Pectus excavatum is a developmental issue with the chest in which the sternum or breastbone caves inward and creates a sunken appearance. It is also known as cobbler’s chest or funnel chest.

Pectus excavatum is the most common congenital anomaly of the chest wall in children.

It may become evident at birth or later in life as a person grows into adolescence.

This article looks at the symptoms, causes, and risk factors of pectus excavatum, as well as diagnosis, treatment options, and outlook.

An ultrasound scan in the womb, when a baby can develop pectus excavatumShare on Pinterest
Science Photo Library – IAN HOOTON/Getty Images

Pectus excavatum is an anomaly of the chest wall in which the breastbone grows inward during the embryologic phase of development.

Usually, as the chest wall grows around the 35th day of gestation, the cartilage that connects the ribs flattens out so the ribs can easily fuse with the breastbone.

In people with pectus excavatum, the breastbone fails to fuse normally and presses inwards. This causes a sunken appearance at the point where the ribs connect to the breastbone.

The condition may be more prominent on one or both sides of the chest.

According to a 2016 article, pectus excavatum accounts for 90% of all chest wall abnormalities and affects 1 in 300–400 live births.

Pectus excavatum is a progressive condition that can worsen with age.

A distinctive feature of pectus excavatum is a depression of the chest. This can make a person have slouched, forward-facing shoulders.

Other physical features may include a curved spine, flared ribs, and a protruding abdomen. A doctor will perform a physical examination of the chest to see if it pushes inward.

A person with pectus excavatum may have other symptoms, such as:

Cases of pectus excavatum can range from mild and asymptomatic to severe. Mild cases may be hard to notice, showing little or no symptoms. Severe cases may cause a hollow depression in the chest wall.

In a mild case of pectus excavatum, a child can live their life without the condition affecting day-to-day activities.

However, if complications from pectus excavatum impair cardiac or breathing functions, a doctor may recommend surgery to ease distress and improve quality of life.

Health experts recommend that people with mild pectus excavatum still contact a doctor for clinical assessment and diagnosis, noting that even a flat, wide chest can compress the heart.

Healthcare professionals do not know what exactly causes the condition.

However, they believe it happens when the ribs and cartilage grow abnormally, resulting in the posterior displacement of the breastbone.

This condition occurs during the developmental phase of an embryo.

While doctors do not know the main cause of pectus excavatum, they have identified some factors that can heighten a person’s risk of the condition.

  • Sex: Male infants are up to five times more likely to develop pectus excavatum than females. However, a study in the Journal of Osteopathic Medicine notes that doctors may miss the condition in people assigned female at birth due to breast tissue disguising it.
  • Family history: Roughly 43% of people with pectus excavatum have a family history of the condition, but scientists have not been able to detect the specific gene responsible.

A doctor can recommend a combination of any of the following tests to make a diagnosis:

Thoracic imaging

Thoracic imaging, such as an X-ray, CT scan, or MRI scan, can help a doctor calculate the Haller index.

The Haller index is a standardized measurement to estimate the severity of curvature of the chest cage. Healthcare professionals calculate it by dividing the chest width by the distance between the breastbone and spine.

A Haller index score of 2.5 to 2.7 is considered standard, while an index of 3.25 or greater is severe.


An electrocardiogram (EKG) records the heart’s electrical activity.

People with pectus excavatum may have an abnormal heart rhythm, which would appear on an ECG.


An echocardiogram detects abnormalities in the heart structure using ultrasound.

The echo evaluates the function or movement of the heart vessels and valves and can detect abnormalities in those with pectus excavatum.

Blood analysis

People with pectus excavatum may have elevated levels of lactate dehydrogenase (LDH) in their blood.

This increase may be due to internal organ compression.

However, elevated LDH levels can occur with other conditions, so a doctor will need more information to diagnose pectus excavatum.

Pulmonary function test

It is common for people with pectus excavatum to experience restrictive lung function. This is when the lungs cannot hold as much air.

Older adults with pectus excavatum may also have obstructive lung disease, which is when something blocks the airways.

Either of these issues will show up on a pulmonary function test.

The following complications are usually associated with pectus excavatum:

  • Heart problems: Pectus excavatum can cause the breastbone and surrounding bony structures to move inward, pushing the heart further to the left side of the chest. This displacement can compress the underlying right side of the heart, leading to right ventricular dysfunction.
  • Breathing problems: Pectus excavatum can exert pressure on the lungs, causing shortness of breath.
  • Problems with self-image: Because the condition can affect a person’s appearance and posture, some people may find that pectus excavatum causes low self-esteem and problems with self-image. However, a 2018 study found that body image and self-esteem improved significantly in pectus excavatum patients after surgery.

Some children with pectus excavatum can have other underlying medical conditions. Examples include:

A doctor will evaluate a person’s physical appearance and symptoms to determine the severity of the condition and choose the most suitable treatment option.

A doctor may recommend surgery if a person’s symptoms are causing cosmetic concerns related to appearance or other health complications that affect daily life.

Research from 2016 suggests that a person may be eligible for surgery if they meet any two of the following criteria:

  • a Haller index score greater than 3.25
  • severe and progressive deformity with associated symptoms
  • cardiology tests showing cardiac compression or displacement affecting heart function
  • pulmonary function tests showing restrictive or obstructive breathing
  • previous failed pectus excavatum repair surgery

A pediatric or cardiothoracic surgeon — a doctor specializing in operating on the heart, lungs, and other structures in the thoracic cavity — can perform this surgery.

Doctors usually wait until a child has crossed their first major pediatric growth spurt. This is generally between the ages of 10–15 years when a child reaches mid-adolescence. Additional evidence suggests that adults can have a successful pectus repair surgery too.

Surgery can be minimally invasive or extensive and may include the following procedures.

The Nuss procedure

This procedure is minimally invasive and is usually the first line of surgical intervention.

A surgeon will make two small incisions just below the nipples and a third one to guide the insertion of the concave metal bar with the aid of a tiny camera.

The surgeon will place the bar directly behind the breastbone at the point of depression so that the metal bar elevates and supports it.

The doctor may remove the metal bar after 2–3 years once the chest has achieved its desired shape. It is suitable for children and adolescents.

The Ravitch procedure

The Ravitch procedure is a more invasive procedure in which a surgeon makes a horizontal incision to open the chest cavity and reposition the breastbone.

The surgeon will then use tiny screws and a metal plate to hold the breastbone to attain an optimal position.

It is suitable for older adults and people with asymmetric deformities.

Pectus repair surgery can benefit people with mild to severe pectus excavatum by improving self-esteem and cardiopulmonary function. Both surgical procedures are safe and offer high patient satisfaction rates.

The risks of pectus repair surgery may include:

Researchers have not found clear evidence that pectus excavatum affects life expectancy.

However, the British Lung Foundation notes that most children with the condition live their everyday life.

Surgery can improve the quality of life of people with severe symptoms, self-image concerns, or both.

Pectus excavatum is a congenital anomaly affecting the chest wall. It makes the breastbone push in rather than assume a flat position.

While some children with the condition may be asymptomatic, others may experience discomforting shortness of breath, chest pain, and self-esteem problems.

A doctor will evaluate a person’s condition and decide if surgery is the best option.

People who undergo pectus repair surgery have an excellent outlook because surgery can correct the condition and improve posture.