Despite the success of the MIRPE procedure in children abundantly reported in the literature [
1,
2,
17], extending this procedure to adolescents, adults, athletic persons, and asymmetric cases remains the subject of discussion. In contrast to the setting in children, remodeling a rigid, stiff chest wall using a single or two pectus bars is exceptionally challenging. Technical intricacy during the surgical procedure, increased rates of ensuing complications [
18‐
20], higher rates of pain proportional to the pressure applied to the thoracic skeleton [
21], and a higher risk of an undesired outcome [
20] and recurrence [
2,
17,
22] are likely to be encountered due to lack of tissue pliability in cases with matured skeletal structures, severe deformities, and, particularly, in asymmetric cases with sternum malrotation.
In a meta-analysis, Nasr et al. compared the two most often applied techniques, i.e., the Nuss and Ravitch procedures, and found no significant differences with respect to overall complications and length of hospital stay, although the rates of reoperation and hemo- and pneumothorax were higher in the Nuss procedure [
23]. Therefore, it appears to be constructive to combine the advantages of both techniques in the MOVARPE approach, consisting of a conventional osteochondrotomies hybridized with the videoendoscopically assisted implantation of a pectus bar [
9]. In contrast to conventional open surgery, this approach is accomplished with rather small surgical incisions and minor surgical trauma, but provides stable support of the remodeled thoracic wall until the skeletal structures have completely healed. Osteochondrotomies or partial chondrotomies reduce immediate- as well as long-term postoperative pain caused by diminished lever forces of the pectus bar against the posterior sternum periosteum [
24]. Elevation and remodeling of the concave anterior thoracic wall to a natural convexity by twisting the intrathoracally placed pectus bar is facilitated by the relaxing osteochondromoties, in contrast to elevation achieved by pressure forces alone as in MIRPE. In 2009, Al-Assiri et al., studying a collective of 15 children, already stated that sternocostal “relaxing” incisions in the cartilaginous portion of the ribs, in addition to the standard MIRPE technique, appear to facilitate retrosternal dissection and reduce postoperative chest wall tension [
25]. The time allotted for healing of the sternotomy and chondroplasties is only 2 to 3 months, and the necessary support afforded by the pectus bar is reduced to only 2 years versus a period of up to 4 years implantation time [
17] for the MIRPE chest wall elevation technique that is based merely on bone and cartilage distension. Osteotomized sternum bone and relaxing chondrotomies usually heal with rapid stable callus and scar formation, thus permitting pectus bar removal much earlier than in the cases solely employing distension [
17]. Lever support by a pectus bar alone has to override the memory properties of the elasticity of a various number of deformed cartilage arches, as well as the bent sternum bone, over a long period [
24,
26]. In the rare cases using a second pectus bar, particularly in adolescents or adults with athletic body shape or very tall patients, the decision for the second bar is made intraoperatively, based on the lever force remaining after the osteochondrotomies are performed.
In addition to our results reported in a prior publication, the results of this new 10-year study without any failed end results also confirm MOVARPE as a rational approach in select patients [
10]. Minor drawbacks of MOVARPE versus MIRPE, consisting of a prolonged operating time of up to 1 hour and additional scars, did not bother any patient in this series. The greater surgical effort and additional minor scars nevertheless appear to be justified with regard to the intra- and postoperative procedural advantages and final long-term outcome.