Pectus excavatum

Overview

Pectus excavatum is the most common chest wall deformity in children. Its cause is unclear.

The condition often becomes noticeable in the years leading up to adolescence and typically becomes more severe over time. It's more common in boys than in girls.

For most children, it doesn't pose a serious health risk. If needed, a surgical repair can improve heart and lung function as well as chest appearance.

One to three years after that repair, a follow-up procedure is done to remove the implanted corrective device. This can be done without an overnight stay.

Surgical procedures for pectus excavatum repair

The Nuss procedure: How it works

The experienced surgeons in our pectus excavatum program have performed more than 1,000 Nuss procedures (minimally invasive chest wall surgeries) in the last 20+ years.

UCSF specialists pioneered the use of intercostal nerve cryoanalgesia, a pain management technique that temporarily freezes specific nerves between the ribs. It protects those nerves as your child heals – often shortening their hospital stay, speeding recovery and reducing the need for opioid medications.

A small incision is made on each side of the chest. A stainless steel "pectus bar" inserted through one of the incisions is placed under the sternum to raise it.

The bar is then secured to the chest wall, using metal stabilizers on each side. (Note: Sometimes two pectus bars are needed.)

Surgical time: about two hours

Most patients can go home the next day. The chest area will be numb while the pain gradually subsides. That usually takes about a month. Chest sensation returns in two to three months.

After two to three years, we remove the pectus bar (or bars) in an outpatient procedure that takes about an hour.

The modified Ravitch procedure: How it works

In this much older procedure, doctors make a long incision across the chest to remove deformed cartilage. Then they move the sternum forward and secure it in the desired position with metal struts.

Surgeons may choose to use cryoanalgesia (described in the Nuss procedure above) for pain control.

Surgical time: about three hours

The struts are removed a year after surgery in an outpatient procedure. It takes about an hour, so your child can return home the same day.

Note: The Ravitch procedure was introduced in 1949 and was the gold standard until the Nuss procedure was published in medical literature in 1998. The Nuss is by far the most common option used today, but the Ravitch is still offered by most clinics and may be preferable in some cases.

Home care

Here's what to expect when your child comes home after surgery:

• Pain. We'll send you home with a pain medication prescription for your child.
• Activity. They can resume regular activities when they feel up to it.
• Baths and showers. After two days, showering is fine. Baths are allowed after a week.
• Dressings. Remove the gauze and clear plastic dressings covering the incisions a few days after surgery. Once those are gone, you'll notice small strips of white adhesive tape over the incision. It's normal to see a small amount of blood on the strips, and the skin around the incision may be red and bruised. The tape will eventually loosen and fall off.
• Swelling. There may be slight swelling at the incision site. After the incision heals, you'll feel a firm ridge (called a "healing ridge") under the incision. This is where the tissues were sewn together. It may be there for several months.

If all goes well, your child will have a scheduled follow-up visit with us two to four weeks after leaving the hospital.

Have concerns or questions?

Once your child is home, don't hesitate to call the Pediatric Surgery Clinic at 415-476-2538 (San Francisco clinic) or 510-428-3022 (Oakland clinic).

Be sure to call us right away if your child develops any of these:

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

Nonsurgical treatments

Not every child with pectus excavatum requires surgery. These are two commonly used nonsurgical options in some mild and moderate cases:

Vacuum bell therapy

How it works:
Suction gradually pulls your child's breastbone and ribs forward over a period of several months.

Bracing

How it works:
Your child wears a brace that reshapes their chest wall over time. Our pediatric orthotics and prosthetics experts fit them with a custom brace and adjust it as your child grows.