Pectus Excavatum

What is pectus excavatum?

Pectus excavatum is an abnormal, inward-growing sternum (breastbone). This creates a noticeable and sometimes severe indentation of your chest wall that involves four or five ribs per side.

Other names for pectus excavatum are sunken chest or funnel chest. This condition gives you less space in your chest, which can limit heart and lung function.

Pectus excavatum is a congenital condition, which means you’re born with it. But people often notice it during their early teen years.

Healthcare providers can correct pectus excavatum with minimally invasive surgery or traditional open surgery.

How common is pectus excavatum?

Pectus excavatum is the most common congenital (present at birth) abnormality that affects your chest wall. About 1 to 8 people per 1,000 have it. It happens more often in boys and people assigned male at birth (AMAB).

What are the symptoms?

Pectus excavatum symptoms can be both physical and psychological.

Physical symptoms can include:

• Shortness of breath with exercise.
• Less stamina compared to peers.
• Fatigue.
• Chest pain.
• Irregular heartbeat.
• Heart palpitations.

Psychological symptoms can include:

• Significant embarrassment from the appearance of your chest.
• Self-esteem issues.
• Clinical depression.

What causes pectus excavatum?

For many people, their pectus excavatum causes are unknown. But some people get it as part of a connective tissue disease like Marfan syndrome or Ehlers-Danlos syndrome.

Is pectus excavatum genetic?

Researchers haven’t found a specific genetic link yet. But they suspect there is one. About 40% to 53% of people with pectus excavatum have a biological family member with the same condition.

What are the risk factors for pectus excavatum?

Without a known cause of pectus excavatum, it’s difficult to pin down risk factors. Still, you may be at a higher risk for pectus excavatum if you have this condition in your family or have a syndrome linked to it.

What are the complications of pectus excavatum?

Pectus excavatum is associated with:

• Impaired exercise tolerance.
• Mitral valve prolapse (leaky heart valve).
• Compression of your heart.

How is pectus excavatum diagnosed?

A healthcare provider can diagnose pectus excavatum with a simple physical examination. Providers may not notice the issue until you’re in your early teens. They may want to do testing to see how much pectus excavatum is affecting your cardiopulmonary (heart and lung) function.

What tests will be done to diagnose pectus excavatum?

Tests for pectus excavatum may include:

• Magnetic resonance imaging (MRI) of your chest.
• Computed tomography (CT) of your chest.
• Cardiopulmonary (heart and lungs) exercise testing.
• Electrocardiogram (EKG).
• Echocardiogram.
• Pulmonary function tests (PFTs).

How is pectus excavatum treated?

A surgeon can correct pectus excavatum with a minimally invasive (Nuss procedure) or an open (Ravitch procedure) operation. Your surgeon will discuss which procedure is best for you. During the surgery, your surgeon repositions your sternum (breastbone) to a more outward position. Both surgeries:

• Lessen pressure on your heart and lungs, allowing them to function better.
• Improve the appearance of your chest.

Surgery may be right for you if you’re having physical symptoms and/or psychological symptoms from pectus excavatum. The best time for a pectus excavatum repair is between 10 and 14 years of age, when your chest wall is still flexible. Your provider can help you decide the right time for surgery.

The Nuss procedure

In this minimally invasive procedure, your surgeon will:

• Insert a camera into your chest to guide the procedure.
• Make two small incisions on either side of your chest.
• Insert a custom-curved steel bar(s) under your sternum and position the bar(s) to elevate your sternum.
• Secure the bar to your chest wall on each side to correct the depression.

The bar stays in place for several years. A surgeon removes it in an outpatient (same-day) procedure.

The Ravitch procedure

In this traditional or open procedure, your surgeon will:

• Make an incision on the front of your chest.
• Remove the overgrown connective tissue that’s pushing your sternum backward.
• Pull your sternum forward, away from your heart and lungs, into your chest wall.
• Use a small plate and tiny screws or a small metal bar to stabilize your sternum in its new position.

A surgeon will remove the bar in six to 12 months during a short outpatient procedure. This bar is smaller than the bar they use in the Nuss procedure. You don’t need additional surgery because surgeons don’t remove the plates.

Complications of the treatment

Like other major surgeries, the surgical repair of pectus excavatum presents risks. Both the Nuss procedure and the modified Ravitch technique are safe and effective procedures. But complications, although rare, can happen.

Possible complications from surgical repair of pectus excavatum include:

• Pneumothorax (collapsed lung).
• Bleeding.
• Pleural effusion (fluid around your lung).
• Infection.
• The chest bar moving out of place.
• Pectus excavatum recurrence (happening again) after bar removal.
• Injury to surrounding structures.
• Chronic pain.

How long does it take to recover from this treatment?

With advances in pain management, recovery from surgery is shorter and less painful now than it used to be.

Cryoablation freezes the nerves between your ribs that provide pain sensation to your chest wall. You also receive an injection of local anesthetics (numbing medicine) of those same nerves and oral painkillers before and after surgery.

Using cryoablation to minimize severe pain after the Nuss procedure significantly shortens hospital stays and reduces the need for opioids.

Before cryoablation-assisted Nuss procedures, students had to have surgery in the summer because it took a month or more to recover. Now, they can have surgery during a short break from school because of the shorter hospital stay and recovery time.

Traditional pain management for the Nuss procedure used to require a one-week hospital stay after surgery. It also required epidural anesthesia, followed by several weeks of potentially addicting opioid medication after discharge.

With cryoablation, most people can go home the day after surgery. Some people don’t need any IV or oral (by mouth) opioids in the hospital. Those who do need oral opioids typically stop using them in one to two days. Cryoablation will result in a numb chest wall for six months to one year.

Can pectus excavatum be prevented?

No. Until researchers find a specific cause of pectus excavatum, you can’t prevent it.

What can I expect if I have pectus excavatum?

The goal of pectus excavatum repair is to relieve pressure on your heart and lungs so they can work better. This typically improves breathing, exercise intolerance and chest pain. You may feel as if your breathing and stamina are normal before surgery and then realize they feel much improved after surgery.

People whose main issue is the abnormal appearance of their chest have had positive changes in their self-esteem and self-confidence after surgery. For adults with pectus excavatum, limitations on activity may not be obvious until their late 30s or 40s.

How long pectus excavatum lasts

You’ll have pectus excavatum until you have an operation to fix it.

When can I go back to my usual activities?

After surgery, you’ll need to take it easy for a while due to discomfort. You can walk and run again when discomfort permits. Your surgeon will determine when you can resume heavy lifting and competitive sports.

Students should be able to go back to school two to three weeks after surgery for pectus excavatum.

Outlook for pectus excavatum

Both the Nuss and Ravitch procedures have excellent results. People are almost always satisfied with the way they feel and look after recovery. The rate of the condition recurring (happening again) is less than 1% for both procedures.

How do I take care of myself?

Symptoms — both physical and psychological — are a part of daily life for people with untreated pectus excavatum. People who tell you this condition is purely cosmetic aren’t acknowledging what you feel. Find a provider who will take your symptoms seriously and help you manage them.

When should I see my healthcare provider?

Regular checkups with a provider can help them decide when you should have an operation (or if your case is severe enough to need it). After surgery, you’ll need to see your surgeon on a regular basis until you’ve completely recovered.

What questions should I ask my doctor?

Questions you can ask your healthcare provider about pectus excavatum may include:

• Can you refer me to a counselor who can help me with the emotional aspects of my condition?
• Is there a support group for people with pectus excavatum?
• Would you recommend surgery in my case?
• At what age should I have surgery?

Does pectus excavatum get worse with age?

You may develop more symptoms over time. This is likely due to the normal aging process. It also gets harder to make up for pectus excavatum limiting your heart and lungs’ function.

If I don’t have surgery, will pectus excavatum harm my heart and lungs or limit my life expectancy?

There’s no evidence that pectus excavatum limits life expectancy or causes progressive damage to your heart and lungs over time. But without surgery, your symptoms may get worse.

People with pectus excavatum can carry a normal pregnancy to term.

If I have pectus excavatum and need heart surgery, can both procedures be done at the same time?

Yes. Surgeons have done combined heart surgery cases with pectus excavatum repair with excellent outcomes. This requires coordination between the surgeons performing both procedures.