Pectus excavatum

Overview

Pectus excavatum is the most common chest wall deformity in children. It results from abnormal growth of the cartilage — the soft, flexible tissue attached to the sternum or breastbone — causing the chest wall to curve inward. The condition is often apparent at birth and typically becomes more severe over time. It occurs more frequently in boys than in girls.

In most children, this deformity poses no health risk and surgical repair is done primarily for cosmetic reasons. Surgical repair requires a follow-up outpatient procedure, performed one to two years after the surgery.

Procedure

Pectus excavatum is generally repaired in one of two ways. The traditional approach involves a long incision across the chest to remove the deformed cartilage. The sternum is then moved forward and secured in the corrected position with metal struts. This operation takes about four hours to complete.

Another approach involves inserting a stainless steel "pectus" bar through a Band-Aid size incision on each side of the chest. The pectus bar is inserted through one of the side incisions and placed under the sternum, moving it forward. The bar is then secured to the chest wall. This operation takes about one hour.

In both operations, all stitches are placed under the skin. These stitches dissolve, so no stitches are removed after the operation. Your child's incision will be covered with small bandages.

With an open or traditional repair, the metal struts are removed a year after insertion. A pre-surgical visit is required. Removal takes about an hour and is performed as an outpatient procedure, so you can return home with your child the same day.

With minimally invasive repair, the pectus bar or bars are removed two years after insertion, in an outpatient operation that takes about an hour. Please arrange a visit to our office one year after the struts or bar was inserted and then again at two years, just prior to removal.

Recovery

The pectus excavatum repair is a painful procedure. The length of your child's hospital stay will depend on his or her pain level after the operation. Most children stay in the hospital for about five days after the operation. An epidural catheter, which is placed in the back, is used to give continuous pain medication for several days, when the pain is the greatest. While the epidural is in place, your child will also have a catheter in the bladder to drain urine. In addition, your child may be given oxygen with a small tube under the nose.

After a few days, pain medication is given orally and the epidural is removed. In some children, it may be necessary to place a small tube or tubes in the incision to drain fluid. These are removed when the drainage stops, usually after several days. You can help speed your child's recovery by encouraging deep breathing, walking and sitting in a chair, as soon as possible after the operation.

If all goes well, we recommend a visit to the Pediatric Surgery office between two and four weeks after your child leaves the hospital. We also recommend a visit with your child's pediatrician one to two weeks after discharge from the hospital.

Home Care

Please keep the following in mind after bringing your child home following the pectus excavatum repair:

• Pain — When your child leaves the hospital, you will be given a prescription for pain medication to take to your local pharmacy.
• Activity — To avoid dislodging the pectus bar, we recommend no contact sports for at least a month following surgery. Except for that restriction, your child can go about his or her activities as usual.
• Bathing — Your child may bathe or shower after the epidural catheter is removed. When your child is home, he or she may bathe or shower without restriction.
• Dressings — Gauze and clear plastic dressings placed over the incisions may be removed a few days after surgery. Over the incision, there will be small, white strips of adhesive tape. You may see a small amount of blood on the strips — this is normal. The skin surrounding the incision may be red and bruised and the incision may be slightly swollen. Your child can bathe with the tape in place. Eventually, the tape will loosen and fall off.
• Swelling — There may be some swelling at the site of the incision. After the incision heals, you will feel a firm ridge, called a "healing ride," under the incision. This is where the tissues are sewn together. It may be present for several months.

If all goes well, we recommend a visit to our office between two and four weeks after your child leaves the hospital. We also recommend a visit with your child's pediatrician one to two weeks after discharge from the hospital.

Signs to Look For

Call the Pediatric Surgery Clinic at (415) 476-2538 if you have any concerns once your child is home, or if your child develops:

• A temperature of 101.5° F or higher
• A red incision
• Worsening pain and tenderness at the incision
• Fluid emerging from the incision