If you have rib flare or costal-margin surgery booked, almost always as part of a pectus repair, this is your preparation plan: exactly what to do in the weeks before so you walk into the operation as strong, fit and ready as possible.

Rib flare on its own rarely warrants surgery; a surgical consult usually only makes sense when it accompanies a significant structural pectus deformity, and the flare is corrected during that repair or with a dedicated costal-margin procedure.^1,7,12 When it is operated on, it's a real chest-wall operation under general anesthesia, and the breathing skill, core control and posture you bring into it shape how the first weeks afterward go.^18,19

This is the discipline of prehabilitation: getting measurably fitter and better-prepared before surgery so you recover faster and with fewer complications. Prehab and structured pre-operative preparation are built into modern enhanced-recovery (ERAS) pathways and are associated with shorter stays and smoother recoveries.^23,24,25

Before anything else: most rib flare does not need surgery. It's usually a position-and-breathing problem, the lower ribs sit lifted because the diaphragm and deep core aren't holding them down, and it responds to the right breathing and core work, not a scalpel.^17,26,27 If you're being operated on, it's because of an accompanying structural deformity, and the same ribs-down breathing and core control is what you want to build before the operation and hold after it.

The fitter, stronger and better-nourished version of you recovers faster. Pre-op breathing practice reduces pulmonary complications after chest surgery,^20,21,22 prehab improves postoperative functional capacity,²³ and stopping smoking plus topping up nutrition moves every dial that's actually in your control.^30,33,35 The operation addresses the structure; preparation decides how the recovery feels, and how well the result holds.

Rib flare is an outward protrusion of the lower costal margin, the bottom edge of the ribcage standing proud, most visible when lying down or leaning back.^2,3,4 It frequently accompanies pectus excavatum and can also appear or persist after a pectus repair.^1,13 When surgery is warranted, the flare is typically addressed during the primary pectus operation, or with a costal-margin technique such as resecting or repositioning the prominent cartilage where the ribs meet the sternum.^6,7

It helps to know what your body will be doing in the weeks after:

• Cartilage & bone remodel slowly under the new corrective load, which is why ribs-down breathing and gradual strengthening matter for months afterward.
• The chest wall is sore early; deep breathing keeps the lungs open while you guard.^20,21
• The deep core and diaphragm are what hold the lower ribs down long-term, surgery sets the position, control keeps it.^17,26

Prehab makes sense once you know what you're preparing for. In the first weeks after surgery you will be asked to:

Everything in this program maps to one of those demands. You're not training to be an athlete, you're loading the dice for an easier recovery and a result that holds.

Ideally you have six to eight weeks. If you have less, do everything you can in the time you have, even two weeks of breathing practice and smoking cessation moves the needle.^22,30

This is the centrepiece of rib-flare prehab, and it does two jobs at once. First, any chest-wall operation under general anesthesia risks the small air sacs collapsing, atelectasis, so deep-breathing practice protects your lungs; preoperative inspiratory-muscle training lowers postoperative pulmonary complications.^20,21,22 Second, exhale-led breathing is the exact pattern that pulls the lower ribs down, train it now and you carry it straight into recovery.^17,26

• Exhale-led diaphragmatic breathing. Slow nasal inhale into the lower ribs and back, then a long, full exhale, feeling the front ribs draw down and the deep abdominals engage at the end. 5–10 minutes, a few times a day.^17,26
• 90/90 supported breathing. On your back, feet on a wall or chair at 90/90, gently posteriorly tilt the pelvis and breathe into the back and sides of the ribs with long exhales, the cleanest way to feel ribs-down.²⁶
• Incentive spirometry / IMT if you have a device, to build inspiratory strength for after surgery.^21,22,42

Surgery can set the rib position; the deep core and diaphragm working together is what holds it. The mistake to avoid is generic ab work, crunches and big sit-ups can pull the ribcage up and out and make flare look worse. The goal is anti-extension control: ribs stacked down over the pelvis, abdominals engaged without flaring.^17,26,27

• Dead-bug: opposite arm and leg lower while the ribs stay pinned down; the cornerstone rib-flare drill.
• Bird-dog and front plank (short, perfect), trunk stability without arching the lower back or flaring the ribs.
• Posterior-tilt holds with exhale-led breathing, wiring the ribs-down position into your nervous system.

Physiotherapy as an adjunct to chest-wall surgery improves posture and function,¹⁸ and the better your control going in, the faster you re-establish it. See the full routine in the Strength Program.

A better cardiovascular base going in means you tolerate anesthesia better, mobilise sooner and reach your walking targets faster.^24,28 Aim for steady aerobic work in the weeks before surgery:

• Most days: 20–40 minutes of brisk walking, cycling or swimming at a conversational-to-slightly-breathless pace.
• Build, don't blast: the goal is a durable base, not personal records, stop heavy or high-impact work in the final two weeks.
• Practise nasal, exhale-led breathing during cardio so the ribs-down pattern reinforces under light load.

Eat to heal, starting now

You'll be healing cartilage, bone and incisions, which is protein- and micronutrient-hungry. Build the stores before surgery, not after. Prioritise adequate protein at every meal, and keep vitamin D topped up (≥800 IU/day, aiming >30 ng/mL) with enough calcium, vitamin D supports bone healing, muscle strength and infection control, and deficiency is linked to worse surgical outcomes.³³ Zinc and vitamin C support wound repair.³⁴

Fix anemia before, not after

Going into surgery iron-replete matters: preoperative anemia is linked to more transfusions and complications, and correcting iron stores beforehand is a core part of patient blood management.³⁵ If you bruise easily, have heavy periods or eat little red meat, ask your team to check your iron and hemoglobin early enough to fix them.

Arrive at a healthy weight

Use the prehab window to steady your nutrition rather than crash-diet, the aim is to arrive well-fuelled and strong, which is also when core control sticks best.²³

If you smoke or vape, quitting before surgery is one of the highest-impact things you can do. Preoperative smoking cessation reduces postoperative complications (wound, pulmonary and otherwise) and the longer the smoke-free interval before surgery, the bigger the benefit; even a few weeks helps.^30,31

Cut alcohol too. Heavy drinking impairs healing and raises complication rates, and a period of abstinence before surgery improves outcomes.³² Treat both as part of the program, not an afterthought.

Some of the most important prep is administrative. In the weeks before surgery:

• Review every medication and supplement with your surgeon. Some blood thinners, anti-inflammatories and herbal supplements must be paused before surgery, but only on your team's instruction, never on your own.⁴³
• Clear active infections. Sort out dental problems, skin infections and chest infections in advance, they can delay surgery or raise risk.
• Be clear on the whole plan. If the flare is being addressed alongside a pectus repair, understand both parts of the operation and the combined recovery.^1,14
• Attend your pre-operative assessment and be honest about your history so your anesthetic care is planned correctly.⁴³

Preparation is mental as much as physical. The encouraging part is well-documented: surgical repair of chest-wall deformity markedly improves body image, self-esteem and confidence in physical activity, with the biggest shift in the first weeks of recovery.^37,38,40 People with chest-wall differences often carry lower quality of life and body image beforehand, and that is exactly what tends to lift after correction.^39,41

Set realistic expectations too: if the flare is being treated alongside a pectus repair, a degree of residual lower-rib prominence can remain, and that's where your breathing and core work earns its keep afterward.^1,5 Knowing the plan, rehearsing the breathing and setting up your home takes most of the anxiety out of it.²³ If you feel persistently low before surgery, tell your team.

Surgery is stressful, and chest-wall differences carry a real psychological weight long before the operating room. People with chest-wall deformities report measurably higher anxiety and poorer body image than their peers.^51,52

A daily meditation practice is one of the best-evidenced, lowest-cost tools for that anxiety. Mindfulness meditation has good-quality evidence for reducing anxiety, across randomized trials and large meta-analyses in both clinical and everyday populations.^{53,54,55,56,57} It won't change the shape of your ribs and it won't replace your surgical team, it changes your relationship to the worry about it, which is exactly what you want steady going into surgery.

How to start, 10 minutes a day

• Guided first. Don't sit in silence wondering if you're doing it right, follow a guided session. Waking Up is what I use; choose the scholarship / $0 option to try it free.
• Same time daily. 10 minutes, ideally in the morning before you reach for your phone. Consistency beats length.
• Notice, don't fight. When a thought about your ribs or the surgery shows up, label it and return to the breath. That's the whole rep.

Do this while you're still mobile and strong, your future self, two days post-op, will thank you.

• A place to sleep semi-upright: a recliner or a stack of firm pillows, so you can breathe easily and avoid twisting onto the repair early on.
• Loose, front-button clothing you don't have to pull over your head, plus a grabber for low items.
• A meds and bowel plan ready to go: pain-medication constipation is predictable, so have a stimulant-laxative plan organised before you start.⁴⁶
• Stock the kitchen with easy, protein-rich food, and line up help with lifting, driving and chores for the first 1–2 weeks.

For rib flare the program is breathing- and core-led, with a light posture and strength base around it. The aim is to wire in ribs-down control you'll carry through recovery, and a fitness base you'll pause briefly and rebuild. Keep everything pain-free, no chest-flaring ab work, and taper the heavier work in the final two weeks so you arrive fresh.

Weekly layout

How to run it

• Weeks 8–3 out: train 3 days, keep the breathing/core day non-negotiable, add a little load to the strength work when it feels clean.
• Final 2 weeks: drop the load, keep breathing and walking daily. Arrive fresh.
• Always: long exhales, ribs down, no breath-holding, and no crunch-style ab work that flares the chest.

• Stop heavy lifting and high-impact training. Keep walking and breathing drills only, you want to be rested, not sore.
• Lock in logistics. Confirm your ride, your time off work or school, and your help at home.
• Finalise medications per your surgeon, including which ones to pause and when.⁴³
• Sleep and eat well. Bank rest and nutrition; this is the foundation you'll heal on.³³
• Re-read the recovery plan so the first days after surgery feel familiar, not foreign.

Follow your hospital's instructions to the letter, they override everything here, especially:

• Fasting: stop eating and drinking exactly when told. This is a safety rule for anesthesia, not a guideline.⁴³
• Skin prep: shower with any antiseptic wash you're given; don't shave the chest yourself unless instructed.
• Pack: loose front-button tops, slip-on shoes, phone and charger, current medications in their boxes, a pillow for the car ride home to splint against, and your spirometer if you have one.
• Sleep: get a good night where you can, and trust the preparation you've done.

Walk into your pre-op appointment with these written down:

• Is the rib flare being corrected on its own or as part of a pectus repair, and what does each part involve?^1,7
• How much residual lower-rib prominence is realistic afterward?⁵
• What's the plan for pain control?²⁴
• Which of my medications and supplements should I stop, and when?⁴³
• How long in hospital, and when can I expect to walk, drive, return to school/work and train?^24,50
• What lifting and twisting restrictions apply, and for how long?¹⁹

Every claim in this program is backed by published research. Because isolated rib-flare surgery is uncommon, the surgical sources span pectus and costal-margin repair, alongside prehab, breathing and core-control evidence. Tap any lime number in the text to open the source in a new tab.

1. Treatment of flaring of the costal arch after minimally invasive pectus excavatum repair. PMID 20850643.
2. Rib flare distance: a novel and highly reliable radiographic metric of the rib-cage deformity. PMID 41452517.
3. Adolescent flared ribs. PMID 13082712.
4. Flaring of the ribs associated with other skeletal anomalies. PMID 14365170.
5. Winged Ribs: An Underestimated Problem That May Compromise Breast Augmentation Outcomes. PMID 31087117.
6. Separation of the seventh costal-sternal junction: a new technique to improve outcomes for chest-wall deformity. PMID 36513003.
7. Parks bridging bar pectus procedure: techniques to optimize functional and aesthetic results. PMID 40946842.
8. Method and apparatus for nonsurgical correction of chest-wall deformities. mrpectus research library.
9. Isolated bifid rib: clinical and radiological findings in children. PMID 22640412.
10. The Double Rib Contour Sign (DRCS) in lateral spinal radiographs: aetiologic implications. PMID 15456003.
11. Thoracic scoliosis: exothoracic and endothoracic deformations and the spinal penetration index. PMID 11973530.
12. Jaroszewski D, et al. The pectus care guidelines: best-practice consensus from the joint specialist societies. PMID 38964837.
13. Reactive costal flare / carinatum in patients treated for pectus excavatum. PMID 18675637.
14. Effectiveness of Minimally Invasive Sternal Compression Combined with the Nuss Procedure for combined chest-wall deformity. mrpectus research library (rs-3906142).
15. Nuss D, Kelly RE. The Nuss procedure for pectus correction. PMID 11795057.
16. Comparison of minimally invasive and modified Ravitch repair. PMID 11877659.
17. Diaphragm action, the zone of apposition and lower rib-cage position: respiratory mechanics of ribs-down breathing. Respiratory physiology reference.
18. Haje SA, et al. Physiotherapy as an adjuvant to the surgical treatment of anterior chest wall deformities. PMID 11051146.
19. Perioperative respiratory physiotherapy around chest-wall surgery. PMID 13129428.
20. Deep-breathing protocols reduce atelectasis and pneumonia after thoracic surgery. Systematic review, Ann Thorac Surg.
21. The Effect of Incentive Spirometry on Postoperative Pulmonary Complications: a systematic review. Chest / Respir Care.
22. Hulzebos EHJ, et al. Preoperative inspiratory muscle training to prevent postoperative pulmonary complications. JAMA 2006; PMID 17077375.
23. Prehabilitation and exercise before major surgery improve postoperative functional capacity: systematic review & meta-analysis. Surgery / Br J Anaesth.
24. Litz CN, et al. Implementation of an Enhanced Recovery Pathway for Minimally Invasive Pectus Surgery. PMID 33401363.
25. Mavi J, et al. Successful use of an ERAS pathway following minimally invasive pectus repair. J Pediatr Surg; PMID 32197827.
26. Posterior, exhale-led breathing for lower-rib control: clinical application. mrpectus research library.
27. Anti-extension core training and rib-cage position: programming principles. Strength & rehabilitation reference.
28. Pulmonary function and exercise response after minimally invasive chest-wall repair. PMID 12677562.
29. Why is exercise capacity reduced in subjects with chest-wall deformity? PMID 10657820.
30. Thomsen T, et al. Interventions for preoperative smoking cessation. Cochrane Database Syst Rev 2014; PMID 24683144.
31. Lindström D, et al. Effects of a perioperative smoking cessation intervention on postoperative complications: a randomized trial. Ann Surg 2008; PMID 18650627.
32. Egholm JW, et al. Perioperative alcohol cessation intervention for postoperative complications. Cochrane Database Syst Rev 2018; PMID 30403278.
33. The Role of Vitamin D Supplementation in Enhancing Muscle Strength Post-Surgery: a systematic review. Nutrients 2025; 17(9):1512.
34. National Athletic Trainers' Association. The Use of Nutrition in Wound Healing (protein, vitamin C, zinc). nata.org, accessed 2026.
35. Muñoz M, et al. International consensus on the peri-operative management of anaemia and iron deficiency (patient blood management). Anaesthesia 2017; PMID 27996086.
36. Jiang S, et al. Efficacy of topical silicone gel in scar management: systematic review & meta-analysis of RCTs. PMID 32119763.
37. Krasopoulos G, et al. Surgical repair of chest-wall deformity markedly improves body image and perceived ability for physical activity. PMID 19047237.
38. Zuidema WP, et al. Early Consequences of Pectus Surgery on Self-Esteem and General Quality of Life. World J Surg 2018; PMID 29411068.
39. Quality of life improves after minimally invasive chest-wall repair. PMID 25293414.
40. Systematic review of physiological and psychological outcomes of pectus surgery. PMID 37827806.
41. Chest-wall patients have lower quality of life and impaired body image before correction. PMID 21440452.
42. Incentive Spirometer and Inspiratory Muscle Training. StatPearls, NCBI Bookshelf.
43. Pre-operative fasting and medication guidance for elective surgery. Specialist patient guidelines, accessed 2026.
44. Schwarz N. Prevention of embolic complications: standardized regimen of early ambulation. PMID 14873475.
45. Pai M, et al. Perioperative Venous Thromboembolism Prophylaxis. Mayo Clin Proc 2020.
46. Opioid-Induced Constipation, management. StatPearls, NCBI Bookshelf NBK493184.
47. Thoracic wall lesions in children: differential of lower chest-wall prominence. PMID 14966820.
48. Classification of anterior chest-wall deformities (excavatum, carinatum and mixed). PMID 13492135.
49. Pectus excavatum and carinatum in children and adolescents: what to say, what to do. PMID 28714634.
50. Cleveland Clinic. Chest-wall deformity surgery, recovery and return-to-activity timeline. Patient guidelines, accessed 2026.
51. Body-image, self-concept and mental exposure in patients with anterior chest-wall deformity. PMID 21290134.
52. Surgical correction of chest-wall deformity improves perceived body image, mental health and self-esteem. PMID 25783317.
53. Goyal M, et al. Meditation programs for psychological stress and well-being: a systematic review and meta-analysis. JAMA Intern Med 2014; PMID 24395196.
54. Hofmann SG, et al. The effect of mindfulness-based therapy on anxiety and depression: a meta-analytic review. J Consult Clin Psychol 2010; PMID 20350028.
55. Hoge EA, et al. Randomized controlled trial of mindfulness meditation for generalized anxiety disorder. J Clin Psychiatry 2013; PMID 23541163.
56. Kabat-Zinn J, et al. Effectiveness of a meditation-based stress reduction program in the treatment of anxiety disorders. Am J Psychiatry 1992; PMID 1609875.
57. Khoury B, et al. Mindfulness-based therapy: a comprehensive meta-analysis. Clin Psychol Rev 2013; PMID 23796855.