Pectus Excavatum

What Is the Correction Index?

The correction index is one of the imaging measurements that expresses, as a percentage, the amount of correction needed for the sternum to reach a normal front-to-back position. In some rib cage configurations, it may provide information in addition to the Haller index. The correction index is not used on its own to make a surgical decision either. Imaging results are interpreted together with the physical examination, symptoms, cardiac evaluation, exercise capacity, and the course of the deformity over time.

Why Is Echocardiography Performed?

Echocardiography uses sound waves to evaluate the structure and function of the heart. It may be used in the following situations:

• Palpitations
• Chest pain during exercise
• Dizziness or fainting
• Heart murmur
• Suspected cardiac compression
• Suspected connective tissue disorder
• Preoperative evaluation

Echocardiography can assess the heart chambers, heart valves, the pumping function of the heart, and, when necessary, the aortic root. In some patients, the shape of the chest wall may make it more difficult to obtain ultrasound images. A normal echocardiogram at rest does not, on its own, prove that there is no physiological effect at all during strenuous exercise.

Pulmonary Function Tests

Pulmonary function tests provide information about airflow and breathing capacity of the lungs. They may be used especially in patients with shortness of breath or exercise-related complaints. In many people with pectus excavatum, pulmonary function tests performed at rest may be normal. The tests can also help distinguish asthma or another respiratory condition.

What Is Cardiopulmonary Exercise Testing?

Cardiopulmonary exercise testing evaluates the combined response of the heart, lungs, and circulatory system during controlled physical activity. During the test, data such as the following may be examined:

• Oxygen consumption
• Carbon dioxide production
• Heart rate
• Breathing response
• Workload
• Exercise duration
• Onset of symptoms

It may be especially useful for people who have marked complaints during exercise even though their resting tests are normal. Low test performance is not always assumed to be caused solely by pectus excavatum. Fitness, coexisting conditions, and effort during the test can also affect the result.

How Is the Severity of Pectus Excavatum Assessed?

Assessing severity is not just a matter of how deep the depression looks from the outside. The evaluation considers the following together:

• Depth and width of the depression
• Symmetry
• Sternal rotation
• Haller and correction indices
• Position of the heart and possible compression
• Pulmonary function
• Exercise capacity
• Physical symptoms
• Progression of the deformity
• Posture
• Psychosocial effects
• Age and growth status

Pectus excavatum may be clinically described as mild, moderate, or severe, but this classification alone does not determine treatment.

Does Pectus Excavatum Progress Over Time?

Pectus excavatum may become more noticeable, especially during periods of rapid growth. A depression that is mild in childhood may deepen or become more asymmetric during adolescence. The rate of progression varies from person to person. During follow-up, the following may be assessed:

• Appearance of the chest
• Symmetry
• Growth
• Physical symptoms
• Exercise capacity
• Posture
• Scoliosis
• Psychosocial effects

In adults who have finished growing, the chest wall is generally stiffer, and the deformity may not change as quickly as it does during adolescence.

Does Every Case of Pectus Excavatum Need Treatment?

No. Deformities that are mild, not progressing, and not significantly affecting the person's physical or psychosocial life can be monitored. Treatment may be considered in situations such as:

• Progression of the deformity
• Reduced exercise capacity
• Significant effects on the heart or lungs
• Recurrent chest complaints
• Marked postural problems
• Impact on daily life or social activities
• Significant body image concerns

The type of treatment depends on the patient's age, growth status, chest wall flexibility, and the anatomy of the deformity.

Can Exercise Correct Pectus Excavatum?

Exercise does not eliminate the structural cause of pectus excavatum. However, appropriate programs can:

• Improve posture
• Bring the shoulders into a more balanced position
• Strengthen the back and shoulder muscles
• Increase the flexibility of the chest muscles
• Support breathing control
• Improve overall physical fitness

A fixed structural deformity of the sternum and costal cartilages should not be expected to fully correct through muscle building alone.

The Role of Physical Therapy in Pectus Excavatum

Physical therapy can provide support particularly for:

• Rounded shoulders
• Hunched posture
• Weakness of the back muscles
• Reduced rib cage mobility
• Breathing control
• Physical preparation before surgery
• Regaining mobility after surgery

The program may include:

• Posture exercises
• Back and shoulder strengthening
• Stretching of the chest muscles
• Diaphragmatic breathing
• Rib cage mobility exercises
• General conditioning

Physical therapy should not be regarded as a method that eliminates a structural deformity without surgery.

What Is the Vacuum Bell?

The vacuum bell is a non-surgical device placed over the sunken area in pectus excavatum that creates negative pressure with the aim of lifting the sternum and the front chest wall forward. Once the device is placed on the chest, the air inside it is reduced in a controlled manner. The negative pressure created can cause the front chest wall to move forward. Vacuum bell treatment generally requires regular, long-term use. The response to treatment may be influenced by factors such as:

• Age
• Chest wall flexibility
• Depth of the depression
• Symmetry of the deformity
• Consistency of use
• Total duration of treatment

Who May Be a Candidate for the Vacuum Bell?

The vacuum bell may be considered in selected patients, particularly those who:

• Have a flexible chest wall
• Have a mild or moderate deformity
• Have a relatively symmetric depression
• Are able to commit to regular use of the device

The greater flexibility of the chest wall in children and adolescents can be an advantage. The vacuum bell can also be used in some adults, but a stiffer chest wall may limit the response to treatment or require longer use. Not every case of pectus excavatum is suitable for the vacuum bell.

How Is the Vacuum Bell Used?

There is no single universal schedule for vacuum bell use that applies to all patients. The duration of use and the negative pressure may be planned according to:

• Age
• Chest wall flexibility
• Device type
• Structure of the deformity
• Skin tolerance
• Clinical response

Shorter sessions may be preferred at the start of treatment, and use can be adjusted gradually according to the patient's tolerance. Applying higher negative pressure in an uncontrolled way does not produce faster or more lasting correction.

What Are the Side Effects of the Vacuum Bell?

During or after vacuum bell use, the following may occur:

• Skin redness
• Bruising
• Small visible blood vessels
• Tenderness
• Temporary swelling
• Chest discomfort
• Numbness
• Dizziness

In case of significant pain, excessive bruising, or other unexpected complaints, the usage schedule needs to be reviewed. Suitability should be evaluated separately in people with bleeding disorders, certain cardiovascular conditions, or other special health conditions.

Does the Vacuum Bell Provide Permanent Correction?

When the vacuum bell is applied, the sternum may temporarily move forward. This change, seen right after the device is removed, does not mean permanent remodeling. Regular, long-term use may be required for a permanent or lasting change. Significant improvement can be achieved in selected patients. However, the following cannot be guaranteed:

• Complete correction
• Perfect symmetry
• A specific treatment duration
• No recurrence
• No need for surgery later

When Is Surgery Considered for Pectus Excavatum?

The decision to operate is not based solely on the appearance of the chest or the Haller index. Surgical treatment may be considered in selected patients in cases of:

• Progressive deformity
• Significant physical complaints related to the deformity
• Significant cardiac compression on imaging
• Impaired cardiopulmonary function
• Markedly reduced exercise capacity
• Significant impact on daily life
• Serious and persistent psychosocial effects
• Non-surgical methods being unsuitable or not giving sufficient results

Before surgery, the expected benefits are discussed together with issues such as pain, the risk of complications, the use of a metal implant, and the possible need for later bar removal.

What Is the Right Age for Pectus Excavatum Surgery?

There is no single ideal age for surgery that applies to every patient. Timing is determined by taking into account:

• Type and severity of the deformity
• Progression
• Chest wall flexibility
• Physical symptoms
• Cardiopulmonary effects
• Psychosocial status
• Whether growth is still ongoing
• Planned surgical technique

Although many patients are evaluated during adolescence, age alone does not determine the decision to operate. Decisions about surgery that is too early or later than necessary should be made based on individual anatomy and the clinical situation.

Can Pectus Excavatum Surgery Be Performed in Adults?

Yes. Pectus excavatum is not a condition treated only in children or adolescents. Surgical correction can also be performed in adults. However, because the chest wall is stiffer:

• More force may be needed for correction
• More than one bar may be used
• Pain management may differ
• Recovery may take longer
• Surgical planning may be more detailed
• Age alone is not a barrier to surgery.

Overall health, heart and lung function, bone and chest wall structure, previous surgeries, and individual risks are evaluated together.

What Is the Nuss Procedure?

The Nuss procedure is a technique that aims to correct pectus excavatum using a minimally invasive surgical approach. One or more shaped metal bars are placed behind the sternum through small incisions on the sides of the chest. Once the bar is in the proper position, it supports the sternum forward and helps correct the sunken chest wall. The bars are left in the body for a certain period so that the rib cage can adapt to its new position, and are later removed in a separate surgical procedure. Although the Nuss procedure is performed through small skin incisions, it is a major chest wall correction procedure that is closely related to important anatomical structures, because a metal bar is passed behind the sternum.

How Is the Nuss Procedure Performed?

The procedure is performed under general anesthesia. Although the surgical technique may vary according to the patient's anatomy, it may include the following steps:

• Making incisions on the sides of the chest
• Viewing the chest cavity with a thoracoscopic camera
• Preparing a safe passage behind the sternum
• Shaping the metal bar to fit the chest
• Passing the bar behind the sternum
• Rotating the bar into position to lift the sternum
• Securing the bar to the chest wall
• Placing additional bars if needed
• Checking the chest cavity and the bar position

In severe or stiff deformities, additional surgical techniques may be used to make it easier to lift the sternum safely.

What Is a Nuss Bar?

A Nuss bar is a metal support shaped to fit the patient's rib cage. The bar:

• Supports the sternum forward
• Helps maintain the corrected chest shape
• Provides mechanical support while the chest wall remodels
• More than one bar may be used depending on the width, stiffness, and asymmetry of the deformity.

Various fixation systems may be used to reduce the risk of the bars rotating or shifting.

How Long Does a Nuss Bar Stay In?

How long the bars remain in the body is not the same for all patients. Age, chest wall stiffness, the structure of the deformity, the correction achieved, and the surgical technique can affect the duration. The bars are generally left in place for several years to allow the rib cage to adapt to its new shape. The timing of bar removal is determined through regular clinical follow-up.

How Is the Bar Removed?

Removal of the Nuss bar is a separate surgical procedure and is usually performed under general anesthesia. The previous side incisions may be used. After the tissues around the bar and fixation systems are freed, the metal bar is removed in a controlled manner. Although it may be a more limited procedure than the initial operation, it is not completely risk-free. Possible complications include:

• Bleeding
• Pneumothorax
• Injury to the lung or pleura
• Infection
• Pain
• Technical difficulty due to bone or scar tissue around the bar

What Is the Ravitch Procedure?

The Ravitch method is based on correcting pectus excavatum with open surgery. During surgery, certain portions of the costal cartilages that contribute to the deformity may be reshaped or removed. When necessary, a corrective cut may be made in the sternum and the breastbone brought into a more forward position. The Ravitch method may be considered particularly for:

• A very stiff chest wall
• Severe asymmetry
• A complex deformity
• Marked sternal rotation
• Some patients who have had previous pectus surgery
• Cases in which the Nuss method is not anatomically suitable

What Is the Difference Between the Nuss and Ravitch Procedures?

In the Nuss method, the breastbone is supported forward by one or more bars placed behind the sternum, without extensive removal of the costal cartilages. In the Ravitch method, the costal cartilages and, when necessary, the sternum are directly reshaped surgically. The Nuss method generally uses smaller side incisions, whereas the Ravitch method requires more direct surgical intervention on the front chest wall. Neither method can be said to be better than the other for all patients. The surgical approach is chosen by taking into account:

• Anatomy of the deformity
• Age
• Chest wall flexibility
• Asymmetry
• Previous surgeries
• The patient's other medical characteristics

Evaluation Before Pectus Surgery

Before surgery, the following may be evaluated:

• Onset and progression of the deformity
• Physical symptoms
• Exercise capacity
• Heart and lung status
• Scoliosis
• Signs of connective tissue disorder
• Previous surgeries
• Current medications
• Allergies
• Smoking
• Body image and expectations
• Support arrangements after surgery

Imaging and functional tests are selected according to clinical need. In people with metal sensitivity or a history of reactions to implants, the materials to be used are evaluated separately.

Pain Control in Pectus Surgery

Because pectus excavatum surgery creates significant mechanical correction of the chest wall, postoperative pain management is an important part of treatment. Depending on the center and the patient, pain control may use methods such as:

• Oral or intravenous pain medications
• Epidural analgesia
• Regional nerve blocks
• Paravertebral or erector spinae plane blocks
• Intercostal nerve cryoanalgesia

Intercostal cryoanalgesia is one of the methods used at certain centers for pain control after the Nuss procedure. The pain control plan is tailored to the patient's age, the extent of surgery, and the patient's medical characteristics. Effective pain control can make it easier to breathe deeply, move around, and walk early.

What Are the Risks of the Nuss Procedure?

The fact that the Nuss procedure is performed through small incisions does not mean it is risk-free. Possible complications include:

• Bleeding
• Pneumothorax
• Hemothorax
• Pleural fluid accumulation
• Lung injury
• Rotation or displacement of the bar
• Problems related to fixation materials
• Infection
• Prolonged pain
• Nerve-related pain or sensory changes
• Metal reaction
• Atelectasis
• Lung infection
• Wound healing problems
• Insufficient correction
• Persistent asymmetry
• Recurrence of the deformity
• Need for repeat surgery
• Anesthesia-related complications

Injury to the heart or major blood vessels is rare, but it is a serious and potentially life-threatening complication. For this reason, appropriate imaging, thoracoscopic visualization, and controlled bar passage are important for surgical safety.

Bar Displacement

A Nuss bar exerts continuous mechanical force on the chest wall. Displacement or rotation of the bar may present with symptoms such as:

• New or worsening chest pain
• A change in chest shape
• New asymmetry
• Shortness of breath
• Feeling the bar in a different position

In cases of significant bar movement, imaging and, if necessary, repeat surgery may be considered.

Infection

Infection may develop at the incision site, around the implant, or in deeper tissues. Possible signs include:

• Fever
• Redness
• Swelling
• Discharge
• Increasing pain
• Tenderness around the bar
• A change in general condition

Superficial and deep implant infections are treated differently.

Metal Allergy or Sensitivity

Reactions to metal implants are rare but may occur in some patients. People who have had significant reactions after contact with jewelry, watches, metal buttons, or previous implants should report this before surgery. In suspected cases, additional evaluation or different implant materials may be considered.

Recovery After Pectus Surgery

In the early period, the following are important:

• Pain control
• Breathing exercises
• Early mobilization
• Walking
• Assessment of the lungs
• Monitoring of the incision sites
• Checking the bar position

The length of the hospital stay varies according to the surgical method, pain control, age, and recovery. Keeping the patient completely immobile is generally not the goal.

Activity Restrictions After Surgery

In the early period, the following may be temporarily restricted:

• Heavy lifting
• Sudden twisting of the trunk
• Strenuous pushing or pulling
• Movements that put direct pressure on the chest
• Contact sports
• Activities with a high risk of falling
• Heavy weight training

The duration of the restrictions varies according to the surgical method used, the number of bars, the fixation technique, and the recovery.

Sports After Pectus Surgery

Return to sports is planned gradually. In the first stage, walking and light daily activities may be allowed. As recovery progresses, the following may be added to the program:

• Light cardio
• Posture exercises
• Controlled stretching
• Light resistance strengthening

For contact sports and heavy weight training, the healing of the chest wall and the status of the bars should be taken into account.

Posture and Physical Therapy After Surgery

Surgery can change the position of the sternum, but long-standing postural habits may not fully correct on their own. At the appropriate time after surgery, the following may be used:

• Strengthening of the shoulder and back muscles
• Stretching of the chest muscles
• Posture work
• Diaphragmatic breathing
• Rib cage mobility exercises
• General conditioning

The program should be adjusted to suit the surgical recovery period.

Returning to Work or School

The time it takes to return to school or work varies from person to person. The timing may be affected by:

• Surgical method
• Pain level
• Number of bars used
• Physical demands of the job
• Commuting conditions
• Recovery
• Whether complications develop

The return plan for someone with a desk job is not the same as for someone who does heavy physical work.

Which Symptoms Should Be Evaluated After Surgery?

After surgery, medical evaluation may be needed in cases of:

• Sudden or increasing chest pain
• Significant shortness of breath
• Fainting
• High fever
• Discharge from the incision site
• A sudden change in chest shape
• Suspicion that the bar has moved
• Newly developed noticeable asymmetry
• Uncontrollable pain
• A significant blow to the chest

These symptoms do not always mean there is a serious complication, but they should not be ignored in patients with an implant.

Can Pectus Excavatum Recur After Treatment?

After vacuum bell or surgical treatment, there is a possibility that the deformity may become noticeable again. The risk of recurrence may be affected by factors such as:

• Ongoing growth
• Structure of the chest wall
• Connective tissue disorders
• Severe asymmetry
• Insufficient correction
• Bar displacement
• Removal of the bar too early
• Adherence to treatment

A slight remaining depression after treatment does not always mean that the treatment has failed.

Will the Chest Be Completely Symmetric After Surgery?

The goal of surgery is to reduce the deformity and bring the chest wall into a more balanced shape. However, perfect symmetry cannot be guaranteed. Some asymmetry may persist, particularly in people with:

• Sternal rotation
• Rib asymmetry
• Scoliosis
• Differences in muscle development
• Previous surgeries
• Complex chest wall anatomy

Is Pectus Excavatum Surgery a Definitive Solution?

In suitable patients, surgical treatment can provide significant and long-lasting improvement in the shape of the chest wall. However, the following cannot be guaranteed:

• Complete symmetry
• Resolution of all physical symptoms
• A definite increase in exercise capacity
• Complete resolution of pain
• Resolution of all body image concerns
• The deformity never recurring
• No complications

The treatment decision should be made by weighing the possible benefits, limitations, and surgical risks together.

Follow-Up After Treatment

The follow-up process varies according to the treatment received. At follow-up visits, the following may be assessed:

• Appearance of the chest wall
• Symmetry
• Persistence or recurrence of the deformity
• Bar position
• Incision sites
• Pain
• Respiratory complaints
• Exercise capacity
• Posture
• Scoliosis
• Return to daily life and sports
• Psychosocial status
• Timing of bar removal

A computed tomography scan is not needed at every follow-up visit. Imaging is planned according to clinical need or suspicion of a complication.

When Is Medical Evaluation Needed?

An evaluation for pectus excavatum may be carried out in the following situations:

• Rapid deepening of the chest depression
• Noticeable or increasing asymmetry
• Shortness of breath during exercise
• Recurrent chest pain
• Palpitations
• Dizziness or fainting
• A marked drop in performance compared with peers
• Scoliosis
• Body image concerns that affect daily life
• Considering vacuum bell or surgical treatment options

Sudden, severe chest pain, fainting, significant shortness of breath, or signs of a marked heart rhythm disturbance should not be attributed solely to pectus excavatum. These symptoms may be related to other heart or lung problems and may require emergency medical evaluation.