Pectus excavatum (sunken chest, funnel chest), the most common chest wall deformity in children, 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.
Learn more about what to expect, during, and after surgery at Children's Mercy.
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
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
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
- How much MiraLAX®?
We recommend 1 capful, twice a day, for 3 days prior to
- 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
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
Call your child's surgeon if:
- Your child's incision is red, swollen, very painful, or has
- 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.