Phẫu Thuật Tạo Hình Đường Nét Cơ Thể Và Hút Mỡ (Body Contouring and Liposuction)

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PART | 5  Abdominal contouring procedures
what sequence is utilized, a well-trained and coordinated
team is necessary in order to effectively maneuver the
patient through the turns with minimal exposure and
heat loss.
Anesthesia and DVT Prophylaxis
In the authors’ experience, adequate anesthesia for a belt
lipectomy is best attained using a general anesthetic with a
thoracic epidural placed preoperatively to aid with postop­
erative discomfort.16 Early evidence suggests that epidural
anesthesia has significant deep vein thrombosis (DVT)/pul­
monary embolism (PE) risk reduction; however, its use in
plastic surgery remains relatively unstudied. If an epidural
is not utilized, then the surgeon must decide whether to add
chemoprophylaxis to alternating compression stockings
and early ambulation protocols. The ideal chemoprophy­
laxis regimen has yet to be elucidated.
Step-By-Step Technique
The belt lipectomy procedure as performed by the authors
is described here.
Following successful induction of general anesthesia,
the patient is placed in the supine position with the arms
abducted to 90°. The preoperative markings are re-enforced
and tattooed using methylene blue. Sequential compression
boots are applied and turned on prior to the induction of the
general anesthetic. An indwelling urinary catheter is
inserted, after which the patient is prepped and draped in
the usual sterile fashion.
The procedure begins with a circumumbilical incision.
Using scissors, the umbilical stalk is freed from the sur­
rounding tissue down to the anterior fascia. Care must be
taken when dissecting the umbilical stalk as patients may
present with an undetected periumbilical hernia.
Next an incision is made along the inferior abdominal
mark and dissection is carried down to, or just deep to,
Scarpa’s fascia, and a superior based abdominal flap is
elevated. The authors believe that leaving a fatty layer of
tissue on the rectus fascia reduces seroma formation along
with quilting sutures placed between the abdominal flap and
the abdominal wall at closure.17
The supraumbilical dissection is dependent upon the
thickness of the abdominal flap. A more traditional eleva­
tion towards the costal margins and the xiphoid process
typically accompanies thin flaps. For thick flaps that need
to be thinned with liposuction a very limited dissection
tunnel from the umbilicus to the xiphoid, exposing the
medial edges of the rectus muscle is performed. Abdominal
flap elevation should not exceed the amount necessary
for proper flap advancement, proper scar placement and
attainment of a superior contour result. Careful attention
superior lines of resection, which can be up to 15 cm in
more obese patients. This necessitates “cheating” at the
time of closure, which often leads to mild puckering that
almost always resolves with time. The authors prefer verti­
cal marks on either side of the mons pubis and at the level
of the ASIS at the very minimum. The size of the patient
and the preferences of the surgeon determine the location
of additional markings.
SURGICAL TECHNIQUE
Positioning Sequence
There are a wide variety of positioning sequences available
to the plastic surgeon performing a belt lipectomy. It is
generally recommended that the surgeon remain fairly con­
sistent with the chosen technique so that greater control
over the final contour will be achieved. Regardless of the
chosen method, there must be adequate operating room
personnel on hand to complete the turns efficiently and
effectively.
Prone/supine positioning completes the circumferential
procedure with only one turn and may afford the surgeon
ease in judging the symmetry of the back excision. Position
injuries are a serious risk of this positioning technique,
especially if the operative time is prolonged. Leaving the
patient in one position for a protracted period puts them at
risk for developing respiratory difficulties, shoulder inju­
ries, ulnar nerve injuries, and an increased potential for eye
damage.
A second single-turn technique is the supine/prone posi­
tioning sequence. Using this sequence, the anterior excision
is completed first, allowing for a more aggressive anterior
resection and superior anterior contour. Compared to the
prone/supine technique, the supine/prone technique has the
additional disadvantage of placing the patient in the prone
position after an anterior resection, potentially dehiscing
the anterior closure during the turn.
The authors prefer the supine/lateral decubitus/lateral
decubitus positioning because it allows for the best pos­
sible contour to be achieved anteriorly. The remainder
of the resection follows and is tailored accordingly. Fur­
thermore, the lateral decubitus position allows for hip
abduction, which enables a more aggressive lateral resec­
tion of redundant tissue. Since a prone position is not
assumed during this sequence, visibility of the entire back
and buttocks during the resection is limited, creating the
possibility of an asymmetric result. However, the authors
have not found that they had more asymmetry using this
sequence as compared to when they utilized prone/supine,
or supine/prone techniques. In addition, an extra turn may
increase the operative time but again the authors have
not found that to be the case in their practice. No matter

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Chapter | 32  Belt lipectomy/circumferential abdominoplasty
Positioning the patient into the lateral decubitus position
is a coordinated effort led by the anesthesiologist and
should involve a minimum of four additional operating
room personnel. At least one person should be assigned to
the crucial task of ensuring waist flexion throughout the
turning process. All pressure points need to be adequately
padded, which includes an axillary roll. Pillows are placed
between the patient’s knees in order to achieve hip abduc­
tion, which as previously discussed allows for maximal
excision of the lateral tissues. The patient is then re-prepped
and draped for the posterior excision from the lateral
dog-ear to the midline of the back. Many patients will also
require liposuction of the lateral thighs, which is often
performed at this time and involves infiltration of the lateral
thigh region with a tumescent fluid.
The authors prefer to begin the posterior excision by
incising the superior back mark. The extent of the subse­
quent dissection depends on the amount of fat that must
remain in order to achieve a desirable buttock projection.
Reduction of an over-projected buttock is best achieved by
dissecting down to the muscle fascia with subsequent eleva­
tion of an inferiorly based flap to the level of the proposed
excision line. The ultimate goal is attenuation of the projec­
tion with the creation of a depression at the waist by cinch­
ing above the hip. Further narrowing of the waist is achieved
by beveling the resection margin when tailoring the flap.
Extension of the superior mark incision down to the super­
ficial fascia level with subsequent dissection of the flap
inferiorly in this plane to the point of the proposed excision
will serve to preserve buttock projection in normal or defi­
cient patients.
The inferior dissection into the lateral thigh region is
typically limited to the proposed inferior excision line.
Some surgeons will undermine the entire lateral thigh
region, disrupting the zones of adherence, in order to
achieve more dramatic elevation of the lateral thigh tissues.
Deep permanent sutures in the superficial fascial system are
used to advance the lateral thighs superiorly onto the muscle
fascia.
Closure is performed in a similar fashion to the anterior
incision and is preceded by drain placement. The patient is
then maneuvered to the second lateral decubitus position
for the contralateral posterior resection. At the conclusion
of the procedure the patient is returned to the supine posi­
tion, with care taken to ensure hip flexion. Under the super­
vision of the operating surgeon, the patient is subsequently
transferred to a flexed hospital bed for transport out of the
operating room.
POSTOPERATIVE CARE
During recovery from anesthesia and while the patient is
drowsy, they are unable to protect the wounds from
must be paid to the tradeoff between vascular perforator
preservation and the creation of the most ideal abdominal
contour.
Following abdominal flap elevation, vertical plication
of the abdominal wall from the xiphoid to the pubis is
performed. While some surgeons prefer a single layer plica­
tion, the authors favor a two-layer plication using a long-
lasting, nonpermanent, barbed, running suture. However,
the choice of suture is ultimately based on surgeon prefer­
ence. If deemed appropriate at the time of surgery, horizon­
tal plications are performed.
Maximum anterior flap advancement is best achieved
with the waist flexed. The flap is advanced inferiorly, tai­
lored and temporarily tacked, with the upper mark as a
guide. If the flap is thick, it may be necessary to bevel the
resection. A thick mons pubis can be reduced using liposuc­
tion or through direct excision of sub-Scarpal fat.
A 1.5–2 cm vertical midline incision is made in the
abdominal flap overlying the umbilical stalk. Blunt dissec­
tion, without fat removal, is carried out through this inci­
sion until a path sufficient for the umbilical stalk has been
created. The authors emphasize the preservation of fatty
tissue in this area as it may stave off vascular compromise
of the flap. Inversion of the umbilicus is achieved using a
three-point fixation technique that requires placement of
inverted 3-0 nonpermanent monofilament sutures through
the abdominal wall fascia, the subcuticular layer of the
abdominal flap and the subcuticular layer of the umbilicus
at the 3, 6, and 9 o’clock positions. This maneuver pulls the
scar inside the umbilical depression while simultaneously
affording the surgeon control over the degree of umbilical
inversion. Using interrupted, inverted subcuticular sutures,
the remainder of the umbilicus is sutured to the surrounding
abdominal flap. External sutures are avoided in order to
minimize suture marks. It should be noted that there are
several, effective umbilicoplasty techniques that have been
reported and may be used successfully. Whatever method
is selected, the resultant umbilicus should be relatively
small and somewhat vertical, with an internally placed
suture line.
One or more closed suction drains are inserted and
brought out laterally at the level of the ASIS. Prior to a
layered abdominal closure quilting sutures from the abdom­
inal flap to the underlying muscle fascia are placed to close
dead space and reduce the risk of seroma. During the
abdominal closure scarpa’s fascia is approximated using a
synthetic absorbable suture material. One to two superficial
layers are subsequently re-approximated for skin closure
using an interrupted 2-0 or 3-0 synthetic absorbable suture
material. Skin-glue is applied to achieve a watertight
closure and the lateral dog-ears created by the anterior
resection are closed temporarily with skin staples prior to
turning the patient.

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PART | 5  Abdominal contouring procedures
Postoperative Weight Gain
It is important to caution patients that the improved contour
achieved postoperatively may be reversed should they
resume weight gain.
Seromas
Seroma formation is the second most common complica­
tion observed following a belt lipectomy and is a near
certainty in patients exceeding a BMI of 35. Although the
mechanism underlying seroma formation is poorly under­
stood, the surface area of the operative field, concomitant
liposuction and the shearing forces on the lower trunk
during ordinary postoperative movement may all be con­
tributing factors. Despite efforts to decrease and obliterate
dead spaces using quilting sutures, the circumferential
nature of this procedure is believed to be a significant
contributor to seroma formation. The authors traditionally
leave a thin layer of fat on the rectus fascia during the
infraumbilical dissection of the abdominal flap, which in
conjunction with quilting sutures, has reduced seroma fre­
quency. Serial aspiration is the mainstay of treatment for
seroma formation. If this is unsuccessful, however, a scle­
rosing agent, dicloxacillin, is injected in an attempt to
close down the pocket. It is the author’s experience that
small or nonexpanding fluid collections call for watchful
waiting, as they will typically resolve spontaneously. Con­
ventionally, the presence of a seroma capsule was an indi­
cation for operative intervention. However, the authors
have noted the presence of capsules in almost all patients
that have undergone belt lipectomy, whether they experi­
enced a seroma or not. Therefore, the presence of a
capsule is no longer an indication for surgery. In the rare
situation that a seroma becomes infected, incision and
drainage with antibiotic coverage and a “wick” type dress­
ing is the most effective management. For real persistent
seromas, the authors will open up part of the incision and
place a Penrose drain into the pocket and allow it to heal
from the “inside out”.
Wound Separation
Small wound separations actually occur more often than
seromas. Owing to the long incisions and high level of
wound tension inherent in the circumferential dermat­
olipectomy procedure, these separations are relatively
common. Fortunately, they often heal without sequelae
and treatment is usually conservative, allowing healing
by secondary intention. It is important to manage
this expectation prior to surgery and offer assurance
that the overall esthetic outcome will be minimally
affected.
mechanical dehiscence. Once the patient is alert, they
should be able to sense wound tension and make adjust­
ments to prevent dehiscence. Patients should be educated
prior to surgery regarding the ability to sense tension and
its importance in preventing postoperative wound compli­
cations. This is especially important during ambulation,
which should occur, with assistance, on the day of surgery.
The anesthesia team manages the epidural catheter, which
is removed on the morning of the second postoperative day.
Four to six hours after the removal of the epidural, the
indwelling urinary catheter is removed. Ambulation with
only one person’s assistance, tolerance of oral pain medica­
tion, the capacity to take food and drink by mouth and the
ability to spontaneously urinate are the criteria used to
assess discharge status. Patients are typically sent home 2
to 3 days postoperatively. Prior to discharge, patients are
educated on proper drain care. Once drain output falls
below 40 ml/day or the patient reaches the 14th postopera­
tive day, the drains are removed.
For the first week postoperatively, the patient remains
flexed at the waist during ambulation. Gradually during the
second week, the patient is allowed to carefully resume an
erect posture. Throughout the first month, patients should
slowly advance their activity as tolerated and can be expected
to return to nonphysical work 4 weeks postoperatively.
Beginning a few days after surgery, an abdom­inal binder is
worn by the patient until it is no longer tolerable.
COMPLICATIONS AND THEIR
MANAGEMENT
Complications, prognosis, and quality of result after belt
lipectomy depend heavily on the patient’s presenting BMI,
fat deposition pattern, and quality of the fat/skin envelope.
Of these three factors, BMI is the most important. The
authors have categorized massive weight loss patients
according to presenting BMI as follows: Group I, BMI ≥36;
Group II, BMI 30 to 35; Group III, BMI ≤29 (see Figs
32.3–32.5). Although relatively arbitrary, this schema is
effective in generating discussion between the patient
and the surgeon regarding the expected cosmetic result
and potential complications. Group I, for instance, can
expect less improvement in overall contour and a higher
complication rate after a belt lipectomy than patients in
Group II. The comparison is similar between Groups II and
III. Within each group, however, BMI is less predictive and
does not follow the same logic. Prior to surgery, it is impor­
tant to explain to patients that although belt lipectomy will
significantly improve their contour, their skin quality will
remain unchanged. The inexperienced surgeon and the
uninformed patient may seek additional tissue excision to
address the unchanged skin laxity, which will ultimately
lead to disappointment.

331
Chapter | 32  Belt lipectomy/circumferential abdominoplasty
FIG. 32.3  Pre- (A–C) and early (D–F) postoperative photographs of a high BMI patient who underwent a belt lipectomy. Note the patient
underwent a breast augmentation by another surgeon in the early postoperative period.
A
B
C
D
E
F
FIG. 32.4  Pre- (A–C), and early (D–F) postoperative photographs of an intermediate BMI patient who underwent a belt lipectomy.
A
B
C
D
E
F

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PART | 5  Abdominal contouring procedures
Wound Dehiscence
In contrast to a superficial wound separation, a dehiscence
is defined as wound separation at the superficial fascial
system or deeper. Competing tensions between the anterior
and posterior closures increase the risk of wound
dehiscence in circumferential procedures. Dehiscence of a
wound may occur immediately postoperatively or a few
weeks into recovery. Fortunately, the incidence of wound
dehiscence is rare under the care of an experienced surgeon
who can take several preemptive measures to reduce the
A
B
C
D
FIG. 32.5  Pre- (A, B, E, F) and (C, D, G, H) postoperative photographs of a low BMI patient who underwent a belt lipectomy. The breast
augmentation was performed by another surgeon.

333
Chapter | 32  Belt lipectomy/circumferential abdominoplasty
E
F
G
H
FIG. 23.5  Continued
risk of dehiscing in the early postoperative period. First, the
importance of preoperatively marking the posterior midline
resection with the patient in the flexed position after com­
pletion of the anterior markings cannot be overstated.
Second, active measures must be taken to prevent patient
manipulation immediately postoperatively until the patient
is awake and can actively respond to tissue tension. Finally,
the patient and the nursing staff should be educated preop­
eratively on the correct procedure for rolling out of bed in
order to avoid positions that acutely strain the closures. A
dehiscence that occurs a few weeks into the healing process
is most often due to rapid bending at the waist, presumed

334
PART | 5  Abdominal contouring procedures
subcostal scars can and will strain the remaining vascular
supply to the flap after elevation. As mentioned previously,
this remaining vascular supply includes the intercostal,
subcostal, and lumbar vessels. Necrosis of the remaining
tissue inferior to the scar may therefore ensue following
flap elevation. Subcostal scars can sometimes be low
enough to act as the superior border of the anterior resec­
tion, which eliminates all potentially compromised tissues.
Some surgeons use a fleur-de-lis approach in which the
subcostal scar is used as one of the vertical limbs brought
together at the midline, but the authors have no experience
with this technique. The authors have been most
successful in handling subcostal scars through alterations
in the sequence of surgical steps. The superior mark inci­
sion is made first with conservative elevation of the sup­
raumbilical flap, just to the medial edges of the rectus
fascia. The blood supply to the sub scar tissues is then
evaluated and if felt to be compromised, the ischemic tissue
is resected and the inferior flap is advanced superiorly.
Patients should be counseled prior to surgery that this will
result in a fairly high and undesirable final scar position. If,
however, the sub scar tissue appears to be adequately per­
fused, then the supraumbilical flap is advanced inferiorly to
the proposed inferior mark. The inferior flap is then tailored
accordingly.
Pulmonary Emboli and Deep
Venous Thrombosis
There are several factors inherent to the belt lipectomy
patient that increase the risk of DVT/PE. Procedures that
require plication of the abdominal wall may lead to an
increased risk of thrombotic events. The prolonged opera­
tive time required for these procedures may also increase
the risk of developing a DVT/PE. Early postoperative
ambulation and the use of sequential compression stockings
are currently the standard prophylaxis for DVT/PE preven­
tion. The value of adding chemoprophylaxis, specifically
low-dose heparin, is the subject of significant debate in the
literature. There is no doubt that a circumferential derma­
tolipectomy places patients at high risk for DVT formation;
however, difficulty exists in deciding which chemoprophy­
laxis regimen is most beneficial. Additionally, surgeons
must accept and manage the occasional bleeding that may
accompany such treatment. The authors have minimal
experience with chemoprophylaxis, but have instead
exploited the antithrombotic effects of postoperative epidu­
ral anesthesia to reduce the incidence of thrombotic events.
Despite the authors’ long-standing success with epidural
anesthesia, additional prospective randomized trials are
necessary to elucidate the benefits of this mode of prophy­
laxis. At the time of writing this chapter, there is no stan­
dard for chemoprophylaxis use.
to occur as the patient begins to experience significant mile­
stones in recovery. It is therefore advisable to instruct
patients to keep their movements slow and deliberate for
the first 3 months following surgery. Unhurried movements
will give the patient time to react to excessive wound
tension before it reaches the level required to dehisce. If
dehiscence occurs in the early postoperative period, the
patient may be returned to the operating room for surgical
closure or application of a wound vac. Later occurrences
are best treated with wound care or the application of nega­
tive pressure wound therapy. The involved area may require
scar revision at a later date.
A delicate balance exists between contour improvement
and wound dehiscence. Generous resection of tissue will
produce the tension necessary to create improved contour,
while simultaneously increasing the likelihood of wound
dehiscence, as tissue tension is common to both processes.
The best, most consistent results are therefore attained if
the surgeon comfortably operates between “not enough”
and “too much” tissue resection.
Infection
The most common nidus of postoperative infection in
patients undergoing a belt lipectomy is an overlooked
seroma. It is therefore wise to observe these patients for at
least a year postoperatively to ensure that there are no
undetected seromas. The authors assert that small, stable
fluid collections do not require intervention, but should be
watched closely for signs of infection.
Tissue Necrosis
Tissue necrosis following a belt lipectomy most commonly
occurs along the inferior aspect of the abdominal flap
at the anterior midline. Tissue necrosis ultimately results
from vascular compromise, which is caused by a variety
of factors including smoking, excessive wound tension,
acute angulation of the superolateral excision line and old
abdominal scars interfering with the natural blood supply
to the abdominal flap. The belt lipectomy procedure
requires more extensive undermining and lateral elevation
compared to the traditional abdominoplasty procedures. As
a result, the flap’s blood supply from the intercostal, sub­
costal, and lumbar vessels is increasingly compromised.
The anteromedial aspect of the flap is farthest from these
vessels and is therefore most commonly necrosed. Sur­
geons who choose to operate on smokers tend to modify
their technique by using discontinuous undermining to
mobilize the flap and limiting the midline supraumbilical
elevation.
Belt lipectomy procedures are no different than the
traditional abdominoplasty in the sense that horizontal

335
Chapter | 32  Belt lipectomy/circumferential abdominoplasty
4. Pitanguy I. Trochanteric lipodystrophy. Plast Reconstr Surg
1964;34:280–6.
5. Psillakis J. Abdominoplasty: some ideas to improve results. Aesth
Plast Surg 1978;2:205–15.
6. Regnault P. Abdominoplasty by the W technique. Plast Reconstr
Surg 1975;55(3):265–74.
7. Lockwood TE. Superficial fascial system (SFS) of the trunk and
extremities: a new concept. Plast Reconstr Surg 1991;87(6):
1009–18.
8. Aly A, Cram AE, Chao BS, et al. Belt lipectomy for circumferential
truncal excess: The University of Iowa experience. Plast Reconstr
Surg 2003;111:398.
9. Aly AS, Capella JE. Staging, reoperation and treatment of com­
plications after body contouring in the massive weight loss patient.
In: Grotting JC, editor. Reoperative Aesthetic & Reconstructive
Plastic Surgery. St. Louis: Quality Medical Publishing; 2007.
p. 1701.
10. Aly AS. Belt lipectomy. In: Aly AS, editor. Body Contouring after
Massive Weight Loss. St. Louis: Quality Medical Publishing; 2006.
p. 83.
11. Aly AS. Belt lipectomy. In: Aly AS, editor. Body Contouring after
Massive Weight Loss. St. Louis: Quality Medical Publishing; 2006.
p. 86.
12. Sebastian JL. Bariatric surgery and work-up of the massive weight
loss patient. Clin Plast Surg 2008;35(1).
13. Aly AS. Option in lower truncal surgery. In: Aly AS, editor. Body
Contouring after Massive Weight Loss. St. Louis: Quality Medical
Publishing; 2006. p. 59.
14. Lockwood T. Lower body lift with superficial fascial system suspen­
sion. Plast Reconstr Surg 1993;92:1112.
15. Lockwood T. Lower body lift. Oper Tech Plast Reconstr Surg
1996;3:132.
16. Michaud A-P, Rosenquist RW, Cram AE, Aly AS. An evaluation of
epidural analgesia following circumferential belt lipectomy. Plast
Reconstr Surg. 2007;120(2):538–44.
17. Pollock TA, Pollock H. No-drain abdominoplasty with progressive
tension sutures. Clin Plast Surg 2010;37(3):515–24.
Psychological Difficulties
Psychological issues are not uncommon in the massive
weight loss patient and often persist following weight loss.
The recovery period following a belt lipectomy is arduous
and quite stressful psychologically, leading to progressive
deterioration in many patients. Major complications can
occur if this psychiatric deterioration interferes with proper
postoperative management. Preoperative psychiatric evalu­
ation is required by the authors prior to any surgical plan­
ning and has been helpful in reducing the rate of
psychological problems postoperatively.
CONCLUSION
The belt lipectomy has evolved over the last decade to
become an effective means of treating the medical, ana­
tomical and esthetic problems associated with massive
weight loss. Careful patient selection, mastery of the
underlying surgical principles and managing potential com­
plications are a few of the challenges that the plastic surgeon
faces when treating massive weight loss patients. Addi­
tional research is needed and is being continuously pursued
by the authors and many others in the field of body contour­
ing in order to establish safer practices and ultimately better
outcomes.
REFERENCES
1. Kelly HA. Report of gynecological cases (excessive growth of fat).
John Hopkins Med J 1899;(10):197.
2. Thorek M, editor. Plastic Reconstruction of the Female Breast and
Abdomen Wall. Springfield, IL: Thomas, 1924.
3. Grazer FM. Abdominoplasty. Plast Reconstr Surg 1973;51(6):
617–23.

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© 2013 Elsevier Inc
Chapter 33 
Key Points
●
Progressive tension sutures (PTS) is a simple suture
technique for advancement and fixation of a flap that
is ideal for use in abdominoplasty.
●
Seromas are eliminated by decreasing dead space as
well as fixing the flap to avoid movement-related
disruption of early healing, without the need for
drains.
●
Other benefits include reduction of complications,
early upright ambulation and a quicker, easier
recovery.
●
PTS can be added to any abdominoplasty procedure.
●
It is an easy to learn technique and once learned,
there is minimal time added, but a very high degree of
patient satisfaction.
Progressive tension sutures
in abdominoplasty
Todd Pollock and Harlan Pollock
INTRODUCTION
Progressive tension sutures (PTS) is a technique for advanc­
ing and securing a flap.1,2 Since it is not an abdominoplasty
procedure in itself, PTS can be adapted to the surgeon’s
personal abdominoplasty operation. PTS is used to decrease
complications in abdominoplasty, especially seroma, while
eliminating the need for drains. The mechanism of these
sutures is to close dead space (Fig. 33.1), as well as, and
maybe more importantly, to secure the skin flap to the
underlying fascia to prevent disruption of early healing by
abdominal motion (Fig. 33.2). Additionally, these sutures
transfer the tension of the advancement over a broad area
to the superficial fascial system and away from the skin,
improving blood flow in the subdermal plexus and taking
tension off the skin closure, to improve scarring. The secure
fixation of the flap permits early ambulation in an upright
posture, which likely decreases pulmonary and venothrom­
boembolic (VTE) complications. What follows are details
of the authors’ abdominoplasty technique, which details the
use of PTS.
PREOPERATIVE PREPARATION
Since progressive tension sutures are simply advancement/
fixation sutures that can be incorporated into any abdomi­
noplasty procedure, no specific preparation is required.
Each surgeon may incorporate their own preoperative
regimen. We mark the patient in recumbent and standing
positions, noting the midline, planned incisions, and areas
to be liposuctioned. All patients get sequential compression
devices placed prior to induction and other VTE prevention
modalities are individualized. If posterior liposuction is to
be performed, it is done first with the patient in a prone
position. For the abdominoplasty, the patient is placed
supine with the arms secured out on arm-boards. A pillow
is placed under the knees. A wide prep and draping is used
to the mid-thighs.
SURGICAL TECHNIQUE
The procedure can be done under general anesthesia or
intravenous sedation. In either case, the procedure starts
with infiltration of local anesthetic into the planned circum­
umbilical and low transverse incisions. The areas of planned
elevation and liposuction are infiltrated with standard
tumescent solution (1000 ml normal saline, 30 ml lido­
caine, and 1 ml epinephrine (adrenaline) 1 : 1000). If the
upper abdomen is particularly bulky, liposuction is carried
out in the upper abdomen and flanks prior to flap elevation.
Care should be taken to suction deep to Scarpa’s fascia to
avoid flap devascularization as well as over-suctioning.
Over-suctioning of the area just above the umbilicus can
lead to a mismatch between the thinner upper abdominal
skin and the thicker mons. Additional liposuction can be
done after flap advancement.
The circumumbilical incision is made within the umbi­
licus and the stalk is dissected down to the deep fascia.
Next, the low transverse suprapubic incision is made and
carried down to the muscle fascia. No attempt is made to
leave fat on the fascia except for a few centimeters in the
Part 5  Abdominal contouring procedures

337
Chapter | 33  Progressive tension sutures in abdominoplasty
When dissection is complete, the rectus diastasis is
repaired with a 0-0 braided Nylon suture as a figure-of-
eight alternating with simple inverted sutures spaced about
1 cm apart and then a second layer of 0-0 PTS barbed suture
in an over-and-over fashion.
The fascia is then generously infiltrated with a long-
acting local anesthetic for early postoperative pain control.
In patients with wide diastasis recti, we often will place a
continuous double-catheter pain pump with an infusion rate
of 2 ml/hr per catheter. We bring the catheters out at the
level of the xiphoid and use the introducers in a retrograde
fashion (from inside to out) so they can be re-used for a
retrofascial placement. The functional portions of the cath­
eters are placed under the rectus fascia on either side of the
umbilicus (Fig. 33.4A–C).
When a ptotic mons pubis is present, correction is
important for a good esthetic result. The mons is under­
mined as needed and a few 2-0 Vicryl sutures are placed
from the underside of the mons to the desired position on
the deep fascia. Typically only three sutures are needed –
one midline and one on either side, with 3–4 cm spacing.
Care is taken to leave the edge of Scarpa’s fascia free for
later suturing to the upper flap. Advancement to an appro­
priate position with secure fixation with progressive tension
sutures gives the mons an attractive appearance and pre­
vents unintentional excessive elevation by flap retraction
(Fig. 33.5).
The patient is then brought to a flexed position of
approximately 45° at the hips with the knees slightly bent.
The bed is placed in a Trendelenburg position so that the
torso is parallel to the floor. This position will help with
visualization in placement of the progressive tension
sutures. A large, broad retractor, such as a Richardson, is
placed to visualize the most superior extent of dissection.
While the assistant holds the retractor in place, the surgeon
central area where bulk may be needed later to help with
the esthetic transition from the thinner upper abdominal flap
to the thicker mons pubis. Dissection is carried out both
sharply and with electrocautery. We have not seen any
increase in seromas with extensive electrocautery use. The
technique and extent of dissection is based on the surgeon’s
judgment and the individual patient’s anatomical character­
istics. We use a triangular dissection, which is wider infe­
riorly and narrowest at the level of the xiphoid, but is
individualized based on the width of rectus diastasis and
extent of soft tissue to be advanced (Fig. 33.3).
FIG. 33.1  Compartmentalization. Drawing shows how PTS divide
the larger dead space into smaller compartments that limit fluid
accumulation.
A
B
FIG. 33.2  Effects of motion. Diagram on the left shows that without
fixation, the two layers are free to move relative to each other with motion.
Diagram on the right illustrates the addition of PTS that affix the
two layers and secure them with motion, thus preventing disruption of
healing.
A
B
FIG. 33.3  Dissection. Picture demonstrating typical extent of dissec­
tion. This is individualized based on the patient’s esthetic needs.

338
PART | 5  Abdominal contouring procedures
FIG. 33.4  Retrograde placement of the pain pump. (A) Introducer brought from inside to out. (B) Catheter is fed into the introducer. With this
technique, introducer can be preserved for retro-facial placement of catheters. (C) The introducer is fed behind the muscle fascia on either side of the
umbilicus.
A
B
C
FIG. 33.5  Mons elevation. Mons elevation is important for a good
esthetic result. Secure and precise fixation avoids under or over-elevation.
The mons area is undermined for a few centimeters and then advanced
with PTS. Typically, three sutures are used, one in the midline (seen here)
and one on either side about 3–4 cm away.
places the nondominant hand on the skin behind the flap
and advances it. With the dominant hand, a 0-0 Vicryl
suture on a large needle (we prefer the CTX from Ethicon)
is placed from below into the midline of the flap (Fig. 33.6).
Care is taken to include Scarpa’s fascia in the bite. The
depth of the suture placement can be felt with the non-
dominant hand as the suture is placed. A bite close to the
skin of the midline sutures results in a midline depression
that is esthetically desirable. The assistant’s dominant hand
now replaces the surgeon’s nondominant hand on the skin
side of the flap to stabilize the flap advancement and relieve
tension from the suture while the surgeon ties the knot. This
is repeated at about 2 cm intervals until the umbilicus is
reached. This typically requires two to three sutures, all
placed in the midline. Once the flap is secured by the PTS
to the level of the umbilicus, the umbilicus is inset
in continuity with the flap advancement. This approach
allows the suture line and final scar to be hidden in the
depths of the umbilicus and creates an attractive umbilical
dimple.

339
Chapter | 33  Progressive tension sutures in abdominoplasty
FIG. 33.7  In-continuity umbilical inset. Once flap advancement reaches the umbilicus, (A) a circle of flap is defatted. A 1 cm hole is made above
this area and (B) three-point sutures are placed between umbilical dermis, flap dermis and deep fascia in 4 points around umbilicus. (C) This serves to
draw the incision into the depths of the umbilicus and splint it from contracture deformity.
A
B
C
FIG. 33.6  PTS placement. Photograph shows placement of a supra-
umbilical progressive tension suture. Note the assistant’s nondominant
hand advancing the flap and taking tension off as the surgeon ties down
the knot. A well orchestrated routine between surgeon and assistant simpli­
fies suture placement and improves efficiency.
The upper portion of the flap is advanced to the level of
the umbilical stalk. At this point, a 2 cm circle of the over­
lying flap is defatted. A finger is then placed into this defat­
ted depression and a mark is made on the overlying skin.
A circle or vertically oriented oval is marked in the midline
over the defatted area, which is then excised with a #15
blade. Additional defatting may be done from above as
needed, leaving a few millimeters of dermis exposed around
the edges. The umbilical stalk is trimmed to about a 1 cm
diameter, generally leaving only the base of stalk. From the
underside of the flap, a 3-0 Vicryl suture is placed as three-
point sutures from the abdominal skin dermis to the umbili­
cal stalk dermis to the muscle fascia in four points around
the stalk. When the sutures are tied, the incision is dragged
into the neo-umbilical depression (Fig. 33.7A–C). It also
serves to splint the umbilical incision from contracture.
Initially, this can be technically challenging but becomes
easier with experience. After complete closure of the
abdomen, the umbilical skin edges are approximated with
a few interrupted 5-0 Prolene sutures (Fig. 33.8).
Once the umbilicus is inset, the flap advancement is
continued below in a similar fashion. The surgeon places

340
PART | 5  Abdominal contouring procedures
FIG. 33.8  Umbilicus before and after in-continuity inset.
A
B
the suture in the flap and then advances the flap to its
desired location where the suture is then placed into the
muscle fascia and secured. Sutures are placed in a triangular
pattern with midline placement about 2 cm apart and with
the greatest amount of tension. Lateral sutures are placed
more sparsely and care is taken to place the sutures sym­
metrically from side-to-side in regard to placement and
degree of advancement. Laterally, less advancement is
needed as the flap has already been advanced by the midline
sutures. Over-advancement of these lateral sutures may
result in dimpling. Typically, four to five sutures are placed
in the infraumbilical midline while three to five sutures are
placed peripherally on either side. This results in about
10–18 progressive tension sutures placed in total, although
this may vary depending on the degree of dissection, patient
size and the surgeon’s judgment. Remember, the goal of the
PTS is not to close all dead space, but to effectively secure
the flap to the fascia to avoid disruption in healing by move­
ment of the torso. A 0-0 suture is used along the midline
while a 2-0 can be used laterally where tension is less.
Variations of the above technique have been described.
Barbed sutures3 have been used as a running progressive
tension suture, in order to decrease the time of placement
while retaining all the benefits of the interrupted suture
technique. We have found the use of individual PTS pro­
vides precise control of the flap advancement and the ability
to replace a suture that has been placed under too much/
little tension or in an unsatisfactory direction.
Once the entire flap has been secured, the excess tissue
is determined, marked and resected. (Note: When a patient
is particularly heavy, the surgeon may choose to remove the
excess abdominal tissue prior to flap advancement to aid in
visualization and PTS placement. In that circumstance, the
flap may need to be further trimmed after it is advanced.)
The flap is resected so that there is minimal gap between
wound edges in the middle third of the abdomen and a little
greater (about 2–3 cm) gap is left in the lateral thirds.
Three-point sutures are placed between the edges of Scar­
pa’s fascia and the muscle fascia using 2-0 Vicryl spaced
about 3 cm apart. The skin is then closed with 3-0 Vicryl
deep dermal sutures and a running subcuticular suture. A
few simple Prolene sutures are used to approximate the
umbilical skin edges.
We do not place drains of any kind. However, many
surgeons continue to use suction drains when they first start
using progressive tension sutures. There is nothing wrong
with transitioning into this technique by using both PTS and
drains. However, studies have shown4,5 that there is no

341
Chapter | 33  Progressive tension sutures in abdominoplasty
advantage to placement of both. Additionally, placement of
the progressive tension sutures is more difficult with drains
in the surgical field and may increase operating time and
the surgeon’s learning curve.
When all incisions are closed, the need for additional
liposuction should be assessed. Liposuction can be done by
introducing the cannula through the closed incision or prior
to closure of the skin with the running subcuticular suture.
OPTIMIZING OUTCOMES
One advantage of this technique is that it allows the surgeon
to dissect as much as is needed and include flanks and
abdominal liposuction based on the individual patient’s
needs, as opposed to other seroma reduction techniques that
limit dissection and liposuction. The surgeon should
perform liposuction and dissect as widely as needed to
achieve the esthetic result desired.
While placement of progressive tension sutures is rela­
tively easy, there is a learning curve to be able to place them
efficiently. Increased efficiency comes with knowing how
to most effectively use an assistant for visualization and
holding tension on the advanced flap while tying the knot.
The sutures above the umbilicus are often the most difficult
and cumbersome to place and are where an assistant plays
the biggest role. Once a routine is developed, the placement
of all progressive tension sutures should take no more than
15–20 minutes.
Dimpling is a common concern of surgeons considering
this technique. However, if the sutures are placed in the
superficial fascia and not into the dermis, any early dim­
pling will resolve as the skin tension redistributes with time.
We have never seen a dimple that did not resolve in days
after surgery. Also, remember that while placing the sutures,
a dimple will be seen at the location of the last suture.
However, once tension is added distal to that suture with
placement of the next suture, the dimple will resolve. Dim­
pling may result from excessive tension or a suture placed
in the wrong direction. Though this dimpling will likely
resolve with time, one may also remove and replace that
suture.
POSTOPERATIVE CARE
Postoperative dressings are at the discretion of the surgeon.
We typically use Steri-strips on the transverse incision and
antibiotic ointment on the umbilical incision, with an
absorptive dressing over this. The patient is instructed to
remove the dressing in 24–48 hours and only the umbilicus
is redressed with antibiotic ointment and a light dressing.
We use a compression garment for patient comfort and
abdominal support, not for seroma control. Patients are
instructed to wear the compressive garment as long as it is
comfortable. This is typically about 2 weeks. A more attrac­
tive and comfortable commercial garment can be obtained
to replace the surgical one at any time. Patients are allowed
to shower at 48 hours.
The patient is instructed to ambulate as soon after
surgery as possible and is encouraged to resume an upright
posture when comfortable doing so. The average patient in
our practice resumed comfortable, upright posture within 2
days. Exercise is limited to walking for 3 weeks in the
patient not requiring rectus diastasis repair and 6–8 weeks
in those that underwent repair.
COMPLICATIONS AND THEIR
MANAGEMENT
Complications of abdominoplasty are greatly reduced by
the use of progressive tension sutures. In a retrospective
series of more than 650 consecutive procedures which is in
preparation for publication, we have seen a complication
rate of 1.6% and only one seroma in the series. In this series
there were no systemic complications and there were no
complications directly related to the progressive tension
sutures. In our series, we did see two hematomas and four
abscesses, which were small and seemed to be compart­
mentalized between sutures. We believe that the compart­
mentalization created by the PTS technique limited the
progression of these complications. Dimpling, as men­
tioned above, has not been a problem with properly placed
sutures and if present, it resolves in a short time, usually
days. Improvement in abdominoplasty complications has
been observed in several studies.4–7
CONCLUSION
Progressive tension sutures are an effective means to reduce
seromas in the abdominoplasty patient. While minimizing
dead space, they additionally secure the flap, preventing
disruption of healing due to movement. The use of this
technique eliminates the need for drains which are incon­
venient, restrictive and generally disliked by abdomino­
plasty patients. The technique is simple in concept and can
be mastered with little experience. A good assistant who
understands the concept of suture placement can improve
the ease of suture placement and increase efficiency. The
use of this technique allows the surgeon to utilize an
in-continuity inset of the umbilicus that produces an estheti­
cally pleasing umbilicus by inverting the scar into the
depths of the umbilicus and splinting it from contracture
deformity. Progressive tension sutures transfer the tension
created by flap advancement to the superficial fascial
system over a broad area, theoretically improving distal
blood supply and decreasing the risk of wound healing
problems and necrosis.8 Tension is minimized at the

342
PART | 5  Abdominal contouring procedures
FIG. 33.9  Preoperative (A, B) and 3 months postoperative (C, D) photographs of representative patients. Notice good contour, no dimpling and
attractive umbilicus with hidden scars
A
B
C
D

343
Chapter | 33  Progressive tension sutures in abdominoplasty
FIG. 33.10  Preoperative (A, B) and 3 months postoperative (C, D) photographs of representative patients. Notice good contour, no dimpling and
attractive umbilicus with hidden scars.
A
B
C
D
incision, potentially improving the final abdominoplasty
scar. Use of this suturing technique allows for a quicker
return to ambulation and upright posture, which not only
improves the patient experience, but also improves lower
extremity venous return9 and thus lowers the risk of venous
thromboembolic disease (Figs 33.9 and 33.10).
REFERENCES
1. Pollock H, Pollock T. Progressive tension sutures; a technique for
reducing local complications in abdominoplasty. Plast Reconstr Surg
2000;105:2583–6.
2. Pollock TA, Pollock H. No-drain abdominoplasty with progressive
tension sutures. Clin Plas Surg 2010;37(3):515–25.
3. Warner JP, Gutowski KA. Abdominoplasty with progressive tension
closure using a barbed suture technique. Aesth Surg J 2009;29(3):
221–5.
4. Andrades P, Prado A, Danilla S, et al. Progressive tension sutures in
the prevention of the post-abdominoplasty seroma: a prospective,
randomized, double-blinded clinical trial. Plast Reconstr Surg 2007;
120(4):935–46.
5. Antonetti JW, Antonetti AR. Reducing seroma in outpatient abdomi­
noplasty: Analysis of 516 consecutive cases. Aesth Surg J 2010;
30(3):418–27.

344
PART | 5  Abdominal contouring procedures
6. Kahn S, Teotia SS, Mullis WF, et al. Do progressive tension sutures
really decrease complications of abdominoplasty? Ann Plast Surg
2006;56(1):14–20.
7. Nahas FX, Ferreira LM, Ghelfond C. Does quilting suture prevent
seroma in abdominoplasty. Plast Reconstr Surg 2007;119(3):
1060–4.
8. Holm MN, Hofter E, Becker A, et al. Effects of aesthetic abdomino­
plasty on abdominal wall perfusion: A quantitative evaluation. Plast
Reconstr Surg 2004;114(6):1586–94.
9. Huang GJ, Bajaj AK, Gupta S, et al. Increased intra-abdominal pres­
sure in abdominoplasty: Delineation of risk factors. Plast Reconstr
Surg 2007;119:1319–25.
A video of this procedure as well as additional references
can be found at

345
© 2013 Elsevier Inc
Chapter 34 
Key Points
●
Primary markings: well defined, but no preset resection
zones.
●
Primary extensive liposuction.
●
Superficial undermining for blood and lymphatic
vessel preservation.
●
Undermining of only those areas to be resected.
●
Deep anchorage to strong structures.
Transverse medial thigh lift
Pierre Nicolau
INTRODUCTION
The medial upper thigh area is often subject to ptosis and
skin wrinkling, due to the thinness of the skin and the
frequent fat deposition. The unsightly appearance of this
region results in a number of patients, some as young as 35
years, seeking consultation and correction. Unfortunately,
the transverse, superior and medial thigh lifts still have a
poor reputation among plastic surgeons and patients alike
due to the high complication rate and unsightly esthetic
results. Complications previously encountered with tradi­
tional procedures included scar visibility at the upper aspect
of the thigh, vulvar dehiscence, hypertrophic scarring
mainly in the gluteal groove, wound dehiscence, infection,
skin necrosis, and lymphocele.1
A well-conducted operation should aim at avoiding any
lymphatic, venous or arterial vessel impairment as well as
any skin trauma, and result in limited or no skin tension.
These goals are possible, and have been advocated and
clearly demonstrated for many years.2–5
PREOPERATIVE PREPARATION
Good communication and avoidance of unreasonable
expectations is essential, especially in those patients with
large thighs.6 We classify our patients into four types:
Type I: The patient presents with isolated fat excess of
the upper inner thigh. This should respond well to lipo­
suction alone.
Type II: The patient shows a limited skin laxity.
Type III: The patient shows important skin laxity or
excess, but limited to the upper third of the inner thigh.
Type II and type III will require skin resection in a verti­
cal manner, for a proper “lift” of the inner thigh.
Type IV: The patient has a skin laxity extending to the
lower part of the inner thigh. Type IV patients will
require additional skin resection, to tighten the thigh
transversally, with a vertical scar extending gradually
down to the knee according to the importance of the
necessary resection.
Below we shall describe the procedure for types II and
III only, although the principles advocated remain the same
for type IV patients.
ANATOMICAL CONSIDERATIONS
Fat Layers
Fat distribution under the human skin is uneven (Fig. 34.1).
There is an almost uniform superficial layer, where lobules
are organized in a “vertical” manner, perpendicular to
the skin surface. In these areas, the fascia superficialis is
fused with the deep, premuscular fascia. In some areas,
there is another layer, deep to the fascia superficialis, where
the fat is organized in a “horizontal”, lamellar fashion,
parallel to the skin surface. Liposuction allows for the
elimination of most of the fat in the different layers, achiev­
ing not only volume reduction but also skin release. Skin
retraction is best in those areas of deep fat, as retraction of
the superficial, “vertical” fat layer often leads to surface
irregularities.
Lymphatic Distribution
The lymphatic vessels of the skin (Fig. 34.1), after collect­
ing from the surface, join into vessels situated just deep to
the fascia superficialis. Therefore, in areas where there is
deep fat, it is of the utmost importance that dissection stays
superficial, in order to avoid any impairment of the lym­
phatic drainage. In some anatomical areas this boundary is
not particularly obvious, for example in the outer thigh.
Part 6  Thigh, buttock and lower extremity contouring

346
PART | 6  Thigh, buttock and lower extremity contouring
FIG. 34.1  Fat layers, fascia superficialis and lymphatic vessels.
Skin
Subdermal “vertical” fat
Fascia superficialis
Lymphatic vessels
Fascia superficialis fused with
premuscular fascia
Deep “horizontal” lamellar fat
Premuscular fascia
Muscle
Nevertheless, due to the frequently described lymphatic
complications,7 dissection should stay superficial.
Skin Particularities
The skin of the upper inner thigh is very thin. Its blood
supply will not tolerate excessive tension, which will sub­
sequently lead to wound dehiscence or necrosis. Deep
anchorage will prevent not only excessive tension on the
suture line, but also secondary deformity, such as scar
migration or vulvar dehiscence.8
SURGICAL TECHNIQUE
Marking of the Incisions (Fig. 34.2A, B)
Markings are performed with the patient standing in order
to avoid any excessive tension. The area of lipodystrophy
is identified and marked, and, if necessary, gentle pinching
of the skin allows for appreciation of the maximum possible
tension between the inner thigh and the pubic tubercle. The
pull is vertical at this medial aspect, and at a 45° angle for
the anterior aspect, realizing a rotation towards the pubis.
Preparation and Positioning
The operation can be performed under general, spinal or
local anesthesia with IV sedation, according to the patient’s
needs and requirements. After anesthesia, the patient is
placed supine on the operating table, legs are positioned on
a gynecologic rest, abducted at 45 ° in the frog leg position.
Pressure socks or compression devices are mandatory.
Sterile stockinettes or drapes cover the lower leg to allow
for positioning the thighs as requested for liposuction and
skin resection.
The incision line should avoid the inguinal crease,
where there is a major risk of impairment of the lymphat­
ics.2,9–11 Our incision is vertical within the pubis, starting
from below the hairline, medial to the groin crease, 3 to
4 cm away from the midline on either side. Another
reason for a pubic positioning is that superficial dissection
in the groin region to preserve lymphatic vessels will
result in a very thin skin flap, which will not tolerate any
tension. The incision is then extended vertically toward
the pubic tubercle along the labia majora. If the amount
of skin resection is major, it seems preferable, as advo­
cated by Le Louarn,11 to extend the marking of the inci­
sion to the inner part of the buttock toward the ischial
tuberosity and the anal margin. This is a superior incision
line as opposed to the gluteal fold, as this area is very
prone to hypertrophic and painful scarring and is techni­
cally difficult to correct.
Skin Release
Extensive liposuction allows for a very thin skin flap (Fig.
34.3); the fascia superficialis is kept deep to undermining,
preserving the lymphatic vessels’ integrity; skin elevation
is limited to the planned resection.
Skin resection does not go beyond the elevated flap
(Fig. 34.4); the risk of skin necrosis is reduced to a minimum.
After infiltration with the following solution (1 liter
saline, 40 ml of 1% lidocaine and 1 mg of epinephrine
(adrenaline)), extensive liposuction will allow for volume
reduction and associated skin tension release. This will
effectively free the superficial dermal layers with preserva­
tion of deep fibrous and vascular attachments, as originally
analysed in 1992 by Le Louarn5 and subsequently by
Illouz.12 Surgical undermining becomes therefore unneces­
sary, apart from the zones to be removed; all fat there
should be removed. The skin incision is superficial to the
subcutaneous tissue. The margin is hooked and lifted, to
undermine as superficial to the fascia superficialis as pos­
sible, as it is fairly easy to identify after removal of all fat.
The excised skin is therefore extremely thin.
Skin Resection
Skin resection limits are not set. It is a “mark as you go”
procedure. First, the previously identified maximum tension
point is controlled and eventually adjusted, with an upward

347
Chapter | 34  Transverse medial thigh lift
FIG. 34.2  (A, B) Preoperative markings.
5 cm
and midline
Vertical
on labia
majora
Not in
gluteal
fold
A
B
FIG. 34.3  Extensive liposuction allows for a very thin skin flap,
fascia superficialis kept deep to undermining, preserving integrity of
lymphatic vessels, skin elevation limited to planned resection.
FIG. 34.4  Skin resection does not go beyond elevated flap, risk of
skin necrosis reduced to a minimum.

348
PART | 6  Thigh, buttock and lower extremity contouring
perpendicular to the surface (skin incisions) or parallel
to it (undermining), to preserve all lymphatic vessels.
● Undermining should be minimal in its extension so as
to avoid impairment of blood supply.
● Tissue release should be maximal to allow for easy
resection of excess skin and fat, and closure without
tension.
● Deep anchorage with fixation to strong structures is
mandatory.
● Incisions should be positioned in areas hidden and not
prone to hypertrophic scarring.
POSTOPERATIVE CARE
Suture lines are covered with iodoform gauze and main­
tained with surgical glue (collodion). Protective gauzes are
positioned before applying a pressure garment. Patients are
allowed to walk the following morning, and advised to
refrain from sitting with thighs abducted. Pressure garments
are worn for at least 3 to 4 weeks. Daily cleaning after each
stool or urine passing is done in a shower to avoid extension
and abduction of the thighs.
COMPLICATIONS AND THEIR
MANAGEMENT
Lymphatic Drainage and Lymphocele
Some authors have advocated the risks of seroma or lym­
phocele formation associated with liposuction. In 1990
Ersek et al7 reported that liposuction associated with under­
mining in nine cases of abdominolipectomies led to seroma
and pseudo bursa formation. This results in uneven skin
retraction and unsightly aspect and he advocates waiting for
6 weeks after suction for resection. In 1995, Candiani et al9
operated on 18 patients for medial thigh lift with a full
thickness undermining including the premuscular fascia,
“cautious lipoaspiration when it was really necessary” and
deep fasciofascial anchoring to Colles’s fascia. They
observed three bilateral seromas requiring repeat aspira­
tions. In their 2008 report on seroma development, Shermak
et al13 found only 4% of seroma formation in thigh lifts.
However, in 2009 Bruschi14 performed 11 liposuctions on
35 cases of thighplasty, and did not report any case of a
lymphatic problem. In 25 cases, over a 2-year period, Le
Louarn and Pascal in 2004,11 while preserving fascia super­
ficialis, had no cases of lymphatic edema or seroma forma­
tion. In 2006, Espinosa-de-los-Monteros et al15 noted only
two seromas in 60 cases of abdominoplasty with extensive
liposuction, but preserving Scarpa’s fascia of the lower
abdomen. Since introducing extensive liposuction, superfi­
cial dissection and no undermining, we have had no cases
of lymphorrhea or lymphocele.
vertical traction. Undermining could eventually be extended
for a few millimeters beyond the defatted flap, but in all
cases it should be kept strictly superficial.
This point is anchored to Colles’s fascia with 2-0 Vicryl
sutures. Two or three other anchoring points are then
defined on either side, the superior flap being rotated medi­
ally towards the pubis with deep stitches grasping the deep
fascia and the muscle insertion at the ischial tuberosity. The
periosteum should be avoided, as this can be painful. Skin
resection is performed step by step, only on the excess skin
thus defined. Closure is achieved in two layers with 3-0
Vicryl sutures. No drainage is required, as there is no dead
space. Figure 34.5 shows the closure of the incisions on the
first side. Note, that despite the thigh position and vertical
component, there is no deformation of the genital fold line.
Note tension in the subgluteal fold; the scar will remain
invisible posteriorly.
OPTIMIZING OUTCOMES
Simple points to note are the following:
● Any surgical approach should stay superficial to the
fascia superficialis, or premuscular fascia, whether
FIG. 34.5  Closure of the incisions on the first side. Note, despite
position and vertical component, no deformation of genital fold line. Note
tension in the subgluteal fold; scar will remain invisible posteriorly.

349
Chapter | 34  Transverse medial thigh lift
Skin Necrosis
This been reported mainly in cases with large undermining
in an attempt to fixate the skin to solid grounds.2 None have
been reported with the liposuction/no undermining/deep
fixation techniques.
Acute Anemia
Bruschi et al14 reported that this occurred in 43% of their
cases. None have been reported by other authors or in our
cases.
CLINICAL CASES
Case 1: Preoperative (Fig. 34.6A, B) and postoperative
views (Fig. 34.6C, D) of the same patient, after bodylift
and thighplasty with extensive circumferential liposuc­
tion of the thighs. A fair result.
Case 2: Preoperative (Fig. 34.7A–C) and postoperative
views (Fig. 34.7D–F): in this early result, correction is
satisfactory, but scar placement, due to extent of skin
resection, could not allow for proper fixation on the
deep planes, therefore allowing for downward scar
migration. Nevertheless, no vulvar dehiscence occurred.
Case 3: Preoperative (Fig. 34.8A) and postoperative
views (Fig. 34.8B): a very difficult condition. No indi­
cation for a vertical thigh approach, as the excess skin
is limited to the upper third of the thigh. Extensive
circumferential thigh liposuction should probably have
been performed to allow for a better rotation of the
anterior skin towards the pubis. No vulvar dehiscence
despite the extreme vertical skin resection.
Case 4: Fig. 34.9A, B: a good result with the described
technique, although today the vertical pubic scar would
be slightly more medially placed.
CONCLUSION
Since we have modified our operative procedure, medial
transverse thigh lift has become a commonly offered solu­
tion to our patients seeking improvement of relaxed or
sagging skin of the upper third of their thighs and has con­
sistent and satisfactory results.
FIG. 34.6  Case 1. (A, B) Preoperative.
A
B
Continued

350
PART | 6  Thigh, buttock and lower extremity contouring
Case 2. (C, D) Postoperative views of the same patient, after bodylift and thighplasty with extensive circumferential
liposuction of the thighs.
FIG. 34.6  Continued
C
D
A
B
FIG. 34.7  Case 2. (A–C) Preoperative. (D–F) Postoperative. In this early result, correction is satisfactory, but scar placement, due to extent of skin
resection, could not allow for proper fixation on the deep planes, therefore allowing for downward scar migration. Nevertheless, no vulvar dehiscence
occurred.
C
D
E
F

351
Chapter | 34  Transverse medial thigh lift
FIG. 34.8  Case 3. (A) Preoperative. (B) Postoperative, a very diffi­
cult condition. No indication for a vertical thigh approach. Extensive
circumferential thigh liposuction should probably have been performed to
allow for a better rotation of the anterior skin towards the pubis. No vulvar
dehiscence despite the extreme skin resection.
A
B
FIG. 34.9  Case 4. (A, B) A good result with the described technique,
although today the pubic scar would be slightly more medially placed.
A
B

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PART | 6  Thigh, buttock and lower extremity contouring
REFERENCES
1. Borud LJ, Cooper JS, Slavin SA. New management algorithm for
lymphocele following medial thigh lift. Plast Reconstr Surg
2008;121(4):1450–5.
2. Shaer WD. Gluteal and thigh reduction: reclassification, critical
review and improved technique for primary correction. Aesth Plast
Surg 1984;8:165–72.
3. Lockwood T. Superficial fascial system (SFS) of the trunk and extrem­
ities: a new concept. Plast Reconstr Surg 1991;87(6):1009–18.
4. Lockwood T. Lower body lift with superficial fascial system suspen­
sion. Plast Reconstr Surg 1993;92(6):1112–22.
5. Le Louarn C. Partial subfascial abdominoplasty: our technique
apropos of 36 cases. Aesth Plast Surg 1992;37:547–52.
6. Lewis CM. Dissatisfaction among women with “thunder thighs”
undergoing closed aspirative lipoplasty. Aesth Plast Surg 1987;11:
187–91.
7. Ersek RA, Schade K. Subcutaneous pseudobursa secondary to
suction and surgery. Plast Reconstr Surg 1990;85:442–5.
8. Hodgkinson DJ. Medial thighplasty, prevention of scar migration,
and labial flattening. Aesth Plast Surg 1989;13:111–4.
9. Candiani P, Campiglio GL, Signorini M. Fascio-fascial suspension
technique in medial thigh lifts. Aesth Plast Surg 1995;19:137–40.
10. Spirito D. Medial thigh lift and D.E.C.L.I.V.E. Aesth Plast Surg
1998;22:298–300.
11. Le Louarn C, Pascal JF. The concentric medial thigh lift. Aesth Plast
Surg 2004;28:20–3.
12. Illouz YG. A new safe and aesthetic approach to suction abdomino­
plasty. Aesth Plast Surg 1992;16:237–45.
13. Shermak MA, Rotellini-Coltvet LA, Chand D. Seroma development
following body contouring surgery for massive weight loss: patient
risk factors and treatment strategies. Plast Reconstr Surg 2008;
122(1):280–8.
14. Bruschi S, Datta G, Bocchiotti MA, et al. Limb contouring after
massive weight loss: functional rather than aesthetic improvement.
Obes Surg 2009;19:407–11.
15. Espinosa-de-los-Monteros A, De la Torre JI, Rosenberg LZ, et al.
Abdominoplasty with total abdominal liposuction for patients with
massive weight loss. Aesth Plast Surg 2006;30:42–6.

353
© 2013 Elsevier Inc
Chapter 35 
Key Points
●
Careful patient screening and education is critical to
optimizing the outcome of medial lift procedures.
●
Major variables contributing to the medial thigh
deformity include descent of the mons pubis,
inferomedial migration of thigh soft tissues, descent of
the buttocks and circumferential thigh soft tissue
excess secondary to weight changes and aging. Prior
liposuction may also contribute to thigh contour
deformities.
●
Correction of soft tissue excess along the abdomen,
thighs and buttocks prior to a medial thigh lift is
essential for an effective medial thigh lift.
●
Thigh lift procedures with an excisional component
limited to the thigh perineal crease usually provide
little if any additional benefit to individuals who have
undergone circumferential body lift procedures.
●
Liposuction in vertical medial thigh lift procedures
serves to create a readily identifiable and safe plane of
dissection and to improve outcome by optimizing the
amount of soft tissue that can be removed.
●
The combination of a prior lower body lifting
procedure and a medial thigh lift with a vertical
component helps minimize the likelihood of the well
described complications associated with media thigh
lifts: labial spreading and scar migration.
Vertical medial thigh lift with liposuction
Joseph F. Capella and Scott Woehrle
INTRODUCTION
Medial thigh contour deformities are a frequent concern for
many individuals seeking body contouring. The deformity
is usually secondary to weight loss and often associated with
prior pregnancy and, in many instances, liposuction of the
thighs. Despite the frequency of this concern, plastic sur­
geons have often been reluctant to embrace the medial thigh
lift procedure because of the risk for significant complica­
tions, relatively poor results and the potential for readily
visible scars.1–3 Until recently, nearly all medial thigh lift
techniques described in the literature attempted to address
the medial thigh deformity by removing soft tissue excess
in a vertical vector alone. An interesting exception was the
first description of a medial thigh lift in 1957 by Lewis.3–14
He advocated both a horizontal and vertical component to
the procedure. Lockwood, a proponent of vertical vector
excision alone, described minimizing complications such as
labial spreading and scar migration and improving outcome
by securing the medial thigh flap to Colles’ fascia. While
the concept appeared to be a logical approach to address
problems associated with medial thigh lifts, it added little
to existing procedures. In recent years, primarily in response
to the increase in numbers of individuals with post-bariatric
body contour concerns, plastic surgeons have once again
advocated the excision of soft excess in both a vertical and
horizontal vector to address medial thigh deformities.15–19
Our approach to medial thigh contour deformities is to
address the variables outside of the medial thighs affecting
the medial thighs prior to performing a medial thigh lift
procedure. In most instances, a body lift or simultaneous
abdominoplasty, thigh and buttock lift is performed first.
For a small number of individuals, only an abdominoplasty
is performed initially. For some patients, the need for a
medial thigh lift may be eliminated altogether by these
techniques (Fig. 35.1). For patients with a remaining defor­
mity, a medial thigh lift with a vertical component is per­
formed (Fig. 35.2A, B, C, D, E, F, G–I).15,20–22 For data and
discussion purposes, we have classified our various forms
of medial thigh lift (Table 35.1).
FIG 35.2B, C, E, F APPEARS ONLINE ONLY
PREOPERATIVE PREPARATION
As with all surgical candidates, individuals seeking surgical
correction of their medial thigh deformity should undergo
a thorough history and physical examination. Information
particularly relevant to medial thigh lift surgery includes a
history of weight change, whether secondary to bariatric
surgery, lifestyle changes or pregnancy. The patient’s
height, current weight and maximum weight should be
noted as should the time interval between their maximum
and current weight. If weight loss was achieved through
bariatric surgery, the technique and when it was performed
For additional online content visit

Part 6  Thigh, buttock and lower extremity contouring

353.e1
Chapter | 35  Vertical medial thigh lift with liposuction
B
C
FIG. 35.2  (B, C) A 40-year-old man 21 months following gastric bypass surgery and weight loss of 75 kg (165 lbs). Current weight and BMI:
90 kg (198 lbs), 32, respectively. Highest weight and BMI ever achieved: 166 kg (366 lbs), 59. (E, F) Seven months following body lift. Type III
thigh lift.
E
F

354
PART | 6  Thigh, buttock and lower extremity contouring
A
B
C
D
FIG. 35.1  (A–C) A 36-year-old woman 23 months following gastric bypass surgery and weight loss of 73 kg (161 lbs). Current weight and
BMI: 55 kg (121 lbs), 20, respectively. Highest weight and BMI ever achieved: 128 kg (282 lbs), 47. The medial thigh deformity was one of her
primary concerns. (D–F) Eighteen months following body lift. The body lift provided sufficient improvement of her medial thighs for her to forgo any
further surgery to her medial thighs.

355
Chapter | 35  Vertical medial thigh lift with liposuction
E
F
FIG. 35.1  Continued
A
D
FIG. 35.2  (A) A 40-year-old man 21 months following gastric bypass surgery and weight loss of 75 kg (165 lbs). Current weight and BMI:
90 kg (198 lbs), 32, respectively. Highest weight and BMI ever achieved: 166 kg (366 lbs), 59. (D) Seven months following body lift.
Continued

356
PART | 6  Thigh, buttock and lower extremity contouring
G
H
I
(G–I) Three months following medial thigh lift
with vertical component extending to junction of knee with leg, Type
III medial thigh lift.
FIG. 35.2  Continued

357
Chapter | 35  Vertical medial thigh lift with liposuction
should be noted. For patients who have lost weight through
lifestyle changes, some discussion should take place as to
how this was accomplished (i.e., exercise, diet and exercise,
medication) and whether they are being supervised by a
professional.23 Previous body contouring procedures should
be noted, including liposuction, as it may impact on a surgi­
cal plan and outcome. A history of lymphedema or periph­
eral vascular disease should also be documented. As part of
the initial interview, the patient’s expectations for medial
thigh lift surgery and their tolerance for scars should be
clearly established.
Physical exam should focus on a careful assessment of
the medial thigh deformity and the variables outside of the
medial thighs potentially contributing to the deformity: soft
tissue excess along the mons pubis, the hips and lateral
thighs and buttocks. In an effort to assess the variables
contributing to the medial thigh deformity during the exam­
ination, patients should be asked to stand in front of a full
length mirror and to apply strong upward traction to the soft
tissues of their lower abdomen with their two hands. At the
same time, the surgeon or examiner should then apply
strong upward traction to the patient’s lateral thighs and
buttocks. This technique for examination helps eliminate
the variables outside of the medial thighs contributing to
the medial thigh deformity. It also serves to illustrate for
patients the function of circumferential body lifting proce­
dures. Patients usually are not aware of the significance of
these variables (Fig. 35.3). A second maneuver that should
also be considered is to have patients abduct one their
thighs (Fig. 35.4). Grasping the soft tissue of the medial
thigh with the patient standing will provide similar informa­
tion. These techniques highlight soft tissue excess in the
horizontal vector, accurately demonstrating the function of
the vertical medial thigh lift with liposuction procedure.
The distal extent of the thigh deformity should be noted.
Many women and some men have concerns about the
excess soft tissue along the medial aspect of the knee and
in some instances the leg as well (Fig. 35.5).22 Some women
TABLE 35.1  Classification System for Medial
Thigh Lifts
Type I – Approach limited to thigh perineal crease and
proximal gluteal crease
Type II – Type I approach plus vertical component limited to
medial thigh
Type III – Type I approach plus vertical component extending
to junction of medial knee with leg
Type IV – Type I approach plus vertical component extending
to medial leg
Type V – Type IV technique plus transverse component over
distal anterior thigh (Type IV and Type V not usually
performed simultaneously)
FIG. 35.3  This maneuver, the application of upward traction to the
lower abdomen by the patient and the lateral thighs and buttocks by
the examiner (B), helps eliminate the variables outside of the medial
thighs contributing to the medial thigh deformity (A). It also serves
to illustrate for patients the function of circumferential body lifting
procedures.
A
B

358
PART | 6  Thigh, buttock and lower extremity contouring
FIG. 35.5  (A–C) A 55-year-old woman 13 months following gastric bypass surgery and weight loss of 52 kg (115 lbs). Current weight and BMI:
71 kg (156 lbs), 30, respectively. Highest weight and BMI ever achieved: 123 kg 271 lbs., 53. (D–F) 22 months following body lift and 10 months
following medial thigh lift with a vertical component extending onto leg, Type IV thigh lift.
A
B
C
D

359
Chapter | 35  Vertical medial thigh lift with liposuction
E
F
FIG. 35.5  Continued
may have soft tissue draping the anterior aspect of the knee
following extreme weight loss (Fig. 35.6). Tissue elasticity
can be assessed by evaluating the skin for the presence of
striae and cellulite. The fat content of the thighs and sur­
rounding structures should also be noted. Patients with less
fat excess usually have a more “deflated” appearance (Fig.
35.2). Note is made as to whether intertriginous dermatitis
is present, potentially along the proximal medial thigh.
Lymphedema, and/or stigmata of lymphedema should be
documented, as should the presence of arterial or vascular
insufficiency. Scars from previous surgery along the lower
body and extremities should be documented, as should
contour irregularities secondary to liposuction. The quality
of existing scars is important to note. Medial thigh lifting
surgery may result in scars that are more perceptible than
with other more traditional procedures.
FIG 35.4, 35.6A–F APPEARS ONLINE ONLY
Patients advised to undergo a body lift and medial thigh
lift will often ask whether both procedures can be per­
formed during one operative setting. We prefer to avoid
performing these two procedures simultaneously because
of the opposing vectors of tension.25 The body lift elevates
the soft tissue of the medial thighs superiorly and laterally,
while a medial thigh lift draws the same tissues inferomedi­
ally. In the past, when we have combined a body lift and
medial thigh lift, a significant number of individuals have
had suboptimal medial thigh results.
While the majority of patients presenting to our practice
with significant deformities of the medial thighs are candi­
dates for surgery, some are not. Absolute contraindications
for a vertical medial thigh lift with liposuction in our
practice at this time are lower extremity arterial and /or
venous insufficiency and moderate to severe lymphedema.
A high risk for development of one of these conditions
(i.e., a history of femoral lymph node dissection or radia­
tion) would also represent an absolute contraindication.
Variables representing relative contraindications to medial
thigh lift are high patient BMI and small BMI change
from highest weight, significant patient reservations regard­
ing thigh scars, a history of poor scars (i.e., hypertrophic,
or hyperpigmented) and unrealistic patient expectations,
particularly with regard to short scar versions of medial
thigh lift.
SURGICAL TECHNIQUE
The goal of the technique is to have the scars lie along the
thigh perineal crease, proximal gluteal crease and the
medial aspect of the thigh. The patient is evaluated for
marking while standing and facing the surgeon. The lower
extremities should be parallel and several centimeters apart

359.e1
Chapter | 35  Vertical medial thigh lift with liposuction
FIG. 35.4  Traction on the soft tissues of the medial thigh (A) with the patient standing and abducting (B) a lower extremity highlights soft
tissue excess in the horizontal vector and illustrates the function of the vertical medial thigh lift.
A
B

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PART | 6  Thigh, buttock and lower extremity contouring
FIG. 35.6  (A–C) 59-year-old woman 18 months following gastric bypass surgery and weight loss of 89 kg 196 lbs). Current weight and BMI:
55 kg (122 lbs), 25, respectively. Highest weight and BMI ever achieved: 145 kg (319 lbs), 64. (D–F) One year following body lift, 6 months
following medial thigh lift with vertical component extending to leg, medial thigh lift Type IV, and three months following addition of transverse
component over anterior distal thigh, Type V thigh lift. Among the patient’s many concerns prior to body contouring was the excess soft tissue
hanging over her knees. The sequence of procedures improved but did not eliminate the deformity over the long term. Much of this is a result of a
recurrence of soft tissue excess secondary to diminished soft elasticity. The elasticity is poor primarily because of the length of time she was extremely
overweight.
A
B
C
D

359.e3
Chapter | 35  Vertical medial thigh lift with liposuction
E
F
FIG. 35.6  Continued

360
PART | 6  Thigh, buttock and lower extremity contouring
from each. A vertical line is drawn along the medial thighs
from the thigh perineal crease to the medial aspect of the
knees. The line should terminate at a point just distal to the
deformity to be treated, typically the junction of the knee
with the leg. The line should not be visible when evaluating
the standing patient from either an anterior or posterior
perspective. The remaining marks are made with the patient
supine and following anesthesia.
Following induction and with the patient under general
anesthesia, a cotton swab soaked in methylene blue is used
to delineate a line extending from just inferior to the pre-
existing scar from a circumferential body lift or abdomino­
plasty to the thigh perineal crease on either side of the mons
pubis (Fig. 35.7). The marking should then transition from
the thigh perineal crease to the proximal gluteal crease. The
marking should stop several centimeters before the gluteal
crease makes contact with the operating table. This will
insure that the proximal medial thigh scar will not be visible
along the lower buttocks from a posterior perspective.
Tumescent fluid (50 ml of 1% lidocaine and 1 ml 1/1000
epinephrine (adrenaline) in 1 liter of normal saline) is then
injected into the soft tissues of the right medial thigh and
knee. The goal is an approximately 1:1 ration of tumescent
fluid to liposuction effluent. While the effects of the tumes­
cent fluid are taking place, the skin along the marking at the
right thigh perineal and gluteal crease is incised. Liposuc­
tion is usually not performed on individuals with a BMI of
less than 21. Less benefit is seen in this patient population.
Liposuction is then performed along the medial knee and
thigh areas, deep to the superficial fascial system. In many
instances more effluent can be removed than tumescent
volume injected. The “pinch” technique is then utilized by
the surgeon to estimate the excess skin and soft tissue to be
removed (Fig. 35.8). This technique maintains the final
closure centered over the least perceptible location. The first
“pinch” is usually over the area of greatest soft tissue excess,
often the middle one third of the medial thigh. The assistant
then uses Adair or towel clamps to maintain the position of
the estimated tissue to be removed. Methylene blue dots are
marked on either skin edge all along the medial thigh and
knee region where the clamps are in place. The clamps are
all released and removed. The series of dots along the
medial thigh and knee delineates the pattern of the skin and
soft tissue to be removed. The cotton swab is used to connect
the dots. Some of the dots may not correspond exactly to
the overall pattern being produced and those are not fol­
lowed (Fig. 35.9A, B). In this way, a smooth contour is
maintained along the medial thighs. Having completely
demarcated an area of skin and soft tissue to be removed
both along the proximal and medial thighs and knee areas,
the skin along the marking is incised completely. Beginning
just distal to the knee, the flap is elevated under moderate
tension. The previously performed liposuction creates a
readily identifiable plane of dissection with a characteristic
“honeycomb” appearance (Fig. 35.10). The closure along
the medial thigh is performed with interrupted 2-0 Vicryl
sutures placed through the superficial fascial system and
deep dermis, approximately 1 cm from the skin edge. The
vertical closure is completed with a continuous, intracuticu­
lar 3-0 Monocryl suture. The tissue edges in the gluteal
crease region are approximated initially with a #1 Vicryl
suture placed through the SFS and deep dermis, approxi­
mately 1 cm from the tissue edge (Fig. 35.11). The closure
continues into the thigh perineal and mons pubis areas in a
similar fashion. Sutures (0 Vicryl) are placed along the
wound at a deep dermal level to further reinforce the closure,
with intracuticular 3-0 Monocryl to complete the closure.
The same procedure is then performed on the left thigh.
Sterile dressings are applied, followed by elastic wraps.
FIG 35.9B, 35.11 APPEARS ONLINE ONLY
OPTIMIZING OUTCOMES
● A careful analysis of the medial thigh deformity is
essential for optimizing outcome.
● Soft tissue excess at the lower abdomen, mons pubis and
buttocks and the inferomedial collapse of the soft tissues
of the thighs should be corrected prior to performing a
medial thigh lift procedure i.e., consider a circumferen­
tial body lift procedure prior to a medial thigh lift.
● Lower body lifting procedures prior to a medial thigh
lift eliminate much of the vertical excess along the
medial thighs, minimizing the need for significant
tension along the thigh perineal closure and the potential
for tension-associated complications: labial spreading,
inferior scar migration, recurrence of soft tissue laxity.
● The vertical component in the medial thigh lift proce­
dure addresses soft tissue excess in the horizontal vector
FIG. 35.7  A cotton swab soaked in methylene blue is used to delin­
eate a line extending from just inferior to the pre-existing scar from
a circumferential body lift or abdominoplasty to the thigh perineal
and gluteal crease on either side of the mons pubis.

360.e1
Chapter | 35  Vertical medial thigh lift with liposuction
FIG. 35.9  The methylene blue swab is used to place dots on either
skin edge. The cotton swab is used to connect the dots (B). Some of the
dots may not correspond exactly to the overall pattern being produced and
those are not followed. In this way, a smooth contour is maintained along
the medial thighs.
B
FIG. 35.11  The cephalad tissue edge along the most posterior extent
of the gluteal crease wound is approximated to the caudal tissue edge
in a manner that does not produce a standing cone or “dog-ear” on
the buttocks. Avoidance of this problem is facilitated by flexing the
right hip and knees to 90° with slight hip abduction and having an
assistant align the tissue edges.

361
Chapter | 35  Vertical medial thigh lift with liposuction
FIG. 35.8  The “pinch” technique is utilized by the surgeon to estimate the excess skin and soft tissue to be removed. The index fingers of both
hands depress the previously made marking along the medial thigh and knee . This technique maintains the final closure centered over the least percep­
tible location. The first “pinch” is usually over the area of greatest soft tissue excess, often the middle one-third of the medial thigh (A, B). The assistant
then uses Adair or towel clamps to maintain the position of the estimated tissue to be removed (C, D).
A
B
C
D
FIG. 35.9  The methylene blue swab is used to place dots on either
skin edge along the medial thigh and knee region while the clamps are
in place (A). The clamps are all released and removed. The series of dots
along the medial thigh and knee delineates the pattern of the skin and soft
tissue to be removed.
A
FIG. 35.10  The previously performed liposuction creates a readily
identifiable plane of dissection with a characteristic “honeycomb”
appearance. An effort is made to preserve the greater saphenous vein
and its tributaries, although this is not always possible.
and also helps minimize tension-related complications
at the thigh perineal crease.
● Liposuction at the time of a medial thigh lift provides an
easily identifiable plane of dissection and significantly
improves esthetic outcome, particularly in higher BMI
individuals.
A clear understanding of the variables contributing to a
patient’s medial thigh deformity is critical to optimizing the

362
PART | 6  Thigh, buttock and lower extremity contouring
results of medial thigh lift surgery. An analysis of the
medial thighs is complicated by their dependent position.
Unlike many other areas of the body commonly treated by
plastic surgeons, the medial thigh contour is very much
affected by the status of the soft tissues immediately cepha­
lad to it, particularly in the weight loss patient. A failure to
address deformities along the mons pubis, hips, thighs and
buttocks, or lower body will produce suboptimal results.
Circumferential body lift procedures effectively address
these concerns (Fig. 35.12). Efforts to approach the medial
thighs prior to addressing the lower body deformities
will usually lead to an undesirable outcome (Fig. 35.13).
Equally important is the recognition of soft tissue excess in
the horizontal vector. Virtually all weight loss patients
and many individuals who have undergone significant lipo­
suction have soft tissue excess in the horizontal vector.
The vertical component of a vertical medial thigh lift very
effectively addresses this element of the medial thigh
deformity.
FIG 35.13A–C APPEARS ONLINE ONLY
In our plastic surgery practice, we rarely use liposuction
as a sole procedure on postpartum or post-bariatric
individuals. The risk for contour irregularities is significant
and the esthetic benefits marginal.24 We have, however,
embraced liposuction as an adjunct to soft tissue excisional
procedures such as brachioplasty and vertical medial thigh
lifts. Liposuction serves several functions in this proce­
dure.26 The first is to create a readily identifiable and safe
plane of dissection. The evacuation of fat from the soft
tissues deep to the SFS facilitates dissection and the identi­
fication and preservation of nerves and veins (Fig. 35.10).
The second is to reduce the volume of the extremity being
treated. A smaller volume allows for more skin and soft
tissue to be removed, improving the esthetic outcome of a
broad range of patients, particularly high BMI individuals.
POSTOPERATIVE CARE
Patients are advised that they may ambulate immediately
after surgery as tolerated. Dressings and elastic wraps are
removed 48 hours after surgery, at which time showering
is permissible. Thereafter, patients are not advised to wear
any supportive garments unless swelling of the legs or feet
becomes evident. In these cases supportive stockings are
suggested. Any exercise or activity that may lead
A
B
FIG. 35.12  (A–C) A 27-year-old woman one year following gastric bypass surgery and weight loss of 73 kg (116 lbs). Current weight and
BMI: 92 kg (202 lbs), 37, respectively. Highest weight and BMI ever achieved: 165 kg (363lbs), 66. (D–F) Twelve months following body lift.
Note improvement of medial thighs by correction of soft issue excess along lower body in vertical vector. Excess soft tissue remains along thighs in
horizontal vector.

362.e1
Chapter | 35  Vertical medial thigh lift with liposuction
A
B
FIG. 35.13  (A–C) This 47-year-old woman had lost 34 kg (75 lbs)
through lifestyle changes prior to undergoing liposuction of her thighs
and a thigh lift limited to a vertical component. Her surgeries were
performed by another surgeon. She presented to us with concerns
about the cellulite and excess skin along her thighs and buttocks.
C

363
Chapter | 35  Vertical medial thigh lift with liposuction
E
F
C
D
FIG. 35.12  Continued

364
PART | 6  Thigh, buttock and lower extremity contouring
increasingly ischemic, take on a dusky appearance and at 2
weeks actual skin separation may take place. The majority
of skin dehiscences are less than 3 cm in size. Avoiding this
complication is challenging. A technique which avoids a
closure intersection at the thigh perineal crease is unlikely
to produce optimal results. We advise patients to limit
abduction of the thighs; however, this restriction is unlikely
to entirely prevent this problem. The dehiscences are treated
with dressing changes. In some instances, hypergranulation
tissue may arise in the area of skin dehiscence. Silver nitrate
application is very effective. Seromas are the second most
frequent complication at 19.8%. The vast majority, approxi­
mately 90%, occur along the distal medial 1/3 of the thigh
and lie immediately beneath the scar. Most become evident
at about 3 weeks postoperative and range in diameter from
1 to 4 cm. Initially we manage them by needle aspiration.
This technique, unfortunately, has a very high recurrence
rate, particularly with seromas larger than 1cm in diameter.
The technique, of “marsupialization” (i.e., incising the skin
over the seroma), draining the seroma and suturing the
seroma cavity to the skin is 100% effective but results in a
scar that may be wider than the adjoining scar and often
results in a prolonged healing process. Our preference at
this time is to drain the seroma via the scar and place a
secured Penrose type drain into the seroma cavity. This
technique has also proven to be very effective. In several
instances, a localized cellulitis has resulted from this tech­
nique. We now prescribe a first generation cephalosporin
while the drain is in place. Overall in our series, infections
have been very infrequent, as have bleeding and hemato­
mas. Skin necrosis has also been very infrequent despite
liposuction being performed in virtually all cases. We have
only one documented instance of DVT in a patient undergo­
ing vertical medial thigh lift with liposuction. There have
been no instances of pulmonary embolism.
Chronic lower extremity edema is often considered to
be a significant risk for patients undergoing a medial thigh
lift procedure.2 Interestingly, this has not been the case in
our series. We have had only two cases where lower extrem­
ity edema has persisted beyond 3 months and in both
instances the patients returned to their presurgical state by
6 months. Preserving lymph nodes at the femoral triangle
and perhaps the incorporation of liposuction in the areas of
tissue removal have helped minimize this complication in
our series. Liposuction may facilitate the preservation of
vascular structures.
Scar quality is often of great concern to patients follow­
ing a vertical medial thigh lift procedure. As described
above, we do not routinely make any particular recommen­
dation regarding scars, aside from the avoidance of ultra­
violet light during the period of scar maturation. In those
instances where patients are not satisfied with the quality
of their scars and when the potential for improvement
to significant perspiration is discouraged for 2 weeks. In
addition, patients are advised to avoid abducting their
thighs beyond 45° to avoid excessive tension along the
thigh perineal closure. Following this period, vigorous
upper body activities are permitted. Vigorous lower body
activities are permitted after 6 weeks. Patients are not
advised to apply or consume any products or perform any
particular therapy for the purpose of improving scar quality.
Patients determined to use a particular product are informed
that silicone gel sheeting is the only product with scientific
data to support its use in scar therapy.27 Silicone gel sheet­
ing may be applied after 2 weeks. All patients are advised
to minimize ultraviolet light exposure to the scar while it
is hyperemic to avoid permanent hyperpigmentation. The
normal process of scar maturation is often reviewed during
follow up visits. Patients are typically evaluated postopera­
tively at 1 week, 6 weeks, 3 and 6 months, and yearly.
COMPLICATIONS AND THEIR
MANAGEMENT
Complications following medial thigh lift procedures are
usually minor but more frequent than with other more tra­
ditional body contouring procedures (Table 35.2). The com­
plications and their management are similar to those
following brachioplasty.26 In our review of 250 cases of
vertical medial lift with liposuction (500 thighs), skin
dehiscence was the most frequent complication at 28.4%.
None of the dehiscences occurred acutely (i.e., within the
first 24 to 48 hours following the operation) but rather
began to become evident approximately 2 weeks following
the procedure. Nearly all (95%) occurred at the intersection
of the closure at the thigh perineal crease. As in many
instances in plastic surgery where a skin flap narrows, the
tip of the flap may have a compromised blood supply. In
the days following the procedure the tip may become
TABLE 35.2  Complication Rates Associated with
Vertical Medial Thigh Lift
Complication
N = 250 Cases (500 thighs)
Complication Rate (%)
Skin dehiscence
28.4
Seroma
19.8
Infection
1.2
Hematoma
0.4
Skin necrosis
0.4
Deep vein thrombosis
0.4
Pulmonary embolism
0.0

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Chapter | 35  Vertical medial thigh lift with liposuction
exists, we perform a scar revision, often with local anesthe­
sia or at the time when another procedure requiring general
anesthesia is being performed. The revisions are usually not
considered before 1 year. Revisions performed at this time
nearly always produce a less perceptible scar. This is likely
due to diminished tension along the closure.
CONCLUSION
Medial thigh deformities are a concern for many body con­
touring patients. Despite this, many plastic surgeons are not
eager to approach this region with soft tissue excisional
procedures. The lack of enthusiasm relates to the frequency
of suboptimal results and related complications. Consis­
tently effective medial thigh lifts are possible when the
vertical and horizontal components of the deformity and
their relationship to the lower body are recognized. Our
approach to the medial thighs, the correction of lower body
deformities prior to a vertical medial thigh lift with liposuc­
tion, has been utilized in hundreds of cases with satisfying
results. Medial thigh lift surgery is a routine and essential
part of our plastic surgery practice.
REFERENCES
1. Leitner DW, Sherwood RC. Inguinal lymphocele as a complication
of thighplasty. Plast Reconstr Surg 1983;72:878.
2. Moreno CH, Neto HJ, Junior AH, et al. Thighplasty after bariatric
surgery: evaluation of lymphatic drainage in lower extremities. Obes
Surg 2008;18:1160.
3. Lockwood T. Fascial anchoring technique in medial thigh lifts. Plast
Reconstr Surg 1988;82:299.
4. Lewis JR. The thigh lift. J Int Coll Surg 1957;27:330.
5. Pitanguy I. Trochanteric lipodystrophy. Plast Reconstr Surg
1964;34:280.
6. Planas J. Crural meloplasty for lifting the thighs. Clin Plast Surg
1975;2:495.
7. Vilain R. Surgical correction of steatomeries. Clin Plast Surg
1975;2:467.
8. Schultz RC, Feinberg LA. Medial thigh lift. Ann Plast Surg
1979;2:404.
9. Lockwood T. Lower body lift with superficial fascial system suspen­
sion. Plast Reconstr Surg 1993;104:1212.
10. Spirito D. Medial thigh lift and D.E.C.L.I.V.E. Aesth Plast Surg
1998;22:298.
11. Le Louarn C, Pascal JF. The concentric medial thigh lift. Aesth Plast
Surg 2004;28:20.
12. Kirwan L. Anchor thighplasty. Aesth Surg J 2004;24:61.
13. Sozer SO, Agullo FJ, Palladino H. Spiral lift: medial and lateral thigh
lift with buttock lift and augmentation. Aesth Plast Surg 2008;32:120.
14. Shermak MA, Mallalieu J, Chang D. Does thighplasty for upper
thigh laxity after weight loss require a vertical scar? Aesth Surg J
2009;29:513.
15. Capella JF. Brachioplasty. Baker, Gordon Symposium. February 1,
2005.
16. Hurwitz DJ. Medial thighplasty. Aesth Surg J 2005;25:180.
17. Kenkel JM, Aly AS, Capella JF, et al. Body contouring after massive
weight loss. Plast Reconstr Surg 2006;117(1) Supplement.
18. Mathes DW, Kenkel JM. Current concepts in medial thighplasty.
Clin Plast Surg 2008;35:151.
19. Cram A, Aly A. Thigh reduction in the massive weight loss patient.
Clin Plast Surg 2008;35:165.
20. Nemerofsky RB, Oliak DA, Capella JF. Body lift: an account of 200
consecutive cases in the massive weight loss patient. Plast Reconstr
Surg 2006;117:414.
21. Capella JF. An approach to the lower body after weight loss. In:
Matarasso A, Rubin P, editors. Aesthetic Surgery after Massive
Weight Loss. New York: Elsevier; 2006.
22. Capella JF. Body lift. Clin Plast Surg 2008;35:27.
23. Capella JF, Travato M, Woehrle S. Screening and safety issues in the
massive-weight loss patient. In: Nahai F, editor. Art of Aesthetic
Surgery: Principles and Technique. 2nd ed. St. Louis: Quality
Medical Publishing; 2010.
24. Capella JF. Special problems in re-operative body contouring. In:
Nahai F, editor. Art of Aesthetic Surgery: Principles and Technique.
2nd ed. St. Louis: Quality Medical Publishing; 2010.
25. Aly AS, Capella JF. Staging, reoperation and treatment of complica­
tions after body contouring in the massive-weight-loss patient. In:
Grotting J, editor. Reoperative Aesthetic and Reconstructive Surgery.
2nd ed. St. Louis: Quality Medical Publishing; 2007.
26. Capella JF, Travato M, Woehrle S. Brachioplasty. In: Nahai F, editor.
Art of Aesthetic Surgery: Principles and Technique. 2nd ed. St.
Louis: Quality Medical Publishing; 2010.
27. Berman B, Perez OA, Kond S. A Review of the Biologic Effects,
Clinical Efficacy, and Safety of Silicone Elastomer Sheeting for
Hypertrophic and Keloid Scar Treatment and Management. Derma­
tol Surg 2007;33:1291.
Fig. 35.2B–F, Fig. 35.4, Fig. 35.6A–F, Fig. 35.9B, Fig. 35.11
Fig. 35.13A–C can be found online
Bonus images for this chapter can be found online at

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© 2013 Elsevier Inc
Part 6  Thigh, buttock and lower extremity contouring
Chapter 36 
Key Points
●
Patient selection is helped by thorough discussion
of the possible outcome, risks and benefits.
●
Understanding the anatomy is vital.
●
The excision and lipomobilization are described.
●
Closure of the wound is described.
●
The prevention and management of complications.
Short vertical scar medial thigh lift
James D. Frame
INTRODUCTION
Lax tissues in the upper thigh can be a concern to many
people, particularly where there has been significant weight
loss.1 Rubbing inner thighs can cause sores and hygiene
problems. The esthetic consequences of redundant skin can
be a major psychological disability and destroy interper­
sonal relationships.
Understanding the anatomical changes is hugely impor­
tant in deciding the best method of correction. A short
medial scar inner thigh lift is indicated where there is a
vertical descent of tissue immediately beneath the groin
crease as it extends into the perineum and thence into the
buttocks. The temptation is simply to excise an ellipse of
skin and fat and hitch up the distal tissues onto the adductor
tubercle and fascia using nonabsorbable sutures.
In my experience, there is an inevitable gravitational
drag on tissue that is undergoing repair and if the holding
suture fails and an excessive amount of “thigh lift” has been
performed, then the labia majora is pulled down, causing
an open introitus and a severe problem with underwear and
hygiene.2 Whilst there may be a good initial result, it
becomes certain that an undesirable scar occurs below the
bikini line. The presence of labial skin in the inner thigh is
a major disaster.
In essence, it is important to remember that the thigh is
an inverted cone, and gravity, plus loosening of tissues, loss
of volume, and reduced elasticity is causing the problem.
Merely pulling the cone upwards increases the vertical
force downwards and thus gives the unsatisfactory result
over time.
Adding a vertical limb to the inner thigh lift effectively
narrows the diameter of the thigh and allows the tissues
to “cling” into a better position. The scars are vertical
(i.e., “antigravity”) and there is no drag downwards of the
introitus.
APPLIED ANATOMY
The mons pubis is held in an elevated position by fibrous
suspensory attachments, but these generally loosen off with
ageing and weight loss. The descent of the mons and tissues
immediately above the inguinal ligament starts the cascade
that results in soft tissue redundancy at a level usually at
the apex of the femoral triangle. Simply lifting the mons,
as occurs in some forms of abdominoplasty, can improve
the appearance of the inner thigh. For a long-lasting effect
though, a vertical narrowing of the base of the cone is
required and this can be achieved in a number of ways (Fig.
36.1). In the tissues over the femoral triangle there are a
significant number of important structures that should be
maintained if possible.
The long saphenous vein passes upwards from a point
one hand’s breadth behind the medial border of the patella,
to a point two fingers breadth below and two fingers breadth
lateral to the pubic tubercle. The vein then turns 90° through
the cribriform fascia, so joining the femoral vein at the
saphenofemoral junction. The vein passes beneath the Scar­
pa’s fascia in its vertical ascent and is superficial to deep
fascia (Fig. 36.2).
Superficial lymphatics in the thigh travel alongside the
saphenous vein as trunks, before separating from the vein
to enter the femoral ring and passing through a complex of
lymph nodes, the most well known being Cloquet’s gland.
Superficial lower leg lymph vessels follow the long saphe­
nous vein medially and are larger and more numerous than
the lower leg lateral lymphatics that pass deeply into the
popliteal fossa. The medial thigh lymphatics ascend to the
lower group of inguinal lymph nodes. Superficial lymphat­
ics around the posterior thigh and buttocks pass medially
and anteriorly to the front of the thigh and terminate in the
upper group of inguinal nodes. By restricting the depth of
resection, the undermining of tissues and the extent of the

367
Chapter | 36  Short vertical scar medial thigh lift
FIG. 36.1  The short vertical scar medial thigh lift.
Ad = Adductor tuberosity V = Femoral vein A = Femoral artery N = Femoral nerve LSV = Long saphenous vein
V
LSV
A
Ad
N
A i Skin markings
ii Resultant scars
B i Skin markings
ii Resultant scars
FIG. 36.2  The anatomy of the upper thigh – transverse section.
Femoral artery and
deep lymphatics:
deep to investing
deep fascia
Deep fascia
Biceps
Split in superficial fascia
containing long saphenous vein
and superficial lymphatics
Femoral nerve
Superficial fascia
Profunda femoris artery
Sciatic nerve
Quadriceps
complex
Adductors
complex
Gluteus
maximus
Femur

368
PART | 6  Thigh, buttock and lower extremity contouring
Most
vector force
Least
vector force
Drop vertical height
Passages created
by liposuction
cannula
FIG. 36.3  Principle of mobilization.
wound, there is less likelihood of lymphatic damage and
subsequent collection of lymph with subsequent morbidity.
The excisional plane, therefore, must be superficial to the
long saphenous vein. Contrary to common procedure, it is
important to preserve bulk to the thigh whilst performing
the lift. For example, in the Brazilian abdominoplasty3 there
is preservation of all tissues above Scarpa’s fascia and there
is no incidence of seroma or lymphocele. Similarly, in the
groin, if lymphatics are preserved by using lipomobilization
techniques, there is no dead space available to create a
problem with fluid collections in the thigh (Fig. 36.3).
If there is a minimal undermining of tissue there is no
possibility of wound edge necrosis as was commonly seen
after groin dissection without a 2 cm skin edge resection
for malignancy.4 As the skin is approximated, the deeper
tissues tighten under compression (Fig. 36.4). This will
Skin
Scarpa’s fascia
Long saphenous
vein
Superficial
lymphatics
Deep fascia
A
Closure of
dead space
Skin
Scarpa’s fascia
Deep fascia
B
Excision to Scarpa’s fascia: superficial to vein and lymphatics
Excision to deep fascia: lymphatics transected
Collection of seroma and lymphocoele
from disrupted lymphatics is avoided by deep suture
FIG. 36.4  Scarpa’s fascia and closing the post-excisional deep space to avoid seroma.

369
Chapter | 36  Short vertical scar medial thigh lift
FIG. 36.6  Oblique inner thigh view – standing.
FIG. 36.5  Patient standing – front view.
loosen eventually but still leave a better result than after a
major debulking of the medial thigh tissues.
PREOPERATIVE PREPARATION
It is wise to consult patients on at least two occasions pre­
operatively, and to show photographs of average outcomes
for the proposed surgery. If the scars do not discourage the
enthusiasm of the patient, then a complete analysis of the
benefits and risks must be discussed to ensure correct
patient selection. Once surgery has been performed there is
no turning back. It is important to have a stable weight
pattern over a period of time. Weight loss after a skin tight­
ening procedure creates problems. Weight gain improves
the esthetics but subsequent weight loss results in further
skin redundancy.
A preoperative nurse assessment, including measure­
ments for support garments, and in-depth social and medical
assessments are extremely helpful in predicting psychologi­
cal outcome. Any medical issues are investigated and acted
upon. Obviously, smoking, obesity, diabetes, hypertension
and other medical problems need to be addressed
pre-operatively.
SURGICAL TECHNIQUE
Immediately prior to surgery the patient is marked in a
standing position and the problem area is addressed (Figs
36.5 and 36.6). Scars are limited in vertical length within
the medial aspect of the thigh then curve anteriorly to
follow the groin crease for a few centimeters, before
ascending vertically again into the mons pubis in cases
where there is significant mons ptosis and redundancy, the
skin markings are as in Fig. 36.1. The surface marking of
the long saphenous vein is noted and the proposed skin
excision is marked accordingly. In the short vertical scar
inner thigh lift the skin paddle excision will extend to a
thigh level just distal to the apex of the femoral triangle.
Variances to the scar are created by several choices of
design in the skin paddle excisions. In general, a horizontal
groin crease scar will drop and widen unless there is a verti­
cal element above it, or if the horizontal scar can be
restricted. Not all vertical scar thigh lifts require an exten­
sion into the mons pubis.
Skin Marking: Erect and Supine Positions
1. Mark from the adductor tuberosity to the medial condyle
of the knee, vertically.
2. Surface mark the course of the long saphenous vein.
3. Using the palm of the hand, slide the soft tissue situated
posterior to this line anteriorly and re-mark the vertical.

370
PART | 6  Thigh, buttock and lower extremity contouring
FIG. 36.7  Patient in “frog-leg” position on the operating table.
FIG. 36.8  Displacing the medial thigh skin anteriorly and vertically
marking the midline.
FIG. 36.9  Displacing the medial thigh skin posteriorly and vertically
marking the midline.
FIG. 36.10  The planned excision extending into the groin crease and
vertically into the mons pubis.
The apex of the marked triangle should only extend 1.5
hand’s breadth below the adductor tuberosity.
4. Using the palm of the hand, slide the tissues anterior to
this vertical line posteriorly with a slight upward eleva­
tion. Re-mark the vertical.
5. The patient lies supine. The breadth of the skin ellipse
marked is equalized and made symmetrical to the oppo­
site side.
6. An oblique line is drawn along the groin crease and the
potential dog-ear is marked for excision. In cases of
excessive skin redundancy a vertical line continues into
and lateral to the pubic hairline of the mons. Further
skin markings to plan the excision of redundant skin,
the sliding advancement of the skin edges with no
undermining, and comfortable skin closure are added.
The patient is supine on the operating table with full
exposure of groins and thighs to knees; skin preparation is
with BetadineTM and spirit. A “frog-leg” position (Fig. 36.7)
is adopted for the surgery but both thighs are kept poten­
tially mobile to assess symmetry of scars. Thromboembolic
stockings, warming blankets and FlotronsTM are used. The
original skin markings, from the erect position, may be
modified in the GA supine frog leg position (Figs 36.8–
36.10). Incisions are made in the skin to mid-dermal level,
closely following the skin marking. Angles and junctions
are marked to align the wound edges symmetrically. The
dermis and underlying fat in the layers superficial to Scar­
pa’s fascia are elevated and put under traction, thence
dissecting with electrocautery. Using traction and counter-
traction forces, the dissection is easy and leaves the intact
long saphenous vein and lymphatics. After reflecting the
composite tissues, the wound is repaired by closing the
space superficial to Scarpa’s fascia, using 2-0 and 4-0 Vicryl
PlusTM (Fig. 36.11). By catching (quilting) the Scarpa’s
layer in the wound depths, all dead spaces are closed