Pectus excavatum, often called “sunken chest” or “funnel chest,” is a congenital chest wall deformity. The breastbone (sternum) and attached ribs grow abnormally inward, creating a noticeable indentation in the chest. This condition is the most common congenital chest wall abnormality and occurs more frequently in males. Although present from birth, the deformity often becomes more pronounced during adolescent growth spurts. Surgery is typically considered the definitive treatment for patients with moderate to severe cases.
The Need for Correction
Surgical correction is not always necessary, and mild cases of pectus excavatum are often monitored without intervention. The decision to proceed with an operation hinges on a combination of functional, physical, and psychological factors. One primary tool for evaluating the deformity’s severity and functional impact is the Haller Index.
The Haller Index is a ratio calculated from a cross-sectional image, such as a CT scan. It divides the chest’s transverse width by its anterior-posterior depth at the point of greatest indentation. An index of 3.25 or greater is considered severe enough to warrant surgical consideration. This severe indentation can compress the heart and lungs, causing symptoms like shortness of breath, decreased exercise tolerance, chest pain, and heart palpitations. Psychosocial distress and body-image concerns, particularly in adolescents, are also important criteria for surgical correction.
The Primary Surgical Approaches
Two main techniques are used for surgical repair: the minimally invasive repair, known as the Nuss procedure, and the open repair, called the modified Ravitch procedure. The Nuss procedure is often the preferred method, particularly for younger patients with a flexible chest wall. This minimally invasive approach involves making two small incisions on the sides of the chest, through which a pre-contoured metal bar is inserted.
The surgeon uses a small camera, or thoracoscope, to guide the bar beneath the breastbone. Once positioned, the bar is flipped, using its curvature to immediately push the sunken sternum outward into a corrected position. The bar is then secured to the ribs or chest wall with stabilizers to prevent shifting. This hardware remains in place for two to three years, allowing the chest wall to remodel and solidify in the new shape.
The modified Ravitch procedure is an older, open surgery involving a larger incision across the chest. This technique is reserved for older patients, those with a rigid or complex deformity, or cases where the Nuss procedure has failed. During the operation, the surgeon removes the deformed costal cartilage connecting the ribs to the sternum.
After cartilage removal, a wedge-shaped cut (osteotomy) may be performed on the sternum to increase flexibility and aid repositioning. The breastbone is then moved into position and temporarily stabilized with a small internal bar or plates. The pectoralis muscles are closed over the aligned chest, allowing natural cartilage to regenerate in the corrected position over the following weeks.
The Recovery Journey
The initial recovery period begins in the hospital, with a typical stay lasting three to five days. Effective pain management is a central focus, often involving intravenous medications, non-steroidal anti-inflammatory drugs, and regional techniques like nerve blocks. Cryoablation, the freezing of intercostal nerves, is also used during the Nuss procedure to reduce post-operative pain for several weeks.
Patients are encouraged to begin walking and performing deep-breathing exercises soon after surgery to aid in lung expansion and prevent complications. Strict physical restrictions are put in place for the first several weeks to ensure the correction remains stable and the hardware does not shift. Patients must avoid twisting or bending at the waist, log-rolling, and lifting anything heavier than 10 to 15 pounds for the first few months.
Most patients can return to school or light work within two to three weeks, but strenuous activities and contact sports are prohibited for at least six weeks. If the Nuss bar was placed, it is scheduled for removal as an outpatient procedure after the two-to-three-year period. The final outcome is a permanent correction of the chest wall deformity, leading to improved cardiopulmonary function and enhanced self-confidence.