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Inner Thigh Reduction
Surgical Preparation and Technique
291
39
Inner Thigh Reduction: Reshaping Using a Two-Way Vector Technique Marcelo Alejandro Cuadrado, MD
The Clinical Problem (Fig. 39.1) The lower extremities, and especially the thighs, are one of the most typical surgery consultations in Argentina. Most patients with massive weight loss desire a better-looking shape of the thighs because they look deflated and have poor skin tone. Deformities in the thigh region vary according to age, degree of skin laxity, and distribution of adipose tissue. Patient dissatisfaction with surgery can be associated with poor wound healing, seroma, inguinal scar migration, and poor contouring requiring revisional surgery. The surgeon’s major challenge is how to restore the skin and redistribute the fat in the upper inner thigh to good effect. Inner thigh laxity can be classified according to the vectors of tissue ptosis in the inner thigh.
Surgical Preparation and Technique Surgical assessment of the thigh involves understanding the ideal anatomic shape, ideal skin envelope, and ideal fat distribution. The inner thighs ideally have the shape of an inverted cone, wider proximally and narrowing gradually toward the knees. This inverted cone appearance is affected by thigh skin laxity and adipose tissue under the influence of gravity (Fig. 39.2). The thigh can be anatomically divided into three zones (Fig. 39.3)—inguinal zone, medial inner thigh, and upper knee section.
Objectives in Inner Thigh Reduction ■ ■ ■ ■
Improvement of contour in medial thigh section Adequate resection to improve skin tension Predictable scar placement Decrease complication rate
Preoperative Evaluation Evaluate skin laxity and lipodystrophy in different areas. Note placement of the inguinal and medial scars. Ask about the presence of lymphedema or vascular disease and history of deep vein thrombosis. Typical patients for an inner thigh reduction show postbariatric deflation. There is skin laxity in patients, who are typically 30 to 60 years of age. They are not concerned about scars but complain about the bulky area in their inner middle thigh.
Planning Inner Thigh Reduction Patients will have mild to severe skin laxity and fat in different areas. Care must be taken for patients with inguinal scars. Avoid patients with an BMI more than 34 and those who are heavy smokers. Avoid patients with massive localized lymphedema. Critical decisions in inner thigh reduction include the following: • How much skin and fat should be removed? • Is liposuction in other areas required first or should it be delayed? • Where should the scars be placed?
Technique SKIN LAXITY Use the pinch test, and determine skin laxity with the patient in standing position. Assess potential elevation of the horizontal (subinguinal) vector. Determine if the need for excision reaches or passes the knee.
SCAR PLACEMENT The inguinal scar should be placed in the inguinal crease. The vertical incision should not be too anterior or posterior. With 291
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CHAPTER 39 • Inner
Thigh Reduction: Reshaping Using a Two-Way Vector Technique
the patient in standing position, there should be no visible scars.
USE OF LIPOSUCTION It should be used only in areas that will not be excised. Lipocutaneous undermining helps advance skin flaps at closure. Try to stage this with other procedure, such as abdominoplasty.
FACTORS TO CONSIDER IN INNER THIGH REDUCTION The amount of skin resection is often smaller than that which was originally thought. No undermining reduces complications.
With longer surgery time, there will be more swelling and more tension in closure. The patient should be given information about postoperative complication.
Case 39.1 A 52-year-old woman had MWL after bariatric surgery. She had a good result in the lateral thigh from circumferential body lift surgery (Fig. 39.4). The patient complains about inner thigh bulk and the poor skin quality in the thigh.
Clinical Approach The patient had skin and fat in the subinguinal region. The medial inner thigh extension is higher than one-third; there is a good shape of the knee region.
Considerations
FIGURE 39.1 The clinical problem.
These patients are in a grey zone because of average skin quality and mild adipose tissue and ptosis. Liposuction only in this area will not allow the skin to reshape because of skin quality; it could worsen the contour, which would be likely to require skin resection at a later stage. Trying to be more conservative by leaving a short inguinal scar will not improve the overall deformity, only the inguinal region, which would leave the medial inner thigh with the same unsatisfactory contour. Vertical resection only is a good option but there will be limited contour improvement in the inguinal area. The subinguinal zone has a bulky fat zone and skin laxity in a downward vector. Also, the vertical extension of the deformity does not reach the knee so the predicted vertical scar extension must be short. Planning includes anchoring the subfascial-inguinal flap to the pubic ligament (Colles ligament) and a vertical resection to reduce skin laxity.
• Inverted cone • Fat • Skin
FIGURE 39.2 The ideal inverted cone shape of the thigh.
Surgical Preparation and Technique
293
Thigh zones
• Inguinal zone blue
• Middle inner thigh purple
• Upper knee section red
FIGURE 39.3 The three zones of the thigh.
A
B
FIGURE 39.4 Case study. (A) Preoperative and (B) postoperative views after circumferential body lift surgery.
Marking (Video 39.1) Markings should be with the patient in supine and standing positions for safer scar placement. Pinch dynamic markings are used; the excision should be less than the original mark by 1 to 1.5 cm to avoid over-resection. Horizontal excess must be anchored to the Colles fascia 2 cm above the inguinal crease, so the skin excision in the inguinal region should be 2 cm less than the pinch. This type of anchoring is strong, and the horizontal flap could be suspended by the superficial fascia using nonabsorbable sutures. Fig. 39.5 shows markings for the
skin pinch test. The incision marks are less than original pinch.
Operative Technique and Postoperative Management (Video 39.2) Compression garments should be applied postoperatively and the patient encouraged to participate in early ambulation. Silicone drains should be left until the output is 25 mL/day.
Results Figs. 39.6 and 39.7 show the results from an inner thigh lift up to 3 years postoperatively.
CHAPTER 39 • Inner
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Thigh Reduction: Reshaping Using a Two-Way Vector Technique
FIGURE 39.5 Pinch test skin markings.
A
C
B
FIGURE 39.6 Anterior views showing preoperative (A) and 2-month (B) and 3-year (C) postoperative results of an inner thigh lift.
Conclusions
A
295
B
FIGURE 39.7 Inner thigh view preoperatively (A) and 3 years postoperatively (B) showing scar placement.
Superficial Fascia Anchoring and Vertical Resection: Two-Way Vector Technique
TIPS FOR THE INGUINAL ANCHORING Marking above and under the inguinal crease will place the scar right in the medial crease. Do not over-resect. Suspension of the thigh has to be 2 or 3 cm above the crease to reach the Colles ligament, so marks should be 2 cm less than original pinch suspension marks. Use polypropylene sutures for anchoring in an X fashion to relax tension in the superficial fascia.
TIPS FOR VERTICAL RESECTION The vertical scar should be planned right in the medial axis of the thigh. Be conservative in patients with mild skin laxity and larger amount of adipose tissue. Dissection should be just above the superficial fascia. Deeper sutures with absorbable sutures in the fascia relax skin tension. If the excess reaches the knee, curve the incision.
Possible Complications These include dehiscence of the inverted T, resuturing and sometimes resection and suturing, alterations in the vulva by over-resection, infection, hematoma, flap necrosis, and lymphocele.
Summary Many operative techniques are described for inner thigh reduction, but none is ideal. It is critical to make a good diagnosis for each patient because the skin and adipose tissue are different. The surgical decision to improve contour will also vary. Accepting a long scar over the thigh is important, and the scar is better placed in a nonvisual position. The fascial anchoring and vertical resection technique is a good technique for select patients because it corrects the medium
and inner thigh regions. This approach has been used in my practice to improve contour and smooth the skin in different patients because of the dynamic marking variations. The use of liposuction in my practice is only for treatment of knee fat or lateral thigh fat, with a different incision to prevent postoperative swelling. However, I recommend the use of only a vertical resection in patients in whom inguinal excess is poor.
Conclusions With a comprehensive diagnosis, patient classification, dynamic markings, and postoperative patient management, the inner thigh lift has evolved from a simple inguinal resection to a multiple vector correction. It provides a good contour and skin tension, and results are consistent over time. However, it is important to be conservative and not to over-resect. Proper planning and marking are critical. Take care of patients’ postoperative management, and be alert for complications. Advise the patient the possible need for a dog ear revision after swelling.
Further Reading Aly, A., Cram, A., 2006. Body Contouring After Massive Weight Loss. Quality Medical Publishing. Missouri. 386p. Cram, A., Aly, A., 2008. Thigh reduction in the massive weight loss patient. Clin. Plast. Surg. 35, 165–172. Grazier, F.M., 1996. Body contouring: introduction. Clin. Plast. Surg. 23, 511–528. Le Louarn, C., Pascal, J.F., 2004. The concentric medial thigh lift. Aesthetic Plast. Surg. 28, 20–23. Lockwood, T.E., 1991. Superficial fascial system (SFS) of the trunk and extremities: a new concept. Plast. Reconstr. Surg. 87, 1009–1018. Song, A.Y., O’Toole, J.P., Jean, R.D., et al., 2006. A classification of contour deformities after massive weight loss: application of the Pittsburgh rating scale. Semin Plast Surg. 20, 24–29.
291
39
Inner Thigh Reduction: Reshaping Using a Two-Way Vector Technique Marcelo Alejandro Cuadrado, MD
The Clinical Problem (Fig. 39.1) The lower extremities, and especially the thighs, are one of the most typical surgery consultations in Argentina. Most patients with massive weight loss desire a better-looking shape of the thighs because they look deflated and have poor skin tone. Deformities in the thigh region vary according to age, degree of skin laxity, and distribution of adipose tissue. Patient dissatisfaction with surgery can be associated with poor wound healing, seroma, inguinal scar migration, and poor contouring requiring revisional surgery. The surgeon’s major challenge is how to restore the skin and redistribute the fat in the upper inner thigh to good effect. Inner thigh laxity can be classified according to the vectors of tissue ptosis in the inner thigh.
Surgical Preparation and Technique Surgical assessment of the thigh involves understanding the ideal anatomic shape, ideal skin envelope, and ideal fat distribution. The inner thighs ideally have the shape of an inverted cone, wider proximally and narrowing gradually toward the knees. This inverted cone appearance is affected by thigh skin laxity and adipose tissue under the influence of gravity (Fig. 39.2). The thigh can be anatomically divided into three zones (Fig. 39.3)—inguinal zone, medial inner thigh, and upper knee section.
Objectives in Inner Thigh Reduction ■ ■ ■ ■
Improvement of contour in medial thigh section Adequate resection to improve skin tension Predictable scar placement Decrease complication rate
Preoperative Evaluation Evaluate skin laxity and lipodystrophy in different areas. Note placement of the inguinal and medial scars. Ask about the presence of lymphedema or vascular disease and history of deep vein thrombosis. Typical patients for an inner thigh reduction show postbariatric deflation. There is skin laxity in patients, who are typically 30 to 60 years of age. They are not concerned about scars but complain about the bulky area in their inner middle thigh.
Planning Inner Thigh Reduction Patients will have mild to severe skin laxity and fat in different areas. Care must be taken for patients with inguinal scars. Avoid patients with an BMI more than 34 and those who are heavy smokers. Avoid patients with massive localized lymphedema. Critical decisions in inner thigh reduction include the following: • How much skin and fat should be removed? • Is liposuction in other areas required first or should it be delayed? • Where should the scars be placed?
Technique SKIN LAXITY Use the pinch test, and determine skin laxity with the patient in standing position. Assess potential elevation of the horizontal (subinguinal) vector. Determine if the need for excision reaches or passes the knee.
SCAR PLACEMENT The inguinal scar should be placed in the inguinal crease. The vertical incision should not be too anterior or posterior. With 291
292
CHAPTER 39 • Inner
Thigh Reduction: Reshaping Using a Two-Way Vector Technique
the patient in standing position, there should be no visible scars.
USE OF LIPOSUCTION It should be used only in areas that will not be excised. Lipocutaneous undermining helps advance skin flaps at closure. Try to stage this with other procedure, such as abdominoplasty.
FACTORS TO CONSIDER IN INNER THIGH REDUCTION The amount of skin resection is often smaller than that which was originally thought. No undermining reduces complications.
With longer surgery time, there will be more swelling and more tension in closure. The patient should be given information about postoperative complication.
Case 39.1 A 52-year-old woman had MWL after bariatric surgery. She had a good result in the lateral thigh from circumferential body lift surgery (Fig. 39.4). The patient complains about inner thigh bulk and the poor skin quality in the thigh.
Clinical Approach The patient had skin and fat in the subinguinal region. The medial inner thigh extension is higher than one-third; there is a good shape of the knee region.
Considerations
FIGURE 39.1 The clinical problem.
These patients are in a grey zone because of average skin quality and mild adipose tissue and ptosis. Liposuction only in this area will not allow the skin to reshape because of skin quality; it could worsen the contour, which would be likely to require skin resection at a later stage. Trying to be more conservative by leaving a short inguinal scar will not improve the overall deformity, only the inguinal region, which would leave the medial inner thigh with the same unsatisfactory contour. Vertical resection only is a good option but there will be limited contour improvement in the inguinal area. The subinguinal zone has a bulky fat zone and skin laxity in a downward vector. Also, the vertical extension of the deformity does not reach the knee so the predicted vertical scar extension must be short. Planning includes anchoring the subfascial-inguinal flap to the pubic ligament (Colles ligament) and a vertical resection to reduce skin laxity.
• Inverted cone • Fat • Skin
FIGURE 39.2 The ideal inverted cone shape of the thigh.
Surgical Preparation and Technique
293
Thigh zones
• Inguinal zone blue
• Middle inner thigh purple
• Upper knee section red
FIGURE 39.3 The three zones of the thigh.
A
B
FIGURE 39.4 Case study. (A) Preoperative and (B) postoperative views after circumferential body lift surgery.
Marking (Video 39.1) Markings should be with the patient in supine and standing positions for safer scar placement. Pinch dynamic markings are used; the excision should be less than the original mark by 1 to 1.5 cm to avoid over-resection. Horizontal excess must be anchored to the Colles fascia 2 cm above the inguinal crease, so the skin excision in the inguinal region should be 2 cm less than the pinch. This type of anchoring is strong, and the horizontal flap could be suspended by the superficial fascia using nonabsorbable sutures. Fig. 39.5 shows markings for the
skin pinch test. The incision marks are less than original pinch.
Operative Technique and Postoperative Management (Video 39.2) Compression garments should be applied postoperatively and the patient encouraged to participate in early ambulation. Silicone drains should be left until the output is 25 mL/day.
Results Figs. 39.6 and 39.7 show the results from an inner thigh lift up to 3 years postoperatively.
CHAPTER 39 • Inner
294
Thigh Reduction: Reshaping Using a Two-Way Vector Technique
FIGURE 39.5 Pinch test skin markings.
A
C
B
FIGURE 39.6 Anterior views showing preoperative (A) and 2-month (B) and 3-year (C) postoperative results of an inner thigh lift.
Conclusions
A
295
B
FIGURE 39.7 Inner thigh view preoperatively (A) and 3 years postoperatively (B) showing scar placement.
Superficial Fascia Anchoring and Vertical Resection: Two-Way Vector Technique
TIPS FOR THE INGUINAL ANCHORING Marking above and under the inguinal crease will place the scar right in the medial crease. Do not over-resect. Suspension of the thigh has to be 2 or 3 cm above the crease to reach the Colles ligament, so marks should be 2 cm less than original pinch suspension marks. Use polypropylene sutures for anchoring in an X fashion to relax tension in the superficial fascia.
TIPS FOR VERTICAL RESECTION The vertical scar should be planned right in the medial axis of the thigh. Be conservative in patients with mild skin laxity and larger amount of adipose tissue. Dissection should be just above the superficial fascia. Deeper sutures with absorbable sutures in the fascia relax skin tension. If the excess reaches the knee, curve the incision.
Possible Complications These include dehiscence of the inverted T, resuturing and sometimes resection and suturing, alterations in the vulva by over-resection, infection, hematoma, flap necrosis, and lymphocele.
Summary Many operative techniques are described for inner thigh reduction, but none is ideal. It is critical to make a good diagnosis for each patient because the skin and adipose tissue are different. The surgical decision to improve contour will also vary. Accepting a long scar over the thigh is important, and the scar is better placed in a nonvisual position. The fascial anchoring and vertical resection technique is a good technique for select patients because it corrects the medium
and inner thigh regions. This approach has been used in my practice to improve contour and smooth the skin in different patients because of the dynamic marking variations. The use of liposuction in my practice is only for treatment of knee fat or lateral thigh fat, with a different incision to prevent postoperative swelling. However, I recommend the use of only a vertical resection in patients in whom inguinal excess is poor.
Conclusions With a comprehensive diagnosis, patient classification, dynamic markings, and postoperative patient management, the inner thigh lift has evolved from a simple inguinal resection to a multiple vector correction. It provides a good contour and skin tension, and results are consistent over time. However, it is important to be conservative and not to over-resect. Proper planning and marking are critical. Take care of patients’ postoperative management, and be alert for complications. Advise the patient the possible need for a dog ear revision after swelling.
Further Reading Aly, A., Cram, A., 2006. Body Contouring After Massive Weight Loss. Quality Medical Publishing. Missouri. 386p. Cram, A., Aly, A., 2008. Thigh reduction in the massive weight loss patient. Clin. Plast. Surg. 35, 165–172. Grazier, F.M., 1996. Body contouring: introduction. Clin. Plast. Surg. 23, 511–528. Le Louarn, C., Pascal, J.F., 2004. The concentric medial thigh lift. Aesthetic Plast. Surg. 28, 20–23. Lockwood, T.E., 1991. Superficial fascial system (SFS) of the trunk and extremities: a new concept. Plast. Reconstr. Surg. 87, 1009–1018. Song, A.Y., O’Toole, J.P., Jean, R.D., et al., 2006. A classification of contour deformities after massive weight loss: application of the Pittsburgh rating scale. Semin Plast Surg. 20, 24–29.