Wikipedia

Rib remodeling

Rib remodeling is a body contouring surgical technique that narrows the waistline by reshaping the lower false and floating ribs through controlled, ultrasound-guided monocortical fractures, without removing bone and without external skin incisions. It was developed by Peruvian plastic surgeon Raúl Manzaneda Cipriani and is commercially known as RibXcar.[1][2] Procedural variants and a reconstructive application have subsequently been described in the peer-reviewed literature.[3][4]

History and development

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The foundational description was published in December 2023 in Plastic and Reconstructive Surgery – Global Open. The initial study applied the technique to 30 women in Peru, Colombia and Mexico, measuring the costal angle and waist circumference by ultrasound before surgery, immediately afterwards, and at one and three months.[1] The article received the journal's 2024 award.[1]

In 2024, Manzaneda described the instrument used in the procedure — an ultrasonic piezotome adapted in three steps (tip redesign, coating and sterilization) for rib surgery without incisions — published under the name "Manzaneda's Tool".[5] The instrument is manufactured by Manzaneda's team and distributed by Marina Medical.[5]

Subsequent publications described procedural variants, including waist reduction through conversion of false ribs to floating ribs (2024),[6] waist reduction by rib incurvation (2026),[7] and the "Dots Point" technique, which presents the controlled fracture pattern as a safety principle (2026).[3] A 2026 prospective cohort study extended the technique beyond aesthetic contouring to reconstructive use in posterolateral thoracic deformities.[4]

Technique

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The procedure reshapes the lower ribs through controlled, ultrasound-guided monocortical fractures performed via small punctures rather than open incisions, using the adapted piezotome.[1][5] Reducing the diameter of the lower costal arch decreases the waist circumference while preserving the integrity of the bone; unlike rib resection procedures, the ribs are repositioned rather than removed.[1][2] Intraoperative control combines ultrasound imaging with the audible feedback of the monocortical fracture, a method examined in a 2024 article.[8]

Safety and evidence

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A 2025 survey-based safety evaluation of 113 surgeons using the technique reported serious complications (pneumothorax or hemothorax) in 2.65% of cases, analysed through multivariable logistic regression.[9] A 2026 prospective cohort of 328 patients with one-year follow-up reported bicortical fractures in 15 patients (4.6%), mostly within the first 20 days after surgery, correlated with higher visceral fat and longer operative time.[10] A 2026 study assessed respiratory function after the procedure.[11]

A 2026 independent systematic review and meta-analysis published in Aesthetic Plastic Surgery, based on searches of PubMed, Cochrane and Embase, examined the efficacy and safety of rib remodeling without rib resection.[12]

Scientific discussion

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Approaches to rib remodeling have been discussed in the peer-reviewed literature. A 2025 article by Alfredo Hoyos and colleagues described a related puncture-based approach,[13] to which Manzaneda published a formal response.[14]

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Manzaneda has described a series of ultrasound-guided body-contouring techniques in the peer-reviewed literature, including iliac crest reduction (XCREST),[15] ultrasound-guided rectus abdominis fat transfer,[16] and direct-vision liposuction.[17] Rib remodeling is the most widely reported of these.

Reception

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The technique has been covered by consumer and industry media as part of wider interest in waist-contouring procedures,[2][18] and is taught to plastic surgeons internationally.[19]

References

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  1. 1 2 3 4 5 Manzaneda Cipriani, Raúl M. (2023). "Waist Remodeling without Incision, with Ultrasound-guided Monocortical Fracture". Plastic and Reconstructive Surgery – Global Open. 11 (12). p e5499. doi:10.1097/GOX.0000000000005499.
  2. 1 2 3 Jackson, Danielle (October 28, 2025). "Rib Remodeling Can Offer a Smaller Waistline—Here's What You Need to Know". Marie Claire.
  3. 1 2 "RibXcar with Dots Point Technique: The Science of Fracture as a Safety Principle". Plastic and Reconstructive Surgery – Global Open. 2026. doi:10.1097/GOX.0000000000007816.
  4. 1 2 "Rib Remodeling (RibXcar) for Posterolateral Thoracic Deformities: A Prospective Cohort Study of Rib Angularity for Reconstructive Purposes". Aesthetic Surgery Journal. 2026. doi:10.1093/asj/sjag107.
  5. 1 2 3 Manzaneda Cipriani, Raúl M. (2024). "Manzaneda's Tool: Adaptation of the Piezotome for Rib Remodeling Surgery without Incisions". Plastic and Reconstructive Surgery – Global Open. 12 (5). p e5819. doi:10.1097/GOX.0000000000005819. PMID 38756956.
  6. ↑ "Waist Reduction through Conversion from False to Floating Ribs". Plastic and Reconstructive Surgery – Global Open. 2024. doi:10.1097/GOX.0000000000005900.
  7. ↑ "Waist Reduction Surgery by Rib Incurvation: A New Approach for Waist Narrowing". Plastic and Reconstructive Surgery – Global Open. 2026. doi:10.1097/GOX.0000000000007754.
  8. ↑ "Is "Clack" Enough? Rib Remodeling Guided by Ultrasound". Plastic and Reconstructive Surgery – Global Open. 2024. doi:10.1097/GOX.0000000000005843.
  9. ↑ "Safety Evaluation of the RibXcar Technique Using the Piezotome: An Analysis of Surgical Complications". Plastic and Reconstructive Surgery – Global Open. 13 (9). p e7130. 2025. doi:10.1097/GOX.0000000000007130.
  10. ↑ "Analysis of Bicorticality in a Cohort of Post-RibXcar Patients: A Clinical and Imaging Follow-up Study". Aesthetic Surgery Journal. 46 (7): 737–744. 2026. doi:10.1093/asj/sjag012.
  11. ↑ "Respiratory Function Assessment After Waist Reduction Through Scarless Ultrasound-Guided Monocortical Fracture (RibXcar) Surgery for Body Contouring". Aesthetic Surgery Journal Open Forum. 2026. doi:10.1093/asjof/ojag007.
  12. ↑ "Rib Remodeling Without Rib Resection: A Systematic Review and Meta-analysis". Aesthetic Plastic Surgery. 50 (2): 667–674. 2026. doi:10.1007/s00266-025-05240-w. PMID 41003707.
  13. ↑ Hoyos, Alfredo (2025). "Waistline Aesthetic Slimming by Puncture and Parallel Approach for Rib Remodeling Procedures". Aesthetic Surgery Journal Open Forum. doi:10.1093/asjof/ojaf044.
  14. ↑ Manzaneda Cipriani, Raúl M. (2025). "Response by Manzaneda to "Waistline Aesthetic Slimming by Puncture and Parallel Approach for Rib Remodeling Procedures" by Hoyos et al". Aesthetic Surgery Journal Open Forum. doi:10.1093/asjof/ojaf137.
  15. ↑ Manzaneda Cipriani, Raúl M. (2025). "Treatment of the High Iliac Crest With Iliac Crest Reduction (XCREST)". Aesthetic Surgery Journal. 45 (7): 683–689. doi:10.1093/asj/sjaf044. Retrieved July 7, 2026.
  16. ↑ Manzaneda Cipriani, Raúl M. (2025). "Muscle Amplification With the Ultrasound-guided Rectus Abdominis Fat Transfer Technique". Aesthetic Surgery Journal.
  17. ↑ Manzaneda Cipriani, Raúl M. (2025). "Safety and Effectiveness of Real-time Direct Vision Liposuction". Aesthetic Surgery Journal.
  18. ↑ "The RibXcar Technique for a pinched waistline". Plastic Surgery Hub.
  19. ↑ "RibXcar costal remodelling". Dr. Alexis Delobaux.
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