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Posts Tagged ‘waistline narrowing’

Case Study – Rib Removals for Waistline Narrowing

Saturday, May 21st, 2016


Background: Rib removal surgery has been done so infrequently that it is a highly misunderstood cosmetic body contouring procedure. While it sounds extreme, and it is certainly for the most motivated, it is neither a dangerous or a radical operation. It is a procedure that is based on an understanding of the lower shape of the ribcage.

Rib Removal Surgery Dr Barry Eppley IndianapolisThe concept behind most rib removal surgeries is to create a more narrow waistline that has an hourglass shape. This is possible when one looks at the anatomy of the lower ribcage. The lower two ribs, known as free floating 11and 12 ribs, are not attached to any ribs above them. In fact careful inspection of their shape shows that they actually point downward more than the ribs above which assume a more horizontal orientation as they wrap around the side of the body. These more vertically oriented ribs point down toward the hip and cross the horizontal level of the anatomic waistline at the level of the umbilicus.

For those women who seek a much more narrow anatomic waistline, these lower two ribs can serve as a vertical physical block for that effect to occur. This can be demonstrated by pushing it at the side of the waistline and feeling the bony obstruction.

Case Study: This young transgender male to female patient wanted a more feminine waistline rather than the torso of a male which is more straight up and down at the sides. She also wanted to improve the hip indentations by fat injections at the same time.

Lateral Waistline Rib Removal Dr Barry Eppley IndianapolisUnder general anesthesia and initially in the supine position the full abdomen and waistline areas in the back were harvested of fat. Then in the prone position, the flanks and upper intergluteal area were also harvested of fat. After concentration of the fat, a total of 200cc was injected into the hip indents. Then through a 4 cm incision oriented over rib #11 that did not come further to the side that the posterior axillary line, the ends of ribs 10, 11 and 12 were removed.

Lateral Wasitline Narrowing result intraop Dr Barry Eppley IndianapolisWhen viewed from behind the combination of rib removals, liposuction and fat injections to the hips made for a more hourglass torso shape. This effect will become greater over time as the waistline reduces as the swelling subsides and the tissues shrink inward.

Rib removal surgery for waistline narrowing is a bit of a misnomer. It should be called ribcage modification by removing of smaller portions of the obstructing ribs. While the pleura of the lung can be found at the level of ribs 10 and 11, careful technique can avoid its violation.


1) Posterior rib removals are for helping create a more narrow anatomic waistline.

2) The removal of the outer or distal portions of ribs 10, 11 and 12 removes the anatomic obstruction to the outer waistline profile

3) Rib removal is best thought of as ribcage modification as complete rib removal is never actually done.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Waistline Narrowing by Rib Removal Surgery

Monday, November 30th, 2015


Background: A more narrow waistline is a desire of just about anyone that does not have one. While both men and women seek a more narrow waistline, a woman’s perception of a more narrow waistline is different than that of a man’s. A man sees his waistline as at the belt or pant line. A women seeks her waistline as higher, known as the anatomic waistline, which is located higher at the umbilical level.

Waistline Narowing by Rib Removal Indianapolis Dr Barry Eppley IndianapolisThe typical woman who seeks a more narrow waistline is often very thin without much body fat. Often they have tried liposuction or even a tummy tuck to narrow their waistline without success. They feel they look like a boy with a straight outer profile to their torso. What they seek is an indentation at the anatomic waistline level that helps create more of an hourglass figure. At the least anything other than a straight line at the waistline is desired.

Rib removal surgery for waistline narrowing is a very uncommon plastic surgery procedure. It is pursued by those women who are willing to go to a radical solution for their body contouring needs. Because of its rarity and scant information about the procedure, it is often viewed by patients and surgeons alike as ‘dangerous’ and one having a high level of risk associated with it. In reality the subtotal removal of ribs located low on the ribcage is neither dangerous or associated with adverse medical concerns.

Case Study: This 30 year female wanted to have a more narrow waistline. She was very thin and had a very low percentage of body fat. She had previously been through a  tummy tuck to help narrow her waistline which did not have the desired effect. She now wanted to seek rib removal surgery to achieve a more narrow waistline. She had a prior history of spinal fusion surgery with a well healed midline scar down the lower half of her back.

rib removal markings Dr Barry Eppley Indianapolis_edited-1While undergoing other body contouring procedures under general anesthesia, she was placed in the prone position for the rib removal surgery. A 5 cm incision was placed in an oblique orientation over the midportion of the 10 rib. Ribs #11 and #12 were completely removed while rib #10 had a 2 cm portion of bone removed from its midportion. This allowed the remaining distal portion of the10th rib to be passively moved inward. Exparel long-acting local anesthetic was injected both an intercostal nerve blocks as well as injecting it directly into the muscle around the ribs.

Waistline Narrowing by Rib Removal Surgery results back view Dr Barry Eppley IndianapolisjpgAt just one week after the surgery, the change in her waistline could be seen. Some bruising was still evident around the incisions. She did not report any undue amount of pain over the rib removal areas.


  1. Rib removal surgery can produce immediate and visible narrowing of the anatomic waistline.
  2. For waistline narrowing, the common ribs removed are the bottom two floating ribs #11 and 12.

3. While often viewed as a dangerous surgery, rib removal surgery for waistline narrowing is not as the  ribs are well below the apices of the lungs.

Dr. Barry Eppley

Indianapolis, Indiana

Rib Removal for Waistline Narrowing – Surgical Technique

Friday, October 23rd, 2015


The surgical technique for rib removal for waistline narrowing involves three basic principles. First the surgical access (incision) must be limited so it does not pose a poor aesthetic tradeoff. Secondly, the correct number and length of the ribs must be removed to create the waistline change. Third, the ribs must be removed carefully so the intercostal   nerves are not injured and the pleura of the lung is not entered.

Rib removal for waistline narrowing incision dr barry eppley indianapolisWhile thoracic surgery uses very large incisions for rib removal procedures, this is not acceptable for an elective plastic surgery procedure. The length of the incisions for this type of rib removal procedure needs to be no greater than 6 cms. The incisions should parallel the orientation of the underlying ribs and should be centered over the ‘central’ rib to be removed. This results in the best looking scar with equal access to the ‘perimeter’ ribs. This incision location is always located behind the mid-axillary line so that it is not seen from the front view.

Rib Removal for Wasitline Narrowing Ribs removed Dr Barry Eppley IndianapolisRib removal for waistline narrowing has been historically described as that of the last two of the free floating ribs, ribs number 11 and 12. This has probably been so described as they are the safest ribs to remove as they are well below the apices of the lungs and the pleura. Their removal does have some waistline reduction effects but they, alone, are not always the most effective or the complete answer. Removal of rib number 10 is often needed as well as it sits higher near the subcostal margin. This whether a total of two or three ribs per side are needed is a matter of preoperative and intraoperative judgment.

Rib Removal for Wasitline Narrowing Muscle Dissection Dr Barry Eppley IndianapolisCareful technique is important to avoiding undesired intraoperative events and long-term adverse effects from rib removal. Two layers of back muscle must be crossed to reach the lower ribs (latissimus dorsi and external oblique muscles) and these should be split longitudinally to lessen the amount of muscle fibrosis when healing. The enveloping lining of the ribs must be separated carefully to avoid injury to the intercostal neurovascular bundle on its inferior edge. Dissection on the back side of the ribs, particularly above rib 11, must hug the bone tightly to avoid inadvertently entering the underlying pleural space.

Rib removal for waistline narrowing can be done very safely and effectively. It is not a so called dangerous procedure in surgeons experienced with rib harvesting. Postoperative recovery can be aided greatly by intecostal nerve blocks and muscle infiltration with long acting local anesthetics.

Dr. Barry Eppley

Indianapolis, Indiana

Rib Removal for Waistline Narrowing – Surgical Risks and Complications

Wednesday, October 21st, 2015


Rib Removal Surgery Dr Barry Eppley IndianapolisRib removal for waistline narrowing, like all surgical procedures, does have its own set of risks and potential complications. Patients should fully understand what they are and their potential consequences. Like all aesthetic plastic surgery procedures, it is all about weighing the trade-offs of the potential benefits of the desired waistline changes vs. the liabilities (real or theoretical) that can occur. These issues are magnified in a surgical procedure where normal support structures are being removed to effect the change.

For rib removal the risks and complications can be classified as scars, temporary vs.permanent pain, pneumothorax and the overall effectiveness of the procedure.

Rib removal requires incisions whose placement varies based on what exact ribs are being removed. Thus there will be scars whose lengths will be anywhere from 6 to 8cms. A single incision can usually only remove two ribs to which it is closest. While a subcuticular wound closure is always done and the scars do heal in a very linear and fine line fashion, where they have to be placed is anything but in a concealed location. The good news is that the incisions are placed parallel to the relaxed skin tensions lines of the torso (which is very good for ensuring the best scar) but their location is ‘out in the open’ so to speak.

ribs and the location of the intercostal nervesintercostal nerve anatomyRemoval of ribs always run the risk of creating chronic pain. There are various muscles and ligaments attached to ribs which makes their immediate removal understandably painful. But because most rib removals are done by fracturing or cutting of the rib bone and cartilages, in essence, creating a fracture line (subtotal removal) there is always the uncertainty of how the cut end of the rib will heal and feel over time. (chronic pain) There is also the risk of injury to the intercostal nerve which runs on the underside of the rib just outside of the periosteal sheath and at the outer edge of the neurovascular bundle.

pleural lining of lungsJust inside the ribs lies the pleural lining which creates an air sac around the lung. One of the major objectives of the surgery is to avoid violation of this thin and friable thoracic wall lining technically known as the parietal pleura. An intact parietal pleura allows the contraction of the diaphragm to creates a negative pressure within the pleural cavity which forces the lungs to expand for inhalation and exhalation. If the pleural lining gets violated air will enter the pleural space, known as a pneumothorax. This negates the negative pressure and the lung can ‘collapse’. Pleural violations are always a risk with any rib harvest/removal procedure and occasionally it does occur. When encountered intraoperatively the air is sucked out of the pleural cavity and the hole closed. A chest x-ray after surgery will check whether any residual air remains and that the lung is properly inflated. In rare cases, a chest tube may be needed after surgery if a lot of residual air remains so the lung can expand fully.

The potential risk of pneumothorax is directly related to the location of the pleural lining to the ribs. The lungs and the pleural lining inside the ribcage does not encompass all ribs. Anteriorly the pleural is not encountered until the bottom of the seventh rib is approached. Posteriorly the level of the pleura angles downward as it goes more into the back. Rib removals 9 and 10 place it at some risk of being encountered.

Lastly how effective can rib removal be at waistline narrowing? That depends on proper identification of the ribs before surgery that can best remove the outward obstruction. Even with properly identified rib segments, some patients may still not achieve their ideal waistline shape. Only so many rib segments can be safely removed.

Dr. Barry Eppley

Indianapolis, Indiana

Rib Removal for Waistline Narrowing – Anatomical Considerations

Wednesday, October 21st, 2015


Rib removal for waistline narrowing involves the selective removal of key portions of the ribs to allow the anatomic waist to become circumferentially smaller. While the circumferential waistline measurement may become reduced by variable amounts, the more important visual assessment is an inward indentation at the sides of the anatomic waist creating the so called hourglass effect.

To achieve this waistline effect through this surgical procedure, removal or modifications of the so called false ribs is needed. To understand how this exactly works it is important to review some basic anatomy of the influence of the ribcage on the waistline.

Rib Removal Surgery Dr Barry Eppley IndianapolisThe ribcage, also called the thoracic cage, is comprised of the posterior vertebral column, the anterior sternum and the ribs that connect the two around the sides.  Most humans have 24 ribs, 12 on each side, and costal cartilages that connect some of the ribs to the sternum. Of the 12 ribs, the upper seven are called the true or fixed ribs because they are directly attached to the sternum. (vertebrosternal ribs) The lower five ribs (8 through 12) are called the false ribs since they have no direct connection to the sternum. (vertebrochondral ribs) Ribs eight through ten do connect indirectly to the sternum through long cartilage connections. The lower eleven and twelve ribs, also known as the floating ribs, are so called because they are only connected to the vertebral column with free floating catilaginous ends.

They are numerous variations to this rib count with the presence of extra ribs or even missing ribs in some people. The tenth rib can also be a floating rib without any cartilaginous connection to the seventh rib and is most commonly seen in the Japanese population.

What ribs needs to be removed to make an inward indentation at the waistline? The waistline is defined as the narrowest portion of the body between the bottom of the ribcage and the top of the hips. It is easy to see that this defies an exact definition of what rib level constitutes the bottom of the ribcage. This is going to vary somewhat amongst women and where they define the exact location of the outer waistline profile. For some women it may be ribs 11 and 12 while for others it may be higher and closer to the outer waistline ‘edge’ where ribs 9 and 10 have more profound influence. Unless there is some anterior protrusion ribs 7 and 8 are not true waistline modifiers.

One question about rib removal is whether a portion or all of the rib needs to be removed. There is also the consideration of whether the bony or cartilaginous portion of the rib needs to be actually removed or whether reshaping by bony osteotomies or cartilaginous cuts may suffice. This must be decided on an individual case basis considering the location of the planned rib removal and whether one is going to undergo after surgery waistline training by garments.

Dr. Barry Eppley

Indianapolis, Indiana

Rib Removal for Waistline Narrowing – General Overview

Tuesday, October 20th, 2015


Rib removal is a plastic surgery procedure that is almost an urban myth. Many have heard about it but trying to find a plastic surgeon who has really done it is a bit like getting photographs of Sasquatch. This makes many wonder if rib removal for a smaller waist is for real.

waisltine locationHaving an hourglass figure is a physical feature for some women that has been desired and pursued through the ages. The hourglass figure is defined has a having a well defined and narrow waistline with contrasting hips. The key component is the waistline and how one defines it as it is frequently confused and its location varies on different people. The waistline is not the location of the belt line or top of the pants level as is frequently perceived. This is the waistline of clothing. The natural or anatomic waistline is where the torso creases when one bends over with straight legs. It is much higher than the belt line. It is measured at the level midway between the lowest rib and the top of the hip bone. (iliac crest) This is usually at or around the level of the belly button.’

Understanding the location of the natural waistline allows one to understand how the location of the ribs can affect. For those women that have a wide lower ribcage or protruding lower ribs, the attainment of a smaller waistline may be blocked by the anatomy of the ribs. So it is true that removal of one or more of the ribs can help narrow the waistline.

ribcage anatomyIn rib removal surgery, the key question is which ribs are removed to create the waistline narrowing effect. This is going to differ amongst women and needs to be determined by actual physical examination. One should feel the location of the ribs and where it relates to the anatomic waistline. Rib removal is clearly done on the lower portion of the ribcage anywhere from rib eight to twelve. Rib removal is historically described as removing the lower eleventh and twelfth ribs (floating ribs) but this is not right for everyone. These are the shortest ribs and often do not extend enough to the sides to really impact the waistline. Portions of the ninth and tenth ribs can also be considered as they wrap more around the sides. Having the patient suck in their waistline as much as possible can really help make this identification much easier.

Rb removal is without question a procedure done under general anesthesia and may require the patient to be prone or on their sides for the surgery. Intercostal nerve blocks with long-acting local anesthetics (e.g., Marcaine, Exparel) is very helpful for pain control in the first few days after surgery. Like all rib removal procedures, it can take months until one has a full recovery. Rib removal for waistline narrowing is unique over other rib removal surgeries because it is done on both sides of the ribcage. Also it requires an incision of some length to gain access to the ribs and this must be considered an aesthetic trade-off (scar) for the amount of waistline narrowing.

narrow waistlineRib removal for aesthetic waistline narrowing would be considered an extreme plastic surgery procedure. It should be reserved for the most motivated of patients who are willing to take relatively drastic measures for an aesthetic gain. There are also many other nonsurgical and surgical procedures that can have a positive waistline effect. Various types of garments and corsets have been well shown to be effective with regular and long-term use. Plastic surgery procedures to change the area above (breast augmentation) and below (tummy tuck) can create a more ‘narrow’ waistline perception. Liposuction that directly removes subcutaneous fat right at the waistline can also sculpt out out a more defined waistline.

Dr. Barry Eppley

Indianapolis, Indiana

Ribcage Narrowing Surgery for a Thinner Waistline

Monday, August 26th, 2013


The desire for an hourglass body shape by women has a long history. The concept can be traced to the Victorian era where a very narrow waist, often times ultra narrow, was viewed as the ideal figure for women to have. A narrow waist, often called a ‘wasp’ waist, revealed flared hips and moderately-sized breasts above and below it.

To achieve that waistline look, many devices and garments have been used. Corsets and other constricting garments can most effectively achieve waistline narrowing although their use is anything but comfortable. But before modern day surgery this was the only option.

Many body plastic surgery procedures when done in combination, such as breast augmentation and abdominal liposuction and tummy tucks, definitely have a waistline narrowing effect through their dual diametric body changes. For most women this is sufficient but for those seeking a more extreme approach to a a more shapely waistline, rib removal can be considered.

The concept of rib removal for waistline narrowing has become a bit of an urban myth. Some claim that surgical ribcage narrowing has been around since the Victorian era. However, without anesthesia, such a surgical endeavor at that time seems implausible. The ‘myth’ of rib removal for body shaping re-emerged in the early 1900s for actresses and, although there is no actual documentation of it every actually occurring, it may well have in a few isolated instances. (the first liposuction case did occur at that time)

Cosmetic rib removal was heard from again in the 70s when Cher was rumored to have had the surgery. (although this has since been discounted) Since then a few other celebrities have been said to have had ribs removed for a variety of body contouring purposes. But whether such surgeries have ever been done does not change the fact that it is a very rare cosmetic procedure and few plastic surgeons have ever performed it. Its rarity is evidenced by the lack of even a single publication of the procedure in the medical literature.

Therefore, is rib removal for waistline narrowing fact or fiction? That answer lies in understanding the anatomy of the ribcage and its effect on the waistline. The ribcage is a bony and cartilaginous structure that surrounds the vital organs of the thoracic cavity and the upper abdominal cavity. The ribcage consists of 24 ribs, the sternum with the xiphoid process, costal cartilages, and the 12 thoracic vertebrae.  The ribcage is a vital component of the human respiratory system. Inhalation occurs with the diaphragm contracts and flattens while the intercostal muscles lift the ribcage up and out, thereby increasing the anteroposterior and transverse diameter of the thoracic cavity in order to allow expansion of the lungs.

The upper seven ribs are attached to the sternum by their costal cartilages.  The 8th, 9th, and 10th ribs are called false ribs because they join with the costal cartilages of the ribs above.  The 11th and 12th ribs are called floating ribs as they do not have any connection to the sternum.

There are innumerable diagrams and pictures of ribcage anatomy but most are inaccurate when the details of the lower rib cage are shown. In my extensive surgical experience harvesting ribs for a variety of purposes, I would certainly not call the the 8th rib a false rib as it is firmly attached to the cartilaginous confluence of ribs 6 and 7. The 9th rib is very loosely attached to the 8th by fibrous tissue and you can feel that on most people by flipping the 9th rib back and forth over the 8th with your fingers. It is almost as long as the 8th rib and courses along most of its inferior border towards the sternum. The 10th rib is a true floating rib as it ends in ‘space’ with no attachments at its anterior tip and stops at about the anterior axillary line. The 11th and 12th ribs are just like the 10th but they fail to make it around the curve of the ribcage.

The goal of ribcage narrowing is to make the waistline vertically longer and narrower from the sides by removing the bulge of the ribs. This is different than low waistline narrowing in circumference above the hip bones as many people envision. Although it is commonly thought that ribcage narrowing involves removal of the 11th and 12th ribs, these floating ribs are located more in your back and will not have any significant effect on bringing in the upper waistline.

In order to achieve effective waistline lengthening/narrowing, the lower false ribs (9 and 10 and possible some of the true 8th rib) are partially or completely resected in order to achieve that whittled look. To surgically access these rib removals, a lateral subcostal incision is needed for direct access. (I have tried it from the an inframammary breast incision and, although some rib resection is possible, it is more limited than desired) Rib removal at this level if well below the pleural lining of the lung and this has no risk of intrathoracic intrusion.

The risks and complications of rib cage narrowing include a permanent subcostal scar and prolonged discomfort at the resection site. It is identical to any traditional rib harvest site for ear and mandibular reconstructive surgery with the exception that it is two sides and not just one. The discomfort from ribcage narrowing may take up to four to six weeks to completely subside.

Dr. Barry Eppley

Dr. Jane Namkung

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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