Pectus excavatum is a chest wall deformity where the breastbone (sternum) and the cartilage connecting it to the ribs grow inward, creating a visible dip or “caved-in” appearance in the center of the chest. It is the most common chest wall deformity, occurring in roughly 1 in 300 to 1 in 1000 births, and it affects males about five times more often than females. The condition ranges from a barely noticeable shallow dip to a deep depression that presses against the heart and lungs.
What Causes It
The exact cause isn’t fully understood, but the abnormal shape results from overgrowth of the cartilage that connects the ribs to the breastbone. As this cartilage grows longer than it should, it pushes the sternum inward. The condition is often present at birth or becomes noticeable in early childhood, then tends to worsen during the rapid growth spurts of puberty.
Genetics play a significant role. About 40% of people with pectus excavatum have a family member with the same condition. It is also frequently associated with connective tissue disorders, the most well-known being Marfan syndrome and Ehlers-Danlos syndrome. Other linked conditions include mitral valve prolapse syndrome, Poland syndrome, and several rarer genetic syndromes that affect the body’s structural proteins. If you have pectus excavatum along with unusually flexible joints, tall and thin body proportions, or vision problems, your doctor may screen for an underlying connective tissue disorder.
How It Affects Breathing and the Heart
In mild cases, the dip in the chest is purely cosmetic and causes no physical symptoms. In moderate to severe cases, the sunken sternum can compress the heart and reduce the space available for the lungs to expand. People with more severe forms often notice shortness of breath during exercise, reduced stamina, or a feeling of chest tightness that they can’t quite explain.
Lung function testing shows measurable differences. In a multicenter study of 327 patients, average lung capacity sat at about 88% of predicted values before surgical correction and improved to roughly 93% afterward. The deeper the depression, the greater the impact: patients with a severity index above 7 (on a scale where 2.5 is normal) were four times more likely to show a restrictive breathing pattern compared to those with a lower index. After surgical repair, oxygen delivery per heartbeat improved by about 20% in patients who completed pre- and post-operative testing, suggesting the heart pumps more effectively once the compression is relieved.
The Emotional and Social Toll
The physical effects are only part of the picture. For adolescents and young adults, the appearance of the chest can weigh heavily. In pre-operative assessments, 40% of patients reported being constantly preoccupied with how their chest looked, and 62.5% described feelings of shame. One in four said the deformity directly harmed their self-image.
Social anxiety is common. About 43% of patients scored high enough on screening tools to suggest a possible social anxiety disorder. Between 44% and 57% of adolescents reported concealment behaviors like wearing layered clothing year-round, avoiding swimming pools, or skipping situations where they’d need to take their shirt off. These patterns can quietly shrink a young person’s world in ways that aren’t always obvious to parents or friends.
The good news is that surgical correction reliably improves these outcomes. Between 97% and 99% of patients report satisfaction with their chest appearance after repair, and studies consistently show reductions in depressive symptoms and increased confidence in social settings.
How Severity Is Measured
Doctors use a CT scan to calculate what’s called the Haller Index, a ratio of the chest’s width to its depth at the deepest point of the depression. A normal chest has an index of about 2.5. Values above 3.2 are generally considered significant enough for surgical discussion, and values above 3.5 are classified as severe. This number, combined with symptoms and how the condition affects your daily life, guides treatment decisions.
Surgical Repair Options
Two main surgical approaches exist, and both aim to reshape the chest wall so the sternum sits in a normal position.
The Nuss procedure is a minimally invasive technique introduced in 1998. A surgeon inserts a curved metal bar through two small incisions on either side of the chest. The bar is positioned behind the sternum and flipped into place, pushing the breastbone outward into its correct position. The bar stays in for two to three years while the chest remodels around it, then is removed in a shorter follow-up procedure. Because it avoids cutting cartilage or bone, the Nuss procedure results in less blood loss and a shorter operative time, averaging about an hour less than the open approach.
The Ravitch procedure is an older, open technique first developed in 1949. The surgeon makes a larger incision across the chest, removes sections of the deformed cartilage, and repositions the sternum with an internal support. It involves more tissue disruption but may be preferred in certain cases, particularly for adults with rigid chest walls or patients who need a second repair. Hospital stays are comparable between the two approaches.
Recovery from either surgery involves significant chest pain for the first few weeks, managed with pain medication. Most patients return to light activity within a few weeks and full physical activity within a few months, though the timeline varies by age and procedure type. Younger patients with more flexible chest walls typically recover faster.
Non-Surgical Treatment With a Vacuum Bell
For milder cases, a vacuum bell device offers a non-surgical alternative. It’s a suction cup that fits over the chest and creates negative pressure, gradually pulling the sternum outward over time. It doesn’t work overnight. Most protocols call for wearing the device at least two hours per day, with some recommending up to six hours daily during puberty when the chest wall is most responsive.
Treatment duration depends on age and severity. Children and pre-adolescents with a mild, flexible chest wall (depression less than 3 cm deep) typically need 12 to 15 months of consistent use. Adolescents and adults with a moderate depression and a stiffer chest wall may need 24 to 36 months. The best candidates are younger patients (under 11) with shallow depressions (less than 1.5 cm), a flexible chest wall, and the discipline to wear the device consistently for at least a year.
The evidence base for vacuum bell therapy is still limited compared to surgery. It works best as an option for mild cases or as a bridge for patients who want to delay or avoid an operation. For moderate to severe pectus excavatum, surgical correction remains the more reliable path to lasting improvement.