266
CHAPTER 34 • Body Contouring Following Massive Weight Loss
and the inframammary fold are marked with the patient in
standing position. The proposed site of the neoposition of the
nipple-areola complex is just above the inframammary fold.
The patient is in the supine position, under general anes
thesia. The staple test is carried out. Marchac’s modification
of the Lejour vertical mastopexy is based on the central pedicle.6
Tumescent infiltration is carried out, followed by the skin
excision. Transposition of the nipple-areola complex on the
central glandular pedicle is done.
Vertical closure with minimal horizontal extension as
described by Lejour and modified by Marchac is completed.6
Skin closure is done with 3-0 and 5-0 Monocryl sutures; the
patient should wear a sports bra.
BRACHIOPLASTY (Fig. 34.10)
The patient is marked in the standing position, with the arms
abducted. Tumescent infiltration under general anesthesia is
done with the patient in the supine position after skin prepara
tion, as described above. Liposuction is limited and is only
done underneath the skin within the marked ellipse.
The staple test is performed, and then the skin-only excision,
with closure as above, without drains. Gamgee dressing and
pressure garments are applied, as above.
Follow-Up
All patients are reviewed in the clinic at 1 week postoperatively,
and the wounds are checked. A planned follow-up is done at
6 weeks and thereafter at 3 to 6 weeks, according to how with
the patient’s outcome has developed.
nipple-areola complex, and zone of liposuction are identified
and marked.
The pinch test is done, and the proposed horizontal ellipse
of skin and underlying soft tissue is determined. The patient
is in the supine position under general anesthesia. Marker
sutures are placed at the suprasternal space and xiphisternum.
Tumescent infiltration is carried out, with extensive liposuction
of the anterior and lateral chest wall. The composite-free,
nipple-areola graft (2–2.5 cm diameter) is harvested using a
nipple marker. Alternatively, the nipple-areola complex can
be harvested on the central pedicle, as shown in Fig. 34.8. The
staple test is done, and then the ellipse is marked again to
ensure tension-free closure. The skin and soft tissue are excised
up to the pectoral fascia. Hemostasis and usual closure are
done as described above.
Mark the location of the free nipple-areola graft position
equidistant from the midline with two marker sutures over
the midclavicular lines at the level of the inferolateral border
of the pectoralis major. Mark the disc of the proposed inset of
the nipple-areola composite graft with a nipple marker.
De-epithelialize the recipient bed. Defat the graft inset using
5-0 Vicryl Rapide continuous sutures and quilting sutures, and
tie over the bolus dressing using 3-0 polypropylene sutures.
Gamgee dressing and pressure garments are applied as usual.
The patient is discharged the next day.
MASTOPEXY AND AUGMENTED MASTOPEXY
Mastopexy is indicated for severe ptosis of the breasts without
volume loss; an augmented mastopexy is indicated when ptosis
is associated with volume loss. Bilateral midclavicular lines
Before
After
A
B
FIGURE 34.8 Upper body lift and revision lower body lift using a fleur de lis approach to address the soft tissue laxity in the vertical axis, mastopexy, liposuction-assisted
thigh reduction, and liposuction of outer thigh. (A) Preoperative. (B) Six weeks postoperative, anterior view.
267
Complications
procedures. The reported overall complication rate varies from
6% to 55%.7–9 For other body-contouring procedures, complica
tions are less common if strict adherence to preventive measures
is maintained. Table 34.2 denotes our experience, as well as
listing key steps to avoid the complications.
Complications
Complications are more commonly encountered in major
procedures involving truncal or combined truncal-extremity
A
D
E
F
B
C
FIGURE 34.9 Liposuction-assisted correction of post–massive weight loss gynecomastia. (A) Anterior view before surgery. (B) Postoperative appearance. (C) Lateral
postoperative appearance. (D) Preoperative marking with the patient in standing position. The outer marking represents the area for proposed liposuction and the periareolar
marking was made for the proposed area for de-epithelializing. The horizontal marking was designed for proposed skin and soft tissue excision following the pinch test with
the patient in standing position and the staple test done intraoperatively. The nipple was transposed on a superiorly based pedicle. (E) Lateral view of preoperative markings
with the patient in standing position. (F) Excised tissue.
Table 34.2 Common complications and principles of prevention
Procedure
Complications
Preventive measures
Lower body lift
• Seroma (~10%)
• Hematoma (~2%)
• Flap necrosis and delayed wound
healing (~1%)
• Meticulous hemostasis
• Liposuction assisted pseudoundermining
• Quilting sutures
• Tension-free closure as ensured by pinch test at the time of
marking and staple test before final excision
• No surgery on chronic smokers
Post–massive weight
loss gynecomastia
• Partial loss of composite nipple graft
(~2%)
• Hypertrophic, keloid scar (up to
10%, more in dark skin)
• Meticulous defattening of the graft
• Precise inset and tie over bolus dressing
• Application of pressure garments
• Strict instruction of avoiding upper body workout for 4 weeks
268
CHAPTER 34 • Body Contouring Following Massive Weight Loss
References
1.
Borud, L., Warren, A., 2006. Body contouring in the postbariatric surgery
patient. J. Am. Coll. Surg. 203, 82–93.
2.
Rieger, U., Heider, I., Bauer, T., et al., 2011. Treatment algorithm for
abdomino-torso body contouring in massive weight loss patients in
the presence of scars—a comprehensive review. J. Plast. Reconstr.
Aesthet. Surg. 64, 563–572.
3.
Abela, C., Stevens, T., Reddy, M., Soldin, M., 2011. A multidisciplinary
approach to post-bariatric plastic surgery. Int. J. Surg. 9, 29–35.
4.
Soldin, M., Mughal, M., Al-Hadithy, N., 2014. National Commissioning
Guidelines: body contouring surgery after massive weight loss. J.
Plast. Reconstr. Aesthet. Surg. 67, 1076–1081.
5.
Saldanha, O., Azevedo, S., Delboni, P., et al., 2010. Lipoabdominoplasty:
the Saldanha technique. Clin. Plast. Surg. 37, 469–481.
6.
Marchac, D., Sagher, U., 1988. Mammaplasty with a short horizontal
scar. Evaluation and results after 9 years. Clin. Plast. Surg. 15, 627–639.
7.
Kitzinger, H., Cakl, T., Wenger, R., et al., 2013. Prospective study on
complications following a lower body lift after massive weight loss.
J. Plast. Reconstr. Aesthet. Surg. 66, 231–238.
A
C
D
B
Before
After
FIGURE 34.10 Liposuction-assisted brachioplexy. Preoperative (A,C) and postoperative (B,D) appearance. The incisions are well hidden within the posteromedial axis.
8.
Fischer, J., Wes, A., Serletti, J., Kovach, S., 2013. Complications in body
contouring procedures: an analysis of 1797 patients from the 2005 to
2010 American College of Surgeons National Surgical Quality Improve
ment Program databases. Plast. Reconstr. Surg. 132, 1411–1420.
9.
Hasanbegovic, E., Sørensen, J., 2014. Complications following body
contouring surgery after massive weight loss: a meta-analysis. J. Plast.
Reconstr. Aesthet. Surg. 67, 295–301.
Further Reading
Winocour, J., Gupta, V., Ramirez, R., et al., 2014. Abdominoplasty: risk
factors, complication rates, and safety of combined procedures. Plast.
Reconstr. Surg. 136, 597e–606e.
269
Surgical Preparation and Technique
269
35
Gluteal Augmentation
Marcelo Olivan MD, PhD
The Clinical Problem (Figs. 35.1
and 35.2)
Gluteal augmentation surgery has grown by 42%/year in Brazil.
Patients who look for gluteoplasty augmentation with implants
are about 36 years of age. This type of surgery does not have
any relationship with occupation and socioeconomic status.1
The main clinical complaints that lead patients to seek this
procedure are related to the following:
1. A lack of projection in the gluteal area
This may present as a purely cosmetic request to give
shape and form to the buttock or, in extreme cases, as a
functional request, such as when the trousers cannot be
held with a belt.
2. Anatomic imbalance between the gluteal volume, torso,
and hips
3. Low body self-esteem
Gluteal augmentation with implants is a surgery with a
high level of satisfaction to patients, affecting and
improving many aspects of their lives. Its outcome
should produce a natural look and be hardly noticed by
others.1
Indications for Buttock Augmentation
Body contour is a concern for most women, and buttock
reshaping has been increasing in importance2 and gaining
popularity over the past decade.3 Buttock reshaping has been
improved by the development of prosthetic implants and
ancillary procedures.4 Gluteal augmentation with implants is
one of the most popular procedures to contour the gluteal
region. It has been used to correct gluteal ptosis, gluteal
hypoplasia, or gluteal agenesis, as well as for aesthetic purposes
and increased self-esteem. In some cases, it has been used to
correct ptosis and enhance hypoplasia.5
Surgical Preparation and Technique
Therapeutic Plan
There are currently two techniques for gluteal augmentation,
as described here.
LIPOSUCTION WITH AUTOLOGOUS FAT GRAFTING
An autologous fat graft is indicated for patients who may have
a surplus of body fat in other areas. In addition to augmenting
the buttock, this allows the surgeon to reproportion the adjacent
body contours. Autologous fat is transferred into both the
subcutaneous layer and gluteus maximus muscle to give an
overall increase in bulk to the region. Fat needs to be available
from donor sites in sufficient quantity to cover primary and
possibly secondary grafting procedures.
GLUTEAL IMPLANTS
These are indicated for patients who do not have body fat
excess or have it in an insufficient amount to increase the gluteal
region. Surgical techniques for buttock implants insertion have
evolved over time to correct anatomic deficiencies and fulfill
patients’ requests. The procedure for aesthetic purposes has
gained strength since the 1970s, after the description of the
use of implants in the gluteus by Cocke and Ricketson,6 the
dissemination of technical enhancements by González-Ulloa,7
and the development of a specific range of gluteal implants.
Several techniques have evolved, including procedures for the
dissection plane, such as for the subcutaneous plane by
González-Ulloa,7 the subfascial plane by de la Peña et al.,8 the
submuscular plane by Robles et al.,9 and the intramuscular
plane by Vergara and Marcos10 (Fig. 35.3).
Subcutaneous placement of a gluteal implant has serious
disadvantages. Because the system that maintains the skin
270
CHAPTER 35 • Gluteal Augmentation
gluteal fascia is very extensive and covers the entire gluteus
maximus muscle. It has the same problems as subcutaneous
implants—visible margins, palpable, rupture, displacement,
and capsular contracture are the most common complications.
The submuscular approach preserves the aponeurotic system
that holds gluteal skin in position and has the advantage of
reducing the incidence of capsular contracture, displacement,
rupture, and palpation. However, it introduced a new anatomic
issue— the potential risk of injury to the sciatic nerve. Another
disadvantage of the submuscular position relies on its small
size and therefore limits the use of larger implants.
To prevent subcutaneous, subfascial, and submuscular
complications, and at the same time gain the benefits of the
muscular cover, the intramuscular plane is the most used
technique. The pocket is created by splitting the muscular fibers
of the gluteus maximus. The goal is to have 2 to 3 cm of muscle
over the pocket and the same 2- to 3-cm thickness of gluteus
maximus deep to the pocket to protect the sciatic nerve, allowing
the surgeon to place the implant in the best position for each
type of buttock.
Selection of Implants
Over the years, different types of implants have been used for
gluteal augmentation, having either a round (Fig. 35.4) or oval
(Fig. 35.5) base and with higher and lower profiles. Buttock
implants are firmer in consistency than breast implants and
have stronger, smooth, elastomer shell covers. Indications vary
according to the buttock dimensions and the capacity to expand
the soft tissues. Virtually all implants in my practice are inserted
within an intragluteus maximus pocket.
The ideal patient for a round buttock implant presents with
a square buttock. That is, the width is similar to the height
(Fig. 35.6).
attachment to the gluteal region is composed of aponeurotic
expansions from the gluteal aponeurosis to the dermis, the
creation of a subcutaneous pocket will damage these expansions,
leaving the skin without fixation. This could possibly result
in implant displacement. Furthermore, in this plane, the implants
are palpable and highly visible, there is an increased chance
of rupture of the implant shell, the skin envelope can become
ptotic, and severe capsular contracture can occur.
The subfascial plane technique described by de la Peña et al.8
is based on gluteal layers. The pocket that is created under the
FIGURE 35.1 The clinical problem—square hip.
FIGURE 35.2 The clinical problem—rectangular hip.
Robles/Otero
de La Peña
Vergara
Ulloa
FIGURE 35.3 Evolution of techniques over time. Implant positions—subcutaneous
(Gonzalez-Ulloa), subfascial (De la Pena), intramuscular (Vergara), and submuscular
(Robles). (From Serra, F., Aboudib, J.H., Cedrola, J.P., de Castro, C.C., 2010.
Gluteoplasty: anatomic basis and technique. Aesthet. Surg. J. 30, 579–592. © The
American Society for Plastic Surgery, with permission.)
271
Complications
The pocket is finished inferiorly toward the ischium. The muscle
boundaries should not be breeched.
6. Implant insertion
7. Muscle suture repair
8. Subcutaneous suture closure in two layers to avoid dead
space
9. Skin closure
Postoperative Care
The patient must avoid sitting and lying on the buttock area
for the first 24 hours and should sleep prone or in a lateral
position. In case of sleeping supine, a cushion should be placed
under the back and legs. The patient may sit after 24 hours
for short periods of time. The time that the patient can be
seated increases gradually.
Broad spectrum antibiotics should be used. Gram-negative
organisms from the intestinal tract and gram-positive organisms
from the skin should be covered therapeutically.
The incisional wound should be kept meticulously clean
and dry to prevent dehiscence. Drains may be used according
to the surgeon’s preference. Postoperative hematoma and seroma
are rare in the intramuscular plane.
A medium to low compression garment should be used.
The patient must avoid gluteal exercises for 60 days. Analgesics
should be prescribed according to the patient’s need.
Complications
Dehiscence is the most common complication (Fig. 35.8). Its
incidence ranges from 4% to 30%.3 Dehiscence is related to
devascularization of the subcutaneous during pocket dissection,
poor vascularization of the skin in the midline, and infection
of the wound. An exact midline skin incision, minimal but
adequate subcutaneous pockets, correct closure technique, and
The ideal patient for an oval implant presents with a rect
angular buttock (Fig. 35.7). That is, the height is greater than
the width, or the width is greater than the height. In such
cases, the oval implant, with its asymmetric measures, is the
most appropriate. The implants can be positioned with the
longer portion orientated vertically, horizontally, or obliquely,
depending on the purpose and the choice of the surgeon.
However, the most common method is to place the largest
portion of the implant at the upper area of the gluteal region.
Preoperative Markings
Because the implant will be placed intramuscularly, all anatomic
markings relate to bony landmarks that limit the area of the
muscle. The superior bony mark is the posterior iliac crest
tuberosity, whereas the inferior border is placed on the ischial
tuberosity. The medial mark is placed at the sacrum, and the
lateral mark is the projection of the great trochanter. The lower
gluteus maximus fibers blend into the tensor fascia lata of the
upper thigh.
Surgical Technique (Video 35.1)
1. Surface marking the bone and muscle landmarks (i.e.,
iliac crest, posterior superior iliac spine, ischial tuberosity,
greater trochanter, gluteus muscle and tensor fascia lata
2. Incision (from 6 to 7 cm) in the midline
3. Subcutaneous pocket definition (2 × 6 cm) exposing the
obliquely running, coarse muscle bundles of the gluteus
maximus
4. Split of the gluteus maximus fibers, up to 2 cm deep
5. Intramuscular pocket dissection
Blunt dissection is carried out using customized blunt dis
secting tools or by direct visualization beginning superolaterally,
then laterally, and then deep toward the greater trochanter.
FIGURE 35.4 Round base implant matches a square hip.
FIGURE 35.5 Oval base implant matches a rectangular hip.
272
CHAPTER 35 • Gluteal Augmentation
☛ Tips and Tricks
The gluteal intramuscular pocket is not as compliant as the
breast pockets. Start with small implants. Make sure that you
can close the muscle incision.
A wide base island in the middle line preserves the vascu
larization and makes it easier to suture the access and prevent
dehiscence.
Patients are not completely forbidden to sit. They just have
to be careful about it.
In regard to direct visualization during dissection, you can
always check the thickness of the pocket. If you just see muscle
above and under the pocket, you are in a safe place.
basic wound care should avoid this complication. If it occurs,
dressing, débridement, and resuturing are indicated.
If the implants are placed in a well-vascularized pocket,
infections are rare. Most cases are related to dehiscence of the
wound, leading to a secondary infection of the pocket and
implant. In this case, they should be removed.
Seroma and hematoma are other rare complications of
intramuscular implants. The cut vessels retract inside the muscle
fibers and are compressed, thus avoiding bleeding. The muscle
also helps reabsorb edema, avoiding seroma formation.
Displacement, palpable implants, pain, capsular contraction,
and rupture are related more to the choice of the pocket
and the use of nonrecommended breast implants with
weaker shells.
A
B
C
D
FIGURE 35.6 Case 1—round implant, before (A,C) and after (B,D).
273
Tips and Tricks
A
B
C
D
FIGURE 35.7 Case 2—oval implant, before (A,C) and after (B,D).
274
CHAPTER 35 • Gluteal Augmentation
References
1.
Serra, F., Aboudib, J.H., Marques, R.G., 2012. Reducing wound
complications in gluteal augmentation surgery. Plast. Reconstr. Surg.
130, 706e–713e.
2.
Aboudib, J.H., Serra-Guimarães, F., Sampaio, F.J., 2016. Profile of
patients undergoing gluteoplasty. Aesthetic Plast. Surg. 40, 30–37.
3.
Aboudib, J.H., Serra, F., Castro, C.C., 2012. Gluteal augmentation:
technique, indications and implant selection. Plast. Reconstr. Surg.
130, 933–935.
4.
Mofid, M.M., Gonzalez, R., de la Peña, J.A., et al., 2013. Buttock
augmentation with silicone implants: a multicenter survey review
of 2226 patients. Plast. Reconstr. Surg. 131, 897–901.
5.
Karacaoglu, E., Durak, N., 2012. A fifteen-year experience of buttock
contouring with combination of silicone implant, liposuction and
structural fat grafting. Eur. J. Plast. Surg. 35, 81–87.
6.
Cocke, W.M., Ricketson, G., 1973. Gluteal augmentation. Plast. Reconstr.
Surg. 52, 93.
7.
González-Ulloa, M., 1991. Gluteoplasty: a ten-year report. Aesthetic
Plast. Surg. 15, 85–91.
8.
de la Peña, J.A., Rubio, O.V., Cano, J.P., et al., 2006. History of gluteal
augmentation. Clin. Plast. Surg. 33, 307–319.
9.
Robles, J.M., Tagllapertra, J.C., Grandl, Y.M.A., 1984. Gluteoplastia
de aumento: implante submuscular. Cir. Plast. Iberolatinoam. 10,
365–375.
10.
Vergara, R., Marcos, M., 1996. Intramuscular gluteal implants. Aesthetic
Plast. Surg. 20, 259–262.
FIGURE 35.8 Dehiscence of the incisional wound.
277
Surgical Preparation and Technique
277
36
Upper Arms: Rejuvenation of the arm
Graeme Southwick OAM, MBBS (Hons), FRACS, FACS
Alenka Paddle MBBS (Hons), FRACS (Plast), PGDipSurgAnat
The Clinical Problem (Fig. 36.1)
Synopsis
Performing procedures to rejuvenate the arm requires an
understanding of the aesthetic arm deformity and its patho
physiology. Excisional techniques (e.g., brachioplasty), liposuc
tion, and nonsurgical treatment options may all be used for
arm rejuvenation. There are a number of technical points that
can make brachioplasty a reliable and rewarding procedure.
The Aesthetic Problem
This 67-year-old woman (see Fig. 36.1) was unhappy with the
presence of loose skin hanging from her arms. She didn’t think
that her arms were harmonious with her overall appearance
and was reluctant to wear short-sleeve tops or dresses.
Two categories of patients present for rejuvenation of the
arm:
1. The patient with signs of aging
2. The massive weight loss patient
These patients present with the following signs:
• Redundant skin, with or without excess soft tissue
This produces increased wrinkling and folds and is
most pronounced in the inner (posteromedial) aspect
of the arm. Pascal and Le Louarn have described this
excess skin as analogous to a sleeve that is too wide
and too long.1
• Increase in the inferior curve of the arm
This is seen when the arm is abducted to 90 degrees at
the shoulder, the so-called bat wing or bingo wing
deformity. It occurs with aging and was quantified by
Glanz and Gonzalez-Ulloa2 using the coefficient of
Hoyer. This ratio of the relative height of the soft
tissues above and below the inferior border of the
humerus increases from 1 : 1 to 1 : 2.2 between the ages
of 10 and 70 years.
• Loss of axillary hollow
• Lipodystrophy
General Considerations
1. Skin quality—thickness, extent of solar damage, senile
changes
2. Excess skin—quantity and distribution
3. Excess fat—quantity and distribution
In Case 36.1 (see below), the patient had poor skin quality.
It was thin and had significant solar damage (see Fig. 36.1E).
She had a moderate excess of skin involving the entire arm
with loss of the axillary hollow and had minimal excess fat.
The desired outcome in this situation was to narrow and shorten
the sleeve of the arm with concomitant deepening of the axillary
hollow.
Surgical Preparation and Technique
Management and Treatment Options
(Table 36.1)
NONSURGICAL TREATMENT OPTIONS
There are an increasing number of transcutaneous energy
delivery devices currently available. Broadly speaking, they
are classified according to the type of energy they deliver to
their target—mechanical (e.g., suction, massage), radiofrequency,
ultrasound, cryolipolysis, and laser.3 Of these, radiofrequency
devices are the most popular.
278
CHAPTER 36 • Upper Arms: Rejuvenation of the arm
A
D
E
B
C
FIGURE 36.1 The clinical presentation.
Table 36.1
FAT EXCESS
SKIN
EXCESS
Minimal
Moderate
Minimal
Non-surgical
treatment
options
Axillary vertical
excision
Short-scar arm
reduction
Circumferential
liposuction
+/− Axillary or
short-scar
reduction
Moderate
Standard
brachioplasty
+/− Lateral chest
wall extension
Circumferential
liposuction
+/− Standard
brachioplasty
+/− Lateral chest
wall extension
Adverse outcomes following noninvasive body-contouring
treatments are uncommon but may include thermal injuries
and temporary dysesthesia.3
LIPOSUCTION
Liposuction can be used alone, in select patients, to provide
satisfactory reduction in arm circumference with some associated
skin retraction.4 It has also been established that it is safe to
perform brachioplasty in conjunction with liposuction outside
the region of excision. With regard to the latter, we advocate
using the principles of SAFE (separation, aspiration, and fat
equalization) liposuction.5
EXCISIONAL TECHNIQUES
In the massive weight loss patient, the skin excision may need
to be extended onto the chest (lateral chest wall extension;
Fig. 36.2).
279
Surgical Preparation and Technique
Treatment and Operative Technique
PREOPERATIVE MARKINGS
The patient is marked while standing with her arms abducted
at the shoulders to 90 degrees and the elbows flexed to 90
degrees. The intended posteromedial scar position is marked
(Fig. 36.4, dotted line). Reference points for this line are the
medial epicondyle of the humerus to the apex of the axilla.
The patient is asked to relax the arms to an anatomic position
by her side, with the forearms supinated, to confirm that the
incision will be hidden.
In principle, however, to mark the area for vertical excision,
axillary suspension is simulated with a finger pushing the
redundant skin toward the axillary apex. This creates a ridge
of skin that demonstrates the area for excision. The maximum
area for excision mark is then reduced by 2 mm, thus reducing
overall tension on the skin. The anterior and posterior axillary
folds are the limits of the excision (see Fig. 36.2).
The anterior longitudinal incision line is marked approxi
mately 2 to 3 cm above the intended scar position. This will
vary, depending on the compliance of the skin; it will therefore
be checked by pinching the skin at the proposed anterior incision
and ensuring that it can be brought down to the intended scar
position. Likewise, the posterior longitudinal incision is marked.
Transverse reference lines are marked on the skin to assist with
skin alignment during closure.
Case 36.1
This patient had a problem of excess skin of the whole
arm, with minimal excess fat. Liposuction alone was con
sidered unlikely to be effective in achieving an improve
ment in contour and satisfactory skin contraction. She
understood the necessity for an excisional procedure but
was unwilling to accept a long scar. Thus, the options for
a modified brachioplasty and its inherent limitations were
discussed.
Under general anesthesia, she underwent a bilateral short-
scar arm reduction with axillary suspension. The vertical limb
measured 6 cm and was located in the axilla. The horizontal
limb was 6.5-cm long and located in a posteromedial position.
Axillary suspension using two 3-0 Prolene sutures secured
the superficial fascial system (SFS) of the posteromedial arm
to the axillary fascia. The remaining SFS was then closed
with 3-0 Vicryl and the subcuticular layer with 4-0 V-Loc
sutures.
It was clear within 6 months postoperatively that although
the appearance of her arms was much improved and her scars
were satisfactory, there was residual skin excess of the distal
arm to elbow (Fig. 36.3).The patient agreed to an extension of
her scar and underwent revision to a bilateral standard arm
reduction.
A
B
C
D
FIGURE 36.2 (A) Standard brachioplasty. (B) Axillary vertical elliptic excision. (C) Short-scar arm reduction. (D) Brachioplasty with lateral chest wall extension. The dotted
line indicates the desired posteromedial scar position.
280
CHAPTER 36 • Upper Arms: Rejuvenation of the arm
Superficial liposuction is then performed to empty the
subcutaneous tissues under the area for excision (Fig. 36.5A
and B). There is no feathering or liposuction of the adjacent
medial inner arm. In this case, 100 mL of lipoaspirate was
removed from each side. The purpose of liposuction in this
manner is to remove fat while preserving the blood and
lymphatic vessels and cutaneous nerves of the arm, along with
the fibrous network of the SFS1,6 (see Fig. 36.5C).
Lymphatic vessels run within the subcutaneous fat. A recent
study has demonstrated that after liposuction, both large vessels
and microvessels are preserved.7 This may explain why plastic
surgeons using liposuction in brachioplasty in this manner
have a low seroma rate.1,6
Incising through the skin only, the anterior longitudinal
incision is made. The skin flap is elevated in a subdermal plane
down to the proposed posterior longitudinal incision marking
(see Fig. 36.5D).
The flap is then divided vertically in approximately three
points to allow segmental resection of the skin flap (see Fig.
36.5D). Once again, a 2-mm principle can be applied. This not
only reduces the risk of over-resection but also slightly reduces
tension on the skin closure.
An alternative rapid skin removal method after liposuction
is to incise the proposed resection margins and avulse the skin
flap proximally to distally.6 Although this works well, it relies
on an accurate skin measurement preoperatively and will not
allow intraoperative adjustment. In this case, resection of 20
× 5.5 cm of skin was performed.
Drains are not routinely required. Closure is meticulous
and in three layers; 3-0 Vicryl is used to reapproximate the
SFS. At several points, the deep soft tissue overlying the brachial
fascia is also picked up in the suture to assist with any dead
space reduction. This SFS suture is critical to restore one of
the support systems of the arm and reduce tension on the skin;
3-0 Vicryl is used as a deep dermal suture, with 4-0 V-Loc
sutures to close the subcuticular layer (see Fig. 36.5E). Dressings
OPERATIVE SEQUENCE
General anesthetic is given, the patient is supine, with the
arms abducted, and is circumferentially prepped from the
fingertips to the lateral chest wall. The area underneath the
ellipse for excision and/or contouring is infiltrated with a local
anesthetic and a vasoconstrictive solution using an infiltration
cannula (≈1 : 1 ratio, infiltration to expected aspiration volume).
A
C
B
FIGURE 36.3 Postoperative appearance 6 months post–bilateral short-scar arm reduction. The right arm is used as an example.
Desired posteromedial
scar position
Anterior longitudinal incision
Posterior longitudinal incision
FIGURE 36.4 Preoperative markings. X marks the medial epicondyle and apex of
the axilla, which are the two reference points for the posteromedial scar position.
281
Complications
This patient was very pleased with her postoperative result
(Fig. 36.6).
Complications
The scar of a brachioplasty has been considered one of the
biggest compromises of the procedure. It is very important to
provide the patient with realistic expectations of its expected
appearance and timeline for improvement, which may be up
to 1 year.
Closure under moderate tension, no undermining of skin
edges, and meticulous three-layer closure assists in allowing
wound healing without complications of wound edge necrosis,
include lightly-applied Steri-Strips and a wool wrap with
overlying crepe bandages.
The patient is discharged on postoperative day 1.
Postoperative Program
Patients are reviewed 1 week postoperatively. At this time, the
patient’s suture lines are retaped, initially with Mefix
tape (Mölnlycke Health Care, Gothenburg, Sweden) and then
with Micropore tape (3M, St. Paul, MN, USA). Taping is
continued for 6 weeks. At the first postoperative visit, they
are fitted with a compression garment and encouraged to wear
this for 5 weeks in total.
A
B
D
E
C
FIGURE 36.5 Intraoperative sequence.
282
CHAPTER 36 • Upper Arms: Rejuvenation of the arm
breakdown, or infection. Intravenous antibiotics are always
administered at the induction of anesthesia.
The incidence of seroma, lymphedema, or sensory distur
bance is reduced significantly by using the described technique.
Contour deformities with over-resection centrally and under-
resection proximally and distally are reduced by a segmental
resection technique.
Residual skin excess at the elbow and forearm can be an
issue and may not be totally corrected with brachioplasty. In
our experience, it is best not to extend the incision across the
elbow, where it will be easily visible. The use of nonsurgical
skin-tightening techniques may be of supplementary assistance
in these areas.
Recurrence of deformity over time is a potential and perhaps
partially expected consequence of any body-contouring pro
cedure, given a patient’s often poor intrinsic tissue quality.
Axillary suspension and SFS reapproximation aim to repair
some of the pathology of the aesthetic arm deformity and may
improve longevity of the procedure. However, it is important
to remember that these patients will still have a new, more
youthful, set point for their age.
A
B
C
D
E
F
G
H
FIGURE 36.6 Comparison of preoperative (A–D) and 2-month postoperative (E–H) appearance.
References
1.
Pascal, J.F., Le Louarn, C., 2005. Brachioplasty. Aesthetic Plast. Surg.
29, 423–429.
2.
Glanz, S., Gonzalez-Ulloa, M., 1981. Aesthetic surgery of the arm. Part
I. Aesthetic Plast. Surg. 5, 1–17.
3.
Mulholland, R.S., Paul, M.D., Chalfoun, C., 2011. Noninvasive body
contouring with radiofrequency, ultrasound, cryolipolysis and low-level
laser therapy. Clin. Plast. Surg. 38, 503–520.
4.
Gilliland, M.D., Lyos, A.T., 1997. CAST liposuction: an alternative to
brachioplasty. Aesthetic Plast. Surg. 21, 398–402.
5.
Wall, S., Jr., 2010. SAFE circumferential liposuction with abdominoplasty.
Clin. Plast. Surg. 37, 485–501.
6.
Knotts, C.D., Kortesis, B.G., Hunstad, J.P., 2014. Avulsion brachioplasty:
technique overview and 5-year experience. Plast. Reconstr. Surg. 133,
283–288.
7.
Bertheuil, N., Chaput, B., Berger-Müller, S., et al., 2016. Liposuction
preserves the morphological integrity of the microvascular network:
flow cytometry and confocal microscopy evidence in a controlled
study. Aesthet Surg J. 36, 609–618.
283
Surgical Preparation and Technique
283
37
Aesthetic Management of the Aging Hand
Kaushik Chakrabarty MBChB, MD, FRCS, FRCS (Plast)
The Clinical Problem (Fig. 37.1)
The hand is a major organ of the body. It is a sensory organ
that has locomotor function and is used as a means of com
munication and assessing social status. The features of an aging
face are in many ways similar to the features of an aging hand.
Both show degenerative features in the skin as well as a reduc
tion in the volume and consistency of tissue. Both are prone
to the ravages of sun exposure. In the hand, skeletal joint
changes in the form of arthritis can cause functional restriction,
as well as deformity. Despite the hand being an important
aesthetic unit in its own right, rejuvenation of the face, breasts,
and trunk frequently takes priority for most patients.
Skin changes to the hand occur naturally over the passage
of time but can be influenced by sun exposure, occupation,
and genetics.1 In intrinsic aging, the skin may feel dry, develop
fine wrinkles, and appear smooth and pale. Pigmented lesions
usually arise from photo-aging of the skin. The epidermis thins,
with flattening of the dermoepidermal junction, keratinocytes
are less proliferative, and the skin can feel dry and rough.
Dermal and epidermal thinning combined with less active
or fewer melanocytes make the skin appear paler and shiny.
The underlying vessels can be disrupted with minor trauma,
presenting with ease of bruising due to capillary fragility. The
skin on the dorsum of the aging hand is more prone to shear
forces, and minor trauma can break the integrity of the skin
in older adults. Surprisingly, though, such wounds invariably
heal well.
In vasospastic disorders, botulinum toxin has been used to
enhance the blood supply to the digits by blocking release of
autonomic neuromuscular transmitters within the digital
vessels2, subsequently improving the appearance of the skin.
Even in the absence of disease, there is small muscle atrophy
and fat volume reduction naturally in the hand, both to the
dorsal and palmar surfaces, appearing as guttering between
the metacarpals and generalized wasting with skin wrinkling
and thinning (Fig. 37.2). Arthritic changes or nerve entrapment
resulting in reduced muscle activity can also contribute to this
appearance.
Other lesions such as actinic keratosis and basal papil
lomas are commonly seen in photo-aging, as are variants
of malignancy, from Bowen disease to full squamous cell
carcinomas.
Surgical Preparation and Technique
Management of the Aging Hand
The management of the aging hand can be considered as
nonsurgical (e.g., camouflage, cosmoceuticals, fillers, Botox,
skin resurfacing) and surgical (e.g., lipofilling, removal visible
veins and excisional).
NONSURGICAL MANAGEMENT
Camouflage acts purely as a cover film over the epidermis
temporarily but visibly improves the appearance. Cosmoceu
ticals are purported to reduce fine wrinkles. These are creams
or lotions with additives such as products based on vitamins
A, C, D, and/or E. These agents have been theorized and
shown in vitro to influence the proliferation of keratinocytes,
but the clinical effectiveness of these products is somewhat
subjective, is often influenced by market forces, and lack
evidence base. Retinoids (vitamin A) have been used for the
treatment of psoriasis, acne, and actinic keratosis.
Dorsal hand skin can be lasered or subjected to cryotherapy
for age-related spots. Thickened scars have also been treated
with these modalities, although scars are usually treated with
topical silicone rather than with triamcinolone steroid injections
because fat atrophy, pigment loss, skin thinning, and telangi
ectasia may occur.
284
CHAPTER 37 • Aesthetic Management of the Aging Hand
Sclerotherapy4 is the most widely used medical procedure
for the ablation of varicose veins and spider veins or capillary
hemangiomas causing endothelial damage and ultimately
fibrosis. Usually, the sclerosant is shaken to create a foam.
The most common detergent sclerosants are polidocanol
and tetradecyl sulfate. They are called detergent sclerosants
because they are active as micelles and have a low incidence
of allergic reactions and staining caused by hemosiderin
deposition.
Skin-resurfacing topical chemical agents can provide a
controlled resurfacing of the skin but the deeper the peel,
the greater the risk of visible scarring and depigmentation. A
deeper peel may be produced by a prolonged single application
of a more concentrated agent or, more superficially, by the
use of milder fruit acid peels. The standard peeling agent is
trichloroacetic acid (TCA), which provides a variable depth
injury by varying its topical concentration and contact time
on the skin. Other peeling agents may be toxic, such as phenol
and salicylic acid.
SURGICAL MANAGEMENT
Fat grafting uses autologous tissue and is potentially a perma
nent filler that softens contours. Aging skin seems to improve
in quality after fat grafting. It is an extremely good filler to
correct neuropathic wasting, such as the thenar eminence in
long-standing carpal tunnel syndrome, where there is irrevers
ible atrophy of the abductor pollicis brevis. Similarly, it can
be used for the hypothenar eminence and for intermetacarpal
guttering and the first web space resulting from wasting to the
small muscles secondary to ulnar nerve palsy. Small volumes of
fat (up to 20 mL) are harvested using the tumescent Coleman
technique.5 I prefer the harvested fat to separate gravitation
ally in a 10-mL aspiration syringe by standing rather than
separation by centrifuge and then titrate or filter away the
unwanted oily and crystalloid layers. A 1-mL syringe and
blunt cannula are used for injection of fat via the dorsal web
spaces, taking care to avoid damaging the dorsal veins. The
fat is layered to lie adjacent to the veins within the dorsal
gutters to mask the prominence of the veins. The injection
sites should be selected with obvious care to avoid damage
to nerves, vessels, and tendons (Fig. 37.3). Fat is harvested
from a region that does not vary significantly in volume with
weight variation; the choice is negotiated with the patient.
Patients are warned that the process may need to be repeated to
allow for variable fat loss. The outcome is usually apparent at
6 months.
Skin tightening can be performed by excision of excess skin,
usually as a triangle or ellipse of skin on the dorsum of the
wrist or ulnar border of the hand, excising skin based dorsal
to or volar to the dorsal skin and glabrous skin junction. In
each case, skin closure should be meticulous, ideally under
minimal tension.
It may be possible to tie off or avulse selected veins through
small incisions,6 but veins have a purpose and, in the aged
hand, are of functional benefit during ill health when venous
access may be required. I prefer to leave the dorsal veins
intact and simply disguise their presence by fat-grafting
around them.
Volume loss is often the primary presenting complaint. In
this situation, a nonpermanent filler is the safest initial approach
because any change of heart is easily redeemable simply by
waiting and allowing the agent to be broken down. Fillers can
injected into the skin or subcutaneous tissue, thereby altering
contour to achieve an aesthetically desirable appearance.
However, these may be more visible and lumpy.
Hyaluronic acid is the gold standard because it is naturally
occurring and potentially reversible with hyalase.3 Its effects
can last for more than 1 year.
FIGURE 37.1 The aging hand.
FIGURE 37.2 This image (along with Fig. 37.1) shows age-related thinning of the
dermis to produce crepelike skin, with intermetacarpal guttering from intrinsic
wasting with aging and prominence of veins in a 96-year-old man. These hands
also show Dupuytren contracture of the little finger.
285
Surgical Preparation and Technique
A
D
E
F
B
C
FIGURE 37.3 Steps involved in fat grafting. (A) The extent of intermetacarpal guttering. (B) The depth and direction for fat grafting. (C) A small entry port in the second
web space. (D,E) Layering of harvested fat into the second and third web spaces, respectively. (F) Immediate postoperative appearance.
286
CHAPTER 37 • Aesthetic Management of the Aging Hand
3.
Gold, M.H., 2007. Use of hyaluronic acid fillers for the treatment of
the aging face. Clin. Interv. Aging 2, 369–376.
4.
Parsons, M.E., 2004. Sclerotherapy basics. Dermatol. Clin. 22, 501–508.
5.
Coleman, S.R., 2002. Hand rejuvenation with structural fat grafting.
Plast. Reconstr. Surg. 110, 1731–1744.
6.
Cohn, M.S., Seiger, E., Goldman, S., 1995. Ambulatory phlebectomy
using the tumescent technique for local anesthesia. Dermatol. Surg.
21, 315–318.
References
1.
Yaar, M., Gilchrist, B.A., 2001. Ageing and photoageing of keratinocytes
and melanocytes. Clin. Exp. Dermatol. 26, 583–591.
2.
Fregene, A., Ditmars, D., Siddiqui, A., 2009. Botulinum toxin type A:
a treatment option for digital ischemia in patients with Raynaud’s
phenomenon. J. Hand Surg. Am. 34, 446–452.
287
Surgical Preparation and Technique
287
38
Inner Thigh Lift
Pedro S. Coltro MD, PhD
Fernanda B. Correa MD
Jayme A. Farina Jr. MD, PhD
The Clinical Problem (Fig. 38.1)
The medial thigh is a problematic zone for body contouring
both in the aging patient, who has skin laxity and lipodystrophy,
and in the massive weight loss patient, with critical skin flac
cidity in the medial thigh.1
Patients with morbid obesity who have undergone massive
weight loss (MWL) following a diet or bariatric surgery develop
body dysmorphia due to skin laxity and dermal fat excesses.
They suffer interference in their quality of life because of the
difficulty of personal hygiene, ambulation, and physical activi
ties, as well as skin infections, postural changes, low self-esteem,
and changes to the body image.2
To remove the dermal fat excesses and improve the thigh
contour, plastic surgeons have performed thigh lift procedures,
associated with or without liposuction. The medial thigh lift
was first introduced by Lewis in 19573 for the treatment of
extreme flaccidness of the medial thigh.
However, this traditional technique was related to the recur
rence of ptosis, scar migration, and vulvar deformities. Therefore,
in 1988, Lockwood4 proposed a technique of anchoring the
dermal tissue from the distal medial thigh to the deep layer of
the superficial perineal fascia (Colles fascia) to reduce scar
migration, leading to a more stable and long-term outcome.5,6
Surgical Preparation and Technique
Indications and Classification
Thigh lift techniques are used to treat thigh laxity, in particular
its medial and proximal portion. Such techniques may be associ
ated with liposuction to reduce the fat content of the entire thigh
or more localized procedures, such as at the medial and lateral
thigh or a region of the knee. Medial thigh patients can be divided
in two categories: MWL patients and non-MWL patients.
MASSIVE WEIGHT LOSS PATIENTS
These are divided in two groups: deflated and nondeflated.
Deflated
In the first group (deflated), the thickness of fat tissue is lower, so
a combination of surgeries is possible because the surgical time
and bleeding are minor. Deflated patients usually present with
skin flaccidity over the thigh, with minor or even without residual
lipodystrophy. These patients are treated using an extended
vertical medial skin excision, with or without liposuction.1,6,7
Nondeflated
In the second group (nondeflated), the association of procedures
at the same time is not recommended because the thicker
adipose tissue is related to greater surgical manipulation, blood
loss, impact on morbidity, and higher incidence of postoperative
complications. Nondeflated patients generally present with
both skin laxity and lipodystrophy. For these patients, liposuc
tion is performed at the first stage, combined with a lower
body lift, and followed by an extended vertical medial skin
excision 4 to 6 months later.1,6,7
NON–MASSIVE WEIGHT LOSS PATIENTS OR PATIENTS
WITH AN AGING THIGH
These patients usually present with lipodystrophy, with varying
degrees of skin laxity. Those with only lipodystrophy without
skin laxity require liposuction alone. Those with lipodystrophy
and skin laxity confined to the upper third of the thigh are
treated by liposuction and a horizontal medial skin excision
at the level of the inguinal fold. According to the progression
of skin flaccidity from the upper to the entire thigh, it can be
associated with a vertical skin excision.1,6,7
To correlate thigh deformities with the appropriate surgical
treatment, some scales that rank the degree of thigh impairment
and laxity have been developed. Here we highlight the Medial
Thigh Classification and Treatment Scale1,6 (Table 38.1).
288
CHAPTER 38 • Inner Thigh Lift
vitamins depletion can be predictors of complications.9 Before
surgery, antimycotic treatment should be performed in patients
with fungal infections. Moreover, patients should stop smoking7;
the prevention of venous thromboembolism is crucial and
should be adopted.
Marking and Surgical Technique
In general, most of the techniques with skin excision involve
skin markings at the proximal and medial thigh using the
pinch test to predict the amount of skin to be removed, which
is adjusted perioperatively to achieve closure without tension.
The patient is marked in the standing position, anterior and
posterior, with the knees apart. The femoral triangle is marked
to avoid dissection into the lymph vessels.6 The location of fat
deposits for liposuction is also marked.1,7
The degree of thigh laxity determines the location of the
incisions and the need to add a vertical component. Usually,
when skin laxity is located only at the upper third of the thigh,
a horizontal incision at the level of the inguinal fold is enough
(Fig. 38.2A). However, if skin laxity reaches the entire thigh,
Preoperative Care
The critical point for successful intervention is the preoperative
evaluation for surgical planning. The surgeon should clarify
the limitations of the procedure, discuss possible complications,
and emphasize the presence of extensive scarring, especially
in patients for whom a vertical medial incision will be needed.
A consent form must be signed. We evaluate the quality of the
skin (MWL patients have depleted collagen fibers8), degree of
elasticity, laxity, identification of lipodystrophy areas, and
presence of previous scars. We also evaluate the vertical and
horizontal skin excess by the pinch test and traction.5
It is important that the patient undergo a psychological
evaluation to check her or his expectations about the outcome.
A nutritional screening must be performed, especially in MWL
patients. Nutritional deficiencies such as iron, albumin, and
FIGURE 38.1 The clinical problem.
Table 38.1 Medial Thigh Classification and Treatment Scale1,6
Type
Description
Treatment
I
Lipodystrophy with no sign of
skin laxity
SAL, UAL alone
II
Lipodystrophy and skin laxity
confined to the upper third
of the thigh
SAL, UAL + horizontal
medial thighplasty
III
Lipodystrophy and moderate
skin laxity that extends to
the middle third of the thigh
SAL, UAL + extended
vertical medial
thighplasty
IV
Lipodystrophy and moderate
skin laxity that extends the
length of the thigh
SAL, UAL + extended
vertical medial
thighplasty
SAL, Suction-assisted lipectomy; UAL, ultrasound-assisted lipectomy.
Adapted from Armijo, B.S., Campbell, C.F., Rohrich, R.J., 2014. Four-step
medial thighplasty: refined and reproducible. Plast. Reconstr. Surg. 134,
717e–725e; and Mathes, D.W., Kenkel, J.M., 2008. Current concepts in
medial thighplasty. Clin. Plast. Surg. 35, 151–163.
A
B
C
D
E
F
FIGURE 38.2 Location of the incisions in a thigh lift according to the amount of
skin to be resected. (A,B) Horizontal incision at level of the inguinal fold—skin
laxity located only at the upper third of the thigh. (C,D) Inverted L–shaped incision
at level of the inguinal fold following medial thigh—skin laxity reaches the entire
thigh. (E,F) T-shaped incision at level of the inguinal fold following the medial
thigh—skin laxity reaches the entire thigh.
289
Surgical Preparation and Technique
After cutaneous resection under the dermis, deep anchoring
nonabsorbable sutures are placed to fasten the subdermal layer
of both medial and inferior thigh cutaneous flaps with Colles
fascia and periosteum.1,5–7 This fixation is performed by at least
three of four deep points, from lateral to medial—inguinal
ligament, periosteum of the symphysis pubis, tendon of the
adductor muscle of the thigh, and periosteum of the ischial
tuberosity. Fascial and periosteum anchoring are performed
to reduce downward scar migration and ptosis recurrence,
leading to a better postoperative aesthetic outcome and greater
patient satisfaction7 (Fig. 38.3).
The placement and type of drain are controversial. A drain
such as a laminar drain or suction drain can be used, or this
can even be avoided.5,6 Some use it when the body mass index
is over 30 or if there is associated liposuction. Finally, closure
is carried out in several layers.
Postoperative Care
Some actions are essential in the postoperative period to mini
mize complications and provide greater comfort for patients.
beyond its upper third, a vertical medial incision, inverted
L–shaped incision (see Fig. 38.2B), or T-shaped incision (see
Fig. 38.2C) may be needed, according to the amount of skin
to be resected.1,6,7 In these cases, an attempt is made to hide
the resultant scar so it is less visible in an anatomic position.
Based on markings, the thigh is infiltrated using a solution
composed of saline solution 0.9% (1 L), epinephrine 0.1% (1 ml)
and ropivacaine 1% (20 ml). When vasoconstrictor effect is
confirmed (approximately 10 min) liposuction is performed
first and can be done in two regions. In the area to be excised,
liposuction is carried out suprafascially, attempting to preserve
the drainage from the saphenous venous system and lymphatic
vessels. Otherwise, throughout the inner thigh, liposuction
can be performed subfascially.10
The skin incision is then carried out after rechecking markings
with a pinch test to avoid over-resection of the skin. A superficial
dissection limited to the superficial fascia is also important to
preserve blood and lymph vessels. Fat tissue below the super
ficial fascia is maintained. These are the key points to reduce
the risk of postoperative seroma, infection, and lymphedema
and to avoid skin dehiscence.1,10
A
D
E
F
B
C
FIGURE 38.3 A 38-year-old woman after massive weight loss due to bariatric surgery. (A–C) Preoperative, skin laxity on the entire thigh: anterior view (A), 45-degree left
view (B), and 45-degree right view (C). (D–F) 6 months after thigh lift (liposuction following resection using inverted L–shaped incision), scar hidden at the anatomic
position: anterior view (D), 45-degree left view (E), and 45-degree right view (F).
290
CHAPTER 38 • Inner Thigh Lift
(0.3%–6%). Risks are higher with advancing age and anemia.9
Scar enlargement and distortion of the vulva are more common
in techniques that use a horizontal incision.
Lower migration of the scar is more common in MWL
patients due to tissue laxity.7,8 Severe complications such as
deep vein thrombosis and pulmonary thromboembolism occur
in less than 1% of patients.
References
1.
Armijo, B.S., Campbell, C.F., Rohrich, R.J., 2014. Four-step medial
thighplasty: refined and reproducible. Plast. Reconstr. Surg. 134,
717e–725e.
2.
Orpheu, S.C., Coltro, P.S., Scopel, G.P., et al., 2009. Body contour
surgery in the massive weight loss patient: three year-experience in
a secondary public hospital. Rev. Assoc. Med. Bras. 55, 427–433.
3.
Lewis, J.R., Jr., 1957. The thigh lift. J. Int. Coll. Surg. 27, 330–334.
4.
Lockwood, T.E., 1988. Fascial anchoring technique in medial thigh
lifts. Plast. Reconstr. Surg. 82, 299–304.
5.
Labardi, L., Gentile, P., Gigliotti, S., et al., 2012. Medial thighplasty:
horizontal and vertical procedures after massive weight loss. J. Cutan.
Aesthet. Surg. 5, 20–25.
6.
Mathes, D.W., Kenkel, J.M., 2008. Current concepts in medial thigh
plasty. Clin. Plast. Surg. 35, 151–163.
7.
Bertheuil, N., Carloni, R., De Runz, A., et al., 2016. Medial thighplasty:
Current concepts and practices. Ann. Chir. Plast. Esthet. 61, e1–e7.
8.
Orpheu, S.C., Coltro, P.S., Scopel, G.P., et al., 2010. Collagen and
elastic content of abdominal skin after surgical weight loss. Obes.
Surg. 20, 480–486.
9.
Gusenoff, J.A., Coon, D., Nayar, H., et al., 2015. Medial thigh lift in
the massive weight loss population: outcomes and complications.
Plast. Reconstr. Surg. 135, 98–106.
10.
Le Louarn, C., Pascal, J.F., 2004. The concentric medial thigh lift.
Aesthetic Plast. Surg. 28, 20–23.
Prevention of thromboembolic events is accomplished through the
use of anticoagulants, early ambulation, compression garments,
and vigorous intravenous hydration after surgery.5–7
Adequate pain management should be carried out because
the medial thigh is an area with great sensibility.5 Urinary
catheterization is indicated during hospitalization to reduce
dirt and local humidity in addition to promoting comfort for
the patient due to vulvar edema.7
Compressive garments can be used from early postoperative
days to 3 to 6 weeks after surgery, but their use can be started
only 15 days after surgery because they lead initially to the
retention of local moisture, which increases the risk of
dehiscence.6
Complications
Thighplasty usually has a high rate of minor complications
due to high moisture levels in the region and very thin skin.
The most common complication is dehiscence, which occurs
in 28.4% to 50% of patients. Generally, it is treated conservatively
with topical agents.7,9
Seroma occurs in about 19% to 25% of patients, mostly in
the distal and medial thirds of the thigh. The first choice to
treat seroma is repeated puncture. Persistent seroma can be
managed using an injection of a sclerosing substance or surgical
drainage. In case of encapsulation, en bloc resection or mar
supialization can be performed.7,9
Edema is common in about 30% of cases and may persist
for 6 months. Other complications include wound infection
(1%–16%) necrosis (0.3%–5%), and bleeding or hematoma
291
Surgical Preparation and Technique
291
39
Inner Thigh Reduction: Reshaping Using a Two-Way
Vector Technique
Marcelo Alejandro Cuadrado, MD
The Clinical Problem (Fig. 39.1)
The lower extremities, and especially the thighs, are one of
the most typical surgery consultations in Argentina. Most
patients with massive weight loss desire a better-looking
shape of the thighs because they look deflated and have poor
skin tone.
Deformities in the thigh region vary according to age, degree
of skin laxity, and distribution of adipose tissue. Patient dis
satisfaction with surgery can be associated with poor wound
healing, seroma, inguinal scar migration, and poor contouring
requiring revisional surgery.
The surgeon’s major challenge is how to restore the skin
and redistribute the fat in the upper inner thigh to good effect.
Inner thigh laxity can be classified according to the vectors of
tissue ptosis in the inner thigh.
Surgical Preparation and Technique
Surgical assessment of the thigh involves understanding the
ideal anatomic shape, ideal skin envelope, and ideal fat distribu
tion. The inner thighs ideally have the shape of an inverted
cone, wider proximally and narrowing gradually toward the
knees. This inverted cone appearance is affected by thigh skin
laxity and adipose tissue under the influence of gravity (Fig.
39.2). The thigh can be anatomically divided into three zones
(Fig. 39.3)—inguinal zone, medial inner thigh, and upper knee
section.
Objectives in Inner Thigh Reduction
■ Improvement of contour in medial thigh section
■ Adequate resection to improve skin tension
■ Predictable scar placement
■ Decrease complication rate
Preoperative Evaluation
Evaluate skin laxity and lipodystrophy in different areas. Note
placement of the inguinal and medial scars. Ask about the
presence of lymphedema or vascular disease and history of
deep vein thrombosis.
Typical patients for an inner thigh reduction show postbar
iatric deflation. There is skin laxity in patients, who are typically
30 to 60 years of age. They are not concerned about scars but
complain about the bulky area in their inner middle thigh.
Planning Inner Thigh Reduction
Patients will have mild to severe skin laxity and fat in different
areas. Care must be taken for patients with inguinal scars. Avoid
patients with an BMI more than 34 and those who are heavy
smokers. Avoid patients with massive localized lymphedema.
Critical decisions in inner thigh reduction include the
following:
• How much skin and fat should be removed?
• Is liposuction in other areas required first or should it
be delayed?
• Where should the scars be placed?
Technique
SKIN LAXITY
Use the pinch test, and determine skin laxity with the patient
in standing position. Assess potential elevation of the horizontal
(subinguinal) vector. Determine if the need for excision reaches
or passes the knee.
SCAR PLACEMENT
The inguinal scar should be placed in the inguinal crease. The
vertical incision should not be too anterior or posterior. With
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the patient in standing position, there should be no visible
scars.
USE OF LIPOSUCTION
It should be used only in areas that will not be excised. Lipo
cutaneous undermining helps advance skin flaps at closure.
Try to stage this with other procedure, such as abdominoplasty.
FACTORS TO CONSIDER IN INNER THIGH REDUCTION
The amount of skin resection is often smaller than that which
was originally thought. No undermining reduces complications.
FIGURE 39.1 The clinical problem.
• Inverted cone
• Fat
• Skin
FIGURE 39.2 The ideal inverted cone shape of the thigh.
With longer surgery time, there will be more swelling and
more tension in closure. The patient should be given information
about postoperative complication.
Case 39.1
A 52-year-old woman had MWL after bariatric surgery. She
had a good result in the lateral thigh from circumferential body
lift surgery (Fig. 39.4). The patient complains about inner thigh
bulk and the poor skin quality in the thigh.
Clinical Approach
The patient had skin and fat in the subinguinal region. The
medial inner thigh extension is higher than one-third; there is
a good shape of the knee region.
Considerations
These patients are in a grey zone because of average skin quality
and mild adipose tissue and ptosis. Liposuction only in this
area will not allow the skin to reshape because of skin quality;
it could worsen the contour, which would be likely to require
skin resection at a later stage.
Trying to be more conservative by leaving a short inguinal
scar will not improve the overall deformity, only the inguinal
region, which would leave the medial inner thigh with the
same unsatisfactory contour. Vertical resection only is a good
option but there will be limited contour improvement in the
inguinal area. The subinguinal zone has a bulky fat zone and
skin laxity in a downward vector. Also, the vertical extension
of the deformity does not reach the knee so the predicted vertical
scar extension must be short.
Planning includes anchoring the subfascial-inguinal flap to
the pubic ligament (Colles ligament) and a vertical resection
to reduce skin laxity.
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Surgical Preparation and Technique
skin pinch test. The incision marks are less than original
pinch.
Operative Technique and Postoperative Management
(Video 39.2)
Compression garments should be applied postoperatively and
the patient encouraged to participate in early ambulation.
Silicone drains should be left until the output is 25 mL/day.
Results
Figs. 39.6 and 39.7 show the results from an inner thigh lift up
to 3 years postoperatively.
Marking (Video 39.1)
Markings should be with the patient in supine and standing
positions for safer scar placement. Pinch dynamic markings
are used; the excision should be less than the original mark
by 1 to 1.5 cm to avoid over-resection. Horizontal excess must
be anchored to the Colles fascia 2 cm above the inguinal crease,
so the skin excision in the inguinal region should be 2 cm less
than the pinch.
This type of anchoring is strong, and the horizontal
flap could be suspended by the superficial fascia using
nonabsorbable sutures. Fig. 39.5 shows markings for the
Thigh zones
• Inguinal zone blue
• Middle inner thigh purple
• Upper knee section red
FIGURE 39.3 The three zones of the thigh.
A
B
FIGURE 39.4 Case study. (A) Preoperative and (B) postoperative views after circumferential body lift surgery.
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CHAPTER 39 • Inner Thigh Reduction: Reshaping Using a Two-Way Vector Technique
FIGURE 39.5 Pinch test skin markings.
A
B
C
FIGURE 39.6 Anterior views showing preoperative (A) and 2-month (B) and
3-year (C) postoperative results of an inner thigh lift.
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Conclusions
A
B
FIGURE 39.7 Inner thigh view preoperatively (A) and 3 years postoperatively (B) showing scar placement.
Superficial Fascia Anchoring and Vertical Resection:
Two-Way Vector Technique
TIPS FOR THE INGUINAL ANCHORING
Marking above and under the inguinal crease will place the
scar right in the medial crease. Do not over-resect. Suspension
of the thigh has to be 2 or 3 cm above the crease to reach the
Colles ligament, so marks should be 2 cm less than original
pinch suspension marks. Use polypropylene sutures for anchor
ing in an X fashion to relax tension in the superficial fascia.
TIPS FOR VERTICAL RESECTION
The vertical scar should be planned right in the medial axis
of the thigh. Be conservative in patients with mild skin laxity
and larger amount of adipose tissue. Dissection should be just
above the superficial fascia. Deeper sutures with absorbable
sutures in the fascia relax skin tension. If the excess reaches
the knee, curve the incision.
Possible Complications
These include dehiscence of the inverted T, resuturing and
sometimes resection and suturing, alterations in the vulva by
over-resection, infection, hematoma, flap necrosis, and
lymphocele.
Summary
Many operative techniques are described for inner thigh reduc
tion, but none is ideal. It is critical to make a good diagnosis
for each patient because the skin and adipose tissue are different.
The surgical decision to improve contour will also vary. Accept
ing a long scar over the thigh is important, and the scar is
better placed in a nonvisual position.
The fascial anchoring and vertical resection technique is a
good technique for select patients because it corrects the medium
and inner thigh regions. This approach has been used in my
practice to improve contour and smooth the skin in different
patients because of the dynamic marking variations. The use
of liposuction in my practice is only for treatment of knee fat
or lateral thigh fat, with a different incision to prevent postopera
tive swelling. However, I recommend the use of only a vertical
resection in patients in whom inguinal excess is poor.
Conclusions
With a comprehensive diagnosis, patient classification, dynamic
markings, and postoperative patient management, the inner
thigh lift has evolved from a simple inguinal resection to a
multiple vector correction. It provides a good contour and skin
tension, and results are consistent over time.
However, it is important to be conservative and not to
over-resect. Proper planning and marking are critical. Take
care of patients’ postoperative management, and be alert for
complications. Advise the patient the possible need for a dog
ear revision after swelling.
Further Reading
Aly, A., Cram, A., 2006. Body Contouring After Massive Weight Loss.
Quality Medical Publishing. Missouri. 386p.
Cram, A., Aly, A., 2008. Thigh reduction in the massive weight loss patient.
Clin. Plast. Surg. 35, 165–172.
Grazier, F.M., 1996. Body contouring: introduction. Clin. Plast. Surg. 23,
511–528.
Le Louarn, C., Pascal, J.F., 2004. The concentric medial thigh lift. Aesthetic
Plast. Surg. 28, 20–23.
Lockwood, T.E., 1991. Superficial fascial system (SFS) of the trunk and
extremities: a new concept. Plast. Reconstr. Surg. 87, 1009–1018.
Song, A.Y., O’Toole, J.P., Jean, R.D., et al., 2006. A classification of contour
deformities after massive weight loss: application of the Pittsburgh
rating scale. Semin Plast Surg. 20, 24–29.