Extreme isn’t a word Dr. Barry Eppley likes to use. Instead, the board-certified plastic surgeon calls the patients who travel from around the world to Carmel, Indiana, to see him “ultra-motivated.” They want procedures that other doctors refuse to perform—skull augmentation, testicle implants, shoulder widening—but that are the bread and butter of Dr. Eppley’s practice.
Rib removal is one of those taboo body modification surgeries, and it made headlines (local and tabloid headlines, at least) four years ago, when Dr. Eppley removed portions of rib pairs 10, 11, and 12 from Pixee Fox, a Swedish woman who has modeled herself into a “living cartoon.” The fact-checking site Snopes questioned whether the surgery was real or just a publicity stunt; plenty of outlets have long written off celebrity rib removal rumors as urban legend. But while it’s true that there is no medical literature on the procedure or knowledge of when it was first performed and by whom, “it’s “absolutely not a myth,” assures Dr. Eppley. He estimates he does 15 to 20 of the surgeries a year.
Who is getting their ribs removed?
Based on his own observations, there are three types of people who request rib removal: One, those who have a medical condition, such as rib asymmetry or iliocostalis syndrome, in which the lower ribs cause friction against the iliac crest and irritate the soft tissue; two, those transitioning from male to female and looking to feminize their waistline; and three, women, like Pixee, who want the ultimate hourglass figure. In other words: “cisgender females who are very thin and have already done everything that is conventionally possible, including liposuction, diet, exercise, and waist trainers or corsets.” These are the patients Dr. Eppley means when he says “ultra-motivated”—and he aims to give them an “ultra result” through a floating rib removal by taking away the last anatomic barrier to a smaller waist. For most, that barrier is ribs 11 and 12 (also called the floating ribs because they don’t attach to the sternum or breastbone), but he’s gone up to 10. (There’s no benefit of going up to 9, he says, “since the point is for the waistline.”)
Is rib removal surgery dangerous?
He’s well aware of what people think of this particular procedure, saying, “Anytime you bring up rib removal, it evokes feelings of, ‘Well, these people shouldn’t be doing it. They have no reason to do it. Anyone that would do it would be crazy.’” And yet he doesn’t see how it’s any different from shaving two millimeters off someone’s nose or putting in larger-than-average breast implants. What’s considered normal is relative, and why a patient wants to look a certain way is irrelevant to him. “What’s relevant to me is, can the surgery come close to achieving their objectives and can it be done safely?”
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To his second point, clearly it can be done safely. Dr. Eppley estimates that he’s removed 300 ribs from 40 to 50 people and has never seen an infection, seroma, or medical complication—and it’s commonly accepted that the floating ribs serve no functional purpose. Dr. Paul G. Ruff IV, a board-certified plastic surgeon in Washington, D.C., performs the procedure on males, typically in their 50s and older, who are transitioning to females. “With the right tools and in the right setting, it’s very safe and straightforward,” he says. “As long as you stay at ribs 10 and below, the risk is relatively minimal.”
Not everyone in the plastic surgery community agrees. Dr. Gerald Imber, a board-certified plastic surgeon in New York City, acknowledges that “the procedure is not rocket science” and that everyone who has gone through bone-grafting training in residency knows how to do it—but he personally refuses to, despite having gotten requests. “In my mind, the risk of complication far outweighs the glory of success,” he says, explaining that in order to reduce scarring, doctors are making “small incisions—an inch or two—on each side of the spine and working the rib out through that little incision with various tools,” which increases the risk of perforating the thorax and internal organs.
“Pneumothorax [a collapsed lung] is a known risk of rib removal surgeries or rib harvest surgeries, due to the proximity of the rib to the underlying pleura,” adds Dr. Kenneth Hughes, a board-certified plastic surgeon in Los Angeles.
But every surgical procedure—whether for aesthetic purposes or not—in which a patient undergoes general anesthesia and a doctor cuts into the body carries risk. It’s difficult to speak definitively about the safety of cosmetic rib removal, because the data on it simply doesn’t exist, yet we know that the complication rate has not been reported to be high and that harvesting rib cartilage is common practice in reconstructive surgery. We also know that far riskier procedures exist—seromas and hematomas occur in one-third of tummy tuck cases; reports from 2018 put the mortality rate for Brazilian butt lifts at 1 in 3,000. So what’s the real reason the vast majority of plastic surgeons won’t go further than liposuction in order to whittle down your waistline?
Related: 5 Common Reasons Plastic Surgeons Will Refuse to Operate On You
“I’ve been asked to do it, and I’ve told patients it wasn’t in their best interest. Generally, the patients who request this have body dysmorphia and are trying to achieve something anatomically that their body is saying they can’t,” says Dr. Robert Singer, a board-certified plastic surgeon in La Jolla, California. “It’s an extreme procedure, and an increased number of people are seeking it out because social media highlights the most extreme individuals.”
Unlike Dr. Eppley, these doctors say they do feel a responsibility to figure out the why behind a patient’s goal. “At some point, someone in the room has to have common sense, and if it’s not the patient, it should be the doctor,” says Dr. Imber.
Is it possible though that rib removal surgery, whether we like it or not, is part of the future social media, filtering apps, and all those Kardashian ads for waist trainers and body-constricting shapewear are building to? Plastic surgery comes down to supply and demand. Breast implants didn’t exist 60 years ago; today, breast augmentation is the most popular procedure in the U.S. “It’s all relative to familiarity,” says Dr. Eppley, noting that the point he wants to make clear isn’t that he thinks everybody should start doing rib removal—he wouldn’t care if he never did another one for the rest of his life. “The point is that the perception of the surgery as [physically] dangerous just isn’t the reality.”
