Pectus excavatum is a condition where the breastbone (sternum) is sunken inward, creating a visible dip or hollow in the center of the chest. It affects roughly 1 in 300 to 1 in 1,000 live births, making it the most common chest wall deformity. The condition is five times more common in males and often becomes more noticeable during adolescent growth spurts.
What Causes the Sunken Appearance
The exact cause isn’t fully understood, but the leading explanation involves the cartilage that connects the ribs to the breastbone. This cartilage appears to grow in an irregular pattern, pushing the sternum inward rather than holding it in a neutral position. Genetics likely play a role: the condition runs in families and is frequently associated with connective tissue disorders.
About half of all people with Marfan syndrome, a genetic condition affecting connective tissue throughout the body, also have pectus excavatum. It’s also linked to Ehlers-Danlos syndrome, joint hypermobility syndromes, and several other inherited connective tissue conditions. Many people with pectus excavatum have no underlying syndrome at all, but the overlap is common enough that doctors sometimes screen for these disorders when the chest deformity is present.
How It Affects the Heart and Lungs
In mild cases, the sunken breastbone is purely cosmetic. In moderate to severe cases, the sternum can physically compress the heart and lungs, reducing how well they function. Studies using cardiac MRI have found decreased pumping efficiency in both sides of the heart. In one study of adolescents with pectus excavatum, over half showed reduced right heart ejection fraction, meaning the right side of the heart wasn’t pumping as effectively as expected.
Lung function takes a hit too. About 23% of patients in one study had a total lung capacity below normal limits, and 13% showed airflow obstruction. In practical terms, this can mean getting winded more easily during exercise, feeling short of breath during activities that shouldn’t be difficult, or simply not being able to keep up physically with peers. Interestingly, the severity of these functional problems doesn’t always match how deep the depression looks from the outside. Some people with a dramatic-looking dip have normal heart and lung function, while others with a seemingly mild case show measurable impairment.
What It Feels Like Day to Day
Many people with mild pectus excavatum have no physical symptoms at all. When symptoms do occur, they typically include shortness of breath during exercise, chest pain or tightness, a racing heartbeat, and fatigue that seems disproportionate to the activity. Some people notice these symptoms worsen during their teenage years as the deformity deepens with growth.
The psychological impact can be just as significant as the physical effects. Research on adolescents and young adults with chest wall deformities consistently finds impaired body image, reduced self-esteem, and social avoidance. In one study, 62.5% of patients reported feeling shame about their chest, and 40% said they were constantly preoccupied with it. Between 44% and 57% of adolescents actively hide the deformity by layering clothing or avoiding situations where their chest might be exposed, like swimming or sports. About 43% of patients in one study scored high enough on screening tools to suggest possible social anxiety disorder.
How Severity Is Measured
Doctors use a CT scan of the chest to calculate the Haller index, which compares the width of the chest to its depth at the deepest point of the depression. A normal chest has a Haller index of 2 or less. Between 2 and 3.2 is considered mild, 3.2 to 3.5 is moderate, and 3.5 or higher is severe. This number matters because it’s one of the key criteria insurers use when deciding whether to approve surgery.
For insurance coverage, most policies require a Haller index above 3.25 along with documented evidence of functional problems: reduced cardiac output on an echocardiogram, total lung capacity at or below 80% of predicted values, or objective evidence of exercise intolerance on pulmonary function testing. Cosmetic concerns alone typically don’t meet the threshold for coverage.
Non-Surgical Treatment: Vacuum Bell Therapy
The vacuum bell is a suction cup device that fits over the chest and uses negative pressure to gradually lift the breastbone outward. It’s used at home, starting with 30-minute sessions twice a day for the first four to six weeks, then increasing up to several hours daily. The total treatment duration depends on age and severity. Children and pre-adolescents with mild, symmetric cases (less than 3 cm deep) and flexible chest walls typically need 12 to 15 months. Adolescents and adults with deeper deformities and stiffer chest walls may need 24 to 36 months, with checkups every three months.
In one long-term study, 61 patients achieved a normal sternal position after an average of about 22 months, though the range was wide (6 to 69 months). The vacuum bell works best on younger patients whose chest walls are still pliable. It’s not effective for everyone, and results depend heavily on consistent daily use.
Surgical Options
The Nuss Procedure
This is the most common surgical approach, especially for children and teenagers. A surgeon inserts a curved titanium bar through small incisions on either side of the chest, threading it under the breastbone. The bar pushes the sternum forward into a normal position. It stays in place for three years while the chest wall remodels around it, then is removed in a second, shorter surgery. Because it uses small incisions rather than opening the chest, recovery is faster than with open surgery, though the first few weeks can be quite painful as the chest adjusts to its new shape.
The Ravitch Procedure
This is an open surgery where the surgeon makes an incision across the chest, lifts the chest muscles, removes the abnormal rib cartilage on each side of the breastbone, and repositions the sternum. A steel bar or plates are placed to hold the breastbone in its corrected position while healing occurs. The Ravitch procedure involves a larger incision and longer recovery, but the supporting hardware shifts out of place less often compared to the Nuss procedure. It’s sometimes preferred for older patients with stiffer chest walls, asymmetric deformities, or cases where a previous Nuss procedure didn’t produce the desired result.
Both procedures have high success rates for correcting the deformity, and studies have shown improved oxygen consumption during exercise after surgical repair. The choice between them depends on the patient’s age, the shape and severity of the depression, chest wall flexibility, and the surgeon’s experience.