Pectus excavatum, often called funnel chest, is a congenital chest wall deformity where the breastbone and some ribs grow inward, creating a central dip in the chest. From the front, the sternum appears sunken, and the chest appearance can vary from subtle to pronounced.
The condition is present at birth for many, but the indentation often becomes clearer during puberty as the body grows. Visibility and impact vary widely; some people have a mild appearance with no symptoms, while others face breathing or activity limits.
This guide shows how to recognize signs, how clinicians assess severity with imaging and measurements, and how families weigh observation versus treatment. It previews CT scans, the Haller index, heart and lung testing, and surgical options like the Nuss and Ravitch procedures.
Care in the United States is individualized and usually guided by pediatric or thoracic specialists. Many mild cases need no intervention; moderate-to-severe chest wall deformity may affect quality of life and prompt treatment discussions.
Key Takeaways
- Pectus excavatum is a congenital inward growth of the sternum and ribs (funnel chest).
- Appearance and symptoms range from mild to severe and often change during puberty.
- Assessment includes imaging, Haller index, and heart/lung tests.
- Treatment choices (watchful waiting vs. surgery) are individualized by specialists in the U.S.
- Many mild cases do not require treatment; more serious cases can affect breathing and activity.
Understanding Pectus Excavatum and Chest Wall Development
What it looks like: A typical “funnel chest” shows a central dip in the front of the chest. The midline depression can sit low or high on the sternum and may be symmetric or slightly lopsided. Small differences in rib placement can change the overall appearance.
Why the breastbone grows inward: This condition stems from abnormal growth of the chest wall framework. As the ribs and cartilage develop, the breastbone can shift inward, altering how the sternum and ribs relate to the heart and lungs.
When it becomes noticeable: Many are born with the shape but do not show clear signs until rapid growth periods. Puberty often reveals a deeper indentation as the chest expands and tissues change.
Severity and impact: Clinicians describe severity as mild, moderate, or severe based on depth and shape. Mild cases may be mainly cosmetic, while deeper deformity can affect breathing and exercise tolerance. Severity reflects both appearance and how the sternum sits relative to vital organs.
Next steps: Later sections explain how CT-based measurements and the Haller index help standardize discussions of severity for families and clinicians.
What Causes Pectoral Excavatum and Who Is at Risk
The most accepted cause centers on abnormal cartilage growth where the ribs meet the sternum. As a child grows, uneven cartilage can pull the breastbone inward, changing the shape and mechanics of the chest wall.
Not one single cause explains every case. Many patients show no clear trigger. Still, patterns in families suggest a genetic component for some people.
Growth and anatomy
When the cartilage grows irregularly, the ribs and sternum can shift inwards. This mechanical change explains how the appearance and breathing mechanics may alter over time.
Family history and syndromes
Children with a close relative who has the same chest shape are at higher risk. Clinicians also screen for connective tissue disorders, notably Marfan syndrome, because these conditions often affect ligaments, cartilage, and bone.
Who to watch closely
- Children with a family history of the condition.
- Children already diagnosed with a connective tissue syndrome.
- Young people whose chest shape changes quickly during growth spurts.
Identifying a cause may not change immediate treatment, but it can guide monitoring of heart, lung, and skeletal development. The same structural changes that alter appearance can also affect breathing and exercise tolerance in more significant cases.
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Signs and Symptoms to Watch For
Chest shape and how it changes over time often prompt the first visit. Changes in the front profile can be subtle at first and grow more evident during adolescent growth.
Visible changes and emotional impact
Visible signs include a central indentation and altered appearance chest contour. Families commonly spot this when clothing fits differently or when the chest looks uneven in photos.
Psychosocial effects matter: for teens, body image concerns can reduce confidence and social comfort. Clinicians discuss both appearance and wellbeing when planning care.
Breathing, energy, and exercise
Moderate-to-severe cases can cause shortness of breath during exertion. Patients may report fatigue and lower exercise tolerance with activities like sports or climbing stairs.
Pain, posture, and spine checks
Some people describe intermittent chest pain. Doctors treat pain reports seriously, especially when they occur with reduced function or breathing issues.
Clinicians also screen for scoliosis and posture changes since spine curvature can coexist with chest wall differences.
When the heart may be affected
In deeper deformities, the heart can have less room to move. This may reduce heart and lung function and lead to tests that check for compression.
- Visible central dip in the front chest
- Self-esteem concerns in adolescence
- Shortness of breath, fatigue, and limited exercise tolerance
- Chest pain and possible spine issues like scoliosis
Symptoms and shape together guide decisions about imaging and testing, including when to refer for specialist evaluation and further diagnostics like CT or heart/lung testing. For related surgical recovery info, see extended tummy tuck details.
How Pectoral Excavatum Is Diagnosed
Diagnosis begins with careful history and a hands-on exam to document chest shape, symmetry, posture, and how symptoms affect daily life and activity. Clinicians note any shortness of breath, chest pain, or exercise limits. They also review family history and prior growth changes.
Physical exam and health history
During the exam, the provider measures the chest visually and by palpation. They check posture and look for spine issues that often accompany chest wall differences.
Chest CT scan and the Haller index
Imaging turns subjective appearance into numbers. A low-dose chest CT maps anatomy and yields the Haller index: a simple ratio from CT slices. Normal is about 2.5; values above 3.2 are often considered severe and may qualify a patient for the Nuss procedure.
CT also shows if the heart is shifted or compressed, which can change surgical timing and planning.
Heart and lung testing
An echocardiogram checks heart structure and function when compression is suspected. Pulmonary function tests measure breathing mechanics and lung function to see how the chest shape affects respiration.
These tests are often required by insurers and help the surgeon weigh symptoms against imaging results.
Pediatric low-dose imaging
For a child or teen, providers use pediatric low-dose CT protocols to limit radiation while keeping diagnostic quality. This protects growing patients without losing key measurements.
- Start: history and physical exam
- Quantify: CT with Haller index
- Assess: echocardiogram and pulmonary function testing
- Protect: pediatric low-dose imaging when applicable
| Assessment | Purpose | Key Result | Notes |
|---|---|---|---|
| Physical exam | Document shape, symmetry, posture | Clinical description | First-line, guides further testing |
| Chest CT | Map anatomy and measure Haller index | Haller ~2.5 normal; >3.2 severe | Shows heart displacement/compression |
| Echocardiogram | Evaluate heart structure/function | Normal or evidence of compression | Noninvasive; used when symptoms or CT suggest impact |
| Pulmonary function tests | Measure lung function and breathing mechanics | Values indicate breathing limits | Often used for clinical decisions and insurance |
When findings are reviewed, a pediatric or thoracic surgeon interprets tests in the context of symptoms—not just imaging alone. For related procedural context, see abdominal etching with high-def liposuction.
How to Decide Whether Treatment Is Needed
Not every visible chest difference needs surgery; many families begin with watchful follow-up. A practical decision framework starts with severity and how the child feels day to day.
When observation is enough
Observation means regular visits, short symptom check-ins, and repeat exams during growth spurts. If the deformity is mild to moderate and lung and heart testing are normal, ongoing monitoring is common.
Common reasons families pursue treatment
Families consider treatment when symptoms such as shortness of breath, exercise limits, chest pain, or fatigue interfere with activities. Significant appearance-related distress or loss of confidence is also a valid reason to act.
“Emotional and physical effects together guide whether to move from observation to active care.”
Why timing often matters
Surgical repair is often easiest between ages 10 and 14 when the chest wall is more flexible. The exact timing is individualized; a surgeon weighs growth stage, anatomy, and readiness for recovery.
Next step: When treatment is needed, the main corrective options are surgical procedures chosen to match anatomy and goals.
Surgical Treatment Options for Pectus Excavatum
When symptoms or anatomy suggest intervention, surgeons discuss two main operations to correct the deformity. Both aim to push the sternum outward to reduce pressure on the heart and lungs and improve chest appearance.
The Nuss approach
What it is: A minimally invasive repair using a custom-curved steel bar placed under the sternum via two small side incisions.
The surgeon uses camera guidance to pass the bar behind the sternum and flip it to lift the chest. The bar is secured to the chest wall and typically stays in place for several years.
Removal is usually an outpatient, same-day procedure when the surgeon decides the pectus correction is stable.
The Ravitch approach
What it is: An open repair with a front-chest incision to remove overgrown cartilage and reposition the sternum.
Surgeons stabilize the chest with a small plate and screws or a short metal bar. If a bar is used, it is commonly removed at about 6–12 months as an outpatient visit; plates often remain.
How surgeons choose
Choice depends on anatomy, severity, and whether the chest shows torsion (twisting). When torsion or complex cartilage issues exist, many surgeons prefer the Ravitch procedure.
Both the nuss procedure and Ravitch reduce cardiac and pulmonary compression and improve appearance. The final decision is individualized and made with a thoracic surgeon and family.
| Procedure | Incision type | Support used | Typical bar removal |
|---|---|---|---|
| Nuss procedure | Two small lateral incisions | Curved steel bar under sternum | Several years; outpatient removal |
| Ravitch procedure | Midline front-chest incision | Cartilage removed; plate/screws or small bar | Bar removed ~6–12 months; plates usually stay |
| Key considerations | Anatomy and torsion | Surgeon experience and patient goals | Recovery timeline and follow-up |
Risks and Possible Complications of Chest Surgery
Choosing operative care means balancing likely benefits with a small chance of significant side effects. Both Nuss and modified Ravitch procedures are generally safe and effective. Still, patients should know the uncommon but real complications that can follow chest surgery.
Pneumothorax, bleeding, pleural effusion, and infection
Early surgical risks include pneumothorax (a collapsed lung), bleeding, pleural effusion (fluid around the lung), and wound or deep infection. These are usually treatable with chest tubes, antibiotics, or brief interventions.
Bar movement, recurrence, and chronic pain
The implanted bar can rarely shift. Signs that need urgent review include sudden increased chest pain, new shortness of breath, or visible asymmetry.
After bar removal, a small percent of patients see recurrence of the chest shape. A minority may develop persistent or chronic pain. Modern pain plans aim to reduce opioid use and lower long-term pain risk.
Risk depends on anatomy, age, and health. Individualized planning and follow-up care reduce complications and improve outcomes.
| Complication | Typical management | When to seek care |
|---|---|---|
| Pneumothorax | Observation or chest tube | Sudden breathlessness |
| Infection | Antibiotics, possible drainage | Fever, increasing redness |
| Bar movement / recurrence | Imaging, possible revision | New pain or chest change |
Next: Advances in pain control and recovery protocols have improved the typical post-op experience and guide safe return to daily life.
Recovery, Pain Management, and Getting Back to Daily Life
Recovery after chest surgery focuses on pain control, breathing, and a gradual return to normal activities. Hospital stay length varies by procedure and how well pain is controlled; many patients stay a few days, though some go home sooner.
Early movement and physical therapy
Physical therapy begins early to help safe movement, restore strength, expand lung function, support bowel recovery, and lower complication risk. Therapists teach breathing exercises and stepwise activity plans for a child’s daily routine.
Cryoablation and opioid-sparing pain plans
Cryoablation freezes the intercostal nerves that carry rib pain. When paired with local anesthetic and oral meds, it shortens stays and cuts opioid needs.
Many patients who receive cryoablation after a Nuss-type surgery can go home the next day and stop opioids within 1–2 days.
Numb chest wall and what to expect
Frozen nerve effects may cause a numb chest wall for 6–12 months. This numbness is common, usually fades over time, and does not signal nerve damage in routine cases.
Follow-up and activity limits
Early follow-up is typically 2–4 weeks after discharge to check incisions, review a pain management plan, assess breathing, and set activity restrictions.
- Expect variable hospital stays based on pain control and procedure.
- Start physical therapy early for lung and function recovery.
- Know cryoablation often reduces opioid use but causes temporary numbness.
- Plan clinic follow-up at 2–4 weeks to guide return to school and sports with a bar in place.
Ongoing Care Considerations With a Chest Bar in Place
After implanting a corrective bar, ongoing attention to simple safety steps makes daily life easier for the child and family.
Allergy testing and material choices
Nickel or chromium testing checks for sensitivity to components in stainless steel bars. If testing is positive, surgeons select a custom titanium bar to avoid allergic reactions and improve comfort.
Travel, screening, and documentation
Most bars do not trigger airport metal detectors, but titanium can sometimes register. Carry clinic documentation to speed screening when traveling.
CPR, AEDs, and medical alert info
CPR is still effective with a chest bar, though compressions may need slightly more force. For defibrillation or cardioversion, place one pad on the front and one on the back (anteroposterior).
“Recommended medical alert: ‘steel bar in chest, CPR more force, cardioversion ant/post placement.'”
Dental care and antibiotics
Antibiotics are not required before routine dental work solely because a bar is present. Standard dental guidance applies unless another heart or implant concern exists.
| Concern | Action | Notes |
|---|---|---|
| Metal allergy | Nickel/chromium testing | Positive → use titanium bar |
| Travel | Carry surgical note | Titanium may trigger extra screening |
| Emergency care | Medical alert card/bracelet | Include CPR and cardioversion instructions |
| Dental procedures | No routine antibiotics | Follow normal dental guidelines unless other risks exist |
Conclusion
Conclusion
In short, the decision path blends visible shape, symptoms, and measured tests to guide care for pectus excavatum. This chest wall deformity spans a wide spectrum, and excavatum include both cosmetic concerns and real functional issues.
Clinicians use a clinical exam plus imaging—low-dose CT with the Haller index—and may add echocardiogram or pulmonary function tests to see heart and lung impact. Many mild cases are monitored without immediate treatment.
When care is needed, surgeons compare two main options: the minimally invasive Nuss and the open Ravitch. Bars often stay for years and removal can be an outpatient procedure.
Families can use this guide to prepare questions for a pediatric surgeon, note growing or new symptoms, and seek evaluation when activity, breathing, or confidence are affected.
