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Background: The desire for waistline narrowing is universal for which conventional surgical approaches work most of the time. The most common waistline narrowing procedure is liposuction which reduces the subcutaneous fat layer between the skin and the muscle. Thinning this tissue layer combined with overlying skin retraction from the volume loss will work for most patients who have rolls, love handles and otherwise waistline excesses. Tummy tucks are often lumped into waistline reduction procedure but this really refers to the anterior waistline between the two hip points, not the lateral waistline. If combined with flank/waistline liposuction a more complete waistline reduction is obtained.

There are other types of patients seeking waistline narrowing for which these common procedures are less effective or not effective at all. Thin cis-females who want an even narrower waistline than the one they have, cis-females who have a straight body profile who desire some semblance of curves and the transgender MTF who seeks body shape improvements over what the genetically wider ribcage and narrow hips gives them. This is where the role of rib removal surgery comes into play as it moves beyond what manipulation of the outermost fat layer can do…of which most of these types of patients have very little of it anyway or have already had liposuction. (probably from a prior BBL procedure)

Case Study: This lean transgender female had a straight body profile and had already been through buttock implants and BBL surgery as well as breast augmentation. Preoperative markings included the area of flank liposuction the oblique back incisions and a midline spine markings to ensure equal locations of the back incisions.

Under general anesthesia and in the prone position 4.5cm lateral back incision were made after an initial flank liposuction was done. (150cc aspirate per side) The latissimus muscle was cut through on its outer aspect to expose the serratus muscle and the floating ribs. (#11 and #12) The ribs were cut at the level of the laeteral edge of the erector spine muscle and dissected out to their cartilaginous tips where they were removed. Preserving the neurovascular bundle on the inferior surface of the rib is part of the procedure. Once the serratus muscle was closed over the empty rib space (filled with Exparel soaked collagen sponges), wedge of the latissimus muscle were taken above and below the split line. The skin was then closed over a drain on each side.

On the operative table I never really see that much of a waistline change although the loss of waistline support/thickness is very palpable.

Recovery consist of a few days of having the drains in place and wearing a circumferential support. (binder, waster trainer etc) The incisions are closed with dissolvable sutures and covered with glued on tapes which stay in placed for weeks. One can shower and get them wet. There aren’t really any postoperative restrictions since you can’t really hurt the surgically changes anatomy…and nobody ever is motivated to be too active. The hardest part is getting up and down initially since this is what much of your core back muscles do in terms of everyday activities. But by day 3 and 4 after surgery some early results can begin to be seen although it takes months to see the complete effects of the surgery.

Case Highlights:

1) Rib removal for waistline narrowing is an often misunderstood procedure, particularly from an anatomic perspective.

2) To maximize the waistline narrowing effective the floating ribs along with some overlying muscle and fat are removed.

3) Recovery from rib removal surgery is primarily of a muscular nature in which getting up and down poses the greatest initial challenge.

Dr. Barry Eppley

World Renowned Plastic Surgeon

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