Pectus Excavatum
What is it?
Pectus excavatum is characterized by a sunken chest caused by the sternum pressing inward. It often becomes more pronounced during growth spurts in childhood or adolescence.
Signs and Symptoms
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Sunken appearance of the chest wall
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Decreased exercise tolerance
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Negative self image
Evaluation and Diagnosis
Diagnosis involves a physical exam, chest CT scans, and tests like echocardiograms and pulmonary function assessments to determine severity.
Treatment
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Nuss Repair (Minimally Invasive): Placement of a metal bar under the sternum to correct the defect, removed 2-3 years later.
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Ravitch Repair (Open Surgery): Removal of cartilage and placement of a strut under the sternum to reshape the chest.
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Non operative treatments are sometimes used in unique cases
Follow-Up Care
Post-surgery follow-ups include monitoring with chest X-rays and restricting contact sports for a brief period of time. The bar is typically removed after 2-3 years.
About Pectus Excavatum
Pectus excavatum is an indentation to the chest wall that occurs in 1 in 300 people. Patients with pectus excavatum may complain of shortness of breath, especially while exercising, or an inability to keep up physically with their peers. They may feel embarrassed or ashamed of their physical appearance, and this impaired body image can result in lower self-esteem and impaired quality of life.
Pectus excavatum often requires an operation to elevate the sternum, potentially improving heart and lung function, as well as improving the appearance of the chest. An extensive evaluation will help determine if a patient is a surgical candidate. At the patient’s initial consultation, we will discuss if and when additional workup testing should be considered.
The surgeons perform the Nuss procedure to correct pectus excavatum. The surgery involves two small incisions made on either side of the chest. One or more bars are guided across the chest and then rotated to lift the sternum. Thoracoscopy allows the surgeons to see inside the chest with a camera during the procedure. We utilize a multimodal approach to pain control to ensure patients are able to return to their normal activities as soon as possible. One aspect of this pain control is cryoablation, which uses extreme cold to temporarily freeze targeted nerves in the chest wall. We restrict certain activities for a short period of time, but within a limited time period our patients are able to resume all activities including contact sports.
At Austin Pediatric Surgery, an enhanced recovery (ERAS) pathway was created by our team of surgeons, advanced practice providers, anesthesiologists, nurses, physical and occupational therapists, pharmacists, and Child Life Specialists. ERAS is a patient-centered and evidence-based approach to optimize surgical outcomes. This team developed a pectus pathway to improve postoperative pain control, encourage early mobility, and decrease hospital length of stay. This pathway optimizes care before, during, and after your surgery.
Pectus Carinatum
What is it?
Pectus carinatum causes the sternum to protrude outward, leading to a pigeon chest appearance.
Signs and Symptoms
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Asymmetric chest appearance
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Negative self image
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Chest pain or breathing difficulties
Evaluation and Diagnosis
Diagnosed via physical exams, sometimes supplemented with chest X-rays for bony abnormalities.
Treatment
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Brace Therapy: Effective for non-rigid cases, requiring continuous wear for 3-6 months.
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Ravitch Repair (Surgical): Reserved for severe or brace-resistant cases, involving cartilage removal and sternum reshaping.
Follow-Up Care
Brace therapy patients are monitored for progress, while post-surgery patients are seen regularly to ensure proper healing.
About Pectus Carinatum
Pectus carinatum is a less common variant of a pectus anomaly and occurs when the sternum and ribs protrude outward. Many patients with pectus carinatum experience continued growth of the protrusion during growth spurts. Some children may experience shortness of breath, most often during exercise.
The most common treatment for pectus carinatum is bracing therapy, though occasionally surgery is indicated. Timing of this treatment is important and is best during early adolescent and teenage years when cartilage is softer and the chest wall is more easily reshaped. We will help you to determine and carry out the right plan for your condition.
Mixed Chest Deformity
Mixed chest deformities may include a combination of pectus excavatum and pectus carinatum. We also see patients with pectus arcuatum. Pectus arcuatum is a rare chest wall deformity that causes the upper part of the sternum to protrude forward and the lower part to angle backward.
Our surgeons will work with patients and families to create individualized treatment plans based on desired outcomes.
Our Pectus Program
The surgeons of Austin Pediatric Surgery have developed a multidisciplinary Chest Wall Program at Dell Children’s Medical Center. They specialize in treating structural deformities of the chest wall including pectus excavatum and pectus carinatum. The conditions are caused by an abnormal growth of the cartilage that connects the sternum to the ribs. Typically, pectus excavatum and pectus carinatum become more prominent during the rapid growth of early adolescent and teen years, but they can also develop at a much younger age. Sometimes there may be a family history of chest wall abnormalities, however these conditions can also be associated with certain connective tissue disorders, such as Marfan syndrome or Ehlers-Danlos syndrome. Our program will work with you and your family to make the best plan for your condition.
If you have any questions, please contact our Chest Wall Program Coordinator at: dcchestwallprogram@ascension.org.
Pectus Program Testimonials
"My Daughter had her surgery with Dr.Josephs in June 2024 and it was a great experience from the start, I had so many questions answered and the staff were so amazing especially Sarah. I am grateful for the care and knowledge that I gained from this experience and for my daughters surgery to go so well! I couldn't thank Dr.Josephs enough for changing the course of my daughters life and making her life better! Forever grateful!"
- Mother of patient with pectus excavatum
"We had an exceptional experience with Dr. Grethel and his team, and I wanted to share our journey in the hopes it might help others.
My 16 year old son Matt had been struggling with his stamina since the indent in his chest started worsening with puberty. He would often feel short of breath quickly, experience premature muscle burn during exercise, and describe the air as feeling “heavy.” After a couple of years of observation and consultation with Dr. Grethel, we felt that the NUSS procedure was the best solution for him.
From the very beginning, Dr. Grethel and his team were incredibly professional, helpful, and supportive. They guided us through every step of the process, including navigating the complexities of insurance approval. Their patience and dedication gave us the confidence we needed during the uncertain times leading to surgery.
The results have been incredible. Just a few days after the surgery, Matt noticed an immediate difference—he could breathe more easily, even at rest, which he had never realized was a challenge for
in a little over six weeks, he was back to running, swimming, rowing, and lifting weights. We are almost 3 months post-op and the improvement in his stamina has been noticeable.
We cannot thank Dr. Grethel and his staff enough for their outstanding care and support throughout this journey. We are so grateful for the positive impact this surgery has had on Matt’s life and highly recommend Dr. Grethel and his team."
-Valerie L.
"No one likes to have to send their child into surgery. No one likes to see the effects of pectus excavatum on their child's physical and emotional health. But the Nuss Procedure performed at Dell Children's hospital changed our child's life forever.
The staff guided us through the preparation process, answering all of our questions and scheduling the requisite tests. The procedure involved a minimally invasive surgery whereby a titanium bar was inserted under the ribs, causing almost instant improvement.
Because of advances in the procedure, the surgeons do a cryo-ablation of the nerves inside the chest wall, which thaw after 8 weeks. This means the patient is home sooner (two to three days instead of a week or longer in the hospital) and no prescription painkillers are necessary during recovery. It took three months to be completely able to do everything but because of the surgery, he feels more confident, healthier and happier."
- Mother of patient with pectus excavatum
"Prior to the surgery, I had a sunken sternum, and I had less breathing capacity. I had shortness of breath many times and I felt rather insecure about myself. However, when I went under the surgery, where they placed a metal bar under my sternum and pushed it up, results were almost instant.
Following the surgery, I had more breathing room, allowing me to do activities more efficiently and not get as tired. I felt I could do more, and while recovery took time and adjusting, I felt more secure about myself. Now, I am happy with my chest and the results from the surgery, as I can do the activities I love and not get as short of breath!"