Pectus excavatum is a congenital disorder which causes the chest to have a sunken or "caved in" appearance. It is the most common congenital chest wall abnormality in children. Typically the disorder is noticeable at birth and becomes more noticeable during the rapid growth period of adolescence. The severity can range from a moderate indentation in the chest to an extreme concave depression that can constrict the internal organs.
Although the sunken chest would seem to be a problem with the breatbone (sternum) and/or the ribs, in fact it is a problem with the cartilage (not bone) piece that connects each rib to the sternum. This costal cartilage connector is deformed, pushing the breastbone inward. When the deformed cartilage pushes the breastbone outward, the condition is called "pectus carinatum" (or "pidgeon chest").
- What is the cause of pectus excavatum?
- What is the outcome for a child with pectus excavatum?
- How is pectus excavatum typically corrected?
- Towards a better solution, The Magnetic Mini-Mover Procedure
What is the cause of pectus excavatum?
The disorder is assumed to be caused by overgrowth of the costal cartilage which connects the ribs to the sternum (center of the chest, or breastbone). As a child with the disorder grows through adolescence, the costal cartilage overgrowth restricts the expansion of the ribs and pushes the sternum inward. The disorder is estimated to occur in one of every 500 to 1000 children; it occurs in males three times as frequently as in females. Pectus excavatum can occur repeatedly in families, but most of the time it occurs randomly. At present, the cause is unknown.
What is the outcome for a child with pectus excavatum?
Historically, pectus excavatum was incorrectly considered as only a cosmetic defect. However, recent studies have revealed that children with significant defects also suffer from heart and breathing difficulties. The sunken chest restricts the volume of the chest and keeps the lung from expanding fully. Lung capacity may be reduced which can result in children having difficulty tolerating exercise or strenuous activity.
The sunken chest can also constrict the heart, reducing blood flow and heart function. These effects on the heart and lung can be measured and are reversible by correcting the sunken chest. It is important to note that these effects on the function of the heart and lung are not life-threatening and that individuals with pectus excavatum can live a full and normal life.
Some patients also suffer psychologically and emotionally as a result of the disorder. Although many patients are able to live comfortably and happily with the deformity, many other patients struggle with negative body image, low self-esteem, and social awkwardness. This is especially true for teenagers as the pectus defect often worsens during the adolescent years, a time when the child may be seeking peer acceptance.
How is pectus excavatum typically corrected?
For more than 50 years, pectus excavatum has been corrected by major surgical reconstruction. Surgical correction requires a large invasive operation under general anesthesia in which the sternum is forced forward and held in place using a metal chest wall strut or bar. Because the bar in the chest is under a great deal of pressure, and the pain and disability can last for weeks or months. There are at present two procedures to reconstruct the sunken chest.
The Modified Ravitch Procedure
The modified Ravitch procedure requires exposure of the sternum and surrounding area, removal of abnormal cartilages, and fixation of the sternum in a more normal position with a metal bar. This metal bar remains in place for at least a year, and then is removed with another operation. While this procedure has a good history of correcting the condition, it requires an incision (and scar) on the front of the chest to resect the abnormal cartilage—an operation that takes several hours and requires hospitalization for pain management. Physical activity is severely restricted for several months as the costal cartilages slowly grow back together.
The Nuss Procedure
The Nuss procedure also aims to force the sternum forward and hold it there with an implanted steel bar, but without making a big incision to resect the abnormal cartilage. In this procedure, the curved steel bar is placed under the sternum through two small incisions on the sides of the chest. Because the sternum is forced outward and held under great pressure, the Nuss procedure results in more pain and discomfort than the modified ravitch procedure. The steel structs must remain in place for approximately 2-4 years in order to properly reform the chest.
While less invasive than the Ravitch procedure, the initial Nuss procedure surgery still requires 4-5 days of hospitalization for pain management due to the rather drastic change in chest shape. Full recovery can take several weeks, during which time the patient's physical activities are restricted. For both the modified Ravitch and the Nuss procedures, the bar removal operation is a much simpler outpatient surgery, and the patient can usually leave within a couple hours.
In most pectus operations, there is very little blood loss. You child will receive blood only in the rare case of an extreme emergency. If you wish to provide a directed donation of blood, contact our office, 1-2 weeks in advance of the operation.
Towards a better solution, the Magnetic Mini-Mover Procedure
Both of the Ravitch and Nuss procedures require big operations and hospitalization for pain management. The fundamental problem with both techniques is that they attempt to correct a significant rigid chest wall deformity all at once, i.e., in a single surgical procedure. Perhaps a better principle for correction of chest wall and other deformities is by gradual (bit-by-bit) correction using minimal force applied over many months. This is the same principle used in moving teeth with orthodontic braces.
In an effort to overcome these problems, we have developed a novel method of achieving gradual deformation/reformation of chest wall cartilage without the need for insertion of painful orthopedic devices or repeated surgeries. We call this new technique the Magnetic Mini Mover Procedure (3MP).