Pictures of Pectus Excavatum: Visual Identification

Pectus excavatum is a depression of the sternum and the cartilage connecting it to the ribs, creating a visible indentation in the center of the chest that can range from a shallow dip barely noticeable in certain lighting to a deep hollow large enough to hold a pool of water when lying flat. The condition is the most common congenital chest wall deformity, and its visual presentation varies far more than many people realize. What looks like a simple “sunken chest” in one person can appear as a lopsided, rotated, or narrow groove in another, and these visual differences matter for both identification and treatment decisions.

The Basic Visual Pattern

The hallmark of pectus excavatum is an inward displacement of the breastbone. In photographs, you typically see a concavity somewhere between the nipple line and the lower border of the ribcage. Looking at someone from the side, the chest profile dips inward rather than curving gently outward. From the front, the depression can appear as a shadow or a visible “bowl” in the center of the chest, sometimes flanked by ribs that seem to protrude by comparison.

Not all cases look the same, though. Clinicians classify the deformity by the shape it takes on the chest surface. A cup-shaped depression is deep and localized, almost like a thumb pressed into clay, while a saucer-shaped type is shallower and spreads across a wider area of the chest. A trench-like deformity creates a longer, more elongated groove running vertically down the sternum. The most extreme variant, sometimes called the Grand Canyon type, describes an eccentric, canal-like depression that can look dramatically uneven. These shape distinctions can also be graded by symmetry, which adds another visual dimension entirely.¹

In photographs, lighting plays a huge role in how obvious the depression appears. Overhead lighting that casts shadows into the concavity makes even mild cases look more pronounced, while flat, diffused lighting can minimize the appearance considerably. This is one reason people searching for pictures online see such a wide range of severity: the same chest can photograph very differently depending on angle and light.

Symmetric Versus Asymmetric Presentations

Many people picture pectus excavatum as a neat, centered dip in the middle of the chest, and some cases do look that way. But a large proportion are asymmetric, meaning the deepest point of the depression sits off to one side, or the sternum itself is rotated. In photographs, asymmetric cases often look like the chest is “twisted” slightly, with one side of the ribcage appearing flatter or more caved in than the other.

Research on asymmetry shows it tends to worsen with age. A study tracking patients across age groups found that in the youngest group, about 83% of cases were classified as symmetric or only mildly asymmetric. By the oldest group, half the patients showed moderate to severe right-sided asymmetry, and the average angle of sternal rotation roughly doubled.² Visually, this means a child’s pectus might look fairly centered in early childhood photos but appear increasingly lopsided by the mid-teen years.

What drives this asymmetry is not exactly what many people assume. A common explanation is that overgrown cartilage between the ribs and sternum pushes the breastbone inward unevenly. But research comparing patients with pronounced sternal rotation (21 degrees or more) to controls found that the ribs themselves, not the costal cartilage, were longer than normal. The cartilage lengths were comparable to those of people without pectus excavatum.³ In pictures, the practical effect is the same: one side of the chest looks deeper or more caved in. But the underlying skeletal cause helps explain why the asymmetry can be so difficult to correct surgically and why it tends to progress during growth.

Rib Flaring and Other Visible Features

When people look at pictures of pectus excavatum, one of the most common things they notice besides the central depression is a flaring of the lower ribs. The bottom edges of the ribcage angle outward prominently, sometimes giving the appearance of a shelf or ledge below the chest. This flaring can be part of the pectus excavatum deformity itself.⁴ In thinner individuals, the flared costal arches can be strikingly visible, sometimes drawing more visual attention than the sternal depression itself.

Posture is another giveaway that often shows up in full-body photographs or side-profile images. A study of adolescents with pectus excavatum and pectus carinatum found that postural changes were extremely common. About 90% had forward head posture, roughly 82% had rounded shoulders, around 68% showed increased thoracic kyphosis (an exaggerated rounding of the upper back), and about half had scoliosis.⁵ A separate study confirmed that thoracic kyphosis angles were significantly higher in adolescents with pectus excavatum compared to healthy peers.⁶

In photographs, this cluster of postural features creates a recognizable silhouette: the head juts forward, the shoulders roll inward, and the upper back rounds, which can make the chest depression look even deeper by comparison. Some people with mild pectus excavatum report that their posture draws more comments than the depression itself. It is worth noting that these postural changes are associated findings, not guaranteed ones, but they appear frequently enough that spotting them in a photo alongside a sunken chest is a useful visual clue.

How It Changes with Age

Pectus excavatum may be visible at birth, but it more commonly becomes noticeable during the teenage growth spurt.⁷ When a deformity is noticed early, it tends to progress slowly through childhood and then worsen quickly during puberty.⁸ This means that pictures of the same person taken a few years apart can look dramatically different. A chest that appeared only mildly concave at age 10 may look much more deeply sunken by age 15.

This rapid progression during adolescence catches many families off guard. Parents who were told the condition was mild and cosmetic sometimes see it transform during a growth spurt into something that looks and feels much more significant. The worsening tends to plateau once skeletal maturity is reached in the late teens or early twenties, but by then the chest wall has stiffened considerably, making the deformity harder to address without surgery. In adult pictures, the depression tends to look more fixed and rigid compared to the softer-appearing chest wall of younger patients.

Body composition also affects how the depression appears at different ages. A thin teenager with low body fat will show the contour of every rib and the full depth of the depression, while an adult who has gained muscle or fat may find the visual severity looks somewhat reduced even though the underlying skeletal deformity hasn’t changed. This is a frequent source of confusion in online communities where people compare photos and wonder whether their pectus “improved” on its own.

Connective Tissue Disorders and What They Add to the Picture

Pectus excavatum is often an isolated finding, but it can also appear as part of a connective tissue disorder. The deformity has been linked to over 27 genetic conditions, including Marfan syndrome, Ehlers-Danlos syndrome, and Loeys-Dietz syndrome.¹ Recognizing an underlying disorder from pictures alone is tricky, because the indicative signs can be subtle: unusually long limbs, hyperextensible joints, thin or translucent skin, or easy bruising that might not show up clearly in a photograph.

Certain visual features in a photo can hint that something more systemic is going on. A very tall, slender body with disproportionately long arms and fingers alongside pectus excavatum is a classic look associated with Marfan syndrome. Overlapping features between Marfan syndrome and Loeys-Dietz syndrome include scoliosis, flat feet, and chest wall deformities.⁹ If you’re looking at pictures of someone with pectus excavatum and also notice unusually flexible-looking joints or a particularly long, narrow face, those combined features may warrant a more thorough evaluation than the chest wall deformity alone would suggest.

Poland syndrome is another condition that can produce a distinctive visual pattern. It involves absence or underdevelopment of the pectoralis major muscle on one side of the chest, sometimes combined with pectus excavatum. In photographs, this creates a markedly uneven chest: one side looks flat or hollow due to the missing muscle, while the opposite side may appear normal or even convex by comparison. The severe form can also involve rib and sternal malformations.¹⁰ This combination is rare but immediately recognizable in images once you know what to look for, because the asymmetry is far more extreme than typical asymmetric pectus excavatum.

What Happens Internally and Why It Matters for Pictures

The surface appearance of pectus excavatum is only part of the story. In severe cases, the depressed sternum compresses the heart and shifts it to the left side of the chest cavity. A case report described preoperative imaging showing the lower sternum pushed so far inward that the gap between the sternum and the spine was less than 2 centimeters, with the heart visibly compressed and displaced into the left chest.¹¹

For visual identification, this internal compression sometimes has external consequences. People with severe cardiac compression may have a visible pulsation in the depression (you can sometimes see the heartbeat through the skin), or the left side of the chest may appear subtly fuller because of the displaced heart pushing outward. These are not features everyone with pectus excavatum shows, but in severe cases, they can be visible in videos or photographs taken at the right angle. This is also why clinicians do not judge severity by surface appearance alone: a chest that looks moderately depressed from the outside can have a very narrow space internally, and the reverse is also possible.

Measuring What You See Without a CT Scan

The traditional way to quantify pectus severity is a CT-derived measurement called the Haller index, which compares the width of the chest to the shortest distance between the sternum and spine. But CT scans expose patients to radiation, which is a real concern when monitoring children over time. This has driven interest in external measurement tools that can quantify severity from the surface of the chest.

Three-dimensional optical surface scanning has emerged as a reliable alternative. One validation study found that an external scanner’s measurements matched well with CT-derived values, making it a dependable option for tracking pectus excavatum development over time without radiation.¹² A separate study using an optical device found it could reliably distinguish mild from severe cases and offered the advantage of being repeatable without requiring any cross-sectional imaging at all.¹³

Even conventional photography, when done carefully, can be clinically useful. A protocol using 3D optical surface imaging showed excellent agreement with standard photography for measuring pectus depth, with results that were essentially interchangeable between the two methods.¹⁴ The 3D approach adds the ability to create a full digital model of the chest, which is valuable for surgical planning and for showing patients how their chest compares before and after treatment. For anyone trying to document their own pectus excavatum with photographs for a medical consultation, using consistent lighting, camera angle, and body position matters more than having expensive equipment.

Newer research has also explored MRI-based and surface-topography methods that avoid radiation entirely. One study found that external measurements taken from the chest surface correlated well with internal measurements derived from MRI, supporting the idea that what you see on the outside does, in fact, reflect what’s happening to the skeleton underneath, at least to a useful degree.¹⁵

How Treatment Changes the Visual Appearance

The two main surgical approaches produce quite different visual outcomes in terms of scarring and chest contour. The Nuss procedure involves inserting a curved metal bar behind the sternum through small incisions on the sides of the chest, pushing the breastbone outward. The Ravitch procedure is more invasive, removing sections of the deformed cartilage through a larger incision across the front of the chest. In post-surgical photographs, Nuss patients typically show small lateral scars and a smoother anterior chest, while Ravitch patients may have a more prominent midline or sub-mammary scar. A meta-analysis comparing the two approaches in children found no significant difference in overall complication rates or reoperation rates, though adult patients undergoing the Nuss procedure had a higher incidence of overall complications.¹⁶

Both procedures generally produce a visually flatter or even slightly convex chest profile compared to the preoperative appearance. However, post-surgical photos are not always as dramatic as people hope. Asymmetric cases that involve sternal rotation often retain some visual irregularity even after bar placement, although research into double-bar techniques has shown improved correction of sternal rotation in patients with more pronounced asymmetry.¹⁷ Rib flaring can also persist or even become more noticeable after the depression itself is corrected, since the lower ribs sometimes angle outward more prominently once the sternum is pushed forward.

The Surprising Role of Fat in Vacuum Bell Results

Vacuum bell therapy is a non-surgical option that uses suction applied to the chest surface to gradually lift the sternum outward. Before-and-after pictures of vacuum bell patients often look impressively improved, and for years the assumption was that the visual improvement came primarily from the breastbone physically moving forward. Recent research has complicated that picture in an interesting way.

A study using fat-selective MRI found that vacuum bell therapy caused a marked increase in subcutaneous fat at the site of the depression, with a median gain of about 6.5 mm of adipose tissue at the deformity site compared to only 0.5 mm at a reference point on the side of the chest.¹⁸ A separate study confirmed this finding: anterior chest wall fat thickness increased in about 96% of patients treated with vacuum bell, rising from an average of 4 mm to nearly 8 mm. The improvement in the visible surface depression was roughly 4 mm, while the actual skeletal change was only about 1.4 mm, meaning the cosmetic improvement was largely driven by fat buildup rather than bone repositioning.¹⁹

This has real implications for interpreting before-and-after photographs of vacuum bell treatment. The chest genuinely looks better in many cases, but the mechanism is a dual one involving both a small skeletal shift and a more substantial layer of fat filling in the depression. The visual result is real, but if the vacuum bell is discontinued, the fat redistribution may not persist permanently. Anyone comparing vacuum bell results in photos should keep in mind that the impressive surface changes do not necessarily reflect an equivalent change in the underlying skeleton.

Tips for Taking Useful Photographs

If you are trying to photograph your own or your child’s pectus excavatum for a medical appointment or to track changes over time, a few practical details make a big difference. Consistent positioning is the most important factor: stand in the same spot relative to the same light source each time. Side-profile shots (with arms relaxed at the sides, not raised) best show the depth of the depression. Front-on shots capture asymmetry and rib flaring. An overhead shot taken while lying flat can reveal the contour of the depression against the plane of the surrounding chest wall.

Natural lighting from a window to one side provides enough shadow to show the depth without washing out detail. Flash photography tends to flatten the appearance of the depression and can make mild or moderate cases nearly invisible in photos. Including a ruler or a coin taped to the skin near the deepest point gives a scale reference that clinicians find helpful, since it is otherwise difficult to judge true depth from a photograph alone. Taking photos in the same position every few months builds a record that is surprisingly useful at clinical visits, particularly during adolescence when the deformity may be changing rapidly.