Pectus Excavatum Surgery: Everything You Need to Know

Pectus excavation surgery is done to correct a chest deformity present at birth in some individuals. With pectus excavation, the sternum (breastbone) caves inward and gives the chest a sunken in appearance.

Although still debated, many experts suspect this is caused by an overgrowth of cartilage over the ribs where they connect to the sternum.

Mild cases do not require treatment, but pectus excavation surgery may be recommended when:

• The deformity compresses the chest so much that heart and/or lung symptoms occur (e.g., chest pain or an intolerance to exercise)
• Patients with pectus excavatum have related cosmetic concerns

What Is Pectus Excavatum Surgery?

Pectus excavatum surgery is an elective operation performed under general anesthesia by a pediatric surgeon or cardiothoracic surgeon, a doctor who specializes in operating on the heart and lungs.

There are two main types of pectus excavatum surgeries:

• Nuss procedure: This minimally invasive surgery takes about an hour or two and involves inserting a metal bar through a small incision under each arm. The bar goes behind the sternum, pushing it forward into its new position. The ends of the bar are then attached to the outer sides of the ribs. The bar is removed once the chest has been reshaped to its desired position (about two years later).
• Ravitch procedure: This open surgery takes around four to six hours and is performed through one large cut made across the chest. It involves removing the cartilage that is causing the chest deformity, allowing the sternum to move forward to a more normal position. A small plate and tiny screws are used to stabilize the sternum in its desired place. Alternatively, a metal bar may be placed behind the sternum. The bar is removed in six to 12 months after surgery; in some instances, it is kept in permanently.

There is also an investigational approach for correcting pectus excavatum called the magnetic mini-mover procedure (3MP).

With this, magnets are implanted—one inside the chest and one outside the chest, which is attached to an external brace. The magnets create a magnetic force field that slowly pulls the chest to reconfigure it.

The effectiveness of this minimally invasive procedure is still being determined, as are logistical issues with the magnetic brace, which has been found to break in some patients.

Contraindications

The following may make pectus excavatum surgery inadvisable:

• Presence of a significant heart problem (not related to the chest deformity)
• Delayed skill development in infants and children (neurodevelopmental delay)
• Multiple other complex problems evident at birth
• Weakened immune system

Doctors need to evaluate each patient individually to determine if this surgery can be recommended.

Potential Risks

Risks of any pectus excavatum surgery include:

• The general risks of surgery (e.g., infection, bleeding, or problems with anesthesia)
• Recurrence of the deformity
• Air around the lung (pneumothorax)

Specific risks associated with the Nuss procedure include:

• Bar displacement
• Heart complications, like the formation of a hole (perforation) or inflammation of the heart's lining (pericarditis)
• Fluid around the lung (pleural effusion)

The main risk associated with the Ravitch procedure is acquired Jeune syndrome. With this, the lungs cannot grow to their adult size because of the restricted size of the chest wall, which may become damaged during surgery.

Purpose of Pectus Excavatum Surgery

The purpose of pectus excavatum surgery is to correct the chest deformity in order to alleviate symptoms related to the pressure being put on the heart and lungs. The extent of the deformity is measured using a calculation known as the Pectus Severity Index (PSI).

The surgery also improves the appearance of the chest.

Pectus excavatum surgery is generally indicated if two or more of the following criteria are met:

• A PSI score greater than 3.25
• Related heart complications (e.g., heart compression or displacement, mitral valve prolapse, heart murmur, or arrhythmias)
• Restrictive lung disease
• Failed prior repair of the pectus excavatum

Progression of the pectus deformity is factored into the decision to proceed with surgery as well. Doctors also consider the extent to which the deformity may be impacting a patient's mental health (e.g., depression or self-esteem issues related to appearance).

When pectus excavatum surgery is scheduled, various pre-operative tests will be ordered, including:

• An echocardiogram
• A computed tomography (CT) scan of the chest
• Pulmonary function tests

General anesthesia clearance, which often includes a detailed medical history and physical examination, is needed. Basic blood tests, like a complete blood count (CBC), may also be done.

How to Prepare

Once pectus excavatum surgery is scheduled, the surgeon will provide instructions on how to prepare.

Location

Pectus excavatum surgery is performed in a hospital.

Food and Drink

Avoid giving your child anything to eat or drink before surgery with the exception of clear liquids, which should be stopped two hours prior to the scheduled arrival time.

Medications

Certain medications must be stopped prior to surgery, including nonsteroidal anti-inflammatory drugs (NSAIDs) and the diabetes drug Glucophage (metformin).

Some surgeons ask their patients to start taking a stool softener one week prior to surgery to help reduce constipation.

What to Wear and Bring

Have your child wear something that is easy to remove, as they will need to change into a hospital gown upon arrival.

Creams, lotions, makeup, perfume, and cologne should not be used on the day of surgery.

Since your child will be staying multiple nights in the hospital, you will have to pack them an overnight bag or suitcase.

Consider the following items when packing:

• Comfort/entertainment items (e.g., favorite stuffed animal or cozy pillow/blanket, tablet, books)
• Personal items (e.g., toothbrush, brush/comb, lip balm)
• A loose-fitting, zip-front shirt to go home in

At least one parent usually stays with their child in the hospital for support, so make sure to pack an overnight bag for yourself as well.

Pre-Op Lifestyle Changes

Adolescent and adult smokers should stop smoking as soon as possible prior to surgery. Smoking increases the risk for complications both during and after the procedure.

What to Expect on the Day of Surgery

Here is what you can generally expect on the day of your child's pectus excavatum surgery. The same applies to adults undergoing this procedure.

Before the Surgery

Upon arrival at the hospital, your child will be led into a small holding area and given a hospital gown to change into. A nurse will then take and record their vitals (body temperature, blood pressure, etc.)

At this time, an intravenous (IV) line may be placed into a vein in their arm or hand. This IV will be used for delivering medications during the procedure.

The doctor will then come to say hello and briefly review the surgery with you/your child. You may need to sign a consent form at this time.

Before going into the operating room, your child may be given a sedative to help them relax and, sometimes, fall asleep. Younger children may receive the sedating medication through a mask; older children/adolescents may receive it through their IV.

Once asleep, any child who does not already have an IV will have one placed by a nurse.

From there, your child will walk into the procedure/operating room or be wheeled there on a gurney.

Depending on the anesthesiologist's preference, one parent or guardian may be allowed to accompany their child into the operating room for the start of anesthesia. For the remainder of the procedure, anyone accompanying the patient will need wait in the waiting room.

During the Surgery

The exact steps of the surgery depend on which procedure is being performed.

As an example, here is the general flow of the Nuss procedure:

• Anesthesia administration: The anesthesiologist will deliver inhaled or intravenous medications to render your child temporarily unconscious. Once the anesthesia has taken full effect, a breathing tube called an endotracheal tube will be inserted through the mouth and into the windpipe. This tube is connected to a ventilator.
• Incisions: After cleaning the skin over the surgical sites, the surgeon will make small cuts on each side of the chest and one in the middle.
• Bar placement: A metal bar of variable length (depending on the patient's chest size) will be inserted behind the sternum, turned to elevate the sternum to its desired position, and attached to the outer edges of the ribs.
• Bar securement: The bars will be secured to the chest wall with a metal plate, stitches, or wire. This will not be visible from outside the body.
• Drain placement: Sometimes a drain will be temporarily placed underneath the skin within the surgical area to remove excess blood or fluid.
• Closure: The incision sites will be closed with dissolvable stitches. The sites will be covered with adhesive strips and a dressing.
• Prep for recovery: Anesthesia will be stopped and the breathing tube will be removed. From there, it's off to a recovery area.

After the Surgery

In the recovery room, a nurse will monitor your child's vitals signs. Pain, nausea, and grogginess, common anesthesia-related symptoms, can be expected.

You/your child will stay in the recovery room until vitals are stable and the anesthesia has completely worn off.

When the nurse deems it appropriate, they will transport your child to a hospital room for what's typically a three- to seven-night stay.

During recovery in the hospital, the surgical team may use different methods to help manage pain. These include:

• Combination of oral or intravenous medications, such as opioids, NSAIDs, Tylenol (acetaminophen), and muscle relaxants
• Epidural analgesia
• Cryoablation, a technique that involves "freezing" the nerves that provide sensation to the chest wall. This pain-minimizing technique has been found to decrease the use of opioids and a patient's hospital stay.

Stool softeners or laxatives will be given to prevent constipation.

Deep breathing exercises will also be recommended to help prevent pneumonia.

A physical therapist will meet with your child to help them get from their bed to a chair the day after surgery. From there, they will work with your child to help them build up strength and start walking around the hospital room before going home.

Recovery

Once discharged home, it's important to adhere to post-operative instructions, which may include:

• Keeping on top of pain control by taking medication as instructed, often during regular intervals
• Taking stool softeners/laxatives until all opioid medication are stopped
• Seeing the surgeon again as directed (usually around two weeks after surgery). If a drain was placed and was not removed at the hospital, it will be taken out at this appointment.

Wound Care

It is important to avoid submerging surgical sites in water. Washing up in the tub either by sponge-bathing or using a handheld showerhead is OK until you are given the go-ahead to shower. Check with your surgeon, but this is typically around five days after surgery.

Follow the surgeon's instructions about how to remove/replace the dressing over the surgical sites. The adhesive strips will usually fall off on their own within 10 days.

Activity

There will be several activity restrictions for the first four to eight weeks or more after surgery.

Examples of such restrictions include having your child:

• Avoid lying on their side or stomach
• Avoid bending or twisting at the waist, pushing or pulling with their arms, or reaching high over their head
• Avoid heavy lifting
• Avoid gym class
• Avoid carrying a backpack
• Avoid slouching (good posture helps optimize surgical results)

Your child will also need to refrain from having a magnetic resonance imaging (MRI) scan during this period.

Medical Alert Bracelet

During the time the metal bar is in place after pectus excavatum surgery, have your child wear a medical alert bracelet that states: "surgical steel bar in place under sternum."

In the event of an emergency, this would inform first responders that CPR needs to be done with a more forceful compression of the chest. Likewise, it would tell them that the placement of paddles used for external defibrillation (shocks to the heart) needs to be adjusted.

Long-Term Care

Surgical repair of pectus excavatum has excellent success rates with most patients reporting an improvement in self-image and exercise tolerance.

Keep in mind, though—follow-up surgeon visits at regular intervals after surgery are necessary until the metal bar is eventually removed.

At these appointments, healing will continue to be monitored and activity limitations may be modified. Chest X-rays may also be done to check the position of the bar.

Future Surgeries

A future same-day surgery to remove the metal bar will be performed around two years after the Nuss procedure and six months after the Ravitch procedure.

Possible future surgeries may also be needed if a complication arises from the initial surgery or if the deformity recurs.

A Word From Verywell

If your child has a sunken chest, it's important to talk with their doctor, especially if they are experiencing physical or psychological symptoms as a result. A medical history, physical examination, and various tests on your child's heart and lungs will help the doctor decide if surgery is needed.

If pectus excavatum surgery is recommended, continue to learn everything you can about surgical options. It's also a good idea to reach out to loved ones or a support group for comfort and assistance during this understandably stressful time.