Ant Waist Surgery: Aesthetic Removal of Floating Ribs to Decrease the Waist-hip Ratio

Summary:

Decreasing waist circumference has become an essential feature in modern body contouring surgery owing to the attractiveness of hourglass body shapes. Traditionally, this can be achieved through lipomodeling and abdominal musculature strengthening techniques. An adjunctive procedure for ideal shaping of the waistline is resection of the 11th and 12th ribs, referred to as floating ribs. This study aimed to report and analyze clinical outcomes and self-reported patient satisfaction after “ant waist” surgery (floating rib removal) for aesthetic reasons. We retrospectively reviewed the medical records of five patients who had undergone bilateral 11th and 12th rib resections at a single institute in Taiwan in an outpatient setting. The mean lengths of the resected left and right 11th ribs were 9.1 and 9.5 cm, respectively. The mean lengths of the resected left and right 12th ribs were 6.3 and 6.4 cm, respectively. The mean waist-to-hip ratio decreased from 0.78 preoperatively to 0.72 postoperatively, with a mean decrease of 7.7%. No adverse events were reported. Generally, all patients reported being satisfied with the operation. Floating rib resection proved useful and effective in decreasing the waist-to-hip ratio using a safe, simple, and reproducible technique without significant complications. Although preliminarily, the authors’ comprehensive demonstration of this ant waist surgery supports further studies focusing on waistline contouring.

Takeaways

Question: Decreasing waist circumference has become an essential feature in modern body contouring surgery. However, literature concerning the effectiveness and safety of resecting floating ribs for aesthetic purposes is scarce.

Findings: All patients were treated in an outpatient setting without hospitalization and could return to their daily lives on the same day. The mean waist-to-hip ratio decreased from 0.78 preoperatively to 0.72 postoperatively, with a mean decrease of 7.7%. No adverse events were reported. Generally, all patients reported being satisfied with the operation.

Meaning: Floating rib resection is effective in decreasing the waist-to-hip ratio using a simple, safe, and reproducible technique without significant complications.

INTRODUCTION

Body contouring surgery is a subspecialty of plastic surgery which has greatly advanced over the past years and is influenced by successful bariatric procedures, medication for patients with massive weight loss, and refinement of lipomodeling techniques.¹ Many invasive and noninvasive body contouring procedures have been developed to achieve a more desirable aesthetic appearance.² Excess skin laxity with subcutaneous fat can be corrected by liposuction and abdominoplasty, which further strengthens the abdominal wall musculature to reduce the waist circumference.³ Furthermore, the waist-to-hip ratio (WHR) is a key determinant of attractiveness. Buttock lift procedures, including liposuction, lipofilling, and intramuscular silicone implant placement are used to achieve ideal buttocks.⁴

A WHR of 0.65 to 0.70 is consistently considered highly attractive in the modern era.^5–8 The term “ant waist” is becoming popular for waists that are tiny and attractive. However, it is difficult for some people, such as transgender individuals, to achieve the ideal WHR even after abdominoplasty and buttock lift because of their bony structures. Removal of the floating ribs to decrease WHR may be an answer.

Aesthetic removal of the 11th and 12th ribs (floating ribs) as a method of decreasing the waistline circumference has attracted much attention since the 1970s. This practice has been considered a subsequent procedure after buttock augmentation for transgender individuals with the aim of feminizing the ideal hourglass body shape.⁹

Literature concerning the effectiveness and safety of resecting floating ribs merely for aesthetic purposes is scarce.¹⁰ Verdugo reported the low complication rate of 11th and 12th rib removal technique as body contouring surgery in 104 patients. Liposuction and abdominoplasty was the most common combination of procedures, and only 10 of these patients underwent rib removal exclusively.¹¹ Effectiveness of exclusive rib resection and patient-reported outcomes were not reported. This study aimed to review our experience with the aesthetic removal of floating ribs to decrease the waist circumference and WHR, and to evaluate patient satisfaction levels following this technique.

PATIENTS, SURGICAL TECHNIQUES, AND OUTCOMES

Five patients underwent removal of the floating ribs for cosmetic reasons in an outpatient setting without other accompanying procedures. Demographic data are shown in Table 1. The waist and hip circumference is the point of the minimal waist and widest part of the hip, which was documented before and 3 months after the surgery. This retrospective study was approved by the institutional review board of the Taipei Veterans General Hospital (No. 2022-06-019ACF).

Table 1.

Patient Demographic Data

	Case 1	Case 2	Case 3	Case 4	Case 5	Average
Gender	M to F	F	F	M to F	F
Age	29	23	28	32	44	31.2 ± 7.9
BMI	18.59	22.03	26.7	23.1	25.1	23.1 ± 3.1
Smoking	N	N	N	N	N	—
Hypertension	N	N	N	N	N	—
Hyperlipidemia	N	N	N	N	N	—
Diabetes mellitus	N	N	N	N	N	—
Accompany procedures	N	N	N	N	N	—
Left 11 rib (cm)	6	12	9.5	10.8	7	9.1 ± 2.5
Left 12 rib (cm)	4.2	10	7.5	6.5	3.5	6.3 ± 2.6
Right 11 rib (cm)	8	11	10.5	10.5	7.5	9.5 ± 1.6
Right 12 rib (cm)	5.5	7	7.5	8	4.2	6.4 ± 1.6

BMI, body Mass Index; F, feminine; M, masculine.

Operative technique was performed in the following steps under general anesthesia. A 2-inch incision was made over the costal margin between the floating ribs, according to the relaxed skin tension line. Wound protectors were placed above the deep fascia, followed by the latissimus dorsi and posterior serratus muscles, deep to the periosteum. For avoiding injury to pleurae and minimized postoperative pain, the dissection plan should follow the subperiosteal layer delicately after water dissection technique. Subsequently, the ribs were resected from the lateral borders of the eractor spinae to the rib tips. The rib tip cartilage was removed to prevent postoperative palpable nodules. Soft tissue repair was performed layer by layer without drainage tube placement. Only one patient received drain placement into the surgical pocket, which was removed one day postoperatively because there was little discharge. Based on our experience, we do not recommend placing drains for the surgical procedure after good hemostasis. All patients were discharged on the same day.

The total average operation time was 205 minutes (range, 156–235 minutes). No perioperative adverse events occurred in any patient. The pain was minimal. All patients were treated in an outpatient setting without the need for hospitalization, and could return to their daily lives on the same day. The patients’ demographic data are shown in Table 1. The outcomes/complications are presented in Table 2. Paired t test analysis of WHR and body weight before and after operation revealed decrease with statistical difference (P < 0.05). The patient questionnaire and survey results are shown in Table 3. A 29-year-old woman who received ant waist surgery, and her photos before surgery and 1 year after surgery were shown in Supplemental Digital Content 1. (See figure, Supplemental Digital Content 1, which displays a 29-year-old woman who received ant waist surgery. A and C, before surgery; B and D, 1 year after surgery; E, surgical wound and ribs; F, surgical scar. http://links.lww.com/PRSGO/C442.)

Table 2.

Outcomes and Complications

	Case 1	Case 2	Case 3	Case 4	Case 5	Average	Paired t Test
Surgical outcomes
WHR before OP	0.75	0.73	0.79	0.82	0.83	0.78 ± 0.04
WHR after OP	0.68	0.65	0.74	0.76	0.79	0.72 ± 0.06	0.001
BW before OP (kg)	47.6	54.9	62.5	56.0	54.0	55.0 ± 5.3
BW after OP (kg)	46.1	52.8	60.8	53.0	53.3	53.2 ± 5.2	0.009
Change in WHR	9.3%	10.9%	6.3%	7.3%	4.8%	7.7 ± 2.4%
Change in BW	3.2%	3.8%	2.7%	5.4%	1.3%	3.3 ± 1.5%
Surgical complications
Pneumothorax	N	N	N	N	N	— —
Seroma	N	N	N	N	N
Hematoma	N	N	N	N	N	—

BW, Body weight; OP, operation.

Table 3.

Patient Questionnaire and Survey Results

Questionnaire	Case 1	Case 2	Case 3	Case 4	Case 5
1. How does your body look compared with your preoperative expectation?	1	2	3	3	3
2. Please describe your pain after operation	1	1	2	2	2
3. Have you lost weight since surgery	2	1	1	1	1
4. Please describe your recovery	1	2	2	2	2
5. Please describe your scar	1	3	1	1	1
6. Do you feel more confident after surgery?	1	1	1	1	2
7. Are you satisfied with the operation in general?	1	2	1	1	1

1. How does your body look compared with your preoperative expectation?

(1) Much better than expected; (2) better than expected; (3) as expected; (4) lower than expected.

2. Please describe your pain after operation

(1) little or no pain; (2) mild, without interfering with daily activities; (3) moderate interfering with daily activities; (4) severe, requiring bed rest.

3. Have you lost weight since surgery?

(1) Lost weight; (2) no change; (3) weight gain

4. Please describe your recovery

(1) Almost no recovery time; (2) shorter than expected; (3) just as expected; (4) longer than expected.

5. Please describe your scar

(1) Light and thin; (2) red and ropey; (3) scar widened; (4) scar tender

6. Do you feel more confident after surgery?

(1) Much more confident; (2) more confident; (3) no difference; (4) less confident.

7. Are you satisfied with the operation in general?

(1) Very satisfied; (2) satisfied; (3) acceptable; (4) not satisfied.

DISCUSSION

Rib resection for therapeutic purposes intended for managing thoracic, abdominal, and chest wall pathological etiologies is a well-established procedure in many fields of surgery.^12–14 For plastic surgeons, harvesting of rib cartilage as an autologous material is also frequently performed and reportedly safe.¹⁵ Pushing the boundaries of body contouring in the era of modern cosmetic surgery allows one to appreciate the rationale of resecting the floating ribs for aesthetic purposes to achieve an attractive “ant waist.”

Certain aspects of our study should be highlighted. First, we performed rib resection in an outpatient setting without the need for hospitalization. No adverse events were observed with meticulous wound care and compressive dressing. Second, only one patient underwent drainage tube implantation for one day. Most patients did not require a postoperative drain. Postoperative pain was minimal to mild, without interfering with daily activities, thereby facilitating the outpatient setting. Third, our results entailed no short-term adverse effects or surgical complications. Finally, the survey data showed that 100% of patients were generally satisfied with the operation and had increased confidence in their body shapes, which may be influenced by a WHR decrease of 6.3% to 10.9%. Eighty percent of the patients were satisfied with their scarring. To our knowledge, this is the first study to accumulate practical quality-of-life data for aesthetic rib removal, which may serve as a valuable reference for surgical consideration in an objective manner.

Mansour et al retrospectively reviewed 200 patients who had undergone chest wall resection and concluded that the most common complications were pneumonia (14%), acute respiratory distress syndrome (6%), and infection/sepsis (5%).¹³ Although in their series, the mean number of ribs resected was 4 ± 2. Other potential concerns include the loss of respiratory function associated with rib defects.¹⁶ However, we only resected the floating ribs with minimal impact on respiratory function. No adverse effects were observed in this cohort. However, the removal of floating ribs avoids associated damage to the kidneys, liver, or spleen during accidental fracture of these ribs.^17,18 Nevertheless, plastic surgeons must be aware of such potential adverse events and should not hesitate to explain these before the surgery.

Our study was limited by the small sample size and by the lack of baseline/control groups for comparison. Further investigation with large prospective studies on floating rib removal with long-term follow-up is warranted to establish more concrete evidence regarding the procedure’s safety and effectiveness. In conclusion, our preliminary cohort study revealed that ant waist surgery is effective, has a low complication rate, and can be performed in an outpatient setting.

ACKNOWLEDGMENT

The datasets generated during the study are available from the corresponding author upon reasonable request.