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Background: Waist reduction can be done by a variety of surgical techniques. Standard and well used techniques include liposuction, lateral fascial plication during a tummy tuck as well as non-surgical methods of weight loss and exercise. For the vast majority of patients the waist reduction obtained by these type of standard approach is aesthetically sufficient.

For the extremely motivated  patient who seeks a maximal waist reduction result, the procedure of rib removal can be done. Such an aesthetic needs exists when standard surgical and non-surgical therapies fails to achieve their waist reduction goals. In this situation the lower ribs serve as the last anatomic barrier that can be surgically reduced.

Gaining access to the lower ribs requires surmounting the latissimus dorsi muscle. This is the largest muscle on the torso that runs from is origin at the lower spine, iliac crest and lower ribs up to its insertion on the upper arm bone. While one would think that retracting the muscle medially from its lateral border would be successful for lower rib access, it is not. The muscle is far too thick and wide to permit adequate retraction…or at least very difficult to do sustained retraction through such a small skin incision even with a willing assistant. As a result It becomes necessary to split the outer border of the muscle to perform lower rib removals.

In looking at the areas needed for waist reduction and the outer border of the latissimus dorsi muscle, it becomes apparent that the muscle itself also has an influence on the width of the waist. This becomes most apparent when working on a body builder who would have much larger lats than more common non-body builder patients.

Case Study: This female body builder desired to have a smaller waist than she already had. In looking at her back the tremendous width of her lats was fully evident. She had natural oblique skin creases which served as the location of the small 4.5cms skin incision locations.

Under general anesthesia and in the prone position, the incision location with surrounding areas of flank and upper back liposuction were outlined. Once the skin incision was made and the overlying fascia opened the fibers of the latissimus dorsi muscle could be seen.

Her lat muscle was tremendously thick as expected which was also quite lateralized. The muscle was split perpendicular to the direction of the vertical running fibers for about a third of its width. This provided good access to reach the ribs. For ribs 10, 11 and 12 the posterior serratus and intercostal muscles were incised parallel to the length of the rib. After circumferential subperiosteal dissection around the location of the rib removal area the bone was cut and the rib released. A subperiosteal tunnel technique with intercostal nerve preservation was done out to their cartilage attachments where the rib bone was released and removed.

Each empty rib tunnel was pack with Exparel-soaked gel foam for postoperative pain control prior to muscle closure. Rather than just putting the lat muscle back together muscle wedges were cut out above and below the split to create a enhanced waist reduction effect. Then the overlying skin incision was closed.

While there are anatomic benefits to removal of the outer ends of the the lower ribs for waist reduction, one should not rely on those effects alone. The width and thickness of the lat muscle also has a significant influence particularly in patients predisposed to larger muscle masses. (female body builders, male to female transgender patients) Some muscle resection should be considered to further improve the waist reduction effect. Such localized muscle reduction has not adverse effects on muscle function afterwards as the zone of resection compared to the overall size of the muscle is relatively small.

Case Highlights:

1) In waist reduction by rib removal the latissimus dorsi muscle plays a crucial role both in access as well as waistline reshaping.

2) The thick latissimus dorsi muscle must be split one its lateral border to provide access go the underlying ribs.

3) The split outer border of the latissimus dorsi muscles has wedges of muscle removed on its upper and lower edges during closure to create an overall soft tissue wedge indentation of the waist which complements that of the effects of the rib removal.

Dr. Barry Eppley

Indianapolis, Indiana

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