Your Questions

Q: Dr. Eppley, I’m currently looking for a surgeon to do my transgender breast augmentation, I’ve done my research for a few years and now. Looking for a surgeon, a little about my profile: I’m a transgender girl with a small rib cage and an overall very small frame and build. I’ve been on hormones for about two years now and believe I’ve achieved all I can naturally. I definitely know that I want to do cohesive gel ( “gummy bear”) implants, if you offer them (I think I read that you do). And would love to hear back from you! 

I also would like to ask about removing ribs 11 12 and maybe 10, I know you’ve recently removed them from two women before and I’ve read your feedback on RealSelf.com about the procedure. I’d love to hear back from you on what you recommend! Much appreciated!

A: All silicone breast implants today are of the highly cohesive gel variety known as the urban term, gummy bear breast implants. All three existing breast implant manufacturers use the same silicone gel today. What implant size, shape and profile remain to be determined. (volume in ccs, round versus tear drop shaped and medium vs. high profiles) Such selections are based on what your breast augmentation goals are.

The role of lower rib removal is for narrowing of the anatomic waist. This is for patients who are unable to achieve a more hourglass shape or any inward indentation at the level of the waistline at the umbilical level. This is often a particular body contouring issue in male to female transgender patients whose ribcages are phenotypcally wider with greater outward rib flare.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a problem with my lower floating ribs. They touch my pelvis bone and cause a lot of pain and discomfort. Typically they render me inactive for weeks, sometimes months at a time. I’ve been to countless physiotherapy sessions, and I have looked and looked for a doctor who would consider rib removals.. I just discovered you on YouTube, and I am wondering if you would consider this for me. Thank you for your time. 

A: Thank you for your inquiry. It is very rare that the lower floating ribs actually touch the iliac crest of the hip with certain body movement…but I have had previous patients tell me this before. And it can be anatomically explained as ribs #11 and 12 actually point downward as opposed to the ribs above it which point more to the side. Also they are partial ribs and not complete ones so they do have a blunt end to them. The good news is that rib removals of them should be a cure for this type of anatomic impingement problem.

Rib removals of ribs #11 and 12 are done through small incisions on the back that parallel the direction of the ribs.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am considering a series of separate body feminizing procedures (transgender body contouring) in this sequence:

1. Butt Implants with body lipo/fat grafting to complete hip/butt shape.

2. Then take 3-6mo to regrow some fat for Breast Implants with body lipo/fat grafting for cleavage and more natural finished shape.

3. Ribs removal. Front and back. Im not sure of the exact rib #s, but Im referring to both protruding ribs in front, and lower floating ribs. Would you kindly advise what exactly is possible, safe, and effective?

4. Tummy tuck with plication and for “internal corset” effect.

My thinking is that doing rib removal as a separate procedure before tummy tuck, allows for removal of more ribs than if removing ribs at the same time as tummy tuck, and will create more potential for the tummy tuck to draw in/around the trunk, for an overall slimmer torso and waist.

Would you kindly let me know your thoughts?

Thank-you Dr!:)

A: Thanks for detailing your transgender body contouring sequence, I would make the following comments to them .

1) Buttock implants with overlay fat grafting is a good approach to these needs. Fat grafting can only be done if the buttock implants are placed in an intramuscular position and not in a subfascial location. This would really be based on implant size. Any buttock implant bigger than 330cc would have to be placed in a subfascial location. In thus case, fat grafting is done first followed by implants secondarily.

2) I doubt once you harvest fat the first time there would be enough for the second time. The concept of growing fat is not usually a good idea for fat grafting since any weight loss will simply make what has been transferred to go away. It is important to remember that grafted fat acts like where it comes from, it retains its donor sit characteristics. It would make the most sense to rely on implants to do the complete breast augmentation/reshaping.

3) For waistline narrowing, ribs #10, 11 and 12 are commonly removed with small incisions from the back. For anterior protruding ribs (ribs 8,and 9) that is done through either a low subcostal incision or through tummy tuck incision.

4) If one is having a tummy tuck then that would be the ideal time to remove the subcostal ribs #8 and 9.

With this information, I would make the following recommendations based on how to best put the body contouring program together in two stages.

#1 Rib removal #10, 11 and 12, intramuscular buttock implants (300cc) and waistline/abdominal liposuction with fat grafting to the hips and around the buttock implants.

#2 Six months later….breast augmentation with implants, tummy tuck with rib removals 8 and 9.

This, in my opinion, would be the best way to put in all together and is actually how it is commonly done.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in rib removal surgery for waistline narrowing. I am 30 years old, 5’2” 135 lbs with a 29  inch waist. I have breast implants and have had 2 fat transfers to my hips and buttocks. My waist may look smaller in these photos because I have added fat to my hips. When I was at my thinnest (125lbs) my waist was 26 inches. I feel I naturally have a very wide upper body. If I do proceed with the rib removal, am I obliged to wear the corset 24/7 for the rest of my life as I saw someone on TV doing? Any chance this would affect future pregnancies?

A: Rib removal surgery does NOT require wearing a corset or any form of wrap around support beyond the initial healing period of a few weeks after surgery. (because it will feel better if you do right after surgery) The patient and TV episode to whom you refer was waist training and that involves the long-term use of a corset. That is the exception and not the rule in rib removal surgery. This surgery would not affect the ability to get pregnant or carry a baby to term.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I just recently read an article that said that you did a rib removal surgery on a woman. This is something that I have been interested in for a very long time. I was born with a disfigured ribcage and there’s nothing I hate more. The left rib protrudes more then my left side! I used to have pectus excavatum, I had a surgery where the doctor inserted a metal bar in my chest which was removed! Please let me know if you can help me. I feel like this is something that I need to actually be happy with my body.

A: Thank you for sending your pictures for consideration for rib removal surgery. Your subcostal protrusion is due to the prominence or bowing out primarily of ribs #7 and #8. (and a little bit from #9) This is not uncommon in pectus excavatum which you obviously had having undergone the Nuss procedure. (placement of the pectus bar and its subsequent removal) It would be necessary to remove ribs #8 and #9 and either do a shave or beveling of #7. (subtotal removal) The only aesthetic issue with this rib removal surgery is that you need a direct subcostal incision to do so. You would need a 6 to 8cm along the subcostal margin on each side. One has to decide whether a fine line scar is a better aesthetic concern than that of the rib protrusion.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in removal surgery.  I was born with pectus excavatum and significant rib protrusion. I have been advised by a thoracic surgeon that the worst ribs are 7-9. The deformities seem to be limiting my lung expansion. My insurance will cover cosmetic procedures to correct congenital deformities, as well as, medically necessary procedures for respiratory issues. I have seen you write about providing a rib resection procedure for narrowing the appearance of one’s waistline. The thoracic surgeon indicated that there is a procedure for removing the ribs while leaving the lining intact so that new ribs can form hopefully more normally (sometimes requiring bracing). I would prefer to have a plastic surgeon do such a procedure to increase the likelihood of having a more aesthetically pleasing result. Therefore, my question is: Do you have experience with any rib removal procedures that would allow for rib regeneration, and if not, do you know of any other plastic surgeon that may?

A: Rib removal in an adult is a permament procedure. As an adult, ribs that are removed whether they be the bone or cartilaginous portion, will not regenerate. That ability is lost when one is older than one year of age. So your thoracic surgeon is either misinformed or you may not have understood fully what he/she was saying. More likely the thoracic surgeon was referring to rib reshaping. The proper treatment for a pectus excavatum deformity in an adult is known as a Nuss procedure. This is where a rigid bar is placed under the ribcage to push it outward and allow for expansion and some rib recontouring. For rib protrusions of the anterior subcostal margin (ribs 7 through 9) the cartilaginous portions of the ribs can be removed to lessen the visible portion. This will improve their appearance but will not provide any improvement in pulmonary function. Only a Nuss procedure can do that. Rib removal is a cosmetic procedure not a functional one. Loss of thoracic support from rib removal can not contribute to improved pulmonary function.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in rib removal surgery to get rid of my lower ribcage which sticks out. I do have a few questions about the surgery.

1. I know rib removal isn’t as common of a procedure as tummy tucks or breast augmentations, how many of them have been done?

2. What are the reasonable cosmetic expectations? 

3. I’ve done some research and have read that in some patients it creates permanent pain. Is this sometimes the case? 

4. Also, is there a chance of uncontrolled bleeding from the operation? 

5. What are some common complications? 

A: Rib removal surgery can be done to be used for grafts in various facial reconstuctions (usually rhinoplasty) or for cosmetic contouring of various ribcage protrusions. The fundamental difference between these two types of rib removal are the length of ribs removed and the number and location of them. In answer to your specific questions:

1. Ribcage contouring by rib removal is a very uncommon cosmetic procedure but i do about 3 to 3 case of it per year. I do many more rib removals for rhinoplasty and jaw reconstructive procedures.
2. The success of rib removal for improved ribcage shape depends on the exact ribcage anamoly. How many ribs and what areas can be removed vs. what is the source of the problem, and how well these match up, determines how successful the procedure can be.
3. I have not seen a rib removal patient who has permanent pain and this most likely relates to rib removal for chest surgery which is done differently. (and at a higher rib level since they are interested in entering the chest cavity….a goal that is the exact opposite of aesthetic ribcage reshaping)  This usually involves rib bone removal not rib cartilage removal in lower ribcage reshaping. In cosmetic rib removal or any rib graft harvest great effort is made to preserve the neurovascular bundle which runs along the bottom of each rib. Nerve injury or neuromas can be a source of chronic pain.The lack of permanent pain in aesthetic rib removal should not  be confused, however, with the fact that there is some significant pain after the procedure. I attempt to limit this immediate postsurgical pain with the injection of Exparel long acting local anesthetic into the surrounding tissues as well as intecostal nerve blocks which usually lasts about 72 hours
4. There is no chance of uncontrolled bleeding from this type of surgery.
5. The complications from this type of surgery are essentially aesthetic….how does the scar look and how effectively has the ribcage protrusion been eliminated.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in rib removal surgery to reduce my protruding ribcage. How risky is this procedure? What are the complications/healing time? What would the results look like? How much, on average, would this cost? What other medical issues would be affected by the surgery? Sorry so many questions! Also, I live in Idaho how do you work with out-of-state patients? 

A: Rib removal is not a dangerous surgery but, like any surgery that involves rib manipulation, it does cause some considerable discomfort. This is magnified when both sides of the ribcage are operated on at the same time. The best method of postoperative pain management I have found is the use of Exparel injections as intercostal nerve blocks done during the surgery. This is a local anesthetic that lasts for 72 hours after its placement. One could expect that it would take up to month after surgery until one has fully recovered. There will be a scar for the incision needed on both sides which would be about  6 to 7 cms long. The goal of the surgery is to remove ribs number 8 and 9 to reduce the subcostal protrusion.

My practice has many patients from all over the world for various types of plastic surgery. Patients usually come in the day before the surgery to have a face to face consultation and have surgery the next day. Whether you would stay overnite in the facility depends on whether you are traveling alone or with someone. I would anticipate your stay here to be no more than 2 or 3 days after rib removal surgery before returning home.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in rib removal surgery. I have a very boxy figure and I am a model. I am looking to get more of an hour glass figure and gain more confidence in my appearance. As of now I refuse to take photos straight on because they make me look wide, but I strongly believe having those ribs removed will assist me in achieving those goals. Right now my measurements are 34C bust and then my hips are 38″ at the smallest point of my midsection I am 26″, and when my personal trainer measures me at my “real waist” it is 33″ I am 5’9 and 133lbs. I would really like to have a better figure, but with wide hips and my ribs I feel like it is difficult without the surgery. What is your professional opinion? 

A: I think you who feel and know your own body better than anyone has the best perspective on what may be of benefit to an improved body shape. the question is not whether rib removal will be effective but exactly what ribs are best to remove. I would doubt that 11 and 12 are the ones as they lie too posterior and do not really wrap round the torso. Thus their removal would have no benefit to bring in the sides of the torso. More likely it is ribs 8,9 or 10. If you could send me a picture of the ribs marked on your ribcage (with a Sharpie) where you feel the greatest reduction is needed, that would be very helpful in determining the exact rib numbers to be removed for your rib removal surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would like to have a consultation for the rib removal, I really want a more hourglass shape, i have read that to be a candidate for this procedure you have to be short waisted which I think I am. I contacted one other surgeon and he said he only does this surgery through a tummy tuck incision. I was wondering if there are any other options as I am not a candidate for tummy tuck and I really dislike that scar. How much is this procedure? And how long would it be before I can fly back home? 

A: Please send me some pictures of your body/waistline so I can assess whether this would be a good procedure for you. Also if you can, please draw on yourself with a marker as to the rib protrusions that you think would benefit by removal. I have never done rib removal through a tummy tuck incision and have always done it through small direct incisions. There is certainly no reason to do it through a tummy tuck incision unless one is also wanting and needing a tummy tuck as well. Its only advantage is that the lack of a chest wall scar.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a botched ear surgery and need to come to you for correction for more prominence. I also want to build up my nose for taller nasal bridge. I know it is best to use rib cartilage for surgery rather than a foreign material like Medpor. My concern is that I am a dancer and have to be shirtless a lot for work. I worry the scar needed for rib removal will be big and also will change my physique? Then I read about rib removal for cosmetic surgery purposes. If this is the case maybe it will give me a more defined figure because rib removal gives a more slender slimmer lower waist? Is that correct? Would you be able to use the same scar? I plan to do the surgery separately, first do ear revision and then few months later do nose. Would they use rib from one side for ears and then rib from other side for nose? Or is there not going to be enough rib? Can they use one scar to remove rib and symmetrically remove rib for each side? 

A: Rib removal, whether it is done for otoplasty correction, augmnetative rhinoplasty or for waistline reshaping, will create a scar. It is not a large scar, usually about 4 cms in length, but it is a scar nonetheless. If harvesting just for the nose or ear, it will not change your physique or cause an indented chest area. The amount of rib cartilage length removed is not that long.

Because of the recovery from rib harvest, it is probably best to do the otoplasty revision and rhinoplasty at the same time. While two separate surgeries could be done the amount of rib cartilage needed for the ears is small and does not seem worthy of a separate surgery to do it.

Rib removal can help define the upper waistline by removing the lower free floating ribs but whether that is worth that effort and the two scars to do it must be considered carefully.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 26 year old female from who is looking to have rib removal done for ribcage narrowing. I saw online that you perform this surgery and was wondering if I would be a good candidate. My ribs have always bugged me because they protrude so much. I want them removed to create a smaller upper body and also because they stick out more than my breasts. I have attached some pictures of me laying down so you can see what I mean. I look forward to hearing from you.

A: Typically ribcage narrowing by rib removal is done  to make one more ‘high-waisted’ or to lengthen the distance between the bottom of the ribcage and the hips. This is done by removing the cartilagious portions of ribs 9 and 10 which are more to the side of the ribcage. What you have/are demonstrating is rib protrusion or ribs that stick out. This involves the inner portion of the ribcage closer to the sternum rather than the side. This is a slightly different rib location. This is seen when one stands up but becomes a lot more noticeable when one lays down. (as seen in your picture) This protrusion occurs because of the confluence of ribs 6, 7 and 8. They all join in this area and the way they come together (angulation) causes them to stick out. This section of ribs can be removed (and is actually commonly done in reconstruction of microtia ears) but will require a 4 to 5 cm incision along the lower edge of the ribs to do it. This results in a fine line scar and one has to be certain that this is a good aesthetic trade-off.

Dr. Barry Eppley

Indianapolis, Indiana