RED Protocol: Ultrasound for Intraoperative Detection of Pneumothorax and Hemothorax in Rib Remodeling Surgeries

BACKGROUND: Ribcage remodeling procedures are increasingly used in aesthetic surgery to reduce waist circumference; however, they carry a potential risk of pneumothorax and hemothorax due to proximity to the lung parenchyma. Early intraoperative detection of these complications is critical but currently not standardized. OBJECTIVES: To evaluate the feasibility and diagnostic performance of the Rib Complication Evaluation and Detection (RED) protocol, an intraoperative ultrasound-based approach for detecting pneumothorax and hemothorax during ribcage remodeling procedures. METHODS: A retrospective observational study was conducted including 113 patients undergoing ribcage remodeling between 2023 and 2024. Due to the low incidence of pneumothorax, the protocol was additionally assessed using 250 high-fidelity simulation scenarios with the CAE Vimedix system. Ultrasound findings were standardized, and sensitivity, specificity, and predictive values were calculated. RESULTS: No cases of pneumothorax or hemothorax were identified in the clinical cohort. In simulation testing, the RED protocol demonstrated a sensitivity of 96% and specificity of 100% for pneumothorax detection, with a positive predictive value of 100% and a negative predictive value of 98%. The protocol successfully differentiated pneumothorax from other thoracic conditions. CONCLUSIONS: The RED protocol provides a structured and reproducible approach for intraoperative lung ultrasound in ribcage remodeling. While simulation was necessary due to the low prevalence of complications, the protocol is based on well-established sonographic signs. Its high negative predictive value suggests utility as a rule-out tool, enhancing intraoperative safety. Further prospective studies are needed to validate its performance in real clinical scenarios.