A variety of women seek waist-narrowing surgery — from transgender women to female bodybuilders — all sharing a common goal: an improved chest-to-waist or hip-to-waist ratio for a more defined figure. Within these diverse patient groups, anatomical differences must be considered. One not-uncommon finding in some rib removal candidates is scoliosis. Some patients have undergone scoliosis surgery in the past, while others have not, but asymmetry of the lower ribcage is almost always present to some degree.
The Role of Scoliosis in Rib Removal Surgery
When scoliosis is present, an important surgical consideration arises: should different lengths or even different numbers of ribs be removed on each side to account for the asymmetry? The best way to answer this question is through a 3D CT scan of the patient’s lower ribcage, which allows correlation between the skeletal anatomy and the visible external shape.
In my experience, it is usually unnecessary to remove a different number of ribs on each side. Rather, adjusting the lengths of the ribs removed — particularly on the more protruding side — is key to achieving symmetry.
Case Study: Female Athlete with Congenital Scoliosis
This patient, a female athlete competing in the bikini category of bodybuilding, presented with noticeable asymmetry of her torso due to congenital scoliosis. Her condition had never required surgical correction, but it caused visible asymmetry in her waistline, including a prominent end of the left-sided 10th rib at the subcostal margin. Her 3D CT scan revealed the characteristic spinal twist and asymmetrical positioning and length of ribs #10 through #12.
For optimal results, I used a vertically oriented, wavy-line incision to provide excellent access to ribs #10, #11, and #12.
Surgical Technique
Under general anesthesia and with the patient in the prone position, the incision was made and the latissimus dorsi (LD) muscle identified. A vertical split through the muscle allowed access to all three ribs. Rib #12, as expected, was deeply embedded and shorter on the right side due to her scoliosis.
Ribs #10 and #11 were removed in the typical subtotal fashion, but greater lengths were taken on the right side — the more protruding side — to balance her asymmetry.
To enhance the narrowing effect, the outer portion of the LD muscle was brought through the incision, split in half, and superior and inferior sections were removed, extending beyond the ends of the incision to create an extended torso effect. The new outer border of the LD muscle was then sewn over the rib removal sites, providing additional narrowing.
Drains were placed, and the vertical incision was closed with subcuticular resorbable sutures. Even while the patient was still in the prone position, the improved symmetry of her lower ribcage was evident. The fonal waistline narrowing effect ill take much longer to fully see.
Understanding Scoliosis and Rib Cage Asymmetry
Scoliosis most significantly affects the lower ribcage, as the greatest spinal curvature usually occurs in the lower thoracic or upper lumbar spine. This twist creates asymmetry in the lower torso: a “good” side with inward curvature, and a “bad” side with outward protrusion. Consequently, different rib lengths often need to be removed on each side to achieve balance — a calculation that can only be accurately made by reviewing the patient’s 3D CT scan preoperatively.
Latissimus Dorsi Muscle: Functional Considerations
A common question among female athletes and bodybuilders is whether removing portions of the LD muscle impairs strength or training ability. The answer is no. The amount of muscle removed is a small, carefully sculpted portion of an otherwise very large muscle, and does not create functional impairments or limit athletic performance.
Key Takeaways
? 3D CT scans are essential to evaluate lower ribcage asymmetry preoperatively in patients with scoliosis.
? Differential rib length removal (not number of ribs) is usually required to correct asymmetry.
? Bodybuilders and athletes can safely undergo rib removal and LD muscle modification without compromising their training or performance.
Dr. Barry Eppley
World-Renowned Plastic Surgeon