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Pectus Excavatum

What is pectus excavatum?

Pectus excavatum (pronounced PECK-tuss ex-kuh-VAW-tum) is when the breastbone (sternum) and rib cartilage are formed in a way that causes a dent in the chest. It is also called sunken or funnel chest. Most times, this dent is in the lower half of the sternum. It may be mild, moderate or severe. The sternum may press on the heart and lungs.

Who gets pectus excavatum?

This condition affects about 1 in 1,000 children. It’s much more common in boys than girls. Boys are five times more likely to have it.

It is caused by a developmental defect in the cartilage that holds the ribs to the breastbone. This cartilage grows abnormally and pushes the breastbone in. This causes the sunken look. The opposite condition, called pectus carinatum, can also occur. In pectus carinatum, the cartilage flares out and pushes the breastbone forward.

Pectus excavatum can run in families, but most often only one person in a family is affected. Some children with pectus excavatum have an associated condition, such as Marfan syndrome. But most children don’t.

You may notice a dent in your baby’s chest, or it may not show until later in life. The dent may become more noticeable as your child grows, especially during growth spurts. Or the dent may disappear and never become a problem. We often see what appears to be pectus excavatum in infants and then the problem goes away on its own over time.

What are the symptoms?

Your child may have no symptoms at all and may not need any treatment. Children with moderate to severe defects can have shortness of breath, chest pain and trouble breathing when they exercise. These symptoms can be from the heart and lungs being pushed on and shifted inside the chest. Sometimes the shape of the chest causes discomfort. Some moderate to severe defects don’t cause symptoms but may affect how your child looks.

How do you diagnose pectus excavatum?

The doctor will examine your child and will ask for a detailed history of any symptoms your child has. If the defect is moderate to severe and your child has any symptoms, your child will need tests to assess their heart and lungs. These may include a CT scan (short for “computed tomography scan” and sometimes said “cat scan”), lung function tests (at times with exercise) to check breathing patterns, and an ultrasound of the heart (echocardiogram, or ECHO).

What is your experience with pectus excavatum at Children’s?

We treat many children with pectus excavatum at Children’s. Dozens are referred to us every year. Many of these children never need surgery. For those who do, our surgeons are experienced at performing the two types of operations used to move the sternum forward into a normal position: the Ravitch repair and Nuss procedure. We have performed several hundred Ravitch procedures over the years. The Nuss procedure is now more common, and we have done more than 100 of these at Children’s.

When you come to Children’s, you have a team of people to care for your child before, during and after surgery. Along with your child’s surgeon, you are connected with nurses, child life specialists, social workers and others. We work together to meet all of your child’s health needs and help your family through this experience.

Since 1907, Children’s has been treating children only. Our team members are trained in their fields and also in meeting the unique needs of children. For example, the doctors who give your child anesthesia are board certified in pediatric anesthesiology. This means they have extra years of training in how to take care of kids. Our child life specialists know how to help children understand their illnesses and treatments in ways that make sense for their age. Our expertise in pediatrics truly makes a difference for our patients and families.

How do you treat pectus excavatum?

For children who can benefit from surgery, we perform an operation to move the sternum and make it stable until it heals into place. There are two options for this surgery.

Ravitch repair

In the Ravitch repair, the surgeon makes a long cut, or incision, across the chest below the breast line and raises the chest muscles off the sternum and ribs. Next the surgeon removes some of the cartilage that attaches the ribs to sternum, leaving the membrane that wraps around the cartilage. Then the surgeon moves the sternum to its new position and places a short stainless steel bar behind the sternum to keep it in place. To move the sternum, the surgeon may need to take out a small wedge of bone. The surgeon reattaches the muscles and closes the incision. As the area heals, cartilage grows and reconnects the sternum to the ribs. Once the healing is done, in about six months, the bar is removed as a day surgery. That means your child goes home the same day.

Nuss procedure

In the Nuss procedure, the surgeon makes three or four small incisions. There is one on each side of the chest for placement of a steel bar and one or two others to insert a telescope in the chest to help safely position the bar. The surgeon inserts a long stainless steel bar that is bent to the desired chest shape. This is passed under the sternum and in front of the heart. The bar pushes the sternum forward and bends the cartilage that holds the sternum to the ribs. Then the surgeon closes the incisions. The idea behind the Nuss operation is that when bone and cartilage is held in a certain position for a long period of time, it will heal that way. As with the Ravitch repair, the bar stays in place during healing — in this case, usually two to three years. It can be removed as a day surgery when the time comes. The Nuss procedure is newer than the Ravitch repair but has been used for more than 10 years. Many surgeons now use the Nuss procedure over the Ravitch repair because it requires smaller incisions.

For either surgery

For either the Ravitch or Nuss surgery, your child will have general anesthesia. This means we will give your child medicine to make them sleep without pain during the surgery. The Ravitch repair takes about four to six hours depending on the age of the child, and the Nuss procedure takes about two to three hours. Your child will be in the recovery room for another hour. The main issue for either operation after surgery is pain control. We will give your child pain medicine to make them comfortable, and most children will be seen by our Pain Medicine team. You can expect your child to be in the hospital for about four to seven days. We will show your child how to do some deep breathing exercises that are important during recovery.

After surgery

After your child goes home, you’ll need to keep the incision(s) clean and dry until they heal. The surgery team will teach you how to care for the incision(s) and how to give your child pain medicine at home. Another important part of home care is limiting your child’s activity while they recover. For example, your child should sit up straight without slouching for the first month. They should not lift anything heavy for a few months, and they should not take part in some kinds of contact sports for about six months after having the Ravitch repair. Restrictions are reduced to three to four months for the Nuss procedure. The surgery team will explain these and other limits before your child goes home.

About two to three weeks after surgery, your child will need to see the surgeon for a follow-up visit. The surgeon will make sure the incision is healing and your child is recovering well.

Resources

Read more about what to expect when your child visits a clinic at Children's, has surgery here or needs to stay in the hospital. You can get practical details about topics like what to do and bring the day of surgery and who will be on your child's care team. You can also take a virtual tour of our surgery rooms and other parts of the hospital.

To learn more about this condition, you may want to visit our resource list.