Safety Evaluation of the RibXcar Technique Using the Piezotome: An Analysis of Surgical Complications

Abstract

Background:

This study analyzed the incidence of minor and major complications associated with rib remodeling performed by punctures (RibXcar surgical technique), specifically using the piezotome instrument. Variables such as learning method, practice time, use of ultrasound support, and type of instrument used were evaluated to determine their relationship with the occurrence of major complications such as pneumothorax and hemothorax.

Methods:

A retrospective analysis of data obtained from a survey distributed to 113 plastic surgeons using rib remodeling performed by punctures was conducted. Descriptive statistics were used to characterize the sample, and chi-square tests were used to analyze the association between variables and complications. In addition, a logistic regression model was applied to adjust for multiple variables.

Results:

Of 113 respondents, 2.65% of respondents reported serious complications, such as pneumothorax or hemothorax. No statistically significant association was found between the use of piezotome and a lower incidence of these serious complications (P = 1.0). Logistic regression analysis also indicated no significant difference in the risk of complications depending on the instrument used.

Conclusions:

The rib remodeling performed by punctures appears to be well adopted and safe according to the surgeons who practice it, with a high acceptance rate of use of ultrasound and piezotome and a low rate of serious complications.

Takeaways

Question: Is there a relationship between the application of the RibXcar technique and the use of a piezotome with the occurrence of complications in patients?

Findings: No statistically significant association was found between the use of a piezotome and a lower incidence of these serious complications (P = 1.0).

Meaning: The RibXcar technique appears to be well adopted and safe according to the surgeons who practice it, with a high rate of use of technologies such as ultrasound and piezotome and a low rate of serious complications.

INTRODUCTION

Rib remodeling has gained relevance in plastic surgery as a significant intervention. Rib remodeling performed by punctures (RibXcar technique), also known as incisionless rib remodeling using ultrasound-guided monocortical fracture, aims to provide optimal and safe aesthetic results for patients. This procedure is performed through a noninvasive skin puncture that leaves no visible scars. Its main objective is to reshape the angulation of ribs 10, 11, and 12, thus achieving a reduction in the waistline.^1,2

A key aspect of the technique is the surgical design, which has shown a significant decrease in recurrences due to muscle memory compared with the straight-line design used in the Kudzaev technique.^3,4 Understanding the importance of costal angles is essential: a wide costal angle results in a wider waist, whereas a reduced costal angle allows for a narrower waist.^5–7 Angulation is achieved by controlled fracture of the external cortex using an adapted piezotome (Manzaneda tool).⁸ Ultrasound is essential to ensure a safe monocortical fracture, allowing 3 critical factors to be modified, rib angulation, loss of bone strength, and cortical disruption, which facilitates obtaining the desired angulation.⁹

This technique has demonstrated favorable results and patient satisfaction, underscoring the importance of training plastic surgeons to ensure an effective and safe procedure. To assess the effectiveness and complications associated with rib remodeling performed by punctures, a study was conducted through a survey of plastic surgeons using this technique, with the aim of presenting the relevant findings.

MATERIALS AND METHODS

For data collection, an online survey platform (Google Forms) was used. The survey link was shared with a database of RibXcar-trained plastic surgeons from 2023 to date. The survey, anonymous and voluntary, included a brief description of its purpose and offered no compensation.

Survey Design

The survey consisted of 12 multiple-choice questions, organized into 3 components:

1. Surgeon education and training in the technique.

2. Implementation of the technique (tools used).

3. Complications observed when applying the technique.

Data Collection

The survey was sent out on 3 different occasions during July 2024 and August 2024. Google Forms¹⁰ allowed anonymous collection and coding of responses using random identification numbers.

Statistical Analysis

Descriptive statistics were used to characterize the sample, and chi-square tests were used to analyze the association between variables and complications. In addition, a logistic regression model was applied to adjust for multiple variables. The analysis was carried out using Statistical Package for the Social Sciences software.

RESULTS

The survey received responses from 113 plastic surgeons. Among the surveyed surgeons, 75.2% reported actively performing the rib remodeling without the incision technique, whereas 24.8% of surgeons have recently begun to implement it in their practice. Regarding the method of learning, 57.5% of surgeons received specific training in rib remodeling without incision, generally provided in specific courses by the lead author (R.M.M.C.). In all, 11.5% of surgeons were trained through general aesthetic plastic surgery courses, and 6.2% through research articles and academic videos (Fig. 1; Table 1).

Fig. 1.

Learning method for RibXcar.

Table 1.

Results of the Surgeon Training Component, According to Frequency of Responses

Component: Training	Response, %
1. Do you currently perform the RibXcar surgical technique?
Yes (1 y ago)	75.2
Recently	24.8
No	—
2. How did you learn the RibXcar technique?
Specific course	57.5
General course	11.5
Research article	6.2
3. How long have you been performing this technique?
3–6 mo	14.2
6 mo–1 y	28.3
>1 y	41.6
4. Approximately how many cases do you estimate that you have applied RibXcar?
20–50 cases	20.35
50–100 cases	23.53
>100 cases	34.5

Percentages are calculated based on the total number of valid responses per question. Missing responses were excluded from the calculations.

Regarding experience in practicing the technique, 41.6% of the participants have been applying the technique for more than 1 year, 28.3% between 6 months and 1 year, and 14.2% between 3 and 6 months. Regarding the volume of cases, 34.5% of the surgeons have performed more than 100 cases, showing a considerable level of accumulated experience; 23.53% between 50 and 100 cases; and 20.35% between 20 and 50 cases.

In terms of the instruments used, all the respondents who answered this question used a piezotome, highlighting uniformity in the use of specialized tools. (See Video [online], which displays the RibXcar procedure.) Regarding the use of ultrasound support, 93.8% of surgeons used ultrasound to visualize the procedure, which underlines the importance of technology in the execution of this technique (Fig. 2). In the postoperative stage, the most used girdle was the corset with clasp, 41.6% of surgeons, followed by 25.7% using the 3-body girdle and 25.16%, the corset with cord (Table 2).

Fig. 2.

Ultrasound support.

Table 2.

Results of the Tools Component in the Technique, According to the Frequency of Responses

Component: Tools	Response, %
1. With which instrument do you perform the RibXcar technique?
Piezotome	100
Others: (manual pressure, rasp, micromotor, gouges)	—
2. Do you use ultrasound support during surgery?
Yes	93.8
No	6.2
3. What type of girdle did the patient use?
Corset with clasp	41.6
3-body girdle	25.7
Corset with rope	25.16

Percentages are calculated based on the total number of valid responses per question. Missing responses were excluded from the calculations.

Video 1. This video shows the RibXcar procedure.

Download video file ^{(10.9MB, mp4)}

Regarding complications, 91.2% of surgeons reported no minor complications, 31.8% reported pain less than 3 months, 30% reported burns, 8.8% reported asymmetry, 7% reported crepitus, and 11.5% reported no good aesthetic result. Regarding major complications, 90.3% of surgeons did not present them. There were isolated cases related to pain greater than 3 months (6.1%), pneumothorax (2.6%), and 1 case of hemothorax. As for the causes attributed to the complications, 27.3% of the complications were attributed to the patient factor and 24.5% to the surgeon (Table 3). In all, 87% of surgeons did not identify recurrence, whereas the remaining 13% reported recurrence attributed to lack of girdle use, muscle memory, late technique, and excess muscle strength (Table 4). Surgeons have achieved aesthetically favorable and satisfactory results for patients (Figs. 3–6).

Table 3.

Results of the Complications Component, According to Frequency of Responses

Component: Complications	Response, %
1. Have you had any minor complications?
None	91.2
Burns	30
Asymmetry	8.8
Pain <3 mo	31.8
Lack of good aesthetic result	11.5
Crepitations	7
2. Have you had any major complications?
None	90.03
Pneumothorax	6.1
Hemothorax	0.8
Pain >3 mo	2.1
Internal organ injury	—
Death	—
3. To what do you attribute the complication?
Surgeon factor	24.5
Patient factor	27.3

Table 4.

Recurrences

Recurrences	Responses (%/Cases)
1. Have you had a recurrence in RibXcar?
No	87%
Yes	13%
2. If your answer above is positive, what do you think is the reason for it?
Lack of use of girdle	12 cases
Muscle memory	8 cases
Very posterior technique	2 cases
Too much muscular strength	4 cases

Fig. 3.

Pre and post RibXcar surgery. A, Pre RibXcar surgery, patient 1. B, Post RibXcar surgery, patient 1.

Fig. 6.

Pre and post RibXcar surgery. A, Pre RibXcar surgery, patient 4. B, Post RibXcar surgery, patient 4.

Fig. 4.

Pre and post RibXcar surgery. A, Pre RibXcar surgery, patient 2. B, Post RibXcar surgery, patient 2.

Fig. 5.

Pre and post RibXcar surgery. A, Pre RibXcar surgery, patient 3. B, Post RibXcar surgery, patient 3.

DISCUSSION

This report is based on a survey designed to collect information on plastic surgeons’ experience and practice with the rib remodeling performed by punctures. The online modality facilitated data collection and analysis and provided unbiased responses.

Education and training of surgeons in RibXcar is critical. Although methods vary, specific courses are standard (86.6%); however, 6.2% applied the technique without adequate training, so correct application could not be assured. The technique is being implemented more frequently, and the aesthetic results and safety seem to contribute to its increasing adoption.

The use of a piezotome (Manzaneda tool) and ultrasound is crucial for the correct application of rib remodeling without incision. Surgeons using alternative tools do not meet the requirements to consider their procedure as RibXcar. To maximize the benefits and minimize any risks associated with the application of the technique, it is crucial to ensure proper training and use of these technologies.

The oblique RibXcar design has proven to be more effective than the straight-line design in reducing recurrences due to muscle memory. This is because it avoids fractures in areas of high muscle activity, which contributes to greater stability of the aesthetic result.

In the postoperative stage, it has been identified that 25.16% of surgeons use the corset with rope. Once the surgical technique has been performed, it is established that during the first 10 days, the girdle should maintain a constant pressure; after that period, it should be pressed 1 cm more every week. However, the use of the corset with rope makes this procedure more difficult, so it is not recommended.

In 90.03% of the cases, there were no serious complications and isolated cases were identified with problems such as prolonged pain, pneumothorax, and hemothorax, attributable to factors related to the management of the procedure and the patient’s characteristics. Minor complications, such as burns and asymmetry, may also be related to the surgeon’s learning process. Therefore, it is important to consider the implications of individual variability as surgeons, regardless of experience in the technique, because there are factors associated with specific training, such as manual dexterity or continuous updating in advanced techniques. Uniformity in training and certification to perform the RibXcar technique are recommended, as this would allow surgeons to reach a similar level of competence in a relatively short period of time, minimizing the impact of the duration of experience on the frequency of complications.

Strengths and Limitations

This study offers valuable insights into the RibXcar technique, a novel approach to rib remodeling in aesthetic plastic surgery. Among its strengths is the inclusion of a large survey sample, with responses from 113 experienced plastic surgeons, which enhances the study’s generalizability and provides a broad perspective on the technique’s outcomes. By capturing real-world data from practicing surgeons, the findings are particularly relevant to everyday clinical practice. The comprehensive survey design, which includes detailed questions about technique implementation, tools, and complications, allows for a thorough understanding of the factors influencing surgical outcomes. Moreover, the low incidence of serious complications (2.6%) highlights the favorable safety profile of the RibXcar technique, emphasizing its potential as a reliable method in rib remodeling surgery.

Another key strength is the study’s focus on structured training, which underscores the importance of standardizing surgical education to minimize complications and achieve better results. Additionally, the use of modern technology, such as piezotome and ultrasound guidance, reflects the RibXcar technique’s relevance in advancing precision and safety in aesthetic procedures. Practical recommendations derived from the study further equip surgeons with actionable strategies to optimize technique safety and patient outcomes. Finally, this research lays the foundation for future studies, contributing significantly to the evolving body of knowledge in rib remodeling surgery.

Despite its strengths, the study is not without limitations. The survey response rate, while substantial, may represent only a small proportion of RibXcar-trained surgeons, which could limit the representativeness of the findings. Furthermore, reliance on self-reported data introduces potential biases, as surgeons may inadvertently overestimate or underreport complications based on personal perceptions or recall. Another limitation is the lack of detailed demographic information about the survey respondents, such as age, sex, practice type, or geographic location, which might have provided deeper insights into factors affecting outcomes.

The study also lacks standardized tools to objectively assess aesthetic results, relying instead on subjective evaluations, which could vary significantly among surgeons. Additionally, the retrospective nature of the survey precludes establishing causal relationships, particularly between surgeon experience and complication rates, limiting the ability to draw definitive conclusions. Finally, the study’s retrospective design makes it susceptible to recall bias and does not account for confounding variables that might influence complication rates. According to the medical literature, response rates in surveys targeting plastic surgeons have been reported to range from as low as 11% to as high as 84%, depending on the survey method and incentives used.^11,12 By recognizing these strengths and limitations, the study provides a balanced perspective on the RibXcar technique while setting the stage for future research to address these gaps.

CONCLUSIONS

The RibXcar technique appears to be well adopted and safe according to the surgeons who practice it, with a high rate of use of technologies such as ultrasound and piezotome. Most practitioners have acquired knowledge through specialized courses, and reported complications are relatively low. This suggests that the technique is effective and relatively safe for rib remodeling, although as in any surgical procedure, there are risks that must be carefully managed. It is essential to perform the procedure in an environment with the appropriate equipment to address any possible complications.

The results of the statistical analysis using the chi-square test indicated that there is no statistically significant relationship between the duration of practice of the RibXcar technique (an indicator of surgeon experience) and the number of complications. This suggests that, within this data sample, experience measured in terms of how long a surgeon has been performing this specific technique is not directly related to a higher or lower incidence of complications.

DISCLOSURE

The authors have no financial interest to declare in relation to the content of this article.

PATIENT CONSENT

Patients provided written consent for the use of their images.