pectus excavatum surgical bar

What is a Pectus Bar

The Pectus Bar is an implant that is inserted underneath the inverted sternum, during the Nuss procedure. 

It is usually made of stainless steel, metal or titanium.

In 1987, Dr. Donald Nuss has developed a minimally invasive procedure to correct pectus excavatum. 

It is called the Nuss procedure.

The Pectus Bar is the most important component of the surgery. 

The chest wall is remodeled after three years of living with the surgical bar that is inserted under the indented breastbone. 

Characteristics of the Nuss Bar

  • The surgical bar has curved ends and dull edges to prevent organ and tissue damage while inserting.
  • Depending on the patient's thorax dimensions, the bar comes in lengths ranging from 7, up to 17 inches.
  • If you have a nickel allergy, a special titanium bar can be used.
  • In its starting position, the pectus bar implant is completely straight. After evaluating the patient's chest, the surgeon curves it accordingly, using a special Pectus Bender instrument.
  • There are pre-bent Pectus Bars, that are crafted after analyzing the patient's CT-scan on the chest.

How to Prepare for a Pectus Bar Removal Surgery

Day Before Surgery

Before undergoing bar removal surgery, you need to do a few specific breathing tests.

The doctor will advise you to not eat or drink anything after midnight.

That's because the pectus bar removal surgery will require general anesthesia. While under its effects, your physique reflexes will be momentarily paused.

If you have any food or liquid in your stomach, there will be a high risk of vomiting and regurgitation.

This will cause the food to fall in your lungs, which can damage your lungs and impair your breathing. 

How is the Pectus Bar Measured?

One day before undergoing a Nuss procedure, the surgeon must measure the pectus excavatum patient's chest.

That will help the surgeon conclude the adequate length of the Nuss bar.

The estimation is done using a measuring tape or a Pectus Bar Template.

They are placed over the deepest part of the hollow, ranging from the left midaxillary to the right midaxillary line.

As a general rule, the Pectus Bar needs to be 1-2 cm shorter than the calculated measurement.

That's because the tape measures the outer diameter of the breast and the Pectus Bar crosses the inner diameter.

KEY POINT:

Don't eat or drink after midnight. If you do, there is a risk of vomiting and organ damage during surgery.

Day of Surgery

You'll be under general anesthesia and fully asleep during the surgery at the clinic. 

You'll be lying on your back, with your arms hanging freely over your head. 

Doctors will provide you Intravenous therapy (IV) which will bring liquids and medication directly to your veins.

After everything is ready, the surgeon will make two cuts in the same place they inserted the Pectus bar.

That's done to minimize scarring and maintain the minimally invasive status of the Nuss procedure.

After that, the Pectus bar is removed using the instruments that I mentioned above.

This time, surgeons won't close the cuts with stitches. They will use two small thin sticky bandages, called Steri-Strips. 

They are often used as an effective substitute for dissolvable stitches.

Then, an anesthesiologist will give you local anesthesia near the site of the cuts. That will help you endure the physical agony after the surgery.

After a successful Pectus bar removal, a chest X-ray is required to make sure the patient's chest wall is repaired without any organ or tissue damage. 

KEY POINT:

You'll be given general anesthesia and Intravenous therapy. Surgeons will make the incisions at the exact same spot as the previous ones. They'll be closed with bandages.

Pectus Bar Removal

removal of nuss bar

Pectus Bar removal is the last step of the Nuss procedure.

A recent 2016 study, supported by the Institutional Review Board (IRB), concluded that Pectus bar removal is a safe and simple procedure with low rates of complications.

The surgeons used a special technique with straightening the bar in a horizontal position.

This technique proved to be effective in both children and adults. Also, it is used to avoid complications.

In the research, 2,553 patients with pectus excavatum and carinatum were examined.

The patients were 9.13 years old on average, and the bar was underneath their sternum for about 2.57 years. 

The least amount of time required was four months, and the most was, surprisingly 14 years.

After bar removal, 43 patients had wound seroma with infection. 

Pectus excavatum re-occurred in nine patients. They needed another surgery to correct the deformity once again.

KEY POINT:

Nuss bar removal is safe, with small chances of complications.

Pectus Bar Removal Anesthesia

Don't worry about pain during the Pectus bar removal surgery.

You'll be completely unconscious because you'll be given general anesthesia.

Additionally, you'll also be given local anesthesia near the incision site, before the doctors re-open the two cuts. 

The purpose of this is that the patient won't feel severe pain after waking up from the general anesthesia. 

They are given to the patient by an anesthetist.

After the bar is removed from your chest, you will usually be admitted to the hospital's Post Anesthesia Care Unit.

KEY POINT:

You won't feel any pain during the Nuss removal surgery.

After Surgery

pectus bar removal recovery

After the surgery, you should expect to be taken to the post-anesthesia care unit at the hospital to recover from the general anesthesia. 

You'll be given Intravenous therapy for pain medication until you are fully awake to receive fluids. 

Once you can swallow without any pain, you'll be given ice chips and a drink.

If the X-ray examination of your chest shows no problems whatsoever, you can go home safely. 

You'll be given painkiller medications to help you with pain management for about a week after surgery.

As a general rule, you are allowed to take a shower two or three days following surgery.

If everything is fine, the doctors will advise you to resume daily physical activities in about ten days. 

You can return to school or work in about a week if you don't feel severe pain.

It is highly recommended to do posture improving and diaphragmic breathing exercises twice a day.

If you don't feel severe agony while inhaling, it is highly recommended to do breath-holding exercises.

KEY POINT:

After bar removal, you'll be taken to the post-anesthesia care unit. You'll be given pain medication and IV therapy. If everything is fine, you'll be good to go  home.

Follow-up Meetings with the Surgeon

It is recommended to do a follow-up meeting with your main surgeon in about two weeks after a Pectus bar removal surgery.

The surgeon needs to inspect your incision site and see for infection or other signs of complications.

Also, expect to be advised to return a year after Pectus bar removal to see whether your chest is permanently corrected and doesn't sink in again. 

The doctor will also analyze the health of your respiratory and cardiac systems.

Call the Doctor If The Following Problems Develop

  • Fever - If your body temperature goes over 37° Centigrade or 100° Fahrenheit)
  • Skin redness, fluid drainage and even inflammation near your incisions
  • Nagging cough that even hinders your sleep
  • Chest pain, especially when you take deep diaphragmic breaths
  • Trouble with breathing and shortness of breath

Nuss Bar Removal Complications

taking away pectus bar

First Case

However, a scientific study in 2009 describes a report of accidental heart puncture which almost killed a 20-year-old girl.

The bar removal operation was scheduled three years after a successful Nuss procedure.

The surgery was performed under general anesthesia.

Throughout the preparation and slackening of the adhesive Pectus bar, heavy bleeding occurred, which required immediate medical intervention to save the poor woman's life.

Second Case

In an article published in 2018, a dangerous complication happened to a 15-year-old patient, immediately after a Pectus bar removal surgery. 

The bar was removed two years after undergoing a successful Nuss procedure.

Unluckily, he developed a hemopneumothorax due to a cut in the right lung.

The boy required immediate treatment. 

Third Case

A study first published in 2014, presented a life-threatening complication because of massive blood loss during Nuss bar removal.

The 19-year-old girl lost 3,5 liters of blood during the surgery.

The bar removal surgery happened three years after undergoing a Nuss procedure.

The patient was treated with inserting two Nuss bars.

An article published in 2017, reports the chances of complications of a Nuss bar removal surgery.

Out of a total of 246 patients, 43 patients endured surgery complications.

The study also concluded that younger patients have lower chances of difficulties. 

Additionally, patients with double bars had a higher chance to have complications during bar removal surgery.

KEY POINT:

Generally, Pectus bar removal complications are rare but very dangerous if they occur.

Previously, there was a lot of evidence of heart puncture while inserting the Pectus bar, especially when surgeons were inserting it blindly, without the help of a thoracoscope.

Now, there are lots of cases that report life-threatening complications of the Pectus bar removal operation.

All three studies mentioned above included some type of internal organ rupture.

In the text that follows, I'll list other types of complications that may lower your quality of life after removing the Nuss bar. 

Nuss Bar Got Stuck In a German Patient

A German patient that I stumbled upon on a German forum for pectus excavatum, wrote that he was living in severe pain for 26 months.

There weren't major problems during the time whatsoever. 

However, as soon as doctors started the Pectus bar removal surgery, they figured out that the bar was stuck underneath the patient's sternum.

They had to cut a third incision, to pull the Pectus bar out.

This left a noticeable scar on the right side of his ribs.

Metal Allergy to Pectus Bars

titanium allergy nuss bar

The Pectus bars are built of metal. 

Metal allergy is a common difficulty related to the Nuss procedure.

Most Pectus bars are built of titanium, which is a biocompatible material that may cause allergic reactions. 

Titanium bars are not approved for patients that have metal sensitivity.

A 2017 study from Yokohama, Japan, reports a 17-year-old patient that had an allergic reaction to titanium, after undergoing a Nuss procedure.

The boy was given oral steroids, which are an effective therapy for this type of allergy.

Even though metal allergies to Pectus bars are rare, they can still occur.

KEY POINT:

If you're allergic to metal, you can have an allergic reaction to the Nuss bar.

Pectus Excavatum Bar Displacement

nuss bar dislocation

A 2001 study led by M.D. Andre Hebra, reported that bar displacement happens in 9.5% of all patients, especially adolescents.

Doctors tried to deal with this problem, by putting a lateral stabilizing bar to support the main bar.

Even though this helped reduce Pectus bar displacements, it is still a common occurrence.

A 2011 Brazillian study concluded that using short bars, exclusion of fixation wires and remodified stabilizers installed in a more central location resulted in more satisfying results of the Nuss procedure. 

This also helped in minimizing the occurrence of bar dislocation.

The problem with Pectus bar dislocation is that it will result in concave chest recurrence and may require re-operation.

In severe cases, bar dislocation can lead to heart and lung puncture, which can lead to excessive bleeding and even death.

These adverse effects aren't acceptable, mostly because the Nuss procedure is performed for cosmetic and psychological purposes in most cases.

The higher percentage of sufferers choose to undergo the surgery, just to correct the sunken chest wall appearance. 

This will help them psychologically because they won't feel uncomfortable around others while being naked.

The condition has to be severe usually with a Haller Index greater than 3.25, to negatively affect the internal organs. It is usually more cosmetic if the severity is mild (HI < 3.25).

If you're still uncertain about undergoing a Nuss procedure because of internal organ rupture risk, I have a suggestion for you. 

In my personal opinion, if you want to correct the appearance of your caved in chest, I'd recommend you undergo a plastic surgery using silicone implants or physical therapy and bracing to fix it non-surgically.

It is scientifically proven that plastic surgery and non-surgical physical therapy is safer than the Nuss procedure. Also, it is proven that both can repair the deformity and make it less noticeable.

KEY POINT:

The most frequent Nuss procedure complication is a pectus excavatum bar displacement. That is very dangerous and can puncture the vital organs like the heart.

17-Year-Old Kay Whiteman Died During Pectus Bar Removal Surgery

Please read the story of 17-year-old Kay Whiteman.

She had extreme complications during Pectus bar removal, which resulted in extreme bleeding and brain damage that sadly, lead to her death. 

Her mother said Kay was in perfect health before the surgery. The deformity didn't cause problems to her heart and lungs.

The only reason why she wanted to undergo surgery was to fix her hollow sternum and look like every normal girl.

Originally, the surgery was considered successful.

However, 6 months after the surgery, Kay experienced complications that required removal of her Nuss bar. 

Sadly, she died during the bar removal surgery.

Pectus Support Bar System Instruments

To simplify the Nuss procedure, a Pectus System has been created, which includes nine instruments.

pectus bar removal instruments

List of Instruments

  • Pectus System Container - It comes in 2 sizes (Standard or Extra Long). It suitably contains all Pectus implants and tools.
  • Surgical Bar Implant - The surgical implants are created to help correct the pectus excavatum deformity. A surgeon uses the implant to reconstruct the concave anterior chest wall of the sufferer. The purpose of this instrument is to apply inward force, outwardly, so it will rebuild the chest bone structure.
  • Lengthened Pectus Stabilizer - The purpose of this instrument is to stabilize the bar, once it is applied underneath the sternum. The stabilizer is fastened to the bar and stitched to the nearby muscle, so it will remain fixed.
  • Pair of Bar Removal Benders - These instruments are designed to remove the Pectus bar following a successful correction after three years. A cut is done on the same location before inserting the bar implant. Through this cut, the bar removal benders will have access to the lateral tip of the Pectus bar. Then, the bar is pulled out while turning the patient to the other side.
  • Pectus Introducer - This instrument helps in lifting the sunken breastbone, before inserting the Pectus bar. This helps with initial bar rotation and firmness. There are two types of Pectus Introducer: Short - for younger patients aged 4-12. Long - for more grown and bigger patients, usually aged 13-18.
  • Pectus Bender - This is used to bend the Pectus bar depending on the patient's chest wall dimensions. The surgeon does this by creating small, progressive curves, starting from the middle, spreading to the sides.
  • Pectus Bender Extra Long - It does the same job as the original Pectus bender. However, it is used for larger and stronger bars, used in more grown patients.
  • Pectus Flipper - After inserting the bar, this instrument flips the Pectus Bar, so it causes the breastbone to rise into the wanted placement.
  • Pectus Table Top Bender - This instrument has been recently recalled because it is creating deep holes in the Pectus Bar. 

Hesitating to Remove Pectus Bar Can Harm You

Living with the Pectus bar below your sternum for a long time can be very painful for some patients. 

It is generally recommended to not remove the surgery earlier than two or three years.

Patients that live with agony are willing to remove the Pectus bar as soon as possible because the pain is intolerable.

However, they will risk a deformity recurrence if they have their bar removed earlier than two years.

To numb the pain, they are required to take opioid painkillers daily, for two years!

Morphine, Percocets, Advils, fentanyl patches, and antidepressants are the most commonly prescribed pills.

Taking those pills for that long is not healthy! It will usually translate to addiction.

The Addiction Center website published a statistical analysis of opioid addiction.

In 2012, in the United States alone, 259 million opioid painkiller prescriptions were written. Out of them all, a predicted 2 million patients later formed an addiction.

If you already had the bar for two years, I recommend you to schedule an examination with your surgeon. 

The risks of pectus excavatum recurrence after the bar removal surgery is far lower than becoming addicted to opiates medications that can kill you.

According to the Center for Disease Control and Prevention, in 2017 alone, overdoses involving opioids killed more than 47,000 people. What's more stunning is that 36% of those fatalities included prescription opioids. 

KEY POINT:

Please don't hesitate to remove the Nuss bar if your deformity is already corrected.

Does Insurance Cover Pectus Bar Removal Surgery?

Most health care and insurance companies in the US, cover the costs of the full Nuss procedure (including Pectus bar removal surgery) if the patient satisfies the following guidelines:

  • The patient's Haller Index needs to be higher than 3.25
  • The deformity is negatively affecting the heart and lung functioning
  • The patient has clear medical proof of exercise intolerance

If the patient doesn't satisfy the above-mentioned criteria, the insurance company won't cover the expenses.

The company views the pectus excavatum surgery as a cosmetic procedure that doesn't fix any physiologic function.

Documentation Requirements to get Full Coverage

As listed by the UnitedHealth Group company, which is the largest healthcare group in the world by generated income ($226 Billion) and customers (115 million), you'll need the following documents to see whether you meet the criteria for full coverage.

  • CT scan (computed tomography) image of your sunken sternum. It needs to prove the Haller Index to be greater than 3.25.
  • Full medical documentation of how your pectus excavatum deformity hinders your cardiovascular and pulmonary functioning.
  •  Respiratory system tests that include the patient's medical records, bodily checkups, and analyses of pulmonary function. The goal of this is to identify the seriousness of pneumonic impairment. The full lung functioning needs to be less than 80% of the predicted capacity.
  • An echocardiogram to examine your heart's chambers and valves are pumping blood within your heart. Doctors need to confirm reduced cardiac production.
  • A full therapy program created by a medical doctor 

You need every single above-mentioned document to get complete Nuss procedure coverage.

Top 3 Pectus Bar Manufacturers

Biotech pectus bar

BioTech GmbH is one of the best producers and merchants of the Pectus bar. 

The company's manufacturing facilities are located in Germany and Hungary, both countries in Europe.

Biotech specializes in creating Orthopaedic, Injury and Spinal medical products that are used during surgical procedures.

All their products have the required CE Quality sign, which is confirmation of safety, well-being, and environmental protection.

These are standards for products sold within the European Union.

The BioTech Nuss bar has the CE sign written on it, along with the "Made in Germany" merchandise mark, which symbolizes amazing quality.

Ecotron Co.,Ltd

Ecotron is a company that specializes in building X-ray generators and systems. 

It is established in 2005 and is based in Seoul, South Korea.

All their products have FDA approval, so their quality is excellent.

The company also creates bars for correcting pectus excavatum.

If you're getting operated in some countries in Asia, there is a high chance that surgeons will insert an Ecotron Pectus bar to correct your funnel chest.

Zimmer Biomet Pectus Bar

Zimmer Biomet is a legal manufacturer of the Pectus bar.

The company was established in 1927 and is based in Warsaw, Indiana.

It is spread in more than 25 countries worldwide and sells products in more than 100 countries.

Walter Lorenz established the Biomet Microfixation, which builds surgical instrumentation like the Nuss bar, more than 30 years ago.

Dr. Donald Nuss, who is the originator of the Nuss procedure, partnered with Walter Lorenz and Biomet Microfixation. 

Together, they created the surgery that uses the Pectus bar to fix the inverted chests of millions of patients worldwide.

Today, Biomet is the leading manufacturer of the Nuss bar.

KEY POINT:

All Pectus bars are built with certain standards that need to be satisfied. It doesn't matter what company manufactures them. They are all designed based on the general surgery requirements.

Which Surgical Code Applies to Pectus Bar Removal?

According to the SuperCoder medical code lookup website, the Pectus bar removal CPT code is 20680.

However, the same code applies for removal of a buried wire, clip, bolt, metal band, nail, plate or rod.

The code overpasses many anesthesia codes, however, none of them identifies with Pectus Bar removal.

As a result, many coders suggest listing 00474.

Conclusion

In this article, I discussed everything you need to know about the Pectus bar. 

Dr. Donald Nuss created the most advanced procedure to correct pectus excavatum. It utilized the Pectus bar, otherwise known as the Nuss bar.

The procedure was instantly accepted by surgeons, globally.

Ever since then, there are lots of modifications of the original Nuss procedure, primarily focusing on improving it's effectiveness and safety.

In this article, I mostly focused on the adverse effects of the Nuss procedure and the Pectus bar. The complications are medically proven to be life-threatening.

I listed a few cases of deaths that happened mostly because of Pectus bar dislocations.

I want you to know that I don't want to bash the Nuss procedure and Pectus bar.

At the end of the day, this procedure changed the lives of millions of patients worldwide. 

Their whole perspective of life changed after correcting the deformity with the Pectus bar, which stayed underneath their sternum for three years.

The point of this article was to show you that the Nuss procedure and Pectus bar aren't always up to good. I backed this up with scientific investigations.

I am shocked that nobody talks about the negative effects and surgery risks.

Also, surgeons won't tell you about the fatalities and chances of complications about the surgery they are about to perform on you.

Hopefully, you are now aware of what may go wrong while living with the Nuss bar below your breastbone.

If you have any questions, please leave them in the comment segment below.

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