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Innovative Non-Surgical and Surgical Procedures
The pediatric chest wall team is committed to caring for children with chest wall malformations throughout childhood and meeting their changing needs as children grow older. Medical options are typically the first line of treatment. Minimally invasive surgical solutions are available when necessary.
Non-Surgical Procedures for Chest Wall Conditions
Non-Surgical Care for Pectus Excavatum (PE)
Many children with PE elect not to have surgery. During the initial evaluation, our team asks three key questions: “Do you have pain in your chest? Do you play sports? Does your chest wall appearance bother you?” When the answer to these questions is no, and the deformity is not severe, the Chest Wall team does not recommend surgery. Instead, patients are monitored annually during in-person or Fast Track Video Visits.
If, in the future, the answers to these questions change and the child is still growing, surgery becomes an option. Patients also benefit from ongoing care for their physical and emotional health.
Custom Bracing Regimens for Pectus Carinatum (PC)
Most patients referred to Shriners Hospitals for Children — Northern California for PC can be treated non-surgically with a custom brace. Because bracing regimens are most effective before a child reaches skeletal maturity, patients usually wear a brace from ages 12 to 16. The on-site Pediatric Orthotic and Prosthetic Services (POPS) lab works closely with the chest wall team to make custom PC braces. Low-profile braces are fitted to each patient for comfort and effectiveness. Every four months, the teams re-evaluate the brace, and as the chest wall shape improves, orthotists modify the brace. Having a “one-stop-shop,” where patients’ conditions and braces are monitored simultaneously, offers greater convenience and an overall better experience to patients and their families. Physicians should refer patients with PC to the Chest Wall Program as early as possible, even as toddlers. Our team will follow the patient and begin a bracing regiment at the most opportune time. We educate patients early on, so they understand the bracing process and are more receptive.
If we do doing bracing during rapid growth and our patients consistently wear the brace 20 plus hours a day, I’ve never seen it fail. For adolescents, having control over your style is pretty important, so our orthotists let them pick the color and design.
Amy Rahm M.D.
Cardiothoracic surgeon at Shriners Hospitals for Children — Northern California
Coordinated Bracing for Multiple Conditions
Scoliosis and Pectus Excavatum (PE) Correction
Between 15 and 30 percent of PE patients with an associated anomaly also have scoliosis. Bracing for both conditions allows corrections to be made simultaneously with one brace. At Shriners Hospitals for Children — Northern California, the scoliosis and spine, orthotics and chest wall teams work together to create customized treatment programs and braces for patients. Because the teams are in the same building, they easily collaborate on patient care, helping to create the best possible outcomes. This also allows patients to see all of their practitioners on the same day.
Kyphosis and Pectus Carinatum (PC) Correction
Pectus carinatum is associated with kyphosis, an exaggerated rounding of the back, in about 40 percent of cases. This means following surgery for kyphosis, patients may require bracing to correct the position of the sternum, which is pulled inward due to the increased tension of abdominal muscles. Our orthopedic surgeons work closely with the Pediatric Chest Wall Program team to monitor patients and coordinate care.
Connective Tissue Disorders
Patients referred for suspected connective tissue disorders, like Marfan syndrome or osteogenesis imperfecta, are carefully screened and monitored. At Shriners Hospitals for Children — Northern California, patients may be seen by geneticists, ophthalmologists, and cardiologists, and followed closely as they grow and their condition develops. Referring physicians and families can be assured that screening and expert care will be coordinated as the child matures.
Surgical Treatment for Chest Wall Conditions
Ravitch Procedure for Pectus Carinatum
Because bracing is highly effective for the treatment of pectus carinaturm (PC), surgery is usually not necessary. For patients who do require surgery, Shriners Hospitals for Children — Northern California offers the Ravitch procedure once patients have stopped growing. Surgeons remove pieces of cartilage that connect the ribs to the breastbone, which is then broken and reset in a more normal position. A temporary metal chest bar may be placed to keep the sternum elevated. Patients report minimal pain after the procedure and retained flexibility. Most patients stay at the hospital for three to five days following surgery, and are limited to light activity for six to eight weeks. Outcomes are excellent and patients are satisfied with the results. Our team offers a peer-to-peer program that connects patients considering Ravitch with those who have had the procedure, to aid them in decision-making.
Surgical Care for Pectus Excavatum: Nuss Procedure
Shriners Hospitals for Children — Northern California is a high-volume center for the Nuss procedure to treat pectus excavatum (PE). Our surgeons perform approximately 30 such procedures, each year. Before surgery, patients receive a CT scan or MRI, an echocardiogram and pulmonary function tests. Surgeons then use a video-assisted, minimally invasive approach under thoroscopy. A concave, custom-sized bar is placed over the heart and behind the breastbone through two small incisions on each side of the chest. Surgeons flip the bar to push the sternum out. Complications are rare and the outcomes are excellent with this procedure. Results are immediate. The bar remains in place during rapid growth to remodel the chest wall. Most patients are age 14 when the bar is placed and 16 when it is removed, but timing can vary by several years. The chest wall team monitors patients every six months. The bar is removed in an outpatient procedure using the same incisions as implantation.
Cryoablation for Pain Relief following Nuss Procedure
Surgeons and anesthesiologists have devoted considerable effort to developing multimodal pain relief for patients following the Nuss procedure. Surgeons use cryoablation when inserting the Nuss bar to freeze the nerves that run along the ribs where the chest is reshaped. This approach significantly reduces postoperative pain. Pain control lasts about three months. Just a few hours after surgery, patients are sitting up, watching TV, smiling and joking. Previously, they were bedridden for two days or more and left the hospital taking opiates for pain relief. With cryoablation, most patients go home taking acetaminophen and ibuprofen, with five valium and oxycodone tablets for rescue. At two-week follow up, nearly all patients report minimal pain and are only taking over-the-counter pain relievers as needed. Using cryoablation significantly reduces the risk of opioid dependency and results in higher patient satisfaction and comfort.
On-site Orthotics and Prosthetics Lab
Every year, orthotists design and make more than 350 braces onsite at the Pediatric Orthotics and Prosthetics (POPS) lab. Located on the hospital’s second floor, the patient often goes directly from their doctor’s appointment to the POPS lab to be fitted for a brace. 3D scanning and CAD/CAM technology offer the most advanced brace fabrication in the area. Members of the patient care team can work side-by-side with the orthotist, making a true team approach possible. Because young patients grow and change quickly, adjustments and new braces are often required quickly and frequently to achieve a correct, effective fit. When families aren’t able to return onsite for adjustments, they can mail in pieces of the brace that require repair instead.
Genetics and Chest Wall Program
Patients with chest wall differences may also show signs of a genetic disorder, which could change the approach for treatment of a chest wall difference. Marfan syndrome, Ehlers-Donlan syndrome, Fragile X syndrome, or other connective tissue disorders may be suspected upon initial evaluation. In these cases, the chest wall team brings in an on-site geneticist to diagnose or rule out a genetic condition.
