Chest Wall Malformations

Nemours pediatric surgeons have significant experience diagnosing, treating and caring for children and teens with chest wall malformations. This includes conditions such as pectus excavatum ("sunken chest" or "funnel chest") and pectus carinatum ("protruding chest" or "pigeon chest"). Your child may only have a minor chest wall anomaly that causes little or no health concerns. However, if the condition is severe, it can cause medical problems, so you should see a specialist early on to make sure your child gets the proper care. 

There are many options when it comes to treating chest wall malformations. Bracing or surgery can often help with medical issues as well as positively affect your child's appearance and self-esteem. The key is to get an evaluation as early as possible. This allows your family to better:

  • understand your child’s condition and its current and potential cardiovascular (heart and lung) impact, if any
  • prepare for potential physical and social impacts
  • learn which surgical procedures and treatment options are available to manage your child’s condition
  • ensure that your child is treated at the ideal time during their skeletal development (it varies from child to child)
  • explore nonsurgical management options
 
Types of Chest Wall Malformations

Pectus Excavatum (PE)

Pectus excavatum (PE) is a malformation that causes several ribs and the breastbone (sternum) to grow in an unusual way, giving your child’s chest a concave, or caved-in, appearance. The condition is also called funnel chest or sunken chest, although we encourage you to refer to it as PE. 

PE is congenital (present at birth), but often it does not become apparent until your child grows, particularly once they become a teen. Mild cases might be barely noticeable, but severe cases can affect your child’s heart and lungs.  

Causes of Pectus Excavatum

Pectus excavatum can occur on its own and is not connected to any genetic defect, although 35 percent of the time there is a family history of the condition. It can also be associated with other syndromes, including:

  • Marfan syndrome — a disorder that affects the body's connective tissue
  • Poland syndrome — a rare birth defect characterized by missing or underdeveloped muscles on one side of the body, especially noticeable in the major chest muscle
  • Rickets — a disorder caused by a lack of vitamin D, calcium or phosphate, which leads to softening and weakening of the bones
  • Scoliosis — a disorder in which the spine curves incorrectly (noted in about 30 percent of pectus patients)

Pectus Carinatum (PC)  

Pectus carinatum (PC) is a condition in which the chest protrudes outward. The breastbone juts out, leaving a narrow depression along the sides of the chest. This gives the chest a bowed-out appearance. It may also be called pigeon chest or protruding chest, although we encourage you to refer to the condition as PC.

Children and teens with PC generally develop normal hearts and lungs, but there can be some impacts. For example, some children and teenagers report breathing and significant psychological problems.

Causes of Pectus Carinatum

The condition can occur on its own, or it can be associated with other genetic disorders or syndromes such as:

  • Down syndrome — also known as trisomy 21, a genetic disorder caused by the presence of all or part of an extra copy of chromosome 21
  • Edwards syndrome —  also known as trisomy 18, a genetic disorder caused by the presence of all or part of an extra  chromosome 18
  • homocystinuria — a disorder that involves the incorrect metabolism (the physical and chemical processes the body uses to convert or use energy) of a specific amino acid that the body uses to make protein and build tissues
  • Marfan syndrome — a disorder that affects the body's connective tissue
  • Morquio syndrome — an abnormality in the growth, development, shape or integrity of the bones and cartilage, most commonly resulting in dwarfism
  • osteogenesis imperfecta — a condition that causes the bones to be excessively fragile (also known as brittle bone disease)
 
Treatment for Chest Wall Malformations

Based on the severity of the malformation, treatment can include surgery or a nonsurgical approach such as bracing, vacuum bell treatment, or observation and monitoring. We’re here to educate you on these options as well as offer guidance and answer questions so you can make the best decision for your child. 

Surgery Options

Ravitch procedure (PE or PC): During, the Ravitch procedure, a surgeon makes an incision then removes abnormal cartilage and repairs or reshapes the sternum and ribs. This procedure can be used to correct either PE or PC and is typically performed when a child is between 13 and 20 years of age.

Nuss technique (PE only): The Nuss technique is a minimally invasive procedure used to repair PE. During this procedure, a surgeon makes small incisions then inserts a bar into the chest to push it forward — like an internal brace.  The chest is reshaped and the bar is removed after three years. This procedure can be performed on children 8 years of age and older.

Nonsurgical Options

Vacuum bell (PE only): This procedure uses a suction cup that creates a vacuum seal on the anterior (front) chest wall. This lifts the sternum and, over time, can correct PE.  This option is more effective in young children. 

Nemours Physical Therapy Services

Your doctor may also recommend physical therapy and exercises to help strengthen your child’s weak chest muscles. Nemours has extensive physical medicine and rehabilitation services available on-site that are staffed by highly experienced experts trained to work with children who have chest wall malformations.

What to Expect When Your Child Needs Surgery

If your child needs surgery, you can trust the highly trained pediatric surgical team at Nemours Children’s Hospital. Our pediatric surgical specialists (surgeons, anesthesiologists and nurses) understand what kids (and families) need, psychologically and physically.

Because we truly believe in family-centered care, we invite you (one parent or guardian) to the operating room to be with your child until just after sedation. We also provide our families with a peaceful place to wait without leaving the surgical floor, in our beautiful rooftop garden.

 
What Happens During the Presurgical Visit

Before any type of surgical procedure, your child will require a presurgical visit. At this visit, you and your child will meet your surgeon, discuss the diagnosis and details of the operation, and get answers to all of your questions or concerns. You may also meet with an anesthesiologist if necessary.

We’ll call you before your visit so you'll know what to bring, like:
  • any medications your child is currently taking
  • your ID
  • insurance and/or Medicaid cards
  • proof of guardianship, if applicable

When you arrive for a presurgical visit, go directly to the presurgical clinic area on the second floor. There, the patient service representative will review and verify your information and insurance. You will also complete a medical history form.

A nurse practitioner will assist with the visit and order any necessary tests. She or he will also inform you about what to expect the day of the surgery, including:

  • how your family will be kept updated during the procedure
  • when you can expect the surgeon to come out and speak with you
  • when you can join your child in the recovery room

EmmiKids Programs: Online Educational Videos for Families

At the end of the presurgical visit, you and your child may have the option to view an online educational program from EmmiKids about the upcoming surgical procedure and the anesthesia. You can watch these programs at the hospital or you may choose to watch them at home or in your local library. We’ll give you an access code to view the program(s).

Learn More About EmmiKids at Nemours »

 
How to Prepare the Day Before Surgery

The day before surgery, the surgical services staff will call you to check on your child’s health status, give you a time of arrival for the next day, update you on feeding instructions, and answer any questions.

General Feeding/Drinking Instructions

No food, milk, formula or breast milk may be consumed after a specific time (provided by your surgeon) on the day of the surgery. Your child may only have apple juice, electrolyte replenishing/sports drinks or water up to four hours prior to scheduled surgery time. These are considered “clear liquids.” We ask that you do not substitute other juices. Special Note: Infants 11 months or younger may have breast milk, but only up to six hours prior to surgery.

Suggested items to pack for your child:
  • empty baby bottle or cup
  • special feeding or suction equipment (if needed)
  • bathrobe
  • slippers
  • socks
  • favorite stuffed animal and/or blanket
  • loose-fitting clothes
  • eyeglasses (if needed)
Please remove the following items from your child:
  • all jewelry — including earrings
  • fingernail polish
  • hair accessories
  • contact lenses
  • retainers
 
What Happens the Day of Surgery

On the day of surgery, we ask that you be here at the time instructed so your child’s surgery won’t be delayed. We encourage you to allow extra time in your travel plans in case of traffic or unexpected delays.

Parking and Where to Go in the Hospital

When you arrive at the hospital on the day of surgery, you can use our complimentary valet parking, or you can self-park in the garage near the outpatient entrance. Valet services are located at the outpatient entrance and are available Monday through Friday, from 8 a.m. to 6 p.m.

Once inside the hospital, go straight to the surgical services desk on the second floor. There, the patient service representative will greet you, review your child’s information and insurance status, and check your child in. We’ll give you a case number, as well as a pamphlet with instructions about where to go and what to do during the waiting period. We’ll ask your child to change into a hospital gown and will then check vital signs: temperature, pulse, blood pressure and weight.

Just Before Surgery

While waiting for surgery, your child can play in our colorful, relaxing surgical commons area featuring many interactive games and activities to help reduce anxiety and pass the time. We also have a “toy store” where your child or teen can choose from a variety of gifts like stuffed animals, ball caps, and electronic items to keep.

When it’s close to the time for surgery, we’ll escort you and your child to an exam room, where you’ll meet the anesthesiologist and operating room nurse. As part of our unique family-centered model of care, our anesthesiologists may allow one parent to accompany your child to the operating room and stay until just after the anesthesia is administered.

During and Just After Surgery

You’ll be asked to stay in the surgical waiting area while your child is in the operating room. A nurse liaison or a trained volunteer will keep you updated during the procedure. If you need to leave the area for any reason, please inform a staff member.

After surgery, your child’s surgeon will come out to discuss the procedure and answer any questions you may have. We’ll inform you as soon as you can join your child in the recovery area or “wake up” room.

Patients must be fully awake before discharge. You should plan to stay in the recovery area for at least one hour (or longer, depending on your child). It’s very common for children to experience nausea and/or vomiting just after surgery, and also have a flushed face. We’ll offer clear liquids to drink when your child is ready. If your child will be admitted to the hospital after surgery, you’ll be given instructions ahead of time.

Once your child is ready for discharge, a nurse will review instructions with you regarding diet, wound care, medication, activity, and when your child should return to see the doctor. You may also be given prescriptions.

 
What to Expect During and Just After Surgery

You’ll be asked to stay in the surgical waiting area while your child is in the operating room. A nurse liaison or a trained volunteer will keep you updated during the procedure. If you need to leave the area for any reason, please inform a staff member.

After surgery, your child’s surgeon will come out to discuss the procedure and answer any questions you may have. We’ll inform you as soon as you can join your child in the recovery area or “wake up” room.

Patients must be fully awake before discharge. You should plan to stay in the recovery area for at least one hour (or longer, depending on your child). It’s very common for children to experience nausea and/or vomiting just after surgery, and also have a flushed face. We’ll offer clear liquids to drink when your child is ready. If your child will be admitted to the hospital after surgery, you’ll be given instructions ahead of time.

Once your child is ready for discharge, a nurse will review instructions with you regarding diet, wound care, medication, activity, and when your child should return to see the doctor. You may also be given prescriptions.

 
What to Expect the Day After Surgery

Make sure your child rests as much as possible after surgery. Temporary nausea or vomiting is quite common after discharge. But if your child experiences any of the symptoms below, call your surgeon or the nursing staff immediately:

  • a fever of more than 101 degrees Fahrenheit
  • persistent nausea or vomiting
  • severe pain that’s not relieved by prescribed medication
  • excessive bleeding from an incision

A nurse will call to check on your child’s recovery and to address any questions or concerns. We’re committed to making your child’s surgical visit as pleasant and safe as possible – before, during and after the procedure.

 
Managing Pain After Surgery: Nemours Pain Management Program

If your child is experiencing postsurgical pain, we can help. Nemours Children’s Hospital has one of the only pediatric pain management programs in the country that provides holistic, whole-child — and whole family — healing for children and teens experiencing acute (temporary) or chronic (ongoing) pain. Our integrated program is led by a world-renowned pediatric anesthesiologist who is also board-certified in pain management. We focus on relieving the physical, mental, and emotional aspects of pain using a variety of therapies in an outpatient or inpatient (day stay hospital program) setting.

Learn More About Pediatric Pain Management at Nemours Children’s Hospital »

Jacksonville

Nemours Children's Specialty Care, Jacksonville

807 Children’s Way
Jacksonville, FL 32207
Get Map & Directions »

For Appointments: (904) 697-3600

Hours: Monday–Friday, 8 a.m. to 5 p.m.
Learn More About This Location »

 
What to Bring
  • your photo ID
  • insurance and/or Medicaid cards
  • referral from your referring physician (if required by your insurance)
  • co-payment, if applicable
  • legal guardianship or custody papers if you are not the patient’s parent
If available, please provide:
  • preferred pharmacy contact information
  • names and dosages of all medications your child is taking (including over-the-counter medications)
  • name and number of your primary care physician
  • parent (and child’s) social security numbers
  • parent work information (address, telephone numbers)
  • immigration information (if your child was not born in the United States)
  • list of prior immunizations
New Patients
  • Patient Registration (PDF)
    English
Returning Patients
  • Release of Information (PDF)
    English | Spanish
  • Patient Presents Without Legal Guardian (PDF)
    English | Spanish
    Note: A parent or legal guardian must be with a child for a first visit.
 
Forms & Resources
New Patient Forms
  • Patient Registration (PDF)
    English
Returning Patient Forms
  • Release of Information (PDF)
    English | Spanish
  • Patient Presents Without Legal Guardian (PDF)
    English | Spanish
    Note: A parent or legal guardian must be with a child for a first visit.
Resources for Patients & Families

At Nemours Children's Specialty Care, Jacksonville, our pediatric general surgeons offer expert care to families from all over Florida, Georgia and beyond. Here, our pediatric general surgeons perform minimally invasive repair of pectus excavatum — including the Nuss procedure — for children with pectus excavatum (PE). We also offer treatment for other types of chest wall anomalies, too.