The Vacuum Bell

A suction cup is used to create a vacuum at the chest wall. A vacuum up to 15% below atmospheric pressure is created by the patient using a hand pump (Fig. 1 ). Three different sizes (16 cm, 19 cm and 26 cm in diameter) exist allowing selection according to the individual patients age. The development of a specific fitted model suitable for women is in progress. Pilot studies performed by Bahr and Schier in Jena, Germany (http://www.trichterbrust.de) showed that the device lifted the sternum and ribs immediately (Fig. 2 ). In addition, this was confirmed thoracoscopically during the MIRPE procedure. According to the user instructions and our experience, the vacuum bell should be used for a minimum of 30 min, twice per day, and may be used up to a maximum of several hours daily.

Complications and relevant side effects include subcutaneous haematoma, petechial bleeding, dorsalgia and transient paresthesia of the upper extremities during the application as well as rib fractures in rare cases. Contraindications of the method comprise skeletal disorders such as osteogenesis imperfecta and Glisson's disease, vasculopathies (e.g. Marfan's syndrome, abdominal aneurysm), coagulopathies and cardiac disorders. To exclude these disorders, a standardised evaluation protocol was routinely performed before beginning the therapy.