If you have pectus excavatum surgery booked, or you're about to book it, this is your preparation plan: exactly what to do in the weeks before the Nuss procedure so you walk into the operating room as strong, fit and ready as possible.

The Nuss procedure corrects the structure by sliding one or more curved metal bars behind your sternum to push it forward; the bar stays in for roughly two to three years before removal.^1,32 It works, but it is a real thoracic operation, and the fitness, breathing skill and posture you bring into it shape how the first weeks afterward go.^2,10

This is the discipline of prehabilitation: getting measurably fitter and better-prepared before surgery so you recover faster and with fewer complications. Prehab and structured pre-operative preparation are built into modern enhanced-recovery (ERAS) pathways and are associated with shorter stays, fewer pulmonary complications and smoother recoveries.^3,4,16,35

The biggest, most preventable problem after chest surgery is in your lungs. Under anesthesia and chest-wall pain, breathing goes shallow and the small air sacs collapse, atelectasis, the most common complication after thoracic surgery and the gateway to pneumonia.^13,15 The single best defense is being fluent in deep-breathing and spirometry before surgery, when it's easy, so you can do it on day one when it hurts.^9,16

The fitter, stronger and better-nourished version of you also recovers faster. Preoperative inspiratory-muscle training reduces postoperative pulmonary complications,¹⁶ prehab and exercise before major surgery improve postoperative functional capacity,³⁵ and a base of posture and back strength gives you something to rebuild toward instead of starting from zero. Add stopping smoking and topping up nutrition, and you've moved every dial that's actually in your control.^36,39,41 The operation fixes the structure; preparation decides how the recovery feels.

In the minimally invasive (Nuss) repair, one or more curved bars are passed under the sternum through small side incisions and flipped to lift the breastbone.^1,23 In the open (Ravitch) repair, overgrown rib cartilage is removed and the sternum repositioned.²⁴ Surgery is generally considered when the deformity is significant, a Haller index above ~3.25 on CT, with cardiac or pulmonary compression, is the usual surgical threshold.^17,28

It helps to know what your body will be doing in the weeks after:

• Bone & cartilage will be under new, sustained load and will remodel slowly, which is why posture and gradual strengthening matter for months afterward.
• Intercostal nerves under the bar drive the sharp early pain, the reason your team plans nerve blocks or cryoablation, not opioids alone.^6,7
• The bar–rib interface needs scar tissue to anchor over weeks to months. Until then the bar can shift, so the first phase of recovery is built around protecting it.^29,31

Prehab makes sense once you know what you're preparing for. In the first weeks after surgery you will be asked to:

Everything in this program maps to one of those demands. You're not training to be an athlete, you're loading the dice for an easier recovery.

Ideally you have six to eight weeks. If you have less, do everything you can in the time you have, even two weeks of breathing practice and smoking cessation moves the needle.^16,37

This is the most important thing you can practise before pectus surgery. Postoperative pulmonary complications hit a large share of thoracic-surgery patients, with atelectasis the usual first domino.¹⁵ Deep-breathing protocols and incentive spirometry are front-line prevention, and preoperative inspiratory-muscle training lowers postoperative pulmonary complications in major surgery.^13,15,16

The goal of prehab breathing is simple: be so fluent that you can do it half-asleep and in pain. Two drills, every day:

• Diaphragmatic breathing. Hand on belly, slow nasal inhale into the lower ribs, long exhale. 5–10 minutes, a few times a day.^9,15
• Incentive spirometry / inspiratory-muscle training. If you can get a spirometer now, practise 10 slow maximal breaths a few times daily. If not, slow maximal inhales with a 3-second hold build the same habit.^13,14,16

Surgery moves your sternum forward; posture is what keeps it looking that way afterward, and the most common way people lose the visual result is spending recovery hunched and guarded.⁸ You can't strengthen through a fresh incision, so the work is done now: build a base of upper-back and scapular strength you'll pause for a few weeks and then rebuild.

• Pull-dominant strength: rows, lat work and face-pulls build the muscles that hold a tall chest.
• Postural drills: chin tuck, shoulder blades back and down, ribs stacked over pelvis, held through the day until it's a habit.
• Gentle thoracic mobility: extension over a foam roller keeps the upper back from stiffening.

Physiotherapy as an adjunct to chest-wall surgery improves posture and function,⁸ and the stronger your starting point, the faster you return to it. See the full routine in the Strength Program.

Exercise capacity is often reduced in pectus excavatum to begin with,¹² and a better cardiovascular base going in means you tolerate anesthesia better, mobilise sooner and reach your walking targets faster.^3,35 Aim for steady aerobic work in the weeks before surgery:

• Most days: 20–40 minutes of brisk walking, cycling or swimming at a conversational-to-slightly-breathless pace.
• Build, don't blast: the goal is a durable base, not personal records, stop heavy or high-impact work in the final two weeks.
• Practise nasal, diaphragmatic breathing during cardio so the two skills reinforce each other.

Eat to heal, starting now

You'll be healing bone, cartilage and incisions, which is protein- and micronutrient-hungry. Build the stores before surgery, not after. Prioritise adequate protein at every meal, and keep vitamin D topped up (≥800 IU/day, aiming >30 ng/mL) with enough calcium, vitamin D supports bone healing, muscle strength and infection control, and deficiency is linked to worse surgical outcomes.^39,40 Zinc and vitamin C support wound repair.⁴¹

Fix anemia before, not after

Going into surgery iron-replete matters: preoperative anemia is linked to more transfusions and complications, and correcting iron stores beforehand is a core part of patient blood management.⁴² If you bruise easily, have heavy periods or eat little red meat, ask your team to check your iron and hemoglobin early enough to fix them.

Arrive at a healthy weight

Very low or high body weight both complicate surgery and recovery. Use the prehab window to steady your nutrition rather than crash-diet, the aim is to arrive well-fuelled and strong.³⁵

If you smoke or vape, quitting before surgery is one of the highest-impact things you can do. Preoperative smoking cessation reduces postoperative complications (wound, pulmonary and otherwise) and the longer the smoke-free interval before surgery, the bigger the benefit; even a few weeks helps.^36,37

Cut alcohol too. Heavy drinking impairs healing and raises complication rates, and a period of abstinence before surgery improves outcomes.³⁸ Treat both as part of the program, not an afterthought.

Some of the most important prep is administrative. In the weeks before surgery:

• Review every medication and supplement with your surgeon. Some blood thinners, anti-inflammatories and herbal supplements must be paused before surgery, but only on your team's instruction, never on your own.²⁶
• Clear active infections. Sort out dental problems, skin infections and chest infections in advance, they can delay surgery or raise risk.
• Attend your pre-operative assessment and be honest about your history; anesthetic planning for the Nuss procedure is specific and your team needs the full picture.²⁶
• Confirm your bar material if you can: steel versus titanium affects future MRI and airport security, and it's worth knowing.⁴⁴

Preparation is mental as much as physical. The encouraging part is well-documented: surgical repair markedly improves body image, self-esteem and confidence in physical activity, with the biggest shift in the first weeks of recovery.^45,46,49 People with pectus often carry lower quality of life and body image beforehand, and that is exactly what tends to lift after correction.^48,49

Set expectations now: the first painful days are the hardest, then it climbs steadily. Knowing the timeline, rehearsing the breathing, and having your home set up takes most of the anxiety out of it. Preoperative education and preparation lower anxiety and smooth recovery.^35,50 If you feel persistently low or panicky before surgery, tell your team, that's part of being prepared too.

Surgery is stressful, and a sunken chest carries a real psychological weight long before the operating room. People with pectus report measurably higher anxiety and poorer body image than their peers.^51,52

A daily meditation practice is one of the best-evidenced, lowest-cost tools for that anxiety. Mindfulness meditation has good-quality evidence for reducing anxiety, across randomized trials and large meta-analyses in both clinical and everyday populations.^{53,54,55,56,57} It won't change the shape of your chest and it won't replace your surgical team, it changes your relationship to the worry about it, which is exactly what you want steady going into surgery.

How to start, 10 minutes a day

• Guided first. Don't sit in silence wondering if you're doing it right, follow a guided session. Waking Up is what I use; choose the scholarship / $0 option to try it free.
• Same time daily. 10 minutes, ideally in the morning before you reach for your phone. Consistency beats length.
• Notice, don't fight. When a thought about your chest or the surgery shows up, label it and return to the breath. That's the whole rep.

Do this while you're still mobile and strong, your future self, two days post-op, will thank you.

• A place to sleep semi-upright: a recliner or a stack of firm pillows, so you can breathe easily and avoid twisting onto the bar early on.
• Loose, front-button clothing you don't have to pull over your head, plus a grabber for low items.
• A meds and bowel plan ready to go: opioid constipation is predictable, so have a stimulant-laxative plan organised before you start the medication.
• Stock the kitchen with easy, protein-rich food, and line up help with lifting, driving and chores for the first 1–2 weeks.

The goal is a posture, posterior-chain and core base you'll pause for a few weeks after surgery and then rebuild, plus the breathing and cardio habits that carry straight into recovery. Train pull-dominant, keep everything pain-free, and taper the heavy work in the final two weeks so you arrive fresh, not sore.

Weekly layout

How to run it

• Weeks 8–3 out: train 3 days, add a little load when a set feels easy and clean. Keep pulling volume higher than pushing to bias posture.
• Final 2 weeks: drop the load and intensity, keep movement light, prioritise walking and breathing. Arrive fresh.
• Always: breathe through every rep, no breath-holding, and stop anything that pinches the chest.

• Stop heavy lifting and high-impact training. Keep walking and breathing drills only, you want to be rested, not sore.
• Lock in logistics. Confirm your ride, your time off work or school (desk work is usually ~3 weeks out), and your help at home.
• Finalise medications per your surgeon, including which ones to pause and when.²⁶
• Sleep and eat well. Bank rest and nutrition; this is the foundation you'll heal on.³⁹
• Re-read the recovery plan so the first days after surgery feel familiar, not foreign.

Follow your hospital's instructions to the letter, they override everything here, especially:

• Fasting: stop eating and drinking exactly when told. This is a safety rule for anesthesia, not a guideline.²⁶
• Skin prep: shower with any antiseptic wash you're given; don't shave the chest yourself unless instructed.
• Pack: loose front-button tops, slip-on shoes, phone and charger, any current medications in their boxes, a pillow for the car ride home to splint against, and your spirometer if you have one.
• Sleep: get a good night where you can, and trust the preparation you've done.

Walk into your pre-op appointment with these written down:

• How many bars will I have, and are they steel or titanium (for future MRI and airport security)?⁴⁴
• What's the plan for pain control, epidural, nerve blocks or cryoablation?^6,7
• Which of my medications and supplements should I stop, and when?²⁶
• How long in hospital, and when can I expect to walk, drive, return to school/work and train?^3,33
• What lifting and twisting restrictions apply, and for how long?³¹
• What are the warning signs that should bring me back urgently?^29,30

Every claim in this program is backed by published research - surgical, rehabilitation and specialist sources. Tap any lime number in the text to open the source in a new tab.

1. Nuss D, Kelly RE. Minimally invasive repair of pectus excavatum (the Nuss procedure). Foundational technique description.
2. Kelly RE, et al. Effect of the Nuss Procedure on the Physical Development of Patients with Pectus Excavatum. PMID 27629820.
3. Litz CN, et al. Implementation of an Enhanced Recovery Pathway for Minimally Invasive Pectus Surgery. PMID 33401363.
4. Mavi J, et al. Successful use of an ERAS pathway to improve outcomes following the Nuss procedure. J Pediatr Surg; PMID 32197827.
5. Thoracic epidural-based ERAS pathway for Nuss repair shortened length of stay and decreased rescue IV opiate use. PMID 34089071.
6. Effect of Cryoablation in Nuss Bar Placement on Opioid Utilization and Length of Stay. mrpectus research library (rs-4720721).
7. Continuous nerve block versus thoracic epidural analgesia for post-operative pain of pectus repair. mrpectus research library (rs-2966890).
8. Haje SA, et al. Physiotherapy as an adjuvant to the surgical treatment of anterior chest wall deformities. PMID 11051146.
9. Perioperative respiratory physiotherapy around the Nuss procedure. PMID 13129428.
10. Pulmonary function and exercise response in patients with pectus excavatum after Nuss repair. PMID 12677562.
11. Pulmonary function changes following surgical correction for pectus excavatum. PMID 11775246.
12. Why is exercise capacity reduced in subjects with pectus excavatum? PMID 10657820.
13. The Effect of Incentive Spirometry on Postoperative Pulmonary Complications: a systematic review. Chest / Respir Care.
14. Incentive Spirometry After Lung Resection: a randomized controlled trial. Ann Thorac Surg.
15. Deep-breathing protocols reduce atelectasis and pneumonia after thoracic surgery. Systematic review, Ann Thorac Surg.
16. Hulzebos EHJ, et al. Preoperative inspiratory muscle training to prevent postoperative pulmonary complications. JAMA 2006; PMID 17077375.
17. Jaroszewski D, et al. The pectus care guidelines: best-practice consensus from the joint specialist societies. PMID 38964837.
18. Preoperative determinants of normative postoperative recovery rate following minimally invasive repair of pectus excavatum. Pediatr Surg Int 2024; doi 10.1007/s00383-024-05889-5.
19. The vacuum bell for conservative treatment of pectus excavatum: the Basle experience. PMID 21240610.
20. Nonoperative management of pectus excavatum with vacuum bell therapy: a single-center study. PMID 29606411.
21. Determinants of success associated with vacuum bell treatment of pectus excavatum. PMID 35525808.
22. Intraoperative use of the vacuum bell for elevating the sternum during the Nuss procedure. PMID 23137116.
23. Recent Modifications of the Nuss Procedure: the Pursuit of Safety During the Minimally Invasive Repair. PMID 32224740.
24. Comparison of minimally invasive and modified Ravitch pectus excavatum repair. PMID 11877659.
25. Early experience with the Nuss minimally invasive correction of pectus excavatum in adults. PMID 12209230.
26. Anesthetic implications in pectus excavatum surgery according to the Nuss technique. PMID 10981448.
27. Pectus excavatum: not just a cosmetic problem. PMID 32749790.
28. Cardiovascular MRI assessment of pectus excavatum in pediatric patients and postoperative changes. PMID 33256973.
29. Review and discussion of the complications of minimally invasive pectus excavatum repair. PMID 12368998.
30. Park HJ, et al. Complications associated with the Nuss procedure: analysis of risk factors and measures for prevention. PMID 15017558.
31. A simple technique for preventing bar displacement with the Nuss repair. PMID 11479873.
32. Cleveland Clinic. Nuss Procedure, recovery and bar duration. my.clevelandclinic.org, accessed 2026.
33. Lee Health / Logan Health. Pectus Excavatum Post-Op (Nuss) Guidelines, return-to-activity timeline. Patient guidelines, accessed 2026.
34. Nemours KidsHealth. Pectus Excavatum: The Nuss Procedure, return to activity. kidshealth.org, accessed 2026.
35. Prehabilitation and exercise before major surgery improve postoperative functional capacity: systematic review & meta-analysis. Surgery / Br J Anaesth.
36. Thomsen T, et al. Interventions for preoperative smoking cessation. Cochrane Database Syst Rev 2014; PMID 24683144.
37. Lindström D, et al. Effects of a perioperative smoking cessation intervention on postoperative complications: a randomized trial. Ann Surg 2008; PMID 18650627.
38. Egholm JW, et al. Perioperative alcohol cessation intervention for postoperative complications. Cochrane Database Syst Rev 2018; PMID 30403278.
39. The Role of Vitamin D Supplementation in Enhancing Muscle Strength Post-Surgery: a systematic review. Nutrients 2025; 17(9):1512.
40. Vitamin D Supplementation in Orthopedic Trauma: fracture healing and infection outcomes. PMC12648633.
41. National Athletic Trainers' Association. The Use of Nutrition in Wound Healing (protein, vitamin C, zinc). nata.org, accessed 2026.
42. Muñoz M, et al. International consensus on the peri-operative management of anaemia and iron deficiency (patient blood management). Anaesthesia 2017; PMID 27996086.
43. Jiang S, et al. Efficacy of topical silicone gel in scar management: systematic review & meta-analysis of RCTs. PMID 32119763.
44. New material for the Nuss procedure (titanium bar, MRI compatibility & airport detectors). PMID 15563267.
45. Krasopoulos G, et al. Surgical repair of pectus excavatum markedly improves body image and perceived ability for physical activity. PMID 19047237.
46. Zuidema WP, et al. Early Consequences of Pectus Excavatum Surgery on Self-Esteem and General Quality of Life. World J Surg 2018; PMID 29411068.
47. Quality of life improves after minimally invasive repair of pectus excavatum. PMID 25293414.
48. Systematic review of physiological and psychological outcomes of surgery for pectus excavatum. PMID 37827806.
49. Pectus patients have lower quality of life and impaired body image before correction. PMID 21440452.
50. Quality of life of patients who have undergone the Nuss procedure. PMID 12720193.
51. Body-image, self-concept and mental exposure in patients with pectus excavatum. PMID 21290134.
52. Factors related to anxiety in paediatric patients and their parents before and after a modified Nuss procedure. PMID 36554581.
53. Goyal M, et al. Meditation programs for psychological stress and well-being: a systematic review and meta-analysis. JAMA Intern Med 2014; PMID 24395196.
54. Hofmann SG, et al. The effect of mindfulness-based therapy on anxiety and depression: a meta-analytic review. J Consult Clin Psychol 2010; PMID 20350028.
55. Hoge EA, et al. Randomized controlled trial of mindfulness meditation for generalized anxiety disorder. J Clin Psychiatry 2013; PMID 23541163.
56. Kabat-Zinn J, et al. Effectiveness of a meditation-based stress reduction program in the treatment of anxiety disorders. Am J Psychiatry 1992; PMID 1609875.
57. Khoury B, et al. Mindfulness-based therapy: a comprehensive meta-analysis. Clin Psychol Rev 2013; PMID 23796855.