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Liposuction is the first step (procedure) in rib removal surgery and is done to treat the superficial fat layer before going deeper into the ribs. While there are few variations as to how the initial liposuction is done the rib removal part can be done using various approaches. Having done hundreds of rib removal surgeries I have developed a tiered strategy to rib removal based on incision location and what can be accessed and treated through it.

While there are four types of rib removal surgeries the vast majority of patients fall into types I and II. The traditional approach (aka Type I) uses a small oblique lateral back incision (4 to 5cms) through which the outer aspects of ribs #11 and #12 are removed as well as a small wedge of latissimus dorsi muscle. Access to rib #10 was always sketchy, sometimes it could be safely accessed and a section taken and other times it could not.

With the desire to reach up higher and more consistently remove a portion of rib #10 and take more latissimus dorsi muscle a Type II technique was developed. In this approach the incision location is changed to a completely lateral location and is a bit longer. (5 to 6cms)

Through this more lateral incision the severe downward angulation of ribs #11 and #12 could be appreciated once exposed by opening the posterior serratus muscle and performing a circumferential dissection. Their downward angulation towards then iliac crest makes it easier to understand how their removal can cause the surrounding waistline to collapse inward.

Rib #10 is different as it is not free floating but wraps around toward the anterior subcostal ribcage. Besides being ‘deeper’ than the lower ribs it also rotates or twists making it hard to dissect tissues away from its inner surface. It is also thicker or has a greater cross-sectional diameter to it so better access to it has value in making it safer to resect as the pleura of the lung is always right behind it.

While the ribs have been resected with safe lengths removals and the posterior serratus muscle closed over them then a strip of the latissimus muscle is taken and tacked down. Over a drain the incision is closed.

The effects of the surgery are not immediately apparent at the end of the surgery even though the change in the waistline can be felt with described structural support.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

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