Rib Removal Surgery: Beyond the Taboo
Dr. Barry Eppley refrains from using the word "extreme" and instead labels the patients who journey from across the globe to Carmel, Indiana, to consult him as "highly motivated". These patients seek procedures that other doctors decline - like skull augmentation, testicle implants, and shoulder widening - which form the mainstay of Dr. Eppley's practice.
Rib removal is one of those controversial body modification surgeries. It made headlines (both local and tabloid) four years ago when Dr. Eppley removed parts of rib pairs 10, 11, and 12 from Pixee Fox, a Swedish woman who has fashioned herself into a "living cartoon". The fact-checking site Snopes questioned whether the surgery was genuine or merely a publicity ploy; many outlets have long dismissed celebrity rib removal rumors as urban myths. But Dr. Eppley asserts that, although there's no medical literature on the procedure or knowledge of its origin and initial performer, "it's definitely not a myth". He estimates conducting 15 to 20 such surgeries annually.
Who Opts for Rib Removal?
Based on his observations, there are three categories of people requesting rib removal. Firstly, those with medical conditions such as rib asymmetry or iliocostalis syndrome, where the lower ribs cause friction against the iliac crest and irritate the soft tissue. Secondly, those transitioning from male to female and aiming to feminize their waistlines. And thirdly, women like Pixee who desire the ultimate hourglass figure. In other words: "Cisgender females who are very slender and have exhausted all conventional means, including liposuction, dieting, exercising, and using waist trainers or corsets." These are the patients Dr. Eppley refers to as "highly motivated" - and he aims to provide them with an "outstanding result" through floating rib removal by eliminating the final anatomical barrier to a slimmer waist. For the majority, that barrier is ribs 11 and 12 (also known as the floating ribs as they don't attach to the sternum or breastbone), but he has gone as high as 10. (There's no advantage in going to 9, he remarks, "since the focus is on the waistline.")
Is Rib Removal Surgery Risky?
He is well acquainted with people's perceptions of this specific procedure, stating, "Whenever rib removal is mentioned, it stirs up sentiments like, 'Well, these people shouldn't do it. They have no valid reason to do it. Anyone undertaking it would be insane.'" Nevertheless, he doesn't discern any significant difference from shaving two millimeters off someone's nose or inserting larger-than-average breast implants. What is considered normal is relative, and the reason a patient desires a particular appearance is immaterial to him. "What matters to me is whether the surgery can nearly achieve their goals and can it be performed safely?"
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Regarding his second point, evidently, it can be executed safely. Dr. Eppley estimates that he has removed 300 ribs from 40 to 50 individuals and has never encountered an infection, seroma, or medical complication - and it's widely accepted that the floating ribs have no functional purpose. Dr. Paul G. Ruff IV, a board-certified plastic surgeon in Washington, D.C., conducts the procedure on males, typically in their 50s and older, who are transitioning to females. "With the appropriate tools and in the correct setting, it's very safe and straightforward," he remarks. "As long as you remain at ribs 10 and below, the risk is relatively low."
Not all within the plastic surgery community concur. Dr. Gerald Imber, a board-certified plastic surgeon in New York City, acknowledges that "the procedure isn't rocket science" and that everyone who has undergone bone-grafting training during residency knows how to perform it - but he personally refuses to do so, despite receiving requests. "In my opinion, the risk of complications far outweighs the potential success," he says, explaining that to minimize scarring, doctors make "small incisions - an inch or two - on each side of the spine and extract the rib through that small incision using various tools", which raises the risk of perforating the thorax and internal organs.
"Pneumothorax [a collapsed lung] is a recognized risk of rib removal surgeries or rib harvest surgeries, due to the proximity of the rib to the underlying pleura," adds Dr. Kenneth Hughes, a board-certified plastic surgeon in Los Angeles.
However, every surgical procedure - whether for aesthetic purposes or otherwise - where a patient undergoes general anesthesia and a doctor makes incisions into the body entails risks. It's challenging to conclusively discuss the safety of cosmetic rib removal since the relevant data is lacking. Yet, we know that the complication rate has not been reported as high and that harvesting rib cartilage is a common practice in reconstructive surgery. We also know that much riskier procedures exist - seromas and hematomas occur in one-third of tummy tuck cases; reports from 2018 indicated a mortality rate of 1 in 3,000 for Brazilian butt lifts. So, what's the actual reason the vast majority of plastic surgeons won't go beyond liposuction to slenderize the waistline?
Related: 5 Common Reasons Plastic Surgeons Will Decline to Operate on You
"I've been asked to perform it, and I've informed patients it wasn't in their best interest. Generally, the patients requesting this have body dysmorphia and are attempting to achieve something anatomically that their body prohibits," says Dr. Robert Singer, a board-certified plastic surgeon in La Jolla, California. "It's an extreme procedure, and an increasing number of people are pursuing it because social media spotlights the most extreme individuals."
Unlike Dr. Eppley, these doctors claim they do feel a responsibility to determine the reason behind a patient's goal. "At some juncture, someone in the room must possess common sense, and if it's not the patient, it should be the doctor," says Dr. Imber.
Could it be possible that rib removal surgery, whether we like it or not, is part of the future that social media, filtering apps, and all those Kardashian ads for waist trainers and body-constricting shapewear are leading to? Plastic surgery is driven by supply and demand. Breast implants didn't exist 60 years ago; today, breast augmentation is the most popular procedure in the U.S. "It's all relative to familiarity," remarks Dr. Eppley, noting that his intention isn't to suggest that everyone should embark on rib removal - he wouldn't mind if he never performed another one for the remainder of his career. "The point is that the perception of the surgery as [physically] hazardous simply isn't the truth."
