A pectus is a chest wall deformity where the breastbone (sternum) and the cartilage connecting it to the ribs grow into an abnormal shape. The two main types are pectus excavatum, where the chest caves inward, and pectus carinatum, where it pushes outward. Together, these are the most common congenital chest wall deformities, affecting up to 8 in every 1,000 live births, and they occur three to five times more often in males than females.
Pectus Excavatum: The Sunken Chest
Pectus excavatum accounts for 65 to 95 percent of all chest wall deformities. The sternum dips inward, creating a visible dip or “funnel” in the center of the chest. It’s usually noticeable in early childhood, though many cases become more pronounced during the growth spurts of adolescence. The true prevalence may be higher than reported rates suggest, with some radiological studies estimating it could affect up to 5 percent of the population, since many mild cases go undiagnosed.
The severity varies widely. Some people have a barely noticeable dip, while others have a deep depression that visibly compresses the space where the heart and lungs sit. Doctors measure severity using something called the Haller index, a ratio taken from a CT scan that compares the width of the chest to the distance between the sternum and the spine. A normal chest scores around 2.5. Scores above 3.2 are typically considered candidates for surgical repair, and anything above 3.5 is classified as severe.
Pectus Carinatum: The Protruding Chest
Pectus carinatum is the opposite deformity. The sternum and attached cartilage push outward, giving the chest a “pigeon breast” appearance. It occurs two to four times less frequently than pectus excavatum, estimated at about 1 in every 2,500 live births, and also skews heavily male, with a four-to-one ratio. Like its counterpart, pectus carinatum tends to become more obvious during puberty as the ribcage grows rapidly.
How a Pectus Affects the Body
Mild cases of either type may cause no physical symptoms at all. The main concerns for many people are cosmetic, and the psychological impact of looking different, especially during adolescence, can be significant on its own.
In moderate to severe pectus excavatum, however, the inward depression physically compresses the heart and lungs. This reduces how much the lungs can expand and limits the heart’s ability to fill with blood between beats, which lowers the volume of blood pumped with each heartbeat. People with this level of compression often notice they get winded more easily than their peers, especially during exercise. As the deformity progresses, the heart may shift position inside the chest, sometimes producing a rapid heart rate, heart murmurs, or irregular electrical patterns on an ECG. Mitral valve prolapse, a condition where one of the heart’s valves doesn’t close tightly, shows up in 7 to 20 percent of patients with advanced cases.
Pectus carinatum is less likely to compress internal organs. Its effects are primarily cosmetic, though some people report chest tightness or discomfort during physical activity.
Links to Connective Tissue Disorders
A pectus deformity sometimes appears alongside inherited connective tissue conditions. Roughly half of people with Marfan syndrome, a genetic disorder that affects the body’s structural proteins, also have pectus excavatum. It also shows up more frequently in people with Ehlers-Danlos syndrome, which causes unusually flexible joints and fragile skin. Many people with a pectus have some degree of joint hypermobility or tissue laxity even without a formal diagnosis of one of these syndromes. In some cases, the chest deformity is the first visible sign that prompts evaluation for a broader connective tissue condition.
Non-Surgical Treatment Options
For pectus carinatum, the first-line treatment is typically a compression brace, a custom-fitted device worn over the chest that applies steady pressure to gradually reshape the protruding bone and cartilage. Bracing works best in younger patients whose chest wall is still flexible. In a four-year prospective study, successful treatment required about six months of active bracing followed by roughly nine months of maintenance wear. The brace needs to be worn consistently each day for it to work.
For pectus excavatum, a non-surgical option called vacuum bell therapy uses a suction cup placed over the depression to gradually lift the sternum outward. Sessions range from 30 minutes to several hours daily, and the approach shows the most promise in preteens with mild deformities. Visible improvement can appear as early as six months. If no meaningful change happens within 6 to 12 months, surgery is generally the next step.
Surgical Repair
Two main surgical approaches exist for pectus excavatum. The Ravitch procedure, first described in 1949, is an open surgery where the surgeon removes sections of the abnormally shaped cartilage and repositions the sternum. It remains the preferred technique for severely asymmetrical cases where the chest is uneven from side to side.
The Nuss procedure, introduced in 1998, is minimally invasive. Instead of cutting cartilage, the surgeon slides a curved metal bar through two small incisions on either side of the chest and positions it behind the sternum, pushing the bone outward into a normal shape. The bar stays in place for about three years while the chest remodels around it, then gets removed in a shorter follow-up procedure. The Nuss approach gained popularity quickly because it involves less blood loss and shorter operating times compared to the open technique.
Recovery from the Nuss procedure takes about six months for full return to all activities, though most people get back to daily routines well before that. The first four weeks are the most restrictive: patients need to sit upright, avoid rolling onto their sides, and bend at the hips rather than the waist to keep the bar from shifting. Contact sports and heavy lifting are off-limits until full recovery. Activities involving torso twisting or raising the arms overhead are restricted early on because they can dislodge the bar.
When It’s Cosmetic vs. Medical
One of the trickier aspects of having a pectus is that many people fall in a gray area between “purely cosmetic” and “clearly causing organ compression.” Mild cases that don’t affect heart or lung function may still cause real distress about body image, particularly in teenagers. More severe cases can genuinely limit exercise capacity and cardiac function, making repair a medical decision rather than an aesthetic one. The Haller index and exercise testing help draw that line, but the psychological impact of the deformity is increasingly recognized as a valid factor in treatment decisions regardless of the severity score.