What is it?
Pectus excavatum (sunken chest, funnel chest) is the most common
abnormality of the chest in children. It can present as a wide
range, from mild depression of the sternum (breastbone) to severe
cases where the sternum nearly touches the spine. Abnormal growth
of the rib cartilage causes the sternum to be pushed inward. The
depression in the breastbone may be symmetrical (even), or it may
be deeper on one side than the other. Also, the breastbone may be
straight or rotated to one side. Some children are known to have
this since they were babies, while in others, it does not become
noticeable until a large growth spurt, usually during
The cause of these abnormalities is unknown, though there is a
familial tendency (25% of patients report a family history of chest
What are the symptoms?
People with this condition can experience shortness of
breath or decreased endurance with exercise. Some people are
treated with different asthma medications for this problem without
any relief. Other children have chest pain, often at the area of
the abnormal rib cartilage or with exercise. Irregular heartbeats
and dizziness have been noticed in a few patients with pectus
excavatum. Some children and their parents report that the children
feel embarrassed about the appearance of their chest.
How is it
Not all children with pectus excavatum require surgery. Some mild
forms can be improved with upper-body strengthening exercises and
improvement in posture.
For those with a moderate to severe chest depression, there is
an operation that is considered minimally invasive, meaning the
incisions (cuts) are small and the cartilage no longer needs to be
excised (taken out). This operation involves making an incision on
each side of the chest about 1.5 inches long and a 1-1.5 inch
incision beneath the breastbone. A stainless steel bar that is
curved to fit around the front of the chest is slid under the
breastbone from one of the side incisions and passed to the other
side. The incision beneath the breastbone is used to guide the bar
under the breastbone. The bar is then turned to push the breastbone
out into a more normal shape. The bar is secured on each side of
the chest. The incisions are closed with dissolving stitches. The
surgery will take about 1-1.5 hours. The bar is left in place for
approximately 3 years to allow the chest to re-shape. After 3 years
have passed, the bar will be removed in a same-day surgery
Please let us know if your child has a known allergy to metal or
other skin reactions that are of concern. A different type of metal
bar will need to be used for those who are allergic to metal.
What can I expect
Before surgery a CT (CAT scan) will be taken of your
child's chest. This is done in radiology and is used to measure the
chest and the depression in the breastbone. It can also see if the
depression is crowding the heart and/or lungs, which can cause
symptoms such as shortness of breath and pain. The CT scan is not
painful. To have a CT, your child will need to lie still for about
5-10 minutes while a series of pictures are taken.
A list of exercises will be given to your child to help
strengthen the chest muscles. These exercises are to be done before
surgery and after surgery as well. Deep breathing and posture
exercises to maintain a "military" posture (shoulders back with
back in straight alignment) will also be extremely beneficial.
Your insurance company may require additional testing to
approve your child's surgery. If additional testing is required by
your insurance we will make arrangements for these exams to be
completed. Most insurance companies will not begin the
precertification process notifying you of this requirement until
2-3 months prior to the scheduled surgery date. This may cause some
difficulty for families who would like to plan their surgery ahead
of time. Please be aware that if your insurance company denies the
surgery for approval, the appeal process may be lengthy. In some
cases, the surgery date may need to be postponed and
Most of the patients undergoing surgical repair of a chest
wall abnormality are in their pre-teen/teenage years. Acne is
common in this age group, and can present a problem if you child
has acne on his/her chest and back. If your child suffers from
acne, or experiences a breakout prior to their operation, it is
important to call and notify your surgeon as soon as possible in
order to prevent your child's surgery from being cancelled when you
arrive. Your child may require treatment for acne including
evaluation and management by a dermatologist.
Pain management is a very important issue for pectus surgery
patients. Patients will require a variety of pain medication
post-operatively, including extended-release medications. These
medicines must be taken in a pill form and are not available as a
liquid. It is important for your child to be able to swallow pills
prior to their operation. Some may want to practice becoming
proficient at pill-swallowing…try Tic-Tacs and a cup of water!
Most families try to schedule their child's operation around a
school break. Expect your child to be in the hospital for 4-5 days,
and home for a week after discharge. If your child is scheduled for
surgery during the school year, it may be beneficial to notify your
child's school of this extended absence. You should receive a
letter during your child's hospital stay excusing him/her from
school and sports activities.
The pain medication required after the surgical procedure often
causes constipation. It is extremely important to start MiraLAX
BEFORE the scheduled surgery date. It will be part of your
discharge instructions as well, so you may want to purchase the
- How much MiraLAX®?
We recommend 1 capful, twice a day, for 3 days prior to
- How do you take MiraLAX®?
MiraLAX is taken daily with liquids. It has no taste and
dissolves easily and completely in everyday beverages such as
water, juice, or tea.
- Where do you find MiraLAX®?
MiraLAX is available in 4 convenient sizes: 7, 14, and
30-dose sizes plus in pre-measured single dose packets (10 ct),
which are handy for taking MiraLAX anytime, anywhere. Look for
MiraLAX with the pink cap in the laxative aisle at national
drugstore chains or supermarkets.
NOTE: There are generic versions available.
Please see your pharmacist for more information and possible
substitutes available at your local
How much pain can be expected with the
Pain is perceived differently by everyone and adequate
pain control is a priority in the post-operative course. Pain is to
be expected, but your child's nurse will be asking about pain
frequently and will have scales for your child to help rate his/her
pain severity. For most patients, pain medication is infused
through an IV continuously with a button that can be pushed by your
child to receive more medication with increased pain. This is
called a PCA (patient-controlled analgesia). A study was done at
our hospital comparing PCA with epidural pain control. The study
showed there is a shorter time in the operating room, an earlier
removal of the urinary catheter, and an easier time transitioning
to oral pain medicine in patients using a PCA. The pain scores were
lower with the epidural the first two days, and lower with the PCA
the last few days.
Once your child is able to tolerate eating and drinking after
surgery, he/she will begin taking pain medication by mouth, and the
PCA will be weaned off. If an epidural catheter is used, the
transition off the epidural occurs on day 3. Before being
discharged from the hospital, your child will be taking all pain
medication by mouth. Over the next 1-3 weeks after the surgery, the
oral prescription pain medicine will be tapered off and pain can
then be controlled with ibuprofen or acetaminophen.
It is important to get a good night's sleep so you do not need
to set an alarm at night to wake up and take pain medication. It is
best to have the medication next to the bedside with a glass of
water in case your child wakes up having pain.
the typical stay in the hospital like?
The timeline for recovery in the hospital will vary from
person to person. The average length of stay in the hospital is
approximately 4-5 days.
On the first day after surgery, we would like your child to get
out of bed to sit in a chair. He/She will have a special breathing
device called an incentive spirometer that we want him/her to
practice at least 10 times per day. This is extremely important for
recovery of the lungs after surgery. Your child will be able to
beginning eating again (starting with clear liquids) but will still
be on continuous IV pain medicine. As long as your child is on
continuous IV pain medicine, the urinary catheter that was placed
during surgery will stay in.
On approximately the second day after surgery,
we would like your child to be up for a walk.
He/She will continue working with the incentive spirometer and will
be working up to eating a regular diet.
As your child works up to a regular diet, he/she will transition
from IV pain medicine to pain medicine that is taken by mouth. This
transition usually takes place between days 2-4 after surgery. Once
the continuous IV pain medication is stopped, the urinary catheter
may be removed.
Once your child is able to tolerate a full diet, pain is
controlled with oral pain medicine, and bowel movements have
resumed, your child may be discharged to home.
After Surgery Information
Care of the
When your child comes out of the operating room, they may have a
bandage over each incision. These outer bandages may be removed two
days following surgery. Underneath these dressings are white
steri-strips over the incisions. Do not pull these off, they will
curl up and fall off on their own as the incisions heal. If
steri-strips are still on after one week, you may gently remove
them (try rubbing gently with washcloth while showering). The
incisions are closed using dissolving stitches that are beneath the
skin. There are not any stitches that will need to be removed. The
incisions will be pink at first, then will gradually fade over the
next year. Notify your child's doctor if there is any redness,
increased swelling, or drainage from the incisions.
Activity will be very limited the first 1-3 post-operative
months. This is done so the bar is not dislodged. This will mean
your child cannot participate in sports or physical education
for at least 1-3 months after surgery. After 1-3 months, your child
may participate in any activities that he/she can comfortably
tolerate EXCEPT for contact/action sports.
In the first 1-3 post-operative months, your child will not be
allowed to lift anything that weighs more than 25 pounds.
Contact sports (i.e. football, wrestling, etc.) will not be
allowed for at least 6 months. After 6 months your
child may return to contact sports or any other prior activities.
However, the risk of bar rotation or another problem requiring
additional operations is unknown and you would assume this risk for
activities such as contact and action sports.
After your child has recovered, the
exercises for the chest strengthening should be restarted.
GOOD POSTURE is extremely important. This is essential for
maximizing the outcome of your child's repair.
Deep breathing exercises and use of the incentive spirometer
should continue after hospital discharge.
Usually children need to be home for about 1-2 weeks after
this surgery. Your child may return to school when energy level and
pain control permits.
He or she may not participate in PE or recess for the first 1-3
months or carry heavy books due to discomfort. You may need to make
arrangements for books to be placed in the classroom instead of
having your child carry them.
Walking up or down stairs is allowed anytime. Your
post-operative letter will outline this information for your
child's school or work.
You will be given prescriptions for pain medication before
you leave the hospital. Please follow the instructions for the
prescriptions. One of the biggest side-effects of prescription pain
medication is constipation.
Your child will need oral stool softeners (MiraLAX, Benefiber,
or Colace) while taking prescription pain medications, and these
will be started when your child begins eating after surgery. While
constipation is a topic most children and adolescents do not like
to discuss, it is important for them to be aware of this common and
troublesome side effect.
Around post-operative day 4-5 constipated patients will often
report nausea and difficulty eating and drinking. If children are
not able to eat, they will not be able to tolerate the pain
medication that is necessary. This usually occurs in patients who
have not been able to have a bowel movement since prior to surgery.
The most effective way to facilitate a bowel movement at this stage
is an enema. If your child is in the hospital, the nursing staff
will help administer the enema. If your child has been discharged,
a Fleets enema may be purchased over-the-counter.
You can anticipate your child needing prescription pain control
for 1-3 weeks. After this time, pain should be controllable with
ibuprofen (Motrin/Advil) or acetaminophen (Tylenol).
We will want to see your child 2-4 weeks after the
operation, then 3 months post-operatively and then yearly until it
is time for the bar to come out. It is important to keep these
appointments to monitor your child's outcome and determine when the
bar can be removed. If an appointment is not scheduled when you
leave the hospital, please call the South Surgery Clinic (913)
696-8570 or the Downtown Surgery Clinic (816) 234-3199 for an
Call your child's surgeon if:
- Your child's incision is red, swollen, very painful, or has
- You think the bar has become dislodged (chest changes shape,
your child has been hit forcefully in the chest).
- You have questions or concerns.
- Your child is still having difficulty having bowel movements
after an enema.
- It is a good idea to wear a medical bracelet or necklace. You
can find these at www.identifyyourself.com.
The inscription should state: steel bar in chest, CPR more force,
cardiac defibrillation ant/post pad placement.
- No MRI's are allowed of the chest/thorax. If an MRI of the
lower body is needed, consult with the radiologist first to assure
the safety of the MRI with the steel bar in place.
- Antibiotic prophylaxis is not needed for dental procedures
unless your child has a history of mitral valve prolapse.
- We will provide a medical travel letter which your child may
need in passing through security devices at airports, etc.
Children's Mercy Center for Pectus Excavatum and
Children's Hospital of the King's Daughters
Home of the Nuss Procedure for Pectus Excavatum
Lorenz Pectus System for the Nuss Correction Procedure
A personal story of a young man with pectus excavatum
These websites are for informational purposes only. Surgical
technique and care will be dictated by your surgeon. Please use
these to find out more information about Pectus Excavatum, but
remember that these sites are provided for educational purposes and
most are not affiliated with Children's Mercy Hospitals and
Clinics. Information should not be viewed as a substitute for
medical advice provided by your family doctor, pediatrician or