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Rib removal surgery for the purposes of aesthetic waistline reduction is a frequently misunderstood procedure. The name conjures up images of what is done in the surgery or how the surgery is done which leads to false perceptions about it. One of the best ways to understand the procedure better is to go through the surgery in a pictorial step by step process.

The patient I will use to do so is an exception to the typical rib removal patient in that she was also having a tummy tuck done…but that provides a lead in to how rib removal is performed.

Rib Removal and Tummy Tucks While it is true that rib removals can be performed through the open tummy tuck approach, the only ribs that can be removed by doing so is the anterior or subcostal ribs…not the free floating ribs that have an impact on the waistline. The subcostal ribs (confluence of 6,7,8, and 9th ribs) create a prominent protrusion in some patients in the upper abdomen which can be reduced through the open tummy tuck. But traditional tummy tucks do not allow good access to substantially affect ribs 10, 11 and 12 which are located way to the side. So while rib removal and tummy tuck surgery can be performed during the same surgery the ribs that can be removed by that approach do not improve the waistline.

Lateral Back Incisions The incisional access needed for waistline rib removal are back incisions located more to the side of the waistline than close to the spine. The ends of the ribs (11 and 12 as marked in the image) are lateral and hence so should the incision used to remove them.

LD Muscle Excision Once past the skin incision the first structure encountered is the large and thick latissimus dorsi (LD) muscle. The target ribs lie under this muscle and anatomically even below another muscle layer, albeit thinner. (serratus muscle) It becomes very apparent that the LD muscle due to its lateral extent makes a major contribution to the width of the waistline. Rather than just cutting through it and then putting it back together during closure I prefer to take a large wedge of muscle which is a soft tissue reduction maneuver to help the waistline narrowing effect. It also aids visualization of the ribs.

Rib Exposure When the lower ribs are fully exposed it becomes apparent how much downward angulation they have. The free floating ribs have around 75 degrees off downward angulation far greater than one would think. This explains why they add width to the waistline with their circumferentially attached soft tissues. The ribs are removed as far proximally as possible but there is no reason to chase the bony rib any further than the lateral border ion the erector spinalis muscle. Any rib removed any further proximally will not have a waistline narrowing effect. This rib removal is really subtotal rib removal, eliminating the outer third or half of the rib closest to the waistline.

Neuromuscular Bundle Preservation In removing ribs it is important to preserve the neurovascular bundle (artery vein and nerve) that runs in a groove on the inferior surface of the rib. Besides preventing bleeding it more important prevents the risk of developing a neuroma which can cause chronic pain.

Exparel Sponge Replacement  To aid with postoperative pain management the ribs are replaced by a collagen sponge that has been soaked in Exparel solution, a long acting local anesthetic that can provide days of pain relief by diffusing into the surrounding tissues.

Rib Removals The short rib #12 and the much longer rib #11 are always removed and they are the true free floating ribs. Whether rib #10 is also partially resected depends on safe accessibility from the limited skin incision and the location of the pleura of the lung which becomes relevant the higher up on the ribcage one ascends.

This short pictorial sequence of rib removal surgery  illustrates some of the basic concepts of the surgery and hopefully alleviates some of the numerous misconceptions about an effective but largely unfamiliar aesthetic surgery.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

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