- Email: [email protected]
Medial thighplasty: Current concepts and practices
Annales de chirurgie plastique esthétique (2016) 61, e1—e7
Available online at
ScienceDirect www.sciencedirect.com
GENERAL REVIEW
Medial thighplasty: Current concepts and practices Le lifting de face interne de cuisse : ´evolution des pratiques N. Bertheuil a,*,b,c,d, R. Carloni a, A. De Runz f, C. Herlin g, P. Girard a, E. Watier a, B. Chaput d,e a
Department of plastic, reconstructive and aesthetic surgery, hospital Sud, university of Rennes 1, 16, boulevard de Bulgarie, 35200 Rennes, France b Inserm U917, university of Rennes 1, CS 34 317, 35043 Rennes cedex, France c SITI Laboratory, ´Etablissement franc¸ais du sang Bretagne, Rennes university hospital, 35000 Rennes, France d STROMAlab, UMR5273 CNRS/UPS/EFS, Inserm U1031, Rangueil hospital, BP 84 225, 31432 Toulouse cedex 4, France e Department of plastic, reconstructive and aesthetic surgery, Rangueil hospital, Paul-Sabatier university, 31059 Toulouse cedex 9, France f Department of maxillofacial, plastic, reconstructive and cosmetic surgery, Nancy university hospital, university of Lorraine, 54000 Nancy, France g ˆ pital Lapeyronie, Montpellier university hospital, 34295 Department of plastic surgery and burn surgery, ho Montpellier cedex 5, France Received 27 July 2015; accepted 30 August 2015
KEYWORDS Medial thighplasty; Medial thigh lift; Body contouring; Obesity; Post-bariatric surgery
Summary Medial thighplasty, also known as medial thigh lift, is a procedure that has been carried out for five decades. The original ‘‘Lewis’’ technique has undergone many changes, and thereby been rendered widely available to plastic surgeons. Given the increasingly high number of surgical reconstructions after massive weight loss, this technique is now an integral part of a surgeon’s therapeutic arsenal as he strives to meet the evolving demands of patients. The objective of this article, which is based on a comprehensive review of the literature, is to summarize current knowledge on medial thighplasty and thereby allow plastic surgeons to adopt the operating technique best suited to the deformations presented by their patients and to the overall context. The different techniques, outcomes and complications are successively discussed. # 2015 Elsevier Masson SAS. All rights reserved.
* Corresponding author. E-mail address: [email protected] (N. Bertheuil). http://dx.doi.org/10.1016/j.anplas.2015.08.006 0294-1260/# 2015 Elsevier Masson SAS. All rights reserved.
e2
MOTS CLÉS Lifting de face interne de cuisse ; Cruroplastie ; Obésité ; Chirurgie des séquelles d’amaigrissement ; Chirurgie post-bariatrique
N. Bertheuil et al. Re ´sume ´ Le lifting de face interne de cuisse est une intervention pratiquée depuis cinq décennies. La technique originelle a bénéficié de nombreuses évolutions permettant sa démocratisation auprès des chirurgiens plasticiens. Avec l’afflux des reconstructions après perte de poids massive, cette technique fait désormais partie de l’arsenal thérapeutique indispensable d’un chirurgien, afin de répondre au mieux aux demandes des patients. Au travers d’une revue exhaustive de la littérature, l’objectif de cet article est de faire la synthèse des connaissances actuelles en matière de lifting de face interne de cuisse de façon à permettre aux chirurgiens plasticiens de choisir la technique opératoire la mieux adaptée à la déformation présentée par leurs patients et au terrain. Les différentes techniques, les résultats et les complications y sont successivement abordés. # 2015 Elsevier Masson SAS. Tous droits réservés.
Introduction The medial thigh lift initially described by Lewis in 1957 [1,2] was first designed to favor rejuvenation of the thighs. In this part of the body, increased cutaneous slackness is one of the first signs associated with observable aging, and localized fat deposits are often secondarily associated. With regard to obesity and its sequels, the chronology is reversed; at first weight gain is accompanied by fat deposits, and ensuing cutaneous slackness is secondary to significant weight loss. This procedure, which is often unpopular with surgeons on account of frequent postoperative complications, is aimed at correcting the cutaneous and fat excess in the inner thigh. Since the first description, numerous improvements of the surgical technique have heightened outcome predictability and lowered the rate of postoperative complications. One of these techniques consists in anchoring the superficial fascia to Colles’ fascia [3], leading to reduction of postoperative cutaneous ptosis and limiting the risks of vulvar widening. Another adjunctive technique consists in liposuction, which helps to reduce postoperative seromas and lymphoedemas [4]. At present, in addition to primary indications, we are called upon to treat patients presenting with massive weight loss entailing major cutaneous slackness. Their condition is closely connected with the increasing incidence of obesity in Western countries. This new pathology of the 21st century is associated over the medium to long term with multiple medical complications including cardiovascular diseases, high blood pressure, dyslipidemias, diabetes, arthrosis and some forms of cancer as well as sleep apnea [5—8]. The etiology of obesity is multifactoral, and it often results from the association of several determinants: genetic predisposition, environmental factors, behavioral factors and socioeconomic conditions [9—13]. Obesity leads to daily difficulties in dressing, in bodily hygiene, in walking and in sports activities as well as intimate relationships. It can also be responsible for serious psychological problems such as a loss of self-esteem possibly leading to a depressive syndrome with an impact on quality of life. Bariatric surgery has developed as a response to this pandemic. It is indicated for patients presenting with a body mass index (BMI) exceeding 40 (or in the case of associated comorbidities, exceeding 35). Operations inducing massive and relatively rapid weight loss tend to entail major cutaneous
excess and weakening, particularly in terms of tonicity of the skin [14]. Several surgical reconstruction procedures are frequently necessary, including treatment of the thighs by means of medial thigh lift, which is also known as crural plastic surgery or crural dermolipectomy. However, when it is a question of the major deformities induced by massive weight loss, the original horizontal scar technique may turn out to be insufficient, and consequently need to be either converted into or associated with vertical scar techniques. The objective of this article is to provide an overall summary on the data from the literature concerning the indications and the different operative techniques applied in medial thigh lift; we also wish to better understand the associated outcomes in terms of morbidity and quality of life.
Materials and methods A systematic review of the literature has been carried out so as to assess medial thighplasty: the indications, the operative techniques and the outcomes. Our April 2015 investigation in the MEDLINE database via pubmed was launched using the following keywords: ‘‘medial thighplasty’’ OR ‘‘medial thigh lift’’ OR ‘‘thighplasty’’ OR ‘‘thigh lift’’. The bibliography composed of the collected articles was also examined in view of discovering relevant published texts. The title; the abstract and the complete text of the recovered articles were all analyzed; and a synthesis of the relevant texts was drawn up so as to provide summarized information on the latest surgical advances in medial thigh lift. Selection criteria: The original articles based on patients having undergone a medial thigh lift up until April 2015 were analyzed. Prospective and retrospective observational studies as well as clinical cases were included. Articles written in a language other than English or French were excluded. All articles describing techniques between abdominal dermolipectomy and medial thigh lift were likewise excluded, as were those using information drawn from other studies without original data. Data collection: Detailed and critical reading of each selected article was carried out in view of obtaining accurate information pertaining to: authors, date of publication, study site, type of article and level of evidence, number of patients, indication, surgical technique, complications
Medial thighplasty: Current concepts and practices such as the number of reoperations, and the therapeutic perspectives suggested by the authors. The studies and data were listed via Microsoft Excel1 2011 (Microsoft, Redmond, WA, USA).
Results Out of the 311 articles found in the search engine, 20 were selected and analyzed to provide an overview of the latest data in the literature on the indications and the different operative techniques applied in medial thighplasty and to understand the associated outcomes in terms of morbidity and quality of life.
Indications The techniques were addressed to patients presenting cutaneous slackness that was associated to some degree with excess fat deposits located in the medial side of the thigh. Two types of patients were distinguished: patients presenting with cutaneous ptosis related to aging and predominating in the upper third of the thigh. These deformities are corrected by the classical horizontal scar technique, for example in the inguinal fold (Lockwood’s original anchoring technique [3]); patients having presented with massive weight loss following a diet or bariatric surgery and presenting with staged deformities at locations ranging from cutaneous and fat excess of the upper third of the thigh to excess on the thigh in its entirety. These types of patients, whose numbers have been increasing concurrently with the development of bariatric surgery techniques, present new problems with regard to reconstruction. More precisely, in addition to the classical technique, which does not always yield satisfactory correction of cutaneous excess, we may be obliged to employ vertical scar techniques.
e3
Surgical technique Horizontal scar [1—4,15] The original technique initially described by Lewis [1,2] was unpopular with plastic surgeons on account of disappointing long-term results, which were largely due to scar migration and to recurring cutaneous ptosis (Fig. 1A and B). In 1988, Lockwood appreciably reduced these unintended consequences by means of improved anatomical knowledge and description of the ‘‘superficial fascial system’’ [16,17], with a direct application to the medial thigh [3]. Up until 2004, at which time Le Louarn [4] was the first author to describe the interest of initial suprafascial and subfascial liposuction in a cutaneous resection area with cutaneous resection just under the dermis, all of the techniques involved removal of tissues by full thickness excision. On the contrary, the procedure described by Le Louarn allowed for conservation of the connective tissue containing not only the blood vessels but also the lymph vessels, thereby reducing the risk of postoperative seroma and lymphoedema. As of now, most authors apply this technique, which consists in cutaneous resection design evaluated by the ‘‘pinch test’’ and peroperatively adjusted so as to produce closure without tension. Liposuction is carried out subfascially throughout the inner thigh and suprafascially in the resection pattern. The operation is concluded by cutaneous resection under the dermis, fixation of anchor points at Colles’ fascia and finally closure on several surgical plans (Fig. 2). This technique corrects the upper third of the thigh with a sizable vertical vector. Vertical scar (massive weight loss patient) [18—21] These techniques are increasingly necessary for patients presenting with massive weight loss and cutaneous and fat excess extending beyond the junction of the upper and middle thirds of the thigh. In this type of case, the horizontal scar technique only rarely yields sufficiently satisfactory results (Fig. 1C to H). Two main variants exist, characterized by either a T-like vertical scar or an inverted J (Fig. 3).
Figure 1 Summary of the different surgical approaches. A. Cutaneous resection design for the horizontal scar technique. B. Potential scarring in the horizontal scar technique. C. Cutaneous resection design for the vertical technique in inverted J. D. Potential scarring in the J technique. E. Cutaneous resection design for the vertical technique in T. F. Potential scarring in the T technique. G. Cutaneous resection design for spiral lift. B. Potential scarring in spiral lift.
e4
N. Bertheuil et al.
Figure 2 Perioperative view of the horizontal technique. A. Preoperative design. B. Liposuction above and below the fascia in the cutaneous pattern. C. Anchoring of Colles’ fascia by non-absorbable stitch. D. Final result at end of procedure.
Figure 3 Perioperative view of the inverted J vertical technique. A. Preoperative design. B. View after liposuction and cutaneous resection just under the dermis; the venous structures, including the saphenous, are conserved. C. Start of surgical closure. D. Final result at end of procedure.
Medial thighplasty: Current concepts and practices While these techniques exhibit less pronounced vertical correction than in the primary description, on the contrary they have a horizontal correction vector that is indispensable for numerous patients coming to the end of a period of massive weight loss [21]. The liposuction procedure that removes fat from the internal hemi-circumference of the thigh can be carried out either during the same procedure or during another intervention, usually 6 months subsequent to thigh lift [19,22]. When the authors thereby proceeding by two stages carry out fullthickness cutaneous resection, it is so as to diminish the risk of lymphoedema that they conserve the great saphenous vein [19]. When, on the contrary, the operation is performed in a single stage, it is necessary to undertake extensive suprafascial liposuction up to the top of the thigh so as to avoid injury to the saphenous vein and the lymphatic network [18]. Indeed, a recent anatomical study showed that the lymphatic vessels are present not only in subfascial fat, but also in the deep layer of superficial fat [23]. In all cases, cutaneous resection takes place perioperatively, and closure is tension-free, were this not to happen, the risk of scar widening and wound dehiscence would increase. Hybrid technique for thigh and buttocks lift (spiral lift) [24,25] These techniques comprise medial thigh lift in which vertical or horizontal scar technique is associated with cutaneous resection that is prolonged in the crural arcade and then in the back, the objective being to simultaneously carry out a buttock lift (Fig. 1G and H).
Complications While serious complications are fortunately rare, this surgery entails numerous minor complications of which patients should be forewarned during preliminary consultation. While the most serious complications, which are thromboembolic events (deep vein thrombosis and pulmonary embolism) are rarely encountered < 1% [15,19,26—28], skin necrosis are present in as many as 5% of cases [15], and their occurrence is favored by undermining of subcutaneous tissue and, more particularly, by repeated operations [29]. And even though hemorrhages and hematomas have seldom been reported in the literature, their incidence may be as high as 6% [19,27]. Other minor complications include wound infections, which are favored by the proximity of the digestive and genito-urinary apparatuses and the location of the scars in a fold susceptible to maceration. The infection rates reported in the literature can reach 16% [19]. In view of preventing overexposure to fluids, it is advisable to peroperatively and postoperatively catheterize patients and to utilize waterproof dressings. As for wound dehiscence, it is exceedingly common, occurring in as many as 51% of cases [19]; it is favored not only by the previously mentioned conditions, but also by the application of vertical scar techniques. Postoperative seromas are relatively frequent in all series, affecting as many as 25% of the patients under treatment. While vulva widening is favored by the horizontal technique, it nonetheless remains a rare occurrence; on the other hand, scar migration after thigh lift is a common
e5 phenomenon due to altered cutaneous tonicity in patients having undergone massive weight loss. Risk factors for complications [19,26] There exist two studies reporting on risk factors for postoperative complications. The first one, published in 2014, considers the body mass index (BMI) prior to massive weight loss and prior to thigh lift as essentially the only factor for postoperative risk [26]. Whereas only a low rate of complication was associated with low BMIs, a higher rate corresponded to increased BMIs. Age, weight, weight loss prior to thigh lift, delta BMI, loss weight method (diet or bariatric surgery), diabetes, high blood pressure, performance or nonperformance of liposuction, surgery duration, and vertical or horizontal technique were not found to be potential risk factors. It is nonetheless worth mentioning that in our series of 53 patients, 50 were treated by horizontal scar as opposed to only three by vertical scar technique, which means that it is impossible for us to point out any difference related to surgical approach. The second study, published in 2015 and including 106 patients, reports that anemia was statistically associated with a sizable rate of complication (odds ratio: 5.3; P = 0.03); as was patient age (OR: 1.29; P = 0.02). The overall complication rate was 49% for the horizontal scar technique, 67% for short vertical and 74% for long vertical scar, and there was no significant difference between the results of the three techniques (P = 0.1). However, the number of patients on whom the horizontal technique was employed was too small to allow for any conclusion to be drawn. On the other hand, it is interesting to note a relatively high rate of postoperative lymphoedema with the vertical technique (22%), of which 1.9% persisted after 1 year (versus 0% with the horizontal technique). The vertical scar was statistically correlated to an elevated rate of lymphoedema (P = 0.007) and also to a comparatively high rate of seroma (OR: 2.9; P = 0.02). Finally, scar infection was correlated with age, hypothyroidism and performance of liposuction outside the cutaneous resection pattern. Patient’s satisfaction [30] To date, the one study reporting benefits in terms of quality of life was carried out by our team. Twenty-one patients were retrospectively assessed using the validated Moorehead-Ardelt questionnaire and notwithstanding an overall complication rate of 43%, 85.7% answered that since the operation, their daily life had improved or greatly improved. The benefit was experienced in terms of self-esteem (90.5%), physical condition (85.7%), social relations (85.7%) and work (76.2%). On the other hand, only 33.3% of the patients noted amelioration in their intimate lives. To note, the enhanced quality of life seem stable over time.
Discussion Medial thigh lift has markedly evolved since it was first described. The two major technical advances were Colles’ fascial anchoring [3] and liposuction [4], which essentially put an end to classical surgical undermining; thereafter cutaneous necrosis is henceforth an exceptional event. However, liposuction is far from unanimously approved; some
e6 authors claim that it favors the appearance of wound infections. It is interesting to note that when liposuction is not applied during an operation and when classical full thickness surgical resection takes place, an elevated rate of lymphoedema has been reported [19], but that this does not occur when extensive liposuction is carried out [18], a finding that tends to confirm the interest of the latter as concerns blood and lymph system conservation. Colles’ fascial anchoring, which has been supplanted by some teams with fixation of the periosteum to the ischiatic bone, we consider it to be just as reliable a way of preventing scar migration and ptosis recurrence without generating occasionally considerable postoperative pain. Moreover, given the weight of gravity, the absence of deep-seated anchoring is systematically associated with downwards scar migration. Fascial anchoring consequently appears to be fundamental as means of improving patient satisfaction; it should be added that while patients are customarily forewarned about uncertain postoperative aesthetic outcomes, they often remain quite demanding. And scar migration outside of women’s underwear is not only hard to accept, but also an evident source of discontent. Due to these technical improvements, medial thighplasty has drawn benefited from renewed interest in our discipline and may now be considered as a routine procedure. Moreover, given increased incidence of obesity and the correspondingly accelerated development of surgical treatment of morbid obesity, we are confronted with an influx of new patients presenting major cutaneous deformities, which means that more and more often, we propose application of the vertical rather than the horizontal scar technique. Indeed, only the vertical technique permits correction of the cutaneous fat excess up to the top of the thigh. We prefer vertical inverted J-scar techniques to T techniques because while achieving similar corrections, they avoid classical cutaneous suffering at the T junction. However, so as to minimize the risk of postoperative complications such as lymphoedema or seroma, we find it fundamental to keep open the ‘‘horizontal’’ option, whenever it is indicated. While seroma represent a complication that is easy to treat through repeated punctures during consultations, they oblige the patient to make one medical appointment after another, thereby fostering workplace absenteeism and concomitant anxiety. When a capsule has been created around the seroma, we may propose resection of the encysted seroma in an operating block. In our opinion, monoblock resection techniques are obsolete; if we wish to improve outcome quality and diminish complications, they should be ruled out. When these techniques are nonetheless still applied, it is important to respect the subfascial fat containing the saphenous vein whose traumatization is considered by some medical teams as a source of lymphoedema [18]. Given the fact that the majority of wound dehiscence takes place in the inguinal folds, it takes, as possible, choose horizontal scar technique. Whatever our answer to that question, it matters to insist to the patient on the need for rigorous personal hygiene, which will help to minimize any staining or soiling arising from sutures. Conservation of a urinary catheter during hospitalization can likewise help to limit soiling and palliate the urinary discomfort, particularly in women, that is caused by frequently encountered reactive vulvar edema. And finally, wearing a medical compressive
N. Bertheuil et al. clothing (Lipo Panty S001, Medical Z, SA, USA) immediately after surgery can help to reduce the edema and limit any risk of wound dehiscence. One advantage of these techniques is that they place the different scars in dissimulated areas of the body, in the inner parts of the two thighs. In contradistinction to the previously mentioned possibility that the horizontal scar will migrate, the vertical scar is readily tolerated by patients in as much as it provides them with an immediately evident functional benefit, namely disappearance off friction between the thighs, which is often bothersome and irritating, especially when walking or engaging in athletic activities. However, and contrarily to other interventions such as monsplasty [31], sexual activity apparently shows no noticeable improvement subsequent to this procedure. As for thrombo-embolic complications, of which the incidence is estimated in the literature at 1%, they are likely to be prevented by rigorous compliance with the following rules: early rising the day after surgery, the wearing of support or compression stockings, and prophylactic anticoagulation by low molecular weight heparin for a period of 15 days. As regards patients at high risk of deep venous thrombosis, we can also offer perioperative and postoperative intermittent pneumatic compression of the limbs. Finally, it is worth noting that notwithstanding relatively elevated rates of complication, these surgical procedures are of real benefit to patients in their daily activities, as is attested by tangible improvement in quality of life [30,32]. In spite of a result often deemed less than impeccable by the surgery team, the patient is likely to show satisfaction. It is with this in mind that we wish to underline the importance of the preoperative consultation in achievement of the expected result; at the same time, we wish to emphasize the limitations with which we are called upon to cope; after all, cutaneous tonicity is more or less considerably altered following massive weight loss. Patients will derive optimal benefit when rendered fully aware of the functional objectives of this surgery: increased ease in putting on and wearing clothes, diminution of the skin problems stemming from macerations, improved walking. . . All of this is appreciable, even though, let us repeat the aesthetic result may leave to be desired. Nutrition therapy is also an important component of efforts aimed at optimizing surgical results. After all, we are confronted with patients who have lost a massive amount of weight; qualitative alterations of their cutaneous tissue and nutritional deficiencies can have negative repercussions on scarring. In our opinion, preoperative albumin assessment and screening for anemia can help to accurately assess nutritional and vitamin status; protein supplementation may in some cases be called for. Finally, tobacco cessation during the period preceding and following surgery is of primordial importance in view of limiting the scar complications that may arise in these surgical procedures [33,34].
Conclusion In this review, we have synthesized existing knowledge on medial thigh lift in view of helping plastic surgeons to make an informed choice of the operative technique best suited to the deformity presented by their patients. These types of surgery have become routine procedures, and they now
Medial thighplasty: Current concepts and practices constitute a key element in the care pathway of an overweight individual who wishes not only to lose weight, but also to engage, more generally speaking, in ‘‘body contouring’’. While the procedures outlined in this review present an admittedly high number of minor complications, they nonetheless lead to significant upgrading in quality of life.
Disclosure of interest The authors declare that they have no conflicts of interest concerning this article.
References [1] Lewis Jr JR. The thigh lift. J Int Coll Surg 1957;27:330—4. [2] Lewis Jr JR. Correction of ptosis of the thighs: the thigh lift. Plast Reconstr Surg 1966;37:494—8. [3] Lockwood TE. Fascial anchoring technique in medial thigh lifts. Plast Reconstr Surg 1988;82:299—304. [4] Le Louarn C, Pascal JF. The concentric medial thigh lift. Aesthetic Plast Surg 2004;28:20—3. [5] Gallagher EJ, Leroith D, Karnieli E. Insulin resistance in obesity as the underlying cause for the metabolic syndrome. Mt Sinai J Med 2010;77:511—23. [6] Lavie CJ, Milani RV, Ventura HO. Obesity and cardiovascular disease: risk factor, paradox, and impact of weight loss. J Am Coll Cardiol 2009;53:1925—32. [7] Montague CT, O’Rahilly S. The perils of portliness: causes and consequences of visceral adiposity. Diabetes 2000;49:883—8. [8] Van Gaal LF, Mertens IL, De Block CE. Mechanisms linking obesity with cardiovascular disease. Nature 2006;444:875—80. [9] Bochukova EG, Huang N, Keogh J, et al. Large, rare chromosomal deletions associated with severe early-onset obesity. Nature 2010;463:666—70. [10] Clement K, Vaisse C, Lahlou N, et al. A mutation in the human leptin receptor gene causes obesity and pituitary dysfunction. Nature 1998;392:398—401. [11] Emilsson V, Thorleifsson G, Zhang B, et al. Genetics of gene expression and its effect on disease. Nature 2008;452:423—8. [12] Menzaghi C, Ercolino T, Di Paola R, et al. A haplotype at the adiponectin locus is associated with obesity and other features of the insulin resistance syndrome. Diabetes 2002;51:2306—12. [13] Strawford A, Antelo F, Christiansen M, Hellerstein MK. Adipose tissue triglyceride turnover, de novo lipogenesis, and cell proliferation in humans measured with 2H2O. Am J Physiol Endocrinol Metabol 2004;286:E577—88. [14] Manzoni AP, Weber MB. Skin changes after bariatric surgery. An Bras Dermatol 2015;90:157—66. [15] Le Louarn C, Pascal JF. Internal faces lifting legs complications. Ann Chir Plast Esthet 2004;49:610—3. [16] Lockwood TE. Transverse flank-thigh-buttock lift with superficial fascial suspension. Plast Reconstr Surg 1991;87:1019—27.
e7 [17] Lockwood TE. Superficial fascial system (SFS) of the trunk and extremities: a new concept. Plast Reconstr Surg 1991;87: 1009—18. [18] Armijo BS, Campbell CF, Rohrich RJ. Four-step medial thighplasty: refined and reproducible. Plast Reconstr Surg 2014;134: 717e—25e. [19] Gusenoff JA, Coon D, Nayar H, Kling RE, Rubin JP. Medial thigh lift in the massive weight loss population: outcomes and complications. Plast Reconstr Surg 2015;135:98—106. [20] Labardi L, Gentile P, Gigliotti S, et al. Medial thighplasty: horizontal and vertical procedures after massive weight loss. J Cutan Aesthetic Surg 2012;5:20—5. [21] Hurwitz DJ. Medial thighplasty. Aesthetic Surg J 2005;25: 180—91. [22] Mathes DW, Kenkel JM. Current concepts in medial thighplasty. Clin Plast Surg 2008;35:151—63. [23] Tourani SS, Taylor GI, Ashton MW. Understanding the threedimensional anatomy of the superficial lymphatics of the limbs. Plast Reconstr Surg 2014;134:1065—74. [24] Kim SW, Han HH, Seo JW, et al. Two cases of lower body contouring with a spiral and vertical medial thigh lift. Arch Plast Surg 2012;39:67—70. [25] Sozer SO, Agullo FJ, Palladino H. Spiral lift: medial and lateral thigh lift with buttock lift and augmentation. Aesthetic Plast Surg 2008;32:120—5. [26] Bertheuil N, Thienot S, Huguier V, Menard C, Watier E. Medial thighplasty after massive weight loss: are there any risk factors for postoperative complications? Aesthetic Plast Surg 2014;38:63—8. [27] Capella JF. The vertical medial thigh lift. Clin Plast Surg 2014;41:727—43. [28] Kolker AR, Xipoleas GD. The circumferential thigh lift and vertical extension circumferential thigh lift: maximizing aesthetics and safety in lower extremity contouring. Ann Plast Surg 2011;66:452—6. [29] Bertheuil N, Aillet S, Heusse JL, Flecher E, Watier E. Large necrosis: a rare complication of medial thighplasty. Aesthetic Plast Surg 2012;36:88—90. [30] Bertheuil N, Thienot S, Chaput B, Varin A, Watier E. Quality-ofLife assessment after medial thighplasty in patients following massive weight loss. Plast Reconstr Surg 2015;135:67e—73e. [31] Pechevy L, Gourari A, Carloni R, Sauvaget F, Bertheuil N, Goga D. Monsplasty after massive weight loss: assessment of its aesthetic and functional impact. Ann Chir Plast Esthet 2015. http://dx.doi.org/10.1016/j.anplas.2014.12.002. [32] Gahagnon T, Guerreschi P, Pattou F, Martinot-Duquennoy V. Study of the benefits after body contouring surgery at the university hospital in Lille. Ann Chir Plast Esthet 2011;56: 298—307. [33] Pluvy I, Garrido I, Pauchot J, et al. Smoking and plastic surgery, part I. Pathophysiological aspects: update and proposed recommendations. Ann Chir Plast Esthet 2015;60:e3—13. [34] Pluvy I, Panouilleres M, Garrido I, et al. Smoking and plastic surgery, part II. Clinical implications: a systematic review with meta-analysis. Ann Chir Plast Esthet 2015;60:e15—49.
Available online at
ScienceDirect www.sciencedirect.com
GENERAL REVIEW
Medial thighplasty: Current concepts and practices Le lifting de face interne de cuisse : ´evolution des pratiques N. Bertheuil a,*,b,c,d, R. Carloni a, A. De Runz f, C. Herlin g, P. Girard a, E. Watier a, B. Chaput d,e a
Department of plastic, reconstructive and aesthetic surgery, hospital Sud, university of Rennes 1, 16, boulevard de Bulgarie, 35200 Rennes, France b Inserm U917, university of Rennes 1, CS 34 317, 35043 Rennes cedex, France c SITI Laboratory, ´Etablissement franc¸ais du sang Bretagne, Rennes university hospital, 35000 Rennes, France d STROMAlab, UMR5273 CNRS/UPS/EFS, Inserm U1031, Rangueil hospital, BP 84 225, 31432 Toulouse cedex 4, France e Department of plastic, reconstructive and aesthetic surgery, Rangueil hospital, Paul-Sabatier university, 31059 Toulouse cedex 9, France f Department of maxillofacial, plastic, reconstructive and cosmetic surgery, Nancy university hospital, university of Lorraine, 54000 Nancy, France g ˆ pital Lapeyronie, Montpellier university hospital, 34295 Department of plastic surgery and burn surgery, ho Montpellier cedex 5, France Received 27 July 2015; accepted 30 August 2015
KEYWORDS Medial thighplasty; Medial thigh lift; Body contouring; Obesity; Post-bariatric surgery
Summary Medial thighplasty, also known as medial thigh lift, is a procedure that has been carried out for five decades. The original ‘‘Lewis’’ technique has undergone many changes, and thereby been rendered widely available to plastic surgeons. Given the increasingly high number of surgical reconstructions after massive weight loss, this technique is now an integral part of a surgeon’s therapeutic arsenal as he strives to meet the evolving demands of patients. The objective of this article, which is based on a comprehensive review of the literature, is to summarize current knowledge on medial thighplasty and thereby allow plastic surgeons to adopt the operating technique best suited to the deformations presented by their patients and to the overall context. The different techniques, outcomes and complications are successively discussed. # 2015 Elsevier Masson SAS. All rights reserved.
* Corresponding author. E-mail address: [email protected] (N. Bertheuil). http://dx.doi.org/10.1016/j.anplas.2015.08.006 0294-1260/# 2015 Elsevier Masson SAS. All rights reserved.
e2
MOTS CLÉS Lifting de face interne de cuisse ; Cruroplastie ; Obésité ; Chirurgie des séquelles d’amaigrissement ; Chirurgie post-bariatrique
N. Bertheuil et al. Re ´sume ´ Le lifting de face interne de cuisse est une intervention pratiquée depuis cinq décennies. La technique originelle a bénéficié de nombreuses évolutions permettant sa démocratisation auprès des chirurgiens plasticiens. Avec l’afflux des reconstructions après perte de poids massive, cette technique fait désormais partie de l’arsenal thérapeutique indispensable d’un chirurgien, afin de répondre au mieux aux demandes des patients. Au travers d’une revue exhaustive de la littérature, l’objectif de cet article est de faire la synthèse des connaissances actuelles en matière de lifting de face interne de cuisse de façon à permettre aux chirurgiens plasticiens de choisir la technique opératoire la mieux adaptée à la déformation présentée par leurs patients et au terrain. Les différentes techniques, les résultats et les complications y sont successivement abordés. # 2015 Elsevier Masson SAS. Tous droits réservés.
Introduction The medial thigh lift initially described by Lewis in 1957 [1,2] was first designed to favor rejuvenation of the thighs. In this part of the body, increased cutaneous slackness is one of the first signs associated with observable aging, and localized fat deposits are often secondarily associated. With regard to obesity and its sequels, the chronology is reversed; at first weight gain is accompanied by fat deposits, and ensuing cutaneous slackness is secondary to significant weight loss. This procedure, which is often unpopular with surgeons on account of frequent postoperative complications, is aimed at correcting the cutaneous and fat excess in the inner thigh. Since the first description, numerous improvements of the surgical technique have heightened outcome predictability and lowered the rate of postoperative complications. One of these techniques consists in anchoring the superficial fascia to Colles’ fascia [3], leading to reduction of postoperative cutaneous ptosis and limiting the risks of vulvar widening. Another adjunctive technique consists in liposuction, which helps to reduce postoperative seromas and lymphoedemas [4]. At present, in addition to primary indications, we are called upon to treat patients presenting with massive weight loss entailing major cutaneous slackness. Their condition is closely connected with the increasing incidence of obesity in Western countries. This new pathology of the 21st century is associated over the medium to long term with multiple medical complications including cardiovascular diseases, high blood pressure, dyslipidemias, diabetes, arthrosis and some forms of cancer as well as sleep apnea [5—8]. The etiology of obesity is multifactoral, and it often results from the association of several determinants: genetic predisposition, environmental factors, behavioral factors and socioeconomic conditions [9—13]. Obesity leads to daily difficulties in dressing, in bodily hygiene, in walking and in sports activities as well as intimate relationships. It can also be responsible for serious psychological problems such as a loss of self-esteem possibly leading to a depressive syndrome with an impact on quality of life. Bariatric surgery has developed as a response to this pandemic. It is indicated for patients presenting with a body mass index (BMI) exceeding 40 (or in the case of associated comorbidities, exceeding 35). Operations inducing massive and relatively rapid weight loss tend to entail major cutaneous
excess and weakening, particularly in terms of tonicity of the skin [14]. Several surgical reconstruction procedures are frequently necessary, including treatment of the thighs by means of medial thigh lift, which is also known as crural plastic surgery or crural dermolipectomy. However, when it is a question of the major deformities induced by massive weight loss, the original horizontal scar technique may turn out to be insufficient, and consequently need to be either converted into or associated with vertical scar techniques. The objective of this article is to provide an overall summary on the data from the literature concerning the indications and the different operative techniques applied in medial thigh lift; we also wish to better understand the associated outcomes in terms of morbidity and quality of life.
Materials and methods A systematic review of the literature has been carried out so as to assess medial thighplasty: the indications, the operative techniques and the outcomes. Our April 2015 investigation in the MEDLINE database via pubmed was launched using the following keywords: ‘‘medial thighplasty’’ OR ‘‘medial thigh lift’’ OR ‘‘thighplasty’’ OR ‘‘thigh lift’’. The bibliography composed of the collected articles was also examined in view of discovering relevant published texts. The title; the abstract and the complete text of the recovered articles were all analyzed; and a synthesis of the relevant texts was drawn up so as to provide summarized information on the latest surgical advances in medial thigh lift. Selection criteria: The original articles based on patients having undergone a medial thigh lift up until April 2015 were analyzed. Prospective and retrospective observational studies as well as clinical cases were included. Articles written in a language other than English or French were excluded. All articles describing techniques between abdominal dermolipectomy and medial thigh lift were likewise excluded, as were those using information drawn from other studies without original data. Data collection: Detailed and critical reading of each selected article was carried out in view of obtaining accurate information pertaining to: authors, date of publication, study site, type of article and level of evidence, number of patients, indication, surgical technique, complications
Medial thighplasty: Current concepts and practices such as the number of reoperations, and the therapeutic perspectives suggested by the authors. The studies and data were listed via Microsoft Excel1 2011 (Microsoft, Redmond, WA, USA).
Results Out of the 311 articles found in the search engine, 20 were selected and analyzed to provide an overview of the latest data in the literature on the indications and the different operative techniques applied in medial thighplasty and to understand the associated outcomes in terms of morbidity and quality of life.
Indications The techniques were addressed to patients presenting cutaneous slackness that was associated to some degree with excess fat deposits located in the medial side of the thigh. Two types of patients were distinguished: patients presenting with cutaneous ptosis related to aging and predominating in the upper third of the thigh. These deformities are corrected by the classical horizontal scar technique, for example in the inguinal fold (Lockwood’s original anchoring technique [3]); patients having presented with massive weight loss following a diet or bariatric surgery and presenting with staged deformities at locations ranging from cutaneous and fat excess of the upper third of the thigh to excess on the thigh in its entirety. These types of patients, whose numbers have been increasing concurrently with the development of bariatric surgery techniques, present new problems with regard to reconstruction. More precisely, in addition to the classical technique, which does not always yield satisfactory correction of cutaneous excess, we may be obliged to employ vertical scar techniques.
e3
Surgical technique Horizontal scar [1—4,15] The original technique initially described by Lewis [1,2] was unpopular with plastic surgeons on account of disappointing long-term results, which were largely due to scar migration and to recurring cutaneous ptosis (Fig. 1A and B). In 1988, Lockwood appreciably reduced these unintended consequences by means of improved anatomical knowledge and description of the ‘‘superficial fascial system’’ [16,17], with a direct application to the medial thigh [3]. Up until 2004, at which time Le Louarn [4] was the first author to describe the interest of initial suprafascial and subfascial liposuction in a cutaneous resection area with cutaneous resection just under the dermis, all of the techniques involved removal of tissues by full thickness excision. On the contrary, the procedure described by Le Louarn allowed for conservation of the connective tissue containing not only the blood vessels but also the lymph vessels, thereby reducing the risk of postoperative seroma and lymphoedema. As of now, most authors apply this technique, which consists in cutaneous resection design evaluated by the ‘‘pinch test’’ and peroperatively adjusted so as to produce closure without tension. Liposuction is carried out subfascially throughout the inner thigh and suprafascially in the resection pattern. The operation is concluded by cutaneous resection under the dermis, fixation of anchor points at Colles’ fascia and finally closure on several surgical plans (Fig. 2). This technique corrects the upper third of the thigh with a sizable vertical vector. Vertical scar (massive weight loss patient) [18—21] These techniques are increasingly necessary for patients presenting with massive weight loss and cutaneous and fat excess extending beyond the junction of the upper and middle thirds of the thigh. In this type of case, the horizontal scar technique only rarely yields sufficiently satisfactory results (Fig. 1C to H). Two main variants exist, characterized by either a T-like vertical scar or an inverted J (Fig. 3).
Figure 1 Summary of the different surgical approaches. A. Cutaneous resection design for the horizontal scar technique. B. Potential scarring in the horizontal scar technique. C. Cutaneous resection design for the vertical technique in inverted J. D. Potential scarring in the J technique. E. Cutaneous resection design for the vertical technique in T. F. Potential scarring in the T technique. G. Cutaneous resection design for spiral lift. B. Potential scarring in spiral lift.
e4
N. Bertheuil et al.
Figure 2 Perioperative view of the horizontal technique. A. Preoperative design. B. Liposuction above and below the fascia in the cutaneous pattern. C. Anchoring of Colles’ fascia by non-absorbable stitch. D. Final result at end of procedure.
Figure 3 Perioperative view of the inverted J vertical technique. A. Preoperative design. B. View after liposuction and cutaneous resection just under the dermis; the venous structures, including the saphenous, are conserved. C. Start of surgical closure. D. Final result at end of procedure.
Medial thighplasty: Current concepts and practices While these techniques exhibit less pronounced vertical correction than in the primary description, on the contrary they have a horizontal correction vector that is indispensable for numerous patients coming to the end of a period of massive weight loss [21]. The liposuction procedure that removes fat from the internal hemi-circumference of the thigh can be carried out either during the same procedure or during another intervention, usually 6 months subsequent to thigh lift [19,22]. When the authors thereby proceeding by two stages carry out fullthickness cutaneous resection, it is so as to diminish the risk of lymphoedema that they conserve the great saphenous vein [19]. When, on the contrary, the operation is performed in a single stage, it is necessary to undertake extensive suprafascial liposuction up to the top of the thigh so as to avoid injury to the saphenous vein and the lymphatic network [18]. Indeed, a recent anatomical study showed that the lymphatic vessels are present not only in subfascial fat, but also in the deep layer of superficial fat [23]. In all cases, cutaneous resection takes place perioperatively, and closure is tension-free, were this not to happen, the risk of scar widening and wound dehiscence would increase. Hybrid technique for thigh and buttocks lift (spiral lift) [24,25] These techniques comprise medial thigh lift in which vertical or horizontal scar technique is associated with cutaneous resection that is prolonged in the crural arcade and then in the back, the objective being to simultaneously carry out a buttock lift (Fig. 1G and H).
Complications While serious complications are fortunately rare, this surgery entails numerous minor complications of which patients should be forewarned during preliminary consultation. While the most serious complications, which are thromboembolic events (deep vein thrombosis and pulmonary embolism) are rarely encountered < 1% [15,19,26—28], skin necrosis are present in as many as 5% of cases [15], and their occurrence is favored by undermining of subcutaneous tissue and, more particularly, by repeated operations [29]. And even though hemorrhages and hematomas have seldom been reported in the literature, their incidence may be as high as 6% [19,27]. Other minor complications include wound infections, which are favored by the proximity of the digestive and genito-urinary apparatuses and the location of the scars in a fold susceptible to maceration. The infection rates reported in the literature can reach 16% [19]. In view of preventing overexposure to fluids, it is advisable to peroperatively and postoperatively catheterize patients and to utilize waterproof dressings. As for wound dehiscence, it is exceedingly common, occurring in as many as 51% of cases [19]; it is favored not only by the previously mentioned conditions, but also by the application of vertical scar techniques. Postoperative seromas are relatively frequent in all series, affecting as many as 25% of the patients under treatment. While vulva widening is favored by the horizontal technique, it nonetheless remains a rare occurrence; on the other hand, scar migration after thigh lift is a common
e5 phenomenon due to altered cutaneous tonicity in patients having undergone massive weight loss. Risk factors for complications [19,26] There exist two studies reporting on risk factors for postoperative complications. The first one, published in 2014, considers the body mass index (BMI) prior to massive weight loss and prior to thigh lift as essentially the only factor for postoperative risk [26]. Whereas only a low rate of complication was associated with low BMIs, a higher rate corresponded to increased BMIs. Age, weight, weight loss prior to thigh lift, delta BMI, loss weight method (diet or bariatric surgery), diabetes, high blood pressure, performance or nonperformance of liposuction, surgery duration, and vertical or horizontal technique were not found to be potential risk factors. It is nonetheless worth mentioning that in our series of 53 patients, 50 were treated by horizontal scar as opposed to only three by vertical scar technique, which means that it is impossible for us to point out any difference related to surgical approach. The second study, published in 2015 and including 106 patients, reports that anemia was statistically associated with a sizable rate of complication (odds ratio: 5.3; P = 0.03); as was patient age (OR: 1.29; P = 0.02). The overall complication rate was 49% for the horizontal scar technique, 67% for short vertical and 74% for long vertical scar, and there was no significant difference between the results of the three techniques (P = 0.1). However, the number of patients on whom the horizontal technique was employed was too small to allow for any conclusion to be drawn. On the other hand, it is interesting to note a relatively high rate of postoperative lymphoedema with the vertical technique (22%), of which 1.9% persisted after 1 year (versus 0% with the horizontal technique). The vertical scar was statistically correlated to an elevated rate of lymphoedema (P = 0.007) and also to a comparatively high rate of seroma (OR: 2.9; P = 0.02). Finally, scar infection was correlated with age, hypothyroidism and performance of liposuction outside the cutaneous resection pattern. Patient’s satisfaction [30] To date, the one study reporting benefits in terms of quality of life was carried out by our team. Twenty-one patients were retrospectively assessed using the validated Moorehead-Ardelt questionnaire and notwithstanding an overall complication rate of 43%, 85.7% answered that since the operation, their daily life had improved or greatly improved. The benefit was experienced in terms of self-esteem (90.5%), physical condition (85.7%), social relations (85.7%) and work (76.2%). On the other hand, only 33.3% of the patients noted amelioration in their intimate lives. To note, the enhanced quality of life seem stable over time.
Discussion Medial thigh lift has markedly evolved since it was first described. The two major technical advances were Colles’ fascial anchoring [3] and liposuction [4], which essentially put an end to classical surgical undermining; thereafter cutaneous necrosis is henceforth an exceptional event. However, liposuction is far from unanimously approved; some
e6 authors claim that it favors the appearance of wound infections. It is interesting to note that when liposuction is not applied during an operation and when classical full thickness surgical resection takes place, an elevated rate of lymphoedema has been reported [19], but that this does not occur when extensive liposuction is carried out [18], a finding that tends to confirm the interest of the latter as concerns blood and lymph system conservation. Colles’ fascial anchoring, which has been supplanted by some teams with fixation of the periosteum to the ischiatic bone, we consider it to be just as reliable a way of preventing scar migration and ptosis recurrence without generating occasionally considerable postoperative pain. Moreover, given the weight of gravity, the absence of deep-seated anchoring is systematically associated with downwards scar migration. Fascial anchoring consequently appears to be fundamental as means of improving patient satisfaction; it should be added that while patients are customarily forewarned about uncertain postoperative aesthetic outcomes, they often remain quite demanding. And scar migration outside of women’s underwear is not only hard to accept, but also an evident source of discontent. Due to these technical improvements, medial thighplasty has drawn benefited from renewed interest in our discipline and may now be considered as a routine procedure. Moreover, given increased incidence of obesity and the correspondingly accelerated development of surgical treatment of morbid obesity, we are confronted with an influx of new patients presenting major cutaneous deformities, which means that more and more often, we propose application of the vertical rather than the horizontal scar technique. Indeed, only the vertical technique permits correction of the cutaneous fat excess up to the top of the thigh. We prefer vertical inverted J-scar techniques to T techniques because while achieving similar corrections, they avoid classical cutaneous suffering at the T junction. However, so as to minimize the risk of postoperative complications such as lymphoedema or seroma, we find it fundamental to keep open the ‘‘horizontal’’ option, whenever it is indicated. While seroma represent a complication that is easy to treat through repeated punctures during consultations, they oblige the patient to make one medical appointment after another, thereby fostering workplace absenteeism and concomitant anxiety. When a capsule has been created around the seroma, we may propose resection of the encysted seroma in an operating block. In our opinion, monoblock resection techniques are obsolete; if we wish to improve outcome quality and diminish complications, they should be ruled out. When these techniques are nonetheless still applied, it is important to respect the subfascial fat containing the saphenous vein whose traumatization is considered by some medical teams as a source of lymphoedema [18]. Given the fact that the majority of wound dehiscence takes place in the inguinal folds, it takes, as possible, choose horizontal scar technique. Whatever our answer to that question, it matters to insist to the patient on the need for rigorous personal hygiene, which will help to minimize any staining or soiling arising from sutures. Conservation of a urinary catheter during hospitalization can likewise help to limit soiling and palliate the urinary discomfort, particularly in women, that is caused by frequently encountered reactive vulvar edema. And finally, wearing a medical compressive
N. Bertheuil et al. clothing (Lipo Panty S001, Medical Z, SA, USA) immediately after surgery can help to reduce the edema and limit any risk of wound dehiscence. One advantage of these techniques is that they place the different scars in dissimulated areas of the body, in the inner parts of the two thighs. In contradistinction to the previously mentioned possibility that the horizontal scar will migrate, the vertical scar is readily tolerated by patients in as much as it provides them with an immediately evident functional benefit, namely disappearance off friction between the thighs, which is often bothersome and irritating, especially when walking or engaging in athletic activities. However, and contrarily to other interventions such as monsplasty [31], sexual activity apparently shows no noticeable improvement subsequent to this procedure. As for thrombo-embolic complications, of which the incidence is estimated in the literature at 1%, they are likely to be prevented by rigorous compliance with the following rules: early rising the day after surgery, the wearing of support or compression stockings, and prophylactic anticoagulation by low molecular weight heparin for a period of 15 days. As regards patients at high risk of deep venous thrombosis, we can also offer perioperative and postoperative intermittent pneumatic compression of the limbs. Finally, it is worth noting that notwithstanding relatively elevated rates of complication, these surgical procedures are of real benefit to patients in their daily activities, as is attested by tangible improvement in quality of life [30,32]. In spite of a result often deemed less than impeccable by the surgery team, the patient is likely to show satisfaction. It is with this in mind that we wish to underline the importance of the preoperative consultation in achievement of the expected result; at the same time, we wish to emphasize the limitations with which we are called upon to cope; after all, cutaneous tonicity is more or less considerably altered following massive weight loss. Patients will derive optimal benefit when rendered fully aware of the functional objectives of this surgery: increased ease in putting on and wearing clothes, diminution of the skin problems stemming from macerations, improved walking. . . All of this is appreciable, even though, let us repeat the aesthetic result may leave to be desired. Nutrition therapy is also an important component of efforts aimed at optimizing surgical results. After all, we are confronted with patients who have lost a massive amount of weight; qualitative alterations of their cutaneous tissue and nutritional deficiencies can have negative repercussions on scarring. In our opinion, preoperative albumin assessment and screening for anemia can help to accurately assess nutritional and vitamin status; protein supplementation may in some cases be called for. Finally, tobacco cessation during the period preceding and following surgery is of primordial importance in view of limiting the scar complications that may arise in these surgical procedures [33,34].
Conclusion In this review, we have synthesized existing knowledge on medial thigh lift in view of helping plastic surgeons to make an informed choice of the operative technique best suited to the deformity presented by their patients. These types of surgery have become routine procedures, and they now
Medial thighplasty: Current concepts and practices constitute a key element in the care pathway of an overweight individual who wishes not only to lose weight, but also to engage, more generally speaking, in ‘‘body contouring’’. While the procedures outlined in this review present an admittedly high number of minor complications, they nonetheless lead to significant upgrading in quality of life.
Disclosure of interest The authors declare that they have no conflicts of interest concerning this article.
References [1] Lewis Jr JR. The thigh lift. J Int Coll Surg 1957;27:330—4. [2] Lewis Jr JR. Correction of ptosis of the thighs: the thigh lift. Plast Reconstr Surg 1966;37:494—8. [3] Lockwood TE. Fascial anchoring technique in medial thigh lifts. Plast Reconstr Surg 1988;82:299—304. [4] Le Louarn C, Pascal JF. The concentric medial thigh lift. Aesthetic Plast Surg 2004;28:20—3. [5] Gallagher EJ, Leroith D, Karnieli E. Insulin resistance in obesity as the underlying cause for the metabolic syndrome. Mt Sinai J Med 2010;77:511—23. [6] Lavie CJ, Milani RV, Ventura HO. Obesity and cardiovascular disease: risk factor, paradox, and impact of weight loss. J Am Coll Cardiol 2009;53:1925—32. [7] Montague CT, O’Rahilly S. The perils of portliness: causes and consequences of visceral adiposity. Diabetes 2000;49:883—8. [8] Van Gaal LF, Mertens IL, De Block CE. Mechanisms linking obesity with cardiovascular disease. Nature 2006;444:875—80. [9] Bochukova EG, Huang N, Keogh J, et al. Large, rare chromosomal deletions associated with severe early-onset obesity. Nature 2010;463:666—70. [10] Clement K, Vaisse C, Lahlou N, et al. A mutation in the human leptin receptor gene causes obesity and pituitary dysfunction. Nature 1998;392:398—401. [11] Emilsson V, Thorleifsson G, Zhang B, et al. Genetics of gene expression and its effect on disease. Nature 2008;452:423—8. [12] Menzaghi C, Ercolino T, Di Paola R, et al. A haplotype at the adiponectin locus is associated with obesity and other features of the insulin resistance syndrome. Diabetes 2002;51:2306—12. [13] Strawford A, Antelo F, Christiansen M, Hellerstein MK. Adipose tissue triglyceride turnover, de novo lipogenesis, and cell proliferation in humans measured with 2H2O. Am J Physiol Endocrinol Metabol 2004;286:E577—88. [14] Manzoni AP, Weber MB. Skin changes after bariatric surgery. An Bras Dermatol 2015;90:157—66. [15] Le Louarn C, Pascal JF. Internal faces lifting legs complications. Ann Chir Plast Esthet 2004;49:610—3. [16] Lockwood TE. Transverse flank-thigh-buttock lift with superficial fascial suspension. Plast Reconstr Surg 1991;87:1019—27.
e7 [17] Lockwood TE. Superficial fascial system (SFS) of the trunk and extremities: a new concept. Plast Reconstr Surg 1991;87: 1009—18. [18] Armijo BS, Campbell CF, Rohrich RJ. Four-step medial thighplasty: refined and reproducible. Plast Reconstr Surg 2014;134: 717e—25e. [19] Gusenoff JA, Coon D, Nayar H, Kling RE, Rubin JP. Medial thigh lift in the massive weight loss population: outcomes and complications. Plast Reconstr Surg 2015;135:98—106. [20] Labardi L, Gentile P, Gigliotti S, et al. Medial thighplasty: horizontal and vertical procedures after massive weight loss. J Cutan Aesthetic Surg 2012;5:20—5. [21] Hurwitz DJ. Medial thighplasty. Aesthetic Surg J 2005;25: 180—91. [22] Mathes DW, Kenkel JM. Current concepts in medial thighplasty. Clin Plast Surg 2008;35:151—63. [23] Tourani SS, Taylor GI, Ashton MW. Understanding the threedimensional anatomy of the superficial lymphatics of the limbs. Plast Reconstr Surg 2014;134:1065—74. [24] Kim SW, Han HH, Seo JW, et al. Two cases of lower body contouring with a spiral and vertical medial thigh lift. Arch Plast Surg 2012;39:67—70. [25] Sozer SO, Agullo FJ, Palladino H. Spiral lift: medial and lateral thigh lift with buttock lift and augmentation. Aesthetic Plast Surg 2008;32:120—5. [26] Bertheuil N, Thienot S, Huguier V, Menard C, Watier E. Medial thighplasty after massive weight loss: are there any risk factors for postoperative complications? Aesthetic Plast Surg 2014;38:63—8. [27] Capella JF. The vertical medial thigh lift. Clin Plast Surg 2014;41:727—43. [28] Kolker AR, Xipoleas GD. The circumferential thigh lift and vertical extension circumferential thigh lift: maximizing aesthetics and safety in lower extremity contouring. Ann Plast Surg 2011;66:452—6. [29] Bertheuil N, Aillet S, Heusse JL, Flecher E, Watier E. Large necrosis: a rare complication of medial thighplasty. Aesthetic Plast Surg 2012;36:88—90. [30] Bertheuil N, Thienot S, Chaput B, Varin A, Watier E. Quality-ofLife assessment after medial thighplasty in patients following massive weight loss. Plast Reconstr Surg 2015;135:67e—73e. [31] Pechevy L, Gourari A, Carloni R, Sauvaget F, Bertheuil N, Goga D. Monsplasty after massive weight loss: assessment of its aesthetic and functional impact. Ann Chir Plast Esthet 2015. http://dx.doi.org/10.1016/j.anplas.2014.12.002. [32] Gahagnon T, Guerreschi P, Pattou F, Martinot-Duquennoy V. Study of the benefits after body contouring surgery at the university hospital in Lille. Ann Chir Plast Esthet 2011;56: 298—307. [33] Pluvy I, Garrido I, Pauchot J, et al. Smoking and plastic surgery, part I. Pathophysiological aspects: update and proposed recommendations. Ann Chir Plast Esthet 2015;60:e3—13. [34] Pluvy I, Panouilleres M, Garrido I, et al. Smoking and plastic surgery, part II. Clinical implications: a systematic review with meta-analysis. Ann Chir Plast Esthet 2015;60:e15—49.