27 Medial thigh lift



10.1055/b-0037-143415

27 Medial thigh lift

DENNIS J. HURWITZ

INDICATIONS




  1. Undesirable skin laxity and adipose excess of the anterior and medial thighs which is correctable by a medial thigh lift (MTL).



  2. The patient is cognitively and psychologically cleared for the treatment. Inappropriate behavior prompts psychological screening and referral as indicated.



  3. The patient understands the aesthetic goals, basic technique, and placement and unpredictability of the scars, as well as the common risks of a MTL. Then the patient signs written consent form.



  4. Chronic skin diseases, swelling, lymphatic, venous or arterial insufficiency are investigated and if not resolved will probably contraindicate surgery.



  5. General medical condition, nutrition, and anemia are noted and improved as needed or the patient is rejected. Massive weight loss patients receive special supplements. History and physical examination and selected laboratory studies identify general or selected malnutrition that should be corrected for optimal wound healing. Obesity is treated by weight loss and if the patient is unable then patient is offered a highly regimented 42-day, 500-calorie-a-day diet plan with HCG (human choriogonadotrophic hormone) single-syringe injections. The daily management is by the physician assistant.



  6. Whenever possible, our aestheticians institute a special package of twice-weekly Lipomassage (Endermologie, LPG, Paris, France) 45-minute sessions for 3 weeks prior to surgery. The mechanico-stimulation activates supportive collagen synthesis, softens adiposity and improves blood flow. Subsequent liposuction appears less traumatic and hemorrhagic. The patient has been prepared for her routine postoperative Lipomassage. If the patient expresses unrealistic expectations during this preparation, then thigh lift is reconsidered.




INTRODUCTION


Medial thigh lift (MTL) encompasses a wide range of operations and procedure combinations dictated by the extent of thigh and lower torso deformity and the patient’s expectations. MTL is essentially an excision of medial thigh skin, followed by closure with superior suspension, resulting in tighter and lifted thigh skin. The most limited MTL is a horizontal crescent excision from the mons pubis to the ischial tuberosity inferior to the labia majora. The advanced medial thigh flap is anchored to Colles fascia to avoid inferior drift of the scar. 1 The horizontal excision may be extended posteriorly beyond the tuberosity along the infragluteal fold to the lateral trochanter to lift the posterior thigh and define the inferior border of the buttocks. The excision may also be extended anteriorly to beyond the mons pubis to the groin as part of an abdominoplasty. With both posterior and anterior extensions, the horizontal excision takes a spiral turn from posterior across medial to the groins; hence the term spiral thighplasty. 2 Regardless of the extensions, the superior horizontal excision lifts roughly only the upper third of the thigh. A mid-medial vertical excision will remove laxity along the mid- to distal medial thigh. The excision is taken as far distally as necessary to tighten loose thigh skin.


This chapter’s vertical MTL description reflects a recent clinical case that also included a lower body lift (LBL). The patient was a 42-year-old woman, with a body mass index (BMI) of 24.7, who lost 100 pounds through a gastric bypass 3 years prior to requesting surgery to improve her lower torso and thighs. She had a prior abdominoplasty and bilateral brachioplasty. This operation started supine with the upper oblique and horizontal portions at the same time as the vertical portion of the thighplasty (Figures 27.127.5). She was then turned prone for completion of the operation (Figures 27.627.9). Table 27.1 lists the special equipment for the procedure.








Table 27.1 Special equipment

Ultrasonic-assisted lipoplasty equipment (LySonix or Vaser)


Rapid saline infusion and aspirating liposuction system with 4-mm cannulas


#1 or #2 PDO Quill suture


3-0 Monoderm Quill suture


Indermil® (Henkel, Dusseldorf, Germany) or Dermabond® (Ethicon) skin glue


Large Marena (Marena Group, Lawrenceville, GA) long-leg tights

Figure 27.1 Spiral thighplasty with a vertical medial extension and the lower body lift (LBL) in 42-year-old massive weight loss (MWL) patient. The buttock segment of the LBL will be deepithelialized for adipose flap augmentation. The drawn lines are numbered in sequence. The initial line is a midline vertical (1) from umbilicus to labia majora commissure. There is no skin excess to be excised along the lower abdominal midline. That line guides symmetry. Equidistant from either side of the midline, a vertical line (2) is drawn down the lateral mons pubis and in the junction between the labia majora and medial thigh. As part of the spiral thighplasty, that line continues to the ischial tuberosity and then along the gluteal fold when the patient is turned. With the right hip and knee flexed, the medial thigh skin falls to the mons pubis. The excess skin is marked, and through this mark, the inferior line (3) of the upper thigh crescent excision is drawn. With the right leg slightly abducted and the anterior thigh skin dragged medially, a vertical line (4) along the medial meridian is drawn to the medial knee. From that line in the middle of the thigh, a pinch test leads to marking the width of resection of the vertical excision. A long, tapered posterior line (5) completes the medial vertical ellipse. The horizontal incision lines (2, 3) of the medial thighplasty taper almost together as they cross the groins on the way to the anterior superior iliac spines (ASISs). From there, superior anchor lines (6) are drawn straight across the hip and back to meet several centimeters superior to the gluteal cleft. This horizontal anchor line (6) holds the suspension from the advanced inferior flaps. Along the lateral thigh, the excess skin is pinched to the superior line, with the widest point at the saddlebag deformity. The inferior incision line (7) descends to that point at which, through grasping, the lateral thigh no longer sags. Then, the inferior line (7) proceeds across the buttocks to the top of the intergluteal cleft. Most of the posterior portion of the LBL excision is deepithelialized and stacked for buttock augmentation. The overhanging inferior buttocks obscure most of the planned excision at the buttock thigh junction.
Figure 27.2 Operation starts with the patient supine. (a) The operator incises skin and fat from the left groin as an assistant holds a gulf-tip LySonix cannula over the right side excision site. (b) The depressed right thigh excision site indicates completion of radical excision site liposuction. Ultrasonicassisted lipoplasty (UAL) of the right thigh begins. There is full-thickness skin and fat resection of the left lateral thigh and partial thickness fat removal from the lower abdomen and groin. A LaRoux dissector is partially inserted over the fascia lata of the thigh to spread for discontinuous undermining.
Figure 27.3 Left hip closure. (a) Four deep throws of #2 PDO Quill start the deep closure of the left hip wound. (b) Wound edges are approximated by pulling both ends.
Figure 27.4 PDO Quill closure. (a) Two horizontal bites are taken on either side of the initial stitch. (b) The wound is closed by pulling on the sutures.
Figure 27.5 Skin glue is applied to the two later closures at the completion of the operation in the supine position with the legs abducted. Open wounds remain at hips and posterior medial thighs.
Figure 27.6 LBL with autoaugmentation of the buttocks. (a) With the patient turned prone, the buttocks are spread out like a mushroom cap. (b) Flaps are deepithelialized with an electric dermatome. (c) Deepithelialized flaps are isolated on subcutaneous islands. (d) Left supragluteal pocket is prepared to receive flaps.
Figure 27.7 Advancement of the buttock flaps. (a) Lateral portion of the right flap is flipped over and advanced into the medial inferior extent of the pocket. (b) Matching flap augmentation is observed from the head of the table.
Figure 27.8 Posterior portion of the spiral thighplasty. (a) Bilateral adipose fascial flap augmentation of the buttocks and LBL has been completed. An ellipse of skin and fat is drawn to be removed from the right buttock thigh junction while the thighs are still abducted. (b) The legs are now adducted, tightening the lateral thigh closures. Skin glue has been applied to all closures. Two 10-mm Jackson-Pratt drains exit at hips.
Figure 27.9 Frontal and right side views 18 months after her lower body and thigh surgery. The bikini tan lines reflect her comfort with her new body shape.

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May 28, 2020 | Posted by in Aesthetic plastic surgery | Comments Off on 27 Medial thigh lift
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