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Rib removal surgery in the properly selected patient can remove the last anatomic barriers to inward reshaping of the sides of the waistline. While the name rib removal is what the surgery is called it actually consists of three specific tissue reduction strategies, fat removal (flank liposuction), muscle modification (lateral latissimus dorsi muscle removal) and rib removals. Modifying all of these tissue layers around the waistline produces maximal waistline contouring.

It is the rib removal part of the procedure that understandably raises the most questions. One of the frequently mentioned concerns about rib removal surgery is that it will cause loss of organ protection. While no one ever specifies which ‘organs’ to which this refers, it is safe to assume the organ(s) referred to are the kidneys.

The kidneys are located in the retroperitoneal space high in the abdominal cavity. The right kidney is usually a bit lower than that of the left due to the location of the liver. In reference to the spine they are at the level of vertebrae T12 to L3. The upper part of the kidneys are provided some protection by ribs 11 and 12 and therein lies the concern about loss of organ protection with rib removal.

But in rib removal surgery the common misconception is that the entire rib is removed…and that is not true. There is no reason to remove the whole rib as it is only its outer section that has any influence on the lateral waistline. Thus rib removal surgery is more accurately described as subtotal or outer rib removal only. This is best visualized by an oblique line drawn through the usual resection line from ribs 10 to 12. When looking where the kidneys are located it can be seen that they would still have rib protection by the proximal rib segments that remain.

Another layer of protection for the kidneys is muscle in origin, specifically the erector spinae muscle group. This complex group of muscles runs along the entire vertebral column and is about a hand wide one each side of the spinous processes of the vertebrae. Over the lower ribs the deeper iliocostalis lumborum of this muscle group inserts directly onto the lower ribs. The longissimus and spinalis thoracic fibers of this muscle group run above the ribs and provide considerable thickening of this muscle layer. The erector spine muscle group provides some coverage of the kidneys but not completely. This is best appreciated by the renal angle which is anatomically described as the angle between the 12th rib and the erector spine muscle where the lower half of the kidney is located. This is more relevant on the right than left given the lower position of the kidney on that side. Bur removing the outer portion of rib #12 does not expose the kidneys anymore than they do naturally.

In conclusion, the only relevant rib in relation to the kidneys is#12 of which the lower half of the kidney does not have significant bone or muscle coverage naturally. But given that only the outer portion of this rib is removed no significant loss of protection occurs. The shortest length of rib removed in rib removal surgery is #12, which is the shortest of the lower ribs, as it has the least impact on waistline reduction. Removing the outer portions of rib #10 and #11 is located laterally and more superiorly than where the kidneys are located and thus has no impact on such organ protection.

Dr. Barry Eppley

Indianapolis, Indiana

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