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Background: The most aggressive surgical approach to waistline narrowing is rib removal surgery. This is usually reserved for those patients that have been through traditional waist reduction techniques such as liposuction and tummy tucks. Some  have had BBL surgery which focuses on enlarging the buttocks and hips below the waistline. When the results from these procedures are not enough the only remaining surgical alternative is the rib removal procedure.

Rib removal surgery falls into two categories, minimally invasive osteotomies of ribs #11 and #12 and the more extensive procedure of open excision of ribs #10, #11 and #12 with muscle modification as well. Having developed the former rib procedure and having done very few isolated rib osteotomies I can not say that one technique produces better results than the other…but it logical to assume that open excision would produce a more significant change.

While the open excision rib removal technique addresses multiple tissue levels of the waistline, most notably bone and muscle, there is one remaining tissue level that does not….loose skin. In some patients seeking maximal waistline reduction removal and tightening of the loose skin provides a cinch-like effect on the torso.

Case Study: This female had a prior BBL surgery with successful results in terms of good buttock augmentation and waistline reduction. She also was a prior bodybuilder with large upper body muscle development in which that avocation was now over. She now desired a more narrow torso/waistline look. Examination showed there was a moderate amount of loose back skin. While she presented for rib removal surgery it was determined that to get the best result the loose skin needed to be addressed in the procedure as well. A vertical backlift was thus planned and she was very accepting of the midline scar down the spine.

Under general anesthesia and in the prone position the marked vertical backlift was initially excised. Extended skin flaps were then raised out to the lateral edge of the latissimus dorsi muscles.

Ribs #11 and #12 were removed by direct excision along their lengths, the space left behind filled with Exparekl-soakedm collagen sponges and the posterior serrates muscle closed over them. Rib #10 was not removed in this case because of the location of the pleura of the lung which was seen behind rib #11. (not safe to go higher with an increased risk of a pleural tear/pneumothorax)

The latissimus dorsi muscle was reduced by taking a long wedge of the muscle vertically. This vertical excision was closed by pulling in the outer edge of the muscle and the attached skin over it to produce a linear closure line from the scapula down to the posterior iliac crest.

The back excision site was closed in a linear line down the spine over a drain placed on each side for a cinching effect on the torso.

The addition of a midline vertical wedge of skin in rib removal surgery adds the final tissue element to maximizing torso narrowing. Through the open backlift exposure the free floating ribs can be removed and optimal latissimus muscle reduction can also be done. This would be the final frontier for profile torso reshaping. It is obviously not for everyone given the midline scar down the back. But for those that can accept the scar or consider tattooing over it later it does provide the best torso reductive reshaping possible. While many would think those with loose skin from weight loss would be the type of patient who would need this type of procedure and that would be true, but the most common aesthetic patient who often benefits from this approach is the patient who has had BBL surgery or 360 liposuction. There is only some much skin contraction that can occur from liposuction and with today’s maximal liposuction procedures that are being performed some patients do end up with redundant skin rolls that defies further reduction by liposuction. Excision of the loose skin and a waistline/torso cinch finally achieves the best body reshaping result.

Case Highlights:

1) Traditional rib removal surgery addresses three tissue layers of bone, muscle and fat.

2) A vertical backlight approach to waistline narrowing addresses the remaining tissue element (skin) through which the other tissue elements can be removed.

3) The length/location of the vertical backlift determines the extent of the torso cinching effect.

Dr. Barry Eppley

Indianapolis, Indiana

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