When Jack Coffey hit about age 13, the middle of his chest started to look dented in.

And if he slouched a certain way, his insides felt cramped. Sometimes while skateboarding or playing the trumpet, Jack noticed a sharp pain from his breastbone pushing into his lungs. It didn’t take much exertion to run out of breath.

The appearance of his caved-in chest also began to affect his confidence whenever he took off his shirt around friends.

“In the last couple years when it started getting more intense, I felt like I was getting a lot of looks,” he said. “It became almost a talking point conversation piece.” 

His chest abnormality became more concerning when his pediatrician detected a possible heart murmur. Jack and his family were referred to Cook Children’s, where he underwent tests for a condition called pectus excavatum, also known as sunken-in chest.

Pectus excavatum affects about 1 in 1,000 people whose sternum grows inward toward the spine. Cases can be mild, moderate or severe, as in Jack’s case. He thinks his scooped-out looking chest was about an inch and a half at its deepest point. 

Jack chose to undergo surgery in December 2021 to correct the structure of his chest wall. Chad Hamner, M.D., a surgeon at Cook Children’s Medical Center – Fort Worth, inserted a curved metal bar that pushed up Jack’s sternum. It was a minimally invasive procedure with two small incisions and immediate results.

Jack was 15 at the time, and his first reaction afterward was to compare his fuller torso to a LEGO mini-figure.

“It’s almost like you changed out a LEGO piece. Like you put in a different middle body but kept the same legs and head,” said Jack, who’s now 17. “It felt strange, but instantly it felt like I had space to breathe.”

The bar stayed in place as his bones, joints and cartilage realigned and stabilized along the outward curve. Dr. Hamner monitored Jack at follow-up appointments over the next two years. In January 2024, the bar was removed during an outpatient procedure. Jack’s chest is less caved in now – and is expected to hold its shape.

Dr. Hamner estimated that surgeons at Cook Children’s do two or three dozen procedures for pectus excavatum each year. Severe cases like Jack’s can compress a child or teen’s heart and lungs, causing pain, shortness of breath or heart palpitations. Most people with the condition don’t have those symptoms, Dr. Hamner said.

The most common incentive for surgery is the desire to improve the appearance and self-esteem for adolescents who are self-conscious about their indented chest. Specialists at Cook Children’s can help you and your teen decide if and when surgery is the best option. Here’s what you need to know.

Diagnosis and Next Steps

People who have pectus excavatum were born with it, although it might not be noticed until the growth spurt of puberty. The cause isn’t always known, but there’s a higher risk for people with Marfan syndrome, a connective tissue disorder.  

Dr. Hamner explained that the chest contains an intricate mesh of bones, joints and cartilage. If the sternum grows inward, and the ribs are protruding, the defect is more obvious. The name “excavatum” sounds like what it describes: a cave or cavity.     

Children as young as 10 come to Cook Children’s to be checked out and possibly treated. Some patients tell Dr. Hamner they’ve eaten cereal out of their indentation or placed a baseball inside it. 

“A lot of the time the kids are shy about it, and some of them don’t want to participate in activities or play sports if they have to change clothes in front of the other guys. They may be getting a little bit of bullying,” he said.

Patients who are considering surgery will first get a CT scan, which allows doctors to calculate how close the sternum has grown toward the spine. Candidates for surgery should be ideally nearing mid-puberty, around age 15, so that they’re mostly through growing by the time the bar comes out. The younger the patient is when the bar goes in, the longer the bar needs to remain in place. 

“We tell families you have a range where the minimally invasive approach has a good result. And that’s typically until the time your cartilages become more rigid, up to your mid- to late 20s,” Dr. Hamner said. “A lot of the kids want to get it done before they’re dating, so they tend to want to do it earlier in adolescence.”

Dr. Hamner says many people choose to live with their sunken-in chest if it isn’t causing problems. He points out to his patients that pectus excavatum didn’t stop Olympic swimmer Cody Miller from excelling at his sport.

Inserting the Bar

When surgery is appropriate, doctors at Cook Children’s use the Nuss procedure. Dr. Hamner described these key points:

• Small incisions are made on each side of the chest. A camera and long-handled tool guide the surgical team as they make a path for a curved metal bar constructed of a nickel-titanium alloy.
• The bar is inserted in a U position. Once it’s under the sternum, the surgeon flips the bar, and the sternum raises up.
• A crossbar is sewn onto one side to help stabilize the hardware while the patient’s body adapts to its new shape over two to three years.
• Sometimes, two bars are needed to do the job.

Dr. Hamner compared the bars to the scaffolding that gives a building its form. How does it feel? It causes pressure and soreness, like when braces reposition your teeth.

“If you stress a bone in a certain direction, it will remodel its shape in response to the stress,” he said. “In the Nuss procedure, you’re reshaping the chest wall by putting outward stress on the breastbone and ribs to break the bone down and rebuild it into a different shape. Ideally, when you take the bar out, the chest has reshaped itself to match the bar.”

To help with pain management, Cook Children’s uses a cryoablation device that numbs nerves along the chest wall. Cryoablation reduces the need for narcotics and other pain medications, and allows patients to go home from the hospital within two or three days of surgery, versus four or five days without cryoablation.

Patients can generally return to school within a week, Dr. Hamner said. They’re instructed to stand up straight and avoid contact sports for at least three months while their chest heals. 

Complications from surgery are rare but can include allergy to the metal, infection, and puncture of the heart or heart sac. The pectus excavatum recurs less than 10% of the time.

Patient’s Perspective

Jack’s mom Audra Massoth said she first thought he might grow out his sunken-in chest when he got older and gained muscle mass. Instead of getting better, the pectus excavatum became more pronounced about the time he turned 13.

“Aside from the effects on his breathing, just cosmetically I didn’t want him to feel self-conscious taking his shirt off at pool parties or when we go to the lake,” she said. “That was probably the biggest thing for me. He is a super fit, super handsome kid. But I didn’t want him to feel like he wouldn’t be able to be comfortable taking his shirt off.” 

They traveled to Fort Worth from their home in Azle for appointments with Dr. Hamner. Audra was in favor of surgery – but it was Jack’s decision, in the end.

Cryoablation reduced how much and how often Jack had to take medication to control the pain during recovery. His chest remained numb for a couple of months. Sleeping, meanwhile, was uncomfortable because the bar held his chest structure in place even when he turned onto his side.  

Jack has two small scars on his sides – and he kept the bar and bracket as mementos of the two-year process of elevating his sternum. His heart murmur resolved itself because of the added room in his chest. He said he feels “evened out and straightened out” as he finishes high school, works as an electrician’s apprentice and pursues his passion for skateboarding. 

Despite the painful recovery, Jack and his mom say they’re glad he went through the correction. He would tell other teens with pectus excavatum that he’s pleased with the results.    

“The bar doesn’t stay forever. There’s good times and there’s bad times, but it’s 100% worth it.”

Experts in Pediatric Surgery 

When your child requires surgery, you want to be certain you receive the most advanced care possible from the most experienced medical team. The surgeons at Cook Children's specialize in pediatric procedures from the simplest to the most complex, including congenital malformations, head and neck masses, abdominal issues and tumors. You can trust that our specialists understand the very specific needs of a child before, during and after surgery. Visit us here to find a map and learn about appointments, referrals and more. 

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• ‘A New Way to Breathe’: Living with Pectus Excavatum

Miami Robertson was a 14-year-old high school athlete with debilitating asthma, or so she thought.

It wasn’t until her friend noticed Miami’s breathing problems and a sunken chest that she was diagnosed with pectus excavatum.

“I sucked on an inhaler for three years before I became best friends with Cassie, my literal lifesaver,” Miami said. “When the inhaler never actually did the job it should have, Cassie became concerned and started looking for symptoms herself. Her older brother, Curry, had previously been diagnosed with pectus excavatum and was treated at Cook Children’s.”

Miami began to doubt the asthma diagnosis when her symptoms worsened with no relief from her inhaler. She took her friend’s advice and began to research pectus excavatum and quickly realized many of her symptoms matched the diagnosis.

“Of course the coaches and parents self-diagnosed me with asthma, but who would have known any better,” Miami remembers. “I had trouble breathing, even just jogging a simple lap around a track.”

Pectus excavatum (PE) is a condition where the breastbone in the chest is sunken inward, causing breathing difficulties and in rare cases mild cardiac issues.

PE can often be hereditary; Miami’s family soon realized her mother may also have the condition and was unaware until Miami was diagnosed.

“Although no one has previously been diagnosed with PE in my family, it may have been due to lack of knowledge,” Miami said. “My mom has always had a depression in her chest, but has never experienced any shortness of breath or any other symptoms that I experienced.”

Miami’s case was different from most with PE. It usually presents in younger children, particularly boys, but in some cases it may start to emerge during puberty.

“It originally began in the seventh grade while I was playing basketball at the YMCA,” Miami said. “I remember feeling as if I was trapped under a huge rock, like something was holding me down.”

Pectus excavatum can make breathing a chore, but Miami didn’t allow her breathing difficulties to stop her from her love for competition.

“The week before volleyball season of my sophomore year, I ran 13 timed miles before I finally conquered those long four laps with a time of 8:57,” Miami recalled. “But this was just normal for me. I grabbed my inhaler, wiped the tears off of my face, and staggered up the hill to the field house.”

Miami was referred to Cook Children’s, where she met José Iglesias, M.D., a Cook Children's surgeon who specializes in pectus excavatum, and eventually found treatment. Her surgery, called the Nuss Procedure, placed a curved steel bar underneath her ribs and sternum, which allowed for the sternum to rise and eliminated the sunken chest.

Miami’s recovery involved a week-long stay at Cook Children’s and limited activity at home for two months post-op, where she did breathing exercises in hopes the procedure would ease her breathing difficulties.

“If the cause of their difficulty breathing appears to be from the chest wall compression, then they have an excellent chance of relief. With correction, they feel significant improvement after initial recovery of the procedure and often additional improvement after removal of the bracing bar,” Dr. Iglesias said.

While in recovery at Cook Children’s, Miami made friends with staff and volunteers, who celebrated for her accomplishments and even washed her hair.

“When I was first able to walk on my own again, the nurses at the stations on each end of the circle hall would cheer me on as I slowly but surely put one foot in front of the other,” Miami said. “I still have the stuffed bear that I picked out off of the huge cart of animals that rolled into my room one day.”

Her procedure didn’t guarantee she would be able to breathe any better, but Miami held onto hope that her breaths would become effortless.

“Although it was said that the Nuss Procedure wasn’t sure to increase my lung capacity, I had faith that it would,” Miami said. “Little did I know that the next time I stepped foot on a volleyball court I would have a bar in my chest, turning my A game into my A+ game.”

A few months after her surgery, Miami began to see a new way of life with a new way to breathe. As she eased into more activity, she soon after dove back in to her athletic lifestyle, beginning with the mile that once gave her so much trouble.

“I was allowed to do some light activities geared more toward my legs,” Miami said. “Before long, I started bumping the volleyball to myself, rotating through some drills, and running the mile with my teammates. My first mile with the bar clocked in at 8:39, and not a tear was shed.”

Now 19 years old, Miami finally feels the relief of a deep breath. Although it was a difficult road to a diagnosis and recovery, Miami is still thankful for her struggles. Her perseverance allows her to stay in the game.

“My life was and is the best adventure I have ever been on. Even when I was battling PE, I was living life to the fullest,” Miami said. “I never let it keep me from participating in the sports that I loved, but it sure was a relief when I didn’t have to fight it any longer.”