Pectus carinatum

In the mirror of the pertinent literature, we present our experiences gained in /6/ operations for pectus
carinatum. The Type I (keel chest) deformity is corrected by bilateral resection of the costal cartilages,
transverse osteotomy of the sternum, detachment of the xiphoid process, and resection of the lower end of
the body of the sternum. The sternum is maintained in its corrected position by utilizing the pulling force
of the rectus muscles through the reattached xiphoid and by tacking the pectoralis muscles together in
front of the breast bone. Type 1/ (pouter pigeon breast) is handled by double transverse osteotomy,
chiseling off the protuberant portion of the sternomanubrial junction, and by supporting the lower sternal
body with either the suspended xiphoid process or with Marlex mesh. Limited forms of Type 11/
(asymmetrical or lateral pectus carinatum] are managed with simple resection of the involved cartilages
only. If the anomaly is more extensive, bilateral resection of the cartilages and correction of the sternal
axis is carried out.

Francis Robicsek, M.D., Joseph W. Cook, M.D., Harry K. Daugherty, M.D., and
Jay G. Selle, M.D., Charlotte, N. C.

We believe it has been demonstrated for the con-
ventional pectus carinatumthat operation is indicated
and achieves excellent results.
Mark M. Ravitch
Pectus carinatum is the second most common anom-
aly of the anterior chest wall. 1-6 In our own surgical
experience, it constitutes about 22 percent of 720 pa-
tients operated upon with anterior chest deformi-
ties. 7- 13 Pectus carinatum was already widely known
and recognized during the time of Hippocrates, who
described it in connection with other abnormalities of
the rib cage and the spine: " ... the chest becomes
sharp pointed and not broad, becomes affected with
difficulty of breathing and hoarseness; for the cavities
which inspire and expire do not obtain proper ca-
pacity. "14
Anatomy and development
The common feature in the different forms of this
deformity is the prominence of the sternum. Besides its
most common designation, "pectus carinatum ," it is
also known under several other aliases: pigeon breast,
From the Department of Thoracic and Cardiovascular Surgery, Char-
lotte Memorial Hospital and Medical Center, and the Heineman
Medical Research Center, Charlotte, N. C.
Received for publication Dec. 15, 1978.
Accepted for publication Jan. 17, 1979.
Address for reprints: Francis Robicsek, M.D., The Sanger Clinic,
P.A., 1960 Randolph Rd., Charlotte, N. C. 28202.
chicken breast, sternogladiolar prominence, pyramidal
chest, thorax cunei forme , and others. Anatomically
these "carinatum" deformities can be conveniently
divided into three groups:
Type I: Keel chest. This anomaly, which resembles
the keel (carina) of the ship, consists of symmetrical
protrusion of the sternum and the costal cartilages.
Usually the sternum arches forward more in its middle
and lower portions than in its upper part. 1 In the more
severe cases, there is also a forward angle at the junc-
tion of the middle and lower third with the tip of the
xiphoid process pointing in the dorsal direction. This
condition is commonly associated with bilateral de-
pression of the lower cartilages,": 15 mistakingly iden-
tified by Brodkirr'" 17 as Harrison grooves.
Type II: Pouter pigeon breast. An interesting va-
riety of pectus carinatum is the chondromanubrial
prominence, 16 which Lester" called arcuate pectus
carinatum and Ravitch I coined pouter pigeon breast. In
this anomaly, only the manubrium and the first two
sternal cartilages are protruding. The body of the ster-
num usually arches backward (chondromanubrial prom-
inence with chondrosternal depression), and the tip of
the xiphoid process points anteriorly.
Type III: Lateral pectus carinatum. Asymmetrical
or lateral pectus carinatum is characterized by unilat-
eral protrusion of the anterior chest wall. Sometimes it
is associated with contralateral depression. The anat-
omy is usually dominated by the deformity of the carti-
lages, and the malposition of the sternum is less sig-
nificant. In the most common form of this lateral pectus

52 0022-5223179/070052+ 10$01.00/0 © 1979 The C. V. Mosby Co.

Volume 78
Number 1
July, 1979
Fig. I. The contour of carinatum deformity in a child (top) and in an adolescent (bottom).
carinatum, there is marked chostochondral prominence
of one side and rotation of the sternum around its lon-
gitudinal axis toward the opposite side, which is mod-
erately sunken. Less frequently seen varieties of this
disease are the localized protrusion of one or more ribs
or cartilages (or both) without sternal involvement.
Pathogenesis
The pathogenesis of pectus carinatum, like that of
most congenital anomalies of the chest wall, is uncer-
tain. The earliest hypothesis on this subject was for-
warded by Brodkin": 17 who, like Chin" a decade later,
blamed the underdevelopment of the central portion of
the sternal attachment of the diaphragm with concomi-
tant hypertrophy of the lateral muscular component. He
thought that this combination causes displacement of
the sternum because "changes in the costal cartilages
then occur as these have no option but to follow the
sternum to its displaced site." 16, 17
The Brodkin-Chin theory to explain the development
of funnel chest, just like the very similar hypothesis of
Brown " has now largely been discarded. The reason
undoubtedly is that the changes described in detail by
the authors have never been confirmed by later inves-
tigators': 18. 20 who, like us,7-13 kept looking inten-
sively for the anatomic and functional changes of the
diaphragm described by these authors and found none.
Our opinion on this subject always agreed with that
of those!: 18 who believed that the diaphragm plays very
little role, if any, in the development of pectus defor-
mities, and the abnormal position of the sternum is
secondary and due to the overgrowth of the costal carti-
lages. As we stated before:
Pectus carinatum 53
To suppose the opposite would be equal to the ac-
ceptance of the fact that the reason the neck of the
giraffe is so long is that otherwise it would not reach its
head. After resecting these elongated, distorted carti-
lages from more than 200 patients, it is our firm belief
that the displacement of the sternum is secondary and
due to an overgrowth of the costal cartilages. If the
sternum is pushed inward, pectus excavatum is the
result; if it pushed outward, pectus carinatum de-
velops.*
Sixteen years and nearly 600 operations later, we are
even more convinced about the validity of this view.
The question naturally arises-what is the cause of
this overgrowth of costal cartilages? Ravitch, I who
wrote the most indepth study on this subject, is inclined
to accept the explanation of Humberd'" given in his
paper' 'Giantism of the Infantilism Type and its Disclo-
sure of the Pathogenesis of Pigeon Breast and Funnel
Chest," written in 1938. Humberd pointed out that in
giants who are not acromegalic, "both pigeon breast
and funnel chest are common and this to be a kind of
infantilism in which they retain the infantile chest at the
same time the ribs are growing excessively rapidly."
Ravitch ' believes that the same mechanism may be re-
sponsible for the development of pectus carinatum,
even if the subject's development is otherwise normal.
This overgrowth of costal cartilages is usually already
present at birth. Interestingly enough, however, where-
as the presence of pectus excavatum is usually recog-
nized in the very young, not infrequently pectus
*From Sanger PW. Taylor FH, Robicsek F: Surg Gynecol Obstel
116:515-522, 1963, published by permission of Surgery, Gyne-
cology & Obstetrics.

54 Robicsek et al.
Fig. 2. Schematic drawing of the repair of keel chest de-
formity.
carinatum may be undetected during the early years of
childhood. I The reason may be that both anomalies are
measured to reference points of the lower chest and
upper abdomen. Whereas the protruding infantile
"potbelly" of the young child tends to emphasize the
presence of pectus excavatum but makes pectus
carinatum less apparent, the recession of the abdominal
contour during the later years of childhood and adoles-
cence evidently works in the opposite direction and
makes pectus carinatum more readily noticeable (Fig.
l). Naturally, late detection of chest deformities can
also occur because either the child has been less con-
scious of his deformity until the beginning of adoles-
cence or simply the parents have never given closer
attention to the chest of their offspring. An amusing
example of this occurred a few years ago when a
9-year-old child was first presented to us by his tearful
mother at 9:00 P.M. in the emergency room with
"acute" pectus carinatum which, according to the par-
ents, was not present during the earlier hours of the
day!
There are data I. 22 indicating that the development of
Type II pectus carinatum, in which chondromanubrial
prominence is associated with chondrosternal depres-
sion (pouter pigeon breast), is more complex than that
of Type I. In 1958, Currarino and Silverman'" demon-
strated that synostosis of the sternum, or complete non-
segmentation on account of premature obliteration of
the sutures, is characteristic of this anomaly-an ob-
servation also confirmed by Ravitch.!
The Journal of
Thoracic and Cardiovascular
Surgery
Fig. 3. Repair of keel chest deformity.
Symptomatology
The physiological effects of pectus carinatum prob-
ably stem from the decreased respiratory excursion of
the thorax, which occurs in both excavatum and pro-
trusion deformities. One may even attempt to draw an
analogy between posterior protrusion of the chest
(kyphosis) and anterior protrusion (pectus carinatum),
because the increase of the anteroposterion diameter of
the chest leads to loss of pulmonary elasticity with all
of its unwanted consequences." These clinical symp-
toms of pectus carinatum may be definite but usually
rather uncertain and even more ill defined than in ex-
cavatum deformities. Three of the 161 patients we have
operated upon for pectus carinatum had severe asth-
matic bronchitis, which may have been a contributory
factor in development, a consequence of their chest
deformities, or even a coincidental finding. Other than
these three, we cannot recall a single patient with se-
vere respiratory or circulatory embarrassment. Less se-
vere symptoms, however, such as moderate dyspnea,
fatigue, and nondescript chest pain, were present in 31
percent of our patients.
The psychological effects of pigeon breast are more
prevalent. Most children and all the adolescents and
adults we have seen are very self-conscious and usually
quite unhappy about their anomaly. To conceal the ab-
Volume 78
Number 1
July, 1979
Fig. 4. Keel chest with significant protrusion of the lower-most part of the sternum before and after repair. (From
Robicsek F, Sanger PW, Taylor FH, Thomas MJ: J THORAC CARDIOVASC SURG 45:691-701, 1963, published by
The C. V, Mosby Company.)
normal shape of the chest, they walk and sit slightly
bent forward with dropped shoulders. As school chil-
dren, they are exposed to mockery, and they avoid
locker rooms, swimming pools, and outdoor activities.
All these factors may lead to an abnormal posture
which may further aggravate the anomaly.
Treatment
Various nonoperative methods, such as physiother-
apy, plaster of Paris cast, external compression, and so
on,24-26 can be dismissed with the words of Howard:
"The remedy for the deformity is operation, Physio-
therapy is useless without operation, and retaining ap-
paratus is worse than useless, "1,5
Surgery, as the only effective method for the treat-
ment of pectus carinatum, was first suggested by
Ravitch and Handelsman in 1952,27 but it was Lester"
who I year later performed the first corrective proce-
dure for this anomaly by resecting subperiosteally the
lower body of the sternum as well as the sternal ends of
the costal cartilages. He 28 later extended his procedure
by removing subperiosteally the entire body of the ster-
num and excising the costal cartilages in the total extent
of their involvement. In 1960, Ravitch.F' "feeling that
the sternum was not primarily at fault and that the prob-
lem was with the ribs and cartilages," resected the
involved costal cartilages, shortened the perichondrial
strips with reefing sutures, but left the sternum
Pectus carinatum 55
alone-a procedure that he continues to use with con-
siderable success.' Chin" in 1957 and Brodkin!" in
1958 employed an operation which used the traction
effect of the rectus muscles to bring and maintain the
sternum in a corrected position, They performed
limited resection of the costal cartilages bilaterally, de-
tached the xiphoid process, and sutured it into a notch
high on the anterior surface of the sternum. Howard"
further modified this method by resecting the cartilages
more radically and by performing a transverse os-
teotomy of the sternum at the level of maximum de-
formity. These procedures were used with or without
minor modifications by several other authors. 4.26.30-33
Our own techniques in the different forms of cari-
natum deformities, first applied in 1957, are as follows:
Type I: Keel chest. The operation is performed
through an upward convex transverse submammary
incision. The length of the incision is proportional with
the extent of the deformity, and the planned extent of
exposure and is carried down to the level of the sternal
periosteum in the midline and to the fascia of the chest
muscles bilaterally, Flaps of skin and subcutaneous tis-
sue are developed and retracted in the cranial and
caudal directions, The pectoralis muscles are detached
from the sternum and mobilized laterally enough to be
allowed later to be pulled and sutured together in front
of the sternum without undue tension. The small pec-
toral branches of the intercostal vessels are divided by
 The Journal of
56 Robicsek et al. Thoracic and Cardiovascular
Surgery

Fig. 5. Significant protrusion of the lower two-thirds of the sternum before and after repair in a child. (From
Robicsek F, Sanger, PW, Taylor FH, Thomas MJ: J THORAC CARDIOVASC SURG 45:691-701, 1963, published by
The C. V. Mosby Company.)

Fig. 6. Significant protrusion of the lower two-thirds of the sternum before and after repair in an adolescent.

means of electrocautery. The sternum is then carefully
inspected, and a wedge-shaped transverse osteotomy is
done at the beginning of the abnormal forward curve,
usually just below the angle of Louis. Care is taken that
the line of osteotomy corresponds to an intercostal
space rather than to a sternocostal junction.
Caudal to the line of the transverse osteotomy, the
sternal ends of all costal cartilages are then sub-
perichondri ally resected. Short segments of the upper
cartilages with progressively longer segments of the
lower ones are removed. If a cartilage appears to be
protuberant, elongated, or knobby, it is removed in its
Volume 78
Number 1
July, 1979
Fig. 7. Schematic drawing of the repair of chondrogladiolar
prominence with xiphoid support.
entire length of involvement. Achieving an appro-
priately smooth contour to the anterior chest wall
sometimes necessitates the removal of portions of osse-
ous ribs as well.
The lower end of the sternal body is now grabbed
with a towel clip, elevated, and the xiphoid process is
detached. If the xiphoid appears to be very rudimen-
tary, the line of resection is carried superiorly to leave a
short portion of the sternal body in continuity with it.
Both the sternum and the xiphoid process are now mo-
bilized, the sternum distal to the osteotomy is de-
pressed, its posterior lamina is broken at the level of the
osteotomy, and thereby its abnormal forward position
is corrected. An appropriate portion, 2 to 6 cm. in
length, of the distal sternum is resected. The new distal
end is smoothed off and united with the xiphoid process
with several stainless steel sutures. This maneuver, la-
beled as "acceptable but probably unnecessary" by
Ravitch, 1 is in our opinion an essential part of the repair
of pectus carinatum. Our view is based not only on the
good postoperative results but also on the pathological
anatomy of this deformity. In pectus carinatum, the
sternum not only is in an abnormally elevated position,
but it also is abnormally long; ergo, the position of the
sternum must be normalized and it also has to be
shortened. Resecting a portion of it will correct its ab-
normal length, and the reattached xiphoid process of
Pectus carinatum 57
Fig. 8. Schematic drawingof repairof stemogladiolarpromi-
nence with Marlex mesh.
the rectus muscles will exert a traction strong enough to
bring and maintain the breast bone in a corrected posi-
tion. If there are protuberances left on the sternum, they
are shaped with osteotomies and rongeurs. The edges
of the pectoralis muscles then are sutured together in
front of the sternum to exert an additional depressing
force upon the sternum and to provide a smooth contour
to the anterior chest wall.
If the deformity is quite advanced and extensive,
dissection is necessary, a wide communication is es-
tablished between the retrosternal space and the right
pleural cavity, and an intercostal water-sealed catheter
is inserted. This provides adequate drainage and as-
sures a smooth wound healing.
Type II: Pouter pigeon breast. The operation
applied for the correction of pouter pigeon breast dif-
fers considerably from the procedure just described,
because it has to correct two anomalies: (l) upper
chondromanubrial prominence, which has to be de-
pressed, and (2) lower sternochondral depression,
which has to be raised.
The exposure of the sternum is done in a fashion
similar to that of the keel chest, but the incision is made
somewhat higher and longer because of the necessity to
reach the manubrium. The protruding manubriosternal
segment is molded with a wide osteotome, the carti-
lages are resected subperichondrially from the second

58 Robicsek et al,
Fig. 9. Sternogladiolar prominence with chondrosternal depression before and after repair.
Fig. 10. Radiograms of sternogladiolar prominence with
chondrosternal depression before and after repair.
down, and the xiphoid process is detached. Two
wedge-shaped transverse osteotomies are done; one in
the level of the third intercostal space and the other (if it
appears to be necessary) about 3 em. above the xiphoid
process. The sternal body is maintained in this cor-
The Journal of
Thoracic and Cardiovascular
Surgery
rected position either by supporting it with the xiphoid
process suspended by heavy wire sutures 13 or, as we
more recently do, by suturing Marlex mesh subster-
nally to the edges of the costal cartilages. 10 The proce-
dure is completed by trans pleural intercostal drainage,
by tacking the pectoralis muscles together presternally,
and by cosmetic closure of the skin incision.
Type III: Lateral pectus carinatum. According to
the severity of the anomaly, the repair of lateral or
asymmetrical pectus carinatum could be very easy but
could also be very difficult. If only a few elongated
cartilages bulge forward, the malformation can be cor-
rected through a small transverse skin incision made
right over the protruding cartilages by simple sub-
perichondrial resection. Even in these cases, however,
it is advisable to be radical rather than conservative.
Otherwise, after closure of the skin or, even worse, at
the time of the first postoperative office visit, it may
become apparent that the protrusion still persists.
It is more frequent, however, that the asymmetrical
pectus carinatum is caused by the overgrowth of not
only one or two cartilages, but by the unilateral pro-
tuberance of all costal cartilages below the level of the
second rib. This anomaly is invariably accompanied by
various degrees of torsion of the sternum around its axis
and often also by some degree of chondrocostal de-
pression of the contralateral side.
Such cases require not only quite radical resection of
the cartilages but often removal of the anterior portion
Volume 78
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July, 1979
Fig. 1I. Correction of sternal rotation with Z-wire suture.
Fig. 12. Sternal rotation occurring after unilateral resection of costal cartilages.
of the bony ribs as well. Special attention should be
given to the chondrosternal junctions, which should be
smoothed off by osteotomes. Otherwise, they may
protrude after the operation as a longitudinal knobby
ridge. We have learned rather painfully that if the
chondral protrusion is significant enough to necessitate
radical removal of the cartilages on one side, the appar-
ently normal or slightly depressed cartilages on the
other side should be resected as well. This is to be done
to a lesser extent but in an equal number. If this is not
done, the unbalanced action of these cartilages tilts the
sternum further, and the result may be a deformity
worse than prior to operation (Fig. 9).
The rotation of the sternum should be corrected by a
high transverse linear osteotomy followed by deliberate
fracture of the posterior lamina and manual torsion of
the sternal body in the opposite direction. This proce-
dure restores a normal transverse sternal axis, and the
breast bone will lie flat in the center of the incision.
This corrected axis can be secured by placing a heavy
figure-of-eight wire suture on the previously depressed
side of the edge of the transverse osteotomy (Fig. 11).
Pectus carinatum 59
Results
During the past 2Y2 decades, we have performed 161
operations to correct pectus carinatum. One hundred
eight patients in this group had Type I deformity (keel
chest), eight patients had Type II deformity (pouter
pigeon breast), and 45 patients had Type III deformity
(asymmetrical or lateral pectus carinatum). There were
neither serious complications nor hospital deaths in this
group. Minor problems consisted of serous fluid col-
lection in the operative wound and a few superficial
wound infections which responded well to drainage and
antibiotic treatment.
The cosmetic appearance of the chest after discharge
from the hospital was regarded as good in 136 cases,
fair in 12 cases, and poor in 13 cases-eight of which
have been reoperated. However, most patients with un-
satisfactory results were operated upon in the earlier
periods, and their residual anomaly usually consisted of
one or more "left behind" knobby cartilages which
were subsequently removed. This not serious, but cer-
tainly embarassing, even can be prevented easily if,
after the bony anomaly is corrected but before the soft

6 0 Robicsek et at.
tissues are closed, the operator approximates the skin
edges with towel-clips, inspects the contours and pal-
pates the surface of the chest wall, and, if necessary,
removes additional portions of the deformed ribs. This
simple maneuver can practically exclude the possibility
of unacceptable postoperative results. By and large, it
can be stated that, because of the nature of the pectus
excavatum deformity, there probably will always be a
definite percentage of true "recurrences" which can be
decreased but cannot be eliminated even by the proper
choice of operation and operator. By contrast, unsatis-
factory results in pectus carinatum operations usually
indicate unsatisfactory surgical technique. Of the 13
unsatisfactory results, nine were readily detectable
within 2 months after the operation and only four ini-
tially showed a satisfactory appearance. The reason for
this is undoubtedly that in excavatum deformities the
vector forces of the corrected human tissues have to
raise the sternum and keep it elevated in its new posi-
tion; the operation in pectus carinatum simply allows
the sternum to fall back into its proper place and keeps
it there. That is not a particularly difficult task.
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July, 1979
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