Traditional thoracoplasty is usually done on the convex side of the curve at the apex of the posterior rib deformity, with the goal of reducing the rib hump deformity (2). It has also been described on the concave side, potentially allowing the rib cage and spine to move posteriorly, an advantage in severely hypokyphotic and rotated idiopathic deformities (3). Thoracoplasty can dramatically improve the cosmetic result of a scoliosis procedure, especially if correction of the rib deformity is limited (4). This may be advantageous in stiff idiopathic or congenital deformities in older adolescents. The technique can also be performed in isolation. Patients with a solid fusion who are unhappy with their posterior chest wall contour may, in some cases, be managed with a thoracoplasty, avoiding the need for spinal osteotomy.

As well as providing for correction of the chest wall deformity, thoracoplasty will also improve the correction of the primary spinal deformity. The technique can be applied as part of an “a la carte” approach to deformity correction as the surgeon adds more techniques to achieve the desired result. Small idiopathic deformities may require simple posterior instrumentation. As the deformity increases, the surgeon may add a variety of techniques including intraoperative traction, aggressive facetectomies, posterior osteotomies, transverse process resection, convex thoracoplasty, concave thoracoplasty, rib head removal, and annulotomy. The rib head has a stout ligamentous attachment to its vertebral body, the annulus, and the superior body. Resection of the rib head may lead to increased mobility, which is an advantage in the correction of hypokyphotic deformities, typical in idiopathic patients (5). Application of these techniques in a stepwise fashion can allow the surgeon to dial up the aggressiveness of the corrective interventions as needed. As long as shortening of the spinal column is not required, the improvement in correction of the apex of a stiff deformity may be significant, approaching that provided by an anterior release.

A final indication for thoracoplasty is the outstanding bone graft that it provides. This is most commonly an issue in very young patients. Rib graft can provide an outstanding fusion solution in cervical spine deformities in very young patients or in patients with poor pelvic bone quality. Rib bone quality is maintained, even in nonambulatory patients, because of the continuous work of respiration. The ribs are also relatively bigger than is the pelvis in young patients, often providing the best source of autograft. The same technique used for reduction of a rib hump deformity can be used to harvest a long rib segment through the primary incision or an additional small incision. The rib bed heals well in young children, quickly forming a new rib. The extrapleural technique minimizes any negative effect on pulmonary function. The rib can be split longitudinally providing a structural graft that can span the occipitocervical and cervicothoracic junctions.

The major contraindication to thoracoplasty is reduced pulmonary function (6). Concern regarding pulmonary function has reduced the incidence of anterior spinal surgery and the use of thoracoplasty. Unfortunately, the patients with the most severe chest wall deformities, who will cosmetically gain the most from thoracoplasty, also frequently already have reduced pulmonary function. Also, patient-based outcome studies indicate that patient satisfaction does not correlate well with deformity correction or posterior trunk surface contour. This further reduces surgeons’ enthusiasm for the technique. It appears that thoracoplasty does lead to a measurable reduction in pulmonary function that is slow to return to expected values and may not reach baseline. Most patients appear to reach preoperative pulmonary function values but not realize the gains in pulmonary function seen 2 years after deformity correction. Aggressive rib resections, creating flail segments, will increase the risk of postoperative pulmonary complications and should be avoided. Resecting more than five contiguous ribs should generally be avoided. The long-term changes in pulmonary function and the effect of thoracoplasty in later life have not been defined. Thoracoplasty has also been associated with an increased risk of development of proximal junctional kyphosis (7).

Thoracoplasty is associated with greater blood loss and should be avoided in patients with a bleeding diathesis or in patients who are very concerned about the risk of transfusion. A previous thoracotomy should be considered a relative contraindication to a thoracoplasty. Significant pleural scarring makes the technique more challenging, leading to greater blood loss, and the surgeon may be left with many pleural rents to be concerned about.