Pectus Bar Implant, Removal, Complications & More

Evidence Based This post has medical citations
pectus excavatum surgical bar

The Pectus Bar is an implant inserted underneath the inverted sternum during the Nuss procedure. It is usually made of stainless steel, metal, or titanium.

In 1987, Dr. Donald Nuss developed a minimally invasive procedure to correct pectus excavatum. It is called the Nuss procedure.

The Pectus Bar is the essential 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 inserted.
  • The bar ranges from 7 to 17 inches, depending on the patient’s thorax dimensions.
  • Pectus surgeons can use a unique titanium bar if they have a nickel allergy.
  • In its starting position, the pectus bar implant is entirely straight. After evaluating the patient’s chest, the surgeon curves it accordingly, using a unique Pectus Bender instrument.
  • Pre-bent Pectus Bars 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 must do a few specific breathing tests. The doctor will advise you not to 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 into your lungs, damaging your lungs and impairing 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.

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 with 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 adequate 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 ensure the patient’s chest wall is repaired without organ or tissue damage.

Pectus Bar Removal

removal of nuss bar

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

A 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 unique technique of 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 time required was four months, and the most were, 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.

Pectus Bar Removal Anesthesia

Don’t worry about pain during the Pectus bar removal surgery. You’ll be utterly unconscious because you’ll be given general anesthesia.

You’ll also be given local anesthesia near the incision site before the doctors re-open the two cuts. The purpose 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.

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 pain, you’ll be given ice chips and a drink.

You can go home safely if your chest X-ray examination shows no problems. You’ll be given painkiller medications to help you with pain management for about a week after surgery.

As a general rule, you can take a shower two or three days following surgery. If everything is fine, the doctors 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.

Follow-up Meetings with the Surgeon

It is recommended to do a follow-up meeting with your primary 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
  • The 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 an accidental heart puncture that 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. Heavy bleeding occurred throughout the preparation and slackening of the adhesive Pectus bar, 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.

Surgeons removed the bar 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 by 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 of complications during bar removal surgery.

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 following text, I’ll list other complications that may lower your quality of life after removing the Nuss bar.

Nuss Bar Got Stuck In a German Patient

A German patient I encountered on a German forum for pectus excavatum wrote that he had been living in severe pain for 26 months.

There weren’t significant problems during the time whatsoever. However, as soon as doctors started the Pectus bar removal surgery, they discovered the bar was stuck underneath the patient’s sternum.

They had to cut the 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 made of titanium, 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, effective therapy for this type of allergy. Even though metal allergies to Pectus bars are rare, they can still occur.

Pectus Excavatum Bar Displacement

nuss bar dislocation

A 2001 study led by MD. 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 common.

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, mainly because the Nuss procedure is performed for cosmetic and psychological purposes in most cases.

A higher percentage of sufferers choose to undergo surgery to correct the sunken chest wall appearance. This will help them psychologically because they won’t feel uncomfortable around others while naked.

The condition has to be severe, usually with a Haller Index greater than 3.25, to affect the internal organs negatively. 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 suggest you.

Suppose you want to correct the appearance of your caved-in chest. In that case, I’d recommend you undergo 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 are safer than the Nuss procedure. Also, it is proven that both can repair the deformity and make it less noticeable.

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 severe bleeding and brain damage that, sadly, led 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 ordinary girl.

Initially, the surgery was considered successful. However, six months after the surgery, Kay experienced complications that required the 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. This instrument’s purpose is to apply inward force to outwardly 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 to 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 exact 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 lift 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 creates small, progressive curves, starting from the middle, and spreading to the sides.
  • Pectus Bender Extra Long does the same job as the original Pectus bender. However, it is used for more extensive and more robust 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 not to 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, doctors wrote 259 million opioid painkiller prescriptions in the United States alone. Out of them all, a predicted 2 million patients later formed an addiction.

If you have already had the bar for two years, I recommend you schedule an examination with your surgeon. The risks of pectus excavatum recurrence after the bar removal surgery are far lower than becoming addicted to opiate 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.

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

The insurance company won’t cover the expenses if the patient doesn’t satisfy the abovementioned criteria.

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.
  • Complete medical documentation of how your pectus excavatum deformity hinders your cardiovascular and pulmonary functioning.
  •  Respiratory system tests include the patient’s medical records, physical checkups, and analyses of pulmonary function. The goal of this is to identify the seriousness of pneumonic impairment. The full lung function must 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 complete therapy program created by a medical doctor

You need every single document mentioned above to get comprehensive 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, confirming 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 impressive quality.

Ecotron Co., Ltd

Ecotron is a company that specializes in building X-ray generators and systems. It was 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 on 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, 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.

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 to removing 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

I discussed everything you need to know about the Pectus bar in this article. 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 have been lots of modifications to the original Nuss procedure, primarily focusing on improving its effectiveness and safety.

In this article, I mainly 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 primarily because of Pectus bar dislocations. I want you to know that I don’t want to bash the Nuss procedure and Pectus bar. 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 adverse 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 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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