Pectus excavatum (funnel chest) is a congenital defect that causes the chest wall to appear sunken. It often results in lack of confidence and shortness of breath.

In most people pectus excavatum (funnel chest) presents before the age of one, but in some cases it does not become apparent until the onset of puberty. It is seen four times more frequently in boys than in girls.

What causes pectus excavatum (funnel chest)?

The defect is caused by abnormal development before birth of the cartilage that joins the ribs and the breastbone. The sternum is thereby pressed in towards the spine, and a depression develops at the front of the rib cage.

Pectus excavatum usually worsens with age. Severe cases of the condition can impair heart and lung function. Many people with pectus excavatum have self-image issues about the way they look.

Researchers are currently unsure what actually causes of pectus excavatum but hypothesize genetic defect. Approximately 37% of individuals with pectus excavatum have a first degree family member with the condition

Symptoms of pectus excavatum (funnel chest)

Many people complain of quickly becoming short of breath during physical activity. The reason for this is that the right-hand side of the heart becomes compressed, and thus does not have enough space to expand when doing work. In some cases funnel chest can cause difficulty eating as a result of compression of the oesophagus.

It is the cosmetic effects, however, that are often the worst ones, and they can cause the young person to refrain from various social and sporting activities.

In order to ensure the best possible result after a Nuss procedure there are certain restrictions to your activity.

The first 6 weeks after Nuss procedure

After a Nuss procedure there are certain movements you should avoid the first six weeks in order to ensure the positioning of the bars(s) stabilizes. You should thus:

• Not lie on your side
• Not bend forward or twist your upper body
• Not lift more than 2 kg in front of your body
• Not lift more than 5 kg in a rucksack, which you should be helped put on and take off
• Not ride a bicycle

After 6 weeks 

After the six weeks you can start jogging, swimming and cycling, and can do general lifting. After 12 weeks you can take part in all activities apart from violent contact sports such as American football, rugby, ice hockey and martial arts.

Work / sick leave

At the preliminary examination you will discuss with the specialist what you should expect. It depends on what you do every day.

Sexual activity after Nuss procedure

For the first six weeks avoid positions that may put a strain on your rib cage and stomach muscles.

You can expect to be more tired than normal during the period after a Nuss procedure. However, it is important that you quickly get back on your feet.

You should not lie in bed, but should promptly resume your everyday life. This is all part of your exercise regime. You should get up and walk around, and sit in a chair when you are eating, watching TV etc. However, it is recommended that you rest during the course of the day.

The right diet after a Nuss procedure

To ensure that you do not lose strength in connection with a Nuss procedure, it is important that your diet gives you extra protein and energy.

If you have lost weight in connection with surgery, you will have lost muscle tissue. It will be some time before you regain energy and return to normal. You will need protein because proteins are the “bricks” you need to rebuild your body. Proteins help to rebuild muscles, promote healing, stimulate blood production and strengthen your immune defence system.

Therefore, be sure to get extra proteins through your food intake for as long as you are tired. Different people require different amounts of protein. As a rule of thumb, we recommend 1 g of protein per kilogramme of body weight per day. For further information see leaflet ’Importance of diet in connection with operation’.

You may find that the implanted bars activates metal detectors at security check points at airports, sights or shopping centres.


In order to avoid any misunderstanding you will receive a card stating that you have undergone a Nuss procedure implanting steel bars in you chest.

You can also show your scars if necessary.

Before a Nuss procedure (pectus surgery) there are several preparations such as X-rays, examination, fasting and pausing medication.

X-ray of your chest

In order to determine whether pectus surgery is the right treatment for you, we need you to send us x-rays of your chest.

Preliminary examination

Before a decision on an operation for funnel chest you will come in for a preliminary examination by our thoracic surgeon. If you are living abroad, the preliminary examination can take place over video.

At the preliminary examination you will talk about your symptoms and wishes. The specialist will examine you and explain the options to you. If you agree that an operation is the right thing for you the specialist will go through the course of events and possible side effects and complications with you. You will discuss what is to be expected from the operation and the importance of rehabilitation.

Fasting before Nuss procedure

The operation takes place under a full anaesthetic, so you must fast before it.

Pausing with medication

If you are taking any of the following drugs you must observe the following
recommendations:

• Drugs containing acetylsalicylic acid (e.g. Hjertemagnyl, Magnyl, Aspirin, ldotyl, Treo, Kodimagnyl). Discontinue for the three days prior to the operation.
• Medication for gout (e.g. Brufen, lpren, Confortid, Naprosyn, Voltaren, Diclon, Ibumetin, Ibuprofen etc.). Discontinue for the three days prior to the operation.
• Anticoagulant treatment (e.g. Marevan, Plavix). At the preliminary examination you will discuss with the specialist how to proceed.
• Fish oil and other natural remedies. Discontinue for one week prior to the operation.

Admission to the hospital

You must expect to be in hospital for two to three days.

On the day of the operation you will talk to the physiotherapist about exercises and restrictions during the period after the operation. You will be given a programme of exercises.

You will also talk to the specialist and the nurse, who will give you information on the period of hospitalisation and the period following discharge.

Before the operation, blood tests will be taken and your rib cage will be X-rayed again.

Then you are ready for surgery.

After a Nuss procedure you will be hospitalized for 2 - 3 days. Immediate mobilization is important and the staff will help and support you.

Mobilization after Nuss procedure

As soon as you wake up from the anaesthetic and regain feeling in your legs you must wiggle your feet. This is to encourage your circulation and reduce the risk of blood clots. 

After the operation it is important that you prevent complications, e.g. of the heart, lungs and gastrointestinal system. It is thus of great importance that you quickly get on your feet again. We expect you to sit up, stand and walk on the day of the operation.

You should not lie in bed, but should promptly resume your everyday life. This is all part of your exercise regime. You should get up and walk around, and sit in a chair when you are eating, watching TV etc.

It is important that you wear your own clothes when you are up and about. This will help increase your feeling of wellbeing. Initially, though, you will need bed rest several times a day. 

Walking around promotes gastric function, thereby decreasing the risk of constipation, but it also means you can better inhale air right down into your lungs, thus reducing the risk of pneumonia. You will also be given a special flute that you must breathe
through several times a day; this will also improve your breathing. 

Straight after the operation you will need the help and support of the staff. The nursing staff and the physiotherapist will help and instruct you regarding how best to move, bearing in mind your restrictions. 

Your relatives will be encouraged to help you and keep you company, but they must remember that you will need a few hours' peace and quiet in the middle of the day, after lunch.

The physiotherapist will instruct you regarding the exercise regime, which you must continue following discharge. The physiotherapist will come once or twice a day to provide guidance in the exercises. 

Baths and bandages

You can take a bath without any dressing on 24 hours after the operation or 24 hours after any drain has been removed. Whilst you still have a dressing on you must bear in mind that it must be changed if it is wettened by blood or water. It is alright for there to be a spot on the dressing.

During hospitalization the nurse will help you look after the dressing and if necessary change it. When the wounds are no longer producing exudate you will not need any dressing.

Pain relief after Nuss procedure

For the first few days you will receive analgesics through the catheter in your back. This takes place automatically using a small pump. You must also take analgesic tablets at regular intervals four times a day. This will be OTC medication supplemented with something stronger.

You will be talking to the staff about pain relief several times a day, so we can adapt it to your needs. You cannot expect to be without pain whilst you are hospitalized, but we will collaborate on making your pain level acceptable.

Urination

The catheter in your bladder will be removed at the same time as the epidural catheter on Day Two. You may have difficulty urinating on your own the first few times, and it may be necessary for us to help you use a disposable catheter the first couple of times, until you can urinate on your own again.

Bowel movement

Whilst you are receiving analgesics and are not moving about as normal you will need a laxative to keep your bowel moving. It will also help to drink a lot of water –  approx. 1½ litres a day. 

Antibiotics

You will be given antibiotics during hospitalisation to reduce the risk of inflammation.

Planning your discharge

At an early stage we will discuss discharge with you and, where appropriate, your relative, the aim being optimum planning of the discharge. The discharge will be planned as a collaboration between you, your relative, the physiotherapist, the nurse and the surgeon who operated on you. 

Before you are discharged you must discuss with the physiotherapist where the subsequent exercises are to take place and what they will comprise. You will be referred for physiotherapy.

Your rib cage will be X-rayed before discharge by way of documentation that the materials are in the correct place. You and, where applicable, the relative(s) who will be helping you at home will talk to the nurse about analgesics, the wound, the dressing, bowel function and follow-up of developments before you go home.

You can go home as a passenger in a normal car. The physiotherapist or nursing staff will walk you to the car and show you how best to get into it. If the journey is to be long it may be a good idea to have a break or two so you can get out and stretch your legs.

Follow-up after Nuss procedure involves removal of stitches, X-ray, appointment with the doctor and removal of the bars after 3 years.

Removal of stitches

The stitches will be removed at your own doctor’s surgery after 10 to 12 days.

Follow-up

After 6 - 8 weeks you will be X-rayed to check whether the positioning of the bars(s) is correct. If you live a long way away you can have the X-ray taken at your local hospital and have the images sent to Aleris Aarhus, where the surgeon will look at them.

We will make an appointment to follow-up on your healing process. It can either take place by phone, video or as a physical consultation. You are welcome to contact us any time if you have questions.

Bar removal

The inserted bars must remain in place for three years, after which they will be removed. This takes place under a full anaesthetic as a day surgery intervention, and you can go back home after a few hours.

The Nuss procedure is minimal invasive technique that takes only 30 - 60 minutes. We take you through the Nuss procedure step by step.

Catheter for pain relief

Before the operation an epidural catheter for pain relief will be inserted in your back. The catheter will automatically administer analgesics using a small pump. It will be removed two days after the operation. 

Anesthesia

You will be anaesthetised through insertion in the back of your hand of a cannula (plastic), through which the anaesthetic will be injected. When you are anaesthetised a catheter will be inserted in your bladder.

The Nuss procedure

The operation takes 30 - 60 minutes. During the operation two to three (maybe more) 5 cm incisions is made. A camera is inserted through one of the wholes allowing the surgeon to monitor the procedure and avoid injury to the heart during insertion. Through the latter the specialist will insert 1  -2 or perhaps 3 steel bars under the sternum so that it is pressed out into a normal position.

Drain

In rare cases a drain will be put in place. This is a thin plastic tube that sucks up excess blood and tissue fluid.

Antibiotics

Antibiotics will be administered in connection with the operation to prevent inflammation in the wounds.

Finishing the Nuss procedure

Local anaesthetic will be applied to the wounds when the operation has been completed. The wounds will be closed using absorbable sutures, and plasters will be applied to them.

The two most common types of surgeries used to correct pectus excavatum is the open repair (Ravitch procedure) or the minimally invasive repair with a metal bar (Nuss procedure).

Ravitch Procedure (Open Repair)

The Ravitch procedure is done through a larger incision across the mid chest. The deformed cartilages attaching the ribs to the lower breastbone is removed, thus allowing the sternum to move forward in a more normal position. In order to keep the sternum elevated in the desired position a temporary metal bar may need to be placed. In certain patients, a break in the sternum is done to allow the sternum to be positioned forward. These supports are removed in 6 to 12 months. The Ravitch procedure takes approximately 4-6 hours.

The Nuss Procedure (minimally invasive technique)

During the Nuss procedure a small incision is made at the right side of the chest wall to insert a camera allowing the surgeon to monitor and avoid injury to the heart during insertion. Through two other small incisions on either side of the chest, a curved steel bar (individually curved for each patient) is inserted under the breastbone in order to push the sternum forward into the new position. The steel bar is then fixed to the ribs on either side. A small steel grooved plate may be used at the end of the bar to help stabilize and attach the bar to the rib. The bar is not visible from the outside and stays in place for 2-3 years. The bar is then surgically removed. The Nuss procedure takes between 1–2 hours.

Pros and cons: Nuss vs Ravitch

Whereas the Ravitch Procedure offers less pain after the procedure, the Nuss procedure gives a better cosmetic result. Dr. Hans Pilegaard primarily uses the Nuss procedure as it is the best option for most patients with pectus excavatum – even for patients older than 30 years. The operating time for the Nuss procedure is shorter and we experience reduced risk of infection and bleeding with the minimal invasive technique.

The Nuss procedure has several advantages over the Ravitch procedure in the immediate postoperative period.

Pain is common after a Nuss procedure (pectus excavatum surgery). Therefore, you will remain at the hospital for two to three days for effective pain management.

During hospitalization

The first few days you will receive analgesics through a catheter in your back. The medicin is given automatically using a small pump. You must also take analgesic tablets at regular intervals four times a day. This will be OTC medication supplemented with something stronger. You will be talking to the staff about pain relief several times a day, so we can adapt it to your needs. You cannot expect to be without pain whilst you are hospitalized, but we will collaborate on making your pain level acceptable.

After discharge

We recommend that you take analgesics for as long as you feel the need. You will be given strong analgesics to take home for the first day or two, but if you need them for a longer period you must discuss the matter with your own doctor.

In the first 3 month after a Nuss procedure (pectus surgery) there are certain precautions to take. Read about pain-relieve, sick leave, restricted activities and rehabilitation.

Pain after Nuss procedure

For the first few days you will receive analgesics through a catheter in your back. This takes place automatically using a small pump. You must also take analgesic tablets at regular intervals four times a day. This will be OTC medication supplemented with something stronger. You will be talking to the staff about pain relief several times a day, so we can adapt it to your needs. You cannot expect to be without pain whilst you are hospitalised, but we will collaborate on making your pain level acceptable

We recommend that you take analgesics for as long as you feel the need. You will be given strong analgesics to take home for the first day or two, but if you need them for a longer period you must discuss the matter with your own doctor.

Swelling

Swelling of the area operated on is normal and can last for several weeks / months after the operation.

Accumulation of blood

Bruising and accumulation of blood on the chest / stomach is also normal and disappears of its own accord after a few weeks.

Fatigue

You can expect to be more tired than normal during the period after the operation. It is recommended that you rest during the course of the day and that you get extra proteins through your food intake for as long as you are tired. See leaflet ’Importance of diet in connection with operation’.

Work / sick leave

At the preliminary examination you will discuss with the specialist what you should expect. It depends on what you do every day.

Activity after Nuss procedure

After the operation there are certain movements you should avoid for the first six weeks in order to ensure the positioning of the bars(s) stabilises. You should thus:

• Not lie on your side
• Not bend forward or twist your upper body
• Not lift more than 2 kg in front of your body
• Not lift more than 5 kg in a rucksack, which you should be helped put on and take off
• Not ride a bicycle

After the six weeks you can start jogging, swimming and cycling, and can do general lifting. After 12 weeks you can take part in all activities apart from violent contact sports such as American football, rugby, ice hockey and martial arts.

Sexual activity after Nuss procedure

For the first six weeks avoid positions that may put a strain on your rib cage and stomach muscles.

Removal of stitches and follow-up

The stitches will be removed at your own doctor’s surgery after 10 to 12 days. After 6-8 weeks you will be X-rayed to check whether the positioning of the bars(s) is correct. If you live a long way away you can have the X-ray taken at your local hospital and have the images sent to Aleris-Hamlet Aarhus, where the surgeon will look at them.

Rehabilitation after Nuss procedure

You must continue to do your exercises conscientiously at home – even if you have been offered further physiotherapy. We will ensure you are referred for further physical exercises.

Airports

You may find that the implanted material activates airport metal detectors. You will receive a card stating that you have undergone an operation. You can also show your scars if necessary.

Most patients who undergo a Nuss procedure (pectus excavatum surgery) experience an improved quality of life and boost in self confidence.

The Nuss procedure for pectus excavatum can be implemented with excellent results and few complications. 

The initial period after Nuss procedure

You must expect to experience pain during the initial period after the operation, so you will need analgesics during the initial weeks. There are some restrictions as to what you can do during the first six weeks after the operation. 

Results after 3 months

After a Nuss procedure most patients experience:

• Normal looking chest
• Less chest pain
• Easier breathing
• Better blood circulation
• Ability to do sports activities
• More confidence and improved quality of life

Removal of bars

The inserted bars must remain in place for three years, after which they will be removed. This takes place under a full anaesthetic as a day surgery intervention, and you can go back home after a few hours.

Although the Nuss procedure is safe and effective, complications can occur and it is important for you to know about potential risks in relation to pectus excavatum surgery.

The surgical repair of pectus excavatum, like other extensive surgical procedures, carries certain risks including:

Risk of infection

There is always a risk of infection in connection with an operation, even if you have prophylactic antibiotics through the operation, but such infections are very rare only around 1 %. If infection should occur you will have to continue antibiotics for a period.

Risk of bleeding

Bleeding is a rare complication, less than 1 %. In case of bleeding during the operation, it will usually be stopped by the scope, but a larger incision may be required.

Risk of pneumothorax

Pneumothorax is the accumulation of air in the pleural space around the lung. Most of the time this only requires a follow up chest X-ray. However, 2% of patients may need a chest drain.

Risk of pleural effusion

Pleural effusion is the accumulation of fluid in the pleural space around the lung. This may require a follow-up chest X-ray and very rarely a chest drain.

Risk of inflammation around the heart - pericarditis

Pericarditis is a condition in which the membrane, or sac, around your heart is inflammed. It is treated with medicine and rest.

Risk of bar displacement

The bars can move out of position (1-2 % risk) and may need to be adjusted in the operating room. With recent modifications in the Nuss procedure, the incidence of bar displacement is less than 2 out of 100 patients. To prevent the bar from moving too much, patients are asked to restrict their physical activities in the first 6 weeks after the surgery and slowly resume them the following 6 weeks. If you suddenly experience violent pain and feel that there has been movement of the bar(s), you must contact us.

Risk of pectus excavatum recurrence

According to the research, the risk of relapse is minimal (< 2 %). This may happen when surgeries are performed prior to growth spurts (puberty) or if not leaving the bar in long enough.

Risk of death

There have been very few reports in the medical literature of injuries to the heart during bar placement over the last 25 years.

Pectus excavatum may be surgically repaired if you have moderate to severe symptoms including the shape of the chest.

Physical therapy for mild cases

Patients who have mild symptoms may be helped by physical therapy. Certain exercises can improve posture and increase the degree to which the chest can expand.

Surgical treatment of pectus excavatum

If you have moderate to severe pectus excavatum with physical symptoms and serious cosmetic effects, we often recommend surgery.

After a pectus excavatum surgery most patients experience:

• Less chest pain
• Easier breathing
• Better blood circulation
• Normal looking chest
• Ability to do sports activities
• More confidence and improved quality of life

Age limit for pectus excavatum surgery

The best results are achieved when the surgery is performed once the pubertal growth spurt is underway or completed. If repair is done before puberty, there is an increased risk of recurrence during adolescence. Adults also have benefitted from pectus excavatum repair.

Pectus excavatum operation types

The two most common types of surgeries used to correct pectus excavatum differ by the size of the incisions made. The surgeon can either choose the open repair (Ravitch Procedure) or the minimally invasive repair with a metal bar (Nuss Procedure). 

The vast majority of the patients with pectus excavatum are candidates for the Nuss procedure. However, the decision for the patient to undergo a Ravitch or Nuss procedure will be determined by the surgeon.

At Aleris Hospitals Dr. Pilegaard primarily uses the Nuss procedure.