Chest Wall Deformities with Dr. Robert Kelly
With Dr. Robert Kelly · hosted by Dr. Todd Ponsky · StayCurrentMD
Cued at 41:23 · stops at 42:08 · press play
Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
Podcast
Chest Wall Deformities with Dr. Robert Kelly
46 min · Published Jan 2017
Video
Pectus Deformities: Update Course 2015
34 min · Published Nov 2015
Video
An Update on Chest Wall Anomalies and Their Treatment: Advanced Practice...
Dr. Todd Ponsky · 46 min · Published Jul 2017
Video
Pectus Deformities: Update Course 2015
34 min · Published Nov 2018
Video
Pectus - Preoperative Assessment - Radiology and Cardiac Evaluation
Dr. Todd Ponsky · 44 min · Published Nov 2018
Video
Pectus - Preoperative Assessment - Genetics
9 min · Published Nov 2018
Only a few other public items share this expert — go deeper there →
Video
Pediatric Surgical Oncology Research Collaborative (PSORC): Studying Rare Pediatric Tumors
56 s · Published May 2026
Video
Update Course Rewind 2025: Hirschsprung + ARM: Rare but Real
1 min · Published May 2026
Video
Update Course Rewind 2025: Hirschsprung + ARM: Rare but Real
1 min · Published May 2026
Video
Pooling Patients to Study Rare Pediatric Tumors: An Introduction to PSORC
56 s · Published May 2026
Video
The fetal frontier: A review of current and emerging fetal therapies for genetic diseases
44 s · Published May 2026
Video
Indocyanine green assists with sentinel lymph node mapping in pediatric and adolescent patients
1 min · Published May 2026
What the experts said
Common presenting symptoms of pectus excavatum are easy fatigability with exertion, shortness of breath with exertion, and chest pain in the area of the pectus depression, generally not occurring at rest but with exertion.
Both Marfan syndrome and Ehlers-Danlos syndrome are conditions for which pectus excavatum is a marker.
In a normal chest, ribs should move like the handle of a bucket (up and out) and the sternum should move like the handle of an old-fashioned water pump (towards the ceiling and out towards the examiner).
In pectus excavatum, the depressed area of the chest is frequently absolutely fixed or in younger patients may move paradoxically, so that when the patient takes in a deep breath the xyphoid pulls back towards the spine.
In a series of more than 4000 patients evaluated for pectus excavatum, just over 25% had scoliosis.
When both severe scoliosis (past 40 or 50 degrees requiring spinal procedure) and pectus excavatum are present, the more clinically disruptive problem should be addressed first.
In the multi-center study of pectus excavatum at 11 centers, roughly 2/3 of patients had symptoms of easy fatigability, shortness of breath, or chest pain.
The Haller index is the ratio of the inner transverse diameter divided by the distance between the back of the sternum and the front of the spine; an index greater than 3.25 indicates severe pectus excavatum.
The Kansas City group recognized that in a patient with a barrel chest, the Haller index underestimates the depth of the depression because the AP diameter is increased, and they advocate an alternative index comparing the AP distance at the depression to the normal lateral chest.
Mitral valve prolapse is present in about 14% of pectus excavatum patients, compared to about 1% in young patients generally.
On average in a large number of pectus excavatum patients, pulmonary function tests are down by about one standard deviation from average (somewhere between 85 and 90% predicted).
Patients with pectus excavatum came up by close to a standard deviation in pulmonary function when they had the bellows action of the chest restored through surgery.
Restrictive lung disease (FVC less than 80% predicted with normal FEV1/FVC ratio) is seen in a significant fraction of pectus excavatum patients and is corrected by pectus operation, unlike asthma which is not corrected.
Patients with worse pectus excavatum have more likelihood of having restrictive pulmonary problems.
Surgical indications for pectus excavatum include at least 3 of 6 criteria: Haller index >3.2, pulmonary function tests <80% predicted, cardiac compression/mitral valve prolapse/other echo abnormalities, symptoms, progressive pectus, and major psychosocial issues related to body image.
The ideal age for pectus excavatum surgery is sometime just prior to the onset of puberty or early in puberty (ages 11-13 for girls, a year or two older for boys).
Having the bar in place during the rapid growth spurt of puberty results in extremely low likelihood of recurrence if the bar remains until that process is completed or nearly completed.
Some Asian groups, particularly in Korea (Dr. Park), operate on pectus excavatum patients when they are quite young (well under 10 years old) and report good results.
The hard part of pain management is not to relieve the pain, but to relieve the pain without obliterating consciousness, which requires feedback from the patient.
About half of pectus excavatum patients don't have their usual appetite after surgery, while about half eat very well.
For the first month after pectus excavatum surgery, patients should only walk and do activities of daily life; beginning at 1 month they can liberalize physical activities; by 3-6 months they can do pretty much any activity except those where they know they'll get a blow to the chest.
The Allergies test developed in Canada includes all components of the stainless steel bar, and patients have reacted against a number of minor components including nickel, chromium, and cobalt.
Titanium bars must be bent at the factory and have to be ordered in advance; they are currently much more expensive than stainless steel bars.
The likelihood of transfusion in Nuss procedure is exceedingly low.
Measuring the bar length from mid-axillary line to mid-axillary line and subtracting an inch is one method that works very well.
It should be standard practice in patients with any difficulty in visualization to use some technique of sternal elevation during Nuss procedure.
The most important part of the Nuss procedure, whatever techniques are used, is that the surgeon sees the tip of the introducer at all times—not just knowing it's in there somewhere, but actually seeing it—to minimize the likelihood of injuring the heart.
The bar must be positioned medial to the pectus ridge so there is a rib providing counterforce; if placed very laterally, only the intercostal muscles prevent movement and they will strip or rip under the load.
In patients who are growing, stabilizers on both sides of the bar can cause a wasp-waist effect when encased by scar, so they are generally placed on only one side.
If a patient is over approximately 6 feet 2 inches tall, the chances of needing two bars are almost 100%.
In multiple series, short-term complications of the Nuss procedure are few and intervention has been infrequent.
In a series of past 2000 Nuss procedures, about 2.7% of patients required some sort of revision for bar displacement.
The incidence of bar displacement has been cut to about half (approximately 1.35%) by using stabilizers and wrapping around the crossing of the bar to the rib with pericostal sutures.
Most bar displacement now occurs due to some kind of marked force or trauma rather than spontaneous displacement.
Bar allergy occurred in a little less than 1% (0.9%) of patients; screening for metal allergy has been performed since 2004 and has dramatically decreased the incidence.
About 6.4% of pectus excavatum patients had clinical or patch test evidence of metal allergy.
Wound infection occurred in 2.3% of patients, with more than 2/3 being superficial or cellulitis.
Recurrence after Nuss procedure occurred in about 1.2% of patients.
Why recurrence happens after pectus excavatum surgery is still poorly understood; it can occur even when the bar is left in for 3 years.
The bar should remain in place for at least 2 years before removal, with preference for closer to 3 years than 2 years.
In a study from Saint Etienne, France published in Journal of Pediatric Surgery, vacuum bell treatment was effective in pretty much eliminating pectus excavatum in 23 of 73 patients.
In patients who are young (under approximately 10 years old), the vacuum bell can be very effective in lifting the chest up.
In patients with recurrent pectus excavatum following a previous Ravitch operation, a Nuss procedure can elevate the chest to some extent but won't restore movement of the chest wall, and patients will have some restrictive process from scarring.
Brace therapy for pectus carinatum is successful somewhere between 2/3 and 3/4 of the time.
Because any operation carries more morbidity than almost any brace, it's hard to say one shouldn't start with brace treatment for most patients with pectus carinatum.
Marcello Ferro's dynamic compression system brace solved two patient objections: it is comfortable (pressure can be adjusted) and it's concealable under even an opaque close-fitting t-shirt.
The Ferro brace works approximately 3/4 of the time in Dr. Kelly's experience.
Most patients with pectus carinatum do not have symptoms, but there is a small subset who complain of pain and exercise limitation who should be considered for operation.
The reverse Nuss operation (Abramson procedure) works well in pectus carinatum patients with a flexible chest.
There is a broad perception among surgeons who have done many Ravitch operations for carinatum that there is an extremely low recurrence rate after that procedure, as opposed to the 10% recurrence rate after excavatum Ravitch.
There is a family tendency in pectus deformities in approximately 40% of patients, but the majority still don't have a family history.