Surgical Treatment
of Pectus Carinatum
Conrad R. Lam, MD, and Rodman E. Taber, MD,
Experience is presented with eight
operations for pectus carinatum. De-
formities of the chest with promi-
nence of the sternum (pectus carina-
tum) are less frequent than those
with a depressed sternum (pectus
excavatum). Surgical correction is
indicated for psychological if not for
physiological reasons. There are two
main types of sternal prominence,
the chondromanubrial and the chon-
drogladiolar. Different operative
techniques are required for their
correction. These involve resection
of the cartilages which are in mal-
position and suitable osteotomies on
the sternum.
The
literally
term
derived
"pectus carinatum"
from the Latin,
is
and
means "chest with a keel."
The term is commonly used, as in
this communication, to include
those deformities of the chest asso¬
ciated with undue prominence of
the sternum, in contradistinction to
Accepted for publication March 22,1971.
From the Division of Thoracic Surgery of the
Henry Ford Hospital, Detroit.
Read before the 28th annual meeting of the
Central Surgical Association, Minneapolis,
March 5, 1971.
Reprint requests to 2799 W Grand Blvd, De-
troit 48202 (Dr. Lam).
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Detroit
deformities with depression, pectus
excavatum or funnel chest. The
names "bird breast" and "pigeon
breast" are also used, and indeed,
some of the deformities more sug¬
gest the avian breast than the keel
of a boat. Significant deformities
from prominence of the sternum are
much less frequent than those with
depression ; during a period in
which we surgically corrected 106
cases of pectus excavatum, we saw
only ten cases of pectus carinatum,
of which eight patients had opera¬
tions.
There are at least two definite
types of chest deformity with ster¬
nal prominence, as originally point¬
ed out by Brodkin.1 The one he
called "chondromanubrial promi¬
nence" is characterized by a protru¬
sion of the manufrium and adjacent
first and second cartilages, and a
vertical or depressed gladiolus. An
example of this is seen in Fig 1.
The second form he called "chon-
drogladiolar prominence," in which
the lower anterior thorax and the
body of the sternum project for¬
ward, so that the gladiolar-xiphoid
junction is the most prominent part
of the anterior chest wall. Brodkin
stated that the first type was the
commoner form, but in our series of
 ten cases, only two were of this
type.
In 1948, Ravitch corrected the
chest of a young man with chon-
dromanubrial prominence corre¬
sponding to Brodkin's first type,
and reported the operation in a pa¬
per with the title "Unusual Sternal
Deformity with Cardiac Symp¬
toms : Operative Correction."2 He
emphasized that there was both
prominence and depression of the
sternum, the prominence being su¬
periorly in the manubrial area and
the depression lower down. He
pointed out that the depression pro¬ Fig 1.—Five-year-old boy with pectus carinatum of chondromanubrial type, fron¬
duced a different picture from that tal(left) and lateral (right) views. Note that gladiolar depression is exaggerated by
of typical pectus excavatum, a fact manubrial prominence.
which is evident in the patient illus¬
trated in Fig 1. Ravitch did not use Fig 2.—Pectus carinatum of keel type in 55-year-old man, frontal (left) and later¬
the term "pectus carinatum" in this al (right) views.
paper, but in a subsequent paper
with the title "The Operative
Correction of Pectus Carinatum
(Pigeon Breast),"3 he included the
first case in his series of three, and
stated that the deformity suggested
the breast of a pouter pigeon. His
other two cases were of Brodkin's
second type, with the keel-like de¬
formity. This type of deformity is
shown in Fig 2. Robicsek et al4
added two other types of deformity
to their classification of pectus cari¬
natum, lateral protrusion (one-sid¬
ed) and lateral protrusion of both
sides. Of their 215 patients with
anomalies of the anterior chest wall,
174 had pectus excavatum and 41,
carinatum deformities.
In our series of ten patients with
pectus carinatum, there was only
one female, and she was operated on Fig 4.—Method of correction of ster¬
at the age of 9 years. One boy had nal deformity (case 1). A, Simple osteot¬
surgical correction at the age of 6 omies in outer table at upper and lower
years, and the others were in the Fig 3.—Sternal prominence of chon¬ dotted lines; resection of entire thick¬
dromanubrial type in 18-year-old boy ness of sternum between center dotted
age range of 13 to 18 years. The lines. B, Inner table fractured above
main indications for operation were (case 1). Note similarity to boy in Fig
1. and below; sternum approximated at
cosmetic and psychological consider¬ site of resection.
ations, although the possibility of
physiologic impairment of lung
function is admitted. Robicsek and
his associates were definitely of the
opinion that chondrosternal protru¬
sion has a serious physiologic effect.
Two patients in our series did not
receive operation. One was the child
of 5 years shown in Fig 1, who was
observed in 1962. Although it was
assumed that operative correction
was feasible and should be under¬
taken relatively soon, there was con¬
cern about the effect of an operation
on the epiphyses of the sternum,

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 and definite advice was postponed
for six months. The patient was
then lost to follow-up. The fear of
interference of bone growth of the
sternum was surely without founda¬
tion ; in fact, it has been suggested
by Currarino and Silverman5 that
premature obliteration of the ster¬
nal sutures may be the cause of the
forward angulation of the sternum.
The other patient not to receive an
operation was the patient with the
keel type of deformity shown in Fig
2. This man, aged 55, a bachelor
and a heavy smoker, was found to
Fig 5.—Immediate postoperative re¬ have inoperable carcinoma of the
sult (case 1). lung. The possibility that his chest
deformity was a psychological bar¬
rier to his attainment of the more
normal marital status is worthy of
serious consideration.
The operative technique for the
Fig 6.—Marked keel-type deformity
in 8-year-old girl (case 2). two types of deformity (chondro-
manubrial and chondrogladiolar)
differs considerably. Resection of
portions of a considerable number
of costal cartilages is indicated in
both types, but the treatment of the
sternum itself is different. Details
of the operative management of a
case with chondromanubrial de¬
formity and one with chondrogladi¬
olar deformity will be presented.
Report of Cases
Case 1.—The patient was a healthy-
looking boy of 18 who had had a
protrusion deformity of his chest all
his life. He sought medical advice
Fig 7.—Step in operation (case 2). Simple osteotomy Fig 8.—Completion of correction of sternal deformity (case
(upper dashed lir.e), wedge resection of outer table (lower 2).
dotted line).
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because he began to have severe sub-
sternal pain when doing heavy work.
He had the characteristic deformity of
the chondromanubrial type of sternal
protrusion (Fig 3). Operation was ad¬
vised for cosmetic if not physiologic
reasons, and this was done on Nov 18,
1958. A transverse incision was made
beneath the nipples, and the skin was
reflected upward and downward to ex¬
pose the deformed area. The pectoral
fascia was incised vertically and the
muscle separated to expose the pro¬
truding sternum and adjacent carti¬
lages. Segments of the second, third,
and fourth cartilages were excised. To
remove the excess length of the ster¬
num because of its curvature, a cunei¬
form segment 2 cm wide was resected
from the prominence of the convexity
(Fig 4). Transverse osteotomies were
made in the sternum above and below
the resection. These osteotomies per¬
mitted the sternum to be fractured
down into a flat position, which was
maintained by sutures at the resection
site. Further trimming of the carti¬
lages made the chest entirely flat. The
pectoral fascia was approximated, and
the skin was closed about a small
drain. The cosmetic result was excel¬
lent (Fig 5), and the patient had no
further complaint of pain in the chest
on exertion.
Case 2.—This patient is an example
of really true pectus carinatum ; there
is actually a keel-like deformity. The
patient was an American Indian girl
who was seen at the age of 8 years
(Fig 6). The important steps in the
correction of the deformity are illus¬
trated in Fig 7 and 8. Osteotomies
were made in the outer tables of the
 Fig 9.—Appearance of chest
operation (case 2).
years after
sternum, the upper one permitting the
protruding sternum to be fractured
backward, and the lower one, from
which a wedge was removed, permit¬
ted the tip of the sternum to be ele¬
vated from its now more depressed
position. In this case, the wedge of
bone from the lower osteotomy was
inserted in the gaping upper osteoto¬
my to maintain the new angulation.
The immediate cosmetic result was
good, and the correction was main¬
tained and can be seen from a photo¬
graph made two years after the opera¬
tion (Fig 9).
A less severe deformity is that in
case 3, 15-year-old boy (Fig 10).
a deformity with cardiac symptoms:
Even this degree of deformity was
distressing to him and his parents, and
it was corrected by the resection of
portions of four cartilages on the left
and four on the right (Fig 11), and
two transverse osteotomies of the out¬
er table of the sternum. The cosmetic
result was pleasing (Fig 12).
Operations similar to those of the
second and third cases were done in an
additional five patients with the more
typical carinatum deformity. There
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two
Fig 10.—Keel-type deformity in 15-
year-old boy (case 3).
Fig 11.—Cartilages removed to
rect deformity (case 3).
was no morbidity or wound complica¬
tion, and the cosmetic result was grat¬
ifying in all, although in several pa¬
tients, it appeared that the result
might have been better with wider
excision of cartilages.
cor¬
Fig 12.—Appearance of chest five
months after operation (case 3).
References
1. Brodkin HA: Pigeon breast\p=m-\
Congenital chondrosternal promi-
nence: Etiology and surgical treat-
ment by xiphosternopexy. Arch Surg
77:261-270, 1958.
2. Ravitch MM: unusual sternal
Operative correction. J Thorac Surg
23:138-144, 1952.
3. Ravitch MM: The operative cor-
rection of pectus carinatum (pigeon
breast). Ann Surg 151:705-714, 1960.
4. Robicsek F, Sanger PW, Taylor
FH, et al: The surgical treatment of
chondrosternal prominence (pectus
carinatum). J Thorac Cardiovasc Surg
45:691-701, 1963.
5. Currarino G, Silverman FN: Pre-
mature obliteration of the sternal su-
tures and pigeon-breast deformity.
Radiology 70:532-540, 1958.