Pectus excavatum is a common congenital chest wall deformity, frequently referred to as “sunken chest” or “funnel chest.” This condition causes the sternum, or breastbone, and the attached ribs to grow inward, creating a noticeable depression in the center of the chest. While the deformity is present at birth, it often becomes more pronounced during adolescent growth spurts. The condition can range from a purely cosmetic concern to one that impacts heart and lung function by reducing the space within the chest cavity. Fortunately, various methods exist for correction, ranging from external devices to modern surgical techniques.
How Pectus Excavatum is Diagnosed and Evaluated
The evaluation of pectus excavatum begins when a patient presents with symptoms such as shortness of breath, easy fatigability, or chest pain, often associated with exercise. Psychological distress and concerns about body image are also significant factors that prompt a medical assessment. The physician needs to determine the severity of the indentation to decide on the most appropriate treatment path.
A computerized tomography (CT) scan is the standard imaging tool used to get a detailed cross-sectional view of the chest. This scan allows the physician to precisely measure the degree of chest compression, including any potential displacement of the heart. The severity is mathematically quantified using the Haller Index, which is calculated by dividing the maximum inner width of the chest by the shortest distance between the spine and the sternum.
A normal Haller Index is around 2.5, while an index of 3.25 or greater is considered severe and is a common threshold for recommending surgical correction. The CT scan also provides specific anatomical information about the chest wall’s structure, which is crucial for surgical planning.
Non-Invasive Treatment Approaches
For patients with mild cases or those who are still young and have a flexible chest wall, non-invasive treatments are often the first line of management. The primary non-surgical option is the Vacuum Bell device, which is a cup-shaped device connected to a hand pump. This device is placed over the sunken area, and suction is created to gently pull the sternum forward.
The Vacuum Bell therapy relies on consistent, long-term use, requiring the device to be worn for several hours a day over many months or even years. The goal is to gradually remodel the chest wall until the sternum retains its corrected position. Efficacy often depends heavily on the patient’s compliance and the flexibility of their chest structure.
Physical therapy and exercises may complement the Vacuum Bell or be used for standalone treatment in mild cases. These exercises focus on improving posture, strengthening the back and chest muscles, and enhancing lung expansion. Combining physical therapy with the Vacuum Bell yields better results and greater patient satisfaction than using the device alone.
Modern Surgical Repair Techniques
Surgical intervention is considered the definitive correction for moderate to severe pectus excavatum, offering the most significant and lasting structural change. The two primary modern surgical techniques are the minimally invasive Nuss procedure and the open Ravitch procedure. The choice between the two often depends on the patient’s age, the rigidity of the chest wall, and the complexity of the deformity.
The Nuss procedure, developed in the late 1980s, is a minimally invasive technique that uses small incisions on the sides of the chest. A curved steel bar, customized to the patient’s chest contour, is inserted under the breastbone using a thoracoscope for guidance. The bar is then flipped, which immediately pushes the depressed sternum outward into its corrected position. This approach results in shorter operating times and less blood loss.
The Ravitch procedure is the open approach to repair that has been modified over time. This technique involves a larger, horizontal incision across the chest to allow the surgeon direct access to the chest wall. The surgeon removes the abnormally grown costal cartilages. The breastbone is then repositioned and held in place, sometimes with a temporary internal support bar, before the chest is closed. This method is preferred for older patients with very rigid chests or for more complex, asymmetrical deformities.
Life After Correction: Recovery and Expectations
Following surgical correction, the initial recovery phase focuses on managing pain, which is more pronounced after the Nuss procedure, despite it being less invasive. Patients usually remain in the hospital for three to five days, during which time pain is controlled with analgesics. Physical therapy, including deep-breathing exercises, is started almost immediately to help restore lung function.
For the first four to six weeks post-surgery, patients must adhere to strict activity restrictions, avoiding bending, twisting, or heavy lifting to protect the repair. Most return to normal, light daily activities within this timeframe, but high-impact or contact sports are restricted for at least three months. The bar placed during the Nuss procedure remains in the chest for two to three years to allow the chest wall to fully remodel and solidify in the new position.
The long-term outcomes following surgical correction are positive, with high satisfaction rates reported by patients. The repair can lead to improvement in cardiopulmonary function, increasing stamina and reducing shortness of breath, particularly during exercise. Furthermore, the correction improves psychological well-being, including improved self-esteem and body image. Recurrence of the deformity after the bar is removed is rare.