Pectus Excavatum (Sunken Chest) Treatment in Children
Nuss and Ravitch correction for the most common chest wall deformity in children — evaluated and treated in Calabasas and across Los Angeles County.
- Typical age
- 10–18 years
- Approach
- Nuss procedure
- Hospital stay
- 3–5 nights
Pectus excavatum, often called funnel chest or sunken chest, is a congenital chest wall deformity in which the breastbone (sternum) grows inward instead of outward, creating a concave depression in the center of the chest. It’s the most common chest wall deformity in children, affecting roughly 1 in 300 to 1 in 1,000 children, and it ranges from a mild cosmetic difference to a more significant deformity that can compress the heart and lungs and limit exercise tolerance.
Most cases are noticed in infancy or early childhood and become more pronounced during the rapid growth of adolescence. While many children with mild pectus excavatum need only monitoring, moderate to severe cases are often evaluated for surgical correction, most commonly with the minimally invasive Nuss procedure.
Pectus Excavatum vs. Pectus Carinatum
Pectus excavatum and pectus carinatum are the two most common chest wall deformities in children, and they’re often confused with one another. Pectus excavatum involves an inward curvature of the breastbone, creating a sunken appearance, while pectus carinatum involves an outward protrusion of the breastbone and cartilage. The two conditions are evaluated and treated differently: pectus excavatum is primarily addressed with the Nuss procedure when surgery is needed, while pectus carinatum often responds well to external bracing. Dr. Frykman evaluates both conditions as part of his chest wall deformity practice.
Symptoms and When Surgery Is Recommended
Many children with mild pectus excavatum have no symptoms beyond the visible chest wall appearance. As the deformity becomes more pronounced, particularly during adolescent growth spurts, children may develop shortness of breath or reduced endurance during exercise compared to peers, chest pain or discomfort, palpitations, and fatigue with physical activity. In more severe cases, the depression in the breastbone can press on the heart, reducing cardiac efficiency during exertion.
Beyond the physical symptoms, the visible chest wall difference can affect a child’s self-esteem, body image, and willingness to participate in activities like swimming or changing in a locker room. Surgical correction is generally recommended for moderate to severe cases, particularly when there is measurable cardiac or pulmonary impact, significant exercise intolerance, or meaningful psychosocial impact. Families should seek a specialist evaluation if the deformity appears to be progressing during a growth spurt, if a child is limiting activity due to chest discomfort or shortness of breath, or if the condition is affecting confidence and participation in daily life.
Diagnosis: Haller Index, Chest CT, and Pulmonary Testing
Diagnosis begins with a physical examination and a detailed history of symptoms and their impact on activity. For children being considered for surgical correction, the workup typically includes a chest CT scan, which allows the surgical team to calculate the Haller index, a ratio of the width of the chest to the distance between the breastbone and the spine. A Haller index above 3.2 is generally considered indicative of a moderate to severe deformity and supports a recommendation for surgical correction.
Pulmonary function testing helps quantify any impact on lung capacity, and every patient being evaluated for surgery has a detailed consultation with a pediatric cardiologist, including an echocardiogram and an ECG, to rule out cardiac compression or displacement. Together, these studies give the surgical team an objective picture of severity that goes beyond visual appearance alone, and help guide the conversation about whether observation or surgery is the right next step.
Surgical Options: Nuss Procedure vs. Ravitch Procedure
The large majority of pectus excavatum repairs today are performed using the Nuss procedure, a minimally invasive technique. During the Nuss procedure, one or two small incisions are made on either side of the chest, and a curved metal bar, custom-fitted to the child’s chest wall, is guided behind the sternum using a small camera for visualization. The bar is then rotated, lifting the depressed breastbone into a more normal position, and secured with stabilizers. Many children also receive cryoablation, a technique that cold-treats the nerves between the ribs during surgery to significantly reduce pain in the days following the procedure.
The Ravitch procedure is an open surgical technique that involves a single incision across the chest, removal of the malformed cartilage, and, in many cases, placement of a supportive strut or bar to hold the chest wall in its corrected position while it heals. The Ravitch procedure is used less often today, generally reserved for children with more complex or asymmetric deformities, cases where the Nuss procedure isn’t a good technical fit, or revision surgery after a prior repair. Dr. Frykman discusses which approach is the better fit for each child’s specific anatomy and deformity pattern during the surgical consultation. For a fuller walkthrough of both operations, see our comprehensive guide to pectus excavatum surgery.
Age Considerations and Timing of Surgery
Timing for pectus excavatum surgery is individualized. Many children benefit from surgery during early to mid-adolescence, when the chest wall is still flexible enough to reshape but developed enough to hold a stable correction, generally in the range of 11 to 16 years old. If a child has significant symptoms, cardiac or pulmonary impact, or notable psychosocial effects, earlier intervention may be appropriate. When the deformity is mild and not progressing, observation with periodic follow-up is often reasonable while growth clarifies the trajectory. Dr. Frykman also helps families plan surgical timing around school calendars and sports seasons to minimize disruption to a child’s academic and athletic commitments.
Recovery: Bar Duration, Activity Restrictions, and Return to Sports
After a Nuss procedure, most children stay in the hospital for 2 to 4 days while the surgical team manages pain, monitors breathing, and helps the child return to safe mobility and normal eating. Pain control typically combines medication with regional anesthesia techniques to minimize opioid use where possible.
The bar remains in place for approximately 2 to 3 years, allowing the chest wall to remodel around its new shape before a short outpatient procedure removes it. During the first six weeks after surgery, children are asked to avoid lifting more than a few pounds, twisting, and bending deeply at the waist, with overhead reaching reintroduced gradually. Walking begins the day of or the day after surgery, and light aerobic activity increases steadily as comfort improves. Most children return to school within one to two weeks, often with temporary accommodations for carrying backpacks and participating in PE. Non-contact sports typically resume in phases as cleared by the surgical team, while contact sports and heavy lifting are restricted longer to protect the bar’s position. Bar removal, once the chest wall has stabilized, is a brief outpatient procedure with a short recovery, typically one to two weeks.
Risks and Outcomes
Pectus excavatum surgery has a strong overall safety profile in experienced pediatric surgical hands, with the large majority of children experiencing durable correction and improved exercise stamina and confidence. As with any surgery, there are risks to be aware of, including bar displacement or shifting, pneumothorax (a small collection of air around the lung), infection, and post-operative pain that requires active management in the first one to two weeks. Choosing an experienced pediatric surgical team, with close post-operative follow-up, is one of the most important factors in minimizing these risks and achieving a good long-term result.
Dr. Frykman's Expertise
Dr. Frykman has extensive experience with the Nuss procedure, having treated well over 100 pectus excavatum patients, and combines this experience with a personalized, family-centered approach to care. Every patient’s evaluation includes chest CT imaging, pulmonary function testing, and a cardiology consultation, and every treatment plan is tailored to the child’s specific deformity pattern, symptom burden, age, and goals, whether that means a scheduled Nuss procedure, a nonoperative approach with monitoring, or a second opinion on a prior recommendation. Families throughout Calabasas and the greater Los Angeles area turn to Dr. Frykman for pectus excavatum evaluation, surgical correction, and long-term follow-up care.
When to Call Us / What to Bring to Your Consultation
If you’ve noticed a sunken or concave appearance to your child’s chest, or a pediatrician has raised a concern about pectus excavatum, Pacific Coast Pediatric Surgery can help. Contact us to schedule a consultation with Dr. Frykman for a thorough evaluation and a treatment plan tailored to your child.
Frequently Asked Questions
What causes pectus excavatum?
Pectus excavatum is congenital, meaning it’s present from an early age, and results from abnormal growth of the cartilage that connects the ribs to the breastbone. The exact cause isn’t fully understood, though it can run in families and is sometimes associated with connective tissue conditions.
What is the best age for pectus excavatum surgery?
Timing is individualized, but many children have surgery during early to mid-adolescence, when the chest wall is flexible enough to reshape yet developed enough to hold a stable correction. Earlier surgery may be appropriate for significant symptoms, while mild, non-progressing cases are often simply monitored.
Is it worth getting pectus excavatum surgery?
For children with functional limitations, cardiac compression, or significant psychosocial impact, surgery can meaningfully improve exercise tolerance, chest discomfort, posture, and self-confidence. A thorough consultation helps families weigh the expected benefits against the recovery commitment.
How long do you stay in the hospital after pectus excavatum surgery?
Most children stay 2 to 4 days after a Nuss procedure, with the focus on pain control, safe mobility, breathing exercises, and returning to normal eating before discharge.
What can't you do after pectus excavatum surgery?
For about the first six weeks, children avoid lifting more than a few pounds, twisting, and bending deeply at the waist. Walking starts almost immediately, light aerobic activity increases gradually, and contact sports and heavy lifting are restricted longest to protect the bar’s position.
Will insurance cover pectus excavatum surgery?
Many insurance plans cover surgical correction when medical necessity is documented, though preauthorization is typically required. Our team assists with benefit checks and the documentation insurers often request, including imaging, cardiopulmonary findings, and notes on symptoms and impact.
Can a child play sports with pectus excavatum?
Yes. Many children with mild pectus excavatum participate fully in sports without any treatment, and children who have surgery typically return to sports in phases once cleared by their surgeon, starting with non-contact activity.
What's the difference between the Nuss and Ravitch procedures?
The Nuss procedure is minimally invasive, using small incisions and an internal bar to reshape the chest, and is the more common approach today. The Ravitch procedure is an open technique involving removal of malformed cartilage, generally reserved for more complex, asymmetric, or revision cases.
How long does the bar stay in after a Nuss procedure?
The bar typically remains in place for 2 to 3 years to allow the chest wall to remodel, and is then removed in a brief outpatient procedure.
