Pectus excavatum

Background and natural history

Pectus excavatum is a condition in which the breastbone (sternum) of the chest is caved in. This happens because several ribs and the breastbone grow abnormally. Pectus excavatum may be mild or severe. Severe pectus excavatum may cause problems with the heart and lungs.

There are options for how to treat a pectus excavatum. Our team will help you understand the options and make the best decision for your child.

Pectus excavatum can be treated with one of the following procedures:

  • Nuss procedure
  • Ravitch procedure

The Nuss procedure does carry a very low risk of injury to the heart, bar movement, bar infection, and bar allergy. However, we are prepared for this with every procedure and are in the safest possible environment to deal with such an injury. We have successfully treated the other complications and only rarely need to remove the bar. We are committed to ongoing research and giving your child the most up to date care. Watch our pectus excavatum video for more information on how we guide you through the Nuss procedure.

In patients with mixed pectus excavatum/carinatum, a partial Ravitch approach may be completed with a Nuss procedure for best results.

Correction and recovery

There are a few options for managing a pectus excavatum. For our youngest children aged under 12 years with symmetric excavatum, we have experience using a Klobe Bell. This approach, developed by an engineering entrepreneur with pectus excavatum, uses a suction cup device to elevate the sternum. Initially, patients wear this for 30 minutes a day, and within weeks increase wear time to as much as tolerable. Recent study indicates that for those in puberty with excavatum deeper than 1.5 cm, that the Bell does not have the ability to permanently correct the depression. However, in younger children, we have seen significant improvements, with some children able to wear the Bell for > 8 hours per day, and we believe that this change can be more permanent. The risks associated with this treatment are minimal and include skin discoloration. If the Bell is unable to correct the sternal deprssion, surgical correction may be safely performed in the pubertal years.

Nuss procedure

The Nuss procedure is a minimally invasive way of using an internal brace to hold the sternum in a corrected position. It was developed in 1989 and our institution has performed this procedure since 1999 when the innovator, Dr. Donald Nuss, came and demonstrated the technique at Children's Wisconsin. Since then we have routinely performed 40-50 procedures per year with great success. The technique involves using a 5 mm camera in the right chest to develop a tunnel behind the sternum and in front of the heart so that a U shaped bar can be introduced. This bar is 1/4" stainless steel and is custom shaped for each patient. Once in place, the bar is rotated and sutured to the chest wall to secure it. The sternal correction is immediate and decisions regarding need for a second bar or reshaping the bar to obtain the best result are made in the operating room. We have found that the risk of subsequent rotation of the bar is decreased by using a stabilizer on the right side. Our surgeons may opt to make a small incision under the tip of the breastbone to aid in the placement of the bar.

Recovery from a Nuss procedure occurs completely within 3 months. Currently, our patients stay 2 days in the hospital and are weaned off of their pain medications within a few weeks. We have seen major improvements in recovery associated with our Multimodal Pain Management program, which uses many different classes of pain medications at the same time to make our patients more comfortable. This involves taking some medications even before surgery. Our families report that meeting with our staff psychologist to learn coping techniques and address anxiety has been a significant help in recovering more comfortably. The team approach at managing comfort is important, as is our patient's mindset entering surgery. While we limit activity such as contact sports for 3 months, aerobic activity is encouraged even at one month. If bar position is unchanged at the 3 month visit, then no activity restrictions are required. As examples, we have motocross riders, football players, Division I volleyball players, soccer players, golfers, tennis players, baseball players, basketball players, swimmers, and others as successful patients. The optimal time for correction is 13-14 years for most affected, and using this method becomes a significantly different recovery for those of adult stature, although we have completed adult Nuss procedures at our center.

For the right patient and family, chest wall correction can be transformative. We have seen changes in confidence, personality, mood, and posture over time. The goal of your visit is to provide you information to help make the best decision. As part of evaluation for surgery, we use a special MRI image of the chest for surgical planning, calculation of the Haller Index, and to assess the effect of the excavatum on the heart. The Nuss procedure does carry a very low risk of injury to the heart, bar movement, bar infection, and bar allergy. In our greater than 20 year experience of well over 400 cases completed at Children's Wisconsin, we have not had heart injury occur with bars placed at our institution. However, we are prepared for this with every procedure and are in the safest possible environment to deal with such an injury. We have successfully treated the other mentioned complications, with bar removal required in only a few occasions. As a team we are committed to continually tracking and improving upon our Nuss procedure outcomes.

Following three years with the bar in place, bars are removed as a day surgery procedure. We have many graduates who have volunteered to share their experiences with families considering surgery.

Ravitch procedure

The Ravitch procedure predates the Nuss procedure by 42 years. It is a an open approach to pectus excavatum, severe pectus carinatum, and mixed/asymmetric chest wall conditions. Using either transverse incision below the nipples or one over the breastbone, the cartilages connecting the breastbone to the rib tips are removed where abnormal. This allows the breastbone to be moved into a corrected position, often supported by a strut or wire, and the cartilages regrow to fix the sternum into the new position. Recovery is often 3-5 days in hospital with 2 drains that are removed a few days after surgery. Wire or strut removal is completed 6-12 months after the initial surgery as a day surgery procedure. Contact sports are avoided until the chest wall becomes more rigid at 9-12 months postoperatively. The final appearance is the exchange of a pectus excavatum for a 10-12 cm incision over the front of the chest. Results are excellent, and this approach may be preferred by adult excavatum patients who will have an easier recovery from such an approach. Ravitch is the procedure of choice for severe pectus carinatum which is unresponsive to compressive therapy. In patients with mixed pectus excavatum/carinatum, a partial Ravitch approach may be completed with a Nuss procedure for optimal correction.
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Pectus chest wall deformity video