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Surgery

Surgery remains one important option to consider when dealing with pectus deformities but should always be considered carefully having discussed the pectus problem with a surgeon experienced in performing all types of pectus surgery and ideally is familiar with other forms of treatment.

Surgery may be offered for both pectus excavatum and carinatum, though increasingly in some countries bracing is becoming the first line treatment for pectus carinatum in younger patients. Prosthetic implants are a type of minor surgery that may be offered in patients with pectus excavatum.

The choice of surgery should be based on type and severity of pectus deformity, and the operation that is likely to offer the best functional and cosmetic result. If surgery is considered you may require some investigations, such as chest x-ray, ECG, lung function tests and possible chest CT or MRI scan.

The common operation performed for pectus excavatum is Minimally Invasive Repair of Pectus Excavatum (MIRPE) or the Nuss procedure.

The Nuss operation

The procedure is carried as a minimally invasive or keyhole operation. Two small incisions are made on either side of the chest wall with a camera placed into the chest through one of the incisions. This is followed by the careful insertion of one or two (rarely three) curved metal bars under the breastbone, the bar is then fixed in place. Sometimes to aid safe positioning of the bar, the sternum is lifted during insertion through a small 3rd incision made a the front of the chest. It immediately corrects the pectus excavatum and is not visible from the outside. A drain is very occasional left in the chest cavity.

The immediate recovery time in the hospital is 3-5 days, with one night in the high dependency unit. Attention is paid to post operative pain relief and advice on how to move about to maintain the position of the bar. After discharge, the patient is expected to slowly resume normal but restricted activity, such as heavy lifting or strenuous exercise. Follow up is typically at two weeks and then again at three to six months and once more prior to removing the bar.

Increasingly the importance of physical therapy following surgery is recognised to both help the recovery and to improve on some of the typical issues around poor posture and muscle tone common in pectus excavatum patients. A graded program of exercises showed be started over the first weeks and months following surgery.

The pectus support bar is removed after between 2-3 years. It involves a short general anaesthetic and can be performed as a day case procedure with resumption to normal activities within a few days.

CT chest scan pectus excavatum
CT chest showing severity of pectus excavatum

Intraoperative keyhole image inside the right chest cavity
Intraoperative keyhole image inside the right chest cavity with the bar being in position behind the sternum (top of the picture) and above the heart and the pericardium (sac surrounding the heart) at the bottom of the picture

Nuss surgery
4 months following Nuss surgery showing the small incision on the side of the chest (with a similar scar on the other side) for a severe pectus excavatum deformity

Modified Ravitch procedure

This open repair can be offered for both pectus excavatum and carinatum and is performed in a similar manner in both types of pectus deformities.

It is performed through a larger incision. It allows the surgeon to detach and partly excise the deformed cartilage connections to the lower sternum. The sternum itself is usually also partly cut to allow it to moved forward or backwards if it for correcting pectus carinatum to a normal position and any rotation or tilt corrected. Once positioned the sternum is then usually held either with a temporary metal bar or supporting 'mesh' to hold the sternum in its new position whilst the chest heals. The mesh does not need to be removed. For pectus carinatum the need to support the sternum is less and so rarely requires any support bars or meshes. A drain is occasional left in the chest cavity.

The immediate recovery time in the hospital is similar to a Nuss procedure, though often a little longer. As with the Nuss procedure, attention is paid to post operative pain relief and advice on how to move about to maintain the position of the bar. After discharge, the patient is expected to slowly resume normal but restricted activity, such as heavy lifting or strenuous exercise. Follow up is typically at two weeks and then again at three to six months.

Increasingly the importance of physical therapy following surgery is recognised to both help the recovery and to improve on some of the typical issues around poor posture and muscle tone common in both pectus excavatum and carinatum patients. A graded program of exercises showed be started over the first weeks and months following surgery.

The patient will be seen once more prior to removing the support bar if used though in most cases a bar can be avoided.

Results

For our outcomes of surgical correction for your pectus deformity see our results and before and after photos. Read some of our success stories: