The large majority of patients who present to referral centers are diagnosed with mild or moderate deformities and do not meet criteria for surgical intervention. These patients are typically started on exercise and posture programs. This strategy is designed to strengthen cardiopulmonary function and improve posture to allow for increased chest wall expansion as the classic pectus posture can contribute to progression of the deformity. Daily breathing and posture exercises are prescribed and patients are encouraged to participate in aerobic activities and team sports to avoid a sedentary lifestyle, which can worsen symptoms. These patients are reevaluated annually to monitor compliance and progression [41].

Several case series in Europe using sternal suction devices applied to the anterior chest wall have reported success in managing patients with mild deformities. The device is used daily for 12–15 months and preliminary studies demonstrate correction of the sternal depression at approximately 1 cm per month. Long-term outcomes with the device, however, are still pending [42–45].

The open approach requires a transverse inframammary skin incision at the level of the deepest portion of the sternal defect. Skin and muscle flaps are raised elevating the pectoralis muscles to expose the entire length of the affected portion of the sternum and bilateral costal cartilages. Subperichondrial resection of all abnormal costal cartilages is performed from the union with the rib laterally to the chondrosternal junction medially via an incision along the anterior surface of the perichondrium and dissection in the avascular plane between the costal cartilage and the surrounding perichondrium. Care must be taken to preserve the perichondrium to avoid devascularization. The xiphoid is then mobilized creating a substernal plane sweeping the pleura and pericardium off their attachments to the posterior sternum. A wedge osteotomy is created to neutralize the posterior depression of the sternum. A retrosternal bar or cartilage tripods are inserted to support the sternum. The incision is then closed and retrosternal and subcutaneous chest drains are typically left in place and removed 2–3 days later [34, 46].

Further modifications to the Ravitch procedure have been described and performed at select centers. The Leonard modification uses a retrosternal wire fixated to an external brace worn for 3 months as sternal support rather than a retrosternal bar [47] and the Robicsek modification stabilizes the sternum using Marlex mesh fixed to the cartilage remnants [48] (Fig. 2.3).

The minimally invasive approach described by Nuss involves surgically placing a convex steel bar underneath the sternum through small bilateral incisions. The bar is kept in place for 2–4 years allowing the sternum to reposition and remodel the deformed cartilage and rotate into a neutral position prior to removal. The original Nuss procedure has since been modified to use thoracoscopic guidance to visualize dissection of the transthoracic retrosternal plane for bar placement and to fixate the support bar in place with pericostal suturing to minimize postoperative displacement [34]. Bilateral thoracoscopic guidance or a subxiphoid incision can also help guide placement of the bar. The Nuss Procedure has become the initial procedure of choice for many pediatric surgeons who believe it to be less radical with better cosmetic results [49–52] (Fig. 2.4).

Pectus excavatum repair is generally well tolerated by patients with low rates of morbidity and mortality. A recent systematic review performed by Johnson et al. demonstrated that complication rates are similar for both procedures; however, to date, there is yet to be a randomized control trial looking at outcome differences between the two surgical approaches. Thus, the choice of operative procedure is primarily dependent on patient, surgeon, and institutional preference [15, 53–55].

The most common complications following pectus repair are bar-related events after the Nuss procedure such as displacement requiring reoperation (5.7–12 %) and pneumothorax (2–3.5 %). Wound infections (1.4–2.2 %) and pulmonary complications (2 %) such as effusions, atelectasis, and pneumonias also can occur but at less frequent rates. A recent analysis of patients undergoing the Nuss procedure using the NSQIP-P database reported a morbidity rate of 3.8 %, readmission rate of 3.8 %, and surgical site infection rate of 0.4 % [51, 52, 55–58]. Other rare but notable complications following the Nuss procedure include case reports of fatal or near-fatal hemorrhage during bar removal due to laceration of the pulmonary vessel or erosion into the sternum or aorta, or from bar rotation and erosion into the internal mammary artery [59–63]. Cases of cardiac tamponade and shock due to strut rotation and erosion to the aorta, bilateral sternoclavicular dislocation, and thoracic outlet obstruction have also been reported [62, 64, 65].

A rare but dreaded complication of the open pectus excavatum repair is acquired Jeune Syndrome (asphyxiating thoracic chondrodystrophy). In 1996, Haller et al. [66] first described 12 children who presented with severe restrictive cardiopulmonary symptoms due to a permanent impairment of normal chest wall growth after undergoing a Ravitch repair . The etiology is not completely clear; however, it is hypothesized that this life-threatening complication is the result of extensive and overzealous resection of the deformed cartilage with possible devascularization of the ossification center of the sternum. Early age of initial repair (less than 4 years old) may also increase the risk of this complication. Pulmonary function tests in these patients demonstrate a marked decreased FVC of 30–50 % and FEV1 of 30–60 %. Treatment is complex and requires re-excision of all substernal cartilage and using rib grafts or substernal support systems to reexpand the compressed chest cavity [67, 68].

The majority of patients report excellent patient satisfaction regardless of operative approach type. The psychological benefits have long been well documented in the literature [69]. A large multicenter trial by Kelly et al. [70] demonstrated significant improvements in patient’s body image difficulties and subjective limitations in physical activity after pectus repair. Ninety-seven percent of patients were satisfied with the postoperative cosmetic results.

Historically, recurrence rates prior to the introduction of the Nuss procedure ranged from 2 to 37 % [52]. More recent studies quote rates between 1.4 and 8.5 % [71, 72]. It was previously thought that the incidence of recurrence is higher in patients who are younger with connective tissue disorders or those who have had previous repairs [73]. However, Sacco-Casamassima et al. [71] did not find any significant patient or procedural factor predictive of recurrence in their series of 85 patients with recurrent pectus excavatum.

Small case series in Europe and South America [74–77] have been reported treating pectus patients who present with solely cosmetic issues with custom-made silicone prosthetic implants to improve the outward appearance of the chest without changing the sternal shape. The procedure is generally well tolerated with satisfactory cosmetic outcomes. The most common complication reported is seroma formation in up to 30 % of patients [77]; however, no long-term studies have been reported.

The magnetic mini-mover procedure [78–80] was designed to use magnetic force to gradually remodel the pectus excavatum deformity . Rather than a large magnitude of force applied at once, a magnetic field is used to apply a small amount of force over an extended period of time. This persistent gentle force theoretically allows the sternum to remold slowly and avoids the significant pain associated with traditional surgical procedures. A disc magnet is inserted surgically through a small subxiphoid incision and secured onto the sternum. A custom-made orthotic brace houses an external magnet and is fitted to the patient’s chest. Patients wear the brace from 18 to 24 months until the internal magnet is subsequently removed. The initial pilot study did not result in a significant change in Haller index in their ten patients at 1 year of follow up, but there was a trend towards improvement in a subset of younger patients under 14. Further analysis demonstrated that the device proved to be safe and cost efficient. Currently, the magnetic mini-mover is in phase 3 multicenter trials.