CHAPTER 67 LOWER BODY LIFT AND THIGHPLASTY
JOSEPH P. HUNSTAD AND REMUS REPTA
LOWER BODY LIFTS
The lower body lift is recommended for patients with circumferential body laxity who have achieved significant weight loss through surgical bariatric intervention or diet and exercise regimens (seeChapter 66). The procedure is performed in both prone and supine positions requiring patient repositioning intraoperatively. The circumferential component of the procedure allows for the treatment of buttocks ptosis, lateral and anterior thigh laxity, abdominal tissue redundancy, as well as mons ptosis. The lower body lift procedure can be combined with various ancillary procedures such as autologous buttocks augmentation, fleur-de-lis abdominal contouring, thigh lift, and mons reduction. There is overlap between this chapter and Chapter 66 on abdominoplasty. We encourage the reader to study both chapters.
The lower body lift serves as the “keystone” procedure upon which all subsequent body contouring procedures are based.1-3 It is important for patients to understand that there is no exercise for skin! This is frustrating for patients who exercise regularly but have skin laxity of the trunk secondary to genetics. The lower body lift procedure is far more than a “belt lipectomy” where circumferential excess skin is removed from the mid-waist area of the trunk (Chapter 66). By placing the resection lower, near the trunk–lower body junction, more powerful lifting of the buttocks and thighs is accomplished. Circumferential resection allows for maximum tissue resection without concern for dog-ears. Ancillary procedures including vertical thighplasty, mons resection, and autologous buttock augmentation can be included.
Patients who present in consultation for a lower body lift usually seek improvement primarily in the appearance of the abdomen and buttocks. Patients must be educated regarding the resulting scar and should be at or near their goal weight. It is necessary that the patient be well informed and compliant. This is a big operation and cooperation in the postoperative period can impact the risk of complications, such as deep vein thrombosis (DVT), and the final result.
During consultation, patients frequently demonstrate their desired surgical outcome by lifting the excessive tissue laxity of the lower abdomen, buttocks, and thighs (Figure 67.1). Massive weight loss patients who have reached a normal BMI (they do not require additional liposuction) and normal weight individuals are the ideal candidates for this procedure.
Relative contraindications for lower body lift surgery include smoking, diabetes, malnutrition, wound healing issues, and immunodeficiency. The use of anticoagulant medications, lower extremity venous insufficiency, lymphedema, a previous history of venous thromboembolism (VTE), and other medical issues such as renal insufficiency, anemia, and pulmonary issues may also be prohibitive. Patients who have a significant amount of excess fat and only a mild or moderate amount of skin laxity should be educated regarding the benefit of weight loss through diet and exercise or through bariatric surgery. The lower body lift is ideally suited to correct skin and soft-tissue laxity and not as a fat reduction procedure.
Preoperative History and Preparation
Patients who have achieved massive weight loss may be malnourished and/or suffer from other metabolic abnormalities.4 Laboratory blood work including complete blood count, basic metabolic panel, coagulation profile, pregnancy test, and total protein/albumin levels is recommended. Abnormal laboratory values warrant additional nutritional analysis and intervention to avoid postoperative wound healing problems. A history is obtained regarding VTE (Chapter 11). A factor V Leiden analysis can be performed to rule out this unusual form of coagulopathy. Hormone replacement therapy and birth control medications are discontinued for several weeks prior to surgery if possible. Patients are encouraged to stop smoking for 6 weeks before surgery and not to resume until 3 weeks post-op. Sequential compression devices are used on the lower extremities throughout the surgical procedure and until discharge. The use of proper intraoperative positioning with the knees partially flexed, perioperative prophylactic medication such as Lovenox, and early postoperative ambulation are also employed.5
Existing abdominal scars are evaluated since they can adversely impact the blood supply to the abdominal apron.1 A lower body lift procedure usually eliminates the inferior and central blood supply to the abdominal soft tissue, basing the remaining vascular supply on the intercostal perforators (Chapter 66). Preexisting scars can also impact the final aesthetic result of the lower body lift procedure if they cannot be included in the resection. The presence of scars may alter the tissue pliability in that region and the surgical markings should take this into consideration.
Preoperative photographs are obtained. Existing scars are marked and included, whenever possible, in the proposed skin resection. When the patient desires the final incision within the boundary of a specific undergarment or swimwear, we mark the outline of the garment and position the incision accordingly. With the patient lifting the abdominal skin superiorly, the lower transverse mark is made at the level of the pubic symphysis (Figure 67.2). The patient then releases the abdominal soft tissue and the incision is lengthened laterally to the level of the iliac crest following a natural skinfold. The desired final location of the posterior incision is marked along the upper portion of the buttocks (Figure 67.3A). If autologous buttocks augmentation is anticipated, the final incision line over the buttocks should be a continuation of a line from the pubic symphysis to the greater trochanter and extended to the posterior midline (Figure 67.3B). This line will indicate the area of maximum projection of the buttocks.1,6 Starting in the midaxillary line with the patient bent slightly away from the surgeon to prevent over-resection the extent of the resection is estimated bilaterally (Figure 67.4A). The posterior resection is marked, noting that the amount of resection is conservative in the midline because of the strong zone of adherence and reduced laxity. When autologous buttocks augmentation is planned, the amount of resection of the posterior segment is reduced to accommodate the volume that will be added. From the upper marking in the midaxillary line a dotted line is continued anteriorly across the abdomen, representing the estimated amount of resection. The exact amount of the resection will be determined intraoperatively (Figure 67.3A). Areas for concurrent liposuction are then marked as well.
FIGURE 67.1. Patient’s concerns relative to lower body contouring. A and B. Patients often demonstrate their desired outcome by strongly lifting the abdominal skin, thigh skin, and the buttocks areas.
A V–Y mark is made within the planned resection amount at the midaxillary line which will allow temporary closure of this area when the patient is repositioned from prone to supine (Figure 67.4B). For patients with significant transverse as well as vertical tissue laxity, a concurrent vertical resection, commonly referred to as a fleur-de-lis resection can be utilized (Figure 67.5). Most massive weight loss patients are willing to accept a vertical midline scar in return for correction of laxity.1 The final shape of the fleur-de-lis resection should be closer to an ellipse than a triangle, to prevent excessive tension at the junction of the vertical and horizontal closure (Figure 67.5). All markings are rechecked to ensure symmetry and to avoid over-resection.
FIGURE 67.2. The lower abdominal incision. The first transverse line is placed at the level of the pubic symphysis with the patient strongly elevating the abdominal skin. This is the ideal final location for the incision which is placed in a pleasingly low location. Notice that the upper third of the hair-bearing mons is routinely resected.
General anesthesia is initiated, antibiotics and steroids are given (Ancef 1 g and Decadron 4 mg), and a Foley catheter is inserted. When concurrent liposuction is planned, thorough tumescent infiltration of all areas to be suctioned is performed.
The patient is carefully rolled in the prone position on the operating room table that has been arranged with padded chest rolls, kneepads, and a roll or pillow beneath the ankles.
The patient is surgically prepped and draped taking care to include the most anterior point of the planned V–Y closure in the midaxillary line bilaterally.
Once prepped and draped, the markings are checked for tension and symmetry. The posterior resection is performed without undermining, forming a “V”-shaped resection. This inward beveling allows closure to occur without dead space. When autologous buttocks augmentation is performed, the intervening tissue between the upper and lower incisions is de-epithelialized. This flap of tissue can be molded with suture in a purse-string method or partially elevated and rotated as a flap.4,7,8
Laterally, the resection continues to the midaxillary line where the temporary V–Y resection and closure is performed (Figure 67.6). Undermining is suggested at this point over the trochanter to release the retaining elements in this area of adherence. The posterior drain is placed and the end is coiled and inserted beneath the skin of the V–Y closure to be brought out anteriorly when the patient is turned supine. Hemostasis is obtained and a three-layer closure is performed. The most important layer of the closure, the superficial fascia, is closed with either a number 1 or 0 Vicryl or equivalent suture. Repair of the superficial fascial layer is performed under tension. Doing so allows the dermis to be approximated under minimal tension which increases the chance of obtaining a thin, inconspicuous scar. Size 2-0 or 3-0 Vicryl or equivalent suture is used in an interrupted buried fashion to approximate the dermis at each vertical oriented/tattoo mark and then at approximately 1 cm intervals. Finally, a running intradermal number 4-0 Monocryl or equivalent suture is used to approximate the skin edges. The patient is carefully repositioned into the supine position. Foam rolls are placed beneath the knees and the heels are padded. The arms are abducted and placed on padded arm boards. Warm air blankets are placed over the lower extremities. A standard surgical prep and drape of the anterior body surface is performed. When indicated, liposuction is performed throughout the areas that were previously infiltrated.
The temporary sutures placed at the midaxillary V–Y closure are removed and the end of the V–Y incision is continued anteriorly connecting to the lower abdominal incision. The superficial inferior epigastric vessels are identified and controlled. Dissection continues in the cephalic direction to the level of the umbilicus where perforating vessels are identified and controlled. Massive weight loss patients often have perforators of significant caliber requiring suture ligature or vascular clipping. The umbilical skin is circumferentially incised at its junction with the abdominal skin, and scissor dissection is performed to the abdominal wall. Frequently, this dissection naturally finds the natural plane between the umbilical stalk and the subcutaneous tissue. The abdominal flap that has been elevated up to the umbilicus is then usually split vertically in the midline which facilitates further cephalic dissection (Figure 67.7A). Dissection is continued in the cephalic direction to the level of the costal margins and xiphoid. Myofascial plication is performed with the help of muscle relaxation provided by the anesthesiologist. The medial borders of the rectus diastasis and the anticipated borders of the plication are marked with methylene blue. The width of the plication can be modified as needed during the plication process (Figure 67.7B). We utilize a number 0, looped nylon suture with a large tapered needle to perform a running single layer myofascial plication, bringing together the lateral borders of the marked plication boundary. This double-stranded suture has proven to be highly effective and durable and has replaced our previous use of interrupted sutures and a two-layer closure. We have not identified a single instance of suture failure and premature release of the myofascial plication utilizing the looped nylon method over the last 10 years. At the level of the umbilicus the suture is placed only on one side of the plication, allowing an appropriate amount of fascial laxity around the umbilical stalk. The looped nylon is tied at the level of the pubic symphysis and the knot is buried. The use of the looped nylon allows complete myofascial plication in a continuous fashion with the creation of only one knot. A second layer of suture can be placed to reinforce the first but we have rarely found this to be necessary.
FIGURE 67.3. Lower body lift markings (A and B). Preoperative markings are demonstrated with the patient relaxed. A. Note how low the anterior incision is in the midline, removing a significant portion of the hypertrophied mons. B. Realignment marks are added. In this case, a buttocks augmentation using a purse-string gluteoplasty will be performed and the markings for this are evident.
Marcaine 0.5% is injected throughout the entire area of undermining and into the rectus sheath to decrease postoperative pain. We place a lidocaine pain pump as a continuous infusion device and suture this catheter over the rectus plication. We usually leave the pain pump catheter in place and refill it as needed for a total of 6 days (Figure 67.7C).
FIGURE 67.4. Lateral markings in lower body lift (A and B). The most important marking is in the midaxillary line where the risk of over-resection is the greatest. A. The final desired incision line is marked and then strong bimanual palpation is used to identify the redundancy. The patient leans away from the surgeon to avoid over-resection. B. An anteriorly pointing V–Y marking is made, which signifies the transition from the prone to the supine portions of the operation.
At this point the final abdominal skin resection is determined by using the tissue demarcator. The patient is placed into a semi-Fowler position with the waist flexed. Appropriate tension is placed in the midline as the abdominal soft-tissue apron is pulled caudally and the level of the lower incision in the midline is translocated and marked on the overlapping abdominal flap. The abdominal soft-tissue apron is divided in the midline up to the level marked and a temporary closure with a towel clip or dermal stapler in the midline is performed. Markings are made and the proposed resection amounts on the left and right are compared to ensure symmetry (Figure 67.7D). If subscarpal fat resection is not planned, the excess tissue marked is resected using a scalpel to make a full-thickness incision through the skin and soft tissue. The tumescent infiltration placed at the beginning of the procedure can make this a nearly bloodless maneuver. Electrocautery is used as needed for hemostasis. If subscarpal fat resection is planned, resection of the abdominal tissue should proceed in a controlled fashion until the superficial fascial layer is transected. The fat below this layer is the subscarpal fat and is visually distinct from the subcutaneous fat. Resection of the subscarpal fat proceeds to the appropriate extent for the individual patient. The new site for the umbilicus is identified with the tissue demarcator (Figure 67.8A). A vertical elliptical incision is made to accommodate the new umbilicus and the subcutaneous tissue beneath is resected (Figure 67.8B).12
FIGURE 67.5. Fleur-de-lis markings. The vertical resection is in the shape of an ellipse. It is not a triangle because a triangle resection will result in excessive tension at the final closure point. With an existing subcostal scar, the vertical ellipse is shifted to the right which allows for the inclusion of this scar and its removal in the fleur-de-lis resection.
FIGURE 67.6. Closure of the superficial fascia. The superficial fascia is marked in methylene blue and this is the line at which the high tension closure is performed. Strong tension on the superficial fascia decreases the tension across the final incision line which lessons scar widening.
FIGURE 67.7. Supine portion of lower body lift (A–D). A. The flap is divided at the umbilicus and some subcutaneous tissues are left surrounding the umbilicus to preserve its vascularity. B. Dissection is continued to the level of the xiphoid and markings are made for rectus plication. The medial borders of the rectus are first marked and then an estimated line of plication is marked lateral to this in methylene blue. C. After the plication has been completed, a final drain and the pain pump catheter are placed. D. Tissue to be resected is determined with the Pitanguy demarcator.
The umbilicus is inset with interrupted 4-0 Monocryl and running intracuticular Monocryl for final closure. Closure of the abdominoplasty flap is performed in a similar fashion to the posterior closure utilizing number 1 or 0 Vicryl for the superficial fascia, 2-0 or 3-0 Vicryl or equivalent for the deep dermis, and 4-0 Monocryl intracuticular for final skin closure. The incision is either taped or glued with cyanoacrylate tissue adhesive. The patient is then transferred to the hospital bed, where they are maintained in the semi-Fowler, partial waist flexed position, to prevent excessive tension on the abdominal skin and soft tissue.
We frequently have the patients stay in our overnight care facility. The decision for overnight care is based on patient health as well as the specifics of the surgical procedure. If they are kept overnight, the suction drains are connected to high vacuum wall suction to assist with drain function. A warm air blanket is placed and continued until the patient is appropriately warm and comfortable. The urine output is monitored throughout the postoperative stay.
The patient is assisted in walking at least twice on the evening of surgery, taking care to maintain a partially flexed waist position. Incentive spirometry is begun on awakening and continued throughout the postoperative course. We have begun a program of routine DVT chemoprophylaxis and administer Lovenox 40 mg 12 h postoperatively. We recognize that there is no universal agreement as to the use, dosage, and method of administration of DVT chemoprophylaxis and care should be individually tailored to each patient’s needs and risk factors.
Following discharge from the overnight facility, patients continue their oral antibiotics and pain medications as prescribed. Patients are seen in follow-up within a few days after their procedure. We take this opportunity to review with the patient their instructions for drain care, incision dressing, and limitations of activity. A binder is recommended if there is no ischemia of the abdominal flap. We recommend frequent ambulation, proper fluid intake, and leg movement while recumbent to help reduce the risk of DVT. We suggest that the patient maintain a flexed waist position for approximately 1 week postoperatively. Drains are removed when output has reached an appropriate level, usually less than 30 ml in 24 h, which may take 2 weeks.
The results with a lower body lift can be dramatic. Overall this procedure completely contours the entire circumference of the body and is effective in reducing abdominal laxity, abdominal striae, buttocks ptosis, and anti-laxity. Although minor incision line suture abscesses are common, major complications are remarkably rare considering the magnitude of the procedure. Figures 67.9 and 67.10attest to the results that can be achieved with lower body lifting. When a circumferential deformity exists, a circumferential surgical procedure rejuvenates the body circumferentially. Not only is the abdominal contour made ideally thin, tight, and flat but also the thighs are elevated and buttocks ptosis corrected. Patient satisfaction is high with this procedure.
FIGURE 67.8. Umbilicus creation and abdominal closure. A. Abdominal closure is performed with either staples or sutures leaving space to use the Pitanguy demarcator to identify the new umbilical location. B. A narrow elliptical skin excision is performed which automatically expands because of normal skin tension. Care should be taken not to make this too large.
FIGURE 67.9. A 37-year-old, 128 lb female before and after lower body lift (A–H). Each pre-op image is shown adjacent to the corresponding post-op image taken 1 year later.
FIGURE 67.10. A 57-year-old, 172 lb female who underwent a significant weight loss with gastric bypass, shown before and after lower body lift (A–H). Each pre-op image is shown adjacent to the corresponding post-op image.
Medial thigh laxity can be addressed through either a proximal inner thigh lift or a vertical thigh lift procedure. The inner thigh lift addresses the laxity of the proximal medial thigh and is most useful in the normal weight individual with mild to moderate inner thigh laxity. This can occur with normal weight fluctuations during life or as sequelae of liposuction. This procedure places the incision in the pubic–thigh crease. Because of the specific anatomic restriction of the pubic area, the inner thigh lift has a high incidence of caudal scar migration. The scar tends to descend from the pubic–thigh crease because the pull is not balanced as in other body lifting procedures where equal tension is applied across the incision line. The inner thigh lift has limited impact on the shape and contour of the lower half of the thigh.
The vertical thigh lift is useful for massive weight loss patients with significant medial and circumferential thigh laxity. This procedure can be performed by itself or in combination with thigh liposuction. When performed with concurrent liposuction, intraoperative swelling may result in suboptimal correction. The final desired tightness of the thigh may be less than ideal and may require revision. The resection of tissue results in a vertical scar from the inner pubic area extending inferiorly and usually ending at the medial aspect of the knee. The exact length of the incision is ultimately based on patient preference and the amount of soft-tissue laxity and excess fat present. This procedure can be continued down below the knee if laxity is present and the patient desires full correction of the excess laxity. When crossing below the knee, the linear scar should be broken up to avoid a scar band contracture. The final scar below the knee tends to heal remarkably well.
The proximal inner thigh lift procedure was first proposed in the 1970s, but it lost popularity as a result of unsightly scars and vulvar disfigurement.9 With Lockwood’s description of the superficial fascial system (SFS) and specific attention to anchoring the SFS of the thigh tissue to immobile structures such as the pubic tubercle, ischio-pubic rami, and Cooper’s ligament, renewed attention to this procedure occurred.10,11 Modifications to limit the incision visibility posteriorly as well as incision migration caudally have improved outcomes and are responsible for the renewed popularity of this operation. This procedure still has significant limitations, however, with respect to the extent of medial thigh laxity correction. The inner thigh lift is designed ideally to address only the proximal medial thigh. Although a small amount of improvement can be seen in the distal medial thigh, at times to the knee, the effect is minor and not enough to market the procedure beyond its role as a proximal thigh lift. Because of moisture in the inner thigh crease area, an increased incidence of superficial wound dehiscence can be encountered in the postoperative period. This, as well as potential scar descent, should be discussed preoperatively.
The vertical thigh lift procedure is a much more useful and powerful tool in tightening and shaping the thighs compared with the inner thigh lift. This procedure can circumferentially tighten and address circumferential thigh laxity from the pubic area to and inferior to the knee . Although lower body lifting can improve the laxity of the anterior, lateral, and posterior thigh, it does not offer any improvement to the medial thigh.10 When significant thigh laxity exists, such as that seen following massive weight loss, the vertical thigh lift, alone or in combination with a lower body lift, can dramatically correct excessive laxity and provide improved shape and contour to the thigh. The vertical thigh lift is the thigh lift of choice for the majority of massive weight loss patients.
A patient who presents in consultation for a thigh lift procedure may be a candidate for either a thigh lift procedure alone, a lower body lift, liposuction alone, or any combination of these procedures. Dissatisfaction with the appearance of the buttocks, hips, and thighs is common and a more global discussion about excess fat, soft-tissue laxity, and scars associated with any potential surgery is required to identify the patients’ preferences. Patients who undergo the inner thigh lift should understand the limited benefits of this procedure and the potential adverse effects including caudal scar descent and vulvar distortion. Patients who undergo the vertical thigh lift should understand that a long and visible inner thigh incision will be present postoperatively. This has been very well tolerated in our patients.
The best candidates for an inner thigh lifting are those with isolated inner thigh laxity of the proximal thigh. This procedure usually benefits patients of normal weight and is useful in treating proximal medial thigh skin that has lost its elasticity due to weight fluctuations, changes with aging, or changes that occur following significant lifetime sun damage. The result that can be obtained with this operation can be demonstrated to the patient by lifting the inner thigh skin up into the pubic thigh crease in front of a full-length mirror. No lifting of the anterior thighs should be done because this demonstrates an unrealistic outcome. This will help the patient reasonably see what outcome can be expected.
The best candidates for undergoing a vertical thigh lift are those with circumferential thigh laxity. They may have concurrent excess fatty tissue amenable to liposuction which can be dealt with as a separate staged procedure or as a combined operation with the vertical thigh lift. The degree of correction can be demonstrated to the patient using a full-length mirror while the surgeon bimanually gathers thigh tissue medially, thereby tightening the skin of the thigh circumferentially.
Relative contraindications for either thigh lift procedure includes smoking, poorly controlled diabetes, malnutrition, and wound healing issues or immunodeficiency. Anticoagulants, lower extremity venous insufficiency, lymphedema, or a history of VTE also warrants careful consideration and may preclude these procedures.
Preoperative History and Preparation
Standard preoperative laboratory analysis is recommended. Massive weight loss patients undergoing a vertical thigh lift may require nutritional assessment if this has not been done previously or they have not already undergone a lower body lift. We do not routinely employ VTE chemoprophylaxis for patients undergoing a thigh lift unless their medical history indicate otherwise or they are having a concurrent lower body lift.
Inner Thigh Lift. The markings for the inner thigh lift are made by marking the pubic thigh (inguinal) crease. Posteriorly, the markings end before they become visible in posterior view. Anteriorly, the markings extend approximately to the level of the pubic tubercle. When performed in combination with lower body lifting, this incision will course along the mons and join the transverse abdominal incision (Figure 67.11). The amount of soft-tissue resection is estimated at this point but should rarely exceed 4 to 6 cm. Limiting the resection will significantly reduce the chance of scar descent postoperatively.
FIGURE 67.11. Inner thigh lift and concurrent lower body lifting resulting in the operation frequently referred to as a complete lower body lift. The inner thigh incision extends vertically up along the hair-bearing mons to join the transverse abdominal portion of the body lift incision.
General anesthesia is employed. The patient is placed in the supine position with the legs in the “frog leg” position. The incisions are infiltrated with lidocaine containing adrenaline. The incision is made into the dermis and then electrocautery is used to complete the incision into the subcutaneous tissue. Dissection is performed rather superficially: deep to the superficial fascia but not into the investing muscular fascia. Dissection is performed inferiorly to the level marked or until the redundant tissue has been undermined. At this point, the amount of skin and soft tissue to be removed is reevaluated, marked, and resected. The Freeman rake is used to retract the skin in the pubic thigh crease, and gauze dissection is used to identify Cooper’s ligament, the pubic tubercle, and the ischio-pubic rami. Additional inferior discontinuous undermining can be performed if indicated using the Lockwood dissector or a large liposuction cannula. This dissection, if performed, is done immediately on top of the investing muscle fascia deep to the superficial fascia. This additional dissection can be performed to the level of the knee. Closure is begun posteriorly with number 0 permanent or long-lasting absorbable sutures are placed in interrupted buried fashion strongly advancing the inferior skin flap anteriorly to avoid a posterior dog-ear. The most posterior sutures are placed into the fibrofatty tissues of the buttocks area. Sutures are placed incrementally approximately every 1 cm anchoring the thigh SFS. Sutures should be anchored such that tension on the sutures does not produce vulvar distortion. As the anchoring advances anteriorly, sutures are anchored from the SFS of the thigh flap to the periosteum of the ischio-pubic rami, pubic tubercle, and Cooper’s ligament. Tissue adjustment is performed as needed to minimize the formation of a dog-ear. Number 2-0 Vicryl or equivalent suture is used for deep dermal closure and can again advance the inferior thigh skin anteriorly and number 4-0 Monocryl or equivalent suture is used for running intracuticular as a final wound closure. The final closure is usually made waterproof with the use of cyanoacrylate tissue adhesive.
Vertical Thigh Lift. The markings for the vertical thigh lift begin at the insertion of the gracilis muscle in the pubic area. The vertical thigh lift incision extends to the inferior level of the deformity usually ending near the knee and may be shortened or extended based on the amount of laxity present and on patient preference (Figure 67.12). Bimanual palpation gathers the redundant tissue centered on the planned final location of the incision. The amount of laxity estimated is marked the entire length of the proposed final incision, usually from the groin crease to just above the knee. If there is a significant amount of fat present, the markings should take this into account to prevent excess tension on closure. Transverse realignment marks are made, which can facilitate accurate closure intraoperatively.
Under general anesthesia, a penetrating towel clip can be used to gather the redundant skin previously marked at multiple locations to verify that this amount of resection is appropriate. Markings are adjusted accordingly. Tumescent infiltration is performed. Additional tumescent infiltration is done if concurrent circumferential thigh liposuction is performed. If circumferential liposuction is planned, the posterior thigh liposuction is completed in the prone position. The patient is then turned supine for the remainder of the liposuction and the vertical thigh lift procedure.
In the planned resection area, a thorough and complete liposuction is performed first to remove virtually all of the subcutaneous fat. The goal is to remove most or all of the subcutaneous fat from the planned resection area, leaving behind only the skin and the subcutaneous neural, venous/lymphatic network. Liposuction should be performed thoroughly throughout the resection area and specifically beneath the incision markings to facilitate skin release from the underlying subcutaneous fat (Figure 67.13). A penetrating towel clip is again used for final verification that the amount of planned tissue resection is appropriate and not excessive. Often these marks have to be adjusted at this point somewhat inside the original markings.
The most proximal portion of the skin removal is strongly grasped and then using a folded towel as a stabilizer is avulsed from proximal to distal keeping all of the soft tissue connected to the underlying musculature. Caudal traction on the thigh skin results in a natural separation of the circumscribed thigh skin from the surrounding tissue (Figure 67.14). Facilitated by the liposuction performed at the beginning of the procedure, removal of the thigh tissue occurs with remarkable preservation of the venous and lymphatic network. Electrocautery is used to achieve meticulous hemostasis and the wound edges are promptly stapled together. This is done efficiently to allow the skin and soft-tissue approximation to be completed before excess swelling occurs, making closure more difficult. Closure is usually performed with 3-0 polydioxanone suture in the deep dermal layer and final intracuticular layer of number 4-0 Monocryl. Drains are used only when circumferential thigh liposuction and vertical thigh lifting are combined. The incisions are either glued with cyanoacrylate tissue adhesive or taped with multiple layers of paper tape that is split every 4 to 5 cm to allow for postoperative swelling.
FIGURE 67.12. Significant laxity of the thighs, knees, and calves. In these patients, the vertical thigh lift can be extended down below the knee. Care is taken to avoid a linear scar across the knee joint and this is where we place an anteriorly pointing notch. This notch allows for proper tension to be determined at the time of surgery and avoids the need for a Z-plasty or other modifications.
FIGURE 67.13. Pre-excision liposuction. During the vertical thigh lift, a complete evacuation of all subcutaneous tissue is performed with liposuction. This evacuation protects the important neural vascular structures and the release, at the proper level, of the overlying skin.
While still on the operating table, 4 inch wraps are used to wrap the feet from the base of the toes to the knees. Absorbent gauze is placed over the final incision lines and 6 inch wraps gently compress the thighs from the knee to the groin. Sequential compression devices are maintained throughout the first postoperative evening. Patients are encouraged to avoid standing or sitting but may ambulate for short periods. When not walking, we recommend the patients recline with the feet at a level higher than the heart.
We see the patients very soon postoperatively and frequently following surgery. Dressings are changed as needed and within 4 or 5 days the taping, when applied, is removed and scar cream containing silicone, mild steroid, and vitamin E is applied. Should a dehiscence occur, steri-strips are placed proximally and distally to prevent its propagation. Saline dressings are used until this wound is closed.
The inner thigh lifting is best suited for patients of normal weight who have experienced inner thigh laxity and dissent. Minimizing the incision so that it is not visible posteriorly and limiting the resection width to approximately 4 to 6 cm usually ensure an acceptable outcome. The medial aspect can be extended as needed and can be integrated into the abdominal incision when performed in combination with a lower body lift (Figure 67.15). The most common complication is dissent of the scar from the medial thigh crease (Figure 67.16).
FIGURE 67.14. Skin removal by avulsion. The proximal part of the skin to be removed is strongly grasped with a Kocher clamp. A lap sponge is placed to stabilize the remaining thigh tissue as the skin is avulsed from proximal to distal.
FIGURE 67.15. Inner thigh lift. A. Preoperative view. B. The final scar is in good position in the pubic thigh crease and easily concealed.
FIGURE 67.16. Scar descent after inner thigh lift. This can occur even if the amount of skin resection is not excessive and proper anchoring has been performed to the immobile structures of ischio-pubic rami, pubic tubercle, and Cooper’s ligament.
The vertical thigh lift is a completely separate entity and is reserved for patients who have experienced massive weight loss. For patients with complete weight loss, it is a completion procedure that eliminates laxity of the thighs from the groin to the knee. For patients with residual excess fat it can be performed as the second stage of a two-stage procedure or in combination with circumferential thigh liposuction. The incision length is determined by the clinical findings and patient request, but usually extends from the origin of the gracilis to the level of the knee. Thorough complete liposuction of the marked area for resection, frequent checking of the resection width to avoid over-resection, and skin avulsion from proximal to distal preserving the neurovascular and lymphatic structures ensure a predictable outcome. This procedure provides circumferential thigh tightening which is simply unachievable with other thighplasty methods (Figure 67.17). Apart from some issues of scar widening or suture line separation which respond to scar revision, the formation of a lymphocele in the region of the knee can occasionally be seen but is less common with the avulsion technique described. Treatment requires surgical exploration and space obliteration or secondary healing, followed by scar revision.
FIGURE 67.17. Vertical thigh lift after massive weight loss following gastric bypass (A–B). A. Preoperative view. B. Note the length of the incision. The notch at the level of the knee avoids a linear scar across this joint and possible scar contracture.
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