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The Nuss Procedure

What is The Nuss Procedure ?

The Nuss procedure reshapes a sunken chest by placing a metal bar beneath the chest wall to push it outward. To insert the bar, our surgeons start by making small incisions (often as short as three centimeters) on the sides of the chest. Then they use a camera to guide them as they fix the bar in place.

Once the bar is in place, it takes time for your child’s chest to stay in the more typical position. After three or more years, when the chest can hold the new shape on its own, we will remove the bar in a surgery that typically does not require staying in the hospital overnight.

What are the benefits of the Nuss procedure?

A sunken chest wall can interfere with breathing and heart function. If this is the case for your child, we can use the Nuss procedure to create more space for the heart and lungs to work properly. 

Having a typical chest shape also enables kids to engage in sports and other activities they couldn’t or wouldn’t try before. Overall, our patients report feeling healthier, more confident and more enthusiastic in the months and years after this procedure.

The Nuss procedure is generally safer than other invasive chest wall operations, which involve cutting away cartilage (the soft material that also forms the structure of your nose). After those procedures, children can develop pain or serious breathing problems if the cartilage doesn’t grow back properly or is separated from the chest bones. With the Nuss procedure, there is very little blood loss and no cutting of bone or cartilage. The scar is also very small and barely visible.

What are the side effects of the Nuss procedure?

The Nuss procedure doesn’t have many side effects. Some children can have an allergic reaction to the steel bar in their body. We test all our patients before the procedure to see if they’ll have an allergic reaction. We can use a titanium bar if there is an allergy risk.

Children can sometimes feel the bar shift slightly when they take a deep breath. The sensation can be strange or unsettling, but this does not indicate a problem with the bar.

What are the risks of the Nuss procedure?

There are some rare risks associated with the Nuss procedure. Worldwide, about 3 percent of all patients see their chest sink inward again in the years after the bar is removed. A similar number will experience the bar slipping significantly out of position. If that happens, we do another surgery to put the bar back in the right place.

What to expect with the Nuss procedure?

We'll use a series of appointments to plan your child's surgery, and to make sure they stay healthy and heal after their surgery.

What to expect before the Nuss procedure?

During your child’s first appointment, we will talk about their health history, perform a physical exam and take pictures of their chest shape. We can almost always diagnose their condition without doing X-rays or other imaging. 

Depending on your child’s condition, we may run tests on their heart and lungs. If they have pain or trouble breathing when they’re playing or exercising, we can take measurements while they’re on a treadmill to understand how their chest wall affects them when they’re active.

We will also talk about your child’s chest wall and their options for treatment. You can take as long as you like to decide how and if you want to treat your child’s pectus excavatum. Some of our patients go home and think it over for weeks or months. Some decide during their first visit.

If you and your child choose the Nuss procedure, we will confirm that the procedure is covered by insurance before scheduling surgery. We will also test your child for metal allergies and give them a simple exercise plan to follow. Having good posture, muscle support and flexibility will help your child recover from the procedure. 

Two weeks before surgery, your child will come in for tests to see how they will react to anesthesia. They’ll also talk to our team about what their follow-up care will look like.

What to expect during the Nuss procedure?

The surgery usually lasts 1 to 2 hours. Your child will be asleep under general anesthesia throughout the procedure. We will also use a technique called cryoablation to freeze some of the nerves in their chest area, to reduce pain while they recover. The frozen nerves grow back and regain function within two to three months.

After the procedure, most patients stay in the hospital for only one or two days, and one parent is welcome to stay with them.

What to expect after the Nuss procedure?

The period after surgery is very important for making sure your child’s chest properly sets into its new shape. They’ll have to restrict their activity and movements for six to eight weeks. This includes sleeping on their backs, avoiding rough play and sports, and being careful not to slouch, twist their torsos or raise their elbows above shoulder height.

We take extra steps — like using special surgical techniques and medications — to keep pain to a minimum. Children may feel some pain and soreness but may need pain medication for only a few days after their surgery. 

Your child will have a follow-up appointment two weeks after surgery, to see how they’re doing and address any pain or other issues. We’ll see them four times during the first year after surgery, to monitor their progress and help them stay on top of their exercises. Then we’ll see them once a year until it’s time to remove the bar.

The chest wall is most likely to hold its new shape after the bar has provided support for at least three years. After three years, we will look at your child’s progress and make a plan for removing the bar.

How do I prepare my child for the Nuss procedure?

We do a physical exam and take pictures during the initial appointment, so your child should dress comfortably and be prepared to take off their shirt. You will be with the child during the entire appointment. Girls keep their bras on, and we have strict measures in place to safeguard the images and information we gather.

To prepare for the procedure and follow-up period, the most important thing is for your child to follow the exercise plan we set up for them. Building strength in their chest, back and core before surgery will help them recover and quickly get back to normal activities.

What questions should I ask my provider about the Nuss procedure?

  • How many of these procedures do you do each year?
  • What other treatments do you do for my child’s condition?
  • How do you decide between the Nuss procedure and other treatment options?
  • Do you test your patients for metal allergies?
  • What is your approach to pain management?

The Nuss procedure Doctors and Providers

 

Frequently Asked Questions

  • Do we have to do this now? 

    You can take as long as you like to decide whether and how to treat your child’s pectus excavatum. The ideal time to do the Nuss procedure is when your child has already begun their major adolescent growth spurt. For girls this is generally age 12 or older, and for boys it’s 13 or older. We want them to be done or mostly done with this growth phase by the time we take the bar out, so that their chest can maintain its new shape in the future.

     

  • What happens if we do nothing? 

    The condition does not resolve on its own. If your child wants to have a typical chest shape — or needs to have one, because of issues with their heart or lungs — they will need to be treated at some point. It is easier to recover from the Nuss procedure as a teenager than it is later in life.