International Journal of Clinical Medicine, 2011, 2, 295-300
doi:10.4236/ijcm.2011.23050 Published Online July 2011 (
Copyright © 2011 SciRes. IJCM
Psychological Distress in Patients with Pectus
Excavatum as an Indication for Therapy
Susanne Habelt1, Stephanie Korn2*, Angelika Berger3, Jozef Bielek1
1Department of Pediatric Surgery, University Childrens’ Hospital Basle, Basle, Switzerland; 2Pulmonary Department, Mainz Univer-
sity Hospital, Mainz, Germany; 3Child and Adolescent Psychitric Department Baselland, Baselland, Switzerland.
Email: *
Received February 6th, 2011; revised April 11th, 2011; accepted April 22nd, 2011.
Background: Adolescents with pectus excavatum (PE) are often affected by their body shape. The aim of our approach
was to quantify the patients individual psychological distress and to create a psychological indication for treatment.
Methods: 10 adolescents (8 male, median age 16 years, interquartile rang e 15 - 17 yrs.) with PE were examined at our
psychological department. Using standardized psychological tests, projective tests and interviews psychologists vali-
dated the patients individual psychological status. All patients were offered psychological therapy and correction of
the deformity. In addition, the children were follo wed-up by a telephone questionnaire (median fo llow-up after starting
therapy 12.8 months (5.9 - 18.0). Results: No patient had a relevant physiological limitation. The median follow-up
since presentation to our psychologists was 15.0 months (9.1 - 20.6). 8 patients (5 were operated, 2 used the vacuum
bell, 1 will undergo surgery) had distinct psychological limitations especially concerning the dimensions attractiveness,
self-esteem and somatisation. They demonstrated increased insecurity, anxiety and denegation of their body. Since all
patients were within puberty the psychological distress due to the PE has to be interpreted as disadvantageous for their
further development. 7 patients completed the follow-up questionnaire and reached a median score of 80.8% (76.4% -
86.8%), which indicates a good improvement in all patients. Conclusions: We conclude that the psychological indica-
tion for treatment is justified, since our results support this indication.
Keywords: Chest Wall Deformity, Pectus Excavatum, Psychological Distress, Surgery, Vacuum Bell
1. Introduction
Pectus excavatum (PE), or funnel chest, is the most
common congenital chest wall deformity occurring in
approximately one per thousand children, with a 4:1
male predominance [1]. Various surgical [2,3] and non-
surgical [4,5] techniques are described for repair of PE.
Although many objective criteria for evaluating chest
wall deformities and determining indications have been
reported such as the Haller Index [6,7], few studies have
examined the psychological problems associated with
PE [8].
In many cases, the degree of pectus deformity does
not warrant repair due to physiological limitations.
Therefore, treatment is often performed on a cosmetic
basis. This creates problems since therapy for cosmetic
reasons is usually not covered by insurance.
It is well known that children with PE are affected by
their body image, that they often experience embarrass-
ment, have low self-esteem and feelings of stigma [9].
These psychological criteria influence the patient’s life
deeply. In the past years, several studies examined the
quality of life of these children, which demonstrated that
the adolescents improve after therapy [10,11]. Neverthe-
less, until now repair of PE a psychological basis with-
out any physiological restrictions has been controversial
[8,11]. It is now recommended to extend the indication
for therapy to psychological factors [12].
With this as background the aim of our evaluation
was to perform an extended psychological status in order
to establish a psychological indication for treatment.
Therefore, psychologists quantified psychological char-
acteris- tics of adolescents suffering from PE, who had
no phy- siological limitations.
2. Materials and Methods
10 consecutive teenagers (8 male, median age at time of
psychological assessment 16 years (interquartile range 15
- 17 yrs.)) with PE were examined at our psychological
Psychological Distress in Patients with Pectus Excavatum as an Indication for Therapy
department in Basle, Switzerland as part of our routine
assessment prior to treatment. Our assessment includes
lung function tests, echocardiographic examinations and
computed tomographies of the chest. Sternum-vertebral
ratio indices are not obtained on a regular basis. In ac-
cordance with Krasopoulos et al. [10] we remain un-
aware of the significance of such indices as a parameter
for the individual distress.
Using special standardized psychological tests and
projective tests in combination with interviews with the
adolescents and their parents’ psychologists assessed the
patients’ individual psychological strain.
All children were offered surgical or non-surgical
treatment. The choice of therapy depended on the pa-
tient’s personal preference. Surgical correction was done
using the Nuss procedur [3]. In the case of non-surgical
therapy the patients used the vacuum chest wall lifter
first described by Schier et al. [5].
All children were followed-up at our outpatient clinic.
In addition, using a telephone questionnaire they were
asked about their social and psychological status and
their individual satisfaction after therapy.
2.1. Tests
For psychological examination several specific psycho-
logical tests were used. All tests were assessed by
Hogrefe, a German test agency (Göttingen, Germany).
Body appraisal inv en tory (FBeK):
The subjective body-experience is examined with a
combination of body and complaint centered question-
naires. It consists of 4 scales: insecurity/worrying, con-
cern of physical appearance, attractiveness/self-confi-
dence, and negative feelings about physical-sexual func-
Body image inventory (FBK-20):
This test consists of 2 scales: negative body appraisal
as well as vitality and body-dynamic.
Manual for the self-esteem for children and youngsters
The manual for the self-esteem for children and ado-
lescents is a self-reporting inventory for classifying chil-
dren’s perception of themselves in various specific do-
mains of life: school, leisure time, family or children’s
home. These scales were constructed on the assumption
that an instrument with separate information of one’s
self-esteem in different domains would provide a more
differentiated picture than those instruments providing
only a single self-concept score.
Youth Self Report (YSR) and Child Behavior Checklist
In the YSR the adolescents classify each position
themselves and rate for how true each item is. The CBCL
is rated by the parents and allows to cross check values
given by the children. Both tests use a three-point re-
sponse scale. The YSR and CBCL scoring profiles pro-
vide scores for two competence scales (activity scale:
measuring the child’s participation in hobbies, games,
sports, jobs, chores, friendship; social scale: measuring
withdrawn, somatic complaints, anxiety and depression,
social problems, thought problems, attention problems,
aggressive behaviour, and delinquent behaviours), for a
total competence scale and for the eight syndrome scales
that form three sub-dimensions. The subdimensions are
referred to as ‘internalizing,’ ‘externalizing’ and ‘neither
internalizing nor externalizing’.
Overall behavioural and emotional functioning are
measured by the total problem scale. In addition, the
CBCL consists of a third scale regarding school achieve-
Symptom Checklist-90-R (SCL-90-R):
The Symptom Checklist-90-R is used as an instrument
to evaluate a broad range of psychological problems and
symptoms of psychopathology. The test describes 9 pri-
mary symptom dimensions (somatisation, obsessive-
compulsiveness, interpersonal sensitivity, depression,
anxiety, hostility, phobic anxiety, paranoid ideation,
psychoticism) and is designed to provide an overview of
a patient’s symptoms and their intensity at a specific
point of time. In addition, the test provides three global
indices: Global Severity Index (GSI): designed to meas-
ure the overall psychological distress, it can be used as a
summary of the test; Positive Symptom Distress Index
(PSDI): designed to measure the intensity of symptoms
and Positive Symptom Total (PST): reports the number
of self-reported symptoms.
Follow-up questionnaire:
This questionnaire consisted of questions of the single
step questionnaire by Krasopoulos et al. [10], of the
Nuss-Questionnaire as published by Lawson et al. [13]
and of questions chosen by a psychologist of our psy-
chological department. The questionnaire consisted of 9
questions (Table 1) and the scoring ranges from 1 to 5
points per question (1 = much worse (--), 2 = worse (-), 3
= about the same (0), 4 = better (+), 5 = much better (++))
resulting in a minimum score of 9 and a maximum score
of 45. A total score of >27, accordingly >60% means
improvement, whereas 60% means no change or wors-
2.2. Statistical Analysis
Scoring profiles of the psychological tests provide raw
scores and percentiles. The interpretive reports are based
on age-appropriate non-patient norm groups. Using the
percentiles data description is primarily based on medi-
ans and quartiles (interquartile range) for continuous
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Psychological Distress in Patients with Pectus Excavatum as an Indication for Therapy
Copyright © 2011 SciRes. IJCM
Table 1. Follow-up questionnaire.
Much worse
Somewhat worse
About the same
Somewhat better
Much better
1 Overall feeling/satisfaction after therapy 1 2 3 4 5
Difficulties (sports without shirt, e.g. swimming,
subjective feeling of shortness of breath) after
1 2 3 4 5
3 Health in general after therapy 1 2 3 4 5
4 Exercise capacity after therapy 1 2 3 4 5
5 Satisfaction with overall appearance of the chest
after therapy 1 2 3 4 5
6 Impact to social life 1 2 3 4 5
7 Self-consciousness because of chest/self-esteem 1 2 3 4 5
8 Therapy was considered to be good for me 1 2 3 4 5
9 Going back, would you have the elected therapy
again? 1 2 3 4 5
endpoints and on frequencies for binary endpoints. Every
psychological test was analyzed on the basis of its
sub-dimensions, its global results and on its special crite-
ria. In addition, all tests combined with the projective
tests and the interviews were used to assess the individu-
als’ psychological distress as a whole.
3. Results
Eight male and two female patients with a median age of
16 years (interquartile range 15 - 17 years) were seen at
our Department of Pediatric Surgery for evaluation of
their pectus excavatum (PE). Prior to treatment they were
examined according to our routine assessment program.
None of the patients had a physiological limitation,
echocardiographic examination was defined as normal in
all patients, lung function tests were normal in 8 patients.
One patient demonstrated a limited restrictive defect and
one patient was known to have asthma (Table 2). Addi-
tionally, the patients were assessed to our psychological
department and a psychological status was obtained. The
median follow-up since presenting at the psychologist is
15.0 months (interquartile range 9.1 - 21.4 months); the
psychological status was taken at the same time or within
a few days after medical examination and at a median of
17.8 weeks (interquartile range 2.4 - 27.0 weeks) before
Table 2. Lung function tests preoperatively.
n Median
(interquartile range)
Vital capacity
(% predicted) 10 84.1 (77.7- 91.6) 69.0; 101.3
FEV1 (% predicted) 10 90.2 (80.9 - 92.8) 70.0; 99.4
Residual volume (%) 10 109.9 (88.3 - 143.4) 54.9; 192.0
Total lung capacity (%) 10 92.9 (81.0 - 100.6) 74.6; 108.6
Displayed are median scores, interquartile ranges, minimum and maximum
of the lung function parameters.
starting therapy.
The results of the single tests and their sub-dimensions
are demonstrated in Table 3. In addition, we specified
how many patients were at risk in a sub-dimension and in
the specific test. Overall, 8 patients had psychological
limitations especially concerning the dimensions attrac-
tiveness, self-esteem and somatisation. Eight children
shied away from presenting their body for instance when
going swimming or doing sports. This resulted in in-
creased insecurity, anxiety and denegation of the own
body. Four patients complained about breathlessness
although they did not have any pulmonary limitation. All
patients were offered surgical treatment, since 2005 sur-
gical or non-surgical treatment. Of the 8 patients with
psychological distress 6 elected surgery (one will un-
dergo surgery in two months), the remaining 2 decided to
use the vacuum chest wall lifter. Of the 2 patients with-
out psychological limitation one did not desire any ther-
apy and the other one elected therapy with the vacuum
bell for a better cosmetic result.
All patients were followed up at our outpatient clinic
and were asked to complete the telephone questionnaire
despite the one who did not desire therapy and the one
who has not undergone surgery by now. 7 patients (of 8
interview patients) completed the questionnaire with a
median follow-up of 13 months (interquartile range 6 -
18 months) after starting therapy; one patient could not
be asked due to being in Africa for one year. The teenag-
ers reached a median score of 80.8% (interquartile range
76.4% - 86.8%). Since a total score of >60% was defined
as improvement, all patients demonstrated good im-
provement after therapy and stated satisfaction with the
overall result of the treatment. All children improved
concerning earlier difficulties, attractiveness, self-esteem
and social life and recommended their type of therapy.
Psychological Distress in Patients with Pectus Excavatum as an Indication for Therapy
Table 3. Results of the different psyc hol ogical tests including their subdimensions.
n Median
(interquartile range) Min.; Max. at risk (n)
Body appraisal inventory (FBeK)
(scores above 84% are classified as at risk) 9 49.0 (18.0 - 86.5) 6.0; 97.0 2
Concern with physical appearance
(scores below 16% are classified as at risk) 9 57.0 (25.0 - 62.5) 15.0; 98.0 1
(scores below 16% are classified as at risk) 9 14.0 (1.5 - 60.0) 1.0; 100.0 5
Physical-sexual functioning
(scores above 84 are classified as at risk) 7 65.0 (22.0 - 69.0) 22.0; 93.0 1
Total 5
Body image inventory (FBK-20)
Negative body appraisal
(scores above 84% are classified as at risk) 9 60.0 (8.0 - 87.5) 1.0; 99.0 4
Vitality and body dynamic
(scores below 16% are classified as at risk) 9 40.0 (15.0 - 47.5) 4.0; 90.0 2
Total 6
Manual for the self-esteem for children and youngster (ALS)
(scores of 11% - 25% are classified as at risk)
School 8 0 1
Leisure time 8 1 1
Family/children’s home 8 1 1
Total 3
Youth Self Report (YSR)
(scores above 98% are classified as at risk; activity and social scale: scores below 2% are classified as at risk)
Withdrawn 5 84.0 (50.0 - 88.0) 50.0; 92.0 0
Somatic complaints 5 92.0 (58.5 - 98.3) 50.0; 98.5 2
Anxiety/depression 5 50.0 (50.0 - 84.2) 50.0; 98.3 1
Social problems 5 50.0 (50.0 - 65.0) 50.0; 80.0 0
Thought problems 5 50.0 (50.0 - 83.0) 50.0; 93.0 0
Attention problems 5 50.0 (50.0 - 75.0) 50.0; 100.0 1
Delinquent behaviours 5 50.0 (50.0 - 83.5) 50.0; 90.0 0
Aggressive behaviour 5 50.0 (50.0 - 85.0) 50.0; 86.0 0
Activity scale 5 69.0 (63.5 - 69.0) 58.0; 69.0 0
Social scale 5 69.0 (57.0 - 69.0) 46.0; 69.0 0
Total 2
Child Behaviour Checklist (CBCL)
(scores above 98% are classified as at risk; activity and social scale: scores below 2% are classified as at risk)
Withdrawn 4 59.5 (50.0 - 81.8) 50.0; 86.0 0
Somatic complaints 4 68.0 (54.5 - 68.8) 50.0; 69.0 0
Anxiety/depression 4 61.0 (50.0 - 86.3) 50.0; 91.0 0
Social problems 4 68.0 (54.5 - 68.8) 50.0; 69.0 0
Thought problems 4 55.0 (50.0 - 86.3) 50.0; 95.0 0
Attention problems 4 60.0 (52.5 - 81.0) 50.0; 88.0 0
Delinquent behaviours 4 50.0 (50.0 - 57.5) 50.0; 60.0 0
Aggressive behaviour 4 59.0 (52.0 - 66.8) 50.0; 69.0 0
Activity scale 4 69.0 (45.0 - 69.0) 37.0; 69.0 0
Social scale 4 69.0 (36.0 - 69.0) 25.0; 69.0 0
School scale 4 60.5 (49.8 - 69.0) 49.0; 69.0 0
Total 0
Symptom Checklist 90-R (SCL-90-R)
(scores above 84% are classified as at risk indicating psychological problems)
Somatisation 1096.0 (6.0 - 96.9) 3.0; 99.0 5
Obsessive-compulsive 1060.5 (12.8 - 98.1) 5.0; 99.0 5
Interpersonal sensitivity 1052.5 (5.0 - 94.3) 5.0; 100.0 4
Depression 1044.0 (7.0 - 98.1) 7.0; 100.0 4
Anxiety 1061.0 (7.0 - 98.6) 7.0; 100.0 4
Hostility 1025.5 (20.8 - 93.3) 7.0; 94.0 4
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Psychological Distress in Patients with Pectus Excavatum as an Indication for Therapy299
Phobic anxiety 1073.5 (55.8 - 94.8) 22.0; 100.0 4
Paranoid ideation 1065.0 (11.0 - 98.1) 11.0; 100.0 4
Psychoticism 1043.5 (11.0 - 94.4) 11.0; 99.0 3
GSI 1057.5 (10.5 - 99.0) 2.0; 100.0 4
PSDI 1056.0 (9.0 - 98.0) 9.0; 99.0 4
PST 1054.0 (2.8 - 96.5) 2.0; 99.0 4
Total 6
Total 10 8
Displayed are median scores, interquartile ranges, minimum and maximum of the several psychological tests with sub-dimensions reached by the patients. In
addition, number of patients with at risk findings, indicating psychological problems are shown. Total: number of patients in whom the test was classified as at
risk (in one or more sub-dimensions).
4. Discussion
Today, the indications for treatment of PE are mainly
based on physiological symptoms or cosmetic factors
[12]. Indications based on psychological or psycho-social
stress are frequently discussed [8,12] and are part of
questionnaires that assess the patients’ preoperative con-
dition [8,10].
Therefore, we picked-up the suggestion made by Suita
et al. [12] and Ohno et al. [8] to extend the indications
for treatment, especially for surgery, in regard to the
patients’ individual psychological stress.
We described the way of establishing a psychological
indication for therapy of PE. To date, there has been in-
creasing research on the psychological aspects of pectus
deformities or other disfiguring conditions in general and
medical procedures used to correct them [14,15]. The
psychological importance of the body image including
the notion that medical treatment can improve quality of
life has been described in some detail and there are ques-
tionnaires to assess the preoperative status of children
with PE [10,11]. Nevertheless, to perform an accurate
and extensive psychological assessment it is important to
identify the children’s individual psychological strain
including various dimensions.
It is well known that patients with PE often experience
embarrassment and shame over the perceived differences
in their physical appearance and that this can lead to
lowered self-concept, feelings of inferiority, depression,
shyness and social anxiety [16]. This was found in the
majority (8/10) of our children. The results of our ex-
amination demonstrated that the handicaps of PE influ-
ence all areas of life. Defensive camouflaging with poor
posture and folded arms, restrictions in lifestyle includ-
ing avoidance of swimming, sports, hugging and intimate
relationships were described by our patients. Particularly,
since all patients hit puberty the psychological strain due
to the PE has to be interpreted as disadvantageous for
their further development.
After psychological assessment our patients were of-
fered surgical and non-surgical treatment. All adolescents
with psychological problems decided to be treated. One
patient wanted to be treated with the vacuum bell some
time after presentation at the psychological department
due to a better cosmetic result although he did not feel
limited. According to the study by Ohno et al. [8] not all
distressed patients wanted surgery, 2 patients wanted to
try therapy with the vacuum bell, which is understand-
able since it is a less invasive therapeutic option produc-
ing increased interest with the patients during the last
year [5].
It is well known that medical therapy improves quality
of life as described by Roberts et al. using the QOL out-
lined by Keith and Shacklock [11]. Their results indicate
an improvement in each of the four areas satisfaction,
social belonging, well-being and empowerment/control.
In accordance, Lawson et al. created a Pectus Excavatum
Evaluation Questionnaire and demonstrated a positive
impact on the well-being of children after surgical repair
[13]. Since there are several studies which confirm im-
provement after correction of the chest deformity we
only used a short questionnaire to ask the patients about
their individual improvement after therapy. Therefore,
we modified the questionnaire of Krasopoulos et al. [10]
and Lawson et al. [13] to especially evaluate the factors
attractiveness, body image, social improvement and sat-
isfaction in general. Nearly all children reported im-
proved endurance and participation in physical education
activities after therapy. We reason this with the better
quality of life and better satisfaction with their physical
appearance, not due to any physiological improvement
since the children did not have any physical limitation
prior to treatment.
A limitation of our study is the small number of pa-
tients. All consecutive patients with pectus excavatum
were included to avoid selection bias. However, it cannot
be excluded that the results of the present study may
slightly change if more patients over a longer study pe-
riod would be included. However, from previous experi-
ence we strongly feel that the results of the present study
are representative for a large referral center in a devel-
oped county such as Switzerland.
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Psychological Distress in Patients with Pectus Excavatum as an Indication for Therapy
Suita et al. comment that the precise indications for
surgical repair of PE is still open [12]. In our opinion, the
definition of the indication should depend on physical
and psychological characteristics in each case. In the
course of this, not only somatic data, but also psycho-
logical factors should be considered. We think psycho-
logical aspects should not only be taken into considera-
tion but the children with PE should be presented to a
psychologist. We recommend including psychological
distress to the list of indications for therapy as an inde-
pendent factor. Nevertheless, further studies with more
patients will be needed to underline our findings.
5. Conclusions
In summary, most children with PE suffered from psy-
chological strain and all patients improved after therapy.
We therefore recommend working together with psy-
chologists to extend the indications for therapy of PE to
psychological problems. The individual psychological
limitation can be assessed by psychologists using special
medical tests, projective tests and interviews with the
patients and their parents. Thus, it is possible to gain in-
formation in several dimensions especially attractiveness,
self-esteem and social life which affect the patients in all
areas of life. We conclude that the psychological indica-
tion for treatment is justified, since our results support
this indication.
[1] K. A. Molik, S. A. Engum, F. J. Rescorla, K. W. West, L.
R. Scherer and J. L. Grosfeld, “Pectus Excavatum Repair:
Experience with Standard and Minimal Invasive Techin-
ques,” Journal of Pediatric Surgery, Vol. 36, No. 2, 2001,
pp. 324-328. doi:10.1053/jpsu.2001.20707
[2] E. W. Fonkalsrud, “Current Management of Pectus Ex-
cavatum,” World Journal of Surgery, Vol. 27, No. 5,
2003, pp. 502-508. doi:10.1007/s00268-003-7025-5
[3] D. Nuss, R. E. Kelly Jr., D. P. Croitoru and M. E. Katz,
“A 10-Year Review of a Minimally Invasive Technique
for the Correction of Pectus Excavatum,” Journal of Pe-
diatric Surgery, Vol. 33, No. 4, 1998, pp. 545-552.
[4] F. M. Haecker and J. Mayr, “The Vacuum Bell for Treat-
ment of Pectus Excavatum: An Alternative to Surgical
Correction?” European Journal of Cardio-Thoracic Sur-
gery, Vol. 29, No. 4, 2006, pp. 557-561.
[5] F. Schier, M. Bahr and E. Klobe, “The Vacuum Chest
Wall Lifter: An Innovative, Nonsurgical Addition to the
Management of Pectus Excavatum,” Journal of Pediatric
Surgery, Vol. 40, No. 3, 2005, pp. 496-500.
[6] S. W. Daunt, J. H. Cohen and S. F. Miller, “Age-Related
Normal Ranges for the Haller Index in Children,” Pediat-
ric Radiology, Vol. 34, No. 4, 2004, pp. 326-330.
[7] J. A. Haller Jr., S. S. Kramer and S. A. Lietman, “Use of
CT Scans in Selection of Patients for Pectus Excavatum
Surgery: A Preliminary Report,” Journal of Pediatric
Surgery, Vol. 22, No. 10, 1987, pp. 904-906.
[8] K. Ohno, Y. Morotomi, M. Nakahira, S. Takeuchi, et al.,
“Indications for Surgical Repair of Funnel Chest Based
on Indices of Chest Wall Deformity and Psychological
State,” Surgery Today, Vol. 33, No. 9, 2003, pp. 662-665.
[9] E. Einsiedel and A. Clausner, “Funnel Chest. Psycho-
logical and Psychosomatic Aspects in Children, Young-
sters, and Young Adults,” The Journal of Cardiovascular
Surgery (Torino), Vol. 40, No. 5, 1999, pp. 733-736.
[10] G. Krasopoulos, M. Dusmet, G. Ladas and P. Goldstraw,
“Nuss Procedure Improves the Quality of Life in Young
Male Adults with Pectus Excavatum Deformity,” The
European Journal of Cardio-Thoracic Surgery, Vol. 29,
No. 1, 2006, pp. 1-5. doi:10.1016/j.ejcts.2005.09.018
[11] J. Roberts, A. Hayashi, J. O. Anderson, J. M. Martin and
L. L. Maxwell, “Quality of Life of Patients Who Have
Undergone the Nuss Procedure for Pectus Excavatum:
Preliminary Findings,” Journal of Pediatric Surgery, Vol.
38, No. 5, 2003, pp. 779-783.
[12] S. Suita, T. Taguchi, K. Masumoto, M. Kubota and T.
Kamimura, “Funnel Chest: Treatment Strategy and Fol-
low-Up,” Pediatric Surgery International, Vol. 17, No. 5-
6, 2001, pp. 344-350. doi:10.1007/s003830000575
[13] M. L. Lawson, T. F. Cash, R. Akers, E. Vasser, B. Burke,
M. Tabangin, et al., “A Pilot Study of the Impact of Sur-
gical Repair on Disease-Specific Quality of Life among
Patients with Pectus Excavatum,” Journal of Pediatric
Surgery, Vol. 38, No. 6, 2003, pp. 916-918.
[14] G. Kent and S. Keohane, “Social Anxiety and Disfigure-
ment: The Moderating Effects of Fear of Negative Eva-
luation and Past Experience,” British Journal of Psy-
chology, Vol. 40, No. Part 1, 2001, pp. 23-34.
[15] A. Thompson and G. Kent, “Adjusting to Disfigurement:
Process Involved in Dealing with Being Visibly Differ-
ent,” Clinical Psychology Review, Vol. 21, No. 5, 2001,
pp. 663-682. doi:10.1016/S0272-7358(00)00056-8
[16] S. W. Noles, T. F. Cash and B. A. Winstead, “Body Im-
age, Physical Attractiveness, and Depression,” Journal of
Consulting and Clinical Psychology, Vol. 53, 1985, pp.
88-94. doi:10.1037/0022-006X.53.1.88
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