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,
and sunken chest.
About 37 percent of people with pectus
excavatum also have a close relative with the condition. This suggests that it
may be hereditary. Pectus excavatum is the most common chest wall anomaly among
In severe cases, it can interfere with the
function of the heart and lungs. In mild cases, it can cause self-image
problems. Some patients with this condition often avoid activities such as
swimming that make hiding the condition difficult.
Symptoms of severe
Patients 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.
Physicians use chest X-rays or CT scans to
create images of the internal structures of the chest. These 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 warrant surgical correction. Patients have the option of doing
nothing if the curvature is mild.
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 is 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. The incisions are closed with
stitches, and temporary drains are placed at or near the sites of the
incisions. This technique requires no cutting or removal of cartilage or bone.
The metal bars are typically removed during
an outpatient procedure about two years after the initial surgery in young
patients. By then, correction is expected to be permanent. The bars may not be
removed for three to five years or may be left in place permanently in adults.
The procedure will work best in children, whose bones and cartilage are still
of pectus excavatum surgery
Surgical correction has an excellent success
rate. Any surgical procedure involves risk, including:
- the risk of infection
- the possibility that the
correction will be less effective than expected
Scars are unavoidable, but are fairly minimal
with the Nuss procedure.
There is 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 8 years of age.
Complications are uncommon with either
surgery, but the severity and frequency of complications are approximately the
same for both.
On the horizon
Doctors are evaluating a new technique: 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.