The shoemakers breast its effect on breathing and is it dangerous

“Shoemaker’s chest,” medically known as Pectus Excavatum, is a congenital chest deformity characterized by the inward sinking of the breastbone, giving the chest a sunken appearance similar to a “shoemaker’s hollow.” The condition is not just a cosmetic issue; in severe cases, it can affect breathing and heart function, and it may also cause psychological stress related to self-confidence and body image, especially during adolescence.In this Dailly Medical Guide article, we will discuss the causes of Pectus Excavatum, its symptoms, possible complications, its impact on breathing and mental health, as well as both surgical and non-surgical treatment options. This comprehensive overview is designed to present all the information in a clear, simple way to help you understand the condition and make the right decision regarding treatment.

1. What Is Pectus Excavatum?

Pectus Excavatum, also known as “shoemaker’s chest,” is a congenital deformity of the chest in which the breastbone sinks inward, giving the chest a hollowed appearance similar to a “shoemaker’s hollow.”

2. How Is It Diagnosed?

• Clinical examination:
The doctor observes the shape of the chest and the depth of the indentation.

• X-ray or CT scan:
Used to determine the impact of the indentation on the lungs and heart.

• Haller Index:
A medical measurement that helps assess the severity of the deformity.

3. Is the Surgery Painful?

Yes, the pain is most noticeable during the first few weeks after surgery.

Painkillers and breathing exercises help ease the discomfort.

The pain gradually decreases as complete healing occurs.

4. Can the Deformity Go Away With Age?

The condition is usually persistent if left untreated.

Early intervention is important to prevent breathing or heart issues and to reduce psychological effects.

5. Does Pectus Excavatum Affect Mental Health?

Yes, especially during adolescence.

It may cause embarrassment or reduced self-confidence.

Surgical treatment or corrective exercises can improve emotional well-being and overall appearance.

Stages of Pectus Excavatum (Shoemaker’s Chest)

Pectus Excavatum develops gradually over time, and its severity varies from person to person. The following stages describe how it progresses based on age, indentation depth, and impact on breathing and the heart:

1. Childhood Stage (Birth to 6 Years)

The indentation is mild or may not be noticeable except when lying down.
Children usually do not experience breathing problems.
Rib cartilage growth is unstable and may improve or worsen over time.
Typically requires no treatment—just regular monitoring.

2. Early School Age (6–10 Years)

The indentation becomes more noticeable as the chest grows.
Appears clearly when standing or after physical activity.
Mild symptoms may appear, such as faster breathing or quick fatigue.
Doctors may recommend physical therapy or a Vacuum Bell device in some cases.

3. Early Puberty (10–13 Years)

During this period, the ribcage grows rapidly and the indentation may deepen.

Common symptoms:

Mild palpitations
Shortness of breath during exercise
Embarrassment or self-consciousness
Moderate cases may benefit from non-surgical treatments.

4. Adolescence (14–18 Years)

This is the stage when the condition usually becomes most severe.

Bone and cartilage growth increases the depth of the hollow.
Clear symptoms may include:
- Chest pain
- Palpitations
- Poor physical endurance
- Occasional displacement of the heart
Surgery, such as the Nuss procedure, is often the best option.

5. Young Adulthood (18–30 Years)

The indentation becomes stable but remains visible.
Symptoms may worsen as body size increases, adding pressure on the heart.
Non-surgical treatments are less effective, but surgery is still successful—though recovery may take longer.

6. Late Adulthood (After 30 Years)

The condition becomes fixed and chronic.
The indentation may affect functions such as:
- Shortness of breath
- Chest pain
- Reduced exercise tolerance
Surgery is possible but more complex due to stiffer cartilage.

Causes of Pectus Excavatum

Pectus Excavatum is a congenital deformity in which the breastbone sinks inward. Its causes are varied and include genetic, developmental, and medical factors:

1. Genetic and Hereditary Factors

Around 30–50% of cases have a family history.
Research suggests complex genetic components and mutations linked to connective tissue disorders.
A positive family history increases the likelihood in children.

2. Connective Tissue Disorders

Conditions like Marfan syndrome and Ehlers–Danlos syndrome make connective tissues overly flexible or weak.
These disorders affect ribcage structure and increase the risk of chest indentation.

3. Abnormal Growth of Ribs or Cartilage

Some theories suggest that rib cartilage grows abnormally, pushing the breastbone inward.
Recent studies show this growth may be excessive or relatively shortened, contributing to the deformity.

4. Developmental Factors

The deformity may be present at birth or appear gradually as the child grows, especially during puberty when the chest expands rapidly.

5. Mechanical or Internal Pressures

Some hypotheses link the condition to:

In-uterine pressure
Diaphragm movement
Breathing patterns during growth
These may contribute but are not primary causes.

6. Neuromuscular or Muscular Causes

Certain neuromuscular conditions—such as spinal muscular atrophy or muscle weakness—can reduce chest support, increasing the risk of indentation.

7. Rare or Temporary Causes

Some theories associate vitamin D deficiency (rickets) or abnormal bone development with chest deformities, but these causes are very rare.

Symptoms of Pectus Excavatum

1. Physical Appearance Symptoms

Visible inward depression of the chest.
Asymmetry between the two sides of the chest.
Protrusion of the lower ribs.
A “hole” appearance when standing or inhaling.
Indentation deepens with growth or during adolescence.

2. Respiratory Symptoms

Shortness of breath during physical effort.
Rapid breathing or difficulty taking deep breaths.
Fatigue faster than peers.
Reason: indentation compresses the lungs in severe cases.

3. Cardiac Symptoms

Palpitations or occasional arrhythmias.
Dizziness or quick tiredness.
Mild chest pain with exertion.
Reduced physical endurance.

4. Psychological and Behavioral Symptoms

Embarrassment about chest appearance.
Avoiding open clothing or swimming.
Low self-confidence, especially during adolescence.

5. Symptoms in Children

Mild back curvature (kyphosis).
Quick fatigue during play.
Recurrent chest infections in some cases.

Types of Pectus Excavatum

1. Based on Symmetry

• Symmetric:
The indentation is centered and even on both sides—usually with milder symptoms.

• Asymmetric:
The indentation is deeper on one side and may cause greater pressure on the heart.

Second: Based on Severity

• Mild:
A slight indentation, usually without symptoms.

• Moderate:
May mildly affect breathing and requires medical evaluation.

• Severe:
A deep indentation that compresses the heart and lungs; surgery (such as the Nuss procedure) is often required.

Third: Based on Shape

• Funnel-shaped:
The most common type.

• Long Depression Type:
A long vertical indentation affecting a larger portion of the chest.

• Localized:
A small, focused depression in a specific spot.

Fourth: Associated With Other Deformities

• With Pectus Carinatum (pigeon chest):
A combination of inward indentation and outward protrusion.

• With scoliosis:
Can worsen cardiac pressure and breathing difficulties.

Fifth: Based on Age of Onset

• Early-Onset:
Appears at birth or within the first few months of life.

• Adolescent-Onset:
Appears or worsens during adolescence due to rapid growth.

Sixth: Based on Associated Genetic Conditions

• Linked to Marfan Syndrome:
Usually severe, asymmetric, and requires careful cardiac monitoring.

• Linked to Ehlers–Danlos Syndrome:
The chest wall is soft and flexible, with significant joint laxity.

Complications and Risks of Pectus Excavatum

Pectus Excavatum is a congenital deformity where the breastbone sinks inward to varying degrees. Mild cases may cause no major issues, but moderate and severe cases can affect the heart, lungs, breathing, physical performance, and psychological well-being.

1. Breathing Problems

Shortness of breath, especially during exercise
Difficulty taking deep breaths
Quick fatigue with physical activity
Feeling like the air intake is insufficient

Cause: the indentation reduces the space available for lung expansion.

2. Heart Problems (Cardiac Compression)

Pressure on the right ventricle, reducing blood-pumping efficiency
Leftward displacement of the heart
Palpitations or irregular heartbeat
Chest pain during exertion
Reduced physical endurance

These symptoms appear mostly in moderate and severe cases.

3. Reduced Physical Fitness

Quick exhaustion during sports
Poor performance in running or high-intensity activities
Difficulty maintaining prolonged exercise
Dizziness or rapid shortness of breath during activity

4. Chest and Back Pain

Caused by compression of internal tissues and poor posture.

Muscular strain due to shallow breathing
Pain sites: center of the chest, between the shoulder blades, or along the sides

5. Recurrent Respiratory Infections

Poor lung expansion increases susceptibility to infections
Persistent cough or difficulty clearing secretions
Upper respiratory problems

6. Psychological and Social Impact

Embarrassment about chest appearance
Avoiding open clothing or swimming
Low self-esteem and social withdrawal
Anxiety or depression in some cases

Many patients seek surgery due to the psychological impact more than the physical symptoms.

7. Progression With Growth

The deformity may worsen during childhood and adolescence
Increased indentation and pressure on the heart and lungs
Harder to treat at an older age
Increased chest asymmetry

8. Spine and Posture Problems

Kyphosis (rounded back) or mild scoliosis
Weak back and shoulder muscles
Chronic upper or lower back pain

9. Reduced Quality of Life

A combination of breathing difficulties, chest pain, reduced exercise tolerance, and psychological burden.
Can affect school, work, daily activities, and sports performance.

⭐ Surgical Treatment of Pectus Excavatum

Surgical treatment is the most effective solution for moderate and severe cases because it corrects the root problem: the inward displacement of the sternum and abnormal cartilage.

Modern and traditional techniques are available, and the surgeon chooses the most suitable option based on age and deformity severity.

1. The Nuss Procedure

⭐ The most common and widely used surgery worldwide

How it is performed:

Two small incisions on each side of the chest
A curved metal bar (Nuss bar) is inserted under the sternum
The bar pushes the sternum outward to correct the deformity
The bar remains for 2–3 years, then removed in a simple procedure

Advantages:

Small incisions and better cosmetic results
Short operative time (30–60 minutes)
Suitable for children, teenagers, and adults up to about 35 years
Faster recovery compared to traditional surgery

Disadvantages:

Pain in the first few weeks after surgery
Rare risk of bar displacement
Requires a second procedure for bar removal

2. Traditional Surgery – Ravitch Procedure

⭐ Suitable for very severe cases or those not eligible for the Nuss procedure

How it is performed:

A vertical incision in the middle of the chest
Removal of deformed cartilage causing the indentation
Repositioning the sternum forward and stabilizing it with a temporary metal support
The support is removed after 6–12 months

Advantages:

Effective for very severe deformities
Direct control over the sternum and cartilage shape
Suitable for older adults

Disadvantages:

Larger surgical incision
Longer recovery period
Limited mobility and chest discomfort for 1–2 months

⭐ Surgical Options for Adults and Complex Cases

Adults require modified techniques because their chest cartilage is stiffer.

3. Modified Nuss for Adults (Adult Modified Nuss)

⭐ Designed for adults with stronger and stiffer cartilage

How it is performed:

Uses stronger or multiple bars
Additional fixation techniques to prevent displacement
Sometimes minor cartilage trimming is performed

Advantages:

Nearly similar results to the pediatric Nuss procedure
Less pain than Ravitch for adults

Disadvantages:

Slightly more postoperative pain compared to teenagers
Longer recovery time

4. Thoracoscopic-Assisted Repair

⭐ Used as an aid during the Nuss procedure

How it is performed:

A small camera is inserted inside the chest
Ensures the bar is placed safely
Reduces the risk of injuring the heart or lungs

Advantages:

Higher safety
Clear visualization during surgery
Fewer complications

5. Full Chest Wall Reconstruction

⭐ For very complex cases such as:

Multiple congenital deformities
Post-traumatic deformities
Recurrence of Pectus Excavatum after failed surgery

How it is performed:

Reshaping the chest cartilage
Using titanium plates or supports to stabilize the chest wall
A major surgery but provides full correction

6. Cosmetic Add-On Procedures

⭐ Not for medical treatment, only for appearance improvement

Includes:

Autologous fat grafting to reduce visible depression
Silicone chest implants to mask the indentation
Chest muscle sculpting (mainly for men)

Notes

These methods do not treat the underlying problem.
They are used for people who want to improve the appearance without undergoing major surgery.

⭐ Post-Surgery Exercises for Pectus Excavatum

Exercises after Pectus Excavatum surgery help speed up recovery, strengthen the chest and back muscles, and improve breathing. They are divided by recovery stage: