General and Thoracic Surgery Pectus Excavatum
General and Thoracic Surgery Pectus Excavatum

What Is Pectus Excavatum?

Pectus excavatum (sunken chest, funnel chest) is the most common chest wall deformity in children. It is a congenital deformity of the anterior chest wall in which several ribs and the sternum grow abnormally. 

Abnormal growth of the rib cartilage causes the sternum to be pushed inward. The depression in the breastbone may be even or deeper on one side and the breastbone may be straight or rotated to one side. The cause of these abnormalities is unknown, though there is a familial tendency (25% of patients report a family history of chest wall abnormality).

Pectus excavatum can become visible anytime from infancy through puberty and kids often aren't bothered by this until they reach their growth spurt. It can present as a wide range, from mild depression of the sternum (breastbone) to severe cases where the sternum nearly touches the spine. Not all children with pectus excavatum require surgery. Some mild forms can be improved with upper-body strengthening exercises and improvement in posture.

Pectus Excavatum Minimally Invasive Surgery

The first reports of correcting pectus excavatum surgically date back to the early 1900s. That operative approach remained the standard of care until the late 1980s when a minimally invasive approach was developed to treat the condition by Donald Nuss, MD, Children's Hospital of The King's Daughters in Norfolk, Va. 

Children's Mercy general surgeons modified the referenced Nuss technique in 1999, which involves making an incision on each side of the chest about 1.5 inches long. A stainless steel bar that is curved to fit around the front of the chest is slid under the breastbone from one of the side incisions and passed to the other side. The bar is left in place for approximately three years to allow the chest to reshape. 

After three years have passed, the bar will be removed in a same-day surgery procedure. This surgery is the standard of care the world over and highly effective with a recurrence rate of less than 1 percent.

What to Expect Before and After Surgery

Before surgery a CT (CAT scan) will be taken of your child's chest. The scan will measure the chest depression and also see whether the heart and/or lungs are crowded. The CT scan is not painful. To have a CT, your child will need to lie still for about 5-10 minutes while a series of pictures are taken.

A list of exercises will be given to your child to help strengthen the chest muscles. These exercises are to be done before surgery and after surgery as well. Deep breathing and posture exercises to maintain a "military" posture (shoulders back with back in straight alignment) will also be extremely beneficial.

After surgery, it is a good idea to wear a medical bracelet or necklace. You can find these at The inscription should state: STEEL BAR IN CHEST  

Learn more about what to expect, during, and after surgery at Children's Mercy.

Additional Testing

Your insurance company may require additional testing to approve your child's surgery. If additional testing is required by your insurance we will make arrangements for these exams to be completed. Most insurance companies will not begin the precertification process notifying you of this requirement until 2-3 months prior to the scheduled surgery date. This may cause some difficulty for families who would like to plan their surgery ahead of time. Please be aware that if your insurance company denies the surgery for approval, the appeal process may be lengthy. In some cases, the surgery date may need to be postponed and rescheduled.

Pain Management

Pain management is a very important issue for pectus surgery patients. Patients will require a variety of pain medication post-operatively, including extended-release medications. These medications may require pre-authorization with your insurance company or may not be covered at all. If coverage is an issue, we will help you explore alternative options for payment.

These medicines must be taken in a pill form and are not available as a liquid. It is important for your child to be able to swallow pills prior to their operation. Some may want to practice becoming proficient at pill-swallowing…try Tic-Tacs and a cup of water!

The pain medication required after the surgical procedure often causes constipation. It is extremely important to start MiraLAX before the scheduled surgery date. It will be part of your discharge instructions as well, so you may want to purchase the larger quantity.

  • How much MiraLAX®?
    We recommend 1 capful, twice a day, for 3 days prior to surgery.
  • How do you take MiraLAX®?
    MiraLAX is taken daily with liquids. It has no taste and dissolves easily and completely in everyday beverages such as water, juice, or tea.
  • Where do you find MiraLAX®?
    MiraLAX is available in 4 convenient sizes: 7, 14, and 30-dose sizes plus in pre-measured single dose packets (10 ct), which are handy for taking MiraLAX anytime, anywhere. Look for MiraLAX with the pink cap in the laxative aisle at national drugstore chains or supermarkets.

NOTE: There are generic versions available. Please see your pharmacist for more information and possible substitutes available at your local

Care of the Incisions

When your child comes out of the operating room, they may have a bandage over each incision. These outer bandages may be removed two days following surgery. Underneath these dressings are white steri-strips over the incisions. Do not pull these off, they will curl up and fall off on their own as the incisions heal. If steri-strips are still on after one week, you may gently remove them (try rubbing gently with washcloth while showering). The incisions are closed using dissolving stitches that are beneath the skin. There are not any stitches that will need to be removed. The incisions will be pink at first, then will gradually fade over the next year. Notify your child's doctor if there is any redness, increased swelling, or drainage from the incisions.


Activity will be very limited the first 1-3 post-operative months. This is done so the bar is not dislodged. This will mean that your child cannot participate in sports or physical education for at least 1-3 months after surgery. After 1-3 months, your child may participate in any activities that he/she can comfortably tolerate EXCEPT for contact/action sports.

In the first 1-3 post-operative months, your child will not be allowed to lift anything that weighs more than 25 pounds.

Contact sports (i.e. football, wrestling, etc.) will not be allowed for at least 6 months. After 6 months your child may return to contact sports or any other prior activities. However, the risk of bar rotation or another problem requiring additional operations is unknown and you would assume this risk for activities such as contact and action sports.

After your child has recovered, the exercises for the chest strengthening should be restarted.


Usually children need to be home for about 1-2 weeks after this surgery. Your child may return to school when energy level and pain control permits.

He or she may not participate in PE or recess for the first 1-3 months or carry heavy books due to discomfort. You may need to make arrangements for books to be placed in the classroom instead of having your child carry them.

Walking up or down stairs is allowed anytime. Your post-operative letter will outline this information for your child's school or work.


You may travel after surgery as soon as you feel comfortable enough to have an enjoyable trip. If you will be traveling by airplane, you may want to take along this form in case there are any questions from security.


We will want to see your child 2-4 weeks after the operation, then 3 months post-operatively and then yearly until it is time for the bar to come out. It is important to keep these appointments to monitor your child's outcome and determine when the bar can be removed. If an appointment is not scheduled when you leave the hospital, please call the Kansas Surgery Clinic (913) 696-8570 or the Downtown Surgery Clinic (816) 234-3199 for an appointment.

Call your child's surgeon if:

  • Your child's incision is red, swollen, very painful, or has drainage.
  • You think the bar has become dislodged (chest changes shape, your child has been hit forcefully in the chest).
  • You have questions or concerns.
  • Your child is still having difficulty having bowel movements after an enema.

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