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Thoracoplasty
By David K. Wolpert

A complementary surgical procedure your surgeon may recommend is called thoracoplasty. This is a procedure to reduce the rib hump that affects most scoliosis patients with a thoracic curve (Figure 8). It may also be done to obtain bone grafts from the ribs instead of the pelvis, regardless of whether a rib hump is present.
     Thoracoplasty is the removal (or resection) of several (usually four to six) segments of adjacent ribs that protrude. Each segment is one to two inches long. The surgeon decides which ribs to resect based on either their prominence or by determining those which are unlikely to be realigned by correction of the curvature alone. Thoracoplasty does not involve the removal of entire ribs, just sections of them. Amazingly, ribs grow back and, when they do, they will grow back straight. The newly-grown ribs are usually just as strong as the original ribs.
     There are two significant benefits of thoracoplasty. The first, as mentioned, is a better cosmetic appearance. Your rib hump will be flattened, providing you with a smoother back and a more natural appearance. Clothing will drape better around your shoulder blades. Leaning back on chairs will feel more comfortable, as your back will not protrude as much.      The second benefit is also cosmetic: you may have one less scar. Recall that spinal fusion requires bone for grafting material. If your surgeon performs a posterior-approach procedure and chooses to use autograft material, he or she has two places from which to obtain it: your pelvis or your ribs. Taking bone from the pelvis may require making a second incision low in the back, thus resulting in a second scar. However, bone can always be taken from the section of ribs resected in thoracoplasty through the same midline incision (down the middle of your back) that the surgeon will make to access your spine, though some surgeons prefer to make a second incision over the peak of the rib hump. In a sense, thoracoplasty kills two birds with one stone—you get a more natural-looking back while potentially avoiding a second scar.
     Related to the second benefit is that bone grafts taken from the ribs typically cause less long-term pain for the patient than grafts taken from the pelvis. Furthermore, although most patients with a rib hump do not experience pain from the hump itself, if you do have pain in the hump area, thoracoplasty can help eliminate this.
     Thoracoplasty has risks and complications. The most significant drawback is increased pain in the rib area during recovery. Indeed, you will experience postoperative pain regardless of whether thoracoplasty is performed, but this procedure will heighten the pain in the specific areas where your ribs were resected. If you have ever had a broken rib, you know roughly what this feels like. Ribs can take two to three months to heal.
     Another complication is temporarily reduced pulmonary function following surgery. A 10-15% reduction in pulmonary function is typical. You will probably find it harder to take deep breaths and may become “winded” more easily than usual. This impairment can last anywhere from a few months to two years. Patients with asthma or other respiratory problems should discuss this issue with their surgeon, though it is usually not problematic.
     Because thoracoplasty may lengthen the duration of the surgery, you may also lose more blood or develop complications from the prolonged anesthesia. A more significant, though far less common risk is that the surgeon will inadvertently puncture your pleura, a protective coating over the lungs. This could cause blood or air to drain into your chest cavity, conditions called a hemothorax or pneumothorax, respectively. To remove excess blood, a chest tube would need to be inserted for two to three days, which is uncomfortable but usually not painful. A pneumothorax may cause one of your lungs to deflate, but this can be remedied in a controlled hospital setting relatively easily. Some pneumothorax conditions will repair themselves without endangering the patient.
     Surgeons differ in their opinions on the effect of wearing a brace after surgery (see Postoperative Bracing in Chapter 6). Some feel it may reduce the risk of a hemothorax by preventing the ribs from rubbing against the chest cavity. Others argue that wearing a brace may actually cause a hemothorax to develop more easily by making deep breathing more difficult.
     If you are not sure you want thoracoplasty, you could initially undergo spinal fusion and note the effect this has on your rib hump. You can always have thoracoplasty later, after a fusion. This will, of course, result in additional pain, cost, time, and trouble, and every time you have surgery there are risks. Therefore, if you think you will ever have thoracoplasty, it is better to have it done at the same time as your fusion. Note that undergoing thoracoplasty without having a spinal fusion will yield no benefit. The resected ribs will grow back crooked if the underlying spinal curvature and rotation is not first reduced.



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