Operative Technique in Plastic Surgery – Kevin C.Chung

anterior oblique view has markings visible for
periareolar mastopexy and 365-cc Sientra textured
round implant augmentation and complete
abdominoplasty, which will start with the lower of the
two superior markings. E. In this posterior view, a
caliper marks the 14-cm diameter of the implant within
the boundary of the left buttocks. Implantech CCBS-
NC-3 14 cm in diameter 330 cc. Contour flex gluteal
“natural contour” implants were chosen to take up the
skin laxity from pelvic rim to lateral gluteal regions
without excessive projection. The gluteal implants are
drawn extending from the pelvic rim. It is better to
keep the placement slightly cephalad as the implants
are likely to drop slightly.
Incision and Dissection
■ Parallel 6-cm-long vertical incisions are drawn 1.5 cm on either side of the
intergluteal cleft. A single midline incision is an alternative approach
reserved for the most experienced operators, because without care the
intragluteal cleft may be blunted.
■ The incision and dissection are completed for one pocket and then the other
prior to inserting the implants.
■ After the 6-cm gluteal incision is made, dissection proceeds through the
medial subcutaneous tissue, to enter the gluteal fascia. A partial-thickness
electrocautery incision is made the medial gluteus maximus muscle.
■ With the aid of electrosurgery and in-line suction, a tedious intramuscular
dissection is continued for the entire pocket for the implant (TECH FIG 7).
Implant Insertion
■ A plastic ruler cut to the diameter of the selected implant is inserted to assure
adequate breadth of the dissected space. Alternatively, a sizer implant is
inserted to assure fit. The Implantech buttock implant is pliable enough to
roll up for insertion through the 6-cm opening.
■ Immediately prior to inserting the implant into the pocket, Betadine-
impregnated Ioban sheet is applied over the incision and operative area. The

folded implant is shimmied into the dissected intramuscular space and then
unfurled and spread out to precisely fill the intramuscular pocket.
TECH FIG 7 • Intraoperative view of buttock surgery.
With her head to the right, the right buttock dissection
has been completed and a tail of a buried lap pad is
seen. Through a left paramedian 6 cm long incision
has been made through skin, and then tediously
electrocautery intramuscular dissection is done as
exposed by the Richardson retractor.
Completion
■ The muscular incision is closed with interrupted absorbable braided suture
(TECH FIG 8A), followed by two more layers in the subcutaneous tissues
and dermis (TECH FIG 8B,C).
■ Over 6 months, the slightly high positioned and large 14 cm in diameter
round implants descend to the desired location.
■ Immediately after her 350-cc intramuscular buttock implant augmentation,
this 42-year-old woman also had 350-cc gel implant periareolar breast
augmentation mastopexy and abdominoplasty. The transformation at 5
months is evident (TECH FIG 8D-G).

TECH FIG 8 • A. After placing an Ioban adhesive
drape (3M Health Care, St. Paul Minnesota), the
gluteal implant was folded, inserted into the dissected
intramuscular space, and then unfurled. The carefully
preserved muscular cuff is grasped by forceps for
interrupted suture closure on the left side. B.
Immediate intraoperative view of the augmented right
buttocks. Compare the height and fullness of the just
augmented right buttocks with the left. The 14-cm-

wide implant gently fills the depressed lateral buttocks.
C. Intraoperative view at the completion of the bilateral
implant augmentation. D. The 6-month result of the
periareolar mastopexy, 365-cc round textured breast
implant subpectoral fascia augmentation, complete
abdominoplasty, and 355-cc silicone elastomer
buttock augmentation. Compare to TECH FIG 6. The
entire buttocks are well shaped without any
surrounding skin laxity. The parallel intergluteal
vertical scar are hidden. E. Right posterior oblique
view shows nicely projecting rounded buttocks that
have taken in the slack of the lower back and upper
posterior lateral thighs. F. Lateral view shows
proportionally youthful shape of the breasts, abdomen,
and buttocks. G. Right anterior oblique view best
shows the dramatic figure change with her implants,
which along with the abdominoplasty adequately took
up the slack. The well-shaped muscular abdomen with
a low-lying and level scar complements her muscular
upper torso.
PEARLS AND PITFALLS
Aesthetic
evaluation
■ The buttock evaluation is considered with lower torso and
upper thighs. Liposuction about the perimeter of the buttocks
enhances buttock appearance and provides donor grafts.
Buttock
lipoaugmentation
■ First choice when adipose donor sites are adequate. Take is
generally very high, but unpredictable. Save potential donor
sites.
Buttock adipose
fascial flaps
■ High rate of delayed wound healing. Avoid over-resecting
with tight closure. Early overprojection is lost within months.

Silicone
elastomer
augmentation
■ As implants in America are soft elastomer and not a firm gel,
they are placed high and intramuscular to avoid uncomfortable
inferior malposition. Minimize wound dehiscence and loss of
intragluteal cleft with paramedian incisions.
POSTOPERATIVE CARE
■ Immediate postoperative elastic garment that hugs the waist, supports the
buttocks, and compresses the upper thighs is fitted according to size.
■ Patient may not to lie directly on the incision closure. She may lie directly on
the augmented buttocks for up to an hour at a time.
■ Suction silicone drains are used after lower back liposuction and alongside
adipose fascial flaps but not worth the risk of infection near silicone implants.
Meticulous drain care maintains function and exit site cleanliness.
■ Extreme hip flexion is avoided.
OUTCOMES
■ When properly informed, patients tend to like the outcomes, even when falling
somewhat short of expectations.
■ Repeat lipoaugmention for inadequate buttock fullness is anticipated and
accepted if performed at reasonable costs.
■ Buttock implant failure needs a complete reoperation, which is hard to accept,
even when forewarned.
■ Adipose fascial flap augmentation, in most instances, settles considerably,
causing considerable loss of projection.
■ Prolonged secondary healing after adipose fascial flaps may be followed by
painful depressed scarring and considerable disappointment.
COMPLICATIONS
■ Infection following lipoaugmention is a difficult and fortunately rare problem
to clear, due to the large reservoir of necrotic fat. Numerous small drainage
procedures and intravenous administered antibiotics are indicated.
■ Forceful injection of fat into the deep gluteal tissues is to be avoided, as
sudden death through large vein fat deposits followed by pulmonary embolism
has been reported in Latin America.3
■ Adipose fascial flaps placed added tension to the lower body lift closure,
which may lead to skin and fat necrosis along the closure.
■ If limited, debridement is a minor office procedure. When extensive,

debridement has been in hospital under general anesthesia procedure, usually
followed by application of VAC.
REFERENCES
1. Robert FC, Leroy VY. Clinical anatomy in aesthetic gluteal body contouring
surgery. Clin Plast Surg. 2006;33:347-358.
2. Small KH, Constantine R, Eaves FF III, Kenkel JM. Lessons learned after 15
years of circumferential body contouring surgery. Aesthet Surg J.
2016;36(6):681-692.
3. Condi-Green A, Kotamari V, Nini KT, et al. Fat grafting for gluteal
augmentation: a systematic review of the literature and meta-analysis. Plast
Reconstr Surg. 2016;138(3):437-446.
4. De la Peña JA, Rubio OV, Cano JP, et al. History of gluteal augmentation.
Clin Plast Surg. 2006;33(3):307-319.

18
CHAPTER
Gynecomastia Procedures
after Massive Weight Loss
Michele Shermak
DEFINITION
■ Gynecomastia technically is defined as enlargement of breast tissue in men.
Often with massive weight loss patients, there is pseudogynecomastia, with
skin redundancy and ptotic nipple-areolar complex (NAC) position, which
might be associated with true breast tissue.
ANATOMY
■ In male massive weight loss patients, there may be underlying musculoskeletal
deformity with barrel chest. Glandular breast tissue may be present. Skin is
excessive vertically and horizontally, with a visible inframammary fold (IMF),
and skin excess may extend posteriorly to the upper back. Standard position of
the NAC is just lateral to the pectoralis muscle, 20 cm from the sternal notch
and 10 cm from midline. With gynecomastia, nipple-areolar position is lower,
oftentimes beneath the inframammary fold.
PATHOGENESIS
■ Most male neonates have some amount of palpable breast tissue. The next
chronological peak for gynecomastia occurs during puberty, with the last peak
occurring in men between 50 and 69 years of age.
■ Physiological gynecomastia in pubertal male teens is benign and self-limited;
on the other hand, several conditions and drugs may induce proliferation of
male breast tissue. Most cases result from estrogen excess and/or androgen
deficiency as a consequence of different endocrine disorders.
■ Thyroid and testicular disease may cause gynecomastia.
■ Biochemical evaluation should be performed once physiological or iatrogenic

gynecomastia has been ruled out. Nonendocrine illnesses, including liver
failure and chronic kidney disease, are other cause of gynecomastia that should
be considered.
■ Medications associated with the onset of gynecomastia are spironolactone,
cimetidine, ketoconazole, hGH, estrogens, hCG, antiandrogens, GnRH
analogs, and 5-α reductase inhibitors.
■ Medications probably associated with gynecomastia include risperidone,
verapamil, nifedipine, omeprazole, alkylating agents, HIV medications
(efavirenz), anabolic steroids, alcohol, and opioids. Cessation of these
medications may result in resolution of gynecomastia.1–3
PATIENT HISTORY AND PHYSICAL FINDINGS
■ History should be queried regarding potential causes of gynecomastia that may
be reversible, such as use of medications or marijuana. Medical history
including hyperthyroidism or testicular disease should be checked, in addition
to family history of breast cancer. Symptoms such as pain and nipple discharge
should be checked.
■ Physical examination should emphasize on the chest as well as other body
regions elicited on medical history. Examination of the chest wall should focus
on symmetry, presence of breast tissue, skin quality, underlying
thoracic/skeletal deformities, and any masses on palpation. Testicular physical
examination is warranted.
■ Examination of the massive weight loss patient may also assess other body
regions that may be directly or secondarily addressed at the time of
gynecomastia correction.
IMAGING
■ Mammogram should be considered in a male with breast asymmetry, palpable
mass, or family history of breast cancer.4 If there are any suspicious findings on
mammogram, ultrasound and MRI studies may follow, with PET/CT if
concerns are present for metastatic breast cancer.
SURGICAL MANAGEMENT
Preoperative Planning
■ After physical examination and any necessary assessments rule out cancer
concern, planning for gynecomastia follows. Lack of skin redundancy and
good skin quality lend themselves to limited incision approaches.5 Massive

weight loss patients with skin excess, stretch marks, and NAC ptosis require
skin reduction techniques and possibly NAC grafting.6 Scars associated with
skin reduction must be discussed with the patient who should weigh in on the
technique chosen.
Positioning
■ Positioning for surgery is standard supine with arms lateral to the body at 90
degrees. Sequential compression devices and lower body warming are optimal.
Approach
■ Approaches range from liposuction to limited scar with glandular resection
and liposuction to skin reduction, glandular resection, and nipple-areolar
grafting.
T E C H N I Q U E S
■ Liposuction
■ Patient is marked preoperatively.
■ Small stab incisions are created medially and laterally on the inframammary
fold (IMF).
■ Superwet tumescent liposuction technique is followed, aiming for 1:1 match
with tumescent fluid volume instilled and lipoaspirate volume removed.
■ After adequate time is allowed for hemostatic effect, liposuction with
traditional approach (suction-assisted liposuction [SAL]), power-assisted
liposuction (PAL), or ultrasound/VASER-assisted liposuction (UAL) is
performed, reducing adipose and glandular elements, with particular attention
to treating the IMF and axillary regions (TECH FIG 1).
TECH FIG 1 • Liposuction of the chest includes small
incisions at the inframammary fold medially and
laterally on each side, utilizing preferably PAL or UAL
to remove the full tissue and gland.

■ Limited Scar Glandular Resection With
Liposuction
■ Technique for liposuction of the chest is followed.
■ Semicircular incision around the lower NAC is made and the NAC is
dissected off of the glandular tissue, maintaining glandular tissue within the
NAC to avoid NAC deformity.
■ The glandular tissue is completely removed, maintaining appropriate
subcutaneous tissue on the chest wall skin.5 (TECH FIG 2).
■ The lateral IMF stab incision may be utilized to place a drain tube.
■ The incision is closed in layered fashion with dermal and subcuticular layers.
■ The patient is dressed with foam compression and a vest to aid in contour
and reduce swelling and bruising.
TECH FIG 2 • A. Diagram of resection of breast
tissue. This will occur after fat surrounding the red
area is liposuctioned out. B. Markings for liposuction
with glandular excision (outer circle) include an added
incision (marked with a semicircle) at the lower edge
of the areola from 3:00 to 9:00. The inner circle marks
palpable breast tissue. Liposuction is performed first,
followed by incision of the NAC and glandular

excision. It is important to maintain some tissue
behind the NAC to create the most optimal contour.
■ Mastectomy With Skin Reduction After Massive
Weight Loss
■ Wise pattern is marked on the patient standing, aiming for nipple-sternal
notch distance of 21 cm and distance of 20 cm between nipples.
■ The new NAC goal is for small ovoid NAC just along the border of the
pectoralis major muscle (TECH FIG 3A).
■ NAC is harvested to superficial dermis and stored on the side table in saline-
moistened gauze.
■ Wise pattern breast reduction follows, removing glandular and
pseudoglandular tissue while maintaining appropriate-thickness skin flaps
(TECH FIG 3B).
■ A drain is placed and the skin is approximated in layered fashion, including
the Scarpa fascia, deep dermis, and subcuticular suture layers.
■ The new NAC recipient site is de-epithelialized and the NAC harvested is
sutured to the site with interrupted and running no. 4-0 chromic sutures
(TECH FIG 3C).
■ Compression dressing is created over the NAC with nonstick gauze and
foam stapled into place.

TECH FIG 3 • A. Markings for Wise pattern
mastectomy with nipple grafting for gynecomastia.
The NAC is 21 cm from the sternal notch and 10 cm
lateral to the midline, and 7 cm is allowed for the
distance between the nipple and IMF. B. The breast
tissue is dissected under the skin flap, which includes
the full thickness of the subcutaneous fat layer. The
breast tissue is then elevated off the pectoralis fascia
after the NAC is harvested and stored, and the breast
tissue is removed at the IMF. C. The Scarpa fascia is
closed with 2-0 or 3-0 interrupted braided absorbable
suture, the dermis is closed with 3-0 interrupted

absorbable monofilament suture, and the skin is
closed with 4-0 continuous intracuticular monofilament
suture. A no. 10 flat Jackson-Pratt drain is placed.
After approximating the medial and lateral skin flaps to
the IMF, the new NAC position is de-epithelialized and
grafted with the NAC harvested earlier in the
procedure.
PEARLS AND PITFALLS
Unsatisfactory
contour
■ Avoid overthinning the NAC and chest skin to create best
aesthetic result. Assure if liposuction is performed that the
surgeon avoids over- or under-resection and aims for symmetry.
Completely
resolve chest
fullness
■ Aim to add glandular tissue resection to liposuction. Men
generally do not like to palpate, let alone see, any chest fullness
after surgery. In massive weight loss, the surgeon should consider
grafting the NAC rather than maintaining the NAC on a pedicle to
avoid residual chest fullness.
Contour takes
precedence
over scar
■ In massive weight loss patients, skin removal is critical to
contour. Scars fade over time. Scars range from inframammary
scars to anchor incisions to transverse or oblique incisions in the
midchest. Scar outcomes may be optimized with patient
engagement and counseling.
Individualize
care
■ Presentation of gynecomastia runs a wide spectrum. Each patient
should be evaluated and treated specifically for his or her
presentation and scar tolerance.
Other
procedures
pair well with
gynecomastia
treatment
■ Massive weight loss patients may choose to also undergo
abdominoplasty, liposuction, and/or brachioplasty, which may be
safely performed together and will complement aesthetic results
of the gynecomastia surgery.
POSTOPERATIVE CARE
■ Surgery is most often performed as an outpatient.

■ Patients are seen within days of surgery at which time any drain tubes are
removed.
■ After this, patients are seen the following week for suture removal and
counseling for optimal scar, which may include compression, topical therapies,
and activity limits for 4 to 6 weeks.
OUTCOMES
■ Scar therapy is managed and cosmetic outcome should be excellent. There
should be no functional deficit (FIGS 1–3).
COMPLICATIONS
■ Contour irregularity—This may result in need for revisions, which are
typically performed under local anesthetic. Focal minimal liposuction or fat
transfer may be necessary, as well as excess skin removal. If a liposuction-only
technique is performed, patients may be able to palpate or see residual breast
tissue after surgery, resulting in patient dissatisfaction and desire to undergo
definitive glandular excision in a subsequent surgical procedure.
■ Visible scarring—After conservative topical management of scars for 4
months, scar management may require injectable steroid, with consideration
for later scar revision under local anesthesia as needed.
■ Seroma—If seroma results, this is initially treated with needle aspiration,
which may be performed several times. If this does not fully resolve the
seroma, a drain may be replaced to more optimally treat residual fluid.
■ Infection—This is not common and may be treated with antibiotics, beginning
with oral antibiotics that cover gram-positive organisms. Local wound care
with topical antibiotics may provide adequate treatment of cellulitis.
■ Wound healing problems—Local wound care tends to be adequate, with local
debridement as needed and moisture with coverage. Antibacterial topical
medications such as mupirocin are helpful if there is cellulitis.

FIG 1 • A,B. Pre- and postoperative photos of a male
who underwent treatment of gynecomastia with
liposuction.
FIG 2 • A-C. Pre- and postoperative photos of a male
who underwent liposuction and glandular resection of
liposuction. He also underwent liposuction of his torso
while being treated for his chest.

FIG 3 • A,B. Pre- and postoperative photos of a male
who underwent Wise pattern mastectomy with nipple
grafting after massive weight loss. He also underwent
abdominoplasty while being treated for his chest.
■ Nipple-areolar pigmentation irregularity—This may occur with nipple grafting
and is first allowed a year to improve with moisturizers. If there is residual
hypopigmentation, then local excision for small areas or tattoo for larger areas
resolves pigment issues.
REFERENCES
1. Sansone A, Romanelli F, Sansone M, et al. Gynecomastia and hormones.
Endocrine. 2017;55(1):37-44.
2. Deepinder F, Braunstein GD. Drug-induced gynecomastia: an evidence-based
review. Expert Opin Drug Saf. 2012;11(5):779-795.
3. Narula HS, Carlson HE. Gynaecomastia—pathophysiology, diagnosis and
treatment. Nat Rev Endocrinol. 2014;10(11):684-698.
4. Yen PP, Sinha N, Barnes PJ, et al. Benign and malignant male breast diseases:
radiologic and pathologic correlation. Can Assoc Radiol J. 2015;66(3):198-
207.
5. Kim DH, Byun IH, Lee WJ, et al. Surgical management of gynecomastia:
subcutaneous mastectomy and liposuction. Aesthetic Plast Surg.
2016;40(6):877-884.
6. Gusenoff JA, Coon D, Rubin JP. Pseudogynecomastia after massive weight
loss: detectability of technique, patient satisfaction, and classification. Plast
Reconstr Surg. 2008;122(5):1301-1311.

19
CHAPTERMons Pubis Reduction
Michele Shermak
DEFINITION
■ The mons region is defined as a part of the vulvar anatomy, which also
includes the labia majora and labia minora.
■ Monsplasty is performed as an isolated procedure or in conjunction with
abdominoplasty and/or medial thighplasty. The goal of monsplasty is to create
a smooth mons with attractive dimensions vertically and horizontally and
appropriate fat composition, with harmonious continuity with the abdomen.
■ The mons is often affected by massive weight loss (MWL) and pregnancy,
with descent of the pubic area, lengthening of the distance between umbilicus
and the vulvar cleft, and residual adiposity.
■ Although shortening of vertical dimensions and thinning and resuspension of
the mons may be performed with abdominal contouring procedures, narrowing
horizontal dimension can occur in conjunction with medial thigh lift.
■ Monsplasty has been shown to improve hygiene, urinary continence, and
confidence in sexuality.
ANATOMY
■ The vulva includes the mons pubis, labia majora, labia minora, vaginal
vestibule, and bulb of the vestibule (FIG 1).
■ The mons pubis is superficial to the pubic bone.
■ The labia majora are paired cutaneous folds that extend posteriorly from the
mons pubis and contain variable fatty tissue. The labia majora converge with
the labia minora at the posterior commissure or fourchette.

FIG 1 • The female genitalia, with anatomic areas
indicated: 1, labia majora; 2, labia minora; 3, mons
pubis; 4, clitoral hood; 5, glans clitoris; 6, urethra; 7,
vaginal opening.
■ The labia minora are cutaneous folds located medial to the base of the labia
majora. The visible rounded portion of the clitoris is located near the anterior
junction of the labia minora, above the openings of the urethra and the vagina.
■ The vasculature of the female external genitalia includes the anterior labial
arteries, branches of the external pudendal arteries, the posterior labial arteries,
and branches of the internal pudendal artery. The labial veins drain to the
pudendal and femoral veins.
■ The vulva is innervated anteriorly by the anterior labial nerves and branches of
the ilioinguinal nerve and by the genital nerve, which extends from the
genitofemoral nerve. The vulva is innervated posteriorly by posterior pudendal
branches.
PATHOGENESIS
■ Mons pubis and labia majora morphology are impacted by aging, pregnancy,
and weight changes that in turn impact fat composition, dimensions, and ptosis.
■ The youthful mons pubis is narrow, with good skin tone, and has a moderate
amount of fat in the subcutaneous plane to provide padding against the bony

symphysis.
■ With age, pregnancy, or weight fluctuations, the mons pubis can appear wide
and protuberant with poor skin tone (FIG 2). The labia majora may be
deflated, and there is ptosis of the external genitalia with increasing distance
from the abdomen inferiorly.
■ With obesity, the mons becomes increasingly protuberant with a relatively
high composition of fat, which often lends itself to surgical correction with
liposuction alone. Difficulty with sexual intercourse and maintenance of
hygiene as well as discomfort when wearing pants and swimsuits may result.
This situation can also impact self-esteem.
■ Techniques to correct the protuberant mons and pubic descent with excess skin
address these issues with pubic lifting, fat excision and liposuction, and/or
elevation and suspension of the fatty layers to the rectus abdominis fascia.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ The surgical consultation should begin with discussion of patient concerns and
desired outcomes. Discomfort or dissatisfaction with sexual intercourse,
bladder control, problems with exercise or wearing certain clothing, and
hygienic concerns could result in a patient initiating a surgical consultation.
■ Medical history should be explored for any medical conditions and history of
weight gain or loss and pregnancies, as well as surgical history.
FIG 2 • A. Mons pubis in MWL demonstrates significant
ptosis and excess fat. B. Abdominoplasty with removal
of the upper part of the mons pubis will allow a
rejuvenated appearance.

■ Physical examination is comprehensive and involves the abdomen as well as
the external genitalia.
■ A surgical plan is then developed to address patient desires and goals, as well
as physical findings, adjusting treatment to health and safety concerns.
IMAGING
■ This is not applicable to monsplasty management.
SURGICAL MANAGEMENT
Preoperative Planning
■ After history and physical examination, planning for monsplasty takes place.
Considerations for the pubic region include fat composition and skin quality
and excess, as well as height and width dimensions. In most abdominal
contouring procedures, the mons pubis is treated with the abdomen with
liposuction.
■ With varying degrees of mons distortion beyond excess fatty tissue, excisional
procedures including horizontal and vertical wedge excision with or without
abdominal or thigh contouring are necessary.
■ Horizontal excision shortens vertical distance and may be performed in
continuity with abdominoplasty, allowing 6 to 7 cm of distance between the
vulvar cleft and the lower abdominal skin incision.
■ Vertical excisions of the mons and labia majora as a central ellipse or as
lateral wedges may be included in medial thighplasty to narrow the mons
pubis, by restoring a more youthful triangular configuration.
■ Lipoplasty through liposuction or excision in conjunction with central wedge
excision techniques allows for thinning a protuberant mons pubis and aids in
final contouring to provide better harmony with the abdomen. When
contouring of the mons pubis and/or labia majora is complete, the pubic tissues
may be suspended up to the fascia of the rectus abdominis to prevent them
from recurrent descent.
Positioning
■ Positioning for surgery is standard supine with arms lateral to the body at 90
degrees, with appropriate padding and heating for the body to optimize safe
surgery without complicated outcomes. Sequential compression devices are
mandated as well. Some surgeons like to perform monsplasty in stirrups, which
may increase VTE risk.

Approach
■ Allowing for a distance of 6 to 7 cm from the vulvar cleft to the top of the
mons pubis is necessary to avoid distortion and overelevation of the mons
pubis. The mons pubis when performed in conjunction with abdominoplasty
should strive for the same depth of skin to deep fascia as is present in the
abdomen to create harmony between the abdomen and mons pubis.
T E C H N I Q U E S
■ Liposuction
■ Patient is marked preoperatively. Small stab incisions are created. Superwet
tumescent liposuction technique is followed, aiming for 1:1 match with
tumescent fluid volume instilled and lipoaspirate volume removed. After
adequate time passes for hemostatic effect, liposuction with traditional
approach (SAL), power-assisted (PAL), or ultrasound/VASER-assisted
(UAL) liposuction is performed, reducing adipose content (TECH FIG 1).
TECH FIG 1 • Liposuction of the mons pubis may be
performed with augmented technologies such as
ultrasound and power to provide skin tightening.

■ Central Wedge Excision of the Mons Pubis
■ Elliptical width is determined for appropriate narrowing of the pubis.
Surgical resection includes skin and fat, working the dog-ear inferiorly into
the vulvar cleft and avoiding injury to the region of the clitoris (TECH FIG
2).
TECH FIG 2 • Central wedge excision is marked,
centered around the central vertical axis of the mons
pubis and short of the convergence of the labia
majora.
■ Horizontal Excision With Lipoplasty and
Suspension to the Rectus Fascia in Conjunction
With Abdominoplasty
■ Markings for abdominoplasty establish 6 to 7 cm of distance between the
lower abdominal incision and the vulvar cleft.
■ Abdominoplasty proceeds with elevation of the lower skin flap for upper
mons excision in continuity with the abdominal skin flap.
■ After completion of the abdominoplasty, subcutaneous fat of the mons is
excised, leaving a layer of fibrofatty tissue on the abdominal wall and
allowing for skin thickness congruent with the abdomen.

■ The deep fat on the mons skin flap is then suspended to the rectus fascia
with 3 to 4 braided absorbable sutures (TECH FIG 3).
■ The abdominal incision is closed over drains in layered fashion with
superficial fascia, deep dermal and subcuticular layers.
TECH FIG 3 • Horizontal wedge excision of the
superior mons pubis in conjunction with
abdominoplasty includes defatting of the mons pubis
with suspension to the rectus abdominis fascia.
■ Lateral Wedge Excision of the Labia Majora and
Mons Pubis in Conjunction With Medial
Thighplasty (See Thigh Lift chapter)
■ In marking the anterior aspect of the APEX thigh lift or vertical extended

thigh lift into the inguinal region, a central axis is marked on the mons pubis.
■ The width of the pubis is determined and should be consistent with
dimensions of the underlying bony pubic symphysis, with symmetry of the
mons result around the central axis measured and marked.
■ In performing the anterior excision of the thigh lift along the inguinal crease,
markings along the lateral pubis are commitment excisions, with excision of
the redundant lateral pubis and anterior medial thigh dependent on avoiding
tense closure and performed in stepwise fashion (TECH FIG 4).
TECH FIG 4 • A. Lateral excision of the mons pubis
and labia majora is carefully marked preoperatively, in
order to create a symmetrical pubis centered around
the central axis. B. Intraoperative photo of the anterior
aspect of medial thigh lift, with pubis markings and
extent of thigh lift excision to occur superiorly. C.
Intraoperative photo of completed medial thigh lift with
contoured, thinned mons dimensions.
PEARLS AND PITFALLS
Contour irregularities
■ Avoid overthinning and assure uniform treatment,

and skin laxity
secondary to
liposuction
recording “ins and outs” of tumescent fluid infiltrated
and lipoaspirate removed to create best aesthetic
result. Augmented technologies such as PAL and UAL
assist in avoiding tunneling deformities and may
tighten the skin beyond what is achievable with SAL.
Horizontal skin
resections rejuvenate
the mons pubis, but
they may descend with
time
■ Suspend the upper mons deep fatty tissue to the rectus
fascia with several absorbable sutures to promote
prolonged suspension of the mons pubis.
Avoid asymmetrical or
shortened mons pubis
dimension
■ Asymmetry in skin dimension horizontally or
vertically is best avoided through careful preoperative
markings, working around a central axis, and allowing
for symmetry around the axis and the vulvar
commissure. Patient presentation may be
asymmetrical, so asymmetrical treatment may be
mandated. Using the vulvar cleft as a fixed point, the
mons should be no shorter than 6–7 cm to avoid overly
high labia majora placement.
Lateral pubic wedge
excision during medial
thighplasty with vertical
reduction through
abdominoplasty can
lead to a puffy mons
pubis due to
pincushion effect of
circumferential scar
■ Markings should not create overly full or overly
shortened pubis at the outset. Lymphatic injury should
be avoided and superficial excision leaving tissue
above deep fascia and vascular and lymphatic
structures helps optimize edema prevention.
Pincushion effect is often unavoidable. Compression
with foam and a support girdle and massage help.
Secondary liposuction may be necessary.
Individualize care
■ Presentation of mons pubis and labia majora
deformity cover a wide spectrum. Each patient should
be evaluated and treated specifically for her
presentation, surgery on adjacent areas such as the
abdomen and medial thigh, and scar tolerance.
Avoid damage to the
clitoris
■ Knowledge of external genital anatomy and limiting
excision inferior to the superior convergence of the
labia majora will help avoid clitoral injury, which is
very difficult to fix.

POSTOPERATIVE CARE
■ Surgery is most often performed as an outpatient. Patients are seen within days
of surgery. After this, patients are seen the following week for suture removal
and counseling for optimal scar, which may include compression, topical
therapies, and activity limits for 4 weeks. Follow-up may then take place
months later for scar management reinforcement.
OUTCOMES
■ Scar therapy and compression are managed expectantly, and cosmetic outcome
should be excellent. There should be no functional deficit, and in fact there
may be improvement in sexual satisfaction and urinary continence.
COMPLICATIONS
■ Asymmetry and contour irregularities—Markings are most important to proper
symmetry and mons dimensions, and suspension of the mons pubis will protect
against recurrent ptosis. Focal liposuction or fat transfer may be necessary, as
well as excess skin removal.
■ Visible scarring—After conservative topical management of scars for 4
months, scar management may require injectable steroid, with consideration
for later scar revision under local anesthesia as needed. The hair-bearing pubis
is a setup for hypertrophic and keloid scarring.
■ Injury to external genitalia—Surgery should not be performed below the level
of the upper pubic symphysis internally, and tissue should be maintained on
deep fascia. More superficially, the anterior labia majora converge over the
clitoral hood, and the clitoris should be protected from surgical injury.
REFERENCES
1. Alter GJ. Pubic contouring after massive weight loss in men and women:
correction of hidden penis, mons ptosis, and labia majora enlargement. Plast
Reconstr Surg. 2012;130:936-947.
2. Alter GJ. Management of the mons pubis and labia majora in the massive
weight loss patient. Aesthet Surg J. 2009;29(5):432-442.
3. Bloom JMP, Van Kouwenberg E, Davenport M, et al. Aesthetic and functional
satisfaction after monsplasty in the massive weight loss population. Aesthet
Surg J. 2012;32(7):877-885.
4. Davison SP, LaBove G. Going in the wrong direction with monsplasty.
Aesthet Surg J. 2013;33(8):1208-1209.

5. Matarasso A, Wallach SG. Abdominal contour surgery: treating all aesthetic
units, including the mons pubis. Aesthet Surg J. 2001;21(2):111-119.
6. Shermak MA, Mallalieu J, Chang D. Does thighplasty for upper thigh laxity
after massive weight loss require a vertical incision? Aesthet Surg J.
2009;29(6):513-522.
7. Triana L, Robledo AM. Aesthetic surgery of female external genitalia. Aesthet
Surg J. 2015;35(2):165-177.

20
CHAPTER
Upper Arm Lift
(Brachioplasty)
Jennifer Capla and Joseph Michaels
DEFINITION
■ A brachioplasty or upper arm lift is a procedure that targets the skin excess
from the axilla to the elbow.
■ The “hammock”-like effect of loose skin is sometimes known as “bat wings.”
ANATOMY
■ With the arm abducted and flexed at 90 degrees, the important landmarks for
assessment are from the apex of the axillary crease to the olecranon (FIG 1).
■ The bicipital groove is the area between the biceps brachii above and the long
head of the triceps below.
■ In the bicipital groove, below the brachial fascia, lie several important
neurovasculature structures including the median and ulnar nerves and the
axillary artery and vein.
■ In the midportion of the upper arm over the bicipital groove, superficial to the
brachial fascia, lies the medial brachial cutaneous nerve.

FIG 1 • Arm serial sections over bicipital groove. The
blue dotted line approximates scar position in the
bicipital groove. B, biceps tendon; T, triceps muscle; H,
humerus.
■ In the distal portion of the upper arm over the bicipital groove, superficial to
the brachial fascia, lies the medial antebrachial cutaneous nerve and the basilic
vein.
PATHOGENESIS
■ Factors that can produce laxity of the upper arm soft tissue:
■ Significant weight changes

■ Aging
■ Previous liposuction
■ Sun damage
■ Despite a good exercise regimen, skin may not retract. This is likely due to
weakness of the connections of the superficial fascial system to the axillary
fascia.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ A history of significant weight loss, aging, or previous liposuction can lead to
skin excess of the upper arms.
■ Patients complain of loose hanging skin of the upper arms that interferes with
daily activities, difficulty with finding shirts that fit, and the need to wear long
sleeves even in the summer to cover up due to embarrassment of the tissue
excess.
■ Physical examination:
■ Examine the patient with arms abducted at 90 degrees and the forearm flexed
at 90 degrees.
■ Visible skin excess from the axilla to the elbow that drapes like a hammock.
■ Determine residual adiposity vs skin laxity.
■ Assess for any arm swelling or lymphedema.
■ Contraindications: chronic swelling from lymphedema or venous
incompetence
IMAGING
■ No radiologic imaging or diagnostic testing is necessary.
SURGICAL MANAGEMENT
Preoperative Planning
■ Assess the patient’s goals—in front of the mirror with the arm abducted and
flexed at 90 degrees, use the pinch technique to demonstrate what the arm lift
will achieve.
■ If the patient has significant residual adiposity, an arm lift alone may leave the
patient with a heavy arm. Consider liposuction prior to debulk the arm, and
then return for an arm lift at a second stage. If the majority of fat is in the
posterior compartment of the arm, then liposuction can be combined with the
procedure.
■ Weight loss patients should be weight stable for a minimum of 3 months.

Nutritional assessment is an important factor in wound healing. Labs should
include albumin, prealbumin, TIBC, and folate.
■ Managing expectations: Preoperative discussion with the patient about the scar
ensures that the patient understands the trade-off. Brachioplasty scars can be
red, raised, thickened, and cordlike. Take a black sharpie and mark the
approximate position of the scar on the patient. This allows them time to go
home and look in the mirror to make sure that they are willing to trade for the
scar.
■ Scar position: The brachioplasty scar can be positioned in either the bicipital
groove or the posterior arm. A patient should be given the opportunity to
choose. We prefer the bicipital groove for scar location. There are patients in
certain professions, like teachers, who raise their arms a great deal and have
opted for the posterior scar.
■ Bicipital groove scar—visible from the front view when the arm is abducted
and flexed, but when the arm is down at the patient’s side, it is not seen.
■ Posterior scar—not visible from the front or back when the arm is abducted
and flexed, but when the arm is down at the patient’s side, it can be seen from
behind.
■ Marking the patient preoperatively is of utmost importance.
■ Using the pinch technique, a guide to the excision pattern can be determined.
Pay careful attention to the pull in the axilla and the lateral chest wall to ensure
that there is no distortion on the chest/breast area.
■ If any arm bands are present, then resection may lead to worsening of the
bands (“Popeye deformity”) that you must make the patient aware of before
surgery.
■ Speak with your anesthesiologist:
■ IV placement in the hand, not the antecubital fossa
■ Blood pressure cuff on the leg or forearm
■ If performing more than one procedure, it is best to start with the arms. If not,
discuss with the anesthesiologist about the possibility of limiting IV fluid to
decrease overall swelling until the arm resections are performed.
Positioning
■ Patient should be in the supine position with arms abducted laterally at 90
degrees on arm boards.
■ Prep arms circumferentially to maintain full mobility and include chest and

lateral chest wall.
■ Sterile self adhesing wrap (Coband) is helpful to cover any tubing or wiring to
maintain a sterile field.
Approach
■ Bicipital Groove Scar Brachioplasty.
T E C H N I Q U E S
■ Full Scar Brachioplasty-Bicipital Groove Scar
Marking
■ Mark the patient in the standing position with the arm abducted and elbow
flexed at 90 degrees.
■ Ask the patient to flex the biceps and palpate the bicipital groove.
■ Draw a horizontal line from the apex of the axillary crease to a point about 2
cm proximal to the olecranon, marking the final scar position.
■ With a marker positioned over your line in place, distract the arm tissue
downward to obtain the superior marks.
■ The next point is essential to the marking.
■ First mark the apex of the axilla (x).
■ Find a point on the low hanging skin that can be distracted inward and
upward to the apex point marked in the axilla. It may take several attempts
until it appears right.
■ Once this point is chosen, mark it with a distinguishable circle point and
call it (xʹ) (TECH FIG 1A).
■ While holding the xʹ point to the axillary apex point (x), do a pinch test at
several places in the arm distal to the axilla to mark the estimated lower
border.
■ The mark in the apex point in the deltopectoral groove (x) is carried
inferiorly on the lateral chest, posterior to the lateral pectoralis border to
carry out the dog-ear or to excise excess lateral chest wall tissue.2
■ With the arm extended, carry the marking from xʹ and connect it to the
inferior aspect of the above marked axillary marking.
■ The length of this line should be estimated using a pinch technique to

determine where the skin excess tapers. Careful attention to the pull on the
chest/breast area should be noted.
■ Last, place hash marks perpendicular to the previous marks as a guide to line
up the closure. Assess both arms from a distance to ensure symmetry (TECH
FIG 1B,C).
Liposuction
■ If combining this technique with liposuction, perform the liposuction of the
posterior arm and then begin the excision. Important, do one arm at a time.
■ Do not liposuction of both arms first, because the swelling will alter the
ability to excise on the other side.
Incision and Flap Elevation
■ Infiltrate with local anesthetic.
■ Incise the superior portion of the marked incision.
■ Elevate a subcutaneous flap above the brachial fascia. Recognize that the
arm is a cylinder, so check the thickness of your flap for consistency. It is
easy to get too deep.
■ Raise the flap just past the inferior border marking.
■ In the axilla, stay superficial to avoid injury to underlying lymphatics and
neurovasculature structures.
■ When approaching the elbow, stay superficial to avoid injury to the medial
antebrachial cutaneous nerve. If you see the basilic vein, the nerve will be
close.
Resection, Stapling, and Closure
■ Once the entire flap is elevated, place two towel clips on the flap and have
an assistant distract the flap superiorly and medially.

TECH FIG 1 • Markings for bicipital groove full scar
brachioplasty. A. Mark bicipital groove (blue line).
Mark the apex of the axilla (point x). Choose and mark
point x’ to adequately distract the tissue upward and
inward. Distract tissue downward to mark upper line.
Using pinch technique, with x’ being pulled into x, to
mark lower border. B. Place hash marks to line up the
border. C. Preoperative markings.
■ Using a heavy forceps, remark the x´ point. Make a vertical cut and inset to
the high point in the axilla. Place 2 to 3 deep 0-Vicryl sutures from the
axillary fascia to the deltopectoral fascia to avoid scar migration out of the
axilla.1
■ Resection must be performed in a segmental fashion to ensure closure.
Starting at the most distal hash mark, use heavy forceps to mark the inferior
excision point. Incise vertically, and staple the point. Continue this for all
hash marks.

■ Once appropriate tension has been set, mark the remainder of the inferior
border and excise.
■ Tailor tack the incision with staples. Do not leave the wound open for an
extended period as swelling may occur, putting unnecessary tension on the
closure or worse off, the inability to close.
■ Lift arm up gently off the arm board to assess tension and appearance.
Perform the procedure on the contralateral arm. When finished, compare both
arms prior to closure for symmetry.
■ If placing a drain, bring out from the lateral chest wall. In our practices, we
have moved away from placing drains.
■ Close the incision in layers.
PEARLS AND PITFALLS
Over-
resection
■ Always perform excision in a segmental fashion. Failure to do so
may lead to an incision that cannot be closed.
Liposuction
■ If performing liposuction in combination with a brachioplasty, be
sure to do liposuction and the excision immediately afterward on one
arm at a time (unless a two-team approach). Otherwise, swelling can
lead to decreased ability to excise the desired tissue or can lead to
failure to close the arm.
Scars
■ Warn patients that the brachioplasty scars can heal red, raised,
thickened, and/or cordlike. They can take up to 2 years to mature
unlike other scars.
Staging
■ For patients with significant residual adiposity, liposuction should be
performed as a first stage to reduce the volume and then return for
brachioplasty in at least 3 months. If the first stage is not performed,
the patient will be left with a heavy arm. If all done in one stage,
when the swelling subsides, the patient will likely have residual skin
laxity.

FIG 2 • A,B. Preoperative and postoperative view of
male patient.
POSTOPERATIVE CARE
■ Place the patient in an arm compression garment for 4 to 6 weeks.
■ Keep arms elevated as much as possible.
■ Do not exceed 90 degrees at the shoulder for 4 weeks.
■ After 4 weeks, the patients can walk their fingers up the wall daily until full
extension is reached.
■ Begin massage therapy with the product of your liking and consider silicone
gel or strips.
OUTCOMES
■ Arm contour will immediately be improved (FIGS 2 and 3).
■ Patient satisfaction with the shape of the arm is high; however, scars can take 1
to 2 years to mature and improve in color and texture.
COMPLICATIONS
■ Seroma—fluid collection generally occurs near the elbow and may require
serial aspirations in the office.
■ Wound dehiscence—generally superficial in the axilla. Treat with dressing
changes.
■ Hematoma
■ Infection
■ Poor scarring—may require Kenalog injections.
■ Over-resection can lead to failure to close the wound or total dehiscence

postoperatively. Avoid by performing segmental excision at the time of
procedure, and do not leave incision open for any meaningful period of time.
■ Contracture across axilla—can cause pulling or banding in the axilla. May
require a Z-plasty to recruit additional tissue to the area.
■ Sensory loss
■ Chronic swelling
FIG 3 • A–D. Preoperative and postoperative view of
female patient.
REFERENCES
1. Lockwood T. Brachioplasty with superficial fascial system suspension. Plast
Reconstr Surg. 1995;96:912-920.
2. Downey S, Dross J. Lateral thoracic excisions in post massive weight loss
patient. Clin Plast Surg. 2008;35:115-120.

21
CHAPTERUpper Thigh Lift
Michele Shermak
DEFINITION
■ Upper thigh lift describes excision of lax and/or redundant thigh tissue to
improve tautness, circumference, and/or shape of the thighs.
■ This procedure is often included in approaching lower body lifting for
individuals who have sustained massive weight loss.
■ The procedure may be performed in combination with lifts of adjacent body
regions such as the abdomen or back to globally improve the lower body
region.
ANATOMY
■ Anatomic details of the thigh are shown in FIG 1.
■ The skin can demonstrate varying degrees of redundancy, vertical excess,
laxity, and collagen strength. Thin skin may have greater recoil after surgery
resulting in exacerbated loosening of the surgical result. Attention should be
focused on the presence of varicose veins, and if there are many, referral to a
vascular surgeon is prudent to minimize varicosities prior to embarking on
thigh lift.
■ Subcutaneous fat varies in thickness.
■ A thinner fat layer is more appropriate for thigh lift than a thick one, which
would more optimally lead to a liposuction contouring procedure or
recommendation for weight loss.
■ The fat between the anterior thigh and posterior thigh is different: anterior
thigh fat is thinner and softer, whereas posterior fat tends to be thicker and
fibrous.
■ The final scar appearance may be impaired by the difference in fat

characteristics in the medial anterior and posterior thigh with fullness and
visibility, particularly if posterior fat is pulled anteriorly.
■ Liposuction of the fat to be excised has been described to aid in better
visualizing veins and lymphatics; however, liposuction may impair healing,
and less is more may be the case here, with improved healing without
liposuction performed in the area to be resected.
■ Scarpa fascia is the pseudofascial plane in the subcutaneous fat that is located
superior to the greater saphenous vein on the inner thigh. The depth of this
fascial plane is short in the groin area where penetration can lead to potential
injury of the saphenofemoral veins and femoral artery or nerve.
■ Deep muscular fascia should be obscured by soft tissue with tissue
undermining during thigh lift to help preserve the greater saphenous vein and
lymphatics.
■ Muscles in this should not be visualized as the muscular fascia is not
penetrated; surgery only involves the skin and subcutaneous fat of the inner
thigh.
■ Patients seeking thigh lift may have superficial dilated varicose veins. The
greater saphenous vein is important, because it is within the field of the vertical
inner thigh lift and should not be traumatized, as injury may lead to distal
extremity swelling. Perforators off the vein are ligated and cut. The
saphenofemoral junction is close to the skin surface and may be seen and
should be preserved.
FIG 1 • A,B. Thigh anatomy is notable anteriorly for the
saphenofemoral junction at the groin and the lymphatic

collections at the groin and knee. External anatomy—
skin quality, fat quantity, and superficial vein and
varicosities—is variable in presentation.
FIG 2 • Prone positioning helps provide the best access
to the posterior thigh, when performing APEX proximal
thigh lift. Safety measures while the patient is in prone
position include the following: A. Face in prone pillow
with goggles protecting eyes from pressure and
desiccation; arms are placed at 90 degrees, and gel
bumps are placed under the chest and lumbar region.
B. Bump under chest lumbar regions and forced
warming blanket to avoid hypothermia.
■ Dissected thigh tissue is always discarded, so arterial perforators are ligated
and cauterized, and no major arteries are within the field of dissection. The
femoral artery is close to the skin surface, and dissection should be carefully
performed in the groin.
■ Dissection deep to superficial fascia may result in injury to lymphatics, which
travel close to the saphenous vein. Lymphoceles may develop postoperatively
near the knee where lymphatics are dense.
PATHOGENESIS
■ With skin laxity and/or weight loss of varying degrees, individuals can suffer
from excess skin in the thigh.
■ This may be focally limited to the proximal aspect of the inner thigh with

minimal skin change outside of this area, most often seen in younger massive
weight loss patients.
■ On the other hand, others present with more diffuse, global changes in the
inner thigh, with significant attenuation and redundancy of the skin, typically
in the older, thinner patient who has experienced massive weight loss.
■ A more extended approach to thigh lift in this patient population will reduce
circumference and improve skin appearance all the way to the knee.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Patient history should be probed for significant weight loss and, if present in
the history, the mode and degree of weight loss, as well as nutritional
challenges that may exist.
■ Weight should be stable at the time of surgery at least 3 months.
■ Medical conditions that may impact outcome of thigh lift surgery such as
peripheral vascular disease, varicose veins, venous thromboembolism,
diabetes, heart disease, sleep apnea, autoimmune and endocrinological
disorders, and coagulation disorders and venous thromboembolic history
should be queried.
■ Any history of surgery in the groin region must also be addressed, such as
that performed for lymph node biopsy.
■ Physical findings should note skin quality and degree of excess and
redundancy and varicosities as well as adiposity.
■ Chronic calf swelling needs to be noted if present.
■ Adjacent body regions such as the mons pubis, abdomen, and back are
examined to see if addressing these regions will improve overall lower body
aesthetics.
SURGICAL MANAGEMENT
Preoperative Planning
■ Preoperative planning with thigh lift includes addressing significant varicose
veins ahead of surgery, as well as discussion of different thigh lift approaches
with differing scar lengths.
■ More focal proximal skin excess and good skin quality lend themselves well
to proximal scar along groin crease, which is well hidden.
■ More extended involvement to the knee with attenuated skin and cellulite
may be better addressed with vertical incision along the length of the inner

thigh.
■ With existing calf swelling, the more limited proximal approach is preferable
as the more extended thigh lift approach can exacerbate thigh swelling.
■ Widened mons pubis may be treated at the time of thigh lift, with inclusion of
lateral mons tissue within the zone of resection, paired with liposuction of the
mons, as needed (see Chapter 19).
Positioning
■ Positioning varies depending on the thigh lift approach.
■ The proximal approach requires prone to supine positioning to treat posterior
dog-ear and impact of result by extending excision into the infragluteal fold.
■ Prone positioning precautions must be followed in the head and neck area and
upper body, as well as the gluteal region and thighs.
■ Gel rolls are placed along the upper chest/axilla, and the neck is placed in a
neutral position with head resting in prone pillow and eyes off-loaded.
■ Arms at elbow and axilla placed at no greater than 90 degrees with padding
under arms and legs to protect pressure points (FIG 2).
■ The more extended vertical inner thigh excision requires only supine
positioning.
■ In the supine position, thigh lift is most easily performed with leg extension
bars off the end of the operating room table to allow the surgeon to stand or sit
between the legs, which are spread apart from each other.
■ Positioning of the thighs in stirrups as seen in gynecological surgical
procedures is not necessary and puts the patient at risk for venous
thromboembolism (VTE) at the groin with flexion of the hip.
Approach
■ Direct excision of the skin excess of the inner thigh is performed.
■ Approach must be symmetrical and may include lateral mons pubis to reduce
the pubis, which may be widened and full.
■ Excision at the lower aspect of the pubis in the groin is most at risk for high
tension, so a bottleneck in the excision is created at this point to avoid too
much tension and predilection for wound healing problems or pull on the mons
pubis or labia.
■ Excisions marked should be equivalent bilaterally to aim for best, most
symmetrical scar placement, and the ideal scar is hidden when the thighs come

together.
T E C H N I Q U E S
■ Proximal “APEX” Thigh Lift
Posterior Portion
■ The patient is marked while standing.
■ Posterior marking is made in the infragluteal fold, which the surgeon may
have to choose with buttock deflation and multiple folds. This mark is
connected to the anterior groin crease along the mons pubis (TECH FIG
1A).
■ A crescent is then marked more distally to define excision, aiming to avoid
over-resection.
■ Skin is grasped and pulled tautly upward to determine skin excision.
■ The midline of the inner thigh should be marked vertically, and hatch
marks may be marked posteriorly to guide closure.
■ The patient is intubated on a stretcher and turned to the prone position with
careful padding and protection of all potential pressure points.
■ The patient is prepared with Betadine.
■ If lower back lift is planned, that procedure should be performed first as the
infragluteal fold marking may migrate superiorly and require revision.
■ Incision is made in the gluteal fold, through the subcutaneous fat to deep
fascia.
■ Vertical incision is made on the medial-most aspect of the thigh at the
vertical marking.
■ Dissection is then directed inferiorly toward the lower marked incision
(TECH FIG 1B).
■ Careful hemostasis is performed and the wound is irrigated.
■ Local anesthetic is injected above and below the deep fascia; long-acting
Marcaine is preferable.
■ The amount of skin that may be safely excised is determined by pulling up
on the skin flap and marking it, adjusting as needed from prior marking.
■ Local anesthetic, preferably long-acting Marcaine, is injected to the deep
tissues in the wound.

■ A braided no. 1 caliber suture is used to approximate the skin flap up to the
ischial periosteum, which is encircled by the surgeon’s fingers.
■ Proper placement in periosteum is ensured by pulling on the suture and
seeing no movement in the buttock.
■ Lateral to the ischium, superficial fascia in the fat is approximated to the
analogous gluteal fold fascia with 2-0 braided absorbable suture (TECH
FIG 1C).
■ The skin is closed with no. 3-0 monofilament absorbable suture to
approximate deep dermis and running no. 4-0 monofilament absorbable
suture as a running subcuticular suture.
■ The skin is then better approximated with 4-0 nylon simple interrupted
sutures (TECH FIG 1D,E).
■ The wound is washed and dressed with cyanoacrylate glue.
TECH FIG 1 • A. Posterior marking is made in the
infragluteal fold, which the surgeon may have to
choose with buttock deflation and multiple folds. This
mark is connected to the anterior groin crease along
the mons pubis. A crescent is then marked to define
the extent of excision. The midline of the inner thigh

should be marked vertically, and hatch marks may be
marked posteriorly to guide closure. B. Incision is
made in the gluteal fold, through the subcutaneous fat
to deep fascia. Vertical incision is made on the medial-
most aspect of the thigh at the vertical marking.
Dissection is then directed inferiorly toward the lower
marked incision. C. Approximation of the posterior
aspect of APEX thigh lift depends on deep suspension
with multiple permanent sutures to ischial periosteum.
D,E. Closure is completed superficially and defines
the infragluteal crease.
Anterior Portion
■ The patient is then turned supine, most safely performed by logrolling onto a
stretcher with a roller on it and then pulling the patient back onto the OR bed
(TECH FIG 2A).
■ Pillows are placed under the legs vertically to elevate the inner thigh up.
■ A small “bump” may be placed between the thighs.
■ The area is sterilized.
■ If abdominoplasty is planned, that is performed first.
■ Incision in the inner thigh is continued along the groin crease, symmetric
from the mons midline.
■ The excision is begun from posterior to anterior in steps to assure there is no
over-resection, with undermining of the marked skin quite superficially, by
avoiding injury to veins and lymphatics in the groin area.
■ The skin is sequentially cut, and the excision is tapered up to the lower
abdomen to achieve lift of the upper anterior thigh.
■ Local anesthetic is injected to the wound and along the periosteum.
■ The skin flap is approximated to pubic periosteum with no. 1 braided
permanent sutures, again taking sufficient bite of periosteum to avoid labial
pull and spread.
■ More superior to the pelvis, approximation of superficial fascia along the
upper groin and abdomen is performed with 2-0 braided absorbable suture,
followed by 3-0 monofilament absorbable suture in deep dermis and running
4-0 monofilament absorbable subcuticular suture.

■ The area is washed and dressed with cyanoacrylate glue (TECH FIG 2B).
TECH FIG 2 • A. Remaining redundant inner thigh
tissue is visible anteriorly in supine position. B. The
excision proceeds from posterior to anterior with
undermining of the thigh skin superficially. The skin
flap is approximated to the pubic periosteum with
multiple permanent sutures to avoid labial pull and
spread.
■ Extended Vertical Thigh Lift
■ The patient is marked standing.
■ Skin is grasped and pulled taut toward midline of the thigh from the knee
to the groin, and this area is marked as an ellipse that tapers distally to the
knee and proximally along the lateral groin crease (TECH FIG 3A,B).
■ Cross-hatches are made to guide in closure.
■ The patient is supine on the OR table, which is ideally fitted with padded leg
extension boards, so the legs may be spread and allow a surgeon to stand or
sit between them (TECH FIG 3C).
■ Sterile Foley catheter is placed, and the patient is prepared with Betadine.
■ Skin excision in stepwise fashion from distal to proximal using hatch marks
as stop points.
■ The pinch test guides the extent of tissue removal (TECH FIG 3D).
■ Depth of excision should be just deep to superficial fascia to avoid injuring

veins and lymphatics.
■ Perforating venous branches are ligated with clips. The skin is stapled with
each stop point.

TECH FIG 3 • Extended vertical thigh lift. A,B. Skin
markings. C. Patient positioning and markings. D.
Tissue removal is guided by the pinch test. E. Skin
excision proceeds in stepwise fashion from distal to
proximal using hatch marks as stop points. Excess
skin and Scarpa fascia are removed with progressive
approximation from distal to proximal. Scarpa fascia is
closed with 2-0 interrupted braided absorbable suture.

The incision is closed over a drain. F. Closure in
superficial fascia within the fat is performed with
barbed continuous suture, and the skin is
approximated in layers, dressed with cyanoacrylate
glue.
■ Once the pubic bone is reached, a bottleneck is made with smaller degree of
skin excision to avoid tension.
■ Above this point, excision is very thin, skin only.
■ A drain is passed from distal to proximal, exiting out the distal incision and
fixed to the skin with 3-0 nylon suture (TECH FIG 3E).
■ The wound is approximated in the superficial fascial plane in fat with
running barbed 0 PDO suture from midincision proximally and distally.
■ The skin is closed with a 3-0 monofilament absorbable suture in deep
dermis and running no. 4-0 monofilament absorbable subcuticular suture.
■ The area is washed and dressed with cyanoacrylate glue (TECH FIG 3F).
■ The leg is wrapped from the toe to above knee with compression wrap to
minimize swelling. The incision is protected by ABD pads.
PEARLS AND PITFALLS
Optimizing
scar
■ The best scar results from reduction of tension on the wound,
assured by limiting over-resection and by scar location and
symmetry. Without gluteal augmentation, the gull wing scar leads
the eye to a focused, well-contoured gluteal region. Maintaining
adequate subcutaneous fat on the skin flap for autologous
augmentation is critical to avoid wounds.
Optimizing
wound
healing
■ Avoid high tension closure and proactively address intraoperative
issues such as hypothermia and anemia. Wounds are extremely
common in the midportion of the incision at the lower sacrum and
respond well to gentle cleansing and petrolatum application.
Avoiding
lower
extremity
swelling
■ Avoid injury to the greater saphenous vein and lymphatic system by
staying superficial to deep fascia while excising tissue. Swelling is
particularly problematic with the extended vertical approach.