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Pectus Excavatum and Pectus Carinatum

Pectus excavatum

A chest wall deformity is an abnormal development in the chest wall. The condition is fairly common and the abnormality can vary from mild to severe.

These deformities are more common in boys and in caucasians. Up to 40 percent of patients will have an affected family member and several monogenic syndromes are associated with pectus deformities including Marfan Syndrome, Homocystinuria and Ehlers-Danlos Syndrome. It can either be present at birth or not develop until puberty. The two most common congenital chest wall deformities fall into the categories of pectus carinatum (sometimes called pigeon chest or sternal protrusion) and pectus excavatum (also called funnel chest or sunken sternum). Treatment will depend on the level of severity.

Pectus excavatum "funnel chest"

For children with pectus excavatum, chest wall deformities may range from mild to severe. Mild cases might be barely noticeable. Pectus excavatum can be completely harmless, but the visual appearance can affect a child's self-image, and they may also be subjected to teasing and even bullying. Severe cases can cause a deep hollow in the chest and may affect the heart and lungs. Surgery can often correct the condition and treat any heart or lung issues.

Who gets it?

Pectus excavatum affects about 1 in 400 children, and is most common in males although females can be affected as well. Up to 40 percent of patients will have a family member, typically a parent or grandparent, who also has it, but there is no clear genetic link. There are several monogenic syndromes associated with pectus deformities including Marfan Syndrome, Homocystinuria and Ehlers-Danlos Syndrome. It can either be present at birth or not develop until puberty.

before photoafter photo
Male, before and after

female before and after photo
Female, before and after

What causes it?

It is generally regarded as a genetic condition, based on the fact that it is usually present in several members of the same family and is often associated with other genetic diseases; however, its causes remain in debate.

What are the symptoms?

Common symptoms of chest wall deformities are:

  • Sunken appearance in the chest.
  • Shortness of breath.
  • Decreased stamina during exercise.

In addition, your child may also have chest pain related to abnormal bone and cartilage growth. Pectus excavatum typically gets worse with age or during growth spurts that occur during adolescence.

How is it diagnosed?

Workup of pectus excavatum includes your child's medical history and a physical exam, along with one or more of the following tests:

  • Chest X-ray.
  • CT scan of chest.
  • Cardiac ECHO.
  • Pulmonary function test (PFT).
  • Testing for possible nickel allergy.
  • Cardiac MRI.

How is it treated?

Treatment of mild pectus excavatum may consist of exercises for improving posture and upper body strength. If your child has moderate to severe pectus excavatum, surgery may be recommended.

Nonsurgical options

For mild deformities, posture control, exercise program (e.g., deep breathing, pushups) and annual follow-up may be appropriate. Many patients are candidates for this non-operative treatment before considering surgical repair. Other non-operative options such as suction devices can be used. Compliance is important for optimal results.

Surgical options

The timing of surgery is dependent on your child's age, symptoms and anatomy. Surgical options are generally deferred until mid to late adolescence–if symptoms allow–to prevent problems with chest wall compliance which may occur if done in younger patients.

Nuss minimally invasive repair of pectus excavatum (MIRPE)

Pediatric Surgery bar
  • Uses small lateral chest incisions and a thoracoscope to place a curved stainless steel bar underneath the ribs and the sternum.
  • No excision of cartilage is needed.
  • The bar is removed in two to three years as an outpatient procedure.
  • Most patients are candidates for this procedure, but some very asymmetric deformities may require other approaches.
Nuss repair

Ravitch repair*

  • A longer anterior thoracic incision is used to excise the abnormally shaped cartilages in a subperichondrial plane.
  • An osteotomy is often made in the sternum to position it appropriately.
  • A stainless-steel bar is placed to keep the sternum in position while the cartilage grows to the sternum (approximately two years).
  • Some patients may be candidates for more limited resections.

Pectus carinatum "pigeon chest"

Who gets it?

carinatum

Pectus carinatum is less common than pectus excavatum. Only a fifth as many children have it. It is more common in in boys – only 1 in every 4 patients diagnosed with this condition are girls. It generally appears later than excavatum deformity (50 percent by 11 years of age). This condition also worsens during puberty.

What causes it?

It is generally regarded as a genetic condition, based on the fact that it is usually present in several members of the same family and is often associated with other genetic diseases; however, its causes remain in debate.

What are the symptoms?

Common symptoms are:

  • Chest wall may protrude forward, thus the name pigeon chest.
  • Chest wall may also be asymmetric meaning one side my protrude forward and the other may sink in (like excavatum).
  • It is associated with congenital heart disease, but it is less likely to have cardiopulmonary symptoms.
  • In addition, your child may also have chest pain.

How is it diagnosed?

Workup includes your child's medical history and physical exam. Less common, one or more of the following tests are performed:

  • Chest X-ray.
  • CT scan of chest.
  • Cardiac ECHO.

How is it treated?

pectus carinatum brace

Surgical repair is an option for people with severe pectus carinatum, but a compression brace can be used to help flatten the chest in most patients. The pectus compression brace is a custom brace made by Cook Children's Orthotics and Prosthetics. This is a preferred treatment for children whose bones are still growing. The brace is worn 16-23 hours a day for the first year and 12-16 hours for the second year. Many patients are candidates for this non-operative treatment before considering surgical repair. Results are often seen in just a few months, when worn according to instruction. Correction is faster and more complete for younger children.

Ravitch repair

  • A longer anterior thoracic incision is used to remove the abnormally shaped cartilages under the connective tissue (a subperichondrial plane).
  • An osteotomy (surgical sectioning of the bone to shorten or lengthen it) is often made in the sternum to position it appropriately.
  • A stainless-steel brace is placed to keep the sternum in position while the cartilage grows to the sternum (approximately two years).

What to expect after surgery

Post-operative pectus information

After surgical repair of your pectus deformity, you will have a steel bar that is positioned across the chest under the breast bone. The bar usually stays in for 2-3 years.

Please follow these instructions to minimize changes or problems with the bar:

  • Your child will be sent home with oral pain medication.Sometimes a stool softener is recommended as well.
  • Only light activities of daily living for the first 4-6 weeks after surgery.
  • Daily deep breathing/breath holding exercises recommended.
  • No contact sports, gymnastics or golf swings for the first 3 months.
  • No bending at the waist (use your hips), twisting or slouching for the first month.
  • Good posture for life.
  • No heavy lifting (backpacks included) for 2 months.
  • Daily walks are encouraged immediately following surgery in order to help the child regain strength.
  • Child will need to sleep on his/her back for the first month.
  • May submerge incisions at 1 week after surgery, may shower 3 days after surgery.
  • Children are typically able to return to school two-three weeks after surgical repair.

Additional information

  • If you need Magnetic Resonance Imaging (MRI) in the future, inform the radiologist about the bar. It can usually still be performed.
  • CPR can still be performed if needed, however, compressions require more force than normal due to the steel bar.
  • Defibrillation for cardiac arrest may be performed if needed with the bar in place but the pads need to be positioned front to back.
  • You will be given a card stating you have a steel implant. Medical alert bracelets or other reminders may be obtained at www.medicalert.org or other providers.

When to call the doctor

  • Coughing that won't stop.
  • Increased pain.
  • Fever greater than 100.5 F.
  • Respiratory distress (difficulty breathing).
  • Any signs of infection from the incision site (redness, swelling, and/or pus like drainage).
Pediatric Surgery
"Keeping up with other athletes was nearly impossible. As I ran, my lungs felt like they were collapsing. A dear friend referred me to Dr. Iglesias, and I was diagnosed with pectus excavatum. After surgery, only a few short months later, I was back in action. I soon began to realize that I could breathe more easily, and I could take deep breaths just like my teammates. What a success this procedure was for me! I thank God that I was able to receive care from some of the greatest nurses and doctors at Cook's Children's." –Miami R. (patient)

We're here to help.

If your child requires surgery, you probably have lots of questions. We can help. If you would like to speak to our staff, please call our offices at 682-885-7080.