Determinants of Successful Pectus Carinatum Bracing: A Narrative Review

Abstract

Pectus carinatum (PC) is a chest wall deformity characterized by the anterior projection of the sternum that typically manifests in adolescence and may result in notable psychosocial morbidity despite insubstantial physiological signs. Historically considered less common than pectus excavatum, recent trends suggest that PC may be underdiagnosed, with increasing recognition and referrals to specialized pectus clinics. The main objective of this review is to provide a comprehensive understanding of the role of bracing, particularly the dynamic compression system, in the non-surgical management of PC. Traditionally, a surgical condition, PC is currently being treated more often with dynamic compression bracing, especially in younger, more flexible chest wall patients. This evidence-based review aims to analyze the optimal time to start bracing, using current literature on anatomical correction, compliance, and psychosocial outcomes. It is known that early treatment, ideally at the pre-pubertal or early pubertal stage, can result in better-bracing success, shorter treatment time, and more favorable cosmetic and emotional outcomes. The key determinants of treatment effectiveness are age, severity of deformity at the start of treatment, pressure limits, brace type, and patient cooperation. Further, physiotherapy and psychosocial support have been found to have a positive impact on adherence and quality of life. However, there is no standard protocol for bracing. As outlined in this review, the proposed solution is a patient-centered, multidisciplinary approach that combines clinical timing and personalized care to develop feasible guidelines for effective and timely bracing in adolescents with pectus carinatum.

INTRODUCTION

Pectus carinatum (PC) is a congenital chest wall deformity characterized by the anterior protrusion of the sternum and costal cartilage, commonly known as “pigeon chest.” It represents variants that differ in anatomy and severity, with the most prevalent being the chondrogladiolar variant, which features anterior protrusion of the sternum body and attached costal cartilage. Other variants include the chondromanubrial variant, which predominantly involves protrusions of the manubrium. Other variants of pectus deformity include pectus arcuatum, also known as the Currarino–Silverman syndrome. Although this deformity is pathologically distinct from pectus carinatum, it is included here because some physicians may mistakenly refer to it as pectus carinatum or even pectus excavatum due to the anterior chest wall prominence. Pectus arcuatum is characterized by a short, broad sternum, a pronounced outward sternomanubrial angulation, and often a mild to moderate depression of the lower third of the sternum. Recognizing this rare variant is important, as its anatomical features and management approach differ significantly from those of pectus carinatum.[1,2,3]

Historically, PC accounts for about 5% to 10% of all chest wall deformities, with an incidence rate of approximately 1 in 1500 individuals, typically becoming prominent during puberty.[4] However, recent studies suggest that the prevalence may be closer to 1 in 1000 children, with a strong male predominance and a peak onset during adolescence when chest wall pliability is highest and psychosocial impacts are most pronounced.[5] While primarily a cosmetic concern for many, with reduced exercise tolerance and chest pain reported by some individuals, the impact on chest wall mechanics and pulmonary function is not thoroughly understood.

The introduction of specialized pectus clinics has led to an increasing number of cases being managed, with some centers even reporting more cases of PC than pectus excavatum (PE), suggesting that the true incidence of PC may be underestimated.[6,7] The availability of various treatment options has also contributed to the rise in referrals to specialized centers.[8] Treatment for PC has evolved significantly over the years. Previously, invasive surgical approaches such as the classic Ravitch surgery and its modified versions were the standard. However, with the introduction of bar insertion by Dr. Donald Nuss in 1998 for pectus excavatum correction, followed by Dr. Horacio Abramson’s modifications to correct pectus carinatum in 2002, the minimally invasive procedures such as minimally invasive repair of pectus excavatum/carinatum emerged. Currently, the most noninvasive approach is bracing, which has gained increasing acceptance for many cases, particularly for mild to moderate and flexible deformities. A 2022 UK study involving 249 adolescents reported that early bracing using high-pressure dynamic compression systems (DCS) led to a sustained correction in >95% of cases within 6 to 8 months.[9]

Custom 3D-printed bivalve orthoses have also shown improved compliance when introduced earlier in the disease progression, reinforcing the critical role of timing in non-surgical management.[10] Recent evidence highlights the importance of early intervention, particularly during pre-pubertal or early pubertal stages, as it enhances cosmetic outcomes and adherence to treatment. Delayed intervention can lead to reduced chest-wall flexibility and longer treatment durations, emphasizing the need for individualized approaches based on the severity and stage of the deformity. Despite promising results, challenges remain in determining the optimal timing, intensity, and duration of bracing for best outcomes.

TREATMENT SELECTION: BRACING VERSUS SURGERY

Pectus carinatum can be treated through bracing and surgical correction. Nevertheless, they are characterized by different levels of invasiveness, potential risks and advantages, and suitability for various patient populations. Bracing as a non-surgical method is usually the first line of treatment for mild to moderate pectus carinatum, particularly in younger patients with skeletal immaturity.[11] More recent research has given increasing credence to bracing as the first-line treatment, especially in younger patients (i.e., prepubertal and early pubertal patients) with more malleable chest walls, which are easier to remodel. In the study by Sargent et al., where 185 patients underwent bracing, it was found that as bracing was continued regularly and adjusted to the anatomical and biomechanical profile of the individual, the pressure needed to correct the deformity would gradually reduce over time, which was a good indication of physiological remodeling.[12] In a retrospective study of 767 pediatric patients by Shang et al., 644 (84%) had good outcomes with orthotic bracing alone. However, the best results were found in those aged <15 years old, as they have more pliable chest walls. The paper also noted that an adequate brace-wearing schedule, which involved wearing the brace for >12 hours a day, was crucial in ensuring effective correction.[13] Surgical intervention is typically reserved for patients with severe pectus carinatum, those who have not responded to bracing, or those who prefer a more definitive correction.[14] Although bracing can be highly effective, surgery remains necessary for cases where bracing fails or for more severe deformities. Of the 123 cases that did not respond adequately to bracing, Shang et al. found that 108 patients underwent minimally invasive surgical procedures. The recovery times were short, around 7 days, and no significant complications were reported in any of the surgical patients.[13] This highlights the role of surgery as a reliable treatment option. Ultimately, the decision between bracing and surgical correction should be guided by a comprehensive clinical evaluation conducted by a qualified healthcare professional. This includes imaging studies and a detailed discussion of the patient’s individual clinical profile, treatment goals, and personal preferences to determine the most appropriate therapeutic approach.

BRACING OPTIONS FOR PECTUS CARINATUM

Understanding that the chest wall can remodel the shape by applying continuous pressure has allowed physicians to develop successful management options and to progress from invasive approaches to noninvasive bracing based on multiple patient factors. While bracing for pectus carinatum has existed since the 1970s, early braces were static and less sophisticated.[15,16,17,18] DCS signify a substantial advancement in the nonoperative management of pectus carinatum. These devices offer a more customized and adaptable approach than traditional static braces [Figure 1]. The introduction of the DCS marked a conceptual shift. In 2008, Martinez-Ferro et al. proposed a pressure-controlled bracing system. This system is custom-fitted with incorporated adjustable components and a pressure docking station, enabling personalized treatment and monitoring.[7] DCSs possess several distinctive features compared to traditional braces, which are typically non-custom, fixed-pressure thoracic belt commonly available as off-the-shelf appliance. These differences are summarized in Table 1.

Figure 1.

Dynamic compression braces used for nonsurgical correction of pectus carinatum at the Pectus Clinic, King Fahd Hospital of the University, Al Khobar, Saudi Arabia. (a) The brace is a custom-made Dynamic Compression System equipped with an integrated pressure gauge, while (b) the other brace is a similar system without a pressure gauge. Both devices are designed to deliver gradual anterior chest wall compression and include adjustable front and back plates to allow individualized pressure modulation throughout treatment

Table 1.

Comparison between the dynamic compression device (dynamic compression system) and the traditional braces

Dynamic compression device	Traditional braces
Custom-made brace	Standard-size brace
Precise pressure control via an integrated docking station	Apply a uniform, generic pressure
Enables gradual correction with minimal discomfort	Correction is less controlled, potentially causing discomfort
Provides objective feedback	Lacks objective monitoring
Designed for comfort, improving patient’s compliance and adherence to treatment protocol	Simpler but less comfortable, potentially reducing patient compliance and adherence to treatment protocol

DCS allows for precise adjustments and monitoring of the applied pressure through an integrated pressure docking station, enabling personalized treatment, in contrast to the more uniform, generic pressure typically applied by traditional braces. The pressure of initial correction (PIC) is an essential parameter in managing pectus carinatum and dynamic compression bracing. PIC refers to the external pressure, measured in pounds per square inch (psi), initially required to correct the chest wall deformity. This metric is used to assess the severity and flexibility of pectus carinatum, guiding treatment decisions. Earlier studies by Martinez-Ferro et al. suggested using the dynamic brace in patients with relatively flexible chest patients with PIC values between 5.0 and 7.5 psi with an average treatment time of 14 months.[7] Studies therafter have shown successful treatment for patients with higher PIC reaching 10–14 psi but with prolonged treatment time; patients with a PIC >14 psi were advised to undergo surgical correction, as brace treatment was considered to not offer benefit for these patients.[19,20,21]

The adjustable pressure in DCSs facilitates a controlled and gradual correction process, minimizing discomfort and potential complications. In addition, the presence of a pressure docking station in DCSs provides objective feedback on pressure force to the patient, aiding in ensuring patient compliance, an aspect not offered by traditional braces. Finally, controlling the pressure in dynamic compression devices can help improve patient comfort, potentially enhancing tolerance and adherence to the treatment protocol.[22] In contrast, traditional braces may be simpler and less expensive but potentially less effective, particularly in cases of moderate to severe pectus carinatum or in patients with less compliant chest walls, as these traditional braces rely on consistent pressure over time, providing a less targeted approach to correction. Frediani et al.[23] demonstrated that when personalized modeling of bracing protocols is used, the effectiveness of treatment significantly improves, aligning with findings from Sargent et al.[12] These advances have contributed to the growing preference for bracing, especially in children, as it preserves the potential for chest wall growth and avoids the complications associated with surgery.

CRITERIA FOR SUCCESSFUL TREATMENT

Several factors play a crucial role in bracing success for pectus carinatum patients [Table 2]. Patient age is a significant factor, with younger patients, particularly adolescents, being more responsive to bracing due to their more malleable chest walls. Clinical evidence consistently shows that initiating bracing between the ages of 10 and 15 yields the most effective results due to the flexibility of the chest wall during adolescence.[24] The degree of skeletal maturity also influences treatment success, which tends to decrease as patients grow older. Consistent and prolonged brace wear, often requiring several hours of daily use, is essential for optimal outcomes.[9,25] Patients who adhere to the prescribed bracing protocol are more likely to experience significant improvement. A well-designed brace custom-fitted to the patient’s anatomy is critical for effective treatment. The brace should provide adequate pressure on the protruding sternum, while ensuring comfort and minimizing skin irritation. The severity of the deformity is another factor, with patients having less severe pectus carinatum deformities generally responding better to bracing than those with more pronounced protrusions. A study by Emil et al. reported that the initial correction pressure does not predict bracing failure alone. Instead, factors such as older patient age, chest wall asymmetry, and a smaller initial drop in correction pressure were associated with treatment failure or prolonged bracing duration.[26] Certain underlying medical conditions, such as connective tissue disorders, can also influence the effectiveness of bracing. Finally, patient motivation, psychological support, and the experience and expertise of the healthcare team, including a multidisciplinary approach, can contribute to successful treatment outcomes.[27]

Table 2.

Factors influencing successful bracing in pectus carinatum

Factor	Impact on bracing outcome
Patient age	Prepubertal and early pubertal patients respond more favorably due to greater chest wall pliability
Skeletal maturity	Lower skeletal maturity correlates with higher success; ossification reduces flexibility
Duration of brace wear	Longer and more consistent daily use, up to 23 h, improves outcomes
Brace fit and design	Custom-fitted braces ensure targeted pressure and greater comfort, enhancing compliance
Severity of deformity	Milder and symmetrical deformities tend to respond more favorably to bracing
Underlying conditions	Connective tissue disorders may increase chest wall malleability and improve initial correction but are associated with a higher risk of recurrence
Patient motivation	High motivation improves compliance and treatment adherence
Psychological support	Encouragement and emotional support contribute to sustained use and patient satisfaction
Multidisciplinary team	Expertise from multiple specialties optimizes care and long-term outcomes

BRACING PROTOCOL

Although the overall principle of dynamic bracing is to apply consistent pressure to the protruding sternum, the details of the protocol may vary between patients, depending on the extent of deformity and the type of brace being used. A complete assessment by a qualified physician is needed to determine the best protocol that suits a specific patient. As a rule, bracing protocols are characterized by wearing the brace for a certain number of hours a day, usually 8-14 or even 23 hours in some cases.[27] Treatment can take several months to several years, depending on the patient’s age, the severity of the deformity, and improvement rate.[28,29] Some protocols may involve gradually increasing brace wear time, starting with a few hours per day and gradually increasing the duration, as tolerated. Others may recommend continuous wear for a specified period, followed by a reduction in wear time as the deformity corrects.[30] Regular follow-up appointments are essential to monitor progress, adjust the brace pressure, and address any complications or concerns.

ROLE OF PHYSIOTHERAPY

Incorporating physiotherapy alongside compression brace treatment enhances outcomes for individuals with pectus carinatum. Alaca et al. examined the effects of adding a physiotherapy regimen to standard bracing therapy. The findings revealed that the group receiving both brace treatment and physiotherapy demonstrated more significant improvements in chest wall measurements, posture, perceptions of the deformity, quality of life, and treatment satisfaction than the group receiving brace treatment alone. The authors suggest that implementing a “proper cardiopulmonary and musculoskeletal exercise program” in conjunction with bracing can benefit patients with pectus carinatum. This combined approach may address not only the physical deformity but also the associated postural distortions and potential scoliosis.[31] While the study by Alaca et al.[31] highlights the benefits of integrating physiotherapy into pectus carinatum bracing protocols, there is limited published research specifically investigating this combined approach. Many studies have focused on bracing outcomes or surgical techniques with less emphasis on the role of adjunctive physiotherapy. Exercise may be beneficial in improving the chest wall appearance and correcting postural deformities, but more rigorous research is needed to understand its efficacy and fully establish optimal protocols.[32]

QUALITY OF LIFE IMPROVEMENTS

The extent of psychosocial and quality of life improvements associated with pectus carinatum can vary depending on individual patient factors, such as the initial severity of the deformity, the patient’s age and personality, and the level of support received from family, friends, and healthcare professionals. Adopting a holistic approach that addresses physical and psychological aspects of chest wall deformity can optimize treatment outcomes and enhance overall patient well-being. Despite the significant psychological and quality-of-life impacts of pectus carinatum, successful bracing interventions have been linked to substantial enhancements in these important domains. Studies and clinical observations indicate that correcting pectus carinatum through bracing or surgical intervention leads to marked enhancements in body image.[33,34] As the visible deformity diminishes, patients often report feeling more comfortable and confident in their appearance, which can be particularly impactful during the critical developmental period of adolescence. Furthermore, research has shown that a high proportion of pectus carinatum patients experienced anxiety or depression related to their chest condition prior to bracing. However, these psychological symptoms significantly decreased following successful treatment.[35] Correcting the physical deformity through bracing also improves self-esteem and confidence. Patients may feel more willing to engage in social activities and situations where their chest is exposed.[36] In some cases, pectus carinatum can also cause discomfort when lying down, affecting sleep quality; successful bracing can alleviate this discomfort and improve sleep, resulting in better rest and quality of life. High patient satisfaction rates have been reported with brace treatment for pectus carinatum, indicating that the positive changes in appearance, psychosocial well-being, and quality of life achieved through successful bracing are highly valued by patients.[37]

CONCLUSION

Bracing, particularly with dynamic compression systems, provides a safe and effective alternative to surgery when applied to patients with flexible chest walls and mild to moderate deformities. The success of bracing depends upon multiple factors, including patient selection, adherence to prescribed wear protocols, and individualized adjustment of corrective pressure. Adjunctive physiotherapy and structured follow-up can enhance therapeutic outcomes and address associated postural and psychosocial concerns. While surgical correction remains necessary for selected cases with severe deformities or poor response to conservative therapy, this review emphasizes the importance of an evidence-based, multidisciplinary approach in guiding treatment decisions.

Peer review

This article was peer-reviewed by three independent and anonymous reviewers.

Ethical considerations

Not applicable

Data availability statement

Data sharing is not applicable for this article, as no new data were created or analyzed.

Author contributions

Z.A. was solely responsible for conceptualization, methodology, writing–original draft, preparation, review and editing, and has read and agreed to the published version of the manuscript.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.