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Rib removal surgery is the final effort used for waistline narrowing. It is a procedure that is poorly understood in terms of what is actually done in the surgery and how it anatomically works. It is perceived as a bone removal procedure which allows the waist soft tissues around the ribs to collapse inward after surgery creating improved waistline shape. And while this is accurate it is not the only procedure that is incorporated into rib removal surgery.

In my rib removal technique I also incorporate additional soft tissue reduction procedure to maximize the waist reduction effect. The most superficial of these is subcutaneous fat from the flanks and waistline. While is some patients this may have already been performed from BBL or tummy tuck surgery, if not there is benefit to doing so. Even lean patients always have some removable fat small as it may be. As rib removal is a maximum effort surgery it is worth removing every anatomic barrier to the best result.

As rib removal surgery is performed in the prone position this is an ideal time for flank liposuction. The entrance sites could be in the dimples of Venus if they exist (blue arrows) but I prefer to move them more medially. They scar better when not in the dimple depressions and they also serve as the exit sites for the drains when rib removal is completed.

A small 3mm basket cannula is used for aggressive fat removal as flank fat tends to be fibrofatty tissue in composition. Suctioning is performed as far anteriorly as possible from the iliac crest up to the 10th rib level along the side of the abdominal wall.

The aspirate will be lighter colored fat which is typical for flank fat. With a 3mm cannula it comes slow but it keeps coming and one has to persist until it becomes non-productive. The amount of aspirate for both sides is usually in the 300cc range in lean patients which is about 50% fat.

Once the flank liposuction is completed the entrance sites remain open for drain exit later.  The rib removal then begins with the opening of the incisions which are in the midst of the liposuction zone.   

Dr. Barry Eppley

World-Renowned Plastic Surgeon

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