Chest Cage Deformities (Funnel Chest and Pigeon Chest)

Chest cage deformities are structural abnormalities that are congenital or develop over time. Among the most common types are funnel chest (pectus excavatum) and pigeon chest (pectus carinatum). These deformities may cause both aesthetic concerns and impairment in respiratory functions.

The question of what causes funnel chest is associated with structural and genetic factors. It is characterized by the inward collapse of the sternum and is usually noticed during childhood. In severe cases, it may put pressure on the heart and lungs, leading to symptoms such as shortness of breath, exercise intolerance, and palpitations.

The question of how pigeon chest is recognized is important in diagnosing this condition. It becomes evident with the forward protrusion of the sternum. It usually increases during adolescence and mostly manifests as aesthetic discomfort. Radiological imaging clarifies the diagnosis and guides the treatment process.

The question of how chest deformities are treated is answered with both surgical and non-surgical methods. The Nuss procedure stands out for funnel chest, while orthopedic braces and the Ravitch surgery are prominent for pigeon chest. The treatment decision is made through individual evaluation and requires a multidisciplinary approach.

What Are Chest Cage Deformities?

Chest cage deformities are structural anomalies that arise due to developmental differences in the sternum and ribs. The most common types are pectus excavatum (inward depression of the anterior chest wall) and pectus carinatum (forward protrusion). More rarely, asymmetric deformities and syndromic conditions are observed. While mild cases cause cosmetic concerns, advanced cases may affect respiratory and cardiac functions. Treatment may include follow-up, orthosis applications, or surgical correction.

What Are the Causes of These Deformities and Are They Genetic?

This is the issue that families are most curious about and sometimes unfairly blame themselves for. I often encounter questions such as “Did I do something wrong during pregnancy?” or “Did we lay the child down incorrectly?” First of all, please be reassured, this condition is not caused by something you did or did not do. Scientifically speaking, the root of the problem lies in the excessive and irregular growth of the cartilage parts of the ribs. These cartilages grow so rapidly and disproportionately that they either push the breastbone inward or bend it outward.

As for the genetic aspect, yes, there is a familial predisposition. When we examine the histories of the patients who come to our clinic in detail, we see that about one third have a similar condition in their family. Sometimes it may be an uncle, sometimes a cousin, and sometimes a grandfather who has a similar chest structure. However, this does not necessarily mean that there will always be genetic transmission.

In terms of frequency, Pectus Excavatum, or sunken chest, occurs in approximately one in every 300 to 400 births. This rate is much higher than that of Pectus Carinatum. It is more common in boys than in girls. It usually shows a mild sign during infancy, but the time when it truly says “I am here” is during adolescence, when bones grow rapidly. That is why we usually plan treatment according to this age group.

Can Pectus Deformity Be Corrected by Doing Sports or Gaining Weight?

This is the question my young patients ask me most often and perhaps the one whose answer they most want to hear. Especially boys believe that by going to the gym, lifting weights, or swimming they can fill the hollow in their chest or hide the protrusion. I wish my answer were “yes,” but the medical reality is a bit different.

Pectus deformities are entirely anatomical skeletal problems based on bone and cartilage. Doing sports is undoubtedly excellent for overall health. It improves posture and straightens the shoulders. Developing the chest muscles (pectoral muscles) may mask the deformity to some extent from the outside. However, no exercise program can pull an inwardly collapsed bone outward or push an outwardly protruding bone inward.

In fact, in patients with Pectus Excavatum, sometimes a paradox occurs: as the chest muscles enlarge, the hollow in the middle may appear deeper due to an optical illusion. Similarly, gaining or losing weight does not change the position of the bone. Therefore, when determining our treatment strategy, instead of distracting our patients, we must focus on realistic methods that provide mechanical correction. These methods may be surgical or, depending on the situation, non-surgical medical devices.

Which Symptoms Show Us That This Condition Is Serious?

It would be a major mistake to see these deformities merely as an “aesthetic defect.” Of course, the cosmetic aspect and the psychological trauma it creates are very important, and I will address that shortly. However, our primary concern is the condition of the vital organs inside the chest cage. Especially in patients with deep depressions of Pectus Excavatum, the bone we call the sternum exerts physical pressure on the heart and lungs just behind it.

This pressure may not be noticeable at rest. However, when the child runs, climbs stairs, or plays a football match, the increased oxygen demand of the body cannot be met. This is because the heart cannot fully fill and empty at its maximum capacity due to the pressure on it. The lungs, on the other hand, cannot expand.

The physiological complaints we frequently encounter in these patients are as follows:

• Getting tired quickly
• Shortness of breath
• Chest pain
• Palpitations
• Feeling of blockage
• Feeling of faintness

In addition, in thoracic surgery practice we evaluate these patients holistically. Because Pectus Excavatum may not occur alone. In a significant portion of our patients, we also observe spinal curvature, namely scoliosis. Sometimes problems in the heart valves, especially the mitral valve, may accompany it.

There is also a psychosocial dimension that is at least as important as physical health. Adolescence is the period when body perception is at its highest. We see young people who do not want to go swimming because of the deformity in their chest, who avoid changing clothes in locker rooms during physical education classes, who constantly wear loose T-shirts and stand hunched over. This situation may lead to introversion, lack of self-confidence, and serious depression. For us, when deciding on surgery, what the patient “feels in front of the mirror” is just as decisive a criterion as the tomography result.

Which Tests Do We Perform in the Diagnostic Process?

Making the diagnosis actually begins with a physical examination; when you enter, an experienced eye immediately recognizes the situation. However, an approximate judgment is not sufficient to decide on treatment, especially when planning surgery. In the light of science, we need measurable and objective data. Therefore, we apply a detailed diagnostic protocol.

Our first and most important step is imaging. In the past, chest X-rays were sufficient, but today Thoracic Computed Tomography (CT) is our map. With tomography, we take a cross-sectional image of the chest cage and perform very critical measurements.

The most popular of these measurements is the Haller Index. Simply put, we divide the widest transverse diameter of the chest cage by the narrowest distance between the sternum and the spine. In a normal person, this ratio is around 2.5. If this ratio is 3.25 or higher, it indicates a deformity severe enough to require surgical correction.

However, in recent years another criterion that has come to the forefront in the literature with contributions from Turkish physicians is the Correction Index. The Haller index may sometimes mislead us in patients with very wide chest cages. The Correction Index shows the true depth of the depression much more clearly regardless of chest width. When evaluating my patients, I try to make the most accurate decision by considering both indices.

Preoperative preparation does not end with tomography. We also add the following tests to our list:

• Echocardiography
• Pulmonary Function Test
• Blood tests
• Nickel allergy test

The nickel test is particularly critical. If we are going to perform a closed surgery and place a steel bar in your chest, we must know whether you have a metal allergy. In patients with allergies, we eliminate the risk by ordering special titanium bars.

To Whom Is Vacuum Bell Therapy, a Non-Surgical Solution, Applied?

Not every patient has to undergo surgery. The fundamental rule of medicine is first to do no harm and, if possible, to solve the problem with the least invasive method. The most effective conservative method developed for Pectus Excavatum, or sunken chest, is Vacuum Bell therapy.

You can think of this device simply as a silicone suction system that applies negative pressure to the chest wall. By removing the air inside with the help of a pump, it pulls the sunken sternum outward through vacuum effect. Especially in children whose chest cage has not yet lost its flexibility and in patients at the beginning of adolescence, it is an excellent option for mild and moderate deformities.

However, this treatment is not a “wear and forget” method; it requires serious discipline. According to our protocol, the use of the device is as follows:

• At least 4 hours of use per day
• At least 6 months of continuity
• Regular pressure control

I always tell my patients: “The success of this device depends entirely on your patience.” In adolescents who use the device regularly, we can see permanent improvements. However, if no improvement is achieved despite strict use for 6 months or if the patient’s chest wall has become very rigid, we begin to discuss surgical options. In addition, this device should be used very carefully in patients with heart disease or coagulation disorders.

How Is the Nuss Surgery, the Closed Method, Performed?

If surgery becomes inevitable, the method accepted as the “gold standard” worldwide and in our clinic today is the Nuss Procedure. This technique, developed by Donald Nuss in 1987, created a revolution in thoracic surgery. Unlike the open surgeries performed in the past, we do not make large incisions on the front of the chest or cut and remove bones.

We call this surgery “Minimally Invasive Pectus Repair.” Its logic is very similar to orthodontic treatment with braces. Just as braces gradually align the teeth, we support the breastbone from inside and bring it into the correct position.

The procedure is performed under general anesthesia. We make small incisions of about 2–3 centimeters on both sides of the chest, corresponding to the axillary line. Through these incisions, we enter with the help of a camera and create a safe tunnel passing above the heart and lungs and directly beneath the sternum.

We pass a C-shaped steel (or titanium) bar that we have pre-shaped according to the patient’s chest structure through this tunnel.

When we place the bar inside, the concave side of the bar faces upward. Then with a special instrument we rotate the bar 180 degrees around its axis. That moment is the most fascinating moment in the operating room. With the turning movement, the collapsed breastbone immediately rises outward and reaches the desired flat position. The result is seen instantly. We place stabilizers on the sides to prevent the bar from shifting and complete the procedure. The operation time is quite short and the risk of bleeding is minimal. The cosmetic results are excellent because the surgical scars remain hidden under the armpits.

Is Brace Treatment Effective for Pigeon Chest?

Our approach for patients with Pectus Carinatum, that is pigeon chest, is somewhat different. Here, surgery is not the first option we consider. This is because this deformity responds very well to pressure applied from the outside. Therefore, our main protocol in the treatment of Pectus Carinatum is Orthotic Brace (Bracing) therapy.

These braces are specially produced according to the patient’s body measurements. The logic is simple: applying controlled and continuous pressure from the outside to the protruding area to push the bone backward. Just like orthodontic braces straighten teeth, the brace reshapes the chest cage.

The success rate is above 90%, especially in patients during adolescence (ages 10–14). However, the key word here is “compliance.” Brace treatment requires patience. At the beginning of treatment, we ask the patient to wear the brace for longer hours each day, and as improvement begins this duration is gradually reduced.

Points to pay attention to during brace use are as follows:

• Skin hygiene
• Pressure adjustment
• Regular doctor follow-up

If the brace is tightened too much it may cause wounds on the skin, and if it is left too loose it will not treat the deformity. Therefore, we see the patient regularly and adjust the pressure of the brace. Usually within 1–2 years the chest cage completely takes its normal shape. If the patient is at a very advanced age and the chest cage is no longer flexible (rigid) or if brace treatment does not provide a response, then we may consider the closed surgery known as the Abramson technique or open surgical methods.

What Are Pain Management and the Recovery Process Like After Surgery?

The issue that my patients and their families fear most before surgery is pain. To be honest, we expect some degree of pain after Nuss surgery. This is because we push outward a bone structure and muscle group that has been collapsed inward for years. This is a significant mechanical change for the body. However, there is no need to worry, because thanks to modern pain management protocols offered by modern medicine, we overcome this process very comfortably.

The method we rely on most for postoperative pain control is Epidural Analgesia. With a very thin catheter placed in the lower back, we prevent the patient from feeling pain. Thanks to this method, the patient wakes up immediately after surgery but does not feel pain. In cases where epidural is not suitable, we use smart pumps called “Patient Controlled Analgesia” (PCA), where the patient presses a button to receive their own pain medication.

The average hospital stay is between 3 and 5 days. During this time we gradually reduce the pain and transition the patient to oral medications. When you return home, there will be some limitations in your movements for the first few weeks.

The restrictions during the recovery process are as follows:

• Not lying on the side
• Not lifting heavy objects
• Not bending the torso excessively
• Avoiding sudden movements

Usually our patients can return to school or desk work within 2 weeks. Walking is allowed and even encouraged. From the third month onward, they may begin sports such as swimming and running. However, we ask them to stay away for a while longer from contact sports such as boxing, wrestling, or intense football where there is a risk of trauma to the chest.

When Is the Bar Placed in the Chest Removed?

The metal bar we place during the Nuss surgery is not permanent in the body. The role of the bar is to act as a “mold” until the chest cage adapts to its new shape and the bones solidify in that position. According to standard protocols worldwide, this period is approximately 2.5 to 3 years.

During this period the bar remains inside, and after some time the patient no longer feels its presence. Many of my patients even do sports, swim, and continue their normal lives with the bar.

When the time is completed, the chest wall becomes hardened and capable of maintaining its new shape.

The bar removal procedure is much simpler than the initial surgery. It is usually performed as a day procedure. Through a small operation lasting about 30–45 minutes, the bar is removed through the small side incisions. After the bar is removed, the risk of recurrence of the deformity is extremely low. Nevertheless, we do not neglect to continue monitoring our patients for a while.

Frequently Asked Questions