Introduction

Body-contouring procedures have gained increasing popu-larity worldwide due to their ability to enhance physical appearance and provide the desired body shape. Among the most performed interventions, liposuction stands out as the leading technique, followed by breast augmentation, bleph-aroplasty, and abdominoplasty.¹ However, despite the effec-tiveness of these procedures, waist narrowing may be limited, particularly in patients with a broad thorax, who may require additional interventions to achieve satisfactory outcomes.^2,3

This context has led to the development of innovative surgical techniques aimed at waist remodeling, including osteotomy and resection of the floating (11th and 12th) ribs. Although removal of these ribs may significantly reduce waist circumference and yield high patient satisfaction, the procedure is invasive and associated with considerable perioperative risks, such as pneumothorax, infections, and nerve injury, in addition to loss of the natural bony protection of internal organs.^2-5

Additionally, advancements in technology have improved procedural accuracy by enabling intraoperative monitoring of fracture angulation, which helps reduce complications. These innovations reflect the growing interest in less invasive approaches that promote a thinner, more harmonious waist while meeting esthetic expectations with improved safety.^2-5

Objective

This study aimed to identify, through an integrative review, the main consistent aspects among existing research on rib-remod-eling techniques and to evaluate the methodological quality of the available publications. The study also aims to analyze the effectiveness, safety, and impact on patient satisfaction of these techniques, while emphasizing the need for more robust re-search to ensure long-term safety and quality of outcomes.

Materials and Methods

We conducted a literature search on the PubMed, Cochrane, LILACS, and SciELO databases using specific terms such as rib remodeling and plastic surgery, combined with Boolean operators. We included articles published in the last 5 years in English, Portuguese, and Spanish to ensure the evidence is current and relevant.

The inclusion criteria were primary studies, systematic reviews, clinical trials, observational studies, and case reports on esthetic rib-remodeling techniques and their outcomes in plastic surgery. We excluded articles that did not directly address the topic, as well as duplicate publica-tions, editorials, letters to the editor, and opinion papers.

Study selection was performed in two stages: initial screening of titles and abstracts, followed by full-text review of the articles that met the inclusion criteria. Two indepen-dent reviewers, unaware of the authors’ identities and institutional affiliations, conducted the selection process. A third reviewer resolved disagreements to ensure methodo-logical rigor.

We extracted data using a standardized form including information on study design, sample characteristics, inter-ventions performed, evaluated outcomes, and main findings.

Results

Cipriani et al.³ (2023) investigated an incisionless waist-remodeling technique using ultrasound-guided monocorti-cal rib fracture. The study demonstrated that the procedure is safe, minimally-invasive, and results in satisfactory esthet-ic outcomes, with high patient satisfaction and nearly im-perceptible scarring.

Cipriani⁴ (2024) evaluated the effectiveness of ultra-sound-guided rib remodeling and discussed the relevance of the “clack” (fracture) sound as an indicator of procedural success. The study reinforced the safety of the technique and highlighted the precision provided by ultrasound for intra-operative monitoring.

Villa et al.² (2025) described the rib osteosynthesis sur-gery (RIBOSS) technique, which combines esthetic rib-cage remodeling with osteosynthesis to achieve high-definition body contouring. This recently-published study demonstrat-ed enhanced esthetic outcomes, good structural stability, and appropriate recovery. The authors presented the technique as an effective and safe alternative for rib remod-eling, with low complication rates and high patient satisfaction.

Valdivieso et al. (2024) analyzed rib remodeling with emphasis on esthetic outcomes and safety. Their findings supported the effectiveness of minimally-invasive techni-ques, reporting low complication rates and high patient satisfaction, while underscoring the importance of detailed surgical planning ►Table 1.

Table 1 - Summary of the studies included in the review

Ethical Considerations

Since the current integrative review used publicly-available secondary data with no direct involvement of human subjects, it is exempt from requiring ethical approval. However, we ensure integrity in the citation of sources and transparency in the conduction of the review.

Discussion

Rib-remodeling techniques for waist contouring have gained prominence by offering less invasive alternatives and pre-senting the potential for significant esthetic improvement. Among the few studies published in the past 5 years, most aimed to introduce and describe new surgical techniques rather than provide high-level evidence of their efficacy and safety.

In the studies included in the present review, the most frequently investigated approach involved the use of intra-operative ultrasound to enhance procedural precision. Ul-trasound monitoring improved the accuracy of monocortical rib fractures, reduced procedural risks, and increased surgi-cal safety. Furthermore, this technology may help standard-ize interventions, which is crucial to ensure methodological reproducibility and enable the objective assessment of outcomes.

Villa et al.² made a significant contribution to the field by presenting the RIBOSS technique, which combines esthetic rib-cage remodeling with osteosynthesis using titanium plates. This strategy provides greater structural stability and improved postoperative comfort. The authors demon-strated the possibility of obtaining enhanced esthetic out-comes with shorter immobilization time and reduced impact on daily activities, potentially increasing patient adherence and satisfaction.

Despite these reported benefits, the literature still presents important gaps. The absence of uniform criteria to define surgical success-illustrated by the variability in detecting the characteristic fracture sound-highlights the need for more rigorous and integrated protocols that combine clinical indicators with technological parameters. Furthermore, most studies focus on shortto mid-term outcomes, leaving unanswered questions regarding the durability of results and the incidence of late complications.

Another relevant limitation involves sample heterogene-ity and insufficient control of confounding variables, such as concomitant procedures (such as liposuction), individual patient characteristics, and associated surgical techniques. This variability limits generalizability and reinforces the need for future studies with more robust designs, including control groups and randomization.

While patient satisfaction is frequently reported as high, studies seldom utilize standardized or validated assessment tools, undermining comparability across investigations. Moreover, psychosocial aspects and quality-of-life outcomes related to body image and self-esteem remain underex-plored, despite their key role in esthetic surgery.

Regarding safety, the reported complications are often mild and transient; however, consistent long-term data on adverse events remain scarce. Such evidence is essential to support the consolidation of these techniques into routine clinical practice.

Lastly, integration of advanced technologies-such as three-dimensional (3D) computed tomography for preoper-ative planning, the ultrasonic Piezotome (Acteon Group) device, and titanium plate osteosynthesis-appears promis-ing in enhancing surgical precision and esthetic outcomes. Widespread adoption relies on factors such as availability, cost, and surgeon training, which must be considered when developing clinical guidelines.

Conclusion

The present review highlights the need for more rigorous and well-designed studies on waist remodeling through rib-fracture techniques, as most current publications present methodological limitations that compromise the reliability of their findings. Future investigations should adopt strict protocols, include control groups, and provide detailed out-come analyses-particularly in combined procedures-to clearly establish the technique’s efficacy and safety. In addi-tion, incorporating patient perspectives through validated assessment tools is essential to develop protocols that safely and effectively address esthetic and functional expectations.