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Dr. Barry Eppley

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Archive for the ‘rib removal’ Category

The Appearance of Rib Removal Scars

Monday, January 29th, 2018


Rib removal surgery removes the last anatomic barrier to maximizing horizontal waistline  reduction. Removal of the free floating ribs allows the overlying soft tissue to collapse inward. When combined with flank liposuction and some muscle removal, whatever waistline reduction is possible will be achieved. Whether this meet the patient’s expectations can not be completely known until after surgery but whatever the result becomes the patient can take solace in knowing all that can be done has been done.

Posterior rib removal requires an incision on each side of the back to do so. This incision must be centered over rib #11 and its size has been reduced down to 5 cms with a lot of experience. An incision this small limits the extent of what can be done underneath it. This is why it is so critical to center it over rib #11 as rib #10 can be taken as well if so desired. Since this small incision allows one to only remove one rib above or below it, if the incision is misplaced higher or lower it will affect what ribs can be removed.

Despite the incision’s small size, patients understandably want to know what the scar eventually looks like. The final scar outcome will have a lot to do with the thickness and pigment of the patient’s skin. But no patient has registered any concerns about the scars, being well informed before surgery that this is the aesthetic tradeoff.

Back skin is rather thick and this always works against creating a virtually undetectable scar. But when compared to scars from traditional rib surgery for other medical purposes, this body reshaping operation results in a scar that is much shorter in length and with a far better aesthetic outcome.

Dr. Barry Eppley

Indianapolis, Indiana

Six Rib Removal Waistline Reduction Through Back Incisions

Monday, January 22nd, 2018


Narrowing one’s waistline can be effectively done for most people by a variety of non-surgical and surgical methods. Dieting, exercise, liposuction and tummy tucks will fulfill the aesthetic goals of the vast majority of people who choose to do so. But for a select few patients such methods are not effective enough for their waistline goals and they seek a more aggressive approach to achieve the maximal reduction possible.

This is where rib removal surgery has a role in waistline reduction. This eliminates the last ‘obstruction’ to further inward movement of the waistline shape. By removing the outer bony support to the overlying soft tissues it allows them to collapse more inward. How effective it would be depends the person’s natural shape and thickness of tissues.

Rib removal surgery is done through a series of surgical steps that strive to remove as much of the lower free floating ribs as possible (usually #10 ribs as well) through the small possible skin incision. (six rib removal waistline reduction) It is done in the prone position under general anethesia through paired 5cm back incisions placed close to the side of the waistline. This is the smallest skin incision that is possible. Going through the fat and two muscle layers the ribs are identified and the proximal bone cut is made at the lateral border to the erector spine muscle. This allows the cut end of the rib to be pulled up and out of the incision.

The tissues are dissected off of the rib in a direction towards its cartilaginous tip with more of the rib being pulled out of the incision as it becomes more free. It continues to be mobilized in a circumferential fashion until the soft tissue attachments to the cartilaginous tip are released at which point the rib is removed. At each rib level the posterior serrates muscle is closed back over the now empty rib tunnel.

The placement of the skin incision on the back is critical. Its small size will only permit one rib to be taken above and below. Thus the importance of centering it over the 11th rib. If the preoperative markings are off, only the 11th or 12th rib may be taken (incision too low) or only the 10th and 11th rib can be taken. (incision too high)

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Subcostal Rib Contouring for Protrusion Removal

Thursday, January 11th, 2018


Background: The ribs occupy a large amount of one’s torso, encompassing substantial surface area coverage on the chest and back. With twelve pairs of ribs (sometimes one less or more) , these 24 body parts provide structural support  and protection for the any organs that keep us alive. While seemingly simple in their design , their location and composition (bone vs cartilage) make for a variety of potential ribcage deformities.

One of the most common areas for such aesthetic deformities is the subcostal rib region. This lower chest area is composed of the merging of the mainly cartilaginous ribs #7, 8 and 9 from the side of the chest into the sternum. When deformities in this area occur, they are especially noticeable but also can cause discomfort in this very palpable area.

The subcostal rib region is prone to deformities particularly from injury. It’s lower margin often sticks out and becomes a prominent target for traumatic events. Because these rib portions are cartilaginous and, more importantly, have an osseo-cartilaginous junction brunt trauma can cause shape deformities. Partial separation of the osseo-cartilaginous junction, subperichondrial hematoma and partial rib cartilage fractures can all make for a prominent subcostal rib protrusion.

Case Study: This middle-aged male developed a very prominent bump along the right subcostal rib margin. It was not present at birth or through the earlier years of his life.  It developed without specific recollection of any traumatic event. While he had overall prominent subcostal rib margins due to his very the body frame, there was a very distinct prominent bump on the right subcostal margin along rib #8. It was medial to the osseo-cartilaginous junction.

Under general anesthesia a small 3 cm incision was made directly over the rib bump. The rectus muscle was vertically separated and the prominent cartilage bump exposed. It was shaved down with a scalpel as much as possible within the limits of what the incision would permit. Then a rotary handpick and burr was used to take it down further and feather into the surrounding rib edges. (rib contouring)

Prominent subcostal rib bumps or protrusions can be very successfully reduced through a small direct incisional approach. While this patient’s case represents the smallest example of subcostal rib contouring, the technique is effective nonetheless.


1) One reason for rib contouring surgery is for prominent and painful rib protrusions.

2) The anterior subcostal ribs margin is a common place for cartilaginous protrusions.

3) Depending on the size of the protrusion, rib shaving reduction is a good technique for its treatment.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – The Synergist Effects of Wedge Latissimus Muscle Removal and Rib Removal on Waistline Reduction

Tuesday, December 26th, 2017


Rib removal offers the elimination of the last anatomic obstruction to narrowing one’s waistline. This procedure creates its effectiveness through the removal of the inner bony component of waistline support. The free floating ribs, unlike the ribs above it, have an almost vertical orientation downward with only soft tissue attachments at their small cartilaginous tips. This is why one can push in on their waistline and feel the length of these ribs. Removal of the outer half of the ribs (there is no reason to remove them back to the vertebral facets) allows the soft tissue to move further inward this narrowing the waistline.

But between the skin and the lower free floating ribs lies other tissues which must be traversed. The biggest structure between the skin and these ribs is the latissimus doors (LD) muscle. Known as the ‘lats’, this is the broadest muscle on the back that extends form the upper arm down to the spine and the iliac crest. While the thickness of the muscle does thin at its most inferior extent over the lower ribs, it is still amazing how thick it still is in the lower back region. It is always at least 1cm thick and often as much as 2 cos.

One technique to improve rib removal results is to resect a wedge from the LD muscle in the lower back along the horizontal waistline area on both sides. By so doing the waistline reduction is further enhanced by the thickness of the muscle removed. This can add up to an inch improvement in the results.

Removal of a wedge of the LD muscle does not cause any functional deficits since the spinal insertion of the main body of the muscle remains intact. This wedge preserves the side to side integrity of the muscle.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – Incision Placement in Posterior Rib Removal Surgery

Saturday, December 16th, 2017


Rib removal surgery eliminates the last anatomic ‘obstruction’ to maximal horizontal waistline reduction. The ends of the free floating ribs (#s11 and 12) and the lowest false rib (#10) provide the only skeletal support to the sides of the torso at and above the waistline area. By pushing in on the sides of the waistline the outer ends of these ribs can be easily felt in most people.

Removing these bony obstructions serve as the anatomic basis for rib removal surgery and its waistline effect. It is commonly believed that the entire rib lengths are removed but this not accurate and also unnecessary. Only enough of the rib length has to be removed to have its desired effect. This is usually their outer half as there is no purpose to carrying the bony resection all the way into the vertebral facets at the spine.

Understanding what length of the rib that needs to be removed is critical in planning the location and extent of the back incision needed to do it. Because the incision is small in length, if it is placed in the wrong location (too high to too low or too close to the spine) it will become limiting as to what ribs can be removed or how much of their length can be resected. The incision is to be located over rib #11 along a natural oblique skin crease that is seen when the patient turns their body to the side. The incision length is 5 cms and it should be halfway between the lateral border of the erector spine muscle and the outer edge of the waistline.

Placing the incision in the right location allows maximal rib removals to be done with the smallest incision possible. A subcuticular skin closure assures the best scar result. The use of drains for twenty-four hours helps minimize postoperative bruising and swelling.

Dr. Barry Eppley

Indianapolis, Indiana

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

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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