What Secondary Chest Wall Problems Can Occur If Pectus Excavatum Is Not Corrected?

Introduction

Many parents think that Pectus Excavatum is only a cosmetic depression of the chest wall and that as long as there is no obvious discomfort, there is no need to address it urgently. However, a chest wall deformity is not an isolated local problem – it exists within the same biomechanical environment as the spine, bones, soft tissues, and even cardiopulmonary function. When the depression persists and gradually deepens, the surrounding structures passively adapt to this abnormal shape, which over time may lead to a series of secondary changes.

1. Scoliosis: An Underestimated “Neighbor” Problem

The probability of scoliosis in children with Pectus Excavatum is much higher than parents imagine. Clinical statistics from paediatric surgery departments in several major Chinese hospitals show that the incidence of scoliosis in children with pectus excavatum ranges from 15% to 30%, and in some severe depression cases it reaches as high as 39% [1].

This association is not a coincidence. The depression in the front chest wall breaks the originally symmetrical mechanical environment on both sides of the spine – the left intercostal spaces are chronically compressed, while the right ribs are relatively “over‑expanded”, so the biomechanical signals on both sides of the spine are no longer balanced. In children and adolescents who are in a rapid growth phase, the spine is undergoing rapid remodelling, and this asymmetric mechanical signal continuously guides the spine to deviate to one side, gradually forming structural scoliosis.

Think of it this way: imagine the spine as a flagpole, and the ribs and muscles on both sides of the chest as the ropes holding the flagpole. When the “ropes” on one side are chronically stretched and the “ropes” on the other side are chronically compressed, the flagpole will naturally lean to one side.

It is important to note that the relationship between scoliosis and pectus excavatum is not one‑way – scoliosis can in turn worsen chest asymmetry, creating a vicious cycle of “mutual promotion of deformities”. This understanding is one of the reasons doctors recommend early detection and early intervention for pectus excavatum [2].

Clinical clue: If your child has uneven shoulder height, a noticeable bulge on one side of the back, or back asymmetry when bending forward, it is advisable to have a paediatric surgery or spine surgery evaluation.

2. Postural Abnormalities: The Vicious Cycle of Slouching and Kyphosis

Children with pectus excavatum often unconsciously adopt a slouched, rounded‑back posture to “hide” the chest depression. In the short term, this compensatory posture reduces attention from others and provides psychological comfort, but in the long run, it becomes a trigger for postural abnormalities.

During childhood and adolescence, the skeleton is growing rapidly, and postural habits directly affect the direction of skeletal development. Chronic slouching increases the thoracic kyphosis (worsening of the natural curve), causes forward translation and winging of the scapulae, and leaves the deep back muscles in a chronically lengthened and weakened state. These changes further aggravate the slouching and kyphosis, forming a clear vicious cycle:

Chest depression → unconscious slouching to hide it → increased thoracic kyphosis → scapular winging → weakened back muscles → fixed slouched posture

Published studies show that the proportion of postural abnormalities in children with pectus excavatum is significantly higher than that in healthy peers of the same age. This is especially true for children with mild‑to‑moderate pectus excavatum, because their parents often delay seeking medical advice thinking the depression “is not obvious”, so the children remain in a long‑term compensatory state, making the postural problems even more prominent [3].

Value of Early Intervention

Intervening while the skeleton is still plastic (typically more effective before age 12) using non‑surgical methods such as a vacuum bell not only improves the chest depression but also breaks the vicious cycle of postural abnormalities, helping the child re‑establish correct body awareness and posture habits.

3. Chest Asymmetry: The Depression Is Not Just “a Hole in the Middle”

Some parents think that the depression in pectus excavatum is evenly centred on the chest, but clinical observations show that more than half of children with pectus excavatum have some degree of chest asymmetry – the centre of the depression may be biased to the left or right, and the shape and angle of the ribs on the two sides differ.

This asymmetry is not fixed. As the child grows and enters the rapid development phase of puberty, the degree of asymmetry may worsen. Asymmetric chest wall brings two main problems:

1) Uneven Restriction of Lung Development

The depression in pectus excavatum mainly compresses the front of the left ventricle, but when the chest wall as a whole leans to one side, the lung on that side is more compressed. Chronic compression of the lung restricts alveolar expansion and alters the ventilation‑perfusion ratio, increasing the risk of shortness of breath and reduced endurance during exercise.

2) Greater Psychological Burden from Visible Asymmetry

Adolescents become significantly more sensitive about their body appearance. When the chest depression is not only in the midline but also markedly asymmetric from side to side, the psychological burden on the child is often heavier than from a symmetrical depression.

3D scanning and 3D printing customisation offer unique advantages here: by accurately capturing the three‑dimensional data of the child’s chest wall, a personalised correction device can be made that fits the child’s actual chest shape, applying targeted corrective pressure to asymmetric areas rather than using a one‑size‑fits‑all mould [4].

4. Cardiac Displacement: The Internal Effect of Being “Pushed” by the Chest Wall

The depression in pectus excavatum is located in the midline of the front chest wall, and directly beneath it lies the heart. As the depression deepens, the heart is gradually pushed toward the left side of the chest – a condition called “cardiac displacement”.

• Mild pectus excavatum: the displacement is slight and generally does not cause obvious cardiac dysfunction.

• Moderate to severe pectus excavatum (Haller index ≥ 3.25): the heart may shift left by 1–2 cm or more, which can affect cardiac pumping efficiency and diastolic function to some extent.

Domestic and international studies have shown that diastolic dysfunction in children with pectus excavatum is not rare, and it is especially evident under exercise stress – children are more prone to palpitations and shortness of breath during aerobic activities like running or climbing stairs. Parents sometimes mistakenly attribute this to “poor physical fitness” without realising it is related to the chest wall deformity [5].

This cardiac displacement usually does not resolve on its own in adulthood; instead, it may become more fixed as the chest wall ossifies and loses flexibility. Therefore, timely intervention during childhood, while the chest cartilages are still soft and elastic, offers relatively more “space” and “efficiency” for correction.

5. Frequently Asked Questions (FAQ)

Q1: Does pectus excavatum always cause scoliosis?

A: Not necessarily. Research data show that the incidence of scoliosis in children with pectus excavatum is about 15%–30% – not all children develop spinal problems. However, this rate is much higher than the 1%–3% in healthy children of the same age, indicating a clear association. During regular follow‑ups, parents can ask the doctor to assess the child’s spinal alignment to achieve early detection and early intervention.

Q2: My child already has some slouching and kyphosis. Can posture recover after pectus excavatum correction?

A: Correcting the pectus excavatum is the key to breaking the vicious cycle of postural abnormalities. Some children, after their chest depression improves and with targeted back muscle exercises (core stability training, scapular retraction exercises, etc.) under the guidance of parents and a rehabilitation therapist, can achieve significant postural improvement. However, established skeletal changes (such as increased thoracic kyphosis) may not be completely reversible. Therefore, early intervention is always better than late intervention.

Q3: If chest asymmetry is not corrected, what happens in adulthood?

A: In adulthood, the chest shape is largely fixed, and the asymmetry will not improve on its own. Asymmetric chest leads to uneven lung development, and some adults experience significant shortness of breath during vigorous exercise. Moreover, correction in adulthood is much more difficult – the bones and cartilages have ossified, plasticity is greatly reduced, non‑surgical correction has very limited effect, and surgery is often required.

Q4: Can cardiac displacement be improved by correcting pectus excavatum?

A: In children and adolescents whose skeletal development is not yet complete, as the depression depth decreases and cardiac compression is relieved, the degree of leftward displacement usually improves to some extent. However, severe cardiac displacement often already reflects structural changes, and complete “return” to normal position is unrealistic. This again emphasises the importance of early detection and early intervention.

Q5: Does a 3D‑printed custom vacuum bell have advantages for improving chest asymmetry?

A: A 3D‑printed custom vacuum bell can be individually designed based on the child’s actual chest wall shape, achieving a precise fit even for complex conditions such as an off‑centre depression or asymmetric chest. Compared with traditional off‑the‑shelf devices, a personalised solution can apply more accurate corrective pressure to asymmetric areas, improving the symmetry and balance of the overall correction outcome.

6. Summary

Pectus excavatum is not just “a hole in the chest”. The secondary problems it can cause involve multiple dimensions: spinal alignment, overall posture, chest symmetry, and even cardiopulmonary function. These secondary changes often only become noticeable and worsen after the child enters puberty, but the root causes are laid down much earlier.

For parents, the real value of understanding these secondary risks is: not to regard pectus excavatum as a “wait‑and‑see” local cosmetic issue, but to view it from the perspective of overall skeletal development and, under the guidance of a specialist, choose a correction plan appropriate for the child’s current age and severity.

Disclaimer: 

Guangzhou Yikang Medical Technology Co., Ltd. focuses on the development and promotion of non‑surgical treatment solutions for chest wall deformities (pectus excavatum and Pectus Carinatum). For product information, visit our official website:  https://www.emkmed.com

References

[1] Liu JP, et al. Analysis of scoliosis incidence and related factors in children with pectus excavatum[J]. Chinese Journal of Pediatric Surgery, 2020, 41(3): 215-219.

[2] Wang L, et al. The relationship between pectus excavatum and scoliosis in children: a systematic review. J Pediatr Orthop, 2021, 41(4): e301-e306. PMID: 33492045.

[3] Zhang W, et al. Clinical observation of postural abnormalities in children with pectus excavatum[J]. Chinese Journal of Rehabilitation Medicine, 2019, 34(5): 556-560.

[4] Chen ZQ, et al. Application of 3D printing technology in personalised correction of pectus excavatum[J]. Chinese Journal of Thoracic and Cardiovascular Surgery, 2022, 38(2): 89-93.

[5] Nasr A, et al. Cardiac function in children with pectus excavatum: a systematic review. Ann Thorac Surg, 2020, 110(6): 1836-1843. PMID: 32590054.