Pectus excavatum is the most common chest wall deformity, characterized by an abnormal inward growth of the sternum and ribs, which creates a sunken or funnel-chest appearance. This condition is often present from birth but becomes more noticeable during adolescent growth spurts, affecting about 1 in 400 births. While mild cases may only be a cosmetic concern, a more severe depression can crowd the chest cavity, potentially compressing the heart and lungs and leading to physical symptoms like shortness of breath or exercise intolerance. The management and treatment of pectus excavatum require a specialized, multidisciplinary team, with the ultimate decision for definitive correction resting with a specific type of surgeon.
The Initial Consultation and Referral Process
The medical journey for a person with pectus excavatum typically begins with a General Pediatrician or a Primary Care Physician (PCP). These providers are usually the first to identify the characteristic sunken chest during a routine physical examination. Since the condition often manifests or worsens during childhood and adolescence, pediatricians play a significant role in early detection.
In cases where the deformity is mild and causes no physical symptoms, the initial approach involves observation and monitoring. The PCP or pediatrician tracks the condition’s progression, especially during periods of rapid growth. They act as the gatekeepers, determining when the severity or the onset of symptoms, such as chest discomfort or fatigue with activity, warrants a referral to a specialist for deeper investigation.
Specialists Who Evaluate Cardiopulmonary Function
Once symptoms develop or the chest wall deformity appears severe, a team of specialists is brought in to assess the impact on internal organs. These specialists do not treat the deformity itself but provide the detailed diagnostic information that guides the decision for surgical correction.
A Pediatric or Adult Cardiologist focuses on the heart, which can be displaced and compressed by the inward-pushing sternum. They use an Echocardiogram, a non-invasive ultrasound of the heart, to check for potential issues like heart compression, displacement, or the presence of mitral valve prolapse.
The Pulmonologist assesses the effect on the respiratory system, as the deformity can restrict lung expansion, leading to a restrictive breathing pattern. Pulmonary Function Tests (PFTs) are performed to measure lung volume and airflow capacity, helping to quantify any reduction in breathing ability.
The Radiologist is responsible for imaging studies, especially the CT scan of the chest, which is used to calculate the Haller Index. This index is the standard measurement of the deformity’s severity, calculated by dividing the maximum transverse diameter by the shortest distance between the sternum and the spine. An index greater than 3.2 is generally considered severe and often qualifies a patient for surgical repair. The detailed imaging also clearly shows any displacement or compression of the heart and lungs, providing objective evidence of functional impairment.
The Surgeons Who Provide Definitive Correction
The definitive structural repair is performed by surgeons, typically a Cardiothoracic Surgeon or a Pediatric Surgeon specializing in chest wall deformities. These specialists use the data collected by the multidisciplinary team to determine the optimal timing and type of surgical intervention.
The two main surgical approaches are the minimally invasive Nuss procedure and the open Modified Ravitch procedure. The Nuss procedure, now the more common technique, involves inserting a curved metal bar beneath the sternum through small incisions on the sides of the chest. This bar is flipped to push the sternum outward, correcting the depression, and is typically left in place for two to four years before being removed.
The Modified Ravitch procedure is an open repair that involves making a larger, central incision to directly remove the deformed rib cartilage and reposition the sternum. It is now often reserved for older patients with a rigid chest wall or for complex, asymmetric deformities.
For patients with mild cases, a plastic surgeon or dermatologist might discuss non-surgical cosmetic options, such as vacuum bell therapy, which uses suction to lift the sternum.