Pectus excavatum is a Latin term that means “hollowed chest.” People with this congenital condition have a distinctly sunken chest. A concave sternum, or breastbone, may exist at birth.
It may also develop later, usually during adolescence.
Other common names for this condition include:
- cobbler’s chest
- funnel chest
- sunken chest
Pectus excavatum is the most common chest wall irregularity in children, according to a 2016 article published in the journal Pediatric Annals. The journal also reports that one-third of children with a sunken chest have a family member with the condition.
However, a specific gene that causes sunken chest hasn’t been discovered. Doctors do know that sunken chest occurs due to a developmental issue during pregnancy.
Usually about 35 days into the gestation period, the ribs start to fuse with the breastbone. In people with a sunken chest, their breastbone doesn’t fuse as expected, and they develop a sunken chest appearance.
Men experience sunken chest at a much higher rate than women.
According to a recent article in the journal Annals of Cardiothoracic Surgery, men are four times more likely to experience sunken chest than women. When women do have a sunken chest, it tends to be more pronounced, the journal article reports.
In severe cases, the condition can interfere with how the heart and lungs function. In mild cases, sunken chest can cause self-image problems. Some people with this condition may avoid activities such as swimming that make hiding the condition difficult.
Doctors can usually look at the chest wall and see it’s sunken in instead of straight or slightly rounded outward in appearance.
In addition to a person’s physical appearance, sunken chest can cause other symptoms in the body because the chest bones press on nearby organs, such as the heart and lungs. Some people with this condition may experience the following:
- abnormal heart rhythms
- poor exercise capacity
- shortness of breath
- unexplained fatigue
A doctor may take measurements of a person’s sunken chest and track it over time to determine if it’s getting worse.
People with severe pectus excavatum may experience shortness of breath and chest pain. Surgery may be necessary to relieve discomfort and prevent heart and breathing abnormalities.
Chest X-rays or CT scans are used to create images of the internal structures of the chest. These scans help measure the severity of the curvature. The Haller index is a standardized measurement used to calculate the severity of the condition.
The Haller index is calculated by dividing the width of the rib cage by the distance from the sternum to the spine. A normal index is about 2.5. An index greater than 3.25 is considered severe enough to require surgical correction.
If the curvature is mild, it generally doesn’t require treatment.
Most often, a doctor can tell if a child has sunken chest at birth. Some children don’t notice they have the condition until they hit a growth spurt in adolescence.
Symptoms of sunken chest in a baby include:
- large, rounded belly
- shoulders that appeared slightly rounded
- slightly sloped or downward-turning ribs
Some children with pectus excavatum also have other medical conditions or bone abnormalities. Examples include:
Doctors consider sunken chest to be a progressive condition.
This means that as a person gets older, the depth to which their chest appears sunken may increase. While a significant number of people with sunken chest have surgery to repair the condition in young adulthood, it’s possible that an adult can also benefit from surgery.
Usually, surgery isn’t recommended unless an adult has symptoms, such as shortness of breath or heart problems. If they do have these symptoms, they can speak to their doctor about potential treatment steps.
Sunken chest treatments depend on how severe a person’s chest cave is. If a person is having breathing or heart problems, their doctor will likely recommend surgery. Other treatments include exercises to improve breathing and posture.
Some people may also benefit from vacuum bell therapy.
This type of therapy involves a person using a special pump applied against the chest wall for anywhere from 30 minutes to several hours. The pump creates negative pressure on the chest that can elevate the chest wall to reduce the incidence of sunken chest.
One of the benefits of vacuum bell therapy is that a person of nearly any age can use it. However, it won’t correct more severe cases of a deeply sunken chest.
Some people can’t use it, including those who have:
- heart problems
- bleeding disorders
- musculoskeletal disorders
Doctors are evaluating a new technique called the magnetic mini-mover procedure. This experimental procedure involves implanting a powerful magnet within the chest wall. A second magnet is attached to the outside of the chest.
The magnets generate enough force to gradually remodel the sternum and ribs, forcing them outward. The external magnet is worn as a brace for a prescribed number of hours per day.
Certain exercises, such as deep breathing exercises and those designed to improve posture, may help people with mild-to-moderate sunken chest who don’t want to have surgery. These approaches can help reduce their symptoms.
Examples of exercises for sunken chest include:
- Chest expansions. Stand as straight as possible, pulling the shoulders back. Take a full, deep breath and hold it for 10 seconds. Exhale and repeat 20 times.
- Back straightening. From a standing position, interlace your fingers behind your head. Pull the elbows back a little further to open up the chest more. Bend slightly forward at the hips, focusing on straight posture. Hold the position for up to 3 seconds, then repeat up to 25 times.
Frequent physical activity, including playing sports, can also help. Staying in good shape can help a person strengthen their heart and lungs so their symptoms are less noticeable.
Some people may choose to have surgery for cosmetic purposes to help them feel less self-conscious about their chest. Others may have health complications from sunken chest, like heart or breathing problems. Surgery can often improve their symptoms.
Whenever possible, doctors usually recommend waiting until after an adolescent has passed their first major pediatric growth spurt, which can occur between ages 10 and 15.
According to a recent article, the average age for a person to have sunken chest surgery is 13.5 years old.
Surgery may be invasive or minimally invasive and may involve the following procedures.
The Ravitch procedure
The Ravitch procedure is an invasive surgical technique pioneered in the late 1940s. The technique involves opening the chest cavity with a wide horizontal incision. Small sections of rib cartilage are removed, and the sternum is flattened.
Struts, or metal bars, may be implanted to hold the altered cartilage and bones in place. Drains are placed at either side of the incision, and the incision is stitched back together. Struts can be removed but are intended to remain in place indefinitely.
Complications are typically minimal, and a hospital stay of less than a week is common.
The Nuss procedure
The Nuss procedure was developed in the 1980s. It’s a minimally invasive procedure.
It involves making two small cuts on either side of the chest, slightly below the level of the nipples. A third small incision allows surgeons to insert a miniature camera, which is used to guide the insertion of a gently curved metal bar.
The bar is rotated so it curves outward once it’s in place beneath the bones and cartilage of the upper ribcage. This forces the sternum outward.
A second bar may be attached perpendicular to the first to help keep the curved bar in place. Stiches are used to close the incisions, and temporary drains are placed at or near the incision sites. This technique requires no cutting or removal of cartilage or bone.
The metal bars are typically removed during an outpatient procedure about 2 years after the initial surgery in young people. By then, correction is expected to be permanent. The bars may not be removed for 3 to 5 years or may be left in place permanently in adults.
The procedure will work best in children whose bones and cartilage are still growing.
Surgical correction has an excellent success rate. However, any surgical procedure involves risk, including:
- pleural effusion, or fluid buildup in the tissues that line the lungs
- pneumothorax, or a collapsed lung portion
- the risk of infection
- the possibility that the correction will be less effective than expected
The most severe and uncommon risk with a Nuss procedure is direct injury to the heart. Scars are unavoidable but are fairly minimal with the Nuss procedure.
There’s a risk of thoracic dystrophy with the Ravitch procedure, which can result in more severe breathing problems. To reduce this risk, surgery is usually delayed until after age 8.
Complications are uncommon with either surgery, but the severity and frequency of complications in children and adults are about the same for types.
According to a 2016 analysis of studies published in the journal Annals of Cardiothoracic Surgery that focused on both procedures in children and adults, the researchers found there are slightly fewer complications resulting from the Ravitch procedure in adults.
Gynecomastia is a medical condition that causes breast development in males. Some males may choose to have surgery to lessen the breast-like appearance of their chest.
Sometimes, when a person has this surgery, they may discover they have sunken chest, which they previously didn’t know about.
Both gynecomastia and sunken chest may become more noticeable during puberty. Surgery to correct gynecomastia doesn’t necessarily cause sunken chest, but it may make a sunken chest more noticeable.
Following surgery, a person can talk to their doctor about whether they need treatment for sunken chest.
Sunken chest is the most common chest wall abnormality.
If the condition causes symptoms, your doctor may recommend surgical correction. Surgery to repair a sunken chest typically offers very positive results. Your doctor can evaluate the severity of your condition and help you decide whether surgery is right for you.