Outline

Excess skin and soft tissue of the thighs after massive weight loss (MWL) can present with varying degrees of severity. The classic medial thigh lift has considerable limitations in the postbariatric population, inspiring the quest for safer and more effective technical solutions. In this study, the circumferential thigh lift (CTL), and CTL with vertical extension, predicated on a theoretical and technical approach that improves safety and aesthetics in thighplasty after MWL, is described and evaluated. Nine patients were treated; all patients experienced MWL and all had previously undergone first-stage contouring with circumferential abdominal dermolipectomy. Patients were treated with a prone-to-supine approach with concomitant suction-assisted lipectomy (SAL). Lumbar and lateral thigh and infragluteal skin and fat were excised to the midaxillary lines and medial thigh meridians. Direct excision of anterolateral thigh skin was carried in a superficial plane into the medial thigh to confluence with the posterior excision. No direct undermining of any skin margin was performed. When soft-tissue excess is limited to the proximal third of the thigh, a horizontal excision pattern is used; with middle and lower one-third thigh excess, a vertical extension is employed. The medial superficial fascial system is anchored to the superficial perineal fascia. Data were reviewed retrospectively. In the 9 procedures performed, 3 achieved MWL by nonsurgical means, and 6 underwent bariatric surgery (bypass or band). Three patients were treated with CTL, and 6 with CTL with vertical extension. There were 3 seromas (33%) treated with percutaneous aspiration. There was 1 case of cellulitis (11%) treated successfully with in-office incision and drainage, and oral antibiotics. There were no hematomas, skin loss, wound dehiscences, lymphedema, or vulvar distortions. The circumferential excision of thigh excess without direct undermining allows for the maintenance of a rich blood supply to skin margins, and concomitant SAL improves thigh contour while providing discontinuous thigh undermining. Anchoring of the superficial fascial system to superficial perineal fascia reinforces the medial lift and prevents scar migration. CTL with or without vertical extension can be combined with SAL to maximize safety and aesthetic results after MWL.

Since its earliest description in 1957,1,2 thigh lift surgery has been performed for the removal and suspension of excess and ptotic soft tissues of the proximal lower extremities. Ideally suited to individuals with localized skin excess and minimal adiposity of the thighs, the medial thigh lift has historically yielded satisfactory results, although it has been somewhat reluctantly embraced by surgeons because of the potential for scar prominence and malposition, labial distortion, under-correction of dermal excess, and recurrent ptosis.3–8 Despite the attendant negative sequelae, there were nearly 12,000 thigh lifts performed in the United States in 2009 according to the American Society for Aesthetic Plastic Surgery,9 an increase of 307.5% since 1997. This dramatic increase in the frequency of thigh lift surgery can be attributed to the increasing incidence of obesity in the United States paired with the access to, and improvements in, bariatric surgery and an ever-growing massive weight loss (MWL) population.

While no longer in its infancy, body contouring after MWL is nevertheless a young subspecialty within plastic surgery that is maturing through the careful identification of heretofore uncommon anatomic and psychological challenges. Classic medial thigh lift surgery has considerable limitations in these patients. Excessive skin and soft tissue of the medial thigh after MWL is present almost uniformly, although it is rarely an isolated finding. Its association with abdominal, flank, and buttock excess, in addition to skin and fat excess in both vertical and horizontal dimensions, begs continued refinements of more classic thigh lift techniques.2,4,10–15 In this study, we present a theoretical and technical approach to thigh contouring after MWL that improves aesthetics and safety by treating not just the medial thigh but the entire thigh, maximizes perfusion to excision margins, minimizes the potential for labial splay and scar migration, allows for liberal concomitant suction lipectomy, and addresses both vertical and horizontal excess.

Nine patients were treated between July 2006 and November 2009 with follow-up ranging from 11 to 24 months (mean follow-up: 14 months). All patients had experienced MWL by bariatric surgery or by major lifestyle modifications including diet and exercise, were nonsmokers, and had reached a weight-loss “plateau” of a body mass index less than 30 and had sustained this level for a minimum of 9 months. All patients had previously undergone first-stage contouring with circumferential abdominal dermolipectomy. Patients were selected to include only ASA class I (no medical problems) and ASA class II (well-controlled thyroid disease or hypertension, with no pulmonary or cardiac disease).16 The data were reviewed retrospectively.

The skin is marked preoperatively in the standing, prone, and ultimately the supine position with lower extremities in abduction. Final assessments are made at this time with regard to the degree of horizontal excess and vertical excess, and the zones of the thigh in which the excess is most pronounced. Patients with excess limited to the proximal third of the thigh were marked for, and treated with, a circumferential thigh lift (CTL); where excess was more marked involving the middle and/or distal thirds of the thigh, circumferential thigh markings were supplemented with a perpendicular-intersecting vertical pattern within the inner thigh. A grid pattern is then marked to facilitate closure (Fig. 1). Superior and inferior circumferential incision lines are oriented to maintain the final suture line location at or below the anterior superior iliac spines and pelvic crest, progressing through the inguinal regions into the perineal-thigh creases, and posteriorly beneath the gluteal regions (Fig. 2), and in the meridian of the medial thigh from the perineal-thigh crease to the knee as indicated (Fig. 3).

Surgery was performed with the patients under general anesthesia in all cases using a prone-to-supine approach, and all were treated with concomitant suction-assisted lipectomy (SAL). Dorsally (with the patient in the prone position), liberal SAL is performed after the 1:1 instillation of lidocaine-free wetting solution consisting of 1 mL of epinephrine (1:1000) per liter of lactated ringers. No local anesthetic is added to the solution, removing the potential for lidocaine toxicity in these cases that are all performed under general anesthesia. Three- and 4-mm cannulas are used for the suction lipectomy. Lumbar, lateral thigh, and infragluteal skin and fat are excised to the midaxillary lines and medial thigh meridians, respectively.

No flap undermining is performed beyond the proposed margins of final excision. The superficial fascial system (SFS) is approximated with interrupted 0-polydioxanone suture, dorsal and lateral dermal approximation is completed, and the patient is replaced to the supine position.

Ventrally, liberal SAL of the medial and lateral thighs is performed. Direct excision of anterolateral thigh skin is carried through in a superficial plane into the medial thigh to confluence with the posterior excision. Meticulous superficial dissection, particularly in the region of the femoral triangle, is carried out to avoid injury to the lymph basin. No direct undermining of any skin margin is performed. When soft-tissue excess is limited to the proximal thigh, that is, when the excess is largely vertical in nature, a circumferential, horizontal excision pattern is used. With middle and/or lower third thigh excess, ie, when there is both vertical and substantial horizontal excess, a vertical extension is employed. Thigh abduction, flexion, and external rotation are dynamically simulated during the course of dissection and excision to confirm the appropriate removal of skin and soft-tissue excess. Incising the anterior limb first, only skin and fat to be removed are undermined and excised. The dissection planes in all cases are maintained superficially, above the SFS and saphenous vein. The medial SFS is then anchored to the superficial perineal fascia (Colles fascia) and periosteum of the ischiopubic ramus. This results in a linear closure in the perineal-thigh crease in the circumferential-only group, and a trifurcation closure in the form of a “T” with horizontal and vertical intersecting limbs in the circumferential approach with vertical extension. Closed suction drains are inserted in all patients.

In 9 patients with 9 procedures performed, 3 had achieved MWL by nonsurgical means, and 6 underwent bariatric surgery (bypass or band). All patients were female, and ranged in age from 27 to 56 years (mean: 38 years). Three patients were treated with CTL and 6 with CTL with vertical extension. There were 3 seromas (33%), each in the region of the vertical scar in the CTL with vertical extension group, treated successfully with percutaneous aspiration. There was 1 (11%) case of cellulitis, also in the vertical extension group, treated successfully with in-office incision and drainage and oral antibiotics, and 1 anterior thigh scar irregularity that was treated with in-office revision under local anesthesia. There were no hematomas, skin loss, wound dehiscences, lymphedema, or vulvar distortions. There were no cases of deep vein thrombosis or pulmonary embolism.

The prevalence of obesity in the United States is currently 32.2% among adult men and 35.5% among adult women,17,18 and there are nearly 180,000 bariatric surgical procedures performed each year.19 These staggering statistics are keeping with the increased number of patients who are seeking treatment for the sequelae of extreme and rapid weight loss. With the influx of patients with marked skin and soft-tissue excess and poor skin elasticity, plastic surgeons have been challenged to adapt the classic approaches to body contouring and to develop improved algorithms for the enhancement of both safety and cosmesis.

The classic medial thigh lift has little roll in the treatment of thigh excess after MWL. Although vertical excess with limited horizontal excess may be present, the majority of patients demonstrate redundancy and inelasticity in multiple vectors that demands the “chasing” of dog-ears that are facilitated by a broader approach to the thigh, inspiring the circumferential technique.

The treatment of medial thigh excess, before the current era of MWL morphology, has been fraught with potential problems related to scar migration, vulvar distortion, and recurrence.20 In his study, Lockwood 4–6 described the necessity of deep-tissue anchoring techniques to minimize complications and maximize the durability of results in thigh lifting. By the apposition of the SFS of the medial thigh caudal excision margin to the superficial perineal fascia, or Colles fascia,4 durable scar maintenance within the perineal-thigh crease is facilitated. In thigh lift after MWL, this technical maneuver is of paramount importance whenever there is any form of horizontally oriented correction of vertical excess maintained within the perineal-thigh crease, and is a cornerstone of the procedure described herein.

The CTL is predicated not only on anchoring of the medial thigh to the superficial perineal fascia and ischiopubic ramus, but also on further distributing the tension of the entire distal thigh margin across the medial, anterior, and lateral aspects of the superior incision lines at the SFS. Baroudi, and Baroudi and Ferreira 21,22 described variations on an inner thigh lift with “flankplasty” that allowed for more aesthetic contouring of the entire thigh, flank, and buttock regions, and Sozer et al 23 described a similar procedure with an extended “flankplasty” and buttock lift for “guitar-shaped” body-contour deformities.

All of the patients in this series experienced MWL and were treated with a circumferential dermolipectomy, or lower body lift (LBL), as a separate procedure prior to formal thigh lift. Whereas there is little effect of a LBL on the medial thigh, we have seen substantial improvements in the anterior and lateral thigh and buttock regions, and consider the LBL the “foundation” of the thigh lift. The preexisting incision serves as a long line for deep anchoring and tension distribution, alleviating the burden borne by Colles fascia and the groin anchor points. Additionally, after the resolution of edema following the initial LBL procedure, any residual inelastic skin and soft-tissue redundancy can be definitively tailored.

Dissection is always undertaken above the SFS planes in efforts to protect the femoral triangle lymphatics and the saphenous vein.24 There has been no development of lymphedema or prolonged swelling in any patient in our experience. Any excessive subfascial adiposity is treated with SAL. SAL aids in aesthetic contouring of the thigh, as well as in decompressing the turgor of the thigh that may remain after MWL. Liberal suction can be safely undertaken as no flap undermining whatsoever is performed; the excisions are direct. With reference to the trifurcation point (the “T” junction) in the medial thigh at the confluence of the vertical and horizontal components with the vertical extension, as there is no undermining, incision line healing has been uniformly excellent, and there have been no cases of marginal necrosis or wound dehiscence (Fig. 4).

The complications have been minor in nature, and we have experienced seroma formation frequently. All cases were in the vertical extension group. Mean closed-suction drain time was 8 days, and compression garments were applied after drain removal. All were successfully managed with office-based aspirations.

Maintaining a body mass index below 30, nicotine avoidance, and regular exercise are strict prerequisites. With elective thigh contouring, and with all contouring after MWL in our experience, this type of preoperative optimization is critical. We have not routinely used anticoagulation in these patients. In addition to intraoperative antiembolic compression sleeves, we adhere to a strict protocol of early mobilization and ambulation postoperatively. There have been no thromboembolic complications of any kind in these patients.

With the CTL, we have found very pleasing cosmetic results and a very high level of patient satisfaction. By addressing the entire thigh as an aesthetic unit, rather than myopically focusing on the medial thigh alone, not only is safety maximized but aesthetic outcomes are also enhanced.

The circumferential excision of thigh excess without direct undermining allows for the maintenance of a rich blood supply to skin margins, and concomitant SAL improves thigh contour while providing discontinuous thigh undermining. Anchoring of the SFS to superficial perineal fascia and ischiopubic ramus reinforces the medial lift and prevents scar migration. CTL with or without vertical extension can be combined with SAL to maximize safety and aesthetic results after MWL.

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Key Words: thigh lift; circumferential thigh lift; thighplasty; medial thigh lift; liposuction; body contouring; massive weight loss