although initially designed to be performed in younger children of less than 10 years of age, whose sternum and cartilage is more flexible, there are successful series of nuss treatment in patients well into their teens and twenties. robicsek technique in 1965, francis robicsek, based at charlotte memorial hospital, now named carolinas medical center in charlotte, north carolina, developed the robicsek procedure. each time the procedure is performed, it is individually tailored based on the extent and location of the deformity in the patient. the operation begins with an incision, no more than 4–6 centimeters, to the sternum. the pectoralis major muscles are then detached from the sternum. using the upper limit of the sternal depression as a guide, the deformed cartilages are removed one by one, using sharp and blunt dissection. the lower tip of the sternum is then grabbed with a towel-clip and, using blunt dissection, is freed of tissue connections with the pericardium and the pleura. the sternum is then forcefully bent forward into a corrected position. to keep the sternum elevated, a piece of mesh is placed under the mobilized sternum and sutured under moderate tension bilaterally to the stumps of the ribs. the pectoralis muscles are united in front of the sternum and the wound is closed. the robicsek procedure is a single-stage procedure (one surgery only). the purported advantage of this technique is that it is less invasive than the ravitch technique, but critics have suggested that the relapse rate may be high due to cartilage and bone displaying memory phenomenon. taulinoplasty in 2016, carlos bardají, a barcelona-based pediatric surgeon, together with lluís cassou, a biomedical engineer, published a paper describing an extra-thoracic surgical procedure for the correction of pectus excavatum called taulinoplasty. a specially designed implant and traction hardware were developed specifically for the procedure. in taulinoplasty, a small hole is drilled into the sternum at the deepest point of defect, and a double screw is driven into the hole. then, a stainless steel implant is placed underneath the skin on top of the sternum and ribs, centered over the double screw. traction tools are then used to lift the sternum up by the double screw using the implant and ribs for traction. additional screws are then used to secure the implant onto the sternum holding the sternum in the desired position. optionally, stainless steel wire may be wrapped around the implant and ribs to further secure the implant in place. like the nuss procedure, taulinoplasty requires follow-up surgery several years later to remove the implanted hardware once the sternum has permanently assumed its new position. the implant and related hardware used in taulinoplasty is a proprietary product of ventura medical technologies and is marketed as a surgical kit under the brand name pectus up. taulinoplasty was developed to be an alternative to the nuss procedure that eliminates the risks and drawbacks of entering the thorax. in particular, patients usually have shorter operating and recovery times, and less post-operative pain than with the nuss procedure. implants the implant allows pectus excavatum to be treated from a purely morphological perspective. today it is used as a benchmark procedure as it is simple, reliable, and minimally intrusive while offering aesthetically pleasing results. this procedure does not, however, claim to correct existing cardiac and respiratory problems which, in very rare cases, can be triggered by the pectus excavatum condition. for female patients, the potential resulting breast asymmetry can be partially or completely corrected by this procedure. the process of creating a plaster-cast model, directly on the skin of the patient's thorax, can be used in the design of the implants. the evolution of medical imaging and cad (computer-aided design) now allows customised 3d implants to be designed directly from the ribcage, therefore being much more precise, easier to place sub-pectorally and perfectly adapted to the shape of each patient. the implants are made of medical silicon rubber which is age-resistant and unbreakable (different to the silicon gel used in breast implants). they will last for life (apart from the case of adverse reactions) and are not visible externally. the surgery is performed under general anesthesia and takes about an hour. the surgeon makes an incision of approximately seven centimetres, prepares the customised space in the chest, inserts the implant deep beneath the muscle, then closes the incision. post-operative hospitalization is typically around three days. the recovery after the surgery typically requires only mild pain relief. post-operatively, a surgical dressing is required for several days and compression vest for a month following the procedure. a check-up appointment is carried out after a week for puncture of seroma. if the surgery has minimal complications, the patient can resume normal activities quickly, returning to work after 15 days and participating in any sporting activities after three months. lipofilling the "lipofilling" technique consists of sucking fat from the patient using a syringe with a large gauge needle (usually from the abdomen or the outer thighs), then after centrifugation, the fat cells are re-injected beneath the skin into whichever hollow it is needed to fill. this technique is primarily used to correct small defects which may persist after conventional surgical treatment. epidemiology pectus excavatum occurs in an estimated 1 in 150 to 1 in 1000 births, with male predominance (male-to-female ratio of 3:1). in 35% to 45% of cases family members are affected. etymology pectus excavatum is from latin meaning hollowed chest. it is sometimes referred to as sunken chest syndrome, cobbler's chest or funnel chest. society american olympic swimmer cody miller (born 1992) opted not to have treatment for pectus excavatum, even though it limited his lung capacity. he earned a gold medal in 2016. actor joel kinnaman underwent surgery prior to the filming of altered carbon, inserting two metal bars to push the sternum outward in order to correct the deformity. english comedian and presenter josh widdicombe and youtuber/streamer ludwig ahgren are known to have this condition. zachary woods is another popular american actor that has pectus excavatum, which is noticeable in his shirtless scene in an episode of the office (season 8, episode 12). dutch bodybuilder, actor and muscle meats ceo olivier richters, "the dutch giant", suffered from the condition before undergoing surgical correction. additionally, eric harris, an american mass murderer who perpetrated the columbine high school massacre, had pectus excavatum. he had surgery at 12 and 13 to correct the deformity, but it was still visible during his autopsy. in animals pectus excavatum is also known to occur in animals, e.g. the munchkin breed of cat. some procedures used to treat the condition in animals have not been used in human treatments, such as the use of a cast with sutures wrapped around the sternum and the use of internal and external splints. these techniques are generally used in immature animals with flexible cartilage.