When a child’s height rapidly increases during adolescence, the center of their chest may begin to look noticeably sunken or protrude outward. Rather than dismissing it as a temporary quirk in body shape, parents should evaluate whether it stems from a structural chest wall deformity.
Pectus excavatum, in which the front of the chest caves inward, and pectus carinatum, in which it pushes outward, are the two most common chest wall deformities. Although they can appear in early childhood, they often become far more pronounced during adolescent growth spurts.
However, a visible difference in chest shape does not automatically mean treatment is necessary. Clinicians decide on an intervention by evaluating the severity of the deformity, physical symptoms, growth trajectory, and the degree of psychological stress the child experiences regarding their body image.
“Because chest wall deformities are typically detected and treated during the growth years, guardians play a crucial role,” said Prof. Kim Bong-jun of the Department of Cardiovascular and Thoracic Surgery at National Health Insurance Service (NHIS) Ilsan Hospital. He advised families to consult a specialist early if a child's chest contour begins to change, helping determine if and when treatment should begin.
Sinking vs. Protruding: Symptoms and Psychological Impact
Pectus excavatum occurs when the sternum and adjacent cartilage collapse inward toward the spine. Pectus carinatum is the exact opposite, causing the sternum and surrounding chest wall to push forward.
While the exact causes remain fully unclarified, both conditions are believed to stem from abnormal development of the costal cartilage connecting the ribs to the sternum during growth.
Symptoms vary widely among patients. Many experience no physical discomfort beyond the visible asymmetry. However, severe pectus excavatum can compress the heart and lungs, leading to shortness of breath during exercise, chest tightness, or a sensation of a racing heartbeat.
The psychological burden can also be substantial. Many adolescents with chest wall deformities avoid swimming, refrain from changing in locker rooms, or refuse to wear thin clothing out of self-consciousness. Recent international clinical guidelines recommend evaluating candidates for treatment by weighing physical impairment alongside appearance-related stress and overall quality of life.
Non-Surgical Compression for Pectus Carinatum
For pectus carinatum, clinicians take advantage of the chest wall’s flexibility during growth years by prescribing a custom compression brace that gradually presses down the protruding sternum.
In a 2024 survey of medical institutions affiliated with the Chest Wall International Group (CWIG), 93% of respondents identified compression bracing as their first-line treatment for pectus carinatum. However, daily wear duration and total treatment length vary depending on the patient's condition and institutional protocol.
At NHIS Ilsan Hospital, brace therapy typically spans 7 to 9 months, requiring patients to wear the device consistently for at least 12 hours a day.
Success heavily depends on patient compliance. Because wearing a rigid brace for half the day presents a challenge for elementary and middle school students, starting treatment solely based on a guardian's wish can lead to poor compliance and disappointing outcomes. Families should discuss whether the child understands the treatment and is personally committed to wearing the device as instructed.
Surgical Realignment for Pectus Excavatum: The Nuss Procedure
Not all patients with pectus excavatum require surgery. Surgical intervention is reserved for cases where diagnostic imaging reveals significant sternal depression, cardiac compression, or clear physical symptoms. In select patients with flexible chest walls, non-surgical suction devices known as vacuum bells may be used to gradually lift the sunken sternum.
When surgery is required, the Nuss procedure remains the standard approach. Surgeons make small incisions on both sides of the chest to insert curved metal bars beneath the sternum, pushing the sunken bone outward into a natural position.
Depending on the patient's anatomy, NHIS Ilsan Hospital utilizes three to four metal bars to maximize stability and correct chest asymmetry. While effective, the procedure requires general anesthesia, involves postoperative pain, and requires a second surgery years later to remove the metal hardware once the chest wall has reshaped.
Determining the Right Age for Treatment
The optimal timing for intervention varies depending on whether the diagnosis is pectus excavatum or pectus carinatum, as well as the degree of deformity.
Clinicians at NHIS Ilsan Hospital often evaluate patients for treatment from late elementary school through middle school to maximize corrective effectiveness and minimize recurrence. If the deformity is severe, treatment may begin earlier, and adult interventions remain possible as well.
Because there is no universal "ideal age" for surgery or bracing, timing must be tailored to the individual. Above all, guardians should focus on the child's lived experience—monitoring whether they experience physical discomfort during exercise or significant distress over their appearance.
“When pediatric patients and their guardians fully understand the condition and navigate the treatment process together, they can achieve excellent results,” said Prof. Kim. He advised parents to watch for worsening asymmetry or depression during growth spurts and seek a specialist’s evaluation if the child expresses physical or emotional discomfort.
