Pectus Excavatum and Carinatum: Chest Wall Deformity in Children and Teenagers

Two opposite deformities

Both arise from abnormal growth of the cartilage connecting the ribs to the breastbone, which pushes the sternum inward or outward.

• Pectus excavatum ("funnel chest") — the sternum is sunken. It is the commonest chest wall deformity and more frequent in boys.
• Pectus carinatum ("pigeon chest") — the sternum protrudes forward. Less common, and typically appears later in adolescence.

Both are often mild in early childhood and become markedly more obvious during the adolescent growth spurt — which is also when they begin to matter to the patient.

Is it dangerous?

This is the first question parents ask, and honesty serves better than either reassurance or alarm.

In most cases, no. The majority of pectus excavatum causes no meaningful limitation of heart or lung function, and the concern is cosmetic and psychological.

In severe cases, it can matter. A deeply sunken sternum can compress the heart and limit how much the lungs expand, producing reduced exercise tolerance, breathlessness on exertion, palpitations and chest discomfort. These patients often describe keeping up with peers as a child but falling behind in the teenage years.

Objective testing separates the two groups, which is why assessment relies on measurement rather than appearance.

The part that is under-treated

The psychological impact is real and routinely dismissed. Adolescents with visible chest deformity commonly avoid swimming, sports, changing rooms and any situation requiring the chest to be uncovered. Refusing to remove a shirt in hot weather for years is not vanity, and social withdrawal at that age has lasting effects.

Dismissing it as "only cosmetic" misses that body image at fifteen is a genuine health issue. It should be asked about directly, because teenagers rarely volunteer it in front of a parent.

Associated conditions

Pectus deformity is more common in connective tissue disorders, particularly Marfan syndrome. Because those conditions also affect the aorta, a patient with pectus plus tall stature, long limbs, joint hypermobility or a family history should be assessed for them — including echocardiography. This is a genuinely important check, not a formality; see our article on aortic aneurysm and dissection.

Scoliosis frequently coexists and should be looked for.

Assessment

• CT or MRI to calculate the Haller index — the ratio of chest width to the distance between sternum and spine, which quantifies severity objectively.
• Echocardiography to assess cardiac compression and screen for valve or aortic abnormality.
• Lung function and exercise testing where symptoms are reported, since this distinguishes true limitation from deconditioning.

Treatment

Pectus carinatum — bracing first

The protruding chest responds well to a compressive brace worn for months during growth, provided the chest is still flexible. Because it depends on remaining growth, timing is everything — referral during adolescence gives a good chance of avoiding surgery, whereas waiting until growth is complete removes that option.

Pectus excavatum — surgery when indicated

Bracing does not work for the sunken chest. Vacuum bell devices help selected patients with mild, flexible deformity.

The main operation is the minimally invasive repair (Nuss procedure): through small incisions on each side, a curved metal bar is passed behind the sternum and rotated to push it forward, then left in place for two to three years before removal. It avoids cutting cartilage, and results are good.

The open repair (Ravitch procedure) — removing abnormal cartilage and repositioning the sternum — remains useful for complex, asymmetric or recurrent deformity and in older patients.

Two honest points: pain in the first weeks after a Nuss repair is significant and requires a proper pain plan, and a second, smaller operation is needed later to remove the bar.

Timing

Surgery is usually best in the mid-to-late teenage years, when the chest is still flexible enough to remodel but growth is largely complete, reducing recurrence. Repair in adults is possible but technically harder because the chest wall is stiffer.

Further reading

MedlinePlus: chest wall examination and deformity and MedlinePlus: chest injuries and disorders.

On this site: thoracic surgery.

General education, not advice about a specific child. Severity should be assessed objectively, and referral during growth keeps more options open.