The last surgical method to help with horizontal waistline reduction is rib removal. The lower free floating ribs in particular have a near vertical inclination which can serve as an obstacle for those seeking to bring their natural waistline in further. Through small oblique lateral back incisions the outer half of these ribs can be removed. This allows the soft tissue support they provide to be removed and the waistline profile to narrow.
The only debate in rib removal surgery is whether rib #10 should be shortened along with that of ribs #11 and 12. The question is not whether it can be done but whether it wold provide any aesthetic benefit to do so. This must be determined on an individual patient basis by examination to determine the level of rib #10 and its contribution to the desired aesthetic result. In most, but not all cases, it can be helpful.
But between the skin and the ribs lies other tissues whose removal may also help with reducing tissue thickness. Fat is the obvious offender and anyone considering horizontal waistline reduction should have aggressive liposuction done either before or during the rib removal procedure. When done from the prone position such liposuction efforts provide dividends even in thin women or patients that have had it done previously. There almost always is at least 50cc to 100cc of liposuction aspirate per side that can be removed even in the thinnest women.
But between the fat snd the rib lies muscle, specifically the latissimus dorsi muscle. Being the largest muscle on the back it is very thick even in thin women. Since the muscles be traversed to get to the ribs, I have appreciated how thick it is and its contribution to waistline width. As a result I have lead that it is useful to remove a v-shaped wedge of the muscle right at the level of the umbilicus. (aka horizontal waistline) This usually adds another 1 cm per side of waistline narrowing. Its removal does not cause any long-term functional issues or adds to the short-term recovery.
Dr. Barry Eppley
Indianapolis, Indiana