da Re-Fit Clinic Thoracic Surgery · Rib Remodeling

History · 1900—

Surgeons have been operating on the chest wall
for more than a century.

Surgery to change chest shape is not new. Attempts to correct chest-wall deformities began in the early 20th century, gradually revealing how far ribs and cartilage could be treated and what the risks were. Today’s chest-wall procedures build on that accumulated experience.

  1. 1900 ScudderFirst recorded open reduction and internal fixation of a rib fracture
  2. 1906 TansiniFirst report of chest-wall reconstruction using a pedicled latissimus dorsi flap
  3. 1911 MeyerFirst attempt to correct pectus excavatum: two costal cartilages removed; symptoms persisted
  4. 1913 SauerbruchExtensive resection relieved cardiac compression but left chest-wall weakness
  5. 1920s SauerbruchPartial resection and sternal osteotomy, with external wire traction for several weeks
  6. 1939 Ochsner & DeBakeyLiterature review reported cumulative mortality of 20–25% after cartilage-resection operations
  7. 1949 RavitchCorrection maintained without external traction—the standard for subsequent decades
  8. 1961 Adkins & BladesSubsternal metal support—a concept leading toward the Nuss procedure
  9. 1984 PsillakisCostal-cartilage resection during abdominoplasty—the earliest record of chest surgery for body contour
  10. 1998 NussMinimally invasive correction without cutting or removing cartilage
  11. 2021 Ferreira et al.Systematic review: only two papers through 2020; insufficient evidence highlighted
  12. 2023 Manzaneda et al.Ultrasound-guided monocortical fracture without an incision
  13. 2024— Two directionsUltrasound-guided techniques and metal fixation—safety remains under discussion
011900—1939

It begins with records of failure.

Surgical approaches to chest-wall deformity began before endotracheal intubation became standard. Opening the chest caused the lung to collapse, so early surgeons chose open anterior approaches to correct deformity.

1911 — Meyer

Two right costal cartilages were removed to address persistent breathlessness in a 16-year-old boy.1 This was the first reported attempt to correct pectus excavatum, but symptoms persisted and the surgeon described the result as unsatisfactory.

1913 — Sauerbruch

A more extensive approach followed: resection of the sunken anterior chest, including left costal cartilages 5–9 and part of the adjacent sternum.2 Before surgery, breathlessness and palpitations even at rest prevented the patient from working. Relieving cardiac compression allowed a return to work.

However, only muscle covered the defect, the heartbeat was visible externally, and an acquired Poland-syndrome-like defect remained. Sauerbruch also considered this result unsatisfactory.

Sauerbruch was a pioneer of thoracic surgery who developed a negative-pressure chamber to allow operations with the chest open. Chest-wall deformity correction and thoracic surgery shared roots from the start.

The 1920s—a change of direction

After encountering a young patient with severe pectus excavatum, Sauerbruch changed his approach. He combined partial cartilage resection with sternal osteotomy, rather than extensive removal. This was a precursor of what is now called the modified Ravitch procedure. Wires through the osteotomised sternum provided external traction for weeks to prevent it sinking again.

1939—Ochsner and DeBakey

The literature available at that time was comprehensively reviewed.3 While cumulative mortality after cartilage-resection operations reached 20–25%, no deaths had been reported with sternal mobilisation and external traction, so the latter was recommended.

The lesson of the first thirty years was clear: the chest wall could be operated on, but the extent was central to safety.

021949

Ravitch establishes a standard.

In 1949, Mark Ravitch published his first case series in Annals of Surgery. Deformed costal cartilages were removed on both sides and a transverse wedge osteotomy fully mobilised the sternum.4

The key was maintaining correction without external traction, removing the burden of living with a traction device for weeks.

The procedure became the standard for chest-wall deformity correction for decades and was widely performed, particularly in children.

1961—Adkins and Blades

The concept of substernal support was added.5 A metal support held the corrected sternum in position, directly anticipating the idea behind the later Nuss procedure.

A principle was established during this period: Resection or division of costal cartilage changes shape, and the chest wall heals in that position. This became a foundation for subsequent techniques altering chest shape.

031998

Nuss removes resection from the procedure.

In 1998, Donald Nuss reported ten years of experience in Journal of Pediatric Surgery. Between 1987 and 1996, he assessed 148 patients with chest-wall deformities and used the new approach in 42 patients younger than 15.6

Small incisions were made on both sides of the chest. A curved metal bar was passed beneath the sternum with its convexity facing backward, then rotated in place. Rotation pushed the sternum forward and corrected the deformity.

The decisive difference was what was not done.

The procedure neither cuts nor removes cartilage. Resection, assumed necessary for half a century, was omitted. Instead, the technique uses chest-wall flexibility and its capacity to remodel with time. It was based on the observation that a growing chest can maintain a changed shape under sustained external force.

The Nuss procedure spread rapidly and became a principal approach to pectus excavatum, while Ravitch surgery remains used mainly for adults, complex cases and reoperations. Current treatment spans a nonoperative vacuum bell for mild cases, minimally invasive correction for moderate or greater deformity, and open correction for severe or recurrent cases.

The concept of chest-wall correction shifted again. From cutting tissue away to shape it, toward guiding shape through force and time. This is the conceptual basis of today’s approaches that avoid resection.

04In parallel

Another history: reconstructing the chest wall.

Alongside deformity correction, techniques developed for other reasons to operate on the chest wall.

Reconstruction after tumour removal

The earliest record of chest-wall reconstruction dates to Tansini in 1906, covering an anterior defect with a pedicled latissimus dorsi flap.7 Early methods relied on autologous tissue such as fascia lata or rib grafts, limiting the extent of resection. From the 1980s, materials such as PTFE, polypropylene mesh and methyl methacrylate, combined with myocutaneous flaps, enabled reconstruction of larger defects.8

Rib-fracture fixation

The first record of open reduction and internal fixation of rib fractures dates to Charles Locke Scudder in 1900.9 Over 120 years, materials progressed from sutures to wires and then external and internal plates. Fixation evolved from open wire ligation to minimally invasive thoracoscopic internal fixation. Titanium is now standard because of its corrosion resistance and compatibility with imaging.

These two fields produced knowledge essential to anyone working on the chest wall: How ribs and cartilage heal, how much removal compromises stability, and whether the anterior or lateral chest is more vulnerable. These are questions of respiratory mechanics, not merely shape.

051984—2026

Expansion into cosmetic applications.

From the 2010s, these techniques began to be applied more widely to shape rather than disease, although individual reports appeared earlier.

Two developments underlie this. One is the lesson of the Nuss procedure: chest-wall shape can change without resection. The other is recognition that costal-cartilage flexibility varies greatly between people and ages, and that assessing it may help define applicability.

1984 — Psillakis

A paper on abdominoplasty records resection of the seventh and eighth Costal cartilage to improve body contour. It treated cartilage rather than ribs, but represents the earliest record of manipulating the rib cage for contour rather than disease correction.10

2000 — Davison

A report of secondary procedures in gender-affirming surgery described resection of ribs 11 and 12 for waist contouring. Five of the 22 patients underwent this procedure.11

2021—the amount of evidence is examined

Ferreira and colleagues systematically reviewed chest-wall contouring through rib resection.12 Only two papers on the topic were identified through 2020, and the authors explicitly highlighted insufficient evidence. Compared with more than a century of chest-wall surgery, cosmetic applications were only beginning to enter the literature.

2021—a method without resection

In the same year, Kudzaev and Kraiushkin reported waist narrowing without rib removal in 93 patients. The posterior cortex was divided to induce a greenstick fracture. Despite the paper’s title, however, this was not an incision-free procedure. Approximately 2 cm incisions were made bilaterally, without ultrasound.13

Just as omitting resection in the Nuss procedure changed patterns of recovery and complications, efforts here sought to reduce the extent of intervention. The progression from resection to osteotomy to induced fracture repeats a theme seen throughout a century of chest-wall surgery.

2022—accumulated experience with resection

An eight-year experience of rib resection in 104 patients was reported, with 2 pneumothoraces.14 However, the journal is not indexed in PubMed, so its review and accessibility cannot be regarded in the same way as the other literature above.

2023—anatomical criteria and an incision-free approach

Manzaneda and colleagues first described anatomical criteria for the thoracoabdominal boundary.15 Later that year, they reported 30 patients treated by ultrasound-guided fracture of only one rib cortex without an incision.16

2024—two directions emerge

One report combined ultrasound guidance with ultrasonic osteotomy equipment for torso contouring;17 another proposed osteotomy followed by metal fixation.18 The first sought to reduce the extent of intervention; the second emphasised maintaining the corrected shape.

2025–2026—discussion continues

Multicenter cohorts and systematic reviews have appeared alongside journal correspondence debating safety.19 The question is whether a perpendicular approach to the rib or an osteotomy parallel to the cortex is safer. No conclusion has been reached.

Evidence continues to accumulate. Long-term follow-up remains limited and standardised reporting is not yet established. This is why clinical courses are documented systematically and reported academically.

Perspective

Built on a century of experience.

More than a century of records describes opening the chest wall, treating ribs and cartilage, and managing the resulting problems.

Meyer and Sauerbruch recorded failures, Ravitch established a standard, and Nuss introduced correction without resection. Reconstruction after tumour removal and rib-fracture fixation added evidence on healing and stability.

This lineage developed within thoracic surgery.

Cosmetic rib remodeling is its most recent branch. It may look new, but the chest wall is the same structure treated for a century, and complications involve the same structures long recognised in that history.

→ Understand rib-cage anatomy
→ Risks and safety

References
  1. Meyer L. Zur chirurgischen Behandlung der angeborenen Trichterbrust. Verh Berl Med Ges. 1911;42:364.
  2. Sauerbruch F. Operative Beseitigung der angeborenen Trichterbrust. Deutsche Zeitschr f Chir. 1931;234:760–764.
  3. Ochsner A, DeBakey M. Chone-chondrosternon. J Thorac Surg. 1939;8:469–511.
  4. Ravitch MM. The operative treatment of pectus excavatum. Ann Surg. 1949;129(4):429–444.
  5. Adkins PC, Blades B. A stainless steel strut for correction of pectus excavatum. Surg Gynecol Obstet. 1961;113:111–113.
  6. Nuss D, Kelly RE Jr, Croitoru DP, Katz ME. A 10-year review of a minimally invasive technique for the correction of pectus excavatum. J Pediatr Surg. 1998;33(4):545–552.
  7. Tansini I. 1906. First report of chest-wall reconstruction using a pedicled latissimus dorsi flap. Cited via Sanna et al. (2017).
  8. Sanna S, et al. Materials and techniques in chest wall reconstruction: a review. J Vis Surg. 2017.
  9. Scudder CL. The Treatment of Fractures. 1900.
  10. Psillakis JM. Plastic surgery of the abdomen with improvement in the body contour. Clin Plast Surg. 1984;11(3):465–477.
  11. Davison SP, et al. Aesthetic considerations in secondary procedures for gender reassignment. Aesthet Surg J. 2000. doi:10.1067/maj.2000.111544
  12. Ferreira LM, et al. Aesthetic contouring of the chest wall with rib resection. Aesthetic Plast Surg. 2021;45:1099–1104.
  13. Kudzaev KU, Kraiushkin IA. Waist narrowing without removal of ribs. Plast Reconstr Surg Glob Open. 2021;9(7):e3680.
  14. Verdugo JP. Rib removal in body contouring surgery and its influence on the waist. Sci Art Plast Surg J. 2022;3. doi:10.47511/sapsj.v3.8144 — Journal not indexed in PubMed.
  15. Manzaneda RM, et al. Anatomical bases for aesthetic costal surgery. Plast Reconstr Surg Glob Open. 2023 Nov. PMID 38025649.
  16. Manzaneda RM, et al. Waist remodeling without incision, with ultrasound-guided monocortical fracture. Plast Reconstr Surg Glob Open. 2023;11(12):e5499.
  17. Oñate Valdez C, Hoyos AE, et al. Ultrasonic- and ultrasound-assisted improvement of silhouette of the torso (Part I). Plast Reconstr Surg Glob Open. 2024 Jan. PMID 38204869.
  18. Aesthetic rib cage remodeling with osteosynthesis (RIBOSS). Plast Reconstr Surg. 2025;155(2). Published online ahead of print in 2024.
  19. ASJ Open Forum correspondence, 2025–2026. Discussion of the safety of perpendicular puncture versus parallel cortical osteotomy.