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Rib removal in aesthetic surgery is associated with waistline narrowing. Once thought to be a myth, the partial removal of the downwardly sloped free floating ribs is a valid surgical procedure that does remove bony support of the lateral waistline. But to make the procedure effective there are some basic steps to maximize its potential effectiveness. 

STEP 1 The location of the back incision needs to be above the circumumbilical line. The 360 degree level of the umbilicus (circumumbilical line) marks the level of the 12th rib. So to get access to rib #11 and even rib #10 the location of the incision must be higher than this line. The incision will also be located at the higher end of the flank liposuction area.

STEP 2 Since rib removal surgery is performed in the prone position this is an ideal time to perform flank liposuction. This is entrance sites done through the dimples of Venus if present and also serve as the exit site for the drains. Even in patients who have had prior liposuction there is almost always some fat which can be removed. Reducing the subcutaneous fat layer at the lateral waistline can only be beneficial for the overall effort even if it is just a modest amount of aspirate is obtained. 

STEP 3 Rib removal is accomplished by a tunnel technique. To keep the back incision as small as possible, the rib is transected proximally and then turned 90 degrees which it can do so because it is free floating. (ribs #11 and #12) The rib is then pulled through the incision as the soft tissues are removed from it in a circumferential manner by subperiosteal dissection and electrocautery. In this dissection is it important to visualize and preserve the intercostal nerve along the inferior border of each rib.

STEP 4 Some reduction/narrowing of the latissimus dorsi muscle is important given its tremendous thickness and contribution to the lateral waistline even in cis females. A wedge reduction of the outer portion of the muscle is done along the same outline as that of the flank liposuction. Removing such a muscle wedge as no effect on function or muscle weakness. Thus in addition to the rib specimens there would also be a small section of the muscle from each side.

STEP 5 Postoperative garment compression of the waistline does have some valuable soft tissue reshaping effects just like that of liposuction. The use of waist trainers are ideal garments whose compressive effects are in exactly the ideal location for waistline reshaping. Their use is intended to only be short term for 6 to 8 weeks after the surgery when most healing will have occurred.

Dr. Barry Eppley

Indianapolis, Indiana

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