The surgical technique for rib removal for waistline narrowing involves three basic principles. First the surgical access (incision) must be limited so it does not pose a poor aesthetic tradeoff. Secondly, the correct number and length of the ribs must be removed to create the waistline change. Third, the ribs must be removed carefully so the intercostal nerves are not injured and the pleura of the lung is not entered.
While thoracic surgery uses very large incisions for rib removal procedures, this is not acceptable for an elective plastic surgery procedure. The length of the incisions for this type of rib removal procedure needs to be no greater than 6 cms. The incisions should parallel the orientation of the underlying ribs and should be centered over the ‘central’ rib to be removed. This results in the best looking scar with equal access to the ‘perimeter’ ribs. This incision location is always located behind the mid-axillary line so that it is not seen from the front view.
Rib removal for waistline narrowing has been historically described as that of the last two of the free floating ribs, ribs number 11 and 12. This has probably been so described as they are the safest ribs to remove as they are well below the apices of the lungs and the pleura. Their removal does have some waistline reduction effects but they, alone, are not always the most effective or the complete answer. Removal of rib number 10 is often needed as well as it sits higher near the subcostal margin. This whether a total of two or three ribs per side are needed is a matter of preoperative and intraoperative judgment.
Careful technique is important to avoiding undesired intraoperative events and long-term adverse effects from rib removal. Two layers of back muscle must be crossed to reach the lower ribs (latissimus dorsi and external oblique muscles) and these should be split longitudinally to lessen the amount of muscle fibrosis when healing. The enveloping lining of the ribs must be separated carefully to avoid injury to the intercostal neurovascular bundle on its inferior edge. Dissection on the back side of the ribs, particularly above rib 11, must hug the bone tightly to avoid inadvertently entering the underlying pleural space.
Rib removal for waistline narrowing can be done very safely and effectively. It is not a so called dangerous procedure in surgeons experienced with rib harvesting. Postoperative recovery can be aided greatly by intecostal nerve blocks and muscle infiltration with long acting local anesthetics.
Dr. Barry Eppley
Indianapolis, Indiana