da Re-Fit ClinicTo assess breathing after rib remodeling, first distinguish which ribs were changed and by what method. A RIBXCAR study found no significant difference in lung function before surgery versus at 6 months and 1 year, but had no control group and a limited population and follow-up. It does not establish that breathing is unaffected in everyone.
The ribs really do move when we breathe
The rib cage is not a fixed container. During inhalation, the ribs rotate at their spinal joints and rise upward and outward.
- Front-to-back expansion — As the front ends of the ribs rise, the chest increases in its front-to-back diameter. This is called pump-handle motion.
- Side-to-side expansion — As the sides of the ribs rise, the chest widens. This is called bucket-handle motion.
In a CT study measuring ribs 3–7 in healthy adults, full inhalation rotated rib 3 by 11 degrees in the pump-handle direction and 13 degrees in the bucket-handle direction; rib 7 rotated by 7 and 10 degrees respectively.1 The relative contributions of these movements also differ between quiet breathing and deep inhalation.2
The ribs do not move alone. The diaphragm descends and the intercostal muscles lift the ribs. A computer model of chest deformation reproduced real breathing only when both diaphragmatic and intercostal muscle contraction were included.3
The lower ribs are no exception. Abdominal muscles—the external and internal obliques and transversus abdominis—attach to ribs 11 and 12, stabilising the chest and spine and contributing to expiratory force.4 It is therefore incorrect to say that the lower ribs have no role in breathing. Equally, breathing does not depend on a single rib. The diaphragm, intercostal muscles, abdominal wall and whole chest work as one system. → How breathing works (Article 11)
Removing ribs and changing their angles are different operations
Some contouring operations remove part or most of ribs 11 and 12: rib resection. Rib remodeling keeps the ribs and changes their angles. Respiratory function after each type has been studied separately.
| Rib-resection study4 | Angle-changing surgery study5 | |
|---|---|---|
| Operation | Removal of ribs 11 and 12 | RIBXCAR without rib removal |
| Participants | 11 women who had surgery and 11 age-matched women who had not | 294 women aged 18–38 (179 RIBXCAR alone; 115 with conversion of rib 10) |
| Comparison | One comparison between groups at an average of 3 years after surgery | Repeated tests in the same participants before surgery, at 6 months and at 1 year |
| Forced expiratory volume in 1 second (FEV1) | Lower in the surgical group: 2.73 L versus 3.56 L | No change: 3.03 → 3.02 → 3.04 L in the 179-patient group; 3.02 → 3.02 → 3.04 L in the 115-patient group |
| Forced vital capacity (FVC) | Lower percentage of predicted value: 83% versus 105% (no difference in absolute values) | No change: 3.26 → 3.25 → 3.25 L in the 179-patient group; 3.25 → 3.24 → 3.27 L in the 115-patient group |
| Other findings | Lower expiratory muscle strength; no difference in inspiratory strength. Longer time since surgery was associated with lower FEV1 | No evidence of obstructive or restrictive ventilatory impairment. No reported complications other than postoperative pain in 3 patients |
The rib-resection authors concluded that people considering the operation should be fully informed about possible reductions in respiratory function.4 In the angle-changing surgery study, lung-function tests at 6 months and 1 year did not differ significantly from baseline.5 The study included 115 patients whose rib-10 cartilage connection was separated, with the same result.
Another report points in the same direction, although it concerns a different technique. In 32 women whose anterior rib prominence was corrected without removing costal cartilage, lung-function tests showed no significant change at 6 months.6
How should these findings be read?
Neither of these statements is accurate:
- “Rib surgery has no effect on breathing.”
- “Any intervention on the ribs reduces respiratory function.”
Which ribs are changed, how extensively, and by which method all matter. Removing a rib also removes attachment sites for its muscles. Angle-changing surgery retains bone and muscle attachments. This could explain the differing findings, but it is an inference; no study has directly compared the two operations.
Both studies have limitations.
- The resection study included only 11 people per group and had no preoperative test results, so pre-existing differences cannot be excluded. The authors acknowledged this limitation.4
- The angle-changing study was conducted at a single centre by the technique’s developers, without a nonsurgical control group. It included only young women without lung disease and followed them for one year.5
What remains unknown
- Respiratory function beyond one year after surgery. Available data extend only to one year.
- Breathing during strenuous exercise. The study used seated spirometry only.
- Respiratory muscle strength. The angle-changing surgery study did not measure it.
- Effects in people with asthma, COPD or other lung disease. A history of obstructive or restrictive lung disease was an exclusion criterion.
This is why the operation is not recommended for people with respiratory disease. → When surgery is not recommended
Breathing-related problems soon after surgery
Separate from long-term lung function, chest-wall complications can occur immediately after surgery.
- Pneumothorax and hemothorax — A study of 3,805 patients from 8 countries reported 4 pneumothoraces and 1 hemothorax.7 In an international survey of 2,351 patients treated with different methods, pneumothorax occurred in 0.17%, all reported with RIBXCAR.8
- Shallow breathing due to pain — Pain can cause shallow breathing and incomplete lung expansion. This is why adequate pain control and deep-breathing practice matter.
These events are uncommon but possible, and must be recognised and managed when they occur. Chest-tube insertion and pleural procedures are part of thoracic surgery training. → Risks and safety
Not how many, but how far
Changing more ribs should not be assumed to produce a better result. Chest width and length, lower-rib direction, the distance between rib cage and pelvis, and muscle and fat distribution vary between people.
The first question is not which numbered rib to operate on, but which structures determine this person’s waistline. Ribs are not simply structures to remove. Understanding their original function and changing only the necessary extent is central to this operation.
Questions for consultation
- Which ribs would be treated in my case, and how extensively?
- I have asthma, lung disease or a smoking history. Is surgery possible?
- Will lung function be assessed before surgery?
- If I become breathless or have chest pain afterwards, when and whom should I contact?
Ribs are familiar structures to a thoracic surgeon. Having always seen their role in breathing, my question in this operation is not how much can be changed, but “How much change is necessary?”.
References
- Wilson TA, Rehder K, Krayer S, et al. Geometry and respiratory displacement of human ribs. J Appl Physiol (1985). 1987;62(5):1872-1877. doi:10.1152/jappl.1987.62.5.1872
- Luu BL, McDonald RJ, Bolsterlee B, et al. Movement of the ribs in supine humans for small and large changes in lung volume. J Appl Physiol (1985). 2021;131(1):174-183. doi:10.1152/japplphysiol.01046.2020
- Zhang G, Chen X, Ohgi J, et al. Biomechanical simulation of thorax deformation using finite element approach. Biomed Eng Online. 2016;15:18. doi:10.1186/s12938-016-0132-y
- Aburub A, Darabseh MZ, Badran R, et al. Ant-waist surgery adversely affects lung function: a cross-sectional study. Multidiscip Respir Med. 2024;19(1):984. doi:10.5826/mrm.2024.984
- Manzaneda Cipriani RM, Adrianzen GA. Respiratory Function Assessment After Waist Reduction Through Scarless Ultrasound-Guided Monocortical Fracture (RibXcar) Surgery for Body Contouring. Aesthet Surg J Open Forum. 2026;8:ojag007. doi:10.1093/asjof/ojag007
- Manzaneda Cipriani RM, Adrianzen GA. Ribs with Anterior Protrusion (Winged Ribs) Treated Using Percutaneous Chondroplasty. Plast Reconstr Surg Glob Open. 2024;12(9):e6178. doi:10.1097/GOX.0000000000006178
- Manzaneda Cipriani RM, Duran H, Adrianzen GA, et al. A Multicenter Cohort Study of 3805 RibXcar Cases: Safety and Efficacy in Incisionless Rib Remodeling. Plast Reconstr Surg Glob Open. 2026;14(7):e7929. doi:10.1097/GOX.0000000000007929
- Aguilar HA, Hoyos AE, Ramirez B, et al. Global Survey on Rib Remodeling Techniques: Assessing Complications and Safety in Waistline Contouring. Plast Reconstr Surg Glob Open. 2026;14(4):e7609. doi:10.1097/GOX.0000000000007609
Rib remodeling is an elective cosmetic operation. Suitability and outcomes vary with individual anatomy and health. A decision should follow examination, testing and a thorough discussion with the medical team.
→ What is RIBXCAR?
→ More on rib-cage anatomy
→ Possible complications
→ When the procedure is not recommended