Original Article

Cosmetic
Waist Reduction through Conversion from False to
Floating Ribs
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Raúl M. Manzaneda, MD*

Gerardo A. Adrianzen, MD*† Background: Waist reduction by ultrasound-guided monocortical fracture
(RibXcar), usually performed on floating ribs, may show limitations when per-
formed on false ribs (9 and 10) because of the stress force exerted on the anterior
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fixation point (cartilage union to sternum). Hence, we introduced a procedure for

conversion from false to floating ribs to improve the final result of the treatment of
false ribs through a rib treatment scheme.
Methods: Forty-nine female patients undergoing rib surgery were recruited.
Waist measurements and angular variations were compared between two groups
of patients, the first (26 patients) consisting of patients who underwent RibXcar
with conversion surgery (ribs 9 and 10) and the second (23 patients) consisting of
patients who underwent RibXcar without conversion surgery (ribs 9 and 10).
Results: The waist measurements taken after 6 months showed a mean decrease
of 8.70 cm in the group where only RibXcar was performed, whereas a statistically
significant mean reduction of 17.04 cm was observed in the group where RibXcar
was performed with rib conversion surgery.
Conclusions: The false-to-floating-rib conversion technique combined with
RibXcar demonstrated more reduction in waist circumference and a more efficient
rib angulation compared with RibXcar alone. (Plast Reconstr Surg Glob Open 2024;
12:e5900; doi: 10.1097/GOX.0000000000005900; Published online 13 June 2024.)

INTRODUCTION them to the sternal manubrium, have a central force

Waist reduction through rib surgery, as part of a body that limits the effect of costal deformation toward the
harmonization treatment, provides many benefits that interior.6–8 This is why costochondral disarticulation is
cannot be achieved with other conventional techniques. required to improve the direction of the monocortical
Waist reduction relies on alteration of the bone structure fracture. In this study, this was performed using ultraso-
at the lower region of the rib cage, which is precisely what nographic guidance and piezotome entry, through the
shapes the waist.1,2 technique known as RibXcar.5 The objective of this study
Waist reduction techniques aimed at rib treatment is to describe a surgical technique for converting false to
generally target the floating ribs (11th and 12th), and in floating ribs (Xonversion Ribs) combined with RibXcar
some cases the false ribs (ninth and 10th), by performing (monocortical fracture without scarring), compared with
monocortical resection and/or fracture and even using RibXcar alone, which is performed in patients whose
osteosynthesis with a fixator in some cases.3–5 ribs 9, 10, 11, and 12 are treated according to a rib treat-
In the treatment by monocortical fracture, the fac- ment scheme. One of the authors (R.M.M) performed
tors to be considered are the support and stress forces the procedure using ultrasound guidance, as well as the
that fix the ribs to the surrounding tissues. Therefore, comparison of the angular variation of the fracture in
when performing this fracture, compensatory forces both cases using ultrasound and waist measurements 6
may alter the result, especially when the targets are the months after surgery.
false ribs, which, by having a cartilage union that joins
MATERIALS AND METHODS
From *Private Practice, Lima, Peru; and †Cayetano Heredia Forty-nine female patients, aged 18–35 years, request-
University, Lima, Peru. ing medical assessment for body contouring surgery
Received for publication February 8, 2024; accepted May 1, 2024. were recruited; the decision to remodel the rib through
Copyright © 2024 The Authors. Published by Wolters Kluwer Health,
Inc. on behalf of The American Society of Plastic Surgeons. This Disclosure statements are at the end of this article,
is an open-access article distributed under the terms of the Creative following the correspondence information.
Commons Attribution-Non Commercial-No Derivatives License 4.0
(CCBY-NC-ND), where it is permissible to download and share the
work provided it is properly cited. The work cannot be changed in
Related Digital Media are available in the full-text
any way or used commercially without permission from the journal.
version of the article on www.PRSGlobalOpen.com.
DOI: 10.1097/GOX.0000000000005900

www.PRSGlobalOpen.com 1
 PRS Global Open • 2024

monocortical fracture was made in consensus and based

on the likelihood of treatments. All patients whose three- Takeaways
dimensional (3D) tomographic assessment of the rib cage Question: Does the complementary Xonversion Ribs
and cartilage did not show floating rib abnormalities, and technique improve RibXcar results by reducing the angu-
patients with all false ribs (8, 9, and 10) showing a com- lations of the ninth and 10th ribs, as well as reducing the
mon cartilage attachment to the sternal manubrium were waist?
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included in the study. The exclusion criteria were comple- Findings: The group of patients in whom RibXcar asso-
mentary liposuction in the surgical plan, having a history ciated with Xonversion Ribs was performed showed a
of previous rib surgery (aesthetic or other specialties), reduction in angulations for ribs 9 and 10, as well as in
Goldman surgical risk greater than II, body mass index
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waist diameter with greater effectiveness, compared with

above 28, and skin flaccidity in the abdomen and/or dor- those in whom only RibXcar was performed (P < 0.05).
solumbar region with a Matarasso index greater than or
Meaning: Xonversion Ribs is an effective and safe tech-
equal to 2.
nique as a complement to RibXcar in ribs 9 and 10, and
The surgical decision scheme for rib treatment is
allows improvement in postsurgery results after 6 months.
shown in Table 1 and was devised by one of the authors
(R.M.M.; Fig. 1).
A comparative study of the two groups of patients who Ultrasound Findings
received rib treatment based on the scheme proposed by With the patient in the right lateral decubitus position
the author was performed as follows: and the flexion of the stretcher at ribs 11 and 12, the trajec-
tories of ribs 8, 9, 10, 11, and 12 were palpated; ultrasound
1. Group 1: patients undergoing ultrasound-guided was performed using the Clarius L7 ultrasound equip-
monocortical fracture (RibXcar) in floating (11 and ment to identify the trajectory of each rib. Each rib had
12) and false (9 and 10) ribs with conversion surgery a previously designed point, and the ultrasound angular
(26 patients) measurement was made before surgery. Immediately after
2. Group 2: patients undergoing ultrasound-guided the procedure, the postsurgery angular variation was mea-
monocortical fracture (RibXcar) in floating (11 and sured by placing the transducer at the site of the fracture
12) and false (9 and 10) ribs without conversion sur- made in each rib (locating the fracture trace). Similarly,
gery in false ribs (9 and 10) (23 patients) ultrasonographic measurement was performed 1 and 6
The procedures in group 2 were performed between months after surgery by identifying the fracture trace, thus
January and June, 2022, whereas those in group 1 were obtaining values that were recorded in a Microsoft Excel
performed between August and December, 2022. All v19.00 database. Statistical analysis was performed using
patients signed an informed consent for surgery in addi- the SPSS, v.25 software.
tion to providing authorization for image use in this study.
The guidelines of the Declaration of Helsinki were fol- Technique Design
lowed (Table 2). With the patient in the dorsal decubitus position, false
ribs 9 and 10 were located by palpation, the trajectory
Waist Measurements was verified by ultrasound, the chondral junction site was
With the patient standing, the equidistant point located, and the sites where the disarticulation was to be
between ribs 9 and 10 was located. Next, the waist cir- performed with needles or piezotome were drawn. Likewise,
cumference was measured using Fith measuring tapes, the patient was placed in the lateral decubitus position to
which were placed at this point and projected toward locate the trajectories of ribs 9 and 10 and draw the frac-
the abdominal midline where the measurement read- ture points on the M line (RibXcar technique) (Fig. 2).
ing was made. Measurements were performed at the [See Video 1 (online), which demonstrates the conversion
same location immediately, 1 month, and 6 months technique from false ribs to floating ribs.] [See Video 2
after surgery. (online), which demonstrates the RibXcar technique.]

Table 1. Therapeutic Decision for Costal Treatment

RibXcar Indication Xonvertion Ribs Indication
Ninth rib* • Ratio carried out between ninth rib and the largest thoracic • 3D tomography indicates cartilaginous junction
diameter is ≥ 0.75 between ribs (8–9)
10th rib* • Ratio carried out between 10th rib and the largest thoracic • 3D tomography indicates cartilaginous junction
diameter is ≥ 0.75 between ribs (9–10)
• Higher iliac crests and short waist: this is determined by the
distance between the iliac crests and the 10th rib (<10 cm)
11th rib • Pass the scapular line • Not needed
12th rib • Pass the outer edge of the longissimus muscle • Not needed
*If RibXcar treatment is required, Xonvertion Ribs will be done if 3D reconstruction tomography with cartilaginous window shows cartilaginous junction between
them.

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 Manzaneda and Adrianzen • Treating False Ribs-Xonversion Rib Surgery

[See Video 3 (online), which demonstrates ultrasound

assessment.]

RibXcar
With the patient in the left lateral decubitus position
and the stretcher in flexion at ribs 11 and 12, the designed
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staggered points were located. Ultrasonography was per-

formed to identify anatomical structures, and a puncture
was performed perpendicularly with a size 18 needle at
the design point, locating the ribs to be operated through
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ultrasound. De-epithelialization was performed with a

needle and complemented with a piezotome tip (not in
operation). Next, two size 21 intravenous catheters were
introduced at approximately 45 degrees, each at 2-cm
equidistant points from the puncture site and located
close to the piezotome head (three-point sign), using
ultrasonography. Fracture was performed by piezotome at
80% power and with the water release function disabled.
This was achieved by multiple 6-second pulses with contin-
uous infiltration of 0.9% NaCl solution at 10°C from both
previously placed equidistant catheters, as well as dripping
of 0.9% NaCl at 10°C with an external syringe at the site of
piezotome insertion5 (Video 2).
Once the fracture trace was verified by ultrasound,
manual deformation was performed using the first finger
of the dominant hand and by applying gentle and contin-
uous pressure. The same procedure was repeated on the
left side. Ultrasound was performed to detect angulation
and monocortical fracture (Video 2).
Fig. 1. Anatomical repairs in rib surgery. Yellow: vertebral line.
Blue: outer border of longissimus muscle. Sky blue: scapula line.
RESULTS
Forty-nine female patients (26 in group 1 and 23 in
Surgical Procedure group 2), aged 18–35 years (mean age, 26.54 years in
Conversion from False to Floating Ribs group 1 and 26.48 years in group 2), who underwent rib
With the patient in the dorsal decubitus position, re-shaping surgery with or without conversion from false
the previously designed points were located. Next, a size to floating ribs (Xonversion Ribs) were assessed. The
18 needle was introduced at the costochondral joints of mean body mass index in groups 1 and 2 was 24.82 and
ribs 8–10, applying a sustained acupressure on the area 23.84, respectively. All patients showed Goldman surgi-
surrounding the puncture to feel the disarticulation of cal risk grade I (100%); the mean surgery time in groups
the rib; this can also be done by a piezotome. This pro- 1 and 2 was 54.31 min and 42.74 min, respectively. All
cess was performed bilaterally, palpating for mobility patients underwent postoperative care without compli-
and resistance loss. Thereafter, the patient was placed in cations, such as surgical site infections, pneumothorax,
the lateral decubitus position to continue with RibXcar hemothorax, or other respiratory complications. Two
(Fig. 3). [See Video 1 (online), which demonstrates the cases of neuropathic pain in group 2 showed favorable
conversion technique from false ribs to floating ribs.] evolution (Table 2). With respect to rib 9, in group 1

Table 2. Characteristics of the Study Groups

Groups
Group 1: RibXcar (9, 10, 11, 12) with Group 2: RibXcar (9, 10, 11, 12) without
Conversion of Ribs 9 and 10 Conversion of Ribs 9 and 10
n Mean SD n Mean SD
Age (y) 26 26.54 4.29 23 26.48 5.69
Duration (min)* 26 54.31 2.87 23 42.74 8.02
Weight (kg) 26 68.15 4.49 23 66.22 4.71
Size (cm) 26 165.92 5.07 23 166.74 4.09
BMI 26 24.82 2.27 23 23.84 1.83
Complications 26 0 — 23 2† —
*P < 0.001.
†Neuropathic pain was found in two cases in group 2.

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(with conversion: Xonversion Ribs), a 10.96 degree

reduction in angularity was observed immediately after
surgery, a 12.42 degree reduction 1 month after surgery,
and a 14.04 degree reduction 6 months after surgery.
In group 2 (without conversion surgery), a 5.13 degree
reduction in angularity was observed immediately after
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surgery, a 5.09 degree reduction 1 month after surgery,

and a 7.22 degree reduction 6 months after surgery
(Table 3).
As for rib 10, in group 1 (with conversion: Xonversion
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Ribs), an 11.96 degree reduction in angularity was

observed immediately after surgery, a 12.81 degree reduc-
tion 1 month after surgery, and a 14.27 degree reduction
6 months after surgery. In group 2 (without conver-
sion surgery), a 3.30 degree reduction in angularity was
observed immediately after surgery, a 3.30 degree reduc-
tion 1 month after surgery, and a 4.87 degree reduction 6
months after surgery (Table 4).
Waist reduction in group 1 (with conversion:
Xonversion Ribs) was as follows: 12.42 cm immediately
after surgery, 15.50 cm 1 month after surgery, and 17.04 cm
6 months after surgery. In group 2, waist reduction was
as follows: 7.48 cm immediately after surgery, 8.30 cm 1
month after surgery, and 8.70 cm 6 months after surgery
(Table 5).

DISCUSSION
The development of concepts in rib surgery allows
the success of many of the techniques devised to per-
form an effective reduction. The body has 12 pairs of
Fig. 2. Presurgical design. Brown: chondral junction. Purple: ribs ribs, which, from number 1 to number 7, are consid-
anterior projection. ered as true because they articulate with the sternal

Fig. 3. Xonversion Ribs procedure. A, Chondral anesthetic block. B, Palpation and location of chondral joint. C, Chondral disarticulation
with size 18 needle. D, Manual pressure and disarticulation of chondral joint. E, Loss of strength at disarticulation site.

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Table 3. Assessment of Angular Variation of the Ninth Rib

Difference from Presurgery Angulation (Degrees) Group n Mean SD t P
Angulation immediately after surgery (degrees) Group 1 52 −10.96 0.824
−8.77 <0.001
Group 2 46 −5.13 3.279
Postsurgery angulation after 1 month (degrees) Group 1 52 −12.42 1.027
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−10.46 <0.001
Group 2 46 −5.09 3.410
Postsurgery angulation after 6 months (degrees) Group 1 52 −14.04 1.038
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−9.48 <0.001
Group 2 46 −7.22 3.503

Table 4. Assessment of Angular Variation of the 10th Rib

Difference from Presurgery Angulation (Degrees) Group n Mean SD t P
Angulation immediately after surgery (degrees) Group 1 52 −11.96 1.183
−14.59 <0.001
Group 2 46 −3.30 2.754
Postsurgery angulation after 1 month (degrees) Group 1 52 −12.81 1.096
−18.53 <0.001
Group 2 46 −3.30 2.344
Postsurgery angulation after 6 months (degrees) Group 1 52 −14.27 1.218
−18.65 <0.001
Group 2 46 −4.87 2.222

Table 5. Waist Reduction Assessment (cm)

Difference from Presurgery Waist Measurement (cm) Group n Mean SD t P
Postsurgery waist measurement (immediate)(cm) Group 1 26 −12.42 1.815
−10.23 <0.001
Group 2 23 −7.48 1.534
Postsurgery waist measurement (1 month) (cm) Group 1 26 −15.50 2.387
−11.38 <0.001
Group 2 23 −8.30 1.987
Postsurgery waist measurement (6 months) (cm) Group 1 26 −17.04 2.441
−13.54 <0.001
Group 2 23 −8.70 1.769

manubrium via a cartilage in a synarthrosis joint; ribs These ribs, which are joined by a costochondral joint to
8–10 are considered as false because they do not have the sternal manubrium, show a stress force that does not
a direct articulation with the sternal manubrium. Ribs allow inward deformation, the main basis of RibXcar’s suc-
11 and 12, which are the floating ribs, are also consid- cess. In this regard, the proposed alternative is the con-
ered false because these do not articulate with the ster- version of false ribs to floating ones to release this stress
nal manubrium and are shorter in length and curvature force, thereby allowing inward deformation and enabling
than those mentioned above.6–8 RibXcar to work effectively.5
Waist treatment through ultrasound-guided (RibXcar)5 Accordingly, who is the ideal patient eligible to
monocortical fracture is usually performed in floating and undergo this procedure (Xonversion Ribs)? The answer
false ribs; however, in the latter, the stress force exerted to this question might cause confusion, because this will
toward the sternal manubrium may limit inward angula- depend greatly on the type of approach and required
tion, producing an unsatisfactory result usually directed results. If we treat the floating ribs, which have a single
toward the ninth and 10th ribs. Although no frequency posterior anchor point at the vertebral level, monocortical
data regarding chondral joints in ribs 8, 9, and 10 exist, fracture will be enough to alter the angulation of the ribs,
based on our surgical experience, rib 10 behaves as float- generating an inward deformation, which allows the waist
ing in most cases.6–10 to be modulated and its diameter to be reduced. However,
The RibXcar procedure has allowed us to satisfactorily when the ribs are false (having an anterior fixation point),
achieve waist reduction through ultrasound monitoring. the deformation that occurs has the risk of becoming
Although the main treatment is directed toward the float- bicortical due to the stress force the anterior point exerts;
ing ribs, occasionally, treatment of ribs 9 and 10 is needed. complications may also arise, such as pseudoarthrosis,

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Fig. 4. False rib conversion concept. A, Remodeling and disarticulation of chondral sites. B, Interior
angulation in false ribs after Xonversion Ribs and RibXcar procedure. C, Complete fracture complica-
tion. D, Deformity complication.

Fig. 5. Patient outcomes: Before (A) and at 6-month postoperative follow-up (B) in posterior view.

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Fig. 6. Patient outcomes: Before (A) and at 1-year postoperative follow-up (B) in posterior view.

Fig. 7. Patient outcomes: Before (A) and at 6-month postoperative follow-up (B) in frontal view.

dextroposition, and pain, in addition to limiting angula- Costochondral disarticulation is achieved using size 18
tion (Fig. 4). needles or a piezotome with digital pressure applied on
Once the patient whose ninth and 10th ribs need to the joint; this allows for better manipulation for disarticu-
be treated has been determined, the next step is to assess lation. This must be verified using ultrasound to ensure its
the location of the floating ribs. For this, the ideal pro- effectiveness.5
cedure is to request a computed tomography scan with In RibXcar, the fracture trace is achieved when the
3D reconstruction alongside a cartilage window; this will ultrasonic tip enters up to 70%–80% of the rib thickness,
allow assessment of the situation of the costochondral thus allowing a controlled fracture (Video 2).
joint to adequately plan for the conversion of false ribs to Notably, despite showing a good angulation and a
floating ribs. good fracture trace, long-term results may be achieved
It is important to emphasize that the use of ultrasound by maintaining the compressive force that stabilizes the
is essential to ensure a good fracture trace when RibXcar fracture and angulation. This is achieved by maintaining a
is performed; this allows us to evaluate the effectiveness fixative waistband for at least 3 to 6 months.11,12
and subsequent costal angulation produced by this mono- The anatomical characteristics of ethnic groups from
cortical fracture (Video 3). different regions of high altitudes, especially in South

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America with countries such as Colombia, Ecuador, Peru, Raúl M. Manzaneda, MD

Bolivia, Chile, and Argentina, undergo an anatomical Private Practice
adaptation of the rib cage to improve the respiratory Av Circunvalación del Golf los Inkas 208
Lima, Peru
capacity, to prevent hypoxia in these places with high
E-mail: [email protected]
altitude. The main anatomical adaptations include the
greater anterolateral width of the thorax and the greater
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surface area and greater angulation of the ribs. Therefore, DISCLOSURE

rib treatment in patients with these characteristics implies The authors have no financial interest to declare in relation to
work on higher (false) ribs, as well as improving the angu- the content of this article.
lation of these ribs to generate a more harmonious effect
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toward the waist (Xonversion Ribs + RibXcar).13–15

Complications are unlikely in Xonversion Ribs. This REFERENCES
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