The costs, risks and results of pectus excavatum surgery for adults
Pectus excavatum is a deformity of the chest wall where the sternum and ribs develop inwards, causing the rib cage and chest to appear sunken. In the vast majority of cases, pectus excavatum is harmless and is a cosmetic issue.
In some cases, the condition can lower the capacity of the lungs and heart, making exercise more difficult.
There are three reasons why you might choose to have surgery for pectus excavatum, although you don’t need to be affected by all of them to undergo surgery:
- Chest pain—in one study, 8% of patients with pectus excavatum reported having chest pain (source). However, surgery is not certain to solve this problem.
- Reduced heart and lung capacity, which affects physical activity—67% of patients in one study reported a decrease in stamina and endurance during exercise (source). However in practice most patients have normal function.
- Cosmetic concerns—if an individual is self-conscious about how their chest looks, this could affect their self-image and self-esteem. In this case, they may choose to have surgery for cosmetic reasons, rather than medical reasons (source). This is the primary reason for surgery in most patients.
In this guide you can find out more about:
- What are the surgery options for pectus excavatum?
- Is surgery necessary?
- Where can I have the surgery?
- Can adults have pectus excavatum surgery?
- How much does the surgery cost?
- What are the complications and risks associated with the costs?
What are the surgery options for pectus excavatum?
There are three types of pectus excavatum surgery: the Nuss procedure, the Ravitch procedure and implant surgery.
Nuss procedure
The surgeon inserts a metal bar through an incision on each side of your chest. Once the bar is inside, the surgeon flips it over, forcing the sternum outwards.
The bar must stay in place for at least three years, depending on the severity of your condition and your age. After this time, it will need to be removed, which requires a further procedure. Some cases, patients will have the bar left in place permanently.
Ravitch procedure
The surgeon:
- opens your chest to access your sternum and ribs
- removes small sections of chest cartilage
- repositions the ribs and sternum
- uses steel bars to hold the sternum and ribs in place
Depending on your condition, the steel bars might need to remain there permanently, which means you don’t have to undergo a second procedure to have them taken out. Otherwise, you would have the bars removed.
The Ravitch procedure is the most invasive surgery for treating pectus excavatum.
Implant surgery
Unlike the Nuss and Ravitch procedures, implant surgery is less invasive cosmetic surgery that doesn’t involve adjusting the sternum or ribs. Instead, the surgeon inserts a silicone implant under your skin and chest muscle. The implant is custom-made to fit your anatomy exactly.
This is the only procedure for correcting pectus excavatum that you can have without invasive surgery into the rib cage. You can find out more about implant surgery here.
Pectus excavatum surgery comparison
| Nuss | Ravitch | Implant | |
|---|---|---|---|
| Operation length | Approx. 90 minutes | Speak to your practitioner | Approx. 60 minutes |
| Hospital stay | Approx. 4 days | Approx. 5 days | 1 day |
| Recovery (when you can resume all usual activities) | Approx. 3 months | Approx. 3 months | 4–6 weeks |
| When the bar is removed | 3–5 years after insertion (if the surgeon decides not to leave it permanently in place) | 1–2 years after insertion (if the surgeon decides not to leave it permanently in place) | N/A |
Is pectus excavatum surgery necessary?
Most people who have pectus excavatum don’t need surgery to correct it, as they have no (or very few) symptoms and the condition doesn’t affect their quality of life.
However, you may decide to have surgery for one, or both, of the following reasons:
- You’re experiencing symptoms such as shortness of breath, palpitations, tiredness, chest pain or difficulty exercising.
- You’re worried about the appearance of your chest and find it’s affecting your self-image. For example, you may try and avoid activities such as swimming or wearing swimwear at the beach.
If your pectus excavatum doesn’t affect your health, you could consider having cosmetic surgery to correct the issue with a custom-made implant.
Where can I have pectus excavatum surgery?
Pectus excavatum surgery for adults isn’t readily available on the NHS. However, if your condition is severe and there is “evidence of cardiac or pulmonary compression on CT or echocardiogram, mitral valve prolapse, arrhythmia, or restrictive lung disease”, you may be considered for surgery on the NHS (source).
In most cases, people with pectus excavatum will need to fund their own surgery.
Implant surgery is an option for people who have pectus excavatum and are bothered by how it looks. This procedure isn’t available on the NHS in most areas but it’s a much more affordable and less risky option than the more invasive Nuss and Ravitch procedures.
If your pectus excavatum is severe or you have symptoms and are considering surgical repair, you should contact your GP in the first instance. They can refer you for tests—such as a chest x-ray, MRI scan, CT scan and/or pulmonary function tests—that will help determine the severity of your condition.
Depending on the outcome of these tests, you may be referred for surgery. It’s highly unlikely that you would be referred for surgery without having these tests done first for severe cases.
If you’re not eligible for pectus excavatum repair on the NHS, your other option would be implant surgery. In that case, you can speak to Stephen McCulley, one of the UK’s leading surgeons in this area, who will explain what’s involved in the procedure.
Can adults have pectus excavatum surgery?
Yes. Although the majority of patients are young adults when they have surgery (source), both the Ravitch and Nuss procedures are effective treatments for adults too.
There’s no age limit to these surgeries and adults are at no greater risk during the procedure and recovery period compared to children. However, the Nuss procedure can be more difficult to carry out on adults than children (source).
One study of patients who’d had the Nuss procedure found the average age was 23.2 and the range of ages was 18 to 45 (source). In another study of 47 women undergoing pectus excavatum surgery, the patients’ average age was 35 (source).
Do the symptoms of pectus excavatum get worse with age?
Pectus excavatum typically worsens when people go through puberty. However, if you’re an adult who has stopped growing, it’s unlikely your pectus excavatum will get any worse.
How much does pectus excavatum surgery cost in the UK?
As a rough guide, you can expect to pay the following for pectus excavatum repair:
- The Nuss procedure: upwards of £32,000 (source).
- The Ravitch procedure: speak to your practitioner
- Implant surgery: £6,000–£11,000
Surgery to repair pectus excavatum is expensive and unfortunately, as it’s an existing condition, it’s unlikely to be covered by health insurance policies.
If you have symptoms associated with pectus excavatum, your GP is likely to refer you for tests, such as a chest x-ray, CT scan or MRI scan and/or heart and lung function tests. In most cases, these tests will be available on the NHS.
However, if you don’t have any symptoms but choose to have surgery, depending on the surgeon and clinic you choose, you may need to pay extra for these tests on top of the cost of the operation.
What results can I expect from pectus excavatum surgery?
The majority of patients who have corrective surgery for pectus excavatum experience positive results (source). In one study, all but one of the 383 patients who had the Nuss procedure reported feeling happy with the outcome (source).
In terms of recovery time for each procedure, you can expect the following:
| Nuss | Ravitch | Implant | |
|---|---|---|---|
| Hospital stay | Approx. 4 days | Approx. 5 days | 1–3 days |
| Recovery (when you can resume all usual activities) | Approx. 3 months | Approx. 3 months | 4–6 weeks |
Implant surgery has by far the quickest recovery time, as you can expect to resume all your usual activities within six weeks of having the procedure. You can find out more about what to expect when recovering from pectus excavatum implant surgery here.
The long-term results of surgery aren’t clear for adults as most research relates to paediatric surgery. Although one study of adults reported that 89.7% of patients who had surgery were happy with the appearance of their chest (source), long-term follow-up studies of pectus excavatum surgery in adult patients are lacking.
However, the studies that have been done on children are positive, with one saying patients experienced a “sustained improvement in cardiopulmonary function” (source).
Is pectus excavatum surgery worth it?
Studies show that most patients who have the surgery are pleased with the results. One study of 86 adults concluded that the surgery had “had excellent post-operative outcome in the short term follow up” (source) and that patient satisfaction was excellent (source).
However, the Nuss and Ravitch procedures are invasive surgeries which have associated risks and come with a long recovery period. They are also expensive and, in many cases, unlikely to be funded by the NHS.
Only you can decide if it’s worth having surgery to correct your pectus excavatum. Speak to your GP in the first instance.
What are the complications and risks associated with pectus excavatum surgery?
First, repairing pectus excavatum involves major surgery. Even though the Nuss procedure in particular is often described as ‘minimally invasive surgery’, it still carries risks and requires a four‑day stay in hospital. The Ravitch procedure is an invasive procedure that is used for more complex cases (source).
The only less invasive procedure which will improve the appearance of pectus excavatum is implant surgery. However, this doesn’t repair the concaved rib cage and sternum typically associated with the condition.
Is pectus excavatum surgery painful?
As the Nuss and Ravitch surgeries both involve adjusting bone, connective tissue and muscle, you can expect to feel pain after the operation. Your surgeon will help you manage this with pain medication so you can comfortably take deep breaths, cough and perform gentle movements such as walking, without being in too much pain.
Are there life-threatening complications associated with pectus excavatum repair?
The following factors can influence the level of risk that pectus excavatum surgery carries:
- Type of surgery
- Patient’s age
- Severity and asymmetry of the condition
- Whether the patient has had chest surgery before
- The surgeon’s experience
One US study reported that life-threatening complications occur in fewer than 0.1% of cases (source), while a report by the NHS stated that the Nuss and Ravitch procedures “were generally safe for paediatric and adult patients with no perioperative mortality reported” (source).
However, as major surgery always carries a risk of danger and death, you should take everything into careful consideration before you decide to go ahead with it.
What are the common complications associated with pectus excavatum surgery?
Your surgeon will give you a full list of the complications and side effects associated with surgery. We list some of them below:
- Wound infection—patients are usually given antibiotics in the first 24 hours after surgery to limit the risk of infection (source).
- Pneumothorax—according to Dr Nuss, the surgeon who pioneered pectus excavatum corrective surgery, pneumothorax (also known as a collapsed lung) is the most common complication (source). In most cases, this is simply monitored with a chest x-ray but some patients might need a chest drain (source).
- Hemopneumothorax—air in the chest cavity.
- Pericardial tear—a tear in the membrane surrounding the heart.
- Displacement of the chest bars and perforations to the atriums and ventricles of the heart (source)—these complications are very rare.
Although chest tubes are used to treat certain complications, they also present their own issues. Rare complications associated with chest tubes include:
- bleeding into the pleural space
- injury to the lungs
- a collapsed lung
- infection (source).
Such major complications are very rare with implant based surgery.
What next?
Speak to your GP about your symptoms or if you have any concerns about pectus excavatum.
If you want to find out more about pectus excavatum implant surgery, read our guide Pectus excavatum implant surgery: explaining the procedure, results and cost or contact Stephen McCulley today by phone on 0115 962 4535 or by email at enquiries@stephenmcculley.co.uk.