1. Z-Type Pattern Pectus Excavatum/Carinatum in A Case of Noonan Syndrome
Maria Grazia Sacco-Casamassima, MD, Seth D. Goldstein, MD, Margaret Birdsong, CRNP, Kimberly H. McIltrot, DNP, Fizan Abdullah, MD, PhD, Paul M. Colombani, MD, MBA 
The Annals of Thoracic Surgery 
Volume 99, Issue 5, Pages (May 2015)
DOI: /j.athoracsur
Copyright © 2015 The Society of Thoracic Surgeons Terms and Conditions

2. Fig 1 Preoperative appearance of the chest wall.
The Annals of Thoracic Surgery  , DOI: ( /j.athoracsur )
Copyright © 2015 The Society of Thoracic Surgeons Terms and Conditions

3. Fig 2
(A and B) Thoracic magnetic resonance images showing extreme rotation of the sternum and Z-pattern excavatum/carinatum deformity.
The Annals of Thoracic Surgery  , DOI: ( /j.athoracsur )
Copyright © 2015 The Society of Thoracic Surgeons Terms and Conditions

4. Fig 3
(A) Sternum was rotated approximately 130 degrees; left costal cartilages lay beneath it. To elevate left sternocostal margin and derotate sternum, multiple linear and wedge incisions were performed at level of left depressed cartilages, and 2 short segments of costal cartilage were removed on this side from the third to seventh costal arches, 1 close to sternum and another close to bony rib. An anterior wedge osteotomy was performed just below sternal-manubrial junction. Sternum was thus completely derotated and elevated in neutral position. Carinatum deformity on right side was corrected by resecting protruding cartilages from third to seventh costal arches. Two precurved 10-inch bars were placed and stabilized with lateral stabilizers. Retrosternal drain was placed under sternum. (B) Reconfiguration of thorax after placement of retrosternal bar.
The Annals of Thoracic Surgery  , DOI: ( /j.athoracsur )
Copyright © 2015 The Society of Thoracic Surgeons Terms and Conditions

5. Fig 4 Postoperative cosmetic appearance.
The Annals of Thoracic Surgery  , DOI: ( /j.athoracsur )
Copyright © 2015 The Society of Thoracic Surgeons Terms and Conditions