Pectus excavatum (sunken chest/funnel chest), a concave chest wall deformity, is far more than a cosmetic concern. In severe cases, it can lead to cardiac compression, restricted breathing, and spinal abnormalities, as well as reduced exercise tolerance and psychological distress. Therefore, timely and appropriate pectus excavatum treatment is crucial.

This article explores 3 minimally invasive surgeries for pectus excavatum: the Nuss procedure, the Wang procedure, and the Wung procedure. Through an analysis of surgical indications, technical features, and the integration of nutritional management with rehabilitation guidance, this article aims to provide a comprehensive overview of the various surgical options, including their advantages, limitations, and ideal patient populations, hereby supporting informed clinical decision-making.

Patient Population and High-Risk Factors for Pectus Excavatum

Pectus excavatum is the most common congenital chest wall deformity, affecting an estimated 1 in 300-400 births. While it can be present at birth, it often becomes more pronounced during adolescent growth spurts. The condition can affect both males and females, though it is more prevalent in males (male-to-female ratio of 5:1)^[1].

Although the exact etiology of pectus excavatum remains unclear, it is widely thought to result from genetic mutations that cause unbalanced overgrowth of the costal cartilage. This genetic basis is supported by several risk factors for developing a more severe deformity that requires professional intervention. These include a strong family history of pectus excavatum and the presence of specific genetic disorders such as Marfan syndrome, Noonan syndrome, or Turner syndrome. Additionally, connective tissue disorders like Ehlers-Danlos syndrome and osteogenesis imperfecta are also associated with a higher incidence of the condition.

Types of Pectus Excavatum

The specific morphological type of pectus excavatum deformity (e.g., asymmetrical, broad, or other complex variations) significantly influences treatment planning. Recognizing these morphological classifications is crucial for the surgical team to determine the most effective operative approach.

Explore more professional knowledge: Six Major Types of Pectus Excavatum

Addressing the condition, especially during adolescence, can prevent the long-term physiological and psychological burdens associated with it. This is why a thorough understanding of all available pectus excavatum treatments is essential for patients and their families.

3 Surgical Treatments for Pectus Excavatum

While non-surgical treatments for pectus excavatum exist, such as the vacuum bell and physical therapy, surgery for pectus excavatum remains the most definitive option for severe cases. The procedure aims to permanently reshape the chest wall, thereby relieving pressure on the heart and lungs and improving both physical function and aesthetics.

Below are three minimally invasive surgical options.

1. Nuss Procedure

The Nuss procedure is currently the most widely used minimally invasive technique for the correction of pectus excavatum. It was first introduced by Dr. Donald Nuss in 1987.

Using the principle of leverage, pre-bent metal bars are inserted into the chest cavity under thoracoscopic guidance. The bars are then flipped to elevate the depressed sternum and ribs outward.

Surgical Principle:

• Utilizes the elasticity and growth potential of the chest wall

• The shaping bars are positioned inside the chest cavity, in direct contact with the heart's surface

• Secures both ends of the bars to the ribs, which may restrict the natural development of the chest

  
  

Indications:

• Patients over 5 years of age (the chest wall needs sufficient rigidity and stability)

• Moderate to severe pectus excavatum deformity

  
  

Technical Features:

• Two to four incisions, each 2-4 cm^[2], on either side of the chest

• Requires thoracoscopic assistance

• The procedure typically takes 1-3 hours

Primary Risks:

• High risk of cardiac injury due to the bars passing over the heart's surface and being flipped

• A scientific literature review on the Nuss procedure for pectus excavatum noted that postoperative complications such as pneumothorax and bar displacement are common. Reported incidences include pneumothorax (29.91%), bar displacement (11.32%), and pleural effusion (9.65%)^[3].

2. Wang Procedure

The Wang procedure, pioneered by Dr. Wenlin Wang in 2018, is an innovative surgical technique for pectus excavatum and is generally suitable for patients under 10 years old. In 2019, it was officially recognized by the National Health Commission of China and became one of the standard surgeries for pectus excavatum in China.

After more than 7 years of refinement and application, the Wang procedure has successfully treated over 500 patients.

Innovative Principle:

• The bar is placed on the surface of the depressed bony structure, thus completely preventing cardiac injury

• Steel wires are used to lift the depressed sternum and costal cartilage

• Fixation is limited to the middle section of the bar, which doesn't restrict bone growth and development

  
  

Surgical Steps:

1. A small 1-2 cm incision is made in the center of the chest wall.

2. Three steel wires are passed through the incision, looped around the sternum and left and right costal cartilages, and exteriorized through the incision.

3. A pre-shaped bar is placed on the surface of the depressed bone structure.

4. The depressed chest wall is lifted with the steel wires until it is fully contoured to the bar.

5. The middle section of the shaping bar is fixed to the sternum, and the incision is closed to complete the procedure.

Key Advantages:

• Wide Age Adaptability: The Wang procedure can be performed on patients as young as 1 month old, taking full advantage of the malleability of an infant's bones

• High Cardiac Safety: Eliminates the risk of heart injury

• Minimal Invasiveness: Usually requires only a single 2 cm incision and no thoracoscopy.

• Lasting Results: Does not restrict the development of the chest wall bones, and minimizes the risk of postoperative recurrence of pectus excavatum deformity.

Indications:

• Young patients with pectus excavatum (under 10 years old), safely applicable even to infants from 1 month of age

• Complex chest wall deformities that involve depression, such as Wenlin Chest, Flat Pectus Carinatum, Saddle Chest, Grooved Chest

• Some uncommon chest wall deformities, such as Depression of Lateral Chest Wall, Asphyxiating Thoracic Dystrophy, Costal Arch Deformity

• Corrective surgery following cardiac surgery or failed Nuss surgery

• Poland Syndrome

3. Wung Procedure (Modified Nuss Procedure)

The Wung procedure is a minimally invasive technique that builds upon the classic Nuss procedure. It was carefully refined by Dr. Wenlin Wang. While it still uses the principle of leverage from the Nuss procedure, it incorporates significant improvements in surgical details.

Technical Modifications:

• Addresses the inherent limitations of the Nuss procedure, integrates several innovative techniques, such as the "Wang Technique" for bar fixation

• Significantly lowers the difficulty and risks of the surgery, reduces patient trauma, and speeds up postoperative recovery

  
  

Surgical Steps:

1. Two incisions, each approximately 2 cm, are made on either side of the chest wall.

2. Two pre-shaped bars are inserted into the chest cavity using surgical strips and a guiding catheter. (effectively prevent damage to the heart)

3. The bars are flipped to elevate the depressed chest wall.

4. The ends of the bars are fixed to the ribs on both sides of the chest wall, and the incisions are then sutured.

Technical Features:

• Two incisions, each approximately 2 cm

• The risk of cardiac injury is lower than with the traditional Nuss procedure

  
  

Indications:

• Pectus Excavatum

• Poland Syndrome

• Complex Chest Wall Deformities that involve depression, such as Flat Chest, Saddle Chest, Wenlin Chest

  
  

Comparison of the 3 Surgeries for Pectus Excavatum:

As the latest generation of minimally invasive pectus excavatum surgery, the Wang procedure offers significant advantages in safety, versatility, and recovery speed. Whether it is for various types of pectus excavatum, such as asymmetric pectus excavatum, pectus excavatum with acute angular deformity, and secondary pectus excavatum following cardiac surgery, or for infants (especially those under 5 years old), adolescents, and young adults with pectus excavatum, the Wang procedure represents the future direction of surgical treatment for this condition.

What should I Do After Pectus Excavatum Surgery?

The recovery time for pectus excavatum surgery is a crucial phase that requires careful management to ensure a successful outcome. The following guidelines are based on professional recommendations and are essential for proper healing. The initial recovery period after surgery for pectus excavatum is critical, typically lasting several weeks.

• Sleep on your back as much as possible within one month after surgery. Avoid touching or getting the wound and surrounding area wet.

• Avoid lifting heavy objects within one month after discharge. Maintain good sitting and walking posture, and avoid movements with a large range of motion, such as rolling, bending, etc.

• 6 weeks after surgery, you may gradually resume low-impact aerobic exercises such as jogging or hiking. 3 months after surgery, you may gradually participate in some competitive sports, but not contact sports such as basketball or football. (This should depend on your own condition. Avoid falls or chest impacts during exercise, and stop immediately if you feel pain.)

• Please have a chest X-ray or CT scan and consult a thoracic surgeon promptly if you develop symptoms such as persistent high fever (temperature >38.5°C), sudden chest tightness, shortness of breath, or difficulty breathing.

• MRI of the chest and upper abdomen is prohibited before the bar is removed.

• Deep breathing training can be performed several times a day.

Diet:

Early Stage (Bedridden): Choose easily digestible, semi-liquid foods such as porridge, fruit juice, and over-cooked noodles.

Recovery Stage (After getting out of bed): Gradually transition to a regular diet, focusing on high-quality protein (e.g., fish, eggs). Ensure daily intake of fresh vegetables and fruits to replenish vitamins and electrolytes.

Precautions: Strictly avoid spicy and greasy foods. Be cautious with ingredients that can cause allergies (e.g., seafood, mango).

Explore more professional insights: What to eat after surgery to help with incision healing?

Consult a Professional Thoracic Surgeon

While this article provides an overview of various pectus excavatum surgeries, only a surgeon can perform a comprehensive evaluation to determine the most suitable approach for your specific condition. This is especially true for complex and severe cases.

ICWS is the world's 1st independent surgical institution dedicated to chest wall disorders and the world's largest center for chest wall deformity correction. We offer highly specialized pectus excavatum treatment for patients of all ages; both the Wang procedure and the Wung procedure are innovative surgical techniques we developed. We have successfully performed over 10,000 chest wall surgeries for patients from around the world.

Contact us today to schedule a consultation. We are committed to providing professional and compassionate treatment for chest wall disorders.

References:

[1] Sonel Tur, B., & Genç, A. (2025). An overview of pectus deformities and rehabilitation approaches. Turkish journal of physical medicine and rehabilitation, 71(2), 131–138. https://doi.org/10.5606/tftrd.2025.16840

[2] Elsayed, H. H., Hassaballa, A. S., Abdel Hady, S. M., Elbastawisy, S. E., & Ahmed, T. A. (2016). Choosing between the modified Ravitch and Nuss procedures for pectus excavatum: Considering the patients's perspective. Annals of the Royal College of Surgeons of England, 98(8), 581–585. https://doi.org/10.1308/rcsann.2016.0254

[3] Šavareikaitė, A., & Valatka, P. (2024). Surgical Treatment and Complications of Pectus Excavatum in Childhood, Adolescence and Adulthood: A Literature Review on the Nuss Technique. Lietuvos Chirurgija, 23(4), 250-271. https://doi.org/10.15388/LietChirur.2024.23(4).3