August 12, 2026 | Uncategorized
A patient with an athletic build told me last month that she had done everything right. Years of training, low body fat, oblique work, clean diet. Her waist would not budge past a certain measurement, and she wanted to know what she was missing.
I put her hand on the spot where her last rib sat. It was nearly touching her pelvis.
That is the piece of anatomy this entire procedure is built on, and it is the first thing I explain in every rib repositioning consultation.
The Anatomy That Sets Your Waist
The waist is defined, or restricted, by the distance between the superior crest of the pelvis and the last rib. In some patients, this last rib almost touches the pelvis, which means that there really can be no further reduction in the waistline. No amount of fat loss changes the position of bone.
To create a smaller waist, what we do is cut the outer portion of the last two floating ribs so that we can reposition them in a narrower configuration. That’s the way we create a smaller waistline.
You may have seen this procedure under other names: rib remodeling, minimally invasive rib contouring, or the marketing versions, the Barbie waist, Invisarib, RibX, Ribella, WASP, RIBOSS, H-Curve. These are all the same procedure with different names.
How the Modern Technique Works
This used to be done by removing the ribs in their entirety, which required a large incision, had an increased risk of injury to the lung or nerves, and sometimes led to chronic pain.
The way it is done now is through a small needle incision, using a device called a Piezotome. This is an ultrasonic needle device that helps us cut the outer portion of the rib with ultrasound guidance, and then the ribs are fractured into their new position, similar to how a controlled fracture is used in rhinoplasty. Today it is a scarless procedure with substantially fewer risks and complications.
I use the ultrasound to identify the ribs and visualize while I’m cutting the outer table of the ribs before repositioning, and this decreases the risk of injury to other structures. My background matters here: I am a board-certified general surgeon and plastic surgeon, with experience in rib fractures and rib removal procedures from both specialties. The technology itself only came into development about two or three years ago.
Who Is a Candidate
The ideal candidate is somebody who wants to reduce their waistline and get a more feminine figure. In my practice that includes women with an athletic body build who do not have much natural waist, male-to-female transgender patients, and women who are already curvy but want further reduction. I also see patients who have already had liposuction and tummy tucks and want even more waist definition; rib repositioning is the last remaining option for them.
Results: Floating Ribs Versus False Ribs
Most patients’ waistline is reduced by about three to four inches when we reposition the last two floating ribs, with a lung injury risk of less than one percent.
The reduction can go further if we also treat the last two false ribs. To perform that, we cut the ribs anteriorly, where they attach to the cartilage, and posteriorly, so that we turn them into floating ribs, and then reposition them. This increases complications to around one to two percent, requires a CT scan to visualize the ribs before surgery, and not every patient is a good candidate. By adding the two false ribs, we can reduce the waistline by six to seven inches.
Recovery: Exparel, the Waist Trainer, and Three Months
Before the procedure I inject Exparel, a local anesthetic that lasts for three days and numbs the area for a much smoother recovery. Most patients describe the pain as mild to moderate.
The waist trainer is not optional. We use it for three months to help heal the ribs in their new position, and patients feel it helps them during recovery. Many notice the trainer can be placed tighter and tighter as they heal, and they often downsize to a smaller trainer toward the end of the three months. Strenuous exercise waits the full three months.
Combining for Maximum Definition
Liposuction is a very strong tool for the waist contour, and I often combine it with rib repositioning when there is pinchable fat at the waistline. My tummy tuck technique adds another layer: I plicate the rectus muscles and the oblique muscles, a triple plication that works like an internal corset and brings the waistline in further.
The ultimate waist definition plan combines liposuction, rib repositioning, the triple plication internal corset through a standard or mini tummy tuck, and the waist trainer through recovery. For post-pregnancy patients this often lives inside a mommy makeover, and for weight loss patients inside a broader body contouring plan.
Why Choose Dr. Agullo
Double board certified in general surgery and plastic surgery, which is precisely the combination this operation rewards. Mayo Clinic fellowship trained. Clinical Associate Professor of Plastic Surgery at Texas Tech University Health Sciences Center. Castle Connolly Top Doctor thirteen consecutive years.
Ready to Talk?
If your waistline has stopped responding to training and even to surgery, the limiting factor may be your ribs. Call (915) 590-7900, text 1-866-814-0038, or book a consultation online. #StayBeautiful
@RealDrWorldWide on Instagram, TikTok, and Snapchat, @Agullo on X, or @AgulloPlasticSurgery on Facebook.
Companion reads: the editorial version on drworldwide.com, and the practice overview at swplasticsurgery.com.
