Nuss Procedure for Pectus Excavatum: Steps and Recovery

The Nuss procedure corrects a sunken chest without opening it. Through a small cut on each side, watching on a camera, the surgeon slides a curved steel bar behind the breastbone and flips it, so the curve pushes the breastbone forward. No cartilage or bone is removed. The bar stays about two to three years while the chest sets, then comes out in a second operation, often as day surgery.

In US data on patients aged 12 to 21, the median hospital stay is 3 days. With cryoablation, a nerve-freezing pain treatment, it’s often 1 to 2. Most people walk the day after surgery, live with strict limits for about six weeks and are back to most activities by around three months. Contact sport is the exception, because each hospital sets its own date.

I was diagnosed with pectus excavatum at 15 and decided against surgery. I corrected my chest over about three years of daily vacuum bell use and structured training, and the change was visible and measurable, but not complete. I’m not a doctor, and I haven’t had this operation. Surgery is the right call for many people. Every medical point below names its hospital or study, and where hospitals disagree, I show you. Your own surgeon’s plan beats every example here.

Below, I cover the steps, who it suits, pain control and cryoablation, a week-by-week recovery table from eight named hospitals, life with the bar, and the risks.

How the Nuss procedure works, step by step

Dr. Donald Nuss developed the operation in 1987 at Children’s Hospital of The King’s Daughters (CHKD) in Norfolk, Virginia, and first published it in 1998. These steps follow his team’s 2016 technique paper, with other centers’ differences noted.

1. Tests and bar sizing. Expect a CT or MRI scan, heart and lung tests, and a metal-allergy check. The bar is chosen about 2.5 cm shorter than your chest is wide and bent into a curve with a flat 2 to 4 cm middle that sits under the breastbone.
2. Anaesthesia and marking. Under general anaesthesia, you lie on your back with both arms out at about 70 degrees, and the surgeon marks the deepest point of the dip and where the bar will enter and exit.
3. Side cuts and a camera. One small cut on each side, about 1 cm in Dr. Park’s technique. A thoracoscope, a thin camera, lets the surgeon watch the heart and lungs throughout.
4. Lifting the breastbone first. Some centers now lift the breastbone away from the heart in every case before anything passes behind it, using a vacuum bell in younger, flexible chests, a retractor, a hook, or a crane (a frame fixed to the operating table that pulls the breastbone up with a wire).
5. Tunnelling behind the breastbone. An introducer, a long blunt steel instrument, is pushed between the breastbone and the heart under constant camera view, then used to lift the breastbone several times to loosen the chest.
6. Passing and flipping the bar. The bar goes in upside down, curve facing back, so it passes behind the breastbone without lifting it. A bar flipper then turns it 180 degrees, and the curve pushes the breastbone out. CHKD leaves it slightly loose, since a too-tight bar can cause pain and wear into the ribs.
7. Fixing the bar. At CHKD, a stabilizer (a small metal plate) goes on the left end, and pericostal sutures, stitches around the ribs, hold the right end to at least two ribs. With both, the developers report the bar moved in under 1% of patients. Other centers use a stabilizer on each side (Children’s Hospital of Philadelphia, or CHOP), bridge plates (Dr. Park, below) or no stabilizer.
8. Checking the lungs. A pneumothorax, air trapped between the lung and the chest wall, is the most common early problem. CHKD lets the air out before closing and X-rays the chest on days 1 and 3.

Most people get one bar, and older, stiffer chests more often need more. In 639 repairs at one Chinese center from 2006 to 2014, 75.7% had one bar, 24% two and 0.3% three.

The Park cross-bar and crane techniques

Dr. Hyung Joo Park, a Korean chest surgeon, built variations for chests one bar handles poorly: lopsided dips, stiff adult chests and a type he named the Grand Canyon. He joined Cleveland Clinic in 2025, which says he brought his NeoPectus techniques to the US in 2023 and credits him with about 7,000 career cases, its own figure.

Park defines the Grand Canyon as an eccentric long canal type, a long off-center groove from below the collarbone to the lower chest, not just a deep dip. It made up 13 to 14% of his repairs in two of his series.

His cross-bar technique, described in 2016 for that shape, crosses two bars at the deepest point, which his team says doubles the lifting force there. Bridge plates join the bar ends on each side, and the crane lifts the breastbone. After 14 patients, with no bar moving and no repeat operation, he called it the best technique so far in his opinion, and said a larger study was needed.

His own unit then reported 247 multiple-bar repairs from 2016 to 2019. The 157 cross-bar patients were older (18.0 against 15.7 years) and had stiffer chests than the 90 with parallel bars. Complications ran at about 10% in both groups, and no bar moved in either. His crane-powered NeoPectus series reported 691 repairs from 2017 to 2022 with no serious complications, minor ones in 16.9% and no bar displacement.

All of these figures come from one surgeon’s own series, with no independent trial. If your chest is lopsided or stiff, ask any center how it would handle your shape. My list of pectus excavatum surgeons by country includes the Cleveland Clinic program.

Who the Nuss procedure suits

Most sunken chests are mild and well tolerated, according to the 2024 Pectus Care Guidelines. They give the strongest recommendation for surgery when:

• the Haller index is above 3.25 and tests show the heart is being compressed
• there’s a dangerous heart rhythm problem
• there’s fainting or near-fainting

The Haller index is a CT ratio: chest width divided by the gap between breastbone and spine. The guidelines add that there’s good evidence people affected psychologically benefit, with a psychological assessment first. CHKD wants at least two criteria from a list that includes symptoms, a moderate or severe dip and a Haller index above 3.2.

Age. The developers recommend about 12 to 14, while the chest is still flexible, so the bar stays in through the growth spurt, which they say may lower the chance of the dip returning. CHOP operates from 10 to 19. The CHKD Nuss Center says its median patient is 15.

Adults. Adults have it too, with more complications. In US hospital data on 360 Nuss patients from 2016 to 2018, a complication was recorded in 30.6% of 12 to 17 year olds, 45.2% at 18 to 29 and 62.1% at 30 and over. Those counts come from billing codes, so minor problems are included. Most still do well: in a Mayo Clinic Arizona series of 361 adults, a modified Nuss succeeded in 96.5% of people aged 18 to 29 and 88.7% of those 30 and over. In a small Brazilian series, 19 adults aged 20 to 27 had more pain than teenagers after day 3 and needed stronger painkillers, with similar results.

For adults, the guidelines say the open Ravitch procedure, which removes overgrown cartilage through a cut on the front of the chest, has slightly fewer complications. Cost and insurance are in my guide to pectus excavatum surgery cost. Unsure how severe your chest is? Start with what pectus excavatum is, including the red flags.

The hospital stay

In US data on repairs at ages 12 to 21 from 2016 to 2020, the median stay after a Nuss was 3 days. Cryoablation shortens it: 2.0 days against 2.8 in US children’s hospitals from 2016 to 2023, and a median of 1 day in the 2026 trial below. Same-day discharge is still rare, 1.7% of pediatric repairs in a US surgical registry from 2017 to 2022.

Children’s Hospital of Philadelphia describes a typical stay:

• bed rest the first night
• an incentive spirometer, a handheld device you breathe into to keep the lungs open, every hour you’re awake
• out of bed to a chair the next day with help, then walking and stairs with a physical therapist
• a chest X-ray before you go home

CHOP says pain control mainly decides how long you stay. It sends people home when pain is controlled with medicine by mouth, you can walk with minimal help, you’re eating and drinking enough, you have no fever, and a bowel routine is in place, because opioids, the strong prescription painkillers, constipate. CHOP’s description doesn’t include time in intensive care, but ask your own center where you’ll recover. Here’s what to buy before you go home.

Pain control and cryoablation

The Nuss hurts. CHKD says plainly it “can be a painful surgical procedure”, and the guidelines rate the pain similar to the open Ravitch.

Plans differ by hospital, and most combine several drugs. CHOP gives gabapentin, a nerve-pain medicine, on the morning of surgery, then skin patches and IV acetaminophen and ibuprofen, then tablets that may include opioids and muscle relaxants for up to a month. A thoracic epidural, a thin tube near the spinal cord that delivers numbing medicine, used to be standard, and the guidelines note its risk of spinal cord injury.

How cryoablation works

Before the bar goes in, the surgeon uses the camera to place a probe on the intercostal nerves, which run under each rib, and freezes them at about minus 70 °C so they stop carrying pain signals. The freeze damages the nerve fibers but leaves their outer sheath intact, so the nerves grow back.

The guidelines say it has largely superseded epidurals internationally and rate it low risk. In US children’s hospitals, its use rose from 33% to 61% of Nuss repairs by 2023. It adds about 23 to 46 minutes of operating time, depending on the study. Cost is mixed: it raised hospitals’ total cost in national children’s-hospital data ($24,045 against $20,751) but lowered it at one Wisconsin center ($21,924 against $23,694).

What the trials show

The strongest evidence is the 2026 ICE trial: 48 Dutch patients aged 12 to 24, randomly given cryoablation or an epidural. With cryoablation:

• median hospital stay: 1 day against 4
• opioid use: 83% lower in hospital and 97% lower after discharge
• less pain on days 7 and 14
• no faster return to school or work
• 56% still had some chest numbness at 6 months

One center, not blinded, but randomized. An earlier UCSF trial of 20 patients found much the same: stays of 3 days against 5, 52% to 82% less opioid on days 1 to 3, 46.5 extra minutes in surgery, and similar pain scores up to a year.

Teams also improve with practice. At Phoenix Children’s, the latest quarter of 350 cryoablation patients went home 1.3 days sooner than the earliest, with 74% less opioid in hospital and similar complications.

Does cryoablation mean no opioids?

Not in the plans I found. It cuts opioids sharply, but Logan Health, in Montana, still sends patients home with oxycodone for about a week, plus a laxative routine, and CHOP gives a weaning schedule. None of these studies measured addiction, so I can’t give you a number. If that’s your worry, ask for the weaning plan before surgery.

Numbness and nerve pain

Expect a numb chest for a while. The guidelines say the nerves regrow over about 2 to 6 months, but feeling normal takes longer. In 121 Cleveland Clinic patients, the median time to normal chest sensation was 6 months, with a range of 1 to 12:

• 14.9% by 3 months
• 62.3% by 6 months
• 85.1% by 9 months
• 98.3% by 12 months

The other 1.7% kept a small numb patch on the lower breastbone. The ICE trial’s 56% with some numbness at 6 months points the same way. The two studies measured it differently, so the percentages don’t match exactly.

In the Cleveland group, 20.7% had a phase of hypersensitivity, skin that over-reacts to touch, usually starting around 3 months and lasting about a month. For 5.8% it was painful, and all of them were treated with gabapentin, capsaicin cream or both. None developed chronic nerve pain. In a Phoenix study, 6.7% screened positive for nerve pain at 6 months.

Who it may suit less

Adults, possibly. In a small study of 43 patients, 3 of 13 people over 21 developed nerve pain against none of the 30 younger ones, and numbness lasted about 10.8 months against 3.4. Worth raising if you’re older.

Children under 12. Cryoablation is off-label at that age, as the authors of a 10-child series note. Their 9 to 11 year olds did well, but ten children is a tiny sample.

Anyone who feels too good. Cleveland Clinic’s surgeons have warned that pain-free patients can forget their restrictions and move the bar.

Nuss procedure recovery week by week

These are examples from named hospitals and the guidelines, not a survey, to show the shape of recovery and how much it varies. Your surgeon’s plan is the one that applies.

When	What’s typical	Named examples, with differences
In hospital	Walking from day 1, breathing exercises, lying on your back	CHOP: bed rest night one, spirometer hourly, chair day 1. SickKids, Toronto: walk 3 times a day
Weeks 1 to 2	Home, short walks, pain medicine tapering	SickKids: 10 spirometer breaths every waking hour for up to a week, about 10% more activity each day. UPMC Children’s Pittsburgh: strictly limited activity for 2 weeks.
Weeks 2 to 4	Back to school for many teens, first clinic visit	Cleveland Clinic: students should be able to return to school 2 to 3 weeks after surgery. CHKD (developers’ paper): school after 3 weeks. KidsHealth: about 3 weeks home from school. CHOP: school once off opioids, first follow-up at 2 to 4 weeks
First 4 to 6 weeks	Strict limits on twisting, bending, lifting and sleeping position	CHOP, first 4 weeks: no side or stomach lying, bending, twisting, heavy lifting, reaching overhead, backpack or PE. Logan: light backpack at 1 month. KidsHealth, about 6 weeks: no running, no driving, ride in the back seat. CHKD: on your back and no sport or heavy lifting for 6 weeks. Aarhus, Denmark: no sport for 6 weeks. Guidelines: study or work at about 4 to 6 weeks
6 weeks to 3 months	Light cardio returns, upper-body limits ease	CHKD: running and swimming at 6 weeks. Logan: light cardio including swimming at 6 weeks, but no driving, no lifting over 15 to 20 lb and no twisting until 3 months. UPMC: normal activity except sport. Guidelines: full upper-body activity at about 3 months
3 to 6 months	Most sport returns, contact sport depends on the hospital	CHKD: competitive sport by 3 months. Logan: all sports at 3 months. UPMC: noncontact sport at 3 months, contact at 6. KidsHealth: 6 months or more to return to everything
Until the bar comes out	Living normally, with some centers limiting hard contact	CHOP: may keep football, wrestling and pole vaulting off the list while the bar is in. Aarhus: no heavy contact sport while the bars are in. Guidelines: some centers warn against hard blows like kickboxing for the whole bar period

Sleeping and breathing. Sleep on your back, and SickKids suggests raising the upper body on a wedge or pillows. My guide to the best sleeping position and surface covers the setup. Keep up the spirometer and breathing exercises, which KidsHealth says help prevent infection.

Work, driving and wound care. For adults I found only the guidelines’ 4 to 6 weeks for study or work, and nothing on physical jobs, so if yours involves lifting, agree a date with your surgeon before the operation. Only KidsHealth (about 6 weeks) and Logan (3 months) give a driving rule here. I found no seat-belt guidance and no current source on showering or wound care, so follow your hospital’s sheet.

Sport. It varies more than anything else here. I’ve compared what four centers say about boxing and wrestling after the Nuss. I also sell a phase-by-phase post-surgery program for people who’ve had the operation. Your hospital’s restrictions come first.

Living with the bar

For two to three years the bar is part of your body, and a few people need to know about it.

Medical alert. CHOP strongly recommends a bracelet reading “steel bar in chest, CPR more force, cardioversion ant/post placement”. Logan Health asks for one too.

CPR and defibrillators. CPR still works, with more force. In an engineering model, bars cut compression depth by at least 69% at a given force, and reaching 5 cm took at least 226% more force. CPR has succeeded on a 17-year-old two years after repair, and in other case reports rescuers struggled. That’s the quiet reason to tell family, coaches and school staff. Per CHOP, a defibrillator works with one pad on the front of the chest and one on the back.

Dentist. CHOP says you don’t need antibiotics before dental work while the bar is in.

Airports. According to CHOP, a stainless steel bar shouldn’t set off metal detectors, though titanium is more likely to. Ask your hospital for documentation and carry it.

MRI scans. Tell the MRI team you have a Nuss bar; rules differ.

Metal allergy. The steel contains nickel and chromium. CHOP patch-tests every patient, uses a titanium bar for a true allergy, and asks parents to mention rashes from belt buckles or earrings. At Phoenix Children’s, 741 patients had a 1.3% allergy rate whether or not they’d been tested first, so centers differ on testing.

Bar movement. Uncommon, but it happens. Rates depend on era and technique: under 1% with the developers’ current fixation, 3.7% needing revision across CHKD’s whole 1987 to 2012 experience, and 7% late displacement in a US multicenter study. It’s more likely in adults and when restrictions are ignored. More in bar movement after the Nuss procedure.

Infection. In an Amsterdam cohort of 695 patients over 25 years, 4.0% had a bar infection, a median of 2 months after surgery, often linked to a bar that had shifted.

When to call. CHOP’s list: fever above 101.5 °F (38.6 °C), more redness or swelling at the cuts, any drainage, trouble breathing, a change in how the chest looks, new or worse chest pain, or any injury to the chest.

When the bar comes out

The guidelines say Nuss bars should come out after about 3 years, and advise against leaving one in for life. The developers use 2 to 4 years. At Children’s Mercy Kansas City, the median time with the bar was 2.9 years. At CHOP, removal is same-day surgery through the same side cuts. What to expect, and the questions to ask, are in my guide to pectus bar removal.

Risks and complication rates

The developers published a full complication table for 1,463 first repairs at CHKD from 1987 to 2012. That era includes their early learning curve.

Complication	Rate
Pneumothorax (early)	3.8%
Drug reaction	2.9%
Infection at a stitch site	1.9%
Pneumonia	0.9%
Fluid around the lung needing drainage	0.9%
Pericarditis (inflamed lining around the heart)	0.6%
Bleeding into the chest	0.3%
Bar moved, needing revision (late)	3.7%
Over-correction (late)	3.1%
Bar allergy (late)	2.7%
Wound infection (late)	1.5%
Dip came back (late)	0.9%
Heart perforation or death	0

Other figures run higher or lower because they count different things. According to the guidelines, pneumothorax happens in up to 20%, the bar moves in about 1%, and the risk of death is about 0.03%. A meta-analysis of 15 studies and 5,978 patients put the overall complication rate at 19.87%. In Graz, Austria, 4.2% of 167 patients had a major complication, including one perforated heart, which the surgeons linked to the learning curve. Across 49 centers and 13,352 patients, results were best at about 73 or more repairs a year.

My reading: serious harm is rare, smaller problems are common, and the team’s experience matters.

Results

Results are good. In 1,215 Nuss patients at CHKD, 95.8% had a good or excellent result when the bar came out, and 1.4% needed another operation because the dip returned.

For the long run, Children’s Mercy surveyed patients a median of 9.6 years after repair. 96.7% were satisfied and 2% had needed another procedure, but 30.7% noticed the chest sinking back somewhat. Only 26% answered, so treat that as rough. More in preventing recurrence after surgery.

Lung function tends to improve, according to a 2012 pooled analysis of 23 studies. In the US multicenter study, forced vital capacity rose from 88% to 93% of predicted, and total lung capacity from 94% to 100%.

The scars are small and sit on the sides of the chest. They still matter: in a Johns Hopkins series of 98 adults, severe pain after surgery and the scars were the main complaints. More in surgical scars after pectus repair.

Where to go from here

• You’ve been offered the Nuss. Ask the center how many it does a year, its pain plan (cryoablation or not), its activity and sport rules, and when the bar comes out.
• You’re recovering. Your hospital’s sheet beats every row in the table above. Keep CHOP’s call list somewhere you’ll see it.
• You’re still deciding, or your chest is mild. Take my free 1-minute quiz for a sense of where your chest stands and which route fits. Surgery is a legitimate choice, and so is trying without it first when your chest allows.

Sources

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