When Operating Was Almost as Dangerous as Not Operating
In the first part of this series, we saw how pectus excavatum was documented for centuries — in the art of Da Vinci and Ribera, in 16th-century medical texts, in 19th-century family records — with no treatment available. Opening the chest was a death sentence: the lung would collapse once it lost the negative pressure of the pleural space.
Read the following blog: The History of Pectus Excavatum
What followed was more than a century of progress, controversy, and reinvention — a continuous search for the same answer: how do you correct this deformity while causing the least possible harm?
1913: Sauerbruch — The First Successful Correction
Ernst Ferdinand Sauerbruch invented the negative-pressure chamber, the device that made it possible to operate inside the chest while keeping the lungs inflated. Without that invention, none of the surgeries that followed would have been possible.
In 1913, Sauerbruch operated on a young man with severe pectus excavatum: breathless at rest, with constant heart palpitations, unable to work in his father’s watch factory. The procedure was radical — resection of the 5th through 9th left costal cartilages and an adjacent segment of the sternum — but the result was transformative. The patient regained his ability to work and got married three years later.
What made Sauerbruch a true pioneer wasn’t just the technique. It was the vision: he was the first to clearly articulate that pectus excavatum wasn’t merely a cosmetic problem, but a deformity with real functional consequences that warranted surgical correction. That premise — which seems obvious today — took centuries to take hold.
In the 1920s, Sauerbruch himself refined the technique by adding bilateral resection of the costal cartilages and a sternal osteotomy, and advocated for postoperative external traction to hold the sternum in its new position for six weeks. Surgeons across Europe and the United States adopted the procedure, and it quickly gained popularity.
1939–1949: The Road to the Ravitch Standard
During the 1930s and 1940s, several surgeons contributed modifications and observations to the original technique.
In 1939, Ochsner and DeBakey published the most exhaustive review of the surgical literature on pectus excavatum to date, laying the groundwork for what was to come.
That same year, Lincoln Brown published his experience with two patients and proposed that short diaphragmatic ligaments pulling the sternum downward were the main cause of the deformity. This theory would go on to decisively shape the technique Ravitch developed a few years later.
Mark Ravitch, having read Brown’s article and convinced by the hypothesis, went further than any of his predecessors: in 1947 he published his experience with a radical modification of Sauerbruch’s procedure that involved completely freeing the sternum from all its attachments — intercostal muscles, rectus abdominis, diaphragmatic insertions, and removal of the xiphoid process.
The logic: if the sternum is completely freed from all tension, there’s nothing left to pull it inward. It shouldn’t sink again.
In 1949, Ravitch published the formal case series that would cement his name in the history of surgery: his technique of bilateral resection of the deformed costal cartilages combined with a transverse wedge sternal osteotomy became the worldwide standard, dominating for the next four decades.
The initial results were promising. Mortality and recurrence rates were significantly lower than with any previous technique. Ravitch became the benchmark.
Later Refinements
- 1956: Wallgren and Sulamaa: introduce internal support using a slightly curved stainless steel bar, passed through the lower part of the sternum to hold it in its new position. The sternum no longer had to rely solely on its own structure for support.
- 1961: Adkins and Blades: refine the concept by passing the bar behind the sternum instead of through it. This form of internal support became the standard approach for the next 40 years.
What did all this mean for the patient in practice? Open surgery with a long chest incision, significant bleeding, resection of multiple costal cartilages, and a long, painful recovery. But it was the best option available, and for decades, it was.
The unexpected problem: operating too soon could be worse
In the late 1980s and early 1990s, two findings deeply unsettled established surgical practice.
Surgeon Pena demonstrated in an animal model that resecting costal cartilages during the growth phase (in newborn rabbits) produced asphyxiating chondrodystrophy: the rib cage, deprived of the cartilage that kept it pliable, progressively hardened and constricted, severely impairing breathing. It was, quite literally, trading one problem for a worse one.
Surgeon Haller reported equivalent human cases under the name “acquired asphyxiating chondrodystrophy“: children operated on too early, with overly aggressive resections, who developed severe chest constriction as they grew.
The surgical community’s response was immediate: surgeons stopped operating on young children, began waiting until puberty, reduced the amount of cartilage resected, and started talking about a “modified Ravitch technique.” Pediatricians became far more cautious about referring patients.
Unknowingly, the field was primed for a revolution.
1998: Donald Nuss and the Paradigm Shift
In 1987, while performing a conventional open pectus excavatum repair, pediatric surgeon Donald Nuss had a thought he couldn’t shake:
“If these cartilages are so flexible and pliable, why am I removing them?”
The question was deceptively simple. The answer it implied was revolutionary.
Nuss began developing a completely different technique, grounded in a principle borrowed from orthopedics and orthodontics: if you apply sustained force to a flexible structure during the growth period, you can remodel the deformity without destroying tissue.
Orthodontic braces don’t extract teeth to align them. They apply gradual pressure and let them move. Why not apply the same principle to the sternum?
His technique consisted of:
- Two small lateral incisions — instead of Ravitch’s large anterior incision
- Creating a retrosternal tunnel using a curved clamp guided by thoracoscopy
- Inserting a convex titanium bar through the tunnel, behind the sternum, with the convex side facing backward
- Rotating the bar 180 degrees — which, as it flips, pushes the sternum forward, immediately correcting the depression
The result: complete correction of pectus excavatum with no cartilage resection, no sternal osteotomy, and minimal blood loss.
To demonstrate his full confidence in the procedure, Nuss made the most personal decision a surgeon can make: he operated on his own son using the technique he himself had developed.
In 1997 he presented his results — a series of 42 patients with 10 years of follow-up — to the American Pediatric Surgery Association. The formal publication followed in 1998 in the Journal of Pediatric Surgery.
The reception began with skepticism, followed by growing enthusiasm. Within a few years, more than 100 surgeons from around the world traveled to Children’s Hospital of The King’s Daughters in Norfolk, Virginia, to learn the technique directly from Nuss.
2002: The Vacuum Bell — Correction Without Surgery
While the surgical community debated between Ravitch and Nuss, an idea that broke with every prior premise was taking hold: what if the sternum could be raised without surgery at all?
The idea wasn’t new. Munich orthopedist Fritz Lange, together with Spitzy, had already described the use of a glass bell to treat pectus excavatum back in 1910. But the glass was heavy, rigid, and uncomfortable, it didn’t achieve good fixation, and it couldn’t be worn long enough. The idea sat shelved for decades.
Its revival came from a patient, not a surgeon. Eckart Klobe, a German chemical engineer with pectus excavatum, refused surgery and corrected his own chest between 1992 and 1995 using a bell he built himself. The key change: he replaced the glass with silicone, a flexible material that allowed for longer, more comfortable sessions. Klobe registered the device as a medical product in 2002, and in 2006 Haecker and Mayr published the patient series that clinically validated it.
The mechanism is as simple as it is ingenious: a silicone cup and a manual pump create a vacuum that gently lifts the sternum, with enough force to overcome the resistance of bones, ligaments, and cartilage.
Its limitations are well defined: it’s worn several hours a day for 6 to 12 months and works best on flexible chest walls — mainly in children and adolescents. It demands consistency, since the sternum tends to sink back down if treatment is interrupted. A conservative treatment that avoids the operating room entirely, and one that’s also increasingly used to help elevate the sternum during the Nuss procedure itself.
2010: The Great Controversy — Ravitch or Nuss?
As the Nuss technique gained popularity worldwide, the world of thoracic and pediatric surgery split into two camps. At the conferences of the time, the question was unavoidable:
Are you a Ravitch person or a Nuss person?
It wasn’t just a technical preference. It carried almost the weight of a statement of principles.
Advocates of the Ravitch technique argued: greater control over the final result, more predictable outcomes in complex or asymmetric deformities, and lower rates of specific complications such as hardware displacement or reoperation.
Advocates of the Nuss technique countered: far less invasive, no cartilage resection, shorter surgical time, less bleeding, and a significantly faster recovery.
A meta-analysis published in 2010 attempted to resolve the debate systematically, analyzing nine prospective and retrospective studies. The results were revealing in their ambiguity: the Nuss technique was faster and involved less blood loss, but showed higher rates of pneumothorax, hemothorax, and reoperation due to bar displacement. Long-term functional outcomes and quality of life were similar between the two techniques.
The honest conclusion was the most uncomfortable one: there was no absolute winner. The choice depended on the surgeon’s experience, the patient’s characteristics, and the specific anatomy of each case.
That lack of a clear verdict was, paradoxically, the driving force behind the next generation of innovation.
2012: The Pectus Up Extrathoracic Technique
If the transition from Ravitch to Nuss had meant moving from radical open surgery to a minimally invasive procedure inside the chest, the next logical step was a bolder question: what if there’s no need to enter the chest at all?
That’s the premise behind extrathoracic techniques, and Pectus Up®, developed by Ventura Medical Technologies in Barcelona, is their most established clinical reference.
The principle is radically different from its predecessors:
- A 3–4 cm horizontal incision at the point of maximum sternal depression
- Creation of a subpectoral space between the pectoral muscles and the sternum
- Placement of an elevation plate resting on the ribs and a sternal plate anchored directly to the sternum with fixation screws
- Progressive, controlled elevation of the sternum through a lifting system, with each full turn equal to 2 mm of elevation
At no point does the procedure enter the thoracic cavity.
The clinical implications of this approach are significant:
- Absence of the thoracic complications typical of the Nuss technique (pneumothorax, hemothorax, risk of cardiac injury)
- Less postoperative pain
- Notably faster recovery
- Ability to treat adult patients whose chest wall is no longer flexible enough to respond to the retrosternal bar technique
2015: The Aesthetic Option — Silicone Implants
For a specific subgroup of adult patients with mild-to-moderate pectus excavatum whose main goal is aesthetic improvement, without significant functional impairment — another alternative emerged in parallel: custom silicone implants.
These implants, custom-designed to match each patient’s chest morphology, are placed subcutaneously to fill the depression and visually restore the normal chest contour.
It’s essential to understand their limitations: silicone implants are a strictly cosmetic option. They don’t lift the sternum, don’t correct the underlying structural deformity, and don’t improve cardiorespiratory function. They’re a “visual filler” solution suited to carefully selected patients with well-defined, realistic expectations.
What Does This Mean for a Patient Today?
More than a century of surgical progress has brought pectus excavatum treatment to a point where patients and their families have more options than ever, each one an improvement over the last in terms of safety, invasiveness, and recovery.
Choosing between techniques isn’t simple or universal. It depends on the patient’s age, the severity and shape of the deformity, the degree of functional impairment, personal goals, and the surgical team’s experience.
What is universal is the most important recommendation of all: a complete, personalized evaluation with a pectus excavatum specialist who can assess the case as a whole before proposing any treatment plan.
The field hasn’t stopped advancing. And it continues to do so.
Important note
The information in this article is historical and educational in nature. It does not replace personalized medical advice. If you or a family member has pectus excavatum, consult a qualified specialist who can evaluate the case individually.
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