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Waistline narrowing is ideally achieved by diet and exercise. When this is not effective surgical methods such as liposuction and tummy tucks can exceed what non-surgical efforts can do. But for those that desire to go further, or make the maximal effort for waistline reduction, there is the surgical procedure of rib removal. 

Rib removal surgery is a bit understated for what is actually done. While ribs are removed in the procedure there is also fat and muscle removal as well. Collectively these tissue removals allow for a more inward movement of the silhouette of the waistline.

Despite the effectiveness of this procedure in the properly selected patient, there are several basic concepts about the procedure which include the following:

LIMITED BACK INCISION Like all aesthetic procedures one of the key elements in making it acceptable is a small or limited incision. This is possible in removing long ribs by using a tunnel dissection and delivery technique. But in keeping a small incisional length (4 to 4.5cms) it must be centered over rib #11 to allow the technique to access one rib above and one rib below. Careful preoperative marking is essential. If the incision is misplaced rib #10 or rib #10 2ill be left behind.

SUBTOTAL RIB REMOVAL It is commonly perceived that rib removal involves removal of the entire length of the rib. There is simply no reason to do so. What matters is the outer portion of the rib which provides support to the sides of the waistline. The inner half of the rib can be maintained, thus avoiding a more tedious dissection and which stays clear of more major blood vessels at the facet area close to the spine.

RIB REMOVAL POSTOP PAIN One would assume based on patient experiences with the more common injury of the ribs, fractures, that rib removal surgery would be very painful. And may even risk chronic pain…as also can be seen in the recovery from rib fractures. But the big difference in rib removal surgery is that a portion of the rib is removed, leaving an unopposed cut end. Thus there are not two rib ends rubbing against each other trying to heal. This makes for a less uncomfortable recovery and a quicker one as well. In addition the intercostal neuromuscular bundle located at the bottom of the rib is always preserved. The placement of Exparel-soaked collagen sponges into the space where the removed rib was really help with early recovery. Preserving the intercostal nerve also avoids any risk of longterm chronic pain which can occur if the nerve is injured or compressed.

UNIQUE ANATOMY OF RIB #10 While ribs #11 and 12 are unattached (free floating), rib #10 wraps around the waistline and loosely attaches to the subcostal rib margin. Usually rib #10 is resected all the way around the waistline and removed from its cartilaginous attachment to rib #9. But in some cases the pleura of the lung is intimately attached to the inner side of the rib and it may be safer to not risk a longer resection. When this occurs, and it is not that often, I remove a small section of the rib and allow it to collapse inward somewhat. (like removing  a small section of a spanning bridge)

MUSCLE SHAVING This is often the most misunderstood but also a very important element in maximizing the waistline reduction effects of rib removal surgery. The latissimus dorsi (LD) muscle is incredibly thick, even at its thinner inferior aspect  above the iliac crest as it crossed the waistline region. Removing an outer wedge or section of the muscle reduces another anatomic barrier to the reduction and has no adverse effect on LD muscle function. It always add at least a full centimeter on each side beyond what the rib removal itself creates.

Rib removal surgery effectively removes all anatomic obstructions that can be safely done for waistline reduction. The question for any patient is not whether it is effective but whether what it can accomplish is in line with what the patient desires.

Dr. Barry Eppley

Indianapolis, Indiana

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