Pectus carinatum (PC), often referred to as “pigeon chest,” is a chest wall malformation characterized by the outward protrusion of the sternum and rib cage. This condition affects the structure of the anterior chest, which can cause concerns about physical appearance and, occasionally, respiratory function. Understanding how this chest deformity progresses during periods of skeletal growth is a common concern for affected individuals and their families.
Defining Pectus Carinatum
Pectus carinatum results from an overgrowth of the costal cartilage, the flexible tissue connecting the ribs to the breastbone. This excessive growth pushes the sternum forward, creating a visible prominence. The condition is the second most common chest wall deformity in children, with a significantly higher prevalence in males.
The appearance of the protrusion can vary in location and symmetry. The most frequent type is the chondrogladiolar prominence, where the mid-to-lower sternum is pushed outward. A less common form is the chondromanubrial type, which involves the upper sternum and is often more complex. In many cases, the protrusion is asymmetrical, meaning one side of the chest wall is more affected than the other. This asymmetry is often accompanied by a compensatory flattening or depression of the adjacent ribs. While many patients experience no physical symptoms, the visual change can lead to body image concerns and psychological distress.
Progression During Growth Stages
The progression of pectus carinatum is directly related to the individual’s stage of skeletal development. The condition is dynamic, changing significantly during periods of rapid growth. It is often subtle in early childhood and becomes most noticeable during the adolescent growth spurt, typically between the ages of 11 and 14.
This acceleration occurs because the overgrowth of the costal cartilage continues at a faster rate than the surrounding bone structure. As the skeletal framework expands rapidly during puberty, the excess cartilage length forces the sternum into a more pronounced outward position. Outside of these intense growth phases, the condition is generally stable and does not progress.
Once an individual reaches skeletal maturity, typically in late adolescence, the chest wall ossifies and becomes rigid. At this point, the protrusion becomes a fixed, static deformity. If the condition is left uncorrected during the period of skeletal plasticity, the chest wall stiffens, making non-surgical treatment options ineffective later on. The opportunity for less invasive correction is directly tied to the presence of pliable, actively growing cartilage.
Non-Surgical Management
For younger patients whose chest walls are still flexible, non-surgical management is the preferred first-line treatment. The most common conservative method is the use of external compression bracing. This custom-fitted orthotic brace works by applying continuous, targeted pressure directly onto the protruding sternum. The constant force gradually remodels the pliable cartilage and bone back into a normal, flatter position.
Treatment success hinges on patient compliance, as the brace must be worn for a substantial part of the day. Many protocols require the brace to be worn between 8 and 24 hours daily, with compliance rates determining the outcome. The typical duration of treatment ranges from six months to over a year, with some studies reporting an average of 16 months until full correction is achieved.
Once the desired sternal flattening is achieved, patients usually transition to a maintenance phase, wearing the brace only at night until their skeletal growth is complete. Non-operative bracing eliminates the risks associated with surgery. It also does not prevent surgical intervention if the treatment proves unsuccessful.
Surgical Correction Procedures
Surgical correction is typically reserved for cases that are severe, unresponsive to bracing, or diagnosed after skeletal maturity when the chest wall has become rigid. The traditional open approach is the modified Ravitch procedure, which involves making an incision on the front of the chest. The surgeon resects the overgrown costal cartilage responsible for the protrusion and performs a sternal osteotomy, which is a controlled cut to reshape the breastbone. The sternum is then repositioned and stabilized, sometimes with a temporary metal support bar or plates, which are removed later.
Another option is the minimally invasive Abramson procedure, which uses a specialized metal bar similar to the technique used for pectus excavatum. This bar is inserted through small incisions on the side of the chest and positioned to press the sternum inward. The Abramson procedure is primarily used for the more common chondrogladiolar type of PC, which tends to be more flexible.
Post-operative recovery for open surgery generally involves a hospital stay of around five days for pain management. The metal support bar, if used in the Ravitch procedure, is typically removed after at least one year. Bars used in the minimally invasive procedure are often left in place for approximately two years.