Pectus Excavatum (PE), commonly known as a sunken chest, is the most common congenital chest wall deformity. This condition is characterized by an inward depression of the sternum (breastbone) and the attached rib cartilages, giving the chest a caved-in or funnel-like appearance. While often present from birth, the deformity typically becomes more pronounced during adolescent growth spurts. PE may impact heart and lung function in more severe cases, but even mild presentations can cause significant self-consciousness and psychological distress. Solutions exist, ranging from external bracing and physical manipulation to definitive surgical repair and cosmetic enhancement.
Understanding Pectus Excavatum and Assessment
The underlying cause of a sunken chest is the abnormal, excessive growth of the costal cartilage, the flexible tissue connecting the ribs to the sternum. This overgrowth pushes the sternum inward, creating the characteristic depression. While the exact mechanism is not fully understood, the condition is often considered idiopathic, meaning it arises without a known cause. PE is sometimes associated with connective tissue disorders, such as Marfan syndrome.
The severity of the deformity is measured using the Haller Index (HI), calculated from a cross-sectional computed tomography (CT) scan. The Haller Index is the ratio of the chest’s transverse diameter to the shortest distance between the sternum and the spine. A normal chest has an HI of approximately 2.5, while an index greater than 3.25 is considered a severe deformity and often meets the criteria for surgical intervention. This assessment helps determine the degree of structural compression on the heart and lungs, which may manifest as symptoms like shortness of breath, chest pain, or exercise intolerance. Further tests, such as pulmonary function tests and echocardiograms, may be used to evaluate cardiopulmonary compromise.
Non-Invasive and Conservative Treatment Options
For patients with mild to moderate conditions, particularly those with flexible chest walls or who are still growing, non-invasive treatments are often the first approach. The most prominent of these is Vacuum Bell Therapy (VBT), which utilizes a cup-shaped device connected to a hand pump. The device is placed over the deepest part of the depression, and the pump is used to create negative pressure, gently pulling the sternum and ribs forward.
This mechanical force gradually stretches the chest wall, aiming to reshape the cartilage over time. A typical treatment regimen involves wearing the device for an extended period, often working up to four hours total daily, which may be required for a year or more to achieve stable results. Patient commitment is paramount to the success of VBT.
Targeted physical therapy complements VBT and is beneficial for improving the patient’s posture, which can often appear slouched to compensate for the sunken chest. Specific exercises focus on strengthening the core and the back muscles, such as the thoracic extensors. This muscular conditioning helps to support the chest cage and reduce the visible appearance of the depression.
Surgical Correction Methods
When the deformity is severe, causing functional impairment of the heart or lungs, or when non-invasive methods have been unsuccessful, structural surgical correction becomes necessary. The two primary surgical approaches are the minimally invasive Nuss procedure and the traditional open-chest Ravitch procedure.
The Nuss procedure, also known as Minimally Invasive Repair of Pectus Excavatum (MIRPE), is the preferred method due to its less invasive nature. It involves making two small incisions on either side of the chest, through which a curved steel bar is inserted under the sternum. Using a thoracoscope to guide the placement, the surgeon rotates the bar to push the sternum outward into a corrected position.
The bar is secured to the ribs and acts as an internal splint, remaining in place for two to four years, allowing the chest wall to remodel. A second procedure is then performed to remove the bar.
The Ravitch procedure is an open repair involving a larger, horizontal incision across the front of the chest. The surgeon removes the abnormally grown costal cartilage and then repositions the sternum. A temporary metal strut is often placed behind the sternum to support it while the remaining cartilage regenerates. This open technique is reserved for complex or asymmetrical deformities, or for older patients whose chest wall is significantly more rigid.
Aesthetic and Minimally Invasive Fixes
For individuals whose sunken chest is primarily a cosmetic concern, or for adults who have a mild deformity without cardiopulmonary symptoms, non-structural aesthetic fixes are available. These methods are designed to mask the depression rather than correct the skeletal abnormality itself.
The most common approach involves custom-made silicone implants. These implants are precisely manufactured based on a three-dimensional CT scan of the patient’s chest, ensuring a perfect fit to fill the concave area. The implant is placed through a small incision and sits under the skin and muscle layer, immediately creating a smooth chest contour. This procedure is generally less painful and has a quicker recovery time than structural repair surgeries.
Injectable fillers, such as hyaluronic acid, are also used in very mild cases to temporarily fill the depression. However, this method is less permanent and requires repeat applications over time. Neither implants nor fillers address the underlying issue or improve heart or lung function; they are purely for improving the appearance.