The “Nuss” procedure has revolutionized the treatment of pectus excavatum. It is very effective, has a low complication rate, and is associated with minimal external scarring when compared to the traditional “Ravitch” operation. The principal drawback is extreme pain, which is usually effectively managed in the immediate postoperative period with a thoracic epidural catheter, and for the first 2–3 weeks with narcotic analgesics. Narcotic addiction is a significant concern but should be rare with ethical and appropriate pain management techniques and conversion of non-narcotic analgesics as soon as possible after the operation.
Whether pectus excavatum produces measurable deficits in cardiac or respiratory function is controversial. Although many believe it is purely a cosmetic defect, patients frequently describe significant symptoms before surgery and many report considerable (albeit subjective) improvement in their stamina and comfort after the operation. Especially in active teenagers, flipping of the bar remains a constant worry but is thankfully rare, especially with the current widespread use of bar stabilizers.
The Ravitch repair done well is elegant and effective in its own right, but should only be offered when there are contraindications to the minimally invasive approach. Rather than remove all the costal cartilages, Dr. Haller described a technique whereby some of the cartilages are bisected at an angle (anteromedial to posterolateral) and the medial half is brought anterior to the lateral half, thus helping to push the sternum anteriorly. They should be stitched in this position to avoid postoperative slippage. A bar is not always necessary, but recommended for severe defects especially in older teenagers and adults.
In many cases, pectus carinatum is even more of a cosmetic concern than pectus excavatum. The operations described for correction of this defect are more invasive and perhaps less effective than those available for pectus excavatum. The external bracing technique, in which external pressure is applied to the sternum, appears to be very effective; however, compliance remains a significant hurdle.