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Archive for the ‘rib removal’ Category

Case Study – Subcostal Protrusion Correction by Rib Shaving

Sunday, December 10th, 2017


Background: The ribcage is formed by a collection of twelve (12) ribs of various lengths, locations and compositions. The first seven (7) ribs are called the true ribs because they run between the spine to the sternum through a direct curvilinear connection. Ribs #s 8, 9 and 10 are called the false ribs because they are indirectly connected to the sternum through long curved cartilaginous connections to the seventh rib. Lastly the floating ribs are #s 11 and 12 because they have no sternal connection at all.

Besides the midline sternum and the shape of the adjoining upper chest, the other distinguishing ribcage feature is that of the subcostal region. Everyone knows this ribcage area well because you can put your hand up under it and even move it a bit. This is formed by the cartilaginous connections of the false ribs as they come around and upward to connect to rib #7. It is somewhat mobile because of its cartilage composition and can create its own aesthetic issues if it is too prominent.

One potential cause of an acquired subcostal ribcage protrusion deformity is trauma. Like all ribs, with the exception of #s1, 11 and 12, there is a bone-cartilage junction. (costochondral junction) This junction can be prone to separation from trauma as it is the ‘weak’ link along the entire length of the rib. Such costochondral disruptions can create a change in the subcostal shape.

Case Study: This middle-aged male developed a right subcostal protrusion after a traumatic event when he was struck by an object on that side of his chest. It was presumed that this caused a separation of the costochondral junction of ribs #s 8 and 9 and a resultant  deformation of the subcostal ribcage.

Under general anesthesia a 4 cm skin incision was made directly over the ribcage protrusion. The rectus muscle was vertically split for access to the protruding cartilaginous ribs. The protruding rib portion was shaved down with a large scalpel blade until the protrusion was eliminated and only a thin layer of cartilage was left. Some shaving was also carried over onto rib #10. After injection of Marcaine local anesthetic into the muscle and intercostal nerves, the muscle and skin were closed with dissolvable sutures.

Shaving is a very effective form of rib removal/reduction that is only useful in the subcostal ribcage because of its cartulaginous composition. With enough shaving as much rib can be removed as if it was removed as a whole piece. It has the benefit of creating a smoother contour than en bloc rib resection and helps avoid direction of the back side of the rib which requires additional tissue elevation and increased risk of intercostal nerve injury and even



1) The ribcage is prone to traumatic deformities particularly at the costochondral junctions

2)  Subcostal ribcage protrusions can be reduced through a direct incisional approach.

3) Cartilage shaving of subcostal protrusions is an effective contouring technique that avoids sharp edge demarcations.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – Subcostal Rib Shaving

Sunday, December 3rd, 2017


Most of the ribs are near circumferential bone and cartilage ‘fingers’ that provide shape to the chest and abdomen. Some of these ribs can be modified to improve the shape of the torso. In the upper abdominal region is the subcostal portion of the ribcage which is composed of the union of ribs #7 through 10 of its lower portion. This creates an arc of cartilage that is shaped like a stretch out ‘U’.

Normally the subcostal ribcage has a slightly more horizontal projection than the rest of the ribcage above it. But it can have an increased projection due to genetics, congenital deformities or injury. This can create a protrusion of the subcostal ribcage that creates an unaesthetic flare or prominence.

Reduction of subcostal rib protrusions must usually be done through a direct incisional approach to be maximally effective. I have used a tummy tuck approach which can be done if the patient needs a concomitant tummy tuck. I have also approached the subcostal ribs through an inframammary incision but this does not provide good access for optimal rib reduction. The direct incision allows the rectus muscle to be vertically split and the ribs easily exposed.

Unlike posterior rib removal (#s 10, 11 and 12) where the removed ribs are done in a full thickness manner, subcostal rib modifications are often done in a reduction technique and not a removal technique per se. The protrusions can be reduced by a subcostal rib shaving technique. This can be done with a scalpel for the softer cartilaginous portions and a high-speed handpiece and burr for the more ossified cartilage portions or actual bone. The ribs can be shaved down to where there is only a thin layer left protecting the intercostal neurovascular bundle and the pleura underneath should it be located this low on the ribcage.

Subcostal rib shaving also prevents blunt ends of the remaining rib from being seen on the outside should a total resection be done. This is of particular relevance in thinner patients where there is little soft tissue cover. Rib shaving ensures that there remains a smooth shape to the reduced subcostal protrusion. Shaving may seem like it does not remove much rib but when the pieces are put together the amount of rib removed looks more substantial.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – Hourglass Figure Surgery

Wednesday, November 29th, 2017


Altering the shape of a woman’s body has been a part of plastic surgery for over fifty years. This has traditionally meant such procedures as breast augmentation, liposuction and tummy tucks. In the most contemporary forms of female body contouring the role of the buttocks and hips, once deemed undesirable, have become popular. This has added buttock and hip augmentation using either fat transfer and implants to the options available for body reshaping.

The hourglass figure shape is one in which there is larger breasts, a narrow waist and hip widths similar to that of the breasts. In its most extreme form it has an appearance to that of an actual hourglass with a wide upper and lower half and being narrow in circumference between the two halves. Some deem such a female body shape as more desirable than others. Between the options available in plastic surgery and the use of traditional corsets the hourglass shape today is more attainable than it has ever been.

One newer addition in hourglass figure surgery in is that of rib removal. Reductions in the lengths of ribs #10, 1 and 12 removes the last rigid anatomic restriction to maximal horizontal waistline reduction. This procedure is only appropriate when the more traditional use of liposuction has already been done to reduce any fat collections around the waistline. When combined with other body contouring procedures such as buttock augmentation (in this picture with buttock implants), the hourglass figure may become a reality.

Hourglass figure surgery has numerous options to both augment the upper and lower half as well as narrow what lies in the middle. Larger breast implants, custom buttock implant designs and rib removal represent options for those women that seek a maximal approach to altering their body into more of the hourglass shape..

Dr. Barry Eppley

Indianapolis, Indiana

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

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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