Rib removals for waistline narrowing is the final step for maximal waistline narrowing. After weight loss, exercise and liposuction the final anatomic ‘obstruction’ remains that of the lower ribs for optimal. What differentiates the lower or free floating ribs from those above it is that they are bony appendages with terminal ends. They do not connected to any ribs above it and, as a result, have a different angulation. Rather than having a more horizontal orientation, they point much more downward. (this is in contrast to many anatomic depictions which show them to be more horizontal in orientation)
The lower two ribs (11 and 12) are known as the free floating ribs because they do not connect to any other ribs and only have a proximal attachment to the spine. The remaining ten pairs of ribs above connect, directly or indirectly, to the sternum. Without a connection this allows the ribs to angle more downward or ‘float’. The reality is that the floating ribs do have firm soft tissue connections at their cartilaginous tips to the abdominal musculature. Thus when the floating ribs are removed the waistline collapses inward due to loss of both structural bony support and their muscular attachments.
One key question in rib removal surgery is whether rib #10 above the free floating ribs would also provide some waistline narrowing effect. This has to be determined by physical examination before surgery. Patients with shorter vertical waistlines usually do while taller patients with longer waistlines may not. But when in doubt rib #10 can be taken and dissected around the waistline to be disarticulated from its cartilaginous attachment to rib #9 at the inferolateral subcostal region. Like ribs #11 and #12, it can still be removed through the same small oblique back incision of 5 cms in length.
One additional technique that I have added to rib removal surgery is to remove a piece of lastissimus dorsi muscle over the removed rib area. The thickness of the muscle allows for an increased waistline narrowing effect by about 1cm per side. Loss of part of the lower end of this back muscle has no functional consequences. To avoid any risk of seromas and to ensure good skin adaptation back down to the recontoured soft tissues, quilting sutures are used. Drains have never been used for rib removal surgery.
Dr. Barry Eppley
Indianapolis, Indiana