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, achieving 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.

FIG. 34.1 Fat layers, fascia superficialis and lymphatic vessels.

Lymphatic Distribution

The lymphatic vessels of the skin (Fig. 34.1), after collecting 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 lymphatic drainage. In some anatomical areas this boundary is not particularly obvious, for example in the outer thigh. 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 subsequently 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

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.

FIG. 34.2 (A, B) Preoperative markings.

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 lymphatics.^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 advocated by Le Louarn,¹¹ to extend the marking of the incision 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 technically difficult to correct.