32 Combination Circumferential Abdominoplasty with Medial Thigh Lift
Abstract
With the advent and success of bariatric surgery for morbid obesity, post–massive weight loss dermatochalasis and its surgical management have become an increasing dilemma for both massive weight loss patients and plastic surgeons alike. The resultant skin laxity can result in intertrigo, functional limitations, and patient dissatisfaction with body image after successful bariatric procedures. In addition, although serious medical problems are often corrected after massive weight loss, the plastic surgeon treating these patients is often confronted with other issues, such as malnutrition and anemia. The optimal treatment for these patients involves proper preoperative screening and preparation for removal, reshaping, and high-tension closure of the excess skin laxity, while appreciating the unique anatomy and possible complications inherent in this patient population. This chapter describes indications as well as our preferred technique of circumferential abdominoplasty combined with medial thigh lifting for bariatric patients with abdominal skin laxity, gluteal ptosis, hip rolls, and skin laxity with descent of the medial thigh. The recommended postoperative care and possible complications are also described, with particular attention to consensus guidelines for postbariatric body contouring.
Introduction
Patients who are successful following bariatric surgery are often confronted with the sequelae of diffuse skin laxity. This can lead to skin breakdown and intertrigo; functional limitations with ambulation, sexual activity, and voiding; and psychological issues, including decreased quality of life and social acceptance.1,2 The surgical management of this post–massive weight loss dermatochalasis includes removal, reshaping, and high-tension closure.3
The dissatisfaction with body image is often the instigating factor in a patient’s deciding to undergo plastic surgery. Evaluating massive weight loss (MWL) patients preoperatively for body contouring should include a discussion of their motivations, expectations, appearance and body image concerns, and psychiatric status and history.4 Sarwer et al4 suggest that several questions pertaining to body image should be included in the preoperative discussion, such as Why are you interested in body contouring now? How do you feel your life will be different following surgery? and Do your feelings about you body ever keep you from doing certain activities?
Relevant Anatomy
Dermatochalasis on the trunk, buttocks, breasts, upper arms, and thighs is the sequela of MWL that plastic surgeons are often called upon to ameliorate. The abdomen and mid-body is the area of most concern for these patients.5 Posteriorly in this region, the back contains several folds of excess skin and fat. Strauch et al6 have defined these as four distinct rolls; from superior to inferior, they are the breast fold, the scapular roll, the lower thoracic roll, and the hip roll. Abdominoplasty alone is insufficient, as lateral thigh and buttock elevation is required. Most of the skin laxity and excess of the mid-body, including the thighs and buttocks, can be addressed with belt lipectomy and lower body lift.5 Posteriorly, the lower thoracic and hip rolls are also addressed during circumferential abdominoplasty.6
The abdominal skin and subcutaneous tissue have been divided into three zones: zone I, the abdomen overlying the rectus abdominus muscle, derives its primary blood supply from perforators of the deep inferior epigastric system; zone II, the lower lateral abdomen, is supplied by the external iliac artery; zone III, the upper lateral abdomen, is supplied by the intercostal, subcostal, and lumbar arteries.7 The dominant blood supply to zone I and most of zone II is sacrificed during an abdominoplasty. For this reason, above the umbilicus, care is taken to limit suprafascial dissection to the area directly overlying the rectus muscles.
Injury to the lateral femoral cutaneous nerve has been implicated as a potentially common complication following abdominoplasty.8 This nerve originates from the lumbar plexus and sends an anterior branch through the fascia of the external oblique muscle medial to the anterosuperior iliac spine. The saphenous vein lies in the medial thigh superficial to the fascia lata prior to joining the femoral vein. Care must be taken during the medial thigh lift portion of the procedure to not injure this vein.
Indications
The indication for circumferential abdominoplasty with medial thigh lift includes MWL with abdominal skin laxity, gluteal ptosis, hip and lower thoracic rolls, and the presence of skin laxity and descent of the medial thigh. Patients must have demonstrated stable weight loss for a minimum of 6 months. Contraindications include systemic illness precluding a safe surgical intervention, active smoking status, active skin infection, and failure to pass the psychological screen. Active smokers must demonstrate smoking cessation for a minimum of 6 weeks. Those who are unable to comply are denied surgery.
Preferred Method
Our preferred method for post-MWL mid-body contouring is single-stage circumferential abdominoplasty with medial thigh lift as an outpatient procedure. We prefer this method because patients go through a single operation with a single general anesthetic. This combined procedure as described has its caveats, however. To perform this combined procedure safely as an outpatient, we feel it should be accomplished in less than 4 hours of surgery time.
Techniques of medial thigh lift continue to evolve with the continued increase in MWL procedures and patients requiring body-contouring procedures. More recently, different authors have described performing the medial thigh lift with a vertical incision and a horizontal vector of pull, in contrast to the classic horizontal incision with vertical vector thigh lift.9 Although we feel that the vertical incision technique certainly has its place in body contouring, we do not perform this procedure in combination with our circumferential abdominoplasty, as this procedure takes significantly more time and would compromise our 4-hour surgery time limit. If this technique is required, we schedule it as a separate procedure.
Technique
Our preferred technique includes circumferential abdominoplasty and medial thigh lift in a single stage. The following subsections describe our approach.
Markings
Lateral Thigh
The lateral thigh is marked at a place where the remaining lateral thigh skin will be able to be elevated 2 cm above the iliac crest to be anchored to the fascia just above the crest.
Medial Thigh
The upper mark is along the perineal-to-thigh junction, extending anteriorly along the inguinal crease. The lower mark estimates the amount that can be removed. The upper and lower marks converge in a lazy-S along the inguinal crease and join the abdominoplasty incision where it meets the inguinal crease.
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