Is “Clack” Enough? Rib Remodeling Guided by Ultrasound

Summary:

Rib remodeling is a surgical technique that allows waist contouring in women and men. This study proposes that the “clack” sound heard in ultrasound-guided scarless rib remodeling (RibXcar technique) is not evidence of the completion of the surgery, but rather, the use of ultrasound is necessary to identify angulations, loss of bone strength, and ultrasound visualization of the loss of bone continuity, and thus consider cosmetic rib surgery to be complete. This study was performed on 100 Peruvian women aged 18–40 years who voluntarily agreed to a rib remodeling procedure. The RibXcar technique was used, and intraoperative ultrasound was performed to obtain objective information during each patient’s procedure. Of the total number of patients who underwent surgery with the RibXcar technique, the “clack” sound was detected in 90% of patients, and no “clack” sound was detected in the remaining 10% of patients. However, the use of ultrasound revealed monocortical fractures in 100% of patients. It is observed that of the total number of patients, only in 90% was the “clack” heard; however, in 100% there was a monocortical fracture evaluated in the immediate postoperative period. We suggest not considering the “clack” as the end point of the surgery; instead, define the end point after the use of the ultrasound examination, which provides information on angulations, the loss of bone resistance, and ultrasound visualization of the loss of bone continuity.

Takeaways

Question: Is the “clack” sufficient as an indicator of the endpoint of rib remodeling or is it a subjective indicator?

Findings: We have observed that of the total number of patients, only in 90% was the “clack” heard; however, in 100% there was a monocortical fracture detected by ultrasound in the immediate postoperative period. The “clack” does not indicate the end point of the surgery; however, the use of ultrasound verification does.

Meaning: The use of ultrasound offers objective information about rib surgery intervention.

INTRODUCTION

Rib reshaping is a technique used in men and women to stylize the waist.¹ The objective of this procedure is to provide patients with a better aesthetic result² by changing the anatomy of the lower region of the rib cage, causing a greater contrast between the iliac crest and the waist by accentuating and defining the waist area.^3,4

This study applies the RibXcar technique (“ultrasound-guided scarless rib remodeling”), which also assesses the degree of angular variation of the fracture and the variation in waist measurement and ends with ultrasound verification of the monocortical fracture.³ RibXcar is an advanced rib remodeling technique, guided by ultrasound, through minimal or almost imperceptible incisions, which allows us to remodel floating ribs 10, 11, and 12 to achieve a thinner and smaller waist with plastic surgery. When this technique is performed, a sound (“clack”) can be detected, indicating that the “fracture” of the ribs has been performed; however, it does not specify the type of fracture.

We consider that, although the “clack” provides valuable information about the intervention, this sound does not indicate the end of the surgery. For this type of intervention, the use of ultrasound is recommended for the intraoperative verification of fractures³ because it is more precise and sensitive for the management of sole rib fractures.⁵ We suggest the use of ultrasound because it permits an infinite number of scanning planes, since it can rotate and perform sweeps in the three axes of space, achieving that the generation of multiple images per second produces the effect of real time, which facilitates greater precisions and practicality in the intervention.⁵

In this study, our objective is to suggest the use of ultrasound in costal aesthetic surgery. Although the “clack” is a subjective reference, we propose the use of ultrasound as an objective contribution to define angulations, identify the loss of bone resistance and visualize the loss of bone continuity, which allows a more precise intervention in favor of the care of each patient, especially in the intrasurgical stage.

MATERIALS AND METHODS

All the patients completed a medical evaluation for body contouring and agreed to undergo the RibXcar technique by consensus with the surgeon.

The surgical procedures were performed in a private clinic in Lima, Peru (Clínica Santa Julia), from November 2022 to January 2024. The inclusion criterion was women aged 18–40 years, and the exclusion criteria were patients with complementary liposuction, a history of surgery (in plastic surgery or other specialties), a surgical risk score of Goldman risk index class II or more, a body mass index of more than 28, and flaccid abdominal skin.

All patients signed an informed consent form before surgery and authorized the use of their image in the present study, in accordance with the guidelines of the Declaration of Helsinki. The research protocol was also approved by the institutional ethics and research board.

The RibXcar^3,6 technique was used, and intraoperative ultrasound was performed to identify each rib, placing the linear transducer parallel to them to highlight the trajectory of each rib, the point, and type of fracture. [See Video 1 (online), which shows the application of the RibXcar technique.] In addition, we sought to identify the “clack” sound during the surgery in all patients.

Video 1. This video shows application of the RibXcar technique.

Download video file ^{(91MB, mp4)}

A Clarius L7 ultrasound scanner connected to an iPad Pro-12.9 was used for all ultrasound scans. For the incorporation of the use of ultrasound as a creator of the RibXcar technique, Manzaneda’s ultrasound verification is proposed, composed of three types of information, which can be obtained from the use of ultrasound in rib remodeling (Table 1).

Table 1.

Manzaneda’s Ultrasound Verification

Type 1	Ultrasound visualization of loss of bone continuity
Type 2	Ultrasound visualization of the loss of bone continuity + ultrasound objectification of angulation
Type 3	Ultrasound visualization of the loss of bone continuity + ultrasound objectification of angulation + loss of bone resistance

RESULTS

The RibXcar technique was performed on 100 women, without any comorbidity, with an average age of 32.07 years, an average weight of 55.2 kg, an average height of 1.61 m, and an average body mass index of 21.2 (Table 2).

Table 2.

Sociodemographic Data of the Sample

Variable	Minimum	Maximun	Mean	SD
Age	18	40	32,07	3.81
Weight	57	70	55.2	4.23
Height (cm)	150	172	161	3.09
BMI	21.1	25.3	21.2	1.82
Comorbidity	—	—	None reported	—

During surgery, using ultrasound, it was possible to detect the images in real time. In addition, the sound (“clack”) could be detected in 90% of the patients, but in the remaining 10% of patients, the sound was not detected. Surgical procedures were guided by ultrasound, and in 100% of them it was verified that the fractures were monocortical (Table 3).

Table 3.

Information Detected by Ultrasound

Variable
Sample (100 patients)	100%
Sound detection (“clack”)	Sound detected in 90%	No sound in 10%
Fracture (verification by ultrasound)	Monocortical	Monocortical
Complications	None reported	None reported

Type 3 information was collected in all patients, which is the most complete according to Manzaneda’s ultrasound verification classification. It was possible to detect at the RibXcar point the ultrasound visualization of the loss of bone continuity, the loss of bone resistance, and the ultrasound objectification of angulation. After the ultrasound information was collected, the surgery could be considered finished. [See Video 2 (online), which shows information collected during the application of the RibXcar technique from the use of ultrasound.] [See Video 3 (online), which shows the “clack” sound detected during RibXcar surgery.]

Video 2. This video shows information collected during the application of the RibXcar technique from the use of ultrasound.

Download video file ^{(77.2MB, mp4)}

Video 3. This video shows the “clack” sound detected during RibXcar surgery.

Download video file ^{(89.5MB, mp4)}

No pleural, vascular, or nervous lesions were evident in this series; however, 2% of burn cases in the puncture site were less than 0.4 cm in diameter, and were treated quickly without causing additional complications, such as infections or larger scars.

DISCUSSION

The RibXcar technique is the pioneer in ultrasound-guided incisionless rib reshaping. In Dr. Kudzaev’s technique,⁷ with a scar of 2–3 cm, an incision is made in rib 11 that rises and falls proprioceptively, and we believe that the “clack” sound has been considered as the end point in the technique; however, it is not a sufficient criterion to determine the type of fracture or the finalization of the surgery because it is a purely subjective issue.

Although there are methods such as radiography to verify patients during surgery, we believe that it is not an ideal method, as it requires greater logistics, exposes patients to radiation, and requires the patient to be briefly removed from direct clinical care at a time when close monitoring is essential.⁸

From our perspective, the “clack” is not enough; we consider it very relevant to incorporate the use of technologies that allow practicality and better patient care. Therefore, the use of ultrasound scanners becomes important due to the high level of sensitivity (89.3%) and high specificity (98.4%) for the diagnosis of any rib fracture.⁹ The main advantages of the system are the practicality at the time of performing the surgery and the surgeon’s comfort during their work.

It is pertinent to mention that this study does not intend to describe a surgical technique. What we propose is to include the incorporation of ultrasound in rib remodeling, and in the RibXcar technique, we promote its use because as surgeons we must include objective tools that allow an accurate intervention in our care.

CONCLUSIONS

We have observed that of the total number of patients, the “clack” was heard in 90%; however, in 100% there was a monocortical fracture detected in the immediate postoperative period. We suggest not considering the “clack” as the endpoint of surgery, but rather defining the end of surgery after the use of ultrasound verification.

DISCLOSURE

The author has no financial interest to declare in relation to the content of this article.