Pectus excavatum – it looks like the chest is sinking inward

Pectus excavatum – it looks like the chest is sinking inward

By Alexander Farivar, MD
Thoracic Surgeon

Have you ever noticed someone whose chest sinks inward in the front, kind of like a funnel? The first time I ever noticed this bony malformation was when I was in high school, and a friend of mine on the soccer team had one. It was called “pectus excavatum,” he told me.

In my thoracic surgery training, I was often called upon to evaluate patients with this chest wall abnormality. As a result, I began to delve deeper into some of the issues that may affect people with this type of defect.

Pectus excavatum is the most common chest wall deformity and results from abnormal development of the sternum and its attachments. Most patients are self conscious about the defect and usually focus on its appearance but because this is usually present for much of a person’s life, symptoms associated with it may not be totally obvious. Individuals affected generally get used to how they feel and try to overcome any limitations to the best of their abilities without even knowing that’s what they are doing. Most patients describe some chest discomfort, shortness of breath when exerting themselves, lack of endurance, or feeling embarrassed in social situations when their shirt is off. It is not uncommon to hear patients say that they have trouble keeping up with their friends during activities, or that they avoid any activities that would require them to take off their shirt in public-such as going to a pool.

Most physicians aren’t even aware that there is an effective treatment for pectus excavatum. In fact, the teaching has been that unless the patient is symptomatic, the surgery is purely cosmetic. When the traditional Ravitch technique - which uses a large incision and then breaks the sternum and the affected ribs, followed by fixing them in a corrected position - was used, this seemed reasonable.

However, over the last 25 years there has been a development of a less invasive means of surgically correcting pectus excavatum called the Nuss procedure (Dr. Nuss in Virginia pioneered the procedure),. This procedure involves placing 1-2 bars across the chest underneath the sternum, to lift and reform the sternum to a more typical appearance. Patients see improvements in the way their sternum looks by the time they awake from anesthesia in the operating room! The bars stay in for 3 years on average before being removed.

Not all patients with pectus excavatum are good candidates for surgery. In order to best determine if surgery is a good option for a person with pectus excavatum, thoracic surgeons at Swedish like to evaluate all who are interested in potentially correcting their pectus in the clinic to determine how the pectus is affecting their life’s activities and then to perform a physical exam. We also will order a CT of the chest to calculate a Haller index which helps to assess how significant is the pectus with respect to its location from front to back, or chest to spine. This is a calculation that determines how much-or little-room there is between the spine and your pectus (or chest) for other organs to occupy-such as your heart.

Our experience thus far has provided those who have undergone the procedure a fresh outlook on how they see themselves. With time we aim for improvements in lung and heart function as these organs regain the room they need to function optimally.

Comments
Alexander Farivar, MD
Jesse B,
To set up an appointment, please contact my office at 206-215-6800.
10/28/2013 1:50:28 PM
Jesse B
Hi Dr. Farivar
I am very interested in getting this operation. How can I setup an appointment with you for an evaluation?
10/26/2013 5:30:39 PM
Robert Weinsheimer, MD
Dear LJ,
Thank you for your question. It is sometimes the case that a child with pectus carinatum can develop a sunken appearance in the long-term after surgery and adolescent growth. We would be happy to see you and then can discuss any potential options at that time. It is sometimes the case that one can benefit from a Nuss bar procedure if there are issues related to compression of the lungs and/or heart due to the now sunken state of the sternum.
Sincerely,
Rob Weinsheimer, MD
3/12/2013 11:35:38 AM
Alexander Farivar, MD
Hello J Brown,
Thank you for your comment. Asymmetry does not preclude us from considering for the Nuss procedure. In fact most patients are asymmetric. We have some experience with the Ravitch and that could be an option too.
3/7/2013 10:44:31 AM
J. Brown
Dr. Farivar,

My PE is very asymmetrical. I have heard the Nuss procedure isn't a good choice for something like that. Is that true? Also, could the Ravitch procedure be done instead by the team at Swedish? Thanks.
3/6/2013 9:16:56 AM
LJ
I had surgery to fix my pectus carinatum when I was 12 years old. Now 10 years later, after I'm fully grown, my sternum sinks in a little bit. Is that something that is usual or something that you can fix after already having surgery?
9/24/2012 9:06:51 PM
Alexander Farivar, MD
Chris,

Thanks for your question and comment. Performing a Nuss after a Ravitch is an involved operation and shouldn't be taken lightly, nor is it done frequently. We certainly would be happy to discuss the issues surrounding such an operation in person.
8/19/2012 2:50:26 PM
Chris Wilson
I had the Ravitch procedure in 1999 at the age of 17. At the time, my Haller Index was one of the higher the surgeon had ever seen. Today, I am 31 and still have quite an indentation in my chest (assume 1"-1.5").

I am not nearly as out of breath as I was prior to the surgery (I did play basketball in college) but can still tell I have trouble with prolonged activity and also feel hard heart palpitations at times.

I was curious your thoughts on additional surgeries, potentially Nuss, for adults who have already had a prior surgery.
I appreciate it.
CW
8/15/2012 7:05:28 AM
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