Background: Rib removal surgery for waist narrowing is a confusing concept because of the different ways surgeons perform it. (and often with different aesthetic outcomes as a result) When one thinks of rib removal it is understandable that the focus is exclusively on the ribs themselves. But rib bone modifications can be done by either osteotomy or subtotal removal of which that distinction is fairly clear….one cuts the bone and bend its while the other removes bone. One can debate the effectiveness of either approach but it fair to say that a removal approach is always going to be more successful as it provides an assured less volume of bone not just changing their curvature.
But my approach to rib removal has always been more than just bone. Management of the surrounding soft tissues (fat, muscle and skin) has always been a priority with the intent of doing as much as possible to get the best waist reduction result. This typically has been doing concomitant flank liposuction if needed as well as removing some of the latissimus dorsi (LD) muscle. The LD muscle overlies the lower ribs as well as extends out further to the sides than the rib…so it does make a contribution to the width of the waist.
As a result two basic variations of rib removal exist which are differentiated by how many ribs can be taken as well as the extent of LD muscle removal. (Type 1 vs Type 2) They also differ slightly in the incision location. But a Type 3 rib removal exists that deals with an issue that Types I and II do not…excess/loose skin. Patients that have lost some significant weight or have had multiple prior liposuction/BBL procedures will have loose skin that would adversely affect the outcome of rib removal surgery. Removing this excess skin from the back with rib removal done through it creates a corset-like effect.
Case Study: This female had lost a significant amount of weight (100lbs) and had been through tropical massive weight loss surgeries of a 360 degree tummy tuck as well as arms lifts. In her desire for a more defined waist through rib removal surgery the loose skin on the back would have limited any rib removal effects. The surgical plan was for a major vertical backlift through which ribs #11 and 12 could be partially removed as well as vertical strips of the lateral border of the LD muscle.
Under general anesthesia and in the prone position the vertical backlift excisions was done exposing then wide expansion of the back muscles.
The skin flaps were then elevated to the sides of the torso through which ribs #11 and 12 were removed of their distal ends. The rib removal areas were closed over Exparel-soaked gel foam sponges for postoperative pain relief. Then 2 to 3 wide strips of the LD muscle were removed starting below rib #12 site and continuing north up to over rib #9.
Over drains the vertical backlift was closed in the midline creating a corset-corset-line effect.
Rib removal for waist reduction shares one similarity with liposuction…it requires good overlying sen that can contract down when the underlying support has been reduced. Loose or non-taut skin works against showing the effects of rib removal surgery. As patients present with different body types and surgical histories and are seeking a smaller waist it is important to recognize what are the limiting factors in seeing that effect.
In Type I and II removals those patients are typically thin and often have a straight waist profile. They have good quality skin and structural internal reactions will work for them. But in patients with significant weight loss or any prior surgery that would affect the skin’s ability to contract the quality of the overlying skin must be considered for removal. The Type 3 approach incorporates a significant vertical skin removal which creates a true corset-like effect with figuratively and literally. It is the most powerful waist reduction/torso narrowing procedure but they patient must be willing too accept the obvious midline back scar as an aesthetic trade-off.
Highlights:
- Rib removal has a number of different variations depending upon what hard and soft tissues are being removed.
- Type 3 rib removal incorporates a vertical backlift to deal with loose torso skin and may be perceived as the Corset Rib Removal procedure.
- The vertical backlift excision provides unparalleled access for power rib and LD muscle removals.
Dr. Barry Eppley
World-Renowned Plastic Surgeon