It is a deformity marked by a sharp posterior curve of the body of sternum sweeping down from the manubrium which becomes deepest just before its junction with the xiphoid. The lower costal cartilages are also angled posteriorly towards the spine. The condition presents in the majority in first year of life and is 3 times more common in males. Genetic factors are active in its causation as 37% patients have family history of chest wall deformities. 15% patients have associated scoliosis. Most severe deformities occur in association with Marfan's syndrome. Congenital heart disease and asthma are occasional associations. Most surgeons document an increased activity and stamina in patients following surgical correction of the deformity. This is attributed to elimination of cardiopulmonary compromise which is believed to exist in these patients. However this is not clearly proven on laboratory cardiopulmonary assessment by many investigators.

Early surgery is recommended in this condition to prevent the development of symptoms or to correct those already present, to correct the orthopedic and cosmetic effect of this deformity and to correct the psychological response to the deformity. Operation is performed between 1 & 3 years of age or even before 1 year if the deformity is reliably noted to be progressive. Surgery usually includes resection of rib cartilage, lifting the sternum, sternal osteotomy and fixation with implants. Implants used are generally K-wires, but fixation with a steel plate as advised by Paltia is quite popular at present. Recently Poly Glycolic Acid (PGA) and Poly - L - Lactic Acid (PLLA) bio-degradable plates have also been used. Complications following surgical repair are limited. Recurrence of deformity is expected in 15%.

It is protrusion deformity of the chest that occurs less frequently than excavatum and consists of a spectrum of deformities with unilateral or bilateral involvement of costal cartilage and superior or inferior protrusion of sternum. It can also exist as a 'mixed deformity with depression of cartilages on one side and protrusion on the opposite side with sternal rotation. The most common clinical presentation is a protrusion of sternal body with symmetric protrusion of lower costal cartilages (chondrogladiolar). In a majority of patients, the deformity appears in late childhood or adolescence with only a third of patients presenting with this condition at birth. It is thrice as common in males then in females. 15% children have associated scoliosis and Marfan's syndrome must be looked for in patients with severe deformity. There is no cardiopulmonary compromise demonstrable in these patients. Consideration for surgery is purely cosmetic and psychosocial.

Generally, surgery should be deferred till maturity. Operative correction involves subperichondrial resection of costal cartilages and sternal osteotomy. Complications are low and recurrences rare. Recurrence is limited to patients who have undergone a unilateral resection of costal cartilages or an inadequate resection of the deformity.

1. Asp K, Sulamaa M. On rare congenital deformities of thoracic wall. Acta Chir Scand 1959, 118: 392.
2. Beiser GD. Epstein SE, Stampfer M. Impairment of cardiac function in patients with pectus exacavatum with improvement after operative correction. N Engl J Med 1972, 287: 267.
3. Haller JA, Peters GN, Mazur D. Pectus excavatum : A 20 year surgical experience. J Thorac Cardiovasc surg 1970, 60: 375.
4. Lester CW. The surgical treatment of funnel chest. Ann surg 1946, 123: 1003.
5. Lester CW. Pigeon breast (pectus carinatum) and other protrusion deformities of the chest of develop mental origin. Ann surg 1953, 137: 482.
6. Paltia V, Parkkulainen VJ, Sulamma M. Operative Technique in funnel chest : Experience in 81 cases. Acta Chir Scand 1958/59, 116: 990.
7. Pickard LR, Tepas JJ, Shermata DW. Pectus carinatum: Results of surgical therapy. J Pediatr Surg 1979, 14:228.
8. Ravitch MM. Congenital defects of the chest wall and operative correction. Philadelphia, WB Saunders Co, 1977.
9. Shambergr RC, Welch KJ. Surgical repair of pectus excavatum. J Pediatr surg 1988, 23:615.
10. Shemberger RC, Welch KJ. Surgical correction of pectus carinatum. J Pediatr surg 1987, 22:48.
11. Welch KJ, Vos A. surgical correction of pectus carinatum (pigeon breast) J pediatr surg 1973, 8:659.