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Minimally Invasive Rib Removal:
Obtaining A More Feminine Torso
Through a New Surgical Technique

By Sheila Kirk, M.D and Dr. Ernest Manders
Perhaps a year ago, I wrote an article wherein I brought the subject of rib removal once again into view. In that publication, I held a cautious view and perhaps influenced many to reject the thought that such a surgical procedure ought not to be considered. In the months to follow a very innovative and successful technique was originated and demonstrated to be successful and safe.

One of my associates, Dr. Ernest Manders, a plastic & reconstructive micro-surgeon, examined the surgical technique performed in the past and has developed a much more effective and cosmetic procedure which is now in the list of surgeries our Transgender Surgical and Medical Care Center offers. Many questions have been raised about this body contouring surgery: its effectiveness, safety and details of its performance and recovery. We want very much to give this information to those interested.

The Human rib has long been a source of bone for reconstructive surgery in other parts of the body. Here at TSMC, Dr. Manders has perfected a method which allows for removal of the lowermost ribs, the 11th and 12th on both sides, through a small one inch incision on either side of the spinal column.

The long, unsightly incisions, formerly used, are eliminated. Instruments have been developed to accomplish this. Endoscopy visualization with very little body intrusion is used a great deal of the time but not exclusively. We believe that the narrowed and tapered effect to the MTF's waist adds greatly to create a shapely, more feminine torso.

Ribs eleven and twelve on both sides of the rib case are called "floating" because their only attachment to other body structure is at the spinal column. They are not attached with cartilage to the ribs above or to the sides of the chest bone called the sternum. They are the very lowest of those ribs forming the rib cage and tend to be shorter and less developed than those that protect the lungs and heart and the great vessels inside the chest. In their anatomic positions, while they lay over portions of the liver and spleen on either side the protection afforded is much less than one may think. Over the liver the 7th and 8th ribs are much more involved with shielding this organ. Over the spleen on the left side, the 8th, 9th and 10th ribs afford more protection than those below them. In fact the 12th rib offers nothing at all to this organ. On both sides, the diaphragm, the very large muscle involved with breathing covers these organs quite notably.

When one looks at the anatomic and physiologic concepts so completely studied by medical research writers in basic scientific study, another very important consideration is explained. The action of the lowermost 11th and 12th ribs is not involved in the important first phase of breathing or inspiration. In fact, they act with the abdominal musculature to antagonize the very activity of all the other ribs of the thoracic cage. The prime function in respiration of all the ribs and the chest bone is to allow chest expansion and increase chest cage space to allow for increased lung volume in inspiration. The diaphragm descends to aid this process. Abdominal wall muscles and the floating ribs work against the physiologic function. Hence removal of them will facilitate respiration, not impede it, and even increased lung activity as in exercise is not interfered with or compromised.

Some have worried over the permanence of this procedure, concerned that ribs grow back and that the waist will revert to the same pre-operative contour. Experience in all the years the ribs have been removed for other reconstructive surgery shows that while growth or regeneration can take place it is minimal and proceeds from where the rib was divided at the original incision site. In our pioneered procedure, this is at the back one inch from the spinal column. If regrowth occurs at all, only small nipples of bone over many years will be evident. And if it occurs, it will follow the course of the periosteal covering originally enclosing it at a very, very slow growth rate. Bone will not grow from other tissues along the course of the rib and we can expect any re-appearance will merely re-inforce the new tapered configuration as it was intended. The actual performance of the surgery has to do with separation of the ribs from a sleeve or sheath known as periosteum. Once freed of this tissue and resected in the back on either side, the ribs are virtually slid out of that covering. The procedure is done under general anesthesia and the patient is kept in the hospital for 24-48 hours. Pain relief with various techniques is very effective and home recovery is not prolonged.

Years ago, previous experience with rib removal produced very favorable body contouring results but left unsightly and long, obvious scarring. With TSMC's pioneering procedure, very small incisions as well as new instruments and technique make the procedure a much more feasible operation. Not all patients can be considered good candidates. Pre-existent lung disease, heavy smoking and obesity could eliminate a number of individuals but a distinct number of people can find reward in their appearance, when this procedure is done for them.

We welcome questions and opportunity to discuss this new technique and to give more clarification. Call us at (412) 781-1092 if you wish to discuss with us this approach more thoroughly.

Ernest K. Manders, M.D. Sheila Kirk, M.D.

Drs. Kirk and Manders are two of three principal surgeons performing Genital Reassignment Surgery and related Trans surgeries at the first Transgender Surgical & Medical Center (TSMC) developed and directed by a Trans surgeon. You can receive more information about the TSMC Center located in Pittsburgh, PA or ask Dr. Kirk questions on your treatment and care, by contacting her at TSMC@aol.com, by phone (412) 781-1092, fax (412) 781-1096 or snail mail: TSMC P.O. Box 38366, Blawnox, PA 15238.
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