Surgical Correction of Pectus Carinatum
By Robert C. Shamberger and Kenneth J. Welch
Boston, Massachusetts
9 Pectus carinatum is an infrequent b u t eminently cor-
r e c t a b l e chest wall deformity. It is encountered much less
frequently than pectus excavatum. In 12 years, f r o m 1973
to 1985, 152 pectus carinatum (16.7%) and 758 pectus
e x c a v a t u m deformities (83.3%) w e r e c o r r e c t e d , It occurs
m o r e f r e q u e n t l y in boys (119 patients) than girls (33
patients). The majority, 89 cases, w e r e symmetric, while
49 w e r e asymmetric, and 14 w e r e mixed d e f o r m i t i e s
(ipsilateral carinatum, contralateral excavatum). In almost
half t h e patients the d e f o r m i t y was not identified until after
t h e 1 l t h birthday. A family history of chest wall deformi-
ties was present in 26%, and of scoliosis in 12%. Asso-
ciated musculoskeletal abnormalities w e r e identified in 34
patients (scoliosis 23, Poland's syndrome 4, neurofibroma-
tosis 2, M o r q u i o ' s disease 2, v e r t e b r a l anomalies 1, hyper-
lordosis 1, and kyphosis 1). Surgical c o r r e c t i o n required
bilateral resection of the third through seventh costal
cartilages in 143 patients, and unilateral resection in nine
patients w i t h an isolated abnormality. A single o s t e o t o m y
was used in 88 patients and a double o s t e o t o m y in 63
patients. In 11 cases no o s t e o t o m y was required, M i x e d
d e f o r m i t y w i t h posterior angulation of t h e sternum was
managed by o s t e o t o m y and anterior displacement. The
remaining cases had sternal o s t e o t o m y and fracture of the
p o s t e r i o r c o r t e x to c o r r e c t anterior angulation. The opera-
tion was completed w i t h a low complication rate 3.9%
( p n e u m o t h o r a x 4, w o u n d infection 1, atelectasis 1, and
local tissue necrosis 1}. Three patients required revision
w i t h additional unilateral l o w e r cartilage resection for
persistent malformation of the costal arch. All patients
ultimately had a satisfactory result.
9 1987 by Grune & Stratton, Inc.
INDEX WORDS: Pectus carinatum; scoliosis.
p E C T U S C A R I N A T U M is the most frequent and
accepted term describing protrusion deformities
of the chest. The condition is not a single entity but a
spectrum of abnormal thoracic development. Three
types of deformity exist with a variety of terms applied
to each. The most frequent type consists of anterior
displacement of the body of the sternum with symmet-
ric concavity of the costal cartilages. Brodkin labeled
this chondrogladiolar or lower type prominence. 1 Less
frequent are the asymmetric deformities with anterior
From the Department of Surgery, The Children's Hospital and
Harvard Medical School, Boston.
Presented before the 17th Annual Meeting of the American
Pediatric Surgical Association, Toronto, Ontario, May 14-17,
1986.
Address reprint requests to Robert C. Shamberger, MD, The
Children's Hospital, 300 Longwood Ave, Boston, MA 02115.
9 1987 by Grune & Stratton, Inc.
0022-3468/87/2201~013503.00/0
48
displacement of the costal cartilages on one side and
normally positioned sternum, and normal or concave
contralateral cartilages. Least common is upper or
chondromanubrial prominence with protrusion of the
manubrium and relative depression of the gladiolus or
body of the sternum. Surgical repair of carinate defor-
mities has a colorful history. Ravitch first reported
correction of chondromanubrial prominence in 1952
resecting the multiple deformed costal cartilages and
performing a double osteotomy. 2 Lester in 1953
reported two methods of repair. 3 The first, involving
resection of the anterior portion of the sternum, was
abandoned because of its sanguine nature and gener-
ally unsatisfactory results. The second, though no less
radical technique, utilized subperiosteal resection of
the sternum. Chin 4 and later Brodkin 5 advanced the
transected xiphoid and attached rectus muscles to a
higher site on the sternum. The procedure, xyphoster-
nopexy, produced posterior displacement of the ster-
num in younger patients with a malleable chest wall.
Howard combined Chin's method with subperichon-
drial costal cartilage resection and a sternal osteoto-
my. 6 Ravitch reported his repair of chondrogladiolar
deformity in 1960. 7 He resected costal cartilage in a
one or two stage procedure and used reefing sutures to
shorten and displace anteriorly the perichondrium. A
sternal osteotomy was required in one of three cases.
Ramsay utilized a rectus muscle flap to fill in the
lateral concavities or runnels in patients with chondro-
gladiolar deformity, but did not resect the deformed
costal cartilage or alter the position of the sternum. ~
Robicsek in 1963 reported subperichondrial resection
of costal cartilages, transverse sternal displacement,
and resection of the protruding lower portion of the
sternum. 9 The xiphoid and rectus muscles were reat-
tached to the new lower margin of the sternum. The
deformed lateral asymmetric costal cartilages required
bilateral subperichondrial resection and a double
osteotomy. In 1973 Welch and Vos reported their
approach to these deformities in 26 patients. 1~ The
method has been employed to the present time with
only minor changes. We report our experience and
results in 152 patients treated since the original
report.
MATERIALS AND METHODS
In 12 years, from 1973 to 1985, 152 patients with pectus carina-
tum (16.7%) and 758 patients with pectus excavatum deformities
(83.3%) were surgically corrected. Pectus carinatum occurred more
frequently in boys (119 patients) than girls (33 patients). The
Journal of Pediatric Surgery, Vo122, No 1 (January), 1987: pp 48-53
SURGICAL CORRECTION OF PECTUS CARINATUM
Fig 1. (A) Five-year-old boy with symmetric chondrogladiolar
deformity. (B) Note the accurate clinical correlation and rendering
of the deformity by Moir6 photography.
majority, 89 cases, were symmetric (Fig 1), while 49 were asymmet-
ric (Fig 2), and 14 were mixed carinatum/excavatum deformities
(Fig 3). None of our patients fit the syndrome of premature
obliteration of the sternal sutures resulting in a short carinate
sternum. T M The age and sex of the children when the deformity was
first appreciated is shown in Fig 4. In almost half the patients the
deformity was not identified until after the 11th birthday. In patients
with mild deformity noted at birth, the deformity often worsened
when they became 11 to 15 years old, leading to surgical repair at
that time (Fig 5). A family history of some type of chest wall
deformity was present in 26% of patients. Forty-three relatives had
pectus carinatum while 14 had pectus excavatum. Twelve percent of
patients had a family history of scoliosis. Associated musculoskeletal
abnormalities in 34 patients are seen in Table 1.
Operative Technique
A transverse incision is made just below and within the nipple
lines. In females particular attention is taken to place the incision
within the inframammary fold (Fig 6), thus avoiding the complica-
tion of breast deformity and development described by Hougaard
and Arendrup. ]~ Skin flaps are mobilized using Bovie electrocautery
primarily in the midline to the angle of Louis superiorly and to the
xiphoid inferiorly. The pectoral muscle flaps are elevated off the
sternum and costal cartilages preserving the entire pectoralis major
and portions of the pectoralis minor and serratus anterior muscles
E BO
Fig 2. Eighteen-year-old boy with asymmetric carinate defor-
mity (A). The marked left upper anterior thoracic protrusion is
best analyzed by Moir~ topography (B).
49
Fig 3. Eight-year-old boy with mixed carinatum/excavatum
deformity (A). The right costal cartilages and the right sternal
border are depressed while the left costal cartilages protrude and
the left sternal border is elevated (B).
(Fig 7). The lateral extent of the muscle elevation is to the
costochondraljunction of the third to fifth ribs and rarely the second.
Particular attention is taken to avoid injury to the intercostal
bundles, which will result in significant bleeding. Subperichondrial
resection of the costal cartilages, with specially designed Welch
Pectus elevators (Codman and Shurtleff, Inc, Randolph, MA), is
performed removing the entire third, fourth, and fifth cartilages to
the costochondral junctions (Fig 8). Longer segments of the sixth
and seventh cartilages (5 to 6 cm) are resected to the point where
they flatten to join the costal arch. This extensive resection is
necessary to correct the usually associated lower lateral depression
or runnels. Familiarity with the cross-sectional shape of the costal
cartilages will facilitate their removal. The third cartilage is broad
and fiat, the fourth and fifth are circular, while the sixth and seventh
are narrow and deep. In this series, 143 patients required bilateral
costal cartilage resection. Only nine patients with a very localized
abnormality had unilateral resection. The attachment of the rectus
muscle to the sternum is dissected free and the xiphoid is divided.
Sternal osteotomies through the anterior cortex are created with the
Hall drill (Zimmer USA, Inc, Warsaw, IN; Fig 9). A single
osteotomy was used in 88 patients and a double osteotomy in 53. In
11 patients, no osteotomy was required. Early in the series, a wedge
of bone or cartilage was placed into the osteotomy defect as
Males (119)
~ 60
40
1 ~ Females (55) :.v...v.........v:
:v......,v.........:
:.v.v.v.....v..:
!:.:.z.3z.5:.:.;.!
v.z.z.............1
:.v//;...,.v,...:
E'Z':':'Z'X':':~ ..z.: ........
['Z'Z':':'Z':':':'! L.;.,..,.,.:.....,,u
r.'/.',','.'.v,'.'.l ,Lx.:.z.:.:.z,z~,
['X':':':'Z':'X'] L'.'.'.'.'.v,'.'.'.'J L'.V.'.'.'.V,':,';
r.'.'.'.'.v.v.v., [':'Z'Z':'Z.:.:.~
Birth 1-5 6-10 1t-15
Age atAppearance of Deform/ty(yrs)
Fig 4. Pectus carinatum (TCH 1973-1985), age at appearance
of deformity.
50 SHAMBERGER AND WELCH

80
iiiii'
' ii!ij',! ~ .Lt- , "~-.. "-.\ \ . "-.\

Females (:55) {iiii{ii!i{{ii{il Elevat/'on o f " ~ ,' ~"-~-'~ ~\ \" \

~60 I:':':':-:-:'X':-:'I pectoral flaps + , . . . . . . . . - . - - - ~----~--
\. ...... ~.~: ~ : ~" ~, ~~
;.v.':.'.'.'.....".

~ .i . ~///
!:i:i:i:i!!:i:i:i:il
- : / /i I

.v.'.'.',..'...
~-~.V.~-~J~i~i~ . /

v.'.'.'.,.'.+..
2O i:.:.:.:'Z.:.:.:-:i ;::::::::::::::::::: ~ ~ / i I ii
.....................
, ........... ::i::iiii~::~ii!!i::!ii

2-5 6-10 1t-15 16-20 >20

Age at Operation (yrs) Fig 7. The pectoralis major muscle is elevated from the
sternum along with portions of the pectoralis minor and serratus
Fig 5. Pectus carinatum (TCH 1 9 7 3 - 1 9 8 5 ) . age at operation 9 anterior muscles. Anterior distraction of the muscles during this
dissection facilitates identification of the avascular areolar plane
just anterior to the costal cartilages and the intercostal muscle
Table 1. Musculoskeletal Abnormalities Identified in 3 4 of 152 bundles.
Patients (22.4%) W i t h Pectus Carinatum

Abnormality NO.
Hemovac drain (Snyder Laboratories, Inc, New Philadelphia, OH)
Scoliosis 23 is brought through the inferior skin flap and placed in a parasternal
Poland's syndrome 4 position to the level of the highest costal cartilage resection. The
Neurofibromatosis 2 pectoralis muscle flaps are joined in the midline and anchored to the
Morquio's disease 2 sternal periosteum advancing the flaps inferiorly to cover the often
Vertebral anomalies 1 previously bare sternum. The xiphoid is removed from the U-shaped
Hyperlordosis 1 rectus muscle flap, which is then joined to the caudal end of the
Kyphosis 1 sternum centrally and to the pectoral muscle flaps laterally to

described by Lam and Taber, presumably to keep it open and

maintain the sternum in a posterior position./4 This was abandoned
as an unnecessary step. Mixed pectus carinatum/excavatum defor-
i::::
mities were managed with a transverse wedge-shaped osteotomy Retracted :: ::~::~ Monubrium '~:;~*
n~P# rn~inr ~ /
allowing anterior displacement and rotation of the sternum (Fig 10).
Occasionally, a second osteotomy was required to displace the lower
portion of the body of the sternum posteriorly. The wound is flooded
with warm saline and cefazolin to remove clots and inspect for a
pleural entry, an uncommon occurrence (2%). A single limb medium

A, B .... -. . . . "
[ncision at
]'unction
-~'~
, ,,
.... I
"~....... r
-- '
with sternum

\: ? 2z2

* -~ Skln incision

/
Fig 8. Subperichondrial resection of the costal cartilages is
Norrn01 /
Protrus/on achieved by incising the perichondrium anteriorly. It is then
dissected away from the costal cartilages in the bloodless plane
Fig 69 The configuration of the medial end of the costal b e t w e e n perichondrium and costal cartilage, Cutting back the
cartilages at their junction with the sternum is seen (A). A perichondrium to 180 ~ at its junction with the sternum (inset)
transverse incision is placed below and well within the nipple lines facilitates visualization of the back wall and encirclement of the
at the site of the future inframammary crease (B). costal cartilages.
SURGICAL CORRECTION OF PECTUS CARiNATUM
/0my
Fig 9. (A) Chondrogiadiolar deformity (90.8%; symmetric or
asymmetric) is managed w i t h a single or double osteotomy after
resection of the costal cartilages. This allows posterior displace-
ment of the sternum t o an orthotopic position. (B) Chondromanu-
brial deformity is more complex and fortunately rare. The superior
osteotomy enables anterior displacement of the upper portion of
the sternum. A second osteotomy allows posterior displacement
of the lower segment thus straightening the Z-shaped deformity.
(Adapted with permission. =)
completely close the mediastinum. Nonabsorbable 2-0 silk sutures
are used for the muscle closure and 3-0 inverted silk sutures for the
combined subcuticular and superficial fascial layers. A small dress-
ing of Telfa (The Kendall Co, Boston, MA), dry gauze, and
Microfoam tape (3M, St Paul, MN) is applied. Perioperative
antibiotics are utilized giving one dose of cefozolin immediately prior
to surgery and three postoperative doses. All patients are warned to
avoid aspirin-containing compounds for 2 weeks prior to surgery to
avoid abnormalities of platelet adhesion and function.
RESULTS
Postoperative recovery was generally uneventful
with a mean postoperative stay of 5.8 days. Blood
transfusions were rarely employed with only five trans-
fusions given early in the series and none in the past 4
years. There was a 3.9% complication rate with four
Wedge
osteotom
(4x from
Mixed Deformity ( Anterior view) - 92% Correction
Fig 10. The mixed pectus deformity is corrected by full and
symmetrical resection of the third to seventh costal cartilages
followed by transverse offset (0 ~ to 10 ~ wedge-shaped sternal
osteotomy. Closure of this defect permits both anterior displace-
ment and rotation of the sternum,
51
Fig 11. (A) Classic symmetrical chondrogladiolar pectus carl-
nature in a 15-year-old boy whose chest was normal t o age 11.
Note the upper Keel-shaped protrusion and the lower depressed
gutters or runnels, (B) Preoperative depiction of deformity by
Moir(; photography,
cases of pneumothorax (2 required a chest tube) and
one case each (0.7%) of atelectasis, wound infection,
and local tissue necrosis. Three patients required revi-
sion, each having additional lower costal cartilages
resected for persistent unilateral malformation of the
costal arch. Clinical and Moir6 photographs are taken
before and after surgery to fully document the preoper-
ative deformity and the surgical result (Figs 11 and
12). 15'~6 Patients are seen in follow-up every 2 years
until full growth is achieved, age 16 for girls and 19 for
boys. Mean follow-up was 15 months (range 2 to 94
months). All patients ultimately had a satisfactory
result.
DISCUSSION
Three major series have been published since our
last report. Pickard et al reported 13 patients repaired
over a 24-year period using a technique very similar to
our own with a generally favorable result. 17 They
recommend deferring repair until late adolescence or
Fig 12. Postoperative (6 weeks) clinical (A) and Moir6 (B)
photographs showing full correction of both elements of the
deformity. The correction is well maintained 20 months later at
age 17.
52
young adulthood because of concern that regrowth or
recurrence of the protrusion deformity might occur if
the operation is performed at a young age. We have not
encountered recurrence in any patient repaired at a
young age, a time when the best results are achieved
and patients tolerate repair best. Robicsek et al con-
tinue to recommend bilateral resection of the costal
cartilages, transverse osteotomy of the sternum, and
resection of the lower end of the body of the sternum (2
to 6 cm) reattaching the xiphoid and rectus muscleJ s'~9
Their experience was generally favorable with only 13
unsatisfactory results out of 161 cases, eight requiring
reoperation. These were all related not to an unsatis-
factory position of the sternum, but rather to inade-
quate resection of costal cartilages or rib ends. This is
similar to our experience where revision has entailed
further resection of costal cartilage, particularly the
sixth and seventh cartilages, which we now resect to a
point close to the formation of the costal arch complex,
and we have not encountered an unsatisfactory result
since employing this method. Resection of the distal
portion of the sternum does not appear to be necessary.
Pefia et al reported 47 cases of pectus carinatum, z~
They advocate resection of the second costal cartilage
in all cases because protrusion of the cartilage has
appeared following surgery. In our series, only three
patients required resection of the second costal carti-
lages. In each case the need was appreciated by the
appearance of the chest preoperatively and review of
Moir6 photographs.
REFERENCES
1. Brodkin HA: Congenital chondrosternal prominence (pigeon
breast) a new interpretation. Pediatrics 3:286-295, 1949
2. Ravitch MM: Unusual sternal deformity with cardiac symp-
toms-Operative correction. J Thorac Surg 23:138-144, 1952
3. Lester CW: Pigeon breast (pectus carinatum) and other pro-
trusion deformities of the chest of developmental origin. Ann Surg
137:482-489, 1953
4. Chin EF: Surgery of funnel chest and congenital sternal
prominence. Br J Surg 44:360-376, 1957
5. Brodkin HA: Pigeon breast--Congenital chondrosternal
prominence: Etiology and surgical treatment by xiphosternopexy.
Arch Surg 77:261-270, 1958
6. Howard R: Pigeon chest (protrusion deformity of the ster-
num). Med J Aust 2:664-666, 1958
7. Ravitch MM: The operative correction of pectus carinatum
(pigeon breast). Ann Surg 151:705-714, 1960
8. Ramsay BH: Transplantation of the rectus abdominis muscle
in the surgical correction of a pectus carinatum deformity with
associated paraste~'nal depressions. Surg Gynecol Obstet 116:507-
508, 1963
9. Robicsek F, Sanger PW, Taylor FH, et al: The surgical
treatment of chondrosternal prominence (pectus carinatum). J Tho-
rac Cardiovasc Surg 45:691-701, 1963
10. Welch KJ, Vos A: Surgical correction of pectus carinatum
(pigeon breast). J Pediatr Surg 8:659-667, 1973
SHAMBERGER AND WELCH
Changes in technique since our original report are
very minor. Hemovac drains are placed in all patients
and removed in 48 hours providing the serous drainage
is less than 15 m L over an eight-hour period. This has
eliminated the problem of substernal seroma formation
seen in the past. Wedges of rib or costal cartilage are
no longer placed in the sternal osteotomy to keep the
sternum depressed. It is held in an orthotopic position
by the presternal watertight closure and support of the
pectoral and rectus muscles.
Unilateral prominence of the costal cartilages is
only rarely resolved by isolated resection of the
deformed cartilages and only when full growth has
been achieved at the time of surgery. O u r experience
with performing unilateral resection in a growing child
is similar to that reported by Robicsek et al. 18 The
unbalanced action of the nonresected cartilages tilts
the sternum to the uninvolved side and ultimately
results in a deformity worse than prior to operation.
Results of our repair have been gratifying as judged
by linear follow-up, clinical and Moir6 photographs,
and by patient satisfaction. Only three patients (2%)
with an asymmetric deformity required a second oper-
ation with limited revision. The complication rate is
low (3.9%). Surgical repair is performed with the
appearance of significant deformity. Delay until full
growth is not justified. Early repair minimizes the
length of time patients must live with their unsightly
deformity, often at an age when they are most con-
cerned with body image.
11. Currarino G, Silverman FN: Premature obliteration of the
sternal sutures and pigeon-breast deformity. Radiology 70:532-540,
1958
12. Briinner S: Premature synostosisin the sternum (Silverman's
disease). Acta Paediatr 50:288-290, 1961
13. Hougaard K, Arendrup H: Deformities of the female breasts
after surgery for funnel chest. Scand J Thorac Cardiovasc Surg
17:171-174, 1983
14. Lam CR, Taber RE: Surgical treatment of pectus carinatum.
Arch Surg 103:191-194, 1971
15. Hiroshi T: Moir6 topography and its application to the human
body, in Moreland MS, Pope MH, Armstrong GWD (eds): Moir6
Fringe Topography and Spinal Deformity. New York, Pergamon,
1981, pp 1-17
16. Kawamura T, Paik N, Wada J: Computerized Moir6 topog-
raphy before and after surgery of funnel chest. Kyobu Geka 36:968-
970, 1983
17. Pickard LR, Tepas J J, Shermeta DW, et al: Pectus carina-
tum: Results of surgical therapy. J Pediatr Surg 14:228-230, 1979
18. Robicsek F, Daugherty HK, Mullen DC, et al: Technical
considerations in the surgical management of pectus excavatum and
carinatum. Ann Thorac Surg 18:549-564, 1974
19. Robicsek F, Cook JW, Daugherty HK, et al: Pectus carina-
turn. J Thorac Cardiovasc Surg 78:52-61, 1979
20. Pefia A, P6rez L, Nurko S, et al: Pectus carinatum and pectus
excavatum: Are they the same disease? Am Surg 47:215-218, 1981
SURGICAL CORRECTION OF PECTUS CARINATUM
Discussion
M.M. Ravitch (Pittsburgh): In general, I would
agree absolutely with almost everything that was said,
with a couple of differences. That so-called mixed
deformity, which Lester way back called a unilateral
pectus excavatum, is neither one or the other. I think
the primary problem is a collapse of the costal carti-
lages. I noticed that the one example that was shown
was on the right. Everyone that we have seen has been
on the right. The protrusion of the left side is simply
compensatory and it is not a deformity itself. Frequent-
ly, the sternum rotates; it is not depressed. So I think
this is an entirely different deformity and probably
neither excavatum nor carinatum. We would differ in
the technique applied only in two respects if I under-
stood the manuscript and illustrations correctly. We
have seen no reason to perform an osteotomy of the
sternum except in the so-called pouter pidgeon type of
deformity in which the manubrium itself goes out and
the sternum digs back and comes up again so on
sagittal section you would see a Z, and in those we do
double osteotomies. In the ordinary type of pectus
53
carinatum, which Russell Howard described as looking
as if a giant hand had crushed the chest from either
side, we think the protrusion of the sternum is in part
compensatory and in part an illusion. It is something
that seems so prominent because of the deep concavi-
ties on either side and we therefore not only resect the
deformed costal cartilages but put in reefing sutures
that tighten up the perichondrium, which is floppy and
redundant; and by taking up that slack, we put tension
on the sternum and we have seen no need to do
osteotomies. The great thing about this is that with
almost any operation you do for pectus carinatum if it
is at all thorough you get 100% good results. In some of
the weird asymmetrical ones, it might take two opera-
tions.
R.C. Shamberger (closing): I will conclude very
quickly just by saying that certainly we would agree
with Dr Ravitch's statement that an adequate resec-
tion of the costal cartilages is the key to the repair; and
a more limited particularly unilateral resection is often
faced with a persistent defect or an early recurrence.