FAQ

How common are chest wall anomalies?

You are not alone! Up to one in four hundred people have a CWA. While this might not sound like a lot, it is a high incidence for a congenital anomaly. Given the US population, almost a million people in the US have a CWA.

Do all CWA need to be repaired?

Some CWA are mild and do not warrant correction. However, many should be repaired since they affect health. The visible problem may be the “tip-of-the-iceberg.” It is best to have a full evaluation by a physician with special expertise in CWA before deciding not to do anything about a CWA, even if it appears mild.

Does correcting a CWA always involve surgery?

No. Dr. Bodenstein is a surgeon, but only a small number of patients he evaluates actually require surgery. For example, most people with pectus carinatum can be treated with bracing. When surgery is necessary, minimally-invasive procedures such as the Nuss procedure are favored.

Is fixing a CWA a cosmetic procedure?

Correction of a CWA is NOT a cosmetic procedure. It is a reconstructive procedure which corrects the shape of the chest wall toward its normal, correctly functioning state. This can provide significant health benefits.

What is the difference between pectus excavatum and pectus carinatum?

In both, the central ribs growth abnormally and displace the sternum (breastbone). If the sternum is pushed inward, it is pectus excavatum. If it is pushed outward, in is pectus carinatum.

Some areas of the chest seem to be pushed out and others seem to be depressed. Is this is pectus excavatum or a pectus carinatum?

Although many CWA clearly can be characterized as either an excavatum or a carinatum, there are also many variants with features of both, or that do not fit the picture of either. Treatment should be tailored to the way the chest actually is rather than trying to shoehorn everything into one or the other category.

What causes chest wall anomalies?

No one really knows. It is thought that excessive growth of the central part of the ribs (which are made of cartilage rather than bone) causes the chest wall to buckle. This either forces the sternum (breastbone) inward causing a excavatum or outward causing an carinatum.

Other members of my family also have CWA. Is this common?

Yes. If someone has a CWA, there is a 40% chance a close relative will also have a CWA. There is an underlying genetic basis for CWA and so it “runs in families.” In some cases, a specific genetic abnormality (such as Marfan Syndrome) is known to be the cause. But in most cases, the genetic cause is unknown.

Dr. Bodenstein runs a research study to uncover the genetics behind CWA. You are welcome to participate in this effort if you wish.

Why did we never notice a chest problem until my child became a teenager?

This is not uncommon – you didn’t miss it. CWA tend to surface during puberty, especially during the teenage growth spurt. The chest wall may seem completely normal before these ages. In some cases, the abnormality is noticed earlier, sometimes as early as infancy.

My child has scoliosis as well as pectus. Is that common?

Yes. Scoliosis (curvature of the spine) is associated with CWA. It does not seem that one causes the other, but rather that there is an underlying genetic abnormality which predisposes to both. Many people have both a CWA and scoliosis, both “run-in-families” and both tend to surface in the teenage years (although both also have early onset forms). If both a CWA and scoliosis are present, Dr. Bodenstein will coordinate care with your orthopedic spine surgeon.

At what age should a person with a CWA be evaluated by a surgeon with special expertise in these conditions?

Evaluation of a CWA should be done as soon as it is noticed. Even if a child is young and no immediate intervention is planned, a complete evaluation will provide characterization of the problem and may uncover related health issues. Counseling will provide detailed information specific for the individual, including what to expect in the future and what type of heath monitoring may be necessary. This personalized information is much more important than what you can get from a FAQ like this or other online sources.

To speed things along, should I have some testing done before my first appointment?

If any relevant testing has been done, you should bring those results with you to your first visit. However, we do not advise specifically getting any testing done before your visit. Some tests may get done that are not necessary. If we feel that additional evaluations or testing is warranted, we can direct you to physicians who are experienced with chest wall patients. The timing of certain studies also may be important. CT or MRI is necessary prior to some surgery. But for a rapidly growing teenager these studies will not be accurate if done too far in advance. It is best to be seen by Dr. Bodenstein first and then he can discuss with you what other testing or evaluations are necessary (if any) and when they should be done.

What medical problems are caused by pectus excavatum?

In pectus excavatum the sternum (breastbone) is displaced backward toward the spine. The heart is shifted toward the left side. There may be some pressure on the right side of the heart from the sternum. Pectus excavatum also is associated with mitral valve prolapse. The overall volume of the chest is reduced and so there is some restriction in the ability of the lungs to fully inflate. These factors tend to reduce maximum heart output and limit respiratory function, which causes shortness-of breath and early fatigue at high exercise levels. Some degree of chest wall pain also is not unusual.

Beyond these physical concerns, there is a profound negative psychosocial impact from all CWA. This is especially true in adolescence where body image and peer acceptance are so important.

Will correcting pectus excavatum resolve the associated medical problems?

Correcting pectus excavatum will return the chest to it normal shape. This will allow the heat to return to its normal position and remove pressure on the right side of the heart. The lungs will also have more room to expand. Improvement is most noticeable when the pectus excavatum is more advanced and the pre-correction heart and lung problems are most pronounced.

The negative psychosocial consequences of pectus excavatum cannot be emphasized enough and correction of a pectus excavatum is associated with profound psychosocial benefit in adolescents. Correction is warranted even in the absence of significant heart and lung problems.

What is the right age for repair of pectus excavatum?

Pectus excavatum is usually done in the early to mid-teenage years. This is because the condition appears and/or worsens during puberty and it begins to have a significant psychosocial effect during those years. Repair generally is not undertaken during pre-teen years although exceptions may be made in some cases. There is no upper age limit for repair and it can be done well into adulthood. We focus on those 25 years of age or younger. However, if you are older please contact us and we will help find you an appropriate adult chest wall specialist, some of whom we work with directly.

What is the difference between a Ravitch procedure and a Nuss procedure for pectus excavatum and which is preferred?

A Ravitch procedure is open surgery where the abnormally shaped parts of ribs are removed and the sternum (breastbone) is placed into normal position. The Nuss procedure, which was described more recently, places a metal bar or bars beneath the sternum to move it into the correct position. The ribs are not removed but instead remodel over time so that in the future the bar(s) can be removed and shape of the chest will remain corrected. This is analogous to repositioning teeth with braces. Both procedures are very effective for treating pectus excavatum and Dr. Bodenstein has extensive experience with both.

For most people with pectus excavatum the Nuss procedure is preferred. The visible surgical scars are less and there is much less internal scarring of the chest wall. In some cases, the shape of the chest is not ideal for treatment with a Nuss procedure and a Ravitch procedure may be more appropriate, or a combination Ravitch and Nuss procedure may be used.

Wil my insurance cover repair of pectus excavatum?

Insurance will cover repair of pectus excavatum as a medically necessary procedure. Some insurance companies are using evermore strict criteria to determine what they deem medically necessary. In some cases, they will demand additional testing. We will take care of all interactions with your insurance company and work to get insurance approval for this needed care.

What type of evaluation and testing is required before a Nuss procedure?

The most important part of the evaluation is a history and physical examination done by a chest wall expert. Prior to a Nuss procedure either a CT or MRI of the chest will be done. This is generally required by insurance companies and also will be used in fabrication of the repair bar(s). Most of our patients also have a cardiogenetics evaluation to determine if there is an underlying genetic factor. Metal allergy testing to determine what type of metal bar is appropriate may also be recommended. Based on the initial evaluation, additional consultations and/or testing may be warranted. These include consultation with a pulmonologist, exercise testing and/or orthopedic spine evaluation. The nature and the extent of the evaluation is individualized – not everyone needs everything.

After a Nuss procedure, when is the repair bar removed, and what’s involved?

The repair bar or bars are usually removed three years after insertion. This is done as a day surgery procedure (no overnight stay).

How much pain is there after a Nuss procedure?

Dr. Bodenstein works closely with the Pain Service to minimize post-procedure discomfort. This begins before surgery with pre-medication, through the surgery with specific medications given by your anesthesiologist and after surgery with a detailed medication protocol. Additional pain management options such as nerve freezing are available on a case-by-case basis and will be discussed prior to surgery. Our protocols are highly effective in minimizing post-surgery pain.

What are the restrictions after a Nuss procedure?

Although there are significant activity restrictions right after surgery, these are progressively lessened over time. By about four months, all activities including most sports are acceptable. Contact sports generally are discouraged although not completely prohibited.

Can the excavatum come back after surgical correction?

Recurrence of a pectus excavatum can occur after any type of repair. Recurrence is unusual today especially if the timing of repair is coordinated with the period of rapid growth in adolescence.

Will the Nuss repair bar cause any problem going through airport security?

The bar can set off metal detectors. We will give you a letter to show airport security.

Is there a way to correct pectus excavatum without surgery?

Surgery is the most effective way to repair pectus excavatum. Both the Nuss and Ravitch procedures have been used extensively for decades and the results are proven. There is a Vacuum Bell method which has shown to be effective in younger patients with milder defects. Dr. Bodenstein can discuss this option with you if your child is a possible candidate.

What medical problems are caused by pectus carinatum?

Some people with pectus carinatum may experience intermittent chest wall pain or discomfort. Although pectus carinatum does not appear to have a major effect on the heart and lungs, the psychosocial aspects can be quite profound. This especially true during adolescence where body image and peer acceptance are so important. Virtually all adolescents will benefit from correction of their pectus carinatum.

Is surgery necessary to correct pectus carinatum?

Previously pectus carinatum was treated with surgery but today the vast majority of adolescent cases respond to bracing. If your child has a pectus carinatum, most likely it can be corrected without surgery. As people reach adulthood their chest wall becomes less flexible and bracing becomes progressively less effective. For adults, surgery usually is necessary for correction.

What is the right age for repair of pectus carinatum?

Pectus carinatum most often becomes noticeable and of major personal concern during the early to mid-teenage years. This is the ideal time for treatment with bracing. Younger children are usually not as affected, and not as concerned. They also may be less likely to cooperate with the bracing protocol. Adults, and some older teenagers with more rigid chest walls, will requires surgical correction.

Can the pectus carinatum come back come back after correction?

Pectus carinatum can recur after correction. This is less likely once your child has completed the adolescent growth phase. After achieving correction using an concentrated bracing schedule, we have teenagers use the brace on a more limited, maintenance schedule until the major growth phase is completed.

Will my insurance cover treatment of pectus carinatum?

We believe that insurance should cover correction for all patients with pectus carinatum. Medical visits are covered. Some companies refuse to cover the brace itself or surgery. We will take care of all interactions with your insurance company and aggressively work to obtain insurance company approval.

What type of evaluation and testing is required before correction of pectus carinatum?

The most important part of the evaluation is a history and physical examination done by a chest wall expert. Most of our patients also have a cardiogenetics evaluation to determine if there is an underlying genetic factor. Usually that is sufficient. Based on the initial evaluation, additional consultations and/or testing may be in order. The nature and the extent of the evaluation is individualized – not everyone needs everything.