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Bracing

Bracing for pectus carinatum is well established in many countries to the point that the American Pediatric Surgical Association recommends it as first line therapy for the compliant pectus carinatum deformity. However, in other countries including the UK expertise in bracing for pectus carinatum remains patchy, with little information or knowledge around its use.

For other types of pectus deformity particularly excavatum the role of bracing appears less obvious and the evidence remains patchy and inconsistent. Bracing or strapping may have some role in helping with rib flaring specifically but its role remains unproven.

We run a very popular bracing clinic throughout the year. The clinic is run with Pectus Services an American pectus bracing company who have over 20 years' experience of treating pectus deformities with a corrective custom made light-weight low-profile brace. Currently it is the only brace available worldwide that is both FDA registered and CE certified Europe wide.

CE certified Europe wide  FDA

After an initial consultation we will assess the most appropriate treatment method for your pectus deformity. Whether it be invasive or non-invasive, we ensure your treatment will be of the highest quality, tailored to your individual needs. For the majority of cases, following measurements including 3D scanning and our unique outpatient procedure to correct the deformity, a custom made brace is fitted and bracing program commenced, that will be all that's needed to restore the ribcage back to a more normal shape.

A bracing system is considered the first line of treatment for pectus carinatum or pigeon chest and is the preferred method to reshape the chest wall.

As doctors we are ethically obliged only to offer you a brace if it is likely to be successful, age and 'musculoskeletal maturity' are two important factors. The bracing clinic offers a unique aspect to your treatment, that of 'mobilization or manipulation', a form of physical therapy that concentrates on the source of the pectus deformity, the flexible costal cartilages to gently correct the deformity. This technique significant improves on the success rates as well as reducing the length needed to wear the brace when compared to other brace reports.

Following the manipulation. a sleek, lightweight brace is fitted applying pressure to the ribcage holding the breastbone in a normal position and over time allowing the ribcage to 'remodel' for a permanent result. The brace is customized to fit each person for maximum comfort and effectiveness. The brace allows unrestricted arm motion and can even be worn during physical activities (except for some contact sports). For the brace to be effective it must be worn virtually everyday for 3 months along with daily exercises which will be instructed by your consultant. At around 6 weeks the brace and results are checked and re-adjusted according to the patients needs. At 3 months following our individually prescribed program the brace will be worn less and less frequently for typically a further 3 to 6 months depending on severity. A second rib brace is not needed with this bracing program though a soft flexible rib strap may be.

The pectus bracing program lasts around 8 to 12 months, and we recommend that we see you 2 to 3 times after the first consultation to assess progress, adjust the brace fitting and give advice around reducing the amount of time the brace is worn. Patients, depending on their needs as part of our follow-up pectus program will also go through a customized exercise and physical therapy assessment, evaluation and training program.

A video describing the bracing program developed at St Anthony's hospital

Bracing before

Bracing after
Measurements taken before (top) and 6 weeks after starting a brace program (bottom) for a boy with severe asymmetric pectus carinatum

Low-profile light weight brace used by the Pectus Clinic
The low-profile light weight brace used by the Pectus Clinic is custom built on-site following extensive measurements and then re-checked following bracing to guarantee an ideal fit. At further follow-ups, the brace will be altered as the pectus carinatum remodels to give the best long-term results

Bracing

Bracing

Bracing

Bracing

Photos (to the left) showing the initial pectus deformity taken as part of the assessment prior to bracing. The red marks protrusion of the chest wall and the green where the chest is dipping in. To the right, photos 6 months after starting the brace program when the brace is being worn at nighttime only.

Frequently Asked Questions about external bracing for treatment of Pigeon Chest

Bracing is a non-surgical technique that relies on sustained pushing on the front of the chest over the protrusion of the pigeon chest to permanently correct or significant improve the appearance of the chest. As such it is like ‘teeth braces’ relying on some ‘flexibility’ (that is why age is important) as well as time for chest wall remodelling and correction to take place.

External bracing often described as dynamic compression bracing is a well-established treatment for pigeon chest with the American Paediatric Surgical Association (APSA) in 2012 recommending it as first line therapy for the compliant pectus Carinatum deformity based on its scientific assessment of the medical literature.

Yes. The Pectus Clinic is run by doctors who practice evidence based practice and are ethically obliged to offer treatments that are likely to be successful. In that regard, data is collected and outcomes of patients who have been treated by the Pectus Clinic with bracing have been published in peer reviewed journals. We are happy to share our data and results with you.

Most bracing techniques rely on progressive tightening of an external brace over time with or without the use of pressure measurements to assess suitability and progress. Known as dynamic compression bracing, there are many scientific publications supporting its use. However, the length the brace needs to be worn can vary considerably from reports of a few months to a few years, as well as some concerns about how successful the brace is worn during this time, what doctors call ‘compliance’. Though rarely reported, the type, fitting and comfort of the brace will certainty affect the success of bracing to treat pigeon chest.

As well as offering dynamic compression bracing, the Pectus Clinic where suitable offers an additional treatment (what doctors call an adjunct) involving ‘manipulation’ of the pigeon chest prior to custom fitting of the brace to the chest to a more corrected positon before the brace is worn. It is based on several well described physiotherapy techniques collectively called ‘soft tissue release’. it involves the soft cartilages joints between the breastbone and ribs (the origin of the pectus deformity) being gently pushed back into a more normal position prior to the brace fitting. The brace then holding the chest in its corrected or nearly corrected position. Our data suggests It appears to improve on how long the brace needs to be worn and particularly the compliance of the brace wearing.

The technique is aimed at treating most patients, male or female with this type of deformity. However, there are two important considerations: Age and what is called ‘musculoskeletal maturity’ (essentially both reflect chest wall flexibility).

The brace corrects the chest deformity by applying sustained pressure to the chest wall and specifically the soft cartilages joints between the breastbone and ribs (the origin of the pectus deformity) holding them in position and over time allowing re-modelling of the chest for a permanent correction.

Age is important and is a useful guide to how much flexibility the chest has. As we get older these cartilaginous joints become increasingly stiff and bone-like making brace correction more difficult. People ‘age’ at different rates and so even though they may be in their 20’s they still may have some flexibility in these joints and of course vice versa. This is what musculoskeletal maturity means.

Yes, age matters. Bracing is most effective in young patients with flexible chest walls and offers a permanent correction. The average age of patients having bracing at the Pectus Clinic is 14 years old. Currently our age range of patients who have successfully worn the brace and achieved results that they rated as very good or Excellent was from 8 years of age to 30 years of age. The type of bracing schedule we recommend can be adjusted to age, and though taking longer a brace may still be appropriate in older age groups.

No, but the success of bracing can be significantly improved by this uniquely-applied physiotherapy technique of first reducing, mobilising and correcting the deformity then using the custom-made brace to ‘hold’ the chest in its new corrected position while its ‘remodels’ over time and so the correction is permanent. There is good evidence it reduces the length of permanent brace wear and most importantly significantly improves ‘the compliance’ (wearing the brace) so that you complete the schedule. If you do not wish to have the manipulation or for some reason are not suitable for this a custom pectus brace can still be created for you and expertly fitted. However, the correction may take longer, so the brace would need to be needed worn longer with more adjustments required.

One reason is that you have been miss-diagnosed, and that you don’t have a pectus Carinatum. Expert assessment by a doctor prior to starting a bracing program ensures the correct diagnosis and the correct treatment offered.

Maybe. Rib flare where the bottom of the rib cage sticks out is common in both pigeon chest and with other types of pectus deformity. It is often quite prominent, particularly on the left and can sometimes actually become more obvious when treating pigeon chest with a brace especially in young patients. In this situation, time and exercises are often all that’s needed to improve its appearance. However, sometimes we recommend using a custom fitted ‘rib strap’ designed by the Pectus Clinic to help support the rib cage during the bracing. Very occasionally, if the rib flare is severe we may recommend a specially designed rib flare brace.

Ideally yes but it is not essential. Sometimes apparent ‘pigeon-chest’ may be caused by another issue, or be associated with other problems. In that regard seeing your GP for an initial assessment and appropriate tests before seeing the Pectus Clinic may be helpful. Remember the Pectus Clinic is run by doctors and it is regarded as ‘good practice’ that the Pectus Clinic receives a referral from your GP and it will assist in booking the appointment at Spire St. Anthony’s Hospital. Following the consultation, a clinic letter (unless otherwise requested not to) will be sent to your GP and/or referring doctor.

No, generally not. Occasionally though if there is doubt about the pectus diagnosis or the best treatment to recommend, a radiological investigation to assess further will be requested but this is not usual.

The Pectus Clinic will request photographs of your chest wall deformity and some basic medical information about your issue. The Pectus Clinic’s Medical director, Mr Ian Hunt, is a very experienced Thoracic Surgeon who may suggest seeing you first prior to the Pectus Clinic. This is necessary if he feels there may be some more complex problems, such as clarification of diagnosis of pigeon-chest, need for further investigation, concerns around suitability for the brace or some other issue. Usually, the appointment for the Pectus Clinic can be booked without the need for a formal medical consultation prior to the Pectus Clinic.

Nothing specific but would suggest wearing loose fitting clothes and coming with a friend or relative. You will be fine to travel by public transport or drive home but you may feel sore in the chest after the outpatient’s appointment.

If appropriate following assessment this will be offered. The manipulation or mobilisation performed to flatten or reduce the deformity is an important and unique part of the technique we use to treat the pigeon chest. Mr Hunt working with the specialised pectus service representative (www.pectusservices.com) have developed this technique and are the only pectus treatment group in the world using this method. A type of soft tissue release or manipulation used commonly by physiotherapists but uniquely applied to the chest wall cartilages, it is performed as an outpatient procedure. The actual mobilisation and reduction of the cartilage between the breastbone and ribs takes around 15-20 minutes and is done as gently as possible. It is essentially a very deep massage of the chest with focused pushing on the flexible cartilages back into the correct or near correct position. It is uncomfortable and sometimes painful but we use a local anaesthetic cream and if needed 'gas and air' (Entonox) to help relieve the discomfort during the procedure. Gas and air is used for many sorts of minor procedures often in the A&E department.

Usually following the bracing for a few days, we would recommend taking simple painkillers like ibuprofen regularly, the pain quickly wears off and no painkiller is usually needed after the first 5 days.

The Pectus Clinic works with pectus services, an American company that specialises in creating custom made braces for pigeon chest. They have been manufacturing braces for pigeon chest and nothing else for nearly 20 years. Nobody in the UK and quite possibly the world has more experience. More information about pectus services and the work they do can be found on their website - www.pectusservices.com.

The brace is made of aircraft grade aluminium, polymer plastic front and back plates covered with medical foam and soft plastic sides. It comes with a set of front, back and side washable covers.

Yes. After the assessment and chest measurements, the brace is custom made on site in our workshop. This takes around 30-45 minutes and includes a custom fitting and adjustments for a perfect fit.

After the manipulation (if used), custom fitting and bracing we arrange to see you the next day (and occasionally the day after that) for a further assessment. This is to check the brace and its fit to make any adjustments and to check the skin is not irritated. At that point, we will go through the personalised bracing program. The time to be seen will be confirmed after the first appointment and for those travelling to the Pectus Clinic from a distance you may need to decide to stay overnight in London.

Yes, but the Pectus Clinic can provide a list of local hotels and give details around travel times.

Generally, no but certainty the following day or two after bracing you may feel a little sore and may wish to take a day off.

Advice will be given and is determined by type and severity of the deformity, but in general the brace is worn continuously for the first five days. On the fifth day, we recommend a 15-minute break for a shower. After that the brace is worn for 12 weeks in most cases with a 15- minute break each day for washing. In some cases, after 6 weeks a 2 to 4-hour break from wearing the brace per week twice per week is possible. A written wearing schedule will be provided.

The Pectus Clinic provides detailed written information about wearing the brace, its maintenance and lots of useful tips as well as a detailed written customised wearing schedule which will be explained to you.

Where the brace touches the chest and the back, the skin can be affected and care particularly in the first few weeks should be taken to avoid a skin problem such as a pressure sore. Advice will be given about what to watch for and how to look after your skin whilst wearing the brace.

The brace has a low profile but as each brace is custom fit its shape and size is dependent on the type of deformity you have. In general, it will be noticeable if only a T-shirt is worn but not if a baggy T-shirt is worn or if you are wearing more layers such as a baggy jumper or coat. But remember, your pectus deformity may have been as equally or more noticeable.

A written wearing schedule is provided. The brace is worn permanently (off for washing only) for around 12 weeks in most patients followed by reducing the brace wear. However, after 6 weeks in some patients there may be an opportunity to remove the brace for short periods each week. By 6 months most will only be wearing the brace at night time when sleeping. The average length of bracing is around 9 months to a year. However, there is some variability around the time needed to correct the pectus and sometimes it may be required to be worn longer defending on the severity and response to treatment. You will be guided through this.

The pectus bracing program lasts around 8 to 12 months, and we recommend that you are seen 2 or 3 times after the first consultation to assess progress, adjust the brace fitting and give advice around reducing the amount of time the brace is worn.

Ideally you should be seen in the first 12 weeks after bracing for a review. After this review, often (but not always) it is recommended that brace wearing is reduced by several hours each day (the weaning period). A further Pectus Clinic review will be offered typically at 6 months and finally at around 12 months following the start of the bracing program. Further appointments after that are usually not required.

Pectus deformity is often associated with other musculoskeletal problems, sometimes called 'pectus posture'. All patients as part of our follow-up pectus program will be shown specific exercises that will help other posture-related problems such as stooped shoulders.

Maybe. The Pectus Clinic works with the department of Physiotherapy at Spire St. Anthony’s and in conjunction with them have developed some specific exercise programs around musculoskeletal issues often seen in patients with pigeon chest. If required, during your assessment a recommendation for additional physiotherapy will be made. This can then be booked to follow the bracing follow-up.

Yes. The brace can be worn during sports and exercise though there are some restrictions around contact sports such as rugby or martial arts as there is a risk during heavy contact (to the opposition). In general, we recommend not wearing the brace during such contact sports, but the decision whether you can play or not will be for your coach or trainer. But remember, the brace is only worn permanently in most for the first 12 weeks with opportunities after 6 weeks to remove the brace for short periods each week, usually after this time you can tailor periods when not wearing the brace around any sports activities.

Swimming is probably best avoided, as continual immersion in water will affect the 'wear and tear' of the brace. Remember, once the 12 weeks is completed (or even after 6 weeks for short periods) most will be able to start wearing the brace less often and with period's off when they are able to play any sport they like including swimming.

For the keen swimmer, we offer an additional brace designed to be used specifically in water. It is a ‘stripped’ down version of the standard brace and is such is very light, waterproof and can be immersed in water for long periods. However, we do not recommend this brace as a ‘replacement’ for the standard brace. Ask for more information about it when you enquire about the pectus bracing program.

The overall cost of the pectus-bracing program is designed to be affordable and certainty when compared to the cost of dental bracing is comparable. For costs and payment methods please contact the Pectus Clinic administrator.

Please contact the Pectus Clinic Administrator for a prompt reply and details including information required. The Pectus Clinic runs a bracing clinic for one week 5 times a year with clinics held roughly every 2 to 3 months throughout the year.

The bracing clinic is a highly-specialised clinic that runs in conjunction with an American bracing expert from pectus services who travels from the USA. It is held 5 times a year and places are very limited. For details of the next clinic, please contact the Pectus Clinic Administrator.

The Pectus Clinic was set up specifically to offer the best impartial advice for your pectus deformity. Because its run by doctors and other health care professionals who truly understand chest wall problems in general and pectus deformities specifically we can provide all the information you need and help you decide what options you have.

Alternative treatments offered by the Pectus Clinic include a ‘hybrid’ procedure involving minimal access keyhole surgery with or without subsequent bracing, as well as more traditional surgical approaches. These treatments will be discussed with you following assessment.