Keywords
Body contouring - Thigh lift - Skin excess
INTRODUCTION
The westernization of the Korean diet is driving the increase in the number of the
obese. Accordingly, various remedies such as dietary control, pharmacotherapy, and
surgical treatment have been developed. In particular, surgical operations such as
gastrectomy, gastric bypass, and gastric banding are performed on extremely obese
patients whose body mass index (BMI) is over 40 kg/m2 [[1]]. The problem is that excessive weight loss, caused by surgical treatment, dietary
control, or exercise, can result in flabby skin and unsightly contours, there is extreme
variation in the extent and exact presentation of this problem from person to person.
Thus, it is important to remove flabby skin in the light of individual characteristics.
In 2010, we reported one case of belt dermolipectomy to remove flabby skin around
the trunk caused by excessive weight loss [[2]]. This paper introduces the technique of lower body contouring and reports on 2
cases of thigh-lifts performed on the lower extremities including the hips.
CASES
In 2011, we undertook 2 cases of thigh-lifts performed on the lower extremities. One
patient had flabby skin over the medial thighs and a vertical medial thigh-lift was
performed. The other patient had excess skin not only on the medial thighs but also
on the lateral hip and buttocks. Therefore, a medial vertical thigh-lift was performed
concurrently with a spiral thigh-lift.
The preoperative design is crucial to an operation, whereby the result is determined.
The lower extremity design was made on the patients in standing and supine positions
with their lower extremities abducted. First, the pinching test was performed on the
whole lower extremities of the patient in a standing position, by which the excision
amount was roughly determined. In the case of the spiral thigh-lift, a line was drawn
along the inguinal ligament, anterior superior iliac spine, posterior iliac crest,
and sacrum via the inferior gluteal fold and perineal-thigh crease, where along the
pinching test was performed to determine the excision amount. Then, incision lines
were marked with the drawn line as the base line ([Fig. 1]). In the process, the lower extremities were properly alternated between abduction
and adduction in order that the skin of the lateral hip might not be excessively tensed.
Next, the medial thigh was designed in a supine position with the lower extremities
abducted. A midline was drawn to connect the midpoints of the perineal-thigh crease
and that of the medial knee for reference as the skin may droop while the patient
is in a supine position. Afterward, the excision amount was determined by the pinching
test while the patient was in a supine position with the lower extremities abducted
([Fig. 2]). The most important point in medial thigh design is not to invade the femoral triangle
in order to prevent the injury of the lymphatic system, which could lead to severe
complications such as lymphocele. Thus, dissection to the anteromedial thigh should
be minimized. If necessary, dissection could be extended to the posterior aspect from
the midline or a design could be made in a bottleneck shape to prevent invasion of
the femoral triangle. It is recommended that the femoral triangle be demarcated in
the process of preoperative design, which is helpful to prevent invasion during the
operation.
Fig. 1 Design
The extent of tissue to excise was determined by pinching the patient in a standing
position. Marking by the pinching method is seen here. A line was drawn along the
inguinal ligament (*), anterior superior iliac spine (#), posterior iliac crest (+)
and sacrum (O) via the inferior gluteal fold and perineal-thigh crease. Then, the
pinching test was performed to determine the excision amount and incision lines were
marked as the base line.
Fig. 2 Preoperative design
The excision amount was determined by the pinching test while the patient was in a
supine position with the lower extremities abducted and also designed by stages preoperatively
and was gradually extended during the course of dissection.
The operation was performed in a supine position with the lower extremities abducted.
A spreader bar was used to make the patient maintain the frog-leg position. If needed,
liposuction is performed beforehand, which was unnecessary in our cases. The medial
vertical thigh-lift was performed first. An incision was made on the anterior side,
and a dissection was performed toward the posterior thigh through the superficial
fat layer, above the superficial fascia system, in order not to injure the major vessels
such as the saphenous vein running through the deep fat layer. Considering tension
during closure, the excision amount was designed by stages preoperatively and was
gradually extended during the course of dissection ([Fig. 2]). Three to four incisions were made perpendicularly to the incision line dividing
the tissue to be excised. It was divided to the proposed incision line and was temporarily
fixed by a skin stapler. When it was not so tense, dissection was performed along
with staged excision in order to forestall the failure of closure.
In the case of the spiral thigh-lift procedure, a dissection was performed along the
inguinal ligament, the anterior superior iliac spine and the lateral hip. Then the
patient was turned to the lateral recumbent position and the dissection was extended
to the buttock and sacrum. Depending on the circumstances, it is possible to perform
the operation after the patient is turned over in the prone position. For the medial
thigh-lift procedure, the skin was temporarily fixed by a skin stapler, and the tissue
was excised in stages. In the spiral thigh-lift procedure, this requires that the
inferior skin flap should be fixed to non-movable tissue. Accordingly, the skin flap
was fixed to the Colles' fascia in the medial region, to the inguinal ligament in
anterior region, and to the periosteum of the anterior superior iliac spine in lateral
region, respectively, by the use of 3/0 Vicryl suture. When the medial vertical thigh-lift
was performed concurrently with the spiral thigh-lift, there was no need to fix it
to the Colles' fascia because the medial vertical thigh-lift alone was enough to lift
the skin in the horizontal vector.
An undermining procedure was not performed to prevent hematoma formation and for rapid
recovery. The subcutaneous layer was sutured by 3/0 Vicryl suture and 4/0 polydioxanone
suture. A surgical drain was inserted. The skin was not sutured but approximated by
using surgical tape.
The two operations took 3 and 5 hours. The patients were encouraged to ambulate early
on the first postoperative day in order to prevent thromboembolic complications. The
drains were removed 3 to 4 days later. In neither cases did complications such as
hematoma formation or wound disruption occur. The patients wore compressive garments
after the drains were removed, and were discharged 6 to 8 days later. In the patient
who underwent the medial vertical thigh-lift, T-shaped scars were left on the perineal-thigh
crease, but did not show when patient was standing ([Fig. 3]). Follow-up care was conducted for 6 months. Both of them are very satisfied with
their final body contours.
Fig. 3 Immediate postoperative view
T-shaped scars were left on the perineal-thigh crease.
Case 1
A 37-year-old woman had undergone Roux-en-Y bariatric surgery 2 years earlier. Before
the operation, she was 182 cm tall and weighed 192 kg. Her BMI was 58 kg/m2. Two years later, her weight and BMI were found to be 107 kg and 32 kg/m2. However, her skin was flabby all over her body. Therefore, belt dermolipectomy was
performed to remove the flabby skin of the trunk. Two months later, reduction mammaplasty
and brachioplasty were performed to remove the flabby skin of the chest and upper
arms. One year after the secondary operation, flabby skin was observed all over her
medial thighs, and further, the flabby skin disturbed her walking. A vertical medial
thigh-lift was performed. The quantity of excised tissue was 685 g from the left thigh
and 665 g from the right thigh. After the three operations, her weight had been reduced
by an additional 10 kg.
Case 2
A 31-year-old woman reduced her weight by 36 kg by diet and exercise over a one-year
period. She was 165 cm tall, weighed 110 kg, and her BMI was 40 kg/m2. After she lost weight, her BMI was found to be 27 kg/m2. First, brachioplasty and abdominoplasty were performed. On physical examinations
performed after the primary operation, excess skin was observed not only on the medial
thighs but also on the lateral hip and buttocks. It was in the shape of a guitar or
pear. Therefore, a medial vertical thigh-lift was performed concurrently with a spiral
thigh-lift. Through the secondary operation, 1,344 g of tissue (642 g from the left
thigh and 702 g from the right one) were excised ([Fig. 4]).
Fig. 4 Case 2
(A) Preoperative view. (B) Postoperative 1 month view.
DISCUSSION
Since the thigh-lift was reported by Lewis [[3]] in 1957, approximately 15,336 cases of thigh-lifts have been performed every year
in the US [[4]]. In Korea, however, it is raely performed. This is because there are few patients
who show indications for this procedure. However, the westernization of the Korean
diet has increased the obesity rate in Korea, and as a result, body contouring surgeries
including thigh-lifts have been becoming more common.
For the medial thigh, the classic Lockwood medial thigh-lift and the vertical medial
thigh-lift can be applied [[5]]. The former is applied in cases where excess skin in a vertical vector is observed
on the upper one-third of the medial thigh and where ptosis has occurred. However,
realistically, there are few cases where the problem is limited to the upper one-third
of the medial thigh. Even if there are such cases, those cases are not severe and
most can be solved by liposuction.
The vertical medial thigh-lift is usually applied to cases where the excess skin is
in a horizontal vector, especially where excess skin is all over the medial thigh.
The effect may persist without the fixation of the dermal layer to the Colle's fascia,
because the tension occurs in a horizontal vector during suturing and disperses throughout
the medial thigh [[5]].
In a medial vertical thigh-lift, the first consideration is to preserve the femoral
triangle. If the lymphatic system in the femoral triangle is injured, prolonged edema
and lymphatic collection may occur. Therefore, the femoral triangle should be demarcated
in the process of preoperative design in order that it may not be dissected mistakenly.
The spiral thigh-lift is effective against excess skin and ptosis on the lateral hip
(trochanteric area) and buttocks. Although large scars are left, most of them can
be covered with underclothes. In addition, it can be performed concurrently with buttock
augmentation by use of a gluteal flap [[6]]. Heretofore, liposuction, belt dermolipectomy and flank-plasty have been substituted
for the spiral thigh-lift. The problem is that such operations are inferior to the
spiral thigh-lift in the effect against excess skin and ptosis on the lateral hip
and buttocks. Furthermore, the problems can recrudesce soon after surgery.
In the case of the spiral thigh-lift, the inferior skin flap is fixed to non-movable
tissues such as the Colles' fascia, the inguinal ligament and the periosteum of the
anterior superior iliac spine, which makes it possible to lift the buttocks, the lateral
hip, and the medial thigh and to prevent recurrence of ptosis shortly after the operation.
Moreover, it can prevent scar widening and malformation as well as labium distortion
on the medial side [[6],[7]].
We did not perform undermining of the skin flap in these two cases. Excessive undermining
increases the risk of hematoma or seroma formation and prolongs hospitalization. This
lesson was drawn from our previous case of belt dermolipectomies [[2]]. It seemed that it would be difficult to fix the inferior skin flap in non-movable
tissue without undermining at the time of the treatment to the author. However, in
practice, it was easily fixed without tension. Furthermore, the simple procedure without
undermining made it possible to shorten the operation time and to ensure rapid recovery
and early ambulation of the patients. This, in turn, reduced the risk of a thromboembolic
event, which often happens in prolonged operations.
The number of obese people is increasing in Korea. They can suffer from flabby skin
after massive weight loss, experiencing many functional and esthetic problems. Skin
excess, especially in the lower body, can be corrected by a thigh lift combining several
procedures, varying from person to person.
