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Rib removal surgery for aesthetic waistline reduction is a newer body contouring procedure in plastic surgery. While talked about as an obscure surgery for decades and often thought to be a myth, it is an actual procedure with an established anatomic basis for its effect. It is typically perceived by patients and surgeons alike as a radical aesthetic procedure which then becomes frequently misconstrued as dangerous and unsafe. But the reality is that its unfamiliarity leads to this impression and its risk profile is actually less than that of tummy tuck surgery when performed by an experienced surgeon.

While the act of removing ribs seems new, it has a long history in plastic surgery for reconstructive purposes. The harvest of rib bone and cartilage is commonly done in facial plastic surgery for nose, jaw and ear reconstructions. Rib cartilage, and occasionally rib bone, is frequently used in primary rhinoplasty for significant dorsocolumellar augmentations, in secondary replacements for nasal implant complications and in selected revisional surgeries. It is typically harvested from osteocartilaginous ribs #4 or #5 through an inframammary incision or from cartilaginous ribs #8 or #9 from a subcostal incision lower on the chest wall.

Extensive ear framework reconstruction, as seen in congenital microtia or traumatic ear avulsions, requires significant sections of cartilaginous ribs #6, #7 and #8 to make a structure that resembles an ear. Such a large combined rib section is taken from a subcostal incision at the lower end of the frontal ribcage in the upper abdomen.

A time honored technique in jaw reconstructions, specifically that of the condylar-ramus section of the lower jaw, has been the use of costochondral grafts. Harvested from bony ribs #5, #6 or #7 from the lateral chest wall, their long curved length with a cartilaginous cap allows one end to fit into the TMJ joint and the other end attached to the lower ramus bone. Split rib grafts can also be used for upper jaw and skull reconstructions as well.

As seen by its multiple reconstructive uses rib graft harvesting in plastic surgery is far from new. What is new about rib removal surgery is its application (waistline reduction) and that the harvest is done to create the aesthetic effect and not to obtain the bone for grafting. Also the ribs removed are on the lowest end of the ribcage which does not typically serve as the donor site in reconstructive skull or facial surgery. But the basic premise of how to remove the rib by circumferential subperiosteal dissection with preservation of the intercostal nerve at its inferior edge remains the same regardless of why it is being done. It is a safe technique that has no greater risk than any other reason for rib graft harvesting.

Dr. Barry Eppley

Indianapolis, Indiana

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