Ribella Procedure

The Ribella Procedure is one of the most innovative and effective medical waist thinning procedures, formed by combining the English words Rib (Rib Bone) and Italian origin Bella (Beautiful) used globally all over the world. It offers patients a thinner waist profile by changing the shape of the rib bones. The procedure is based on the principle of identifying the ribs with ultrasound and shaping the individual’s skeletal structure in a way that maximizes their aesthetic elegance.

Patients are under anesthesia during the procedure and do not feel any pain. There is no pain after the procedure as the nerves are anesthetized. Patients can usually be discharged after a day stay or stay in the hospital for one night.

The risks of the procedure are low and when performed by expert surgeons, the risk of complications (unexpected results of the procedure) is close to zero. The alternative rib removal surgery can put internal organs at risk and has a large incision.

The experience and expertise of your doctor is critical to the success of the procedure. It is important to choose an expert thoracic surgeon like Dr. Curver for complex procedures such as the Ribella Procedure

The Ribella Procedure is revolutionary in waist reduction surgeries because it is painless, sutureless and has no incision marks. When performed by an expert surgeon, it provides women with the waist curve they desire.

Assoc. Prof. Dr. Hasan Ersöz has focused on rib cage and rib deformities for many years and has a very wide experience in this patient group for 15 years with his clinic called Dr. Pektus. Now, he offers this technique, which is his own design, to the service of individuals who request it under his second brand, Dr. Curver. If you want to achieve an aesthetic appearance with feminine curves by thinning your waist by at least 7 cm in a very short time without pain and incision marks, you can reach Dr. Curver.

What are the Anatomical Differences in Waist Circumference in Men and Women?

There are significant differences between the skeletal and soft tissue characteristics of men and women. Biacromial diameter is the measurement of shoulder width and is 39.62 (36.32-43.18) cm on average in men. The female biacromial diameter is less and the mean value is 35.31 (32.51-38.61) cm (1). The ratio of the mean lateral rib cage diameter to the person’s height is 14.16 cm/m for men and 13.68 cm/m for women (2). In short, the male rib cage is larger than the female.

From a visual and aesthetic point of view, the larger shoulders and chest parts of the body in men provide a masculine aesthetic appearance. However, a proportional thin waist provides an inverted triangle appearance with the base facing upwards and creates the aesthetic structure we call the triangular body in the individual.

However, in social norms, women having too wide upper chest and shoulders is not demanded by women, giving the impression that it disrupts the feminine elegance of the individual. Even if there are not too many broad shoulders, a body structure in which the upper part of the body is a little wider, the waist is thinned as much as possible in a curved way and then expands towards the hip area creates an image that women desire for themselves and is liked by the majority of the society. To summarize; a body silhouette similar to a tea cup or an hourglass in women is the ideal norm accepted in social aesthetics. Scientifically speaking, the literature also states that this is the aesthetically accepted norm. (3).

There are many anatomical reasons for this difference between male and female silhouettes. One of them is the narrow angle of the ribs in women. This is designed as an evolutionary adaptation to accommodate the increased intra-abdominal volume during pregnancy (2). In addition, the female pelvis, or pelvic region, is designed to be wide enough to allow for childbirth. In contrast, the human male pelvis is optimized narrower for bipedal locomotion than the female pelvis. The female pelvis has a larger pelvic inlet and outlet than the male pelvis. In addition, the hip is wider in females than in males (4). The iliac crests of males are higher than females, which makes their pelvis appear longer and narrower.

Apart from the difference in bone structure between men and women, the difference in body fat distribution in these two genders is another reason for this visual contrast. Although body fat distribution for both sexes is comparable in childhood and old age, it is quite different in the age range when the effects of reproductive hormones come into play. In men, the dominant hormone testosterone leads to fat accumulation predominantly in the abdominal area and inhibits fat accumulation in the hip area, leading to android (masculine) body fat (big belly, small hips silhouette). On the other hand, estrogen, the predominant female hormone, leads to a gynoid (feminine) body habit with predominant fat accumulation in the hips, resulting in a narrow waist and wide hips (5).

If we look at the counterpart of this aesthetic understanding in our instincts; The triangular body of the man creates attraction on women because it is an indicator of the presence of physical strength in him and, as a result, his ability to better protect himself, his children and his family from natural conditions that require physical strength and other negative situations that may be encountered.

The Tea Cup shaped body structure is also a sign of fertility in women. Wide hips can facilitate the passage of the baby’s skull through the uterus during childbirth. This anatomical feature is related to the width of the pelvis, and a wide pelvis allows for a wider birth canal. This is why wide hips have historically been associated with healthier and more successful births. This may cause men to subconsciously find women with wide hips more attractive. In addition, the fatty tissue that accumulates in the buttock area of women is formed under the influence of the hormone estrogen. Estrogen is directly related to fertility and reproductive health. Therefore, large hips can signal high estrogen levels for men and therefore healthy reproductive potential. Large breasts, on the other hand, are attractive to men because of the instinct that the woman can better nourish the children born. The thin waist between these two widths is attractive to men because it is an indicator of health and fertility, as we have detailed (6).

In general, it can be added that the anatomical features that distinguish each sex are attractive to the other. For example, a man’s beard or a woman’s breasts are attractive to the opposite sex because they are not present in the opposite sex. As a result, a man’s body shape, which we call the “Triangular Body”, and a woman’s body shape, which is shaped like a “Tea Cup”, are attractive to the opposite sex.

In the scientific literature, in parallel with what we have described, the waist-to-hip ratio (WHR) in the ideal range is associated with increased physical attractiveness and is considered a sign of a healthy body for both sexes. WHR is a data obtained by measuring waist and hip circumference and proportioning these values. Waist circumference is measured at the narrowest part of the body between the ribs and the iliac crest, while hip circumference is measured at the level of maximum hip protrusion. In women, a tea cup or hourglass shaped waist is associated with a lower WHR, while in men, a broad upper body shape is associated with a higher WHR. Dr. Singh suggested that the ideal WHR range that men find attractive in women of different ethnicities is between 0.67 and 0.80, although there are slight differences between various cultures (7). Various other studies have also reported that in the modern era, women with a WHR between 0.65 and 0.70 are considered highly attractive (8-11). According to the literature, the ideal WHR in men is reported to be between 0.80 and 0.95 (12).

Why is it very important that the Waist-Hip Ratio (WHR) is within the normal ranges you mentioned?

It is a well-established fact in the medical literature and widely known in society that waist circumference is directly related to a person’s health. What are the anatomical differences between men and women in terms of waist circumference? As we have answered in detail in the question, the ideal Waist-Hip ratio (WHR) for women is stated in the range of 0.65-0.80 in the scientific literature (7-11). This is a very important indicator for visual attractiveness, social aesthetics and health.

In summary, as in every situation in life, waist circumference is neither too thin nor too thick, but is expected to be within the normal range. However, it is known that it is especially undesirable for the waist circumference to be thicker than it should be.

In terms of health, waist circumference fat is very important especially in cardiovascular health, insulin resistance and oxidative stress. For this reason, an average waist circumference of 94 cm or less for men and 80 cm or less for women are ideal waist circumference values. When it is 102 cm or more for men and 88 cm or more for women, it means that the danger bells are ringing for these individuals in terms of health.

In terms of aesthetics and attractiveness; instinctively, those with a narrow waist circumference are always attractive to the opposite sex. The reason for this is that our instincts feel that a low waist circumference is an indirect indicator of health and reproductive success in the opposite sex. This is because our instincts are designed to live and perpetuate our lineage by giving birth to children with high quality genes. The key to having a healthy, intelligent, good-looking and successful child is to choose the best quality mate, both physically and in terms of personality and character. It is the ability to pass on the quality genes of that partner to the child to be born.

Moreover, symmetrical thinning of the waist not only helps to increase hip volume, but also gives a better style to other aesthetic procedures to be performed in the abdominal region such as rectus abdominis, oblique and serratus muscles (13).

In summary, a low waist circumference is the most basic indicator of good health in that person and is a factor of sexual attractiveness and social aesthetics for both sexes.

How to Slim Waist Circumference?

The first answer that comes to everyone’s mind in this regard will undoubtedly be to get rid of the fat accumulated around the waist. Of course, the healthiest way to do this would be proper nutrition, sports and changes in lifestyle.

However, this may not always be the case in practice. Because the difficulties of modern life and lack of time may not allow us to change our lifestyle. This is why body contouring surgeries are part of the global trend towards improving physical appearance and body beauty. Individuals tend to resort to faster and effortless methods. However, it should not be forgotten that any intervention related to human health (especially for aesthetic purposes) should be based on quality scientific evidence for the safety and efficacy of the procedure (14,15). Due to social disinformation, patients are sometimes exposed to applications that are mediatized and claimed to be miraculous (16-18). However, none of these are scientifically evidence-based (17,19).

Today, the most common surgical method of body shaping, including the waist, is liposuction (20). For this reason, various liposuction procedures performed by plastic surgeons have become widespread, but despite these procedures, if there is no change in the lifestyle of the person, liposuction will occur again (21). Since the main problem with thickening around the waist is the difficulty of changing lifestyle, this option does not seem useful for most people.

Moreover, even if the person makes all these healthy diet, sports and lifestyle changes or has liposuction and completely gets rid of the fat around the waist; if the skeletal system of the person has ossified widely in the waist area depending on the genetic structure; this individual may not be able to thin his waist as desired in aesthetic norms. The removal of subcutaneous fat in liposuction procedures helps very little in transforming the “box” shape of the body into an “hourglass” in thin people (21). As you can see in the picture I have shared with you below, the woman on the left (marked as L) has a body structure with a much higher fat content than the other woman. However, from an aesthetic point of view, even in this state, she has a narrower waist circumference than the woman on the right (marked as R) and therefore looks more aesthetic. This is entirely due to the genetic advantage of the woman on the left. The woman on the right, whose lower ribs are not genetically narrow, has no chance of looking like the other woman naturally, no matter how much she loses weight.

For this very reason, waist narrowing surgeries such as rib contouring procedures provide better results than those obtained with classical procedures such as liposuction (22,23). In some cases, patients may have a small amount of fat in the waist, or although a good amount of fat has been removed from this area, there may be a thickness due to the bony structures in the waist and this thickness may appear as a result of fat removal. Therefore, other options such as rib surgery may help achieve the best result (13).

In any case, waist narrowing surgeries are not suitable for women with sagging waist-abdominal skin or high fat content. These women are recommended to have liposuction and tummy tuck surgeries first. If the waist area is still thick in individuals who naturally have a tight abdomen and a waist area free of fat or who have undergone liposuction-abdominoplasty, rib contouring surgeries come into play.

The ribs that are intervened in rib contouring surgeries are the lowest ribs on the right and left. The lower region of the rib cage, including the lowest ribs, is the transition area between the rib cage and the abdomen and is often a key area when performing procedures to emphasize the buttocks. In addition to the technique described by Dr. Juan Pedro Verdugo to remove the two lowest ribs, which we call floating ribs, various rib remodeling techniques described by Dr. Kudzaev in 2020, which have been further developed and modified. In summary, interventions on the ribs in waist narrowing procedures can basically be performed by either removing or reshaping the lowest ribs (21,24,25,26).

Rib reshaping involves lower risks than rib removal and is relatively simple. When performed by an experienced surgeon, it results in very favorable aesthetic outcomes (25). Moreover, it is very safe for the patient when performed under ultrasound guidance. Many patients have expressed concern about scarring that may result from rib removal or reshaping surgery. While the procedure is an aesthetic procedure, it is pointless to burden the individual with a new aesthetic problem such as scarring in order to achieve an aesthetic result. Therefore, developing a procedure that eliminates this disadvantage is crucial to achieve satisfactory aesthetic results.

We have designed a waist narrowing procedure to perform ultrasound-assisted rib remodeling without removing any ribs, without any incision scars and pain, and without stitches. With this procedure, which we call the “Ribella Procedure” and which we have patented as Dr. Curver Clinic, a thinning of at least 7 cm is achieved in the waist circumference of the applied person, completely independent of the individual’s lifestyle change, starting sports or eating habits, with a direct result at the end of the procedure. This procedure, which is performed without any incision other than a needle tip entry and without stitches, is completely painless. Immediately at the end of the Ribella procedure, the waist of the individual is significantly thinned by at least 7 cm. Moreover, one of the differences that distinguishes the Ribella Procedure from other rib contouring procedures is that, unlike other rib contouring procedures, patients can watch themselves in 3D in virtual reality glasses with 3D simulation and simultaneously see the contouring options that we can give to their waist in the simulation environment. Thus, patients themselves decide how thin their waist will be before surgery and the procedure is designed accordingly. In other words, the patient can see the result in 3D before the procedure and this technological design is defined only in the Ribella Procedure among rib contouring procedures.

How Long Have Rib Reshaping Surgeries Been Practiced?

If we look at the question not as rib shaping but as waist thinning; the search for a thinner waist dates back to the Queen Victoria period, when women started to use increasingly narrower corsets.

However, the process of removing the ribs for waist thinning dates back to the 1970s with celebrities undergoing this procedure (25). More recently, this procedure has been practiced by trans-women to give their bodies a feminine curve (3). Aesthetic contouring of the ribs is a topic of constant interest both in patients seeking methods to reduce waist circumference and in the medical community (27). Designing and defining body shape through skeletal contouring surgeries has become increasingly popular, especially for female beauty standards that associate attractiveness with athletic physique and body volume (22,28).

However, thoracic surgeons have traditionally performed all surgical procedures, such as removal or remodeling of various ribs (including the 11th and 12th ribs), for non-aesthetic health reasons for many years (29, 30). With 15 years of experience in thoracic surgery, Dr. Ersöz has performed rib surgery in numerous patients

Can you elaborate on the Ribella Procedure (Seamless Waist Shaping Procedure)?

The Ribella Procedure is a combination of the English words Rib (Rib Bone) and Bella (Beautiful), which is of Italian origin and used globally all over the world. It is one of the most up-to-date and innovative procedures for shaping the ribs.

When determining the method of rib contouring, questions may arise as to which method is better or provides better results, or whether some types of surgery have a specific indication (medical rationale) compared to others. The decision in this regard depends on the training of each surgeon and the risk-benefit analysis performed with the patient (21,24). Assoc. Prof. Dr. Hasan ERSÖZ Private Thoracic Surgery Clinic, under the trade name Dr. Pectus, has been successfully treating rib cage deformities for many years, and as a Thoracic Surgery Clinic, we have performed numerous rib surgeries for many medical reasons such as rib fractures, rib tumors and thoracic outlet syndrome. With all this experience, we have developed our rib contouring procedure under our new brand “Dr. Curver” and named it “Ribella Procedure” within our clinic.

The Ribella Procedure is the reshaping of the last two, three or four ribs on the right and left depending on the patient’s condition with a small intervention on the ribs without any incision marks, stitches or pain, except for a few needle insertions in the rib cage.

To elaborate, in all of us, the rib cage starts from the spine on the back, continues with the ribs on the sides and ends with the sternum in the front, the bone known as the board of faith. These ribs extend from the right and left sides of the spine along our sides, 12 on each side. From top to bottom, the first 10 ribs extend all the way to the sternum bone in front, while the bottom 11th and 12th ribs do not extend all the way to the bone in front, but come to the back or a little bit to our back-sides and stop there. This is why these two ribs on the right and left are called “floating ribs” in anatomy (26,31).

In some people, these last two ribs and the two ribs that precede them genetically extend to the side at a wider angle and cause a thick waist appearance, no matter how lean the person is. In some people, they curve at a narrower angle than in others, resulting in a thin waistline. We help individuals who genetically have all or at least one of the last four ribs extending at an obtuse angle and therefore have a thick waist circumference, are visually uncomfortable with this situation and want to change it through the “Ribella Procedure”.

We achieve this by changing the angle of the last four ribs. This procedure takes less than 1 hour, is performed under operating room conditions, is completely painless and without any incision scar. It is applied by entering the skin through several areas as thick as the tip of a needle in the back and chest areas of the patient through various instruments. During the procedure, the ribs and the entire anatomy are seen from the outside with the help of ultrasound and no blind application is performed. This procedure has no complications or difficulties for the patient. It is not performed inside the chest or abdominal cavity, it is performed completely under the skin and muscle tissues and above the ribs. There are no stitches. There are no incision scars, only a few bee sting-thick needle insertions, resulting in zero scarring over time. In our survey of patients who have undergone the Ribella Procedure to date, 95% of respondents did not notice the needle puncture site, resulting in high satisfaction (100%). Only 5% of the respondents stated that they could recognize the puncture site, but despite this, we had no patients who were dissatisfied with the result (0%).

Moreover, one of the distinguishing features of the Ribella Procedure is that, unlike other rib contouring procedures, patients can watch themselves in 3D through virtual reality glasses and simultaneously see the shaping options we can apply to their waist in the simulation environment. This way, patients can decide how slim their waist will be before the surgery, and the procedure is designed accordingly. In other words, patients can see their results in 3D before the procedure, and this technological design is exclusive to the Ribella Procedure among rib contouring treatments.

The Ribella Procedure is not only for waist narrowing but can also be applied as a treatment method for patients with rib flare deformity (protruding ribs), whether they request waist narrowing or not. It can be used for male or female patients with rib flare deformity who do not necessarily seek waist slimming. As Dr. Pectus Clinic, we have been offering treatment methods for rib flare deformities to patients of various age groups for years. Traditional treatments include surgical interventions and non-surgical options like bandages or braces, but these methods have certain disadvantages.

Surgical interventions for rib flare treatment typically leave large scars of 4-5 cm on both the right and left sides and require long recovery periods. They are also painful. Bandage treatment has its limitations, such as the difficulty of wearing a bandage for 20 or more hours daily and the fact that it only provides permanent improvement until the age of 17. Moreover, it does not always offer a solution, and in such cases, a much more difficult brace treatment may be required.

The Ribella Procedure, on the other hand, is a newly invented method that we have established as the gold standard for rib flare treatment. This procedure is performed by reshaping the ribs under ultrasound guidance and offers the following advantages:

• Scar-Free: The Ribella Procedure does not require any incisions or stitches, leaving no scars.
• Painless:Thanks to the numbing of the nerves, no pain is felt after the procedure.
• Fast Recovery:*Patients are typically discharged on the same day, and the recovery process is quick.
• Natural Results: The shape of the ribs is altered precisely under ultrasound guidance, resulting in a natural appearance.

The Ribella Procedure stands out among other treatment methods for rib flare deformities as a minimally invasive, painless, stitch-free, and scar-free approach. This innovative method provides excellent aesthetic and functional results, offering our patients high satisfaction. As Dr. Pectus Clinic, we consider this procedure the gold standard in rib flare treatment, combining our expertise in this area with this new method.

The Ribella Procedure can be applied in combination during the same session if necessary for both waist narrowing and rib flare treatment.

In conclusion, the Ribella Procedure maximizes the aesthetic goals of patients aiming for a feminine waist curve or the correction of rib flare deformities in both men and women, while minimizing surgical scars and completely eliminating pain issues.

Is the Ribella Procedure Painful? Do Patients Feel Pain After the Procedure?

Never! This is an important feature that distinguishes the Ribella Procedure from its peers!

As a thoracic surgeon, I have been a specialist in all rib diseases and traumas, especially rib fractures, for 15 years. I know very well how painful these problems are. Moreover, as a thoracic surgeon (Dr. Pectus) who specializes in the treatment of rib cage deformities (Pectus deformities), I am an expert who has experienced enough that the Nuss operation is one of the most painful operations known. In this way, I have helped to solve the problems of countless (thousands) patients and with the experience I have gained from all these patients, I have developed the Ribella Procedure with the Dr. Curver brand. While developing this procedure; I ensured the originality of the procedure by knowing that the first condition is that the procedure should be painless. Yes, the Ribella Procedure is the only method available that provides a zero pain guarantee in its own way, unlike rib removal or other shaping procedures. Considering the inexperience of plastic surgeons in rib surgery, it is obvious that other methods applied by plastic surgeons will yield different results in terms of pain, in a way that cannot be compared to this method. In the literature, there has been a great increase in opioid (addictive and green prescription painkiller) abuse (addiction) among patients undergoing aesthetic procedures (32). Plastic surgeons who describe other versions of the rib shaping procedure clearly state in their articles in the literature where they publish their own techniques that post-procedure pain is the biggest problem (13,21,33). This is the most important difference that distinguishes the Ribella Procedure from its counterparts.

If we go into detail, I must first say that since the procedure will be performed under anesthesia, it is not possible for them to feel any pain during the procedure.

Patients never feel pain after the procedure. Those who have experienced it know that rib traumas or surgeries are quite painful. However, the nerve that causes the patient’s pain passes just below the rib and the source of the pain is this nerve. Of course, it is not difficult to eliminate this pain, the cause of which is clear.

Since the procedure is performed with ultrasound, we first identify these nerves with ultrasound before starting the procedure. Then, we perform a special procedure that will put the nerve to sleep for at least three months. Since the pain that the patient may feel due to the Ribella procedure is limited to a maximum of 6 weeks, when the nerve that has been put to sleep for 3 months returns to its function at the end of this procedure, the patient’s pain is long gone and the patient does not feel any pain during this process.

I would like to prevent a misunderstanding here. Of the nerves connected to our nervous system, only the motor (movement) nerves cause movement restriction if they do not do their job. However, the nerve we are talking about does not have such a situation. Since the nerve we are talking about is a sensory nerve, putting it to sleep does not cause movement restriction. The procedure we will perform – just as we wanted – only eliminates the pain sensation in the rib.

In addition, since this nerve is not a nerve that transmits sensations to the skin tissue, the patient does not experience any deficiency in feeling sensations such as touch and pain on the skin tissue in the relevant rib region for 3 months. The application only eliminates the feeling of pain in that rib, which is exactly what we want.

Are There Any Possible Side Effects of Changing the Shape of the Ribs in the Ribella Procedure?

Ribs are immobile bones, unlike the arm and leg bones in our body. They do not have any load-bearing function. The main function of the rib cage in our body is to protect important organs such as the heart, lungs and large vessels, which would be life-threatening in case of injury, from being directly exposed to various traumas. As its name suggests, it is a cage that protects the chest.

For this reason, the shape-changing procedure to be performed on the rib cage does not cause any restriction of movement like an intervention to be performed on an arm and leg bone, or does not cause any change in our physical movements or functions since it does not carry a load. Since all ribs will still be in place after the procedure and only their angles will be changed, the ribs continue to protect the internal organs after the procedure, just as they did before the procedure.

In summary, it is clear that the Ribella procedure will not cause any loss of function and has no side effects.

Are There Alternatives to the Ribella Procedure? What Are the Differences?

As an intervention to the ribs for the purpose of narrowing the waist, the surgery of completely or partially removing the last 2 or 3 ribs by making an incision on the back, also known among the public as “rib removal”, has been performed since the 1970s. We have been able to perform these procedures for years under the name of Dr. Pectus for some patients with rib flare deformity or those who request an extremely narrow waist. However, the biggest advantage of rib removal surgery compared to other rib shaping procedures is that it allows individuals who want an extremely narrow waist to have a thinner waist with this surgery compared to the Ribella procedure. You know, those extremely narrow waists observed in celebrities, which are clearly unnatural… I guess it is known among the public as the “Barbie Waist”. We also recommended and performed rib removal surgery for individuals who want this “Barbie Waist” look, and we still do. However, the “Ribella” procedure seems to be more advantageous not only for individuals who want a natural and thin waist appearance, but also for patients who want a “Barbie Waist”. I emphasize it again; Unlike other rib shaping procedures, the Ribella Procedure also provides appropriate results for patients who want a “Barbie Waist”. Unlike other rib shaping procedures, in the Ribella procedure, patients decide how thin their waists will be in virtual reality glasses with 3D simulation before the surgery and the procedure is designed accordingly. If the patient has an extremely narrow waist like a “Barbie Waist”, they do not need rib removal surgery for this. However, despite this, we can still perform rib removal surgeries for waist reduction purposes on patients who request rib removal in the traditional way for whatever reason.

If we examine the results of various rib shaping techniques in the literature; Kudzaev, who first defined it, stated that he achieved an average of 8 cm (min: 4, max: 15 cm) waist circumference reduction as a result of the procedure he performed on his patients (21). Chiu, in his article, based his evaluation on the waist-hip ratio instead of waist circumference and stated an average 7.7% (min: 4.8%, max: 9.3%) decrease (13). In his article on the RibXCar technique, Manzaneda reported that the median waist circumference of his patients, who had a preoperative 69 cm, decreased to 58.7 cm in the measurements taken three months after surgery (34). Valdivieso reported a 7 cm reduction in the median waist measurement in patients who underwent rib reshaping alone, and that they were able to increase this number to 9 cm by performing additional liposuction and other plastic surgery procedures (33). Manzaneda stated that a waist circumference reduction of approximately 30% can be achieved with rib reshaping surgery, and that this reduction can be compared to rib removal (35).

At Dr. Curver Clinic, using the Ribella Procedure, we have achieved an average waist circumference reduction of 8.1 cm (min: 4.2 cm, max: 9.3 cm) in our patients as of 2024, in line with alternative procedures in the literature. However, it is worth emphasizing that the greatest distinction of the Ribella Procedure from its counterparts is that patients can decide how much they want their waists to be reduced in a 3D simulation environment, and the procedure is applied accordingly to achieve this exact result. Therefore, our results may vary in the coming years depending on patient preferences.

In summary, achieving an average waist circumference reduction of 7-9 cm from rib contouring surgeries is quite satisfactory, and there is generally no need for rib removal surgeries except for very specific requests.

The disadvantages of rib removal surgeries compared to the Ribella Procedure are quite significant:

1. Rib removal surgeries carry the risk of local and systemic complications (unexpected outcomes of the procedure), such as pneumothorax (lung membrane rupture), empyema (lung membrane inflammation), excessive pain, herniation at the incision site, chest wall instability, surgical site infection, seroma, intercostal nerve damage, and others, depending on the extent of the procedure. However, none of these issues reach life-threatening levels for a thoracic surgeon. Rib surgery is classified under thoracic surgery specialization because it is capable of handling these complications, unlike orthopedic or plastic surgery. Thoracic surgery training provides the experience and knowledge needed to manage these complications effectively.
2. Hatano et al. (37) published a study about the relationship between the placement of the void after rib removal and loss of respiratory function, showing that the void in the lower and lateral rib regions leads to an average of 42% loss of respiratory function. This result is a significant consideration when recommending rib removal procedures for body shaping. This is why Kudzaev (21) patented a waist shaping method performed with small skin incisions on the 11th and 12th ribs. This method represents the first waist slimming technique without rib removal (and its associated complications, i.e., unexpected results of the procedure). In other words, the risks in rib contouring surgeries are almost negligible compared to rib removal surgeries.
3. Ferreira et al., in their review articles, concluded that there is insufficient scientific evidence to support the application, effectiveness, and safety of rib resection for aesthetic purposes (25). Rib removal has the potential to reduce lung expansion and affect the structural integrity of the lower chest wall (38), and the authors do not overlook this procedure. Readers are advised to review the detailed procedure written by Davison et al. (3). However, unlike rib removal, all rib contouring procedures reported in the literature are noted to be quite safe.
4. Complete removal of the last two ribs eliminates their function, i.e., the function of protecting adjacent internal organs is removed. This increases the likelihood of damage to the kidneys, spleen, liver, diaphragm, and even the lungs in case of future accidents or other trauma (21, 39,40). In rib contouring procedures, however, these ribs remain in place, continuing to perform their protective function, thus eliminating this risk.
5. In rib removal surgery, incisions of 5-6 cm are made on both the right and left sides, muscles over the ribs are cut, resulting in loss of muscle function and scarring on the skin. The patient’s skin (especially if prone to scarring) may end up with a visually unappealing appearance due to these aesthetic procedures. Large incisions and open surgery bring issues such as infection risk, prolonged hospital stay, and pain associated with the procedure. In a series of rib removal surgeries reported in the literature, 80% satisfaction was indicated (13), while in a study describing incision-free rib reshaping procedures, the satisfaction rate was 100% (34). Similarly, 95% of patients in the Ribella Procedure did not notice the needle entry sites. The satisfaction rate regarding skin scarring with the Ribella Procedure is also 100%.When comparing the Ribella Procedure with other rib contouring surgeries, the key factor that distinguishes it is pain. The Ribella Procedure offers a completely pain-free experience by numbing the nerves for three months, whereas RibXCar and other rib contouring procedures are known to be painful (13,21,33).For more details, please refer to: Is the Ribella Procedure Painful? Do Patients Feel Pain After the Procedure?Moreover, one of the distinguishing features of the Ribella Procedure is that patients can view themselves in 3D using virtual reality glasses, unlike other rib contouring procedures. This allows patients to see the shaping options we can provide to their waists in real-time in the simulation environment. Thus, patients can decide how slim they want their waists to be before the surgery, and the procedure is designed accordingly. In other words, the patient can see their result in 3D before the procedure, and this technological design is unique to the Ribella Procedure among rib contouring procedures.For all these reasons, the Ribella Procedure is the most innovative and advantageous of the rib-based waist reduction procedures today.

Why Do Mostly Women Prefer the Ribella Procedure (Sutureless and Painless Waist Reduction Procedure)?

The waist plays an important role in the search for female beauty and body harmony. Because it helps to emphasize the hips and leg muscles. Thus, having a narrow waist creates the visual effect of beauty and femininity that many women seek (34). A narrow waist, especially together with round hips, is an important part of feminine beauty (6). The presence of these features in a woman, together with full breasts, is an indication of a good hormonal background in that woman (21).

As we mentioned when answering the question “What are the Anatomical Differences in Waist Circumference in Men and Women?”, it is important for both sexes to have a low waist circumference. However, while this should be straight in the form of an “inverted triangle” and gradually narrowing downwards in men, it is desired for women to have hips that first narrow in a curvy way and widen as they go down below the waist, ending with widened hips in the shape of a “tea glass”.

There is another important group I want to mention: Fit female athletes who develop their abdominal oblique muscles. These women cannot achieve a curvy and feminine waist due to the lateral expansion of the rib cage. While excessive muscle formation generally provides the development of wide back muscles that strengthen the “inverted triangle” shape in men, it leads to the loss of the waist curve in women (41,42). For this reason, I believe that especially the sportswomen I mentioned in this group need rib shaping surgeries quite a lot.

This anatomical difference between men and women is of great importance for individuals who were born female (cis-women) as well as for individuals who have feminized themselves through sex change operations (trans-women). There are individuals who still want to improve their body lines so that their general body shape is compatible with their body image after undergoing sex change surgery (3). Body shaping in transgender individuals can be achieved by changing the skeletal structure or the upper soft tissues or by combining both. Surgical alteration of the pelvis carries higher risks; therefore, soft tissue shaping is primarily preferred in this area. Since the body fat ratio in the chest and shoulder area is less than in the lower half of the body, there is less area for soft tissue shaping in the upper half of the body. Therefore, rib shaping surgery is a very good option to meet expectations.

After gender reassignment surgery for body feminization, the majority of transgender individuals request breast augmentation and breast creation surgeries as their first surgery. Secondarily, other shaping procedures that can be offered to these individuals are waist and hip lipoplasty, hip augmentation, reduction of shoulder width by clavicle (collarbone) reduction and shaping of the lower ribs, which is our subject (5).

Reproductive hormones are at least as important a factor as bone structure in the formation of body shape according to gender. Because it is the main factor in the distribution of body fat and causes the formation of a feminine (gynoid) or masculine (android) appearance. As Dr. Curver, although it is not mandatory according to the guidelines for transgender women, since hormone therapy will cause positive changes in their body structures towards feminization, we recommend body shaping surgeries after the maximum effect of 1 year of hormone therapy after gender reassignment surgery. For these and similar reasons, hormone therapy has an important role in providing physical transformation as well as changing body lines and should be considered before body shaping surgery (5).

The “Ribella Procedure”, that is, the painless, sutureless and incision-free waist thinning procedure, provides a curvy narrowing of the upper part of the waist. Since we do not intervene in the lower parts of the waist in the procedure, the waist, which is thinned from the upper part, widens with a sharper curve towards the hips. This helps to define the desired “tea glass” or “hourglass” appearance in cis or trans women.

What Do You Know About Celebrities Who Had Waist Tightening Procedures?:

Who Should Perform Rib Removal or Shaping Procedures?

Who Should Perform Rib Removal or Shaping Procedures?
The “Ribella Procedure”, that is, a painless, sutureless and incision-free waist reduction procedure, is a patented procedure by us, and is currently only performed by me (2024) at Dr. Curver Clinic. However, there is some information I would like to say about other alternative rib removal or shaping procedures:

Nowadays, when it comes to aesthetic surgery, the first thing that comes to patients’ minds is to consult a plastic surgeon. However, we need to look at the situation as follows: When it comes to bone trauma, fractures and other surgical diseases, which department do we first think of applying to? Of course, orthopedics. However, when it comes to the sternum and ribs, these bones are not within the scope of orthopedists’ training and interests. Because a rib fracture may have penetrated the lungs, heart or other important chest organs underneath, and in approaching this patient; in addition to an orthopedist’s knowledge of bones, additional internal organ surgery knowledge may also be required. For this reason, patients with rib fractures or other diseases such as tumors of the ribs are treated by thoracic surgeons, not orthopedists. Individuals who have applied to the emergency room with a rib fracture in the past, or who have experienced this in their loved ones, already know this information very well.

Isn’t this the purpose of creating ribs? Ribs are the bone cages that surround the most important and sensitive internal organs in the human body. Naturally, it is not considered appropriate for a specialist who does not perform internal organ surgery to perform an intervention on the ribs. For this reason, orthopedists do not deal with these rib and sternum diseases. For the same reason, plastic surgeons should not deal with rib surgery. I think that the plastic surgeons who do deal with this issue are dealing with this issue outside of their educational curriculum and without authority, and are putting patients at risk.

For example, if even a small damage occurs to the lung membrane, which we call the “pleura” located just inside the rib, while trying to remove these ribs, the plastic surgeon will need to invite a thoracic surgeon to the surgery to evaluate and eliminate this condition. However, if the same situation occurs in the hands of a thoracic surgeon, he/she will be able to easily overcome this situation.

When we look at the literature, it can be clearly seen that plastic surgeons try to use the rib removal data from the past in their practices and recommend that a thoracic surgeon be present in case of a possible complication in their surgeries. To give some examples,

• Thoracic surgeons have traditionally performed various surgical procedures involving the removal or remodeling of ribs, including the 11th and 12th ribs, for non-aesthetic health reasons for many years (29, 30). 
• Ferreira et al. reviewed literature on rib removal procedures performed by plastic surgeons for waist slimming, selecting only high-quality articles meeting specific objective criteria. As a result, 56 articles were identified. However, a meta-analysis summarizing scientific evidence could not be produced from these articles. Although the procedures’ effects on waist slimming were noted, factors such as side effects, scar assessment, patient satisfaction, effectiveness, safety, complications (unintended results of the procedure), and follow-up results were not reported. The conclusion in the article written by plastic surgeons stated: “Despite complications such as neuralgia, pneumothorax, chest wall deformities, and respiratory function loss reported by other specialties (thoracic surgery), it was not possible to compile research data” (25). This implies that plastic surgeons acknowledge that their knowledge and experience on the topic are derived from thoracic surgery articles. 
• For certain surgical procedures involving the kidneys or adrenal glands, urologists may invite a thoracic surgeon. For example, during a kidney transplant, floating ribs (the 11th and 12th ribs in our context) may be removed to access the kidney (43). Dissection of floating ribs is often laborious and requires careful handling to avoid damaging the pleura. Therefore, urologists require the expertise of a thoracic surgeon. Additionally, entry into the pleural cavity (chest cavity) and intercostal nerve injury are common complications (unintended results of the procedure), which further justifies leaving such interventions to a thoracic surgeon (44-46). Thoracic surgery training provides the experience and knowledge to handle these complications effectively. 
• Not only traditional results of rib removal but also Dr. Kudzaev, who first described rib reshaping and is also a plastic surgeon, admitted in his article that “for beginners, it is advisable to have a thoracic surgeon on the team” (21). This acknowledges that the topic falls within the expertise of thoracic surgeons. 
• Rib removal surgeries carry the risk of local and systemic complications (unintended results of the procedure), such as pneumothorax, chest wall instability, surgical site infection, seroma, intercostal nerve injury, and others, depending on the scope of the procedure (36). Hence, it is defined within the field of thoracic surgery training. 
• Ferreira and colleagues discussed in their published article how thoracic surgeons select anatomical application methods for aesthetic rib removal (25). 
• Many studies discuss the removal of lower ribs by thoracic surgeons due to Slipping Rib Syndrome (47, 48). Hatano et al. (37) published a study on the relationship between the space created by rib removal and respiratory function loss, showing that the space in the lower and lateral rib regions led to an average 42% loss of respiratory function. This result is a significant consideration for patients undergoing rib removal for body shaping, as understanding respiratory dynamics is beyond the expertise of a plastic surgeon but is part of a thoracic surgeon’s foundational training and knowledge. 
• Manzaneda and colleagues noted in their article that tearing of the pleura is possible during procedures involving the 10th and 11th ribs (35). This presents a risk for plastic surgeons performing these procedures. 
• Therapeutic rib resection (removal) for the treatment of thoracic, abdominal, and chest wall pathologies is a well-known procedure within the field of thoracic surgery (13, 29, 33, 43, 50). One article states, “Plastic surgeons should be aware of potential adverse events and should not hesitate to explain these to patients before surgery” (13). However, it is also necessary for them to explain which specialty can handle these complications. 
• Valvidesso et al. discussed the potential for life-threatening complications (unintended results of the procedure) such as hemothorax (bleeding into the chest cavity), pneumothorax (lung tear), and/or undetected organ damage due to the close relationship of the last rib pair with internal organs (33). These complications are included in the basic training curriculum for thoracic surgery, and every thoracic surgeon is well-trained to manage them. 

Moreover, these are just a few excerpts from the literature discussing the popularization of aesthetic rib reshaping or rib removal for waist slimming in recent years. We cannot discuss the hundreds or even thousands of articles published by thoracic surgeons on rib removal here, but from the sentences shared, it is clear that this is the work of thoracic surgeons. This is precisely why I strongly recommend that both rib removal surgeries and the “Ribella Procedure” be performed by a thoracic surgeon to avoid putting patients at risk.

Many Thoracic Surgeons State That They Do Not Perform Rib Removal Surgery for Waist Reduction. What Is The Reason?

Thoracic surgeons do not only deal with the ribs and sternum, which are the bones of the chest, but also deal with important health problems of the internal organs of the chest such as lung cancer and thymus gland surgeries, which are life-threatening.

Removing the entire lung through a tiny incision with a robotic lung cancer surgery and providing the patient with a healthier life is the priority of most thoracic surgeons. I think that if the ribcage bones, which we call the chest wall, are not injured as a result of a trauma or if they do not cause a life-threatening condition such as a bone tumor, they do not perform aesthetic surgeries such as waist reduction due to their notions. On the contrary, all thoracic surgeons are quite competent and experienced in rib removal and every surgery related to the rib. Also, just think, wouldn’t it be much more appropriate for a surgeon who is capable of removing the patient’s lung by ligating all the vessels of the lung through a 3 cm incision to perform this rib surgery, which may be considered simple, than for a plastic surgeon to do this job?

For the same reasons; The vast majority of thoracic surgeons do not deal with the deformities of the chest wall bones (pectus excavatum, pectus carinatum, pectus arcuatum, etc.), which is my special area of ​​interest. There are those who think that it is wrong to intervene in these cases only for aesthetic purposes, especially if there is no health reason such as the patient’s sternum bone applying pressure to the heart. However, even the scientific literature states that if the patient is only bothered by the appearance of the deformity, these conditions should be corrected. However, as I mentioned, the majority of thoracic surgeons only consider patients for health reasons.

I am in the minority of these thoracic surgeons. I see how important aesthetic and psychological concerns, such as a self-confidence problem, are on patients with thoracic cage deformities. For this reason, I can perform such aesthetic surgeries with peace of mind under the Dr. Pectus Brand, respecting the patient. I believe that I help my patients in this way.

In order to apply the same benefit to my patients who request waist reduction, I developed the “Ribella Procedure” under the name of my second brand, “Dr. Curver”

What are the risks of the Ribella procedure?

The risk of the Ribella Procedure is almost zero if performed by a thoracic surgeon who is an expert in internal organ surgery. Even if the probability of any occurrence is very low, it can be immediately intervened by a thoracic surgeon. However, if we explain the most probable of these risks that are close to zero:

1. Swelling and bruising at the needle insertion site: This will resolve on its own within a week or two, even if nothing is done. Rarely, your surgeon may insert a needle into the area to drain the fluids and relieve the swelling.
2. Infection in the procedure area: In such a case, your doctor may start various antibiotics and other treatments, and if necessary, needles may be inserted into the incision site to drain the content and take a fluid sample.
3. Post-procedure pain: Normally, the Ribella procedure is described as painless because the nerves are anesthetized. However, there is a very low probability that the patient may feel pain, albeit at an acceptable level. In such a case, without any general anesthesia, a needle is inserted to anesthetize the nerve under ultrasound guidance and the pain is completely relieved. Since the patient will be awake this time, the procedure is not terminated until it is certain that the pain is relieved as a result of this second procedure.
4. Among the complications (unexpected results of the procedure) reported for rib removal surgery (removal, not reshaping), pneumothorax (rupture of the pleural membrane), empyema (inflammation of the pleural membrane), and other possible very rare systemic complications have been described (29, 36). In fact, rib surgery is a thoracic surgeon, not an orthopedic or plastic surgeon, because it has the ability to deal with all these problems.uzmanlık eğitimi alanında tanımlanmıştır.

What tests and examinations are performed before the procedure for patients who want to slim their waist with the Ribella Procedure?

During the first appointment (which can be face-to-face at the clinic or completely in accordance with the Turkish Ministry of Health’s approved personal data protection law, an online interview) patients are given a detailed explanation about the procedure and what to expect according to their individual anatomy. From the patient’s anamnesis (through the patient’s own story or the previous health assessment results they share with us), we learn about their previous health status, any surgeries they have had, any medications or chronic diseases they are currently using, and the patient’s risk factors for this procedure.

We ask the patient to fill out a body satisfaction questionnaire before the procedure, which will be repeated in the second and sixth months after the procedure (53). In this way, we provide objective feedback from the patients about their changes after the surgery.

We measure the patient’s body measurements such as neck circumference, waist circumference, hip circumference, chest circumference, and height with a physical examination. We measure and record their body weight and provide or calculate the individual’s Body Mass Index (BMI), waist-hip ratio (WHR), body fat percentage, and other body measurements. We also perform a detailed examination of the patient’s musculoskeletal structure for body shaping surgery. After receiving our privacy approval regarding the Personal Data Protection Law from our patients, we take professional photographs and 3D scans of their waist regions from various angles in order to see and evaluate the changes after the procedure.

Then, we evaluate the patient’s bone structure by requesting a tomography (or by viewing a recently taken tomography if available) and plan the procedure accordingly. We record the measurements we obtain with this tomography in detail and this becomes our map for the surgery. If the patients are found suitable for the procedure as a result of all these evaluations, the next stage is moved on to.

At this stage, the image that the patient’s body will gain after the procedure is shown to the patient using VR glasses in a virtual reality environment. In other words, when the patient puts on the virtual reality glasses, they observe themselves in 3D from the outside. Simultaneously, the doctor narrows the patient’s waist in this three-dimensional simulation using special algorithmic software. The doctor tells the patient, “I will continue to gradually narrow the waist, please warn me when the image is too tight for you” and according to the patient’s guidance, the patient’s most liked version of himself is determined and the surgery design is provided by the doctor accordingly.

Of course, if the patient wants a narrowing that will negatively affect his own health, the doctor intervenes in the situation and the patient and doctor decide on the operation with the principle of “health first, then aesthetic beauty”.

Which patient groups do you find unsuitable for the Ribella procedure?

If we were to list the patient groups that we did not find suitable for the procedure as a result of our evaluations before the Ribella Procedure:

1. As before every anesthesia, situations where the patient is at high risk of anesthesia (patients with ASA>2, e.g. heart attacks in the last 6 months, etc.)
2. Presence of uncontrolled chronic diseases in the patient
3. The patient has been diagnosed with serious mental problems.
4. Cases where the body mass index is 28 kg/m2 or more
5. Patients with a waist-hip ratio of ≥1.6
6. Excessive sagging skin in the abdomen or waist area (Matarasso Score of 2 or more)

The patient group summarized in these 6 main groups was not deemed suitable for the procedure not only by Dr. Curver but also for similar rib shaping procedures (21,33,34). In such patients, after determining the reason why the patient is not suitable for the Ribella procedure, it should be investigated whether this condition can be treated. For example, if the body mass index is high and therefore the patient cannot undergo surgery, it should first be brought to normal limits through diet and exercise or liposuction, and then if the waist is still considered thick, the Ribella Procedure can be applied. Or, a patient with sagging skin on the waist may be suitable for Ribella after skin tightening. A chronic disease that is not under control, such as diabetes, may become suitable for the Ribella procedure after it is brought under control.

How Long Does a Patient Stay in the Hospital After the Ribella Procedure (Painless, Seamless and Scarless Waist Reduction Procedure)?

If the procedure was performed in the morning, the individual can be discharged in the evening or a maximum of 1 night hospital stay after the surgery may be sufficient.

Although there is almost no possibility, it is still worth mentioning that if a problem such as swelling, bruising or discharge is observed in the procedure area within the first three days, it will be sufficient to apply to your doctor on an outpatient basis or online. Your doctor may recommend medication or, very rarely, may want to drain the fluid with a needle. An outpatient application is sufficient for all these procedures. There is no need for another hospital stay.

How Experienced Are You With This Procedure?

First of all; Since I have a 15-year thoracic surgery background as of 2024, as I have stated in many places in the answers to other questions, I have naturally treated thousands of patients with rib trauma, rib tumors and other rib diseases. Like all thoracic surgeons, I have a very good knowledge and experience about the anatomy and physiopathology of the ribs.

Apart from being a thoracic surgeon, conditions related to the chest wall, namely the ribs and the sternum bone, are my special areas of interest. First of all, surgical and non-surgical treatments of pectus deformities, namely rib cage deformities. Therefore, not only the diseases of the rib cage but also its aesthetic problems are my special area of ​​interest, which I have researched, read and treated the most, and I love this field very much.

My process of dealing with the correction of thoracic cage deformities and thoracic cage aesthetics began in 2009, the first year I started my thoracic surgery residency. In 2009, I received my specialty training at the clinic with my late instructor Dr. Ahmet Önen was one of the first people to perform these surgeries in Turkey and we hosted many international and national congresses in our clinic under his leadership. Since we lost him in 2014, I have been solely concerned with the treatment of problems related to this special area of ​​interest in my own clinical practices. I have undertaken the duties of session chairman, speaker and even congress host in many national and international congresses on this subject. During the years I served as the Head of Department, I provided training on live surgery at the Pectus Society Izmir Meeting held within our university and on surgeries to correct rib cage deformities to important thoracic surgeons from Italy and other important countries of the world.

The number of thoracic surgeons specialized in chest wall aesthetics is quite limited not only in Turkey but also in the world. We come together in a corner of the world to share our experiences and develop at the annual congresses of the Chest Wall International Group, which is formed by all thoracic and pediatric surgeons in the world who are closely interested in chest wall deformities and rib problems. I have served as a session chairman and speaker at many of these congresses and continue to do so every year.

I have written important chapters in the field of chest wall deformities and other rib diseases in the international textbook scientific book “Advanced Thoracic Surgery”, of which I am one of the three editors, and in many other textbooks. I also have many articles on thoracic aesthetics and other thoracic surgery in the world’s most important thoracic surgery journals indexed by Oxford University Press or the Japanese Thoracic Association. You can click on the link on our website to reach my academic CV.

With all this experience, in order to focus solely on rib cage surgeries and provide the highest level of service to this patient group, I have opened my own private clinic since 2022, apart from my academic position at the university, and as Dr. Pektus Clinic, I brought countless patients from Australia, Indonesia, USA, Canada, England, Argentina, Germany and many other countries to Izmir through health tourism and treated them in my clinic. As Dr. Pektus Clinic, we provide an international quality clinic service that focuses entirely on rib cage deformities and provides all the equipment.

After my countless 15 years of experience in correcting the rib cage shape, we started to apply the “Ribella Procedure” that I designed as a result of all this experience in our clinic and after dozens of successful results we decided to brand it. After Dr. Pectus, we decided to announce our second brand, “Dr. Curver”, in order to offer the “Ribella Procedure” to the service of all individuals.

In summary, the “Ribella Procedure” includes the experience of eliminating thousands of rib diseases or deformities, dozens of academic textbooks and articles, scientific research projects, dozens of national and international congresses attended, university faculty membership and 15 years of professional practical experience. Before me, there is all the experience of my late teacher Dr. Ahmet Önen, who passed on to me. There are the congress and non-congress friendships I have had with my rare colleagues who are experts in this field in the world at CWIG Congresses for years and the experience I have gained through online consultations with these friends.

As a physician who has the patent for the “Ribella Procedure” that I designed with all this knowledge, I am currently only applying the procedure at Dr. Curver Clinic.

You can also reach “Dr. Curver Clinic” to get information about the painless, incision-free, stitch-free “Ribella Procedure” for a curvier waist or for the treatment of Rib Flare Deformity.