Abstract
Background
Body contouring techniques have limited impact on waist definition because of their focus on soft tissues. Rib remodeling surgeries have emerged as a safer, minimally invasive option to improve the aesthetic definition of the waistline compared with more invasive and aggressive techniques, such as rib resection.
Objectives
In this study, the authors introduce waistline aesthetic slimming by puncture (WASP) and a parallel approach to enhance the hourglass silhouette and effectively decrease the waist diameter in body contouring procedures.
Methods
The authors conducted a retrospective cohort study from July 2023 to August 2024, at 3 specialized plastic surgery institutions in Colombia and Brazil. Inclusion criteria were patients undergoing WASP technique. Exclusion criteria included previous rib surgeries, BMI >30 kg/m2, chronic respiratory diseases, spinal disorders, and incomplete data. Patients completed a satisfaction questionnaire (Global Aesthetic Improvement Scale) 3 to 6 months postprocedure.
Results
The authors of this study included 125 patients who underwent WASP technique, primarily females (96.8%). Mean age was 34.7 years (standard deviation [SD] 7.1) and mean BMI was 24.1 kg/m2 (SD 2.4 kg/m2). Most patients (63.8%) had no previous aesthetic procedures. Overall complication rate was low at 3.8%, with no serious adverse events reported. Waist measurements improved significantly from a median of 76 cm (interquartile range [IQR] 7.9 cm) preoperatively, 68 cm (IQR 8 cm) postoperatively, and 65 cm (IQR 7.4 cm) 3 months postprocedure, resulting in a waist-to-hip ratio (WHR) decrease from 0.8 to 0.7. Patient satisfaction was high, with 92.9% reporting being “very satisfied” with the outcomes.
Conclusions
WASP is a safe and reproducible technique, effective for decreasing waist measurements and WHR, overall contributing to the body contouring process.
Level of Evidence: 3 (Therapeutic)
One of the main goals of body contouring surgery has been the enhancement of an aesthetically pleasing waistline. Although conventional techniques, such as liposuction and abdominoplasty, effectively address subcutaneous fat and skin laxity and can aid in decreasing the waist-to-hip ratio (WHR), they are inherently limited in altering underlying skeletal structures. It is well established that WHR may be the most appealing feature of the female body, capturing male attention for both mating purposes and aesthetic appreciation.1-3 Rib surgery represented a paradigm shift in body contouring procedures by enabling surgeons to selectively modify the rib cage structure to obtain enhanced waistline definition. Through selective fracture and reshaping of false and floating ribs, surgeons can achieve a pronounced hourglass silhouette that is unattainable through soft-tissue procedures alone. Previous methods of rib surgery for contouring purposes involved floating rib resection, but the aggressive nature of this approach, with considerable associated risk for serious adverse events, such as hemothorax and pneumothorax,4,5 has raised concerns. Additionally, recent reports have shown the effects of rib removals and their inherent impact on internal organs' protection and respiratory functions.6-8 One of the techniques of floating rib removals for body contouring is the “Ant Waist” described by Chiu et al in a series of cases, which, in a comparative cross-sectional analysis by Aburub et al, proved to produce a significant detrimental effect on lung and respiratory muscle function, when compared with matched controls.6,9
Over the past decade, Dr Kazbek Kudzaev has pioneered less invasive rib remodeling techniques, developing the idea of inducing greenstick fractures in the floating ribs and shaping them with external physical measures. This breakthrough shifted the paradigm of rib surgery for aesthetic purposes, allowing for a safer approach to body contouring with minimal invasiveness. In his latest publication in 2021, Kudzaev and Kraiushkin described a technique of osteotomy on the 11th and 12th ribs through 2 cm incisions, using an oscillating saw or piezotome, followed by manual pressure.4 Despite the refinement of his method, compliance with postoperative corset use remains critical, as demonstrated by 3 cases of suboptimal results requiring revision. Other significant advancements in rib remodeling techniques include the “ultrasonic- and ultrasound-assisted indentation surgery of the thorax” (UUAIST) method introduced by Oñate Valdivieso et al.10 UUAIST uses real-time ultrasound (US) to guide piezotome-assisted greenstick floating rib fractures. Although this technique has proven effective for waist narrowing, it reported 2.5% residual asymmetry because of noncompliance with corset use and 9.1% incidence of severe postoperative pain requiring opioid treatment. “RibXcar” technique described by Manzaneda Cipriani et al11 is an US-guided procedure aimed at creating through puncture, monocortical fractures of the 10th, 11th, and 12th ribs, providing an incision-free alternative. However, the technique has been evaluated on a small sample size, which limits the ability to draw broader conclusions regarding its overall safety and efficacy, in addition to an increased risk of organ puncture because of its perpendicular approach. In comparison, “rib osteotomy with osteosynthesis stabilization” (RIBOSS) technique described by Aguilar Villa et al combines floating ribs corticotomy and osteosynthesis using titanium plates, demonstrating promising results with minimal complications and removing the limitation of postoperative permanent corset use.12
Drills operate through a rotating motion to cut bone and other hard tissues, whereas piezotomes utilize ultrasonic vibrations for precise bone cutting. To enhance the efficacy of corticotomy, some authors have explored the use of either drills or piezotomes. However, both techniques present advantages and limitations. For instance, UUAIST and RIBOSS might leave visible scars, whereas the “Ribxcar” technique can lead to thermal injury because of overheating of the tip in addition to its perpendicular puncturing of the cortical bone, which may pose additional risks. Waistline aesthetic slimming by puncture (WASP) technique introduces a mini drill or piezotome for externally controlled rib corticotomy. This method incorporates an anatomically guided approach and a specially designed tip (ultrasonic), aiming to enhance precision while minimizing complications and improving procedural efficiency. Currently, no evidence favors 1 tool over the other in terms of clinical superiority; rather, surgeons typically choose the tool they feel most proficient with. We are describing our experience with this technique by analyzing postoperative outcomes and complications.
METHODS
Study Design and Population
A retrospective analytical cohort study was conducted using data from patients at 3 specialized plastic surgery institutions in Sao Paulo (BRA), Bogotá and Bucaramanga (COL), from July 2023 to December 2024. All patients included in this study underwent WASP technique, performed by 4 experienced plastic and reconstructive surgeons highly experienced in body contouring and rib remodeling techniques. Rib corticotomy was achieved by using 2 different tools: a power drill (Group 1) and a piezotome (Group 2). Inclusion criteria were adult patients between 18 and 55 years old, in overall good health, who will not achieve the desired reduction in WHR through less invasive body contouring procedures. Previous ribcage surgeries, BMI >30 kg/m2, chronic respiratory diseases (eg, asthma), comorbidities that affect calcium metabolism (eg, osteoporosis), and moderate or severe spine disorders (eg, scoliosis, lordosis, and kyphosis) were considered exclusion criteria. Patients with a follow-up of <1 month or incomplete clinical/surgical information were excluded from the analysis. All patients were asked to complete the Global Aesthetic Improvement Scale to assess satisfaction between 3 and 6 months after surgery.
Ethical Considerations
Each patient was explained in detail about the objectives and techniques. Patients were informed that the authors had no sources of funding and no conflicts of interest. A thorough explanation of all the surgery procedures and WASP technique was provided, covering its innovative features, potential risks vs benefits, and potential adverse effects. Every procedure was designed based on the patient's expectations and body type. All patients gave written informed consent for the surgical procedures and the use of their data and photos for academic and research purposes. This study is categorized as minimal risk because of its retrospective nature, and it was conducted following the Declaration of Helsinki.
Data Collection
Data on patient demographics, the type and duration of the procedure, the areas targeted for liposculpture, areas and muscles for fat grafting, ribs being remodeled, waist and hip measurements, adverse events, and satisfaction scores were retrospectively collected from clinical charts for analysis. A trained nurse with experience in research data collection, who was blinded to the study's objectives, gathered the data to ensure its accuracy.
Statistical Analysis
All the variables were summarized using univariate statistical analysis depending on the data characteristics. Qualitative variables were described with frequencies and percentages. For quantitative variables, the normally distribution of the data was evaluated using the Shapiro–Wilk test. For normal distributed variables, the mean and standard deviation (SD) were used to summarize the data, whereas the median and interquartile range (IQR) were employed to describe non-normally distributed variables. All statistical analyses were performed on IBM SPSS Statistics Software (version 29.0.2; IBM Corporation, Armonk, NY).
Surgical Technique
Special Concepts
“Kudzaev's principle” has introduced an innovative approach to body contouring surgery. This concept applies orthopedic principles to create a greenstick fracture for improving rib curvature. Kudzaev and his students pioneered this technique, popularizing rib remodeling through selective corticotomy of the outer edge of the floating ribs to reduce the waistline diameter. There are 2 main approaches for performing the corticotomy: the “longitudinal approach,” as developed by Kudzaev and Oñate Valdivieso et al, and our “ladder approach,” which we recommend when the shoulder width exceeds the hip width (a biacromial distance greater than the interiliac distance, >1:1). When the shoulder-to-hip ratio is less than or close to 1:1, the traditional longitudinal approach should be used instead (Figure 1).
Figure 1.
Artificial intelligence–generated images of female patients in her thirties showing the 2 different shoulder-to-hip ratios. (A) The ladder approach is recommended when the shoulder width exceeds the hip width. Incisions do not follow a linear pattern along the ribs; instead, each successive incision is positioned 1 cm farther from the midline than the 1 below. (B) The longitudinal approach (linear pattern) is used for a shoulder-to-hip ratio less than or close to 1:1. Of note, biacromial distance is measured between the acromion processes of each shoulder, whereas the interiliac distance is determined by the most lateral projections of the iliac crests. This figure was generated using Krea.ai (San Francisco, CA). After the image was created, the authors reviewed and edited using Photoshop (Adobe, San Jose, CA). The authors take full responsibility for the content of the publication.
Preoperative Evaluation
Blood tests and 3-dimensional (3D) reconstruction computed tomography scans were required for health assessment, anatomical study, and surgical planning. Skeletal structures of the torso were analyzed in detail; measurements of hip, waist, and torso were taken; and a detailed explanation of the procedure, postoperative garments, and required duration of use, complications, and expectations was discussed. We followed the same principle of Oñate Valdivieso et al for the rib remodeling approach (Table 1). However, puncture for rib access was done by puncture over a line following the anatomical distribution of the ribs. Additional safety protocols for patient preparation were completed as per any other body contouring procedure.13-18
Table 1.
Rib Remodeling Approach Based on Computed Tomography Scan
| Criteria | Conduct per rib(s) |
|---|---|
| Standard interventiona | 10, 11 (BL) |
| Short 12th rib(s) (≤7 cm) | 10, 11 (BL), 12 (UL or BL)b |
| Short torso | 10, 11, 12 (BL)b |
| Long projection of 10th rib(s) (≥10 cm) in long torso | 10, 11, 12 (BL)b |
| Long projection of 11th rib(s) in both short and long torsos | 10, 11 (BL)b |
Procedure has to be also adjusted to the curvature of the spine: mild and moderate scoliosis might need an asymmetric intervention as well. BL, bilateral; UL, unilateral. aVerify the symmetry and presence of both 12th ribs (rule out rib agenesis). bUL and BL will depend on symmetry and length of the ribs.
Liposculpture and Rib Remodeling
High-definition lipoplasty is performed as a 3-step procedure: infiltration, emulsification, and extraction. We perform traditional tumescent solution infiltration (1000 mL of normal saline and 1 mL of epinephrine). Then, we use third-generation US (VASER Lipo System; Solta Medical—Bausch Health Companies Inc., Bothell, WA) for fat emulsification. Liposuction is done using 4.0 and 3.0 mm Mercedes cannulas connected to MicroAire system (MicroAire, MicroAire Surgical Instruments, LLC, Charlottesville, VA).13,19 Autologous adipose grafts are prepared through decantation and then selectively lipoinjected. With the patient in prone, the “Rib Remodeling” procedure begins by identifying the ribs (10th, 11th, and 12th) ∼7 to 8 cm from the midline, using manual palpation and/or US-guided mapping to locate the incision at the midpoint of each rib's width and following the patient’s anatomical landmarks (ladder vs longitudinal approach). After anesthetic solution is infiltrated into the periosteum, a 16 G needle is used to reach the cortical bone, followed by periosteum stripping using a zig–zag motion along the rib width. Given the proximity to the pleural space and the intercostal neurovascular bundle, we perform the rib corticotomy using a parallel rather than a perpendicular approach—considering the angle of the drill/piezotome relative to the outer cortex of the bone (Figure 2). Making a horizontal cut across the outer cortical layer over the rib width minimizes the risk of penetrating the deeper cortical bone or inadvertently entering the pleural space. For that purpose, we use either a Teflon-coated drill tip (0.8-1.0 mm in diameter) or a Woodpecker piezotome with a 44 mm long head and a diamond-like blunt tip for Groups 1 and 2, respectively (Figure 3). The drill operates at 40% micromotor speed to reduce frictional trauma and prevent burns, effectively dissecting and cleaning the bone surface while creating a horizontal notch across the rib (Video). The piezotome, on the other hand, requires a clean bone surface and continuous irrigation to achieve an optimal bone cut. Once corticotomy is complete, we apply firm inward pressure (in-fracture) to produce a single-cortex greenstick fracture. We recommend starting with the lower rib fractures and moving to the next one on top. This will facilitate the larger ribs to move inwards. The fracture and rib angle are then confirmed by US. The improvement in waistline contour can be visually compared with the opposite side, where only liposculpture has been performed (Figure 4).
Figure 2.
Parallel approach and its significance for patient safety: the pleural space (purple line) and intercostal blood vessels (red dotted lines) are critical structures that must be protected during rib remodeling surgeries (A). Considering the angle of approach of the drill/piezotome relative to the outer cortex of the bone, the parallel technique ensures safety by remaining superficial, avoiding penetration into deeper cortical bone, as shown by the yellow arrow (B). Conversely, the perpendicular approach (C) increases the risk of penetrating the deeper cortical bone (multiple yellow arrows), potentially damaging the intercostal blood vessels (red) or breaching the pleural space (purple line).
Figure 3.
Three-dimensional models of the 2 different blunt tips used for waistline aesthetic slimming by puncture. (A) The Teflon-coated 1.0 mm drill and (B) the diamond-head tip of the piezotome.
Figure 4.
Intraoperative photograph of a 32-year-old female patient undergoing high-definition liposculpture combined with the waistline aesthetic slimming by puncture technique on the patient's right side. The patient's right silhouette demonstrates enhanced definition and contour compared with the less pronounced left side.
Postoperative Care
Optimal rib angulation will be heavily impacted by the correct use of garments. A corset must be worn nonstop for up to 12 to 16 weeks. Its width has to be adjusted 1 cm tighter every week. High-definition liposculpture pressure garments with rib support should be worn continuously for the first 8 to 10 weeks, being only removed for showering. We use ergonomic foams that are incorporated into the postoperative garments and have been 3D designed to produce uniform pressure, aiding in both even pressure for body contouring while also enhancing the rib fracture healing process (Figure 5, Table 2). As part of our institution's pain management protocol, patients are prescribed the following oral medication regimen for the first 7 days after the procedure: 100 mg of prolonged-release diclofenac once daily, 325/5 mg of hydrocodone/acetaminophen every 8 h, and 75 mg of pregabalin twice daily. Massages over the fracture zones are contraindicated in the initial 4 weeks. Manual lymphatic massages are recommended for other body areas 24 h postop and gently over the ribcage area. Hyperbaric oxygen therapy (HBOT) is compulsory for all patients unless contraindicated. Overall, the general protocol for HBOT is a 30 min daily session at 2 atm of pressure with 99% oxygen for 10 to 20 days postoperative. Measurements were taken at the 3- to 4-month postoperative period, coinciding with the discontinuation of garments and corsets, because this timeframe reflects the stabilized waist contour maintained by the use of a waist belt.
Figure 5.
Artificial intelligence–generated images of female patients in their thirties utilizing 3D-printed foams and vests designed specifically for the waistline aesthetic slimming by puncture postoperative period. (A) Triangular foams together with the waist belt provide strong support in the early phase when rib remodeling is done alone. (B, C) In comparison, complete foam vests for the torso provide firm compression during the early postoperative phase when liposuction is done together with rib remodeling. This ensures even pressure distribution following high-definition liposuction. Gray dotted lines represent the 3D-printed foams for rib remodeling lying underneath the top foam. After 2 weeks, patients transition to wearing a traditional corset continuously for up to 12 weeks to support optimal healing and contouring. This figure was generated using Krea.ai (San Francisco, CA). After the image was created, the authors reviewed and edited using Photoshop (Adobe, San Jose, CA). The authors take full responsibility for the content of the publication.
Table 2.
Postoperative Garment Wearing Protocol After Waistline Aesthetic Slimming by Puncture
| Phase I 1 week po |
Phase II 2-4 weeks po |
Phase III 5-12 weeks po |
Phase IV 10+ weeks po |
|
|---|---|---|---|---|
| Rib procedure alone |
|
|
|
|
Po, postoperative.
RESULTS
A total of 125 consecutive patients underwent rib remodeling through the WASP technique. Most of the patients were biological females (n = 121, 96.8%), whereas 4 transgender patients underwent the procedure as part of their body feminization process. Mean age was 34.7 years (SD 7.1 years), with a mean weight of 64.8 kg (SD 7.1 kg), mean height of 164 cm (SD 5.8 cm), and mean BMI of 24.1 kg/m2 (SD 2.4 kg/m2). In terms of medical history, 1 patient had a previous cancer diagnosis but was considered disease free for several years before undergoing surgery, and 2 others had medically controlled mild comorbidities (dyslipidemia and hypothyroidism). Baseline demographic and clinical characteristics of patients within the drill vs piezotome groups showed comparable distribution, with no statistically significant differences observed (Table 3).
Table 3.
Baseline Demographic and Clinical Characteristics
| Variable | Complete cohort | Drill (n = 56) | Piezotome (n = 69) | P-value |
|---|---|---|---|---|
| Gender, n (%) | .396 | |||
| Female (cisgender) | 121 (96.9) | 55 (98.2) | 66 (95.6) | |
| Female (transgender) | 4 (3.8) | 1 (1.8) | 3 (4.4) | |
| Age (years) | Mean 34.7 | Mean 34.46 | Mean 35.42 | .489 |
| SD 7.1 | SD 6.88 | SD 7.24 | ||
| Min 21-Max 54 | Min 21-Max 49 | Min 24-Max 54 | ||
| Weight (kg) | Mean 64.75 | Mean 65.05 | Mean 64.5 | .693 |
| SD 7.05 | SD 7.32 | SD 6.86 | ||
| Min 49.3-Max 93 | Min 54-Max 93 | Min 49.3-Max 78 | ||
| Height (cm) | Mean 164 | Mean 163 | Mean 164.6 | .259 |
| SD 5.79 | SD 6.18 | SD 5.41 | ||
| Min 151-Max 181 | Min 151-Max 181 | Min 153-Max 175 | ||
| BMI (kg/m2) | Mean 24.07 | Mean 24.4 | Mean 23.8 | .193 |
| SD 2.36 | SD 2.6 | SD 2.13 | ||
| Min 18.6-Max 27.9 | Min 20.3-Max 27.9 | Min 18.6-Max 28.3 | ||
| Race, n (%) | .134 | |||
| Hispanic | 58 (46.4) | 26 (46.4) | 32 (47.4) | |
| Caucasian | 64 (51.2) | 27 (48.2) | 37 (53.6) | |
| African American | 3 (2.4) | 3 (5.4) | 0 | |
| Medical history, n (%) | .457 | |||
| None | 122 (97.6) | 56 (100) | 66 (95.7) | |
| Cancer | 1 (0.8) | 0 | 1 (1.4) | |
| Dyslipidemia | 1 (0.8) | 0 | 1 (1.4) | |
| Hypothyroidism | 1 (0.8) | 0 | 1 (1.4) |
P-values for categorical variables were obtained through a χ2 test, whereas for normally distributed numerical variables using an independent sample t test. IQR, interquartile range; Max, maximum; Min, minimum; SD, standard deviation.
Total median surgical time was 210 min (IQR 53.8 min), differing significantly between groups, with the piezotome group averaging longer times than the drill group (P = .005). For the majority of patients (65.6%), this was their first aesthetic procedure. Additional aesthetic procedures were frequent, the most common being liposuction (95.2%), muscular fat grafts (58.1%), breast implants (20%), and lipectomy (16.2%). The overall complication rate was 6.4%, including 4 patients with skin burns because of the drill use, 2 patients who reported severe pain, 1 patient with relapse, and 1 patient with a seroma because of liposculpture. The relapse case was associated with noncompliance with the proper use of the corset and/or garments. This patient required reintervention for correction. No serious or life-threatening adverse events, including hemothorax or pneumothorax, were reported. Additionally, no chronic pain or nerve damage was reported. Tables 3 and 4 provide a comprehensive description of all the demographic, clinical, and surgical information, with a comprehensive comparison (including P-values) between drill and piezotome groups. Average follow-up was 8 months (range, 1-12 months), with a loss of follow-up of 7.2% and 28% at the third and sixth months.
Table 4.
Surgical Characteristics
| Variable | Complete cohort | Drill (n = 56) | Piezotome (n = 69) | P-value |
|---|---|---|---|---|
| Surgical time (min) | M 210 (IQR 53.8) Min 96-Max 470 |
M 200 (IQR 49) Min 96-Max 325 |
M 210 (IQR 40) Min 133-Max 470 |
.005 a |
| Previous aesthetic surgery, n (%) | .204 | |||
| First-time surgery | 82 (65.6) | 37 (64.2) | 45 (65.2) | |
| Second time | 35 (28) | 14 (25) | 21 (30.4) | |
| Third time or more | 8 (6.4) | 6 (10.7) | 2 (2.8) | |
| Other aesthetic procedures, n (%) | ||||
| Liposuction | 120 (96) | 55 (98.2) | 65 (94.2) | .396 |
| Fat grafts | 74 (59.2) | 39 (69.6) | 35 (50.7) | .064 |
| Breast implants | 25 (20) | 9 (16) | 16 (23.2) | .433 |
| Lipectomy | 20 (16) | 12 (21.4) | 8 (11.6) | .236 |
| Fat grafting anatomical area, n (%) | ||||
| Buttocks | 97 (77.6) | 42 (75) | 55 (79.7) | .631 |
| Breast | 18 (14.4) | 2 (3.6) | 16 (23.2) | .007a |
| RAFT | 14 (11.2) | 5 (8.9) | 9 (13) | .360 |
| SPARTANb | 8 (6.4) | 2 (3.6) | 6 (8.7) | .346 |
| Complications, n (%) | .085 | |||
| Burns | 4 (3.2) | 4 (7.1) | 0 | |
| Severe pain | 2 (1.6) | 1 (1.8) | 1 (1.4) | |
| Relapse | 1 (0.8) | 1 (1.8) | 0 | |
| Seroma from liposuction | 1 (0.8) | 0 | 1 (1.4) | |
| Use of other technologies, n (%) | ||||
| VASERc | 124 (99.2) | 56 (100) | 68 (98.6) | .356 |
| MicroAired | 124 (99.2) | 56 (100) | 68 (98.6) | .356 |
| Renuvione | 25 (20) | 16 (28.6) | 9 (13) | .031a |
| BodyTitef | 23 (18.4) | 2 (3.6) | 21 (30.4) | <.001a |
| Morpheusg | 6 (4.8) | 4 (7.2) | 2 (2.9) | .115 |
| Waist circumference (cm) | ||||
| Preoperative (n = 105) | M 76 (IQR 7.9) | M 75.5 (IQR 7.9) | M 76 (IQR 8.3) | .577 |
| Min 65-Max 99 | Min 65-Max 99 | Min 67-Max 93 | ||
| Immediate POP (n = 105) | M 68 (IQR 8) | M 67 (IQR 6.97) | M 68 (IQR 8) | .519 |
| Min 59.8-Max 83 | Min 59.8-Max 83 | Min 60-Max 79 | ||
| 3 months POP (n = 51) | M 65 (IQR 7.4) | M 65 (IQR 8.15) | M 65 (IQR 7) | .932 |
| Min 58-Max 76 | Min 59-Max 75.9 | Min 58-Max 76 | ||
| Hip circumference (cm) | ||||
| Preoperative (n = 91) | M 100 (IQR 7.8) | M 98 (IQR 8) | M 100 (IQR 8) | .104 |
| Min 86-Max 116 | Min 91-Max 111 | Min 86-Max 116 | ||
| Immediate POP (n = 90) | M 100 (IQR 6.2) | M 99 (IQR 4.9) | M 100 (IQR 7) | .707 |
| Min 88-Max 118 | Min 92-Max 117 | Min 88-Max 118 | ||
| 3 months POP (n = 53) | M 99 (IQR 5.6) | M 98 (IQR 5.47) | M 100 (IQR 5.45) | .155 |
| Min 89-Max 117 | Min 89-Max 110 | Min 92-Max 117 | ||
| Waist-to-hip ratio | ||||
| Preoperative (n = 91) | M 0.8 (IQR 0.1) | M 0.8 (IQR 0.1) | M 0.8 (IQR 0.1) | .623 |
| Min 0.6-Max 0.9 | Min 0.6-Max 0.9 | Min 0.7-Max 0.9 | ||
| Immediate POP (n = 90) | M 0.7 (IQR 0.1) | M 0.7 (IQR 0.1) | M 0.7 (IQR 0.1) | .881 |
| Min 0.6-Max 0.8 | Min 0.6-Max 0.8 | Min 0.6-Max 0.8 | ||
| 3 months POP (n = 43) | M 0.7 (IQR 0.1) | M 0.7 (IQR 0.1) | M 0.7 (IQR 0.1) | .648 |
| Min 0.6-Max 0.8 | Min 0.6-Max 0.8 | Min 0.6-Max 0.7 | ||
| Follow-up, n (%) | ||||
| 1 month | 124 (99.2) | 56 (100) | 68 (98.6) | |
| 3 months | 116 (92.8) | 53 (94.6) | 63 (91.3) | |
| 6 months | 90 (72) | 40 (71.4) | 50 (72.4) |
P-values for categorical variables were obtained through a χ2 test, whereas for non-normally distributed numerical variables using Kruskal–Wallis test. IQR, interquartile range; M, median; Max, maximum; Min, minimum; POP, postoperative; RAFT, rectus abdominis fat transfer; SD, standard deviation. aStatistically significant difference. bSemilunaris PArallel to Rectus fat Transfer (SPARTAN). cVASER Lipo System, 2021 Solta Medical (Bausch Health Companies Inc., Bothell, WA). dMicroAire Liposuction System (MicroAire Surgical Instruments, LLC Charlottesville, VA). eRenuvion (Apyx Medical Corporation, Clearwater, FL). fMorpheus8 (InMode Ltd, Irvine, CA). gBodyTite (InMode Ltd).
Regarding the waist measurements: preoperatively, median waistline circumference was 76 cm (IQR 7.9 cm); immediately postoperatively median was 68 cm (IQR 8 cm); and 3 months postprocedure median was 65 cm (IQR 7.4 cm). Statistically significant differences were found between preop and postop waistline measurements for both groups at both time points (immediate postop P = .031, 3 months postop P = .023). For hip measurements, the preoperative median was 100 cm (IQR 7.8 cm), the immediate postoperative median was 100 cm (IQR 6.2 cm), and the 3-month postprocedure median was 99 cm (IQR 5.4 cm; Figure 6). The WHR preoperatively had a median of 0.8 (IQR 0.1), whereas postprocedure, the median decreased to 0.7 (IQR 0.1). No statistically significant differences between groups were observed on these measurements. WHR was found to be significantly different between preop and postop measurements (P = .035; Figure 7). Patient's satisfaction with aesthetic outcomes was high, with 97.6% of patients reporting that they felt either “very much” or “much” improved in appearance after the procedure. Additionally, 92.9% of patients reported being “very satisfied,” whereas 7.1% were “satisfied” with the overall surgical procedure (Table 5). Almost all patients would recommend the procedure to someone else.
Figure 6.
Changes in waist and hip measurements preoperatively, immediately postoperatively, and at 3 months postoperative, following high-definition liposculpture combined with waistline aesthetic slimming by puncture technique. A statistically significant reduction in waist circumference is observed in both immediate and 3 months postoperatively (indicated by **), whereas the hip measurements remain relatively stable.
Figure 7.
Changes in waist-to-hip ratio from preoperative measurements to immediate postoperative, following high-definition liposculpture combined with waistline aesthetic slimming by puncture technique. As indicated by **, the postoperative WHR measurements show a statistically significant decrease, suggesting effective body contouring and silhouette enhancement.
Table 5.
Satisfaction Scores Based on the Global Aesthetic Improvement Scale
| Variable | Complete cohort | Drill (n = 50) |
Piezotome (n = 62) | P-value |
|---|---|---|---|---|
| n (%) | n (%) | n (%) | ||
| How do you feel about your appearance after the surgery? (n = 112) | .552 | |||
| Very much improved | 87 (77.6) | 36 (72) | 45 (82.3) | |
| Much improved | 22 (20) | 12 (24) | 10 (16.1) | |
| Slightly improved | 2 (1.8) | 1 (2) | 1 (1.6) | |
| Are you satisfied with the surgery? (n = 112) | .136 | |||
| Very satisfied | 104 (92.9) | 44 (88) | 60 (96.8) | |
| Satisfied | 8 (7.1) | 6 (12) | 2 (3.3) | |
| Would you recommend the surgical procedure? (n = 112) | .873 | |||
| Yes | 110 (98.2) | 49 (98) | 61 (98.4) | |
| Perhaps | 2 (1.8) | 1 (2) | 1 (1.6) |
DISCUSSION
Advancements in aesthetic rib remodeling surgery have fundamentally transformed the field of aesthetic body contouring over the last decade.4,5,10,11,20 By introducing the concept of producing greenstick fractures in the floating ribs rather than complete removal, Kudzaev has not only enhanced the aesthetic outcomes for patients but also prioritized their safety.4 This approach minimizes the potential complications associated with traditional rib resection techniques, enabling a more favorable recovery trajectory. Various groups have explored rib remodeling surgery, each contributing unique techniques that highlight the specialty's ongoing evolution. As these methods advance, assessing their effectiveness in terms of postoperative outcomes, patient satisfaction, and safety becomes increasingly important. Although most studies on rib remodeling consist of case series or prospective cohorts, only the research by Aguilar Villa et al and Oñate Valdivieso et al rigorously evaluates patient outcomes.10,12 These studies employed the validated Body-QOL scale to examine the impact of rib remodeling on patient quality of life, incorporating long-term follow-up and providing a comprehensive account of complications and their management.14 ,21
Our WASP technique has evolved from Oñate Valdivieso et al approach by minimizing tissue trauma.10 Instead of using a single incision to access all ribs, we utilize individual puncture points for each rib, which reduces tissue disruption. In contrast to Manzaneda Cipriani et al, we are against performing multiple perpendicular punctures along the rib because we are working close to the pleura and the intercostal neurovascular bundle, particularly along the lower rib border.11 Repeated perpendicular punctures significantly increase the risk of inadvertently injuring the intercostal artery or nerve, puncturing the pleura, and/or reaching the deep cortical bone, which could result in severe complications (eg, hemothorax, pneumothorax, bi-cortical fractures, and neurogenic pain).22,23 We believe that our parallel approach offers a safer alternative with a lower likelihood of such complications. The technique developed by Aguilar Villa et al, on the other hand, appears more suited to a different patient population.12 We view titanium plate fixation as an excellent option for patients facing issues such as relapse, nonunion fractures, or those unable or unwilling to wear a garment or corset postoperatively, including athletes and models. Regardless of specific techniques, we strongly agree with other authors on the importance of thorough training to achieve optimal results and prevent complications. Every plastic surgeon aiming to perform these procedures should gain experience with each approach, progressing from more invasive to less invasive techniques as they develop their skills, bearing in mind that complication rates generally may increase if a nonexperienced surgeon begins with less invasive methods (excluding rib removal).20 Because 1 of our co-authors (M.E.P.P.) aptly put it, “The goal is to hang the painting properly; the tools, timing, and approach are secondary as long as it is done safely and effectively.”
Among the complications encountered in rib aesthetic surgery, prolonged pain remains the most common.4,7,9-12,22 Effective management strategies, including analgesia control with NSAIDs, are critical for enhancing patient comfort and guaranteeing garment use. Furthermore, complications that could adversely affect aesthetic results, including relapses, abnormal consolidation, and asymmetry, are often linked to noncompliance with postoperative garment use. This emphasizes the importance of thorough preoperative discussions about the critical need for adherence to recovery protocols and the potential implications of noncompliance. In some cases, revision procedures may be required to correct aesthetic outcomes. Although less frequent, serious complications like pneumothorax and hemothorax can arise, requiring chest tube placement depending on severity, highlighting the importance of careful surgical technique and postoperative monitoring.6,8,22,24
The WASP technique has proven to be a safe procedure, with a low overall complication rate of 6.4%. Importantly, none of these complications were life-threatening or severe, and all were successfully managed in the postoperative period. The switch from the drill to the piezotome reduced the complication rates from 10.7% to 2.9%. The impact on waistline circumference and WHR has been remarkable and statistically significant, with over 92% of patients reporting high satisfaction with both the procedure and their results (Figures 8, 9). These results are likely due in part to rib-specific postoperative protocols, including the use of specially designed compression garments and ergonomic foams, which we consider essential for ensuring compliance, rib stabilization, and proper healing. Although the procedure carries minimal risks, we believe strict adherence to such recovery protocols is crucial to prevent complications such as scarring, asymmetry, or chronic pain.20 Aesthetic rib surgery is a constantly evolving field, aiming not only for aesthetic improvements but also for enhanced patient safety. Rib osteotomies for body contouring are a recent development, with limited and somehow low-quality information available regarding their long-term impact on respiratory function.6,8,22 This highlights the fundamental importance of careful patient selection and appropriate postoperative care measures.
Figure 8.
A 27-year-old female patient with a shoulder-to-hip ratio above 1 who underwent high-definition liposculpture combined with the waistline aesthetic slimming by puncture technique (ladder approach). The patient had previously undergone liposculpture at another institution before the described intervention. (A-C) Preoperative photographs depict a wide waistline and a straight body contour. (D-F) Seven-month postoperative images reveal a transformed silhouette with a slimmer, curvier, and more athletic appearance, showcasing the effectiveness of the waistline aesthetic slimming by puncture technique in enhancing the female figure. Preoperative and postoperative waist-to-hip ratios were 0.77 and 0.65, respectively.
Figure 9.
A 35-year-old female patient with a shoulder-to-hip ratio close to 1, who underwent high-definition liposculpture combined with the waistline aesthetic slimming by puncture technique using a longitudinal approach. The tape on the patient's flanks is used to cover identifiable tattoos for privacy purposes. (A-C) Preoperative photographs display mild-to-moderate thoracic scoliosis to the right with lumbar compensation to the left, as well as a poorly defined waistline contour. (D-F) Six-month postoperative images highlight a curvilinear, aesthetically balanced silhouette with anatomical compensation for her scoliosis. The procedure involved performing more distal rib corticotomies on the left to subtly reduce the contour and more proximal corticotomies on the right to accentuate waist indentation. Fat grafting to the mid-back was also carried out to enhance the midline's straightness, creating the visual illusion of symmetry and balance. Preoperative and postoperative waist-to-hip ratios were 0.81 and 0.67, respectively.
Limitations of this study include a relatively small sample size and an observational design, which may limit the generalizability and introduce potential biases. There was a loss of follow-up in the third and sixth months, and for some of the patients, hip and/or waist measures were not taken at follow-up visits. The steep learning curve for surgeons adopting the WASP technique and somehow variability in patient compliance with postoperative protocols could all impact outcomes. The impact of liposuction on waist measurements, and consequently on the WHR, was not estimated in this study. The absence of a direct comparative study between techniques limits a more definitive assessment of the technique's advantages. Longer follow-up periods would allow us to estimate the long-term outcomes of the technique on the waist measures and WHR; however, this was considered unfeasible in clinical practice. Future research addressing these limitations could enhance the understanding and application of the different rib remodeling techniques.
CONCLUSIONS
The WASP technique for rib remodeling has demonstrated high efficacy and safety, offering significant waistline reduction and high patient satisfaction with a low complication rate. Our approach, which integrates parallel corticotomy and specialized postoperative protocols, not only minimizes risk but also enhances patient outcomes by tailoring treatment to individual anatomical and aesthetic needs. Because the field of body contouring continues to evolve, WASP represents a patient-centered approach that emphasizes prevention of complications, effective recovery, and sustainable results.
Acknowledgments
Figures 1 and 5 of this manuscript were generated using Krea.ai (San Francisco, CA). After the images were created, the authors reviewed and edited them using Photoshop (Adobe, San Jose, CA). The figure legends describe the images and state they were created with artificial intelligence. The authors take full responsibility for the content of the publication.
Disclosures
The authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article.
Funding
The authors received no financial support for the research, authorship, and publication of this article.
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