index for pectus carinatum is needed. Compressive orthotic brace can be tried
on all patients of severity. The effectiveness is largely dependent on compliance, and the length of therapy is
dependent on the severity of the condition. Mild condition will take short time to fix with good compliance,
within 3 months. For moderate condition, it may take 6 months or longer. For severe conditions, it may take
one year or longer.

The weaknesses of this study include the small number of participants in this initial cohort. Based on this
limited MRI results, we have started to apply the balloon brace on our patients. We encourage our patients to
use the brace at least 12 h a day or use the brace as much as they can. They should also use the brace during
sleep. They may remove the brace during vigorous exercise such as during Physical Education at school. Our
preliminary results on 30 patients treated thus far showed no complications such as skin ulceration. This
finding is consistent with the design of the balloon brace. The contact surface of the balloon brace conforms
to the surface shape of the chest and provides even force distribution compared to a hard surfaced non-
malleable orthotic devices typically available in the market.

In summary, dynamic MRI studies done on pectus carinatum patients wearing an orthotic chest brace show
chest wall can be molded to a different desired shape when a directional force is properly applied.

DECLARATIONS
Authors’ contributions
Manuscript preparation: Ewbank C, Idowu O, Chung T, Kim S
Data analysis: Idowu O, Kim S, Chung T
Literature search: Ewbank C, Kim S
Data acquisition: Idowu O, Kim S, Chung T
Study design and definition of intellectual content: Idowu O, Kim S

Data source and availability
All data are stored in a password protected hard drive and available on request via the corresponding author.

Financial support and sponsorship
None.

Conflicts of interest
The authors have no conflicts of interests or financial disclosures.