Pushing the Limits: Combining Multiple Structural Body Contouring Procedures

Background

Aesthetic body contouring encompasses a wide array of procedures, most of which focus on the soft tissues. Traditional techniques such as liposuction and various excisional or tightening procedures of the breast, abdomen, and extremities address the consequences of weight loss, pregnancy, or unfavorable genetics.

However, a unique category of body contouring procedures targets the structural, bone-based framework. These include rib removal for waistline narrowing, shoulder reshaping, and pelvic plasty. As more recent innovations, these structural procedures are less widely known and performed. While they are sought primarily by transfeminine patients, a smaller subset of cisgender women also pursue them.

Because structural procedures involve deeper, bony manipulation, they tend to impose greater physical restrictions and longer recovery times compared to soft tissue surgeries—an important consideration in postoperative planning.

Combining Structural and Soft Tissue Contouring

Many patients desiring structural body contouring also wish to combine it with traditional soft tissue procedures. This raises a key question: How many procedures can safely be combined in a single session without causing an excessively prolonged or difficult recovery?

While many patients are young and better able to tolerate surgical trauma, safety and a manageable recovery period must remain paramount. Appropriate patient selection—both medically and psychologically—is critical.

Case Study: Four Combined Body Contouring Procedures

This case illustrates the possibilities—and considerations—of combining multiple procedures in one surgery.

Patient History

The patient, a female, previously underwent:

Shoulder narrowing surgery
Breast implant exchange (550cc to 800cc)
Intramuscular buttock implants (360cc), which became infected and were removed six weeks later.

She had already planned a second stage of contouring, including rib removal, hip implants, and an even larger breast implant exchange. Following the removal of her buttock implants, re-augmentation of the buttocks was added to the surgical plan—for a total of four combined procedures.

Surgical Approach

Prone Procedures

Under general anesthesia in the prone position:

Buttock Implants: Reduced 310cc implants were inserted into the scarred intramuscular pockets through the existing intergluteal scar.
Rib Removal: Through wavy vertical waistline incisions, the outer portions of ribs 12, 11, and 10 were removed by splitting the latissimus dorsi (LD) muscle. The outer margin of the LD muscle was then trimmed and sutured over the rib resection sites. The incisions were closed without the need for drains.
These two prone procedures produced a dramatic change in contour.

Supine Procedures

With the patient turned supine:

Breast Implant Exchange: The 800cc gel implants were replaced with XL 1240cc gel implants via existing inframammary scars.
Hip Implants: Custom implants were placed into the subiliac hollow through small incisions below the iliac crest. As is standard for hip implants, a drain was used.
These supine procedures complemented the changes achieved in the prone position.

Total operative time: 7 hours.

Candidacy and Safety Considerations

Combining four major body contouring procedures in a single session is reserved only for highly qualified and motivated patients. Ideal candidates are those with:

A prior history of surgical experience (e.g., facial feminization surgery or other body procedures).
A committed companion to assist them after discharge (following the first night spent at the surgical center).
No significant medical or health issues.

Motivation is somewhat subjective, but willingness to invest the necessary time, resources, and effort is a strong indicator.

This case highlights what is possible when careful patient selection, meticulous planning, and advanced surgical techniques come together. While not every patient is a candidate for such extensive surgery, those who are can achieve transformative results.

Dr. Barry Eppley

World-Renowned Plastic Surgeon