Treatment of Pectus Excavatum
For symptomatic or severe pectus excavatum, minimally invasive repair of pectus excavatum (MIRPE/Nuss procedure) is the standard of care, while non-surgical options including vacuum bell therapy and orthotic approaches can be considered for mild cases or patients who decline surgery. 1, 2
Treatment Algorithm
Initial Assessment and Workup
Before determining treatment approach, complete the following evaluations:
- Cardiac evaluation is mandatory, particularly screening for mitral valve prolapse (present in approximately 15% of cases) and assessment for connective tissue disorders such as Marfan or Noonan syndrome 3, 4
- Pulmonary function testing (spirometry) to assess restrictive respiratory patterns 3, 5
- Imaging studies: CT with IV contrast provides detailed anatomic assessment for surgical planning, while MRI can facilitate chest wall reconstruction planning 3
- Severity assessment using Haller index and clinical symptoms (dyspnea, chest pain, exercise intolerance, cosmetic concerns) 1
Treatment Options by Severity and Patient Factors
Surgical Treatment (Primary Option for Moderate-to-Severe Cases)
Minimally Invasive Repair (MIRPE/Nuss Procedure):
- This has become the standard of care for pediatric and adolescent patients and is increasingly used successfully in adults 1, 6
- The technique involves temporarily implanting metal bars to correct the deformity 1, 7
- In adults, advanced preoperative evaluations and technique modifications are essential due to increased calcification and rigidity of the chest wall, which increases complexity and complication risk 1
- For severe cases, modified taulinoplasty with double Pectus Up bars offers improved correction, increased stability, and reduced complications, though with increased technical complexity 5
Open Repair (Ravitch Procedure):
- Alternative surgical approach, though less commonly employed than MIRPE 7
Non-Surgical Treatment (Select Patients with Mild Disease)
Vacuum bell therapy can be considered for pectus excavatum in appropriately selected patients 2
Autologous fat grafting and hyaluronic acid injections represent emerging non-surgical options for cosmetic improvement 2
Orthotic brace therapy is primarily indicated for pectus carinatum rather than excavatum 2
Special Clinical Considerations
Patients with genetic syndromes require comprehensive cardiac workup:
- Those with connective tissue disorders (Marfan, Noonan) need thorough evaluation as pectus excavatum may be one phenotypic manifestation 3
- Patients with osteogenesis imperfecta may have more severe restrictive respiratory patterns 3
Surgical planning modifications:
- In patients with kyphoscoliosis and pectus excavatum, cardiac migration to the left hemithorax may limit working angles during procedures 3
Common Pitfalls to Avoid
- Do not rely on chest radiograph alone—HRCT is routinely indicated to fully characterize the deformity and plan surgical approach 3
- Do not overlook associated cardiac abnormalities, particularly mitral valve prolapse, which requires preoperative identification 3, 4
- In adults, do not underestimate the increased technical difficulty and higher complication risk compared to pediatric repairs 1
- Monitor for postoperative complications including atelectasis and pleural effusion 3
Expected Outcomes
Adult patients undergoing MIRPE with proper preoperative evaluation and technique modifications can achieve highly successful repair resulting in symptom resolution and satisfying cosmetic results 1. The procedure allows the implant to remain completely invisible with appropriate technique 5.