Conditions We Treat

If your child has pectus excavatum (sunken chest), our chest wall providers will do an in-depth evaluation to determine if the pectus workup is needed. The testing results will help us determine if your child is a candidate for a Nuss surgical procedure or if other treatment options can be pursued. 

Pectus workup testing may include the following:

• Magnetic resonance imaging (MRI) of the chest to see how deep the pectus is with measurements called the Haller Index and Correction Index.
• Cardiopulmonary exercise test (metabolic stress test). Our center is one of the few in the country that uses a metabolic stress test to better understand if your child’s pectus is affecting how your child’s body is able to use oxygen.
• Echocardiogram to help evaluate if (and how severely) your child’s condition is impacting their heart function.
• Metal allergy test called Allergeaze (if applicable) to ensure metal bars used during surgery will be tolerated. Your provider will discuss this test during the consultation.

Early evaluation by a pediatric surgeon is beneficial. Bones are softer in teens and more easily reshaped. With age, the bones become harder, which can make it more difficult to raise the sternum. However, surgery can be successfully performed on patients through adulthood.

The Nuss procedure is an operation used to correct severe pectus excavatum. The procedure has the most optimal results when done between 10 and 20 years of age. It is considered “minimally invasive” because only a few small incisions (cuts) are needed.

The Nuss procedure has several steps:

• The surgeon makes two small cuts in the side of the chest.
• A video camera used for surgery (thoracoscope) is inserted to see inside the chest.
• The sternum is lifted off the heart externally.
• While using the camera to see inside the chest, a curved introducer instrument is used to create a pathway across the chest below the sternum.
• A metal bar shaped to fit the patient, called a pectus support bar, is placed in the pathway under the sternum and then rotated to lift the chest and correct the deformity.
• Cryoablation is performed to numb the nerves that cause pain in the chest. Read more about cryoablation and other programs and services we offer.
• The video camera is removed, and all incisions are closed at the end of the surgery.
• After three years (often four years for patients with a history of connective tissue disorders to avoid reoccurrence), the pectus support bar is removed through the same two small incisions on the sides of the chest.

Over the years, the team at Phoenix Children’s has refined and re-engineered the Nuss procedure to deliver better outcomes with decreased risks to children. Traditionally, the Nuss procedure carefully slides a metal bar between the heart and sternum. At Phoenix Children’s, our team lifts the sternum before inserting the bar, which lowers the risk of injury to the heart or lungs. This approach is gaining traction around the world because of our team’s dedication to sharing their insights and teaching other pediatric surgeons.

For many patients, we place multiple bars to balance the pressure of the sternum on the ribs. We also tie the bar in place with a special material that is very strong and does not break. In girls, we hide the incision under the breasts.

While uncommon, complications can occur during and after surgery. Complications include, but are not limited to:

• Metal sensitivity reaction or allergic reaction to the implant (pectus support bar) material (metal)
• Pain, discomfort or abnormal sensation due to the presence of the device
• Surgical trauma; permanent or temporary nerve damage; permanent or temporary damage to heart, lungs and other organs, body structures or tissues
• Skin irritation, infection and pneumothorax (air leaking in the space between the lung and chest wall, which may cause the lung to collapse)
• Fracture, breakage, migration or loosening of the implant

The Nuss operation does involve discomfort. However, we have an outstanding pain management team at Phoenix Children’s that will make sure your child is comfortable throughout the process.

Also, cryoablation (cryo) treatment is a standard practice with any Nuss procedure. It involves freezing the nerves located in the patient’s chest underneath each rib. This treatment helps by temporarily shutting off the nerves, decreasing the sensation of pain. Our studies have shown easier recoveries, less narcotic use, shorter hospital stays and less pain when using cryoablation.

The expected hospital stay for a pectus surgery is one to three days. The average stay is two days. A quarter (25%) of our patients will go home within 24 hours, and another 70% of patients go home the second day after surgery. All our patients are off narcotics between seven to ten days after the procedure. When you come for pectus surgery, you can expect:

• Your child will be taken to the preoperative area where they will change into a hospital gown. Nurses will begin an IV and prep them for surgery.
• Before surgery begins, you and your child will have a chance to meet the team (the surgeon, anesthesiologist, pain specialists, chest wall physician assistant and chest wall coordinator). 
• Once ready, your child will be taken back to the operating room and will be given medication to go to sleep. They may be in surgery for two to four hours. Your surgeon will speak with you in a private room once the procedure is completed.
• Your child will be taken to the recovery area immediately after surgery. They may stay in the recovery area for about 1.5 hours before going to a designated private room.
• Once your child is in their room, nurses will monitor their pain and will make sure their pain is manageable prior to discharge from the hospital. 
• Prior to discharge your child must:
  • Walk with minimal assistance and without dizziness
  • Eat a meal without vomiting
  • Urinate normally
  • Have pain controlled with oral pain medication
  • Use incentive spirometer 10 times each hour to prevent complications
  • Have a chest X-ray at the hospital

The first four weeks after surgery are critical for healing. After four weeks, your child may start doing cardiovascular exercises and lower body strengthening. Most contact sports can be resumed after two to three months. Our chest wall providers may also encourage physical therapy to strengthen the chest wall muscles.

After three years (often four years for patients with a history of connective tissue disorders to avoid reoccurrence) the pectus support bar is removed through the same two small incisions on either side of the chest.

On bar removal surgery day:

• Your child will be taken to the preoperative area where they will change into a hospital gown, and nurses will initiate an IV and prep them for surgery.
• Before the procedure begins, you and your child will have a chance to meet the team (the surgeon, anesthesiologist, pain specialists, chest wall physician assistant and chest wall coordinator). 
• Once ready, your child will be taken back to the operating room and will be given medication to go to sleep. They may be in surgery for approximately 90 minutes. Your surgeon will speak with you in a private room once the procedure is completed.
• Your child will be taken to the recovery area immediately after surgery. They may stay in the recovery area for about 1.5 hours before going home. The nurse in the recovery area will ensure your child is comfortable and stable prior to discharge.
• Children are regularly discharged from the hospital only taking over-the-counter pain medications, like acetaminophen or ibuprofen. If needed, their doctor will prescribe other pain medications.
• Your child will have a postoperative appointment with the surgeon, where the bars can be returned if desired by the patient. 

You can call our office at 602-933-0016, and arrange for a consultation during our Pectus Clinic with one of our eight pectus surgeons. Our Pectus Clinic is located at Phoenix Children's Hospital, Clinic D.

You can also address any other questions to our Chest Wall Program Coordinator, Rebeca Verduzco Padilla, at rverduzcopadilla [at] phoenixchildrens.com (rverduzcopadilla[at]phoenixchildrens[dot]com).

At Phoenix Children’s, we do an in-depth family history and a thorough physical examination to diagnose pectus carinatum. We also conduct a chest X-ray as part of the diagnosis process.

While surgical repair is an option for patients with pectus carinatum, the most common treatment is a brace. Bracing therapy eliminates risks involved with surgery.

During this therapy, a brace uses compression to push the deformity backwards, slowly reshaping the chest into its expected position.

Early evaluation for pectus carinatum is important to ensure treatment is successful. Bones are softer in young children and adolescents, and are more easily reshaped. Patients get a better correction during the early teenage years, as bones are still growing, and skeletons are not as rigid.

Phoenix Children’s offers different braces customized for each patient. The brace is typically worn under clothing (if desired) and is optimally worn for 23 hours per day. The time of the treatment is associated with the severity of the pectus carinatum and the stiffness of the chest wall.

Patients must build a tolerance to the brace. Our team provides a schedule to help get to the desired brace time discussed with your provider. Our chest wall providers may also encourage physical therapy to strengthen the chest wall muscles and help correct poor posture.

Pectus carinatum is not a life-threatening condition; however, many patients benefit physically and psychologically when they have their chest wall deformity corrected.

If you have any questions about pectus carinatum, please contact our Chest Wall Program Coordinator, Rebeca Verduzco Padilla, at rverduzcopadilla [at] phoenixchildrens.com (rverduzcopadilla[at]phoenixchildrens[dot]com).

SRS may occur on one side of the chest or on both sides. Symptoms include:

• A “clicking” or “popping” sound
• Pain in the lower chest or upper abdomen. Initial pain is usually described as sharp and stabbing, lasting a few minutes, and dull pain is described as lasting hours.
• Nausea and vomiting (associated with severe pain)

Some people with SRS get temporary relief by stretching the affected area, placing pressure on the area, using over-the-counter medications (such as acetaminophen or ibuprofen) or using a heat or ice pack.

Movements such as twisting, bending, deep breathing, sitting, sneezing or coughing may make the pain worse.

SRS is regularly underdiagnosed. The diagnosis of SRS is recognized by a thorough clinical history, physical examination and a dynamic ultrasound.

Phoenix Children’s developed a protocol for dynamic ultrasounds. The ultrasound is performed while the patient performs multiple prescribed movements. These movements allow our team to see the cartilages and if the ribs move under each other in real-time.

Some patients can cope with their SRS symptoms. Rest, along with ice, NSAIDS (anti-inflammatory medications) and topical pain relievers may be adequate to lessen the symptoms completely. Avoiding the movements that cause pain, however, may not be possible, especially for those involved in sports. For some, SRS pain can be devastating. Removing the nonattached cartilages surgically is often the cure for most patients. Referral to an interventional pain specialist is another option.

SRS surgery does involve discomfort. However, we have an outstanding pain management team at Phoenix Children’s that will make sure your child is comfortable throughout the process.

We also have cryoablation (cryo) to help with pain management. Cryoablation involves freezing the nerves located in the patient’s chest underneath each rib. This treatment helps by temporarily shutting off the nerves, decreasing the sensation of pain. Our studies have shown easier recoveries, less narcotic use, shorter hospital stays and less pain when using cryoablation.

The expected hospital stay for an SRS procedure is one to two days. The average stay is one day. When you come for SRS surgery, you can expect:

• Your child will be taken to the preoperative area where they will change into a hospital gown, and nurses will initiate an IV and prep them for surgery.
• Before surgery, you and your child will have a chance to meet the team (the surgeon, anesthesiologist, pain specialists, chest wall physician assistant and chest wall coordinator). 
• Once ready, your child will be taken back to the operating room and will be given medication to go to sleep. They may be in surgery for two to four hours. Your child’s surgeon will speak with you in a private room once the procedure is completed.
• Your child will be taken to the recovery area immediately after surgery. They may stay in the recovery area for about 1.5 hours before going to a designated private room.
• Once your child is in their room, nurses will monitor their pain and will make sure their pain is manageable prior to discharge. 
• Prior to discharge the patient must:
  • Walk with minimal assistance and without dizziness
  • Eat a meal without vomiting
  • Urinate normally
  • Have pain controlled with oral pain medication
  • Use incentive spirometer 10 times each hour to avoid postoperative complications

The first six weeks after surgery are critical for healing. After six weeks, your child may start doing cardiovascular exercises and lower body strengthening. They will not be able to play sports for eight weeks but may return to school/work once they are no longer taking narcotic pain medications (typically seven to ten days).

If you have any questions about SRS, please contact our Chest Wall Program Coordinator, Rebeca Verduzco Padilla, at rverduzcopadilla [at] phoenixchildrens.com (rverduzcopadilla[at]phoenixchildrens[dot]com).