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How to Treat Pectus Excavatum
Pectus excavatum can be treated:
 Surgically 
 Non-surgically
The most used surgical technique is the Nuss procedure. Even though this technique is effective,
it still comes with side effects. Dr. Nuss doesn’t recommend surgery in very young patients
because of the potential risk of relapse after removing the Nuss bar. 
Non-surgical methods such as bracing and vacuum bell therapy are practical, proven ways to
improve pectus excavatum non-surgically. 

How Bracing Improves Pectus Excavatum
Bracing applies progressive external force on the flared ribs that often come with pectus
excavatum. This type of treatment is more known for patients with pectus carinatum. However, it
is scientifically proven to be highly effective in patients with pectus excavatum.
Specific physical exercises are also used to increase the effectiveness of the method. The most
critical factor in a successful treatment is chest flexibility and consistency in application. Even
though this method is relatively unknown to the public, scientific publications by researchers
show impressive results. 

Law in Orthopedics
The non-surgical treatment of pectus excavatum with braces is based on Nicolas Andry’s
principles of bone remodeling. He is the “father of orthopedics.” His book, published in 1741,
explained that bone and cartilage are flexible substances, and external forces (in our case,
bracing) can remodel them. This is accepted as a law in orthopedics, known as the law of bone
remodeling. Applying a gradual external pressure to the deformed bone structure can remodel the
chest wall.

32 Years of Studies
A 32-year study collected data from 4012 patients with pectus deformities from 1977 to 2009.
The study showed a direct connection between pectus deformity and orthopedics. Researchers
concluded bracing was an effective alternative to surgery in correcting pectus excavatum. 
Researchers said bracing could bring exceptional outcomes in one, two, or more years,
depending on how well the patient follows proper directions.
According to researchers, the best-proven method to improve pectus excavatum is the
combination of compression to the costal edges (flared lower ribs that often come with pectus
excavatum) and increasing the intrathoracic pressure by exercising and breathing while wearing
a brace. 
There are a few factors that can predict success.
 Chest wall flexibility
 Type of pectus excavatum (broad or localized)
 Age
 How disciplined is the patient in applying the brace
 Correct guidelines for treatment given by the therapist
It has been concluded that the flexibility of the deformed bones and cartilage is more critical than
the deformity severity for bracing to succeed. You can do a test to determine the flexibility.

Test
Take a deep breath and squeeze the abdominal muscles. Hold the air in like you’re about to get
punched. This will increase your intrathoracic pressure. Then, the tester should manually
compress your flaring of both lower ribs. It is considered flexible if the protrusion reduces. 

Surgery or Bracing?
According to Dr. Sydney Haje and Dr. Davi Haje, if the patients are still growing, they should
first try a non-surgical method of improving pectus excavatum.
This method is low risk, proven effective, and the patients can always change their minds if they
are satisfied or need to be disciplined to follow it. With the Nuss procedure, you will need to live
with the Pectus bar inserted below your sternum for a few years.
The treatment of pectus excavatum involves understanding basic orthopedic
concepts. Prescribing a brace to a patient doesn’t mean successful treatment of the deformity. The
patient must follow a protocol to achieve a successful treatment. 

Bracing for Adults
According to research, bracing can be effective in adult patients with pectus excavatum.
However, it is essential to know that it can be more complex compared to younger patients, but
still possible. The chest wall flexibility is most important, and you must do the test before
treatment. Adults can be more consistent and motivated to apply the brace than kids. That can be
very advantageous. 

Overcorrection Is a Proof of Effectiveness
According to research published in 2006, overcorrection in patients with pectus excavatum who
use braces can happen. Out of 1824 patients with pectus deformities, overcorrection occurred in

30. However, the overcorrection was easily corrected. It is essential to know that the treatment
    with braces was successful in all 1824 patients.
    Overcorrection shows how effective bracing can be in improving pectus excavatum non-
    surgically. According to research, the most common side effect of bracing is overcorrection. This
    happens to highly motivated patients with flexible deformities. 

Conclusion
Bracing for correcting pectus excavatum is proven to be effective. The risk of complications is
minor, and the success rate is high. You can also combine bracing with other non-surgical
methods for improving pectus excavatum, such as vacuum bell therapy.
This will speed up the improvement process. It is important to know that wearing the LA Rib
Flaring Brace won’t fix your deformity magically. It would be best if you still were disciplined
and motivated to see great results non-surgically. Thank you for reading!

About the Author
Mihail Veleski is the CEO at PectusExcavatumFix.com. Established in 2015, Pectus Excavatum
Fix has helped thousands of people with sunken chests improve their deformity, both physically
and mentally.
I pride myself on ensuring the information and methods I share are tried by me, correct, and
backed by research. I personally improved my concave chest and rib flare deformities non-
surgically.

Sources
 Wolff’s law. In: Wikipedia [Internet]. 2022 [cited 2023 Feb 9]. Available from:
https://en.wikipedia.org/w/index.php?title=Wolff%27s_law&oldid=1116135964
 Vacuum Bell: What It Is, Therapy, Risk & More [2023 Updated] [Internet]. 2019 [cited
2023 Feb 9]. Available from: https://pectusexcavatumfix.com/vacuum-bell-therapy/
 Haje SA, de Podestá Haje D. ORTHOPEDIC APPROACH TO PECTUS
DEFORMITIES: 32 YEARS OF STUDIES. Rev Bras Ortop. 2015 Nov 16;44(3):191–8.
 HAJE DDP, HAJE SA, VOLPON JB, SILVA ACOD, LIMA LFB, HUANG W.
LOCALIZED PECTUS EXCAVATUM TREATED WITH BRACE AND EXERCISE:
LONG TERM RESULTS OF A BRAZILIAN TECHNIQUE. Acta Ortop Bras.
2021;29(3):143–8.
 Top 3 Pectus Excavatum Braces In [2023]: Real User Opinion [Internet]. 2015 [cited
2023 Feb 9]. Available from: https://pectusexcavatumfix.com/pectus-excavatum-braces/
 Haje D de P, Haje SA, Volpon JB, da Silva ACO, Lima LFB, Huang W. BROAD
PECTUS EXCAVATUM TREATMENT: LONG TERM RESULTS OF A BRAZILIAN
TECHNIQUE. Acta Ortop Bras. 2021;29(4):197–202.
 Dynamic Remodeling Method [2023]: Fix Pectus Non-Surgically [Internet]. 2022 [cited
2023 Feb 9]. Available from: https://pectusexcavatumfix.com/dynamic-remodeling-
method/
 Haje S. ABORDAGEM ORTOPÉDICA DAS DEFORMIDADES PECTUS: 32 ANOS
DE ESTUDOS. Revista Brasileira de Ortopedia. 2009;44(3):191–8.

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The sternum is a plate of bone forming the middle of the anterior wall of the thorax and articulating with the clavicles and the cartilages of the first seven ribs. Measuring around 6 inches in an adult, the sternum has three main parts:

• Manubrium: Wide rectangular portion at the top

• Body: A long and flat part that makes up most of the sternum

• Xiphoid process: Small point at the end of the sternum that’s significantly more narrow and thinner than the rest of the sternal body

The direction the sternum is pushed outwards determines the Type of PC that presents. Directly outwards results in a Central Mid PC. When the manubrium is more prominent we have a Central High PC. When the xiphoid is more prominent we have a Central Low PC. The left side of the sternum pushing outwards more than the right side results in a Lateral Left PC whereas the right side pushing out more results in a Lateral Right PC. See more on the Types of PC Page.

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Long-Term Results of Compressive Brace Therapy for Pectus Carinatum

Background:  Purpose of this study was to determine the long-term outcome of compressive brace therapy for PC.

Methods: Patient satisfaction was investigated via telephone survey.

Results:  320 patients were included with average age was 13 years. The median follow-up period was 42 months (13-68). Good compliance was observed in 286 patients (89.4%; compliance group). After the 6-month period, 255 patients (89.1%) and 31 patients (12.1%) in the compliance group were very satisfied and satisfied, respectively. Satisfaction at the last follow-up via telephone survey was very satisfied in 250 patients (87.4%) and satisfied in 36 (12.6%). In the compliance group, no patient needed compressive braces again after the therapy period.

Conclusion: Given the findings presented in this study, compressive brace therapy appears to be a relatively simple and safe method with good long-term outcome in treating patients with PC.

For Full Study Details please see: https://pubmed.ncbi.nlm.nih.gov/30216948/

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In a growing child the chest wall consists of bone and cartilage and is therefore pliable and easier to correct. In adults the growth plates have fused and we are now dealing with bone only. However, some correction is possible in adults through the process of bone remodeling, called “Wolff’s law”.  In the late 19th century a German surgeon, Julius Wolff, first described the process of bone remodeling and how it relates to the stress placed on bones. According to Wolff, bones will adapt according to the demands placed on them. This process involves the use of specialized bone cells, called osteoclasts, that absorb old or damaged bone tissue, including things like calcium and collagen. After this, another type of cell called an osteoblast deposits new bone tissue where the old tissue once was.

Therefore, through the application of forces on the chest and ribs, the bones will adapt over time. This process requires the application of appropriately directed force applied over a specific length of time. The key is applying the force over the correct amount of time. Too short a time and the insufficient remodeling has occurred and the chest will resort to its previous shape, However, through the experience of fitting hundreds of patients, we now know there is a limit, for each individual, on how much correction can be achieved and any continuance of force applied beyond this limit will no longer produce any change.

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• post-surgical, which happens when the sternum doesn’t heal properly after surgery or chest trauma
• congenital, where premature fusion of the chest cavity is present at birth
• idiopathic, the most common type of PC, which usually appears between ages 7 and 15 and correlates with growth spurts
• adult, usually an untreated idiopathic PC

PC is also classified according to the severity of the deformity as either:

• Mild
• Moderate
• Severe

We classify Pectus Carinatum into seven categories based on the location of the primary prominence, as follows.

1. Central Low
2. Central Mid
3. Central High
4. Right Lateral
5. Left Lateral
6. Double Lateral

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These estimates assume the chest has some flexibility (i.e. can be manually pushed in at least 1/2″).
Total wear time is 12-18 months and it requires a period of 24/7 brace wear time (for the LABTP, we determine the times needed by evaluation your information on receipt of an order/payment).

* Results presented are the predicted maximum possible based upon limited data. Results vary and are not guaranteed

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During the wearing time, it is expected that the skin will become red in the area where the anterior (front) force pad applies pressure. Usually this is not excessive and dissipates once the user stops wearing the brace.

There are some general rules for skin management.

1. It is important to keep both the pad and skin clean. user should wash the skin twice daily and wipe the surface of the pad daily with an alcohol wipes. In addition, undershirts should be worn between the skin and the brace and these replaced twice daily.

2. Where possible, avoid using creams, lotions and powder on the chest. This is because these will often the skin and make it less tolerant of pressure.

When redness is excessive additional measures are needed to avoid skin breakdown. While some people (in particular fair skinned individuals) are more sensitive to pressure, the most common cause is a user wearing the brace too tight.  If excessive redness occurs, wear the brace looser. In doing so, if you have issues with the brace sliding off the chest, attach the shoulder straps.

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Intermediate results for Seventy-eight patients of 284 who had completed brace treatment; the mean treatment time was 14 months. Twenty-seven patients abandoned treatment because of lack of motivation, loss to follow-up, persistent protrusion of the sternal bone or flaring that required surgical correction, failure of treatment because of a bifid rib, fear of locking the brace, and delayed correction. One hundred eighty-one patients are still wearing the brace, either in the active or in the retainer phase. Patients with a high PIC also showed improvement when they were compliant. Adverse events were minor and included skin lesions (n = 4, 1%) and vasovagal reactions at the start of therapy (n = 3, 1%).

Conclusions

The study suggests that brace therapy can be considered a valuable treatment option to correct pectus carinatum in patients with a flexible pectus.

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A “pigeon chest” is medically known as Pectus Carinatum. In this condition, the anterior to posterior dimensions of the chest cavity are increased when the sternum (breastbone) is relatively protruded.

Pectus carinatum is an overgrowth of costal cartilage causing the sternum to protrude forward. It primarily occurs among four different patient groups, and males are more frequently affected than females. Most commonly, pectus carinatum develops in 11-to-14-year-old pubertal males undergoing a growth spurt.

Mild to Moderate cases can usually be treated with a brace, for which the LA Pectus Brace is the gold standard. In very severe cases, surgery can be done to correct the condition.

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