UNC Surgeons Correct "Funnel Chest" With New Surgery

An 18-year-old male patient at UNC Hospitals has undergone improved treatment for pectus excavatum, a condition that occurs roughly once in every 2,000 U.S. births.

Pectus excavatum displaces the sternum, or breastbone, rearward and leaves a deep groove in the chest, making it appear caved-in. Stooped shoulders and poor posture exaggerate the effect, which carries both a physiological and a psychological burden, says Dr. Don K. Nakayama, professor and chief of pediatric surgery at the UNC-CH School of Medicine.

"The physiologic effect is that the chest doesn't expand normally," he explains. "While the children are able to breathe and measure normal in pulmonary function studies, most complain of easy fatigability and shortness of breath. In gym class, these may be the kids toward the back when they're running around the track. And during summer, they're the kids with T-shirts on when they go swimming."

Nakayama also points out that children commonly become self-conscious about the appearance of their chest. "All you have to do is look at newsstand magazine racks and you'll see how important chest appearance is to boys and girls. So this condition is very discomfiting, particularly when the child reaches adolescence. They become very self-conscious."

The new surgery, developed at Children's Hospital of the King's Daughters in Norfolk, Va., takes about 90 minutes, compared to the 4 1/2 hours required for the traditional procedure.

In the older operation, cartilage is removed from the ribs where they attach to the sternum. Muscle is also removed. The sternum is levered upwards and held in place with a flat steel bar, which rests on each side of the chest wall. The bar remains in place for six months, much like an orthopedic pin, and is removed in a second operation.

However, in the new procedure, neither muscles nor cartilage are removed. "We put in a much thicker and longer bar underneath the sternum. The bar is curved to conform to the desired shape of the chest and just holds things in place," Nakayama says.

He points out that the newer surgical method can take place two to three years later in life because the procedure is less radical. "You're relying on the body's own natural remodeling forces to bring the sternum and chest wall into a better position."

After the traditional operation, patients are restricted in activities involving arm and chest wall muscles for at least six weeks. Vigorous activity may resume after 12 weeks. But because muscle is not removed in the new procedure, such activity can be resumed as desired.

Nakayama notes that for both the older and new procedures, postoperative recovery time and pain are about the same. "But as bones conform to the desired configuration, then it becomes less painful," he says.

Although Nakayama's first Tar Heel patient was 18, he says children 6 to 10 years of age probably are more likely better candidates because their bones are more malleable, thereby increasing the chances for a good correction.

"I believe the new procedure will replace the old one for pectus excavatum. It's a shorter, less radical operation and should require shorter hospitalization."