Pectus Program

Pectus Excavatum and Carinatum Program

Pediatric Surgery at Children’s Hospital offers the Pectus Excavatum and Pectus Carinatum Program using minimally invasive options. These techniques are used by only two other facilities in the state. Children’s Hospital pediatric surgeons Robert L. Gates, MD, James F. Green Jr., MD, and Keith M. Webb, MD have further modified the procedures, which has resulted in pain reduction and decreased time to full recovery for these patients.

One key difference between the procedures at Children’s Hospital and other institutions is the addition of a directed physical therapy program that begins before the procedure and continues after surgery.

  • This program is a collaboration between Pediatric Surgery and Kidnetics® (both departments of Children’s Hospital specializing in therapeutic services) and provides a multidisciplinary approach for patients with chest-wall deformities
  • Patients are evaluated by a Kidnetics physical therapist who has specialty training in the treatment of respiratory mechanics, strength, endurance and posture
  • This intensive physical therapy program has resulted in less post-operative pain and quicker recovery time
  • The child usually returns to his or her normal activities within three to six months

Pectus Excavatum

Pectus excavatum is a depression in the chest caused by a malformation of the cartilage between the ribs and sternum. It usually takes the form of a cup or saucer-shape defect and may be centrally located or shifted on one side with varying angulation of the sternum. This is a congenital condition but may not be noticeable until the pubertal growth spurt that coincides with rib ossification. The incidence is one in 1,000 children.

A mild pectus excavatum may be considered cosmetic; however, when severe, it can impair cardiac and respiratory function and cause pain in the chest and back. In addition, these children experience negative psychosocial effects and often avoid activities that expose their chest.


Evaluation involves a complete history and physical exam to evaluate any physiologic dysfunction

  • The most common symptoms are exercise intolerance, shortness of breath, chest pain, lack of endurance and asthma
  • These children may deny chest pain or shortness of breath with activity but, when asked specifically, they have learned to avoid athletic activities because of previous history of exercise intolerance and decreased stamina
  • After surgical referral, a chest X-ray is obtained to calculate the Haller index and grade the severity of the depression
  • A CT scan of the chest sometimes is performed to determine the degree of cardiac compression

A grading system is used to determine the extent and depth of the defect and assigned as mild, moderate or severe.

  • Mild depressions are treated with exercises that strengthen the chest wall muscles and improve posture
  • Moderate to severe depressions usually require surgery to elevate the sternum to relieve cardiac compression and increase lung capacity

Previously, surgical corrections of the deformity were made through an invasive procedure requiring resection of cartilage and bone. Surgeons now have developed a minimally invasive surgical procedure to implant a customized pectus bar that allows remodeling of the chest wall over a two- to three-year period. The ideal age for insertion is between 11 and 14 years of age, and depends on the child’s developmental growth.

Benefits of the minimally invasive procedure:

  • Reduced operating time
  • Minimal blood loss
  • Quicker return to regular activity (approximately one month)
  • Better long-term cosmetic result

Pectus Carinatum

Pectus carninatum, also called pigeon or funnel chest, is a deformity of the chest characterized by a protrusion of the sternum and ribs. In approximately 25 percent of cases, the patient has a family member with the condition.


Pectus carinatum initially is treated non-surgically with the use of a chest-wall brace. Surgeons at GHS Children’s Hospital have developed a customized brace that applies direct pressure on the protruding area of the chest and produces excellent outcomes. The brace consists of front and back compression plates that are anchored to aluminum bars. These bars are bound together by a tightening mechanism that varies from brace to brace. This device, easily hidden under clothing, must be worn from 14 to 24 hours a day.

If children with pectus carinatum are not treated with a brace by the end of their teens, this method is less likely to be successful as the shape of the ribcage and sternum become more permanently fixed. Operative intervention then is often required.