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Dr. Barry Eppley

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Archive for the ‘rib removal’ Category

Subcostal Rib Removal Through a Tummy Tuck Approach

Saturday, August 26th, 2017


The ribs constitute the structural support for the trunk. It plays a vital role in how the lungs work and in the support and protection of many other vital organs. This statement applies to much of the upper ribcage but does not necessarily apply to every aspect of every rib throughout their full lengths around the chest and abdomen. As such, there is some latitude to remove or reduce selective rib areas for body contouring effects.

Rib removal, or what I prefer to call ribcage modification surgery, is most commonly associated with waistline reduction. This is specifically horizontal waistline reduction. This is accomplished by removal of the outer half of the posterior ribs 11 and 12 and sometimes part of rib 10 as well. But this is not the only rib area which can be modified.

On the front or anterior surface is the subcostal portion of the ribcage. This rib area is distinctly different from that of the back for reasons that are different than just body location alone. The subcostal rib cage is cartilaginous and not bony. It can cause aesthetic distraction by either having too much protrusion due to a bowing of the ribs or sits low causing a short vertical waistline. Like the lower ribs on the back, subcostal rib removal can also be done to reduce a bulge in the upper abdomen/lower chest wall or to vertically lengthen the waistline.

Subcostal rib removal can be done through either a direct incision over them or from below through a tummy tuck incision. Each approach has its own advantages and disadvantages. The direct incision, even though relatively small, still leaves a scar in a non-hidden area. It limits the zone of tissue trauma by dissecting directly down to it. But it remains for the highly motivated patient.

The other approach to subcostal rib reduction is through a tummy tuck incision. In theory this should be reserved for patients that are already having or want abdominal work…but this does not need to be the case. It can be done in patients who do not necessarily need a tummy tuck as a longer lower abdominal scar may be preferable to two smaller subcostal scars. The distance to the subcostal ribs is easier to access when a full tummy tuck is performed as the upper edge of the abdominal skin flap is closer to the target than when no lower abdominal tissue is removed.

Since the subcostal ribs are cartilage and not bone, they do not have to always be excised completely. They can be shaved down with a large scalp blade for reductions in their protrusions. The ribs can be made quite thin by sequential shaving reductions where they also become more flexible/weaker which has an additional effect on protrusion reduction.

Subcostal rib reduction is more challenging than posterior rib reduction due to scar considerations from the incisional access. Both the direct and tummy tuck approaches can be used to perform it. The effectiveness of either approach in reducing subcostal protrusions is the same.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – Rib Removal Cartilaginous Ends

Monday, June 26th, 2017


Rib removal is the last surgical option for maximal waistline reduction. After liposuction the only remaining anatomic obstruction is the lower ribcage. The outer and downward flare of the free floating ribs does influence the width of the waistline at the horizontal level of the umbilicus. Contrary to its perception rib removal is not a myth or an urban legend but an actual procedure that is both safe and effective. The aesthetic tradeoff is the small fine line scar on the back which is needed to do the procedure.

Rib removal is really subtotal rib removal, only the outer portion of the rib is removed. There is no aesthetic benefit to removing the whole rib by disarticulating it from its vertebral facets. The rib only needs to be removed back to the outer edge of the erector spinae muscle. At this point a full-thickness bony cut is done to separate from its medial attachment.

The rib is then dissected out laterally in a circumferential suboperiosteal fashion until its cartilaginous tip is reached. At the cartilaginous end numerous muscular and fascial attachments exist. These are easily stripped off. Thus aesthetic rib removal involves only one bone cut per rib as the distal end is ‘free’. (not attached to bone but its does have soft tissue attachments.

In some cases of rib removal for maximum effectiveness, rib #10 is also removed in a subtotal manner also. Even though it is not a true free floating rib it still has a cartilaginous attachment to the anterior subcostal ribcage at the 7-8-9-10 cartilaginous unit.

Dr. Barry Eppley

Indianapolis, Indiana

Waistline Narrowing with Rib and Muscle Removal

Saturday, June 17th, 2017


Rib removals for waistline narrowing is the final step for maximal waistline narrowing. After weight loss, exercise and liposuction the final anatomic ‘obstruction’ remains that of the lower ribs for optimal. What differentiates the lower or free floating ribs from those above it is that they are bony appendages with terminal ends. They do not connected to any ribs above it and, as a result, have a different angulation. Rather than having a more horizontal orientation, they point much more downward. (this is in contrast to many anatomic depictions which show them to be more horizontal in orientation)

The lower two ribs (11 and 12) are known as the free floating ribs because they do not connect to any other ribs and only have a proximal attachment to the spine. The remaining ten pairs of ribs above connect, directly or indirectly, to the sternum. Without a connection this allows the ribs to angle more downward or ‘float’. The reality is that the floating ribs do have firm soft tissue connections at their cartilaginous tips to the abdominal musculature. Thus when the floating ribs are removed the waistline collapses inward due to loss of both structural bony support and their muscular attachments.

One key question in rib removal surgery is whether rib #10 above the free floating ribs would also provide some waistline narrowing effect. This has to be determined by physical examination before surgery. Patients with shorter vertical waistlines usually do while taller patients with longer waistlines may not. But when in doubt rib #10 can be taken and dissected around the waistline to be disarticulated from its cartilaginous attachment to rib #9 at the inferolateral subcostal region. Like ribs #11 and #12, it can still be removed through the same small oblique back incision of 5 cms in length.

One additional technique that I have added to rib removal surgery is to remove a piece of lastissimus dorsi muscle over the removed rib area. The thickness of the muscle allows for an increased waistline narrowing effect by about 1cm per side. Loss of part of the lower end of this back muscle has no functional consequences. To avoid any risk of seromas and to ensure good skin adaptation back down to the recontoured soft tissues, quilting sutures are used. Drains have never been used for rib removal surgery.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – Neurovascular Bundle Preservation in Rib Removal Surgery

Monday, June 12th, 2017


Rib removal can be done for a variety of aesthetic and medical purposes. The most common aesthetic reason is for horizontal waistline narrowing with the subtotal resection of the truly free floating ribs. (#s 11 and 12) Through a small obliquely oriented skin incision on the back the midportion of the ribs are identified just lateral to the erector spine muscle and cut. From that position the rib is then dissected out to its cartilaginous tip and removed.

One of the keys to rib dissection is that it is done in a subperiosteal plane. The periosteum is tightly wrapped in a circumferential manner around the bony rib. Getting under this tissue layer allows for the smoothest and cleanest plane of dissection but also preserves all surrounding structures. This is most relevant to the neurovascular bundle that sits in a groove on the inferior side of the rib. Elevating and preserving the artery and vein makes not only for less intraoperative bleeding but prevents inadvertent nerve injury/transection and the potential for chronic postoperative rib pain.

The subperiosteal rib plane of dissection is easiest on its superior aspect and harder to get out the neuromuscular bundle from its inferior bony groove. But the same instruments that are used to dissect the mucoperichondrium from the nasal septum are used to get the neuromuscular bundle out of its bony groove. Once started more proximal it is much easier to elevate out to the cartilaginous end of the rib. Once the rib is removed the vessels and nerve should be seen intact in the periosteal soft tissue cuff.

Rib removal is often associated with a destructive and very invasive surgery, undoubtably influenced by thoracic surgery  which has a different intent for its performance. From an aesthetic stand point it is important that rib removal be doing through small incisions and minimize any risk for chronic postoperative pain from intercostal nerve injuries.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Costo-Iliac Impingement Syndrome Treatment by Rib Removal

Monday, June 12th, 2017


Background: The Costo-Iliac Impingement Syndrome, also known a the Rib Tip Syndrome, is a well known syndrome of back and hip pain caused by the touching of the 12th rib against the iliac crest. It most commonly occurs in patients who have had osteoporosis of the spine and loss of vertebral height. This allows the spine to curve and bend towards one side. It can also occur in patients with congenital scoliosis as well as younger patients who have a naturally longer 12 rib or an accentuated angulation downward at its takeoff from the spine or from a previous fracture.

Diagnosis can be done by physical examination and history as most patients can tell you that they know the rib is touching their hips. Deep palpation can feel the length of the 12th rib on its course downward.  The pain can be provoked by lateral flexion on the affected side. Ribcage x-rays can confirm the diagnosis. Definitive treatment is subtotal resection of the 12th rib on the affected side. Few clinical series exist but the few that have been published report relief of symptoms 100% of the time.

The free floating ribs (#s 11 and 12) have a different angulation from the spine than that of the superior ten ribs. Because their anatomy is not to wrap around the waistline or chest, they have a more downward angulation rather than a horizontal one. While many anatomic representations show the 11th and 12 ribs, I am often impressed how significant this downward rib angulation is in the many posterior rib removal surgeries that I have done. It is often 60 to 75 degrees downward in many cases, greater than what textbook illustrations would led you to believe. It is easy to see how it is possible that it could touch the hips in flexion in some short-waisted patients.

Case Study: This 30 year-old female was bothered by left hip/back pain on flexion to that side in numerous body positions. She was well aware that it was probably rib-related. Palpation revealed a long 12th rib that was at the level of the iliac crest. On bending to that side the discomfort could be elicited. For purposes of symmetry and any waistline reduction benefits, bilateral rib removals were planned.

Markings done before surgery showed the relationship of the 12 rib to the height of the iliac crest. Bilateral subtotal 11 and 12th ribs were done through 4.5 cm long oblique back incisions.

Provided a proper diagnosis is done before surgery, one can expect a near complete resolution of hip and back pain from the Costo-Iliac Impingement Syndrome with subtotal rib removal. Whether one chooses to add rib 11 along with 12 depends on the preoperative physical findings and the patient’s goals. If any doubt about rib length or angulation a 3D ribcage CT scan should be preoperatively done. This will remove all doubt about the shape of the lower ribcage anatomy.

When removing any rib for aesthetic or functional purposes, preservation of neurovascular bundle at the inferior edge on the rib is important. Injury to the intercostal nerve during its dissection could potentially end up trading off one source of pain for another.


  1. The Costo-Iliac Impingement Syndrome is due to a long or severely angulated 12th rib that touches the top of the iliac crest in flexion or sitting.
  2. An effective treatment for this syndrome is subtotal removal of the 12th rib and even the 11th rib if necessary.
  1. For purposes of waistline symmetry, bilateral subtotal rib removals can be done.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – Tummy Tuck Rib Removal

Wednesday, March 15th, 2017


Rib removal is done for a variety of waistline concerns. Such concerns must be divided into anterior and posterior aesthetic waistline issues. The most common perception of the aesthetic benefits of ribs being removed is for horizontal waistline reduction where ribs #10, 11 and 12 may be reduced through a posterior or back approach. `This allows the sides of the waist to fall in at the level of the belly button, contributing to more of an hourglass figure.

But other forms of aesthetic ribcage modification exist. Vertical waist shortness can be caused by a short length between the subcostal rib margins and the hips. The subcostal ribs, made up of the cartilaginous portions of ribs #7,8 and 9, create the downward slope of the ribcage out to the sides. With a low or prominent subcostal rib margin the waistline can be seen as vertically short. In some cases it is not that the subcostal margin is too low but that it may stick out prominentl either on one side or both.

Tummy Tuck Rib Removal Dr Barry Eppley IndianapolisThe subcostal ribs are cartilaginous, thus they are softer than bone and can be effectively reduced by either shaving or complete removal of their prominences. While this can be done through a relatively small skin incision over them, it is also possible to remove them at the same time as as tummy tuck. The tummy tuck has to be of a full variety, but the subcostal rib margins can be accessed by splitting the rectus fascia and muscle from below. (the same anatomic dissection one has to do from the external skin incision)

From this approach ribs #7 and 8 can be separated from their sternal locations and taken back to the bony junction at the sides of the chest wall. Along the way the cartilaginous portions of ribs #9 and 10 can be removed as well.

Dr. Barry Eppley

Indianapolis, Indiana

Clinic Snapshots – Rib Removal Waistline Narrowing

Saturday, March 4th, 2017


Rib removal surgery can be an effective procedure for anatomic waistline reduction in properly selected patients. Such patients typically include the already thin female who is seeking an ‘extreme’ waistline reduction as well as the male to female transgender patient who is trying to achieve a more feminine waistline shape.

Rib removal is effective in either type patient because it removes an anatomic bony obstruction that then allows the soft tissues to collapse inward. It is only necessary to remove the outer half of the ribs that extend laterally beyond the outer border of the erector spinae muscle. The inner half of the rib remains intact as its medial end is still attached to the vertebral facets.

Rib Removal for Waistline Narrowing Dr Barry Eppley IndianapolisThe procedure is done through  incisions of about 4 cms in length  that are obliquely placed in a skin crease that is made evident by turning at the waist. While the resolution of swelling and waist training can create an even greater change, the increased narrowing of the anatomic waistline can be appreciated even at one week after surgery.

Rib removal is a perfectly safe surgery contrary to the perception of many patients and even most surgeons. Since only a portion of the rib is removed and there is no real loss of structural support, it can be performed for purely aesthetic purposes.

Dr. Barry Eppley

Indianapolis, Indiana

Clinic Snapshots – Rib Removal Waistline Narrowing

Thursday, February 9th, 2017


Rib removal is an aesthetic body contouring procedure that has an impact on narrowing the anatomic waistline. It is most commonly performed in my experience on already lean women that are trying to achieve an ultra narrow waistline or on male to female transgender patients to get some semblence of a waistline shape. While historically portrayed as an urban myth, rib removal surgery is very real and effective in the properly selected patient.

Rib Removal results front view Dr Barry Eppley IndianapolisTo create a waistline narrowing effect, the free floating (11th and 12th) ribs are shortened in their length. The concept of rib removal does not mean the entire ribs are removed back to their vertebral facets. Rather they are shortened back to the lateral border of the erector spinae muscle. This removes some support from the overlying soft tissues but does so without risk to any internal organs. This collapse inward of the soft tissues creates the waistline narrowing effect.

The debate in each patient is whether a portion of rib #10 should also be removed in addition to ribs #11 and #12. Rib #10 is not a free floater and has a more horizontal orientation. Its removal has less of an effect on the waistline than the lower two but a portion is often removed as well.

Rib Removal result back view. Dr Barry Eppley IndianapolisTraditional rib removal by chest surgeons is done through long incisions. But that is not acceptable in the cosmetic patient. Aesthetic rib removal is done through a 4 to 4.5 cm long incision placed in an oblique skin fold seen when the patient turns at the waist. This produces a far more acceptable incisional tradeoff. This patient picture shows the result seen just two days after rib removal surgery.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – Rib Removal Surgery

Sunday, December 18th, 2016


Rib removal is an effective surgery for anatomic waistline reduction. It is reserved for those women who have tried every other non-surgical and surgical method to narrow their waistlines and are seeking the last resort to do so. It is clearly for the most motivated of women who are willing to accept small back scars to do so.

Removal of the lower ribs does work to narrow the waistline by eliminating some structural support that helps hold the wasitline out. The lowermost two ribs, #s 11 and 12, are called the floating ribs because they are attached only to the vertebrae and not to the sternum or cartilage of the sternum. These ribs taper down to a cartilaginous tip where soft tissues attach. The floating ribs are often called small and delicate but they are not really either. Having taken out many of them they are much longer and stouter than one would think or diagrams show.

rib-removal-12-angulation-dr-barry-eppley-indianapolisWhat is interesting about the free floating ribs is their orientation to the rest of the ribcage. If one looks carefully at a diagram or skeletal representation, it becomes apparent how much of a downward angulation they have. They are oriented more than 60 degrees at a downward angle which is always impressive when they are exposed surgically.

Seeing their downward angulation during surgery allows for an appreciation of why it works for anatomic waistline narrowing. They do go as far down as almost the iliac crest which provides some support to the width of the waistline. It is also clear why some people may complain that they feel their ribs touch their hip bones when they bend to the side…because they in fact do.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – Rib Removals in Waistline Slimming

Friday, December 9th, 2016


Rib removal is most commonly known for its effect on helping reduce the anatomic waistline or waistline slimming . Usually the ribs that are partially removed (outer halves) are #s 11 and 12. This is because these are the true free floaters and are pointed 45 to 60 degrees straight downward. Once one realizes the true orientation of these two ribs compared to all of the ribs above them, it is easy to understand why they would be effective in helping to narrow the anatomic waistline.

Rib #10, like #11 and #12, are part of the five false ribs but differ from the two below them. It is oriented slightly more horizontal and wraps around the waistline to a cartilaginous connection to the rib above it. This still makes its management useful in anatomic waistline reduction but just not as much as the lower two free floater ribs.

rib-removal-for-waistline-reduction-dr-barry-eppley-indianapolisBecause of the curvature and longer length of rib #10, it is harder (albeit not impossible) to remove from the typical small back incision used for the lower rib removals. An alternative strategy that I have developed is the ‘rib arc reduction’ technique. Rather than removing the outer half of the rib, a smaller section is taken out of its curvature in the middle. This allows the arc of the rib to be reduced as it collapses, like removing the central part of a spanning bridge. This keeps most of the rib in place but it has lost some of its outward support thus playing a role in waistline slimming. In looking at an intraoperative picture of rib removals this is why one can see just a small portion of rib #10 that has been removed.

Rib removal for waistline slimming uses two basic approaches to the ribcage, subtotal outer half rib removal and rib arch reduction techniques. These are different than how many people perceive rib removal as the complete removal of the rib which just not how it is done.

Dr. Barry Eppley

Indianapolis, Indiana

Dr. Barry EppleyDr. Barry Eppley

Dr. Barry Eppley is an extensively trained plastic and cosmetic surgeon with more than 20 years of surgical experience. He is both a licensed physician and dentist as well as double board-certified in both Plastic and Reconstructive Surgery and Oral and Maxillofacial Surgery. This training allows him to perform the most complex surgical procedures from cosmetic changes to the face and body to craniofacial surgery. Dr. Eppley has made extensive contributions to plastic surgery starting with the development of several advanced surgical techniques. He is a revered author, lecturer and educator in the field of plastic and cosmetic surgery.

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