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Dr. Barry Eppley

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Archive for the ‘rib removal’ Category

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

OR Snapshots – Subcostal Rib Shave

Sunday, December 4th, 2016


There are a variety of aesthetic ribcage modification procedures that are not well known. When people speak of ‘rib removal’ this is commonly perceived as a procedure for waistline reduction through removal of portions of ribs #11 and 12. (and sometimes #10) While this is certainly true this is not the only rib removal procedure done for aesthetic body contouring benefits.

Another type of rib removal is that of the ‘rib shave’. This is technique that is used almost exclusively on the anterior ribs along the subcostal margin. The subcostal rib area is composed of ribs #7, #8 and #9 and makes up the bottom of the curved ribcage at the upper abdominal region. In some individuals the subcostal rib may protrude out in an abnormal fashion. When present this often occurs only one side creating an obvious asymmetry.

subcostal-rib-shave-dr-barry-eppley-indianapolisReduction of a prominent subcostal margin can be done by either rib removal or a rib shave. Which approach is most appropriate depends the amount and location of the subcostal protrusion. The more medial (closer to the sternum) the protrusion is or the minor that it is a rib shave is usually most effective. The more lateral or larger the subcostal protusion is then removal of portions of ribs #8 and #9 may be needed. In some cases of subcostal protrusions a combination of rib removal and rib shave may be needed.

In a rib shave a very small subcostal incision (3 cms) can be used right along the prominent area. Once through the rectus muscle by a splitting technique the subcostal rib margin is easily accessed for modification.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – Rib Removal for Pain

Thursday, November 17th, 2016


Rib removal for aesthetic purposes is most commonly done for waistline reduction or narrowing. It is most commonly done in thinner women who desire the maximal waistline reduction beyond what weight loss and exercise can achieve. It is also done in transgender females who strive to have more of an hourglass shape but have a genetically wider ribcage.

Rib removal in waistline reduction focuses on ribs #s 11 and 12 which have a more vertical orientation than all the ribs above them which wrap around more horizontally.  The downward angulation of the true free floating ribs can pose the last barrier to structural waistline support for maximal inward narrowing.

But rib removal can also be done for other more medical reasons as well. Known as impingement, ribs that have been fractured or displaced can cause pain by putting pressure on adjacent structures. The level of the rib involvement would determine the type and location of this type of compressive discomfort.

rib-removals-for-chronic-rib-pain-dr-barry-eppley-indianapolisThis is a young man who sustained multiple rib fractures that bent inward the lower half of his ribcage. Even though the ribs went on to heal he felt a rubbing or scratching pain as he moved. A 3D CT scan showed showed the abnormal inward curvature which affected the bottom two free floater ribs the most on the affected side. Rib removal of #11 an #12 was performed stopping short of the vertebral facets up under the erector spinae muscle. This was done through an oblique skin incision on the lower back.

Dr. Barry Eppley

Indianapolis, Indiana

Tummy Tuck Rib Removals

Thursday, September 22nd, 2016


The most perceived reason that rib removal surgery is performed is for narrowing of the anatomic waistline. This is done by removing portions of ribs 11and 12 and sometimes even rib #10. This operation works because it removes the outward support of the musculature that occurs from the very downward projecting terminal 11 and 12 ribs. This is done through a small oblique incision on the lower back. This is known as posterior rib removal as it is on the posterior or dorsal surface of the trunk.

anterior-rib-removal-dr-barry-eppley-indianapolisBut ribcage modifications for aesthetic purposes is not just limited to the posterior or lower ribs. Rib #s 7, 8 and 9 on the anterior subcostal margin of the chest can also be treated. Subcostal ribs that are too protrusive can be removed. Unlike the posterior ribs which are bony, anterior ribs are softer and cartilaginous in structure. These ribs run form the sternum out to the side where they turn into bone at their osteocartilaginous junction at the side of the chest. This is known as anterior rib removal or subcostal resections.

tummy-tuck-rib-removal-dr-barry-eppley-indianapolisThe access to anterior rib removal can be done through two very different incisional approaches. Like the posterior ribs a small incision over the subcostal margin can be used. (direct approach) Another option is to use a tummy tuck incision. (indirect approach) If one is having a tummy tuck anyway then this would be the obvious choice. It is a long way from the low tummy tuck incision up to the subcostal margin but it can be done without undue difficulty. The rectus muscles are split right over the subcostal edge of the ribs and they are then removed. Once could also choose the indirect approach even if they don’t need a tummy tuck but one has to accept the traditional low tummy tuck scar.

Anterior rib removals iare less known and discussed than the more well known posterior rib removals for waistline narrowing. But in my rib removal experience, there are as many requests for anterior rib removal as there is for the posterior ones. The incision chosen is based on whether they have had a prior tummy tuck or are in need of one.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Maximum Waistline Reduction with Rib Removal and Liposuction

Tuesday, July 12th, 2016


Background: Waistline reduction is effectively achieved by good weight control and exercise for the majority of people. Those with more difficulty in helping reduce the waistline may resort to surgical approaches from liposuction, a tummy tuck or some combination there of. These traditional abdominal surgical approaches will produce very satisfactory waistline improvements in most everyone.

Various maneuvers in both liposuction and tummy tuck surgery can help achieve waistline reduction. Aggressive and focused liposuction at the side of the waistline/flanks can help create a more inward shape. Rectus muscle plication and Scarpa’s fascial advancement performed during a tummy tuck can help pull in the sides of the waistline also.

Rib removal #11 and #12 Dr Barry Eppley IndianapolisBut for those women seeking a maximal waistline change who already are at good weight and don’t need a tummy tuck or a lot of liposuction, resorting to ribcage modification is the end-stage surgical approach. The bottom lower three ribs do have a role to play in the width of the anatomic waistline. The oblique orientation of the free floating ribs (#s 11 and 12 in particular) can serve as an ‘obstruction‘ to the creation of a more hourglass waistline shape.

Maxumum Waistline Reduction Surgery with Rib Rermovals Dr Barry Eppley IndianapolisCase Study: This 33 year-old female presented for waistline reduction surgery. She had prior abdominal and flank liposuction which provided some improvement but not to the degree that she wanted. A plan was devised to do additional liposuction with emphasis on the v-shaped sides of the abdomen as well as supplementing that result with multiple lower rib removals.

Posterior Rib Removal incisions Dr Barry Eppley IndianbapolisPosterior Rib Removal specimens Dr Barry Eppley IndianapolisUnder general anesthesia she initially had full abdominal, back and flank liposuction done removing an additional 1800 of fat aspirate. In the prone position through a 6 cm long oblique incision on each side of the back, the end portions of ribs #10, 11 and 12 were removed.

Effects of Posterior Rib Removal for Waistline Narrowing Dr Barry Eppley IndianapolisIt could be seen during surgery after removal of one side of the ribs how the abdominal contour was already further inward with the partial loss of outer bony support.

At the removal of her liposuction cannula entrance sutures and the taped dressings over the back incisions, improvement in the waistline could already be seen. With the resolution of all of her swelling in the next 6 to 8 weeks after surgery, very evident waistline reduction will be seen.


1) Maximal or extreme waistline reduction requires a combined liposuction and rib removal techniques.

2) Liposuction is done in both the supine and prone position to maximize the reduction along the sides of the waistline.

3) Subtotal rib removal of #s 10, 11 and 12 provide further waistline reduction over what fat removal alone can do.

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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