Answer:
(From Grabb and Smith CD-ROM:)
Lax skin is the defining characteristic of patients who are candidates for thigh lift. The skin laxity may be genetic, but more frequently it is seen in patients who have gained and lost excessive amounts of weight, sometimes repeatedly. Patients whose lax skin is accompanied by significant degrees of excess fat generally benefit less from thigh lifts, because the skin is more difficult to elevate and to fix in position.
Patients may have laxities affecting the hips, buttocks, outer thighs, inner thighs, posterior thighs, anterior thighs, or any combination of the above. Medial thigh lift, with an excision confined to the groin area, usually benefits only the upper portion of the inner thighs. Lateral thigh lift, with an excision extending from the posterior midline laterally and around to the anterior groin area, will benefit the buttocks, the outer thighs, posterior thighs, anterior thighs, and medial thighs. Abdominoplasty, by pulling up on the tissues of the groin, can also benefit the upper anterior and medial thighs.
The exact operation offered to a particular patient depends on the patient’s desires and the particular and unique features of that patient’s skin and subcutaneous fat over the lower torso and thighs.
Most patients having skin laxities of the lower torso and upper thighs will benefit from combined inner and outer thigh lift. If abdominal skin laxity is very severe, abdominoplasty may be added to inner and/or outer thigh lift. If the patient has laxity limited to a particular area, however, only a portion of the combined procedures need be done. I will describe a complete inner and outer thigh lift. The reader should understand that it is possible to perform only inner or only outer thigh lift or to combine inner and outer thigh lift with abdominoplasty.
Markings
The outline of the patient’s normal underwear or bathing suit is marked on her skin. After the patient removes her garment, she stands with her feet 18 inches apart, and a transverse reference line is drawn starting at the midline above the natal crease and approximately 2 cm below and parallel to the top of the bathing suit line. The reference line is carried around the body towards the anterior superior iliac spine, from which it proceeds medially and downwards in a gentle curve to the symphysis pubis. It then drops down vertically into the groin crease (genitofemoral sulcus). The line continues in a posterior direction but stops well short of the point at which it would be visible from behind. This reference line represents the planned line of closure and eventual position of the final scar.
The lateral thigh excess is estimated by pulling up on the skin in the mid lateral thigh area and pulling down on the skin in the mid axillary line. The same estimates are carried out in a posterior direction over the buttocks and in an anterior direction over the lateral groin areas. The maximal width of planned skin excision at the mid lateral thigh is usually 10–12 cm, but it may range up to 20 cm. About 25% of the skin excess is above the reference line, and 75% is below the reference line.
The medial thigh excess is estimated by pulling the skin of the upper mid medial thigh up to the groin crease and marking on the mid medial thigh at the level which the skin comes up to the groin without undue tension. This mark is connected to the posterior end of the reference line in the groin crease, and, in an anterior direction, connects to the line marking the planned inferior limit of lateral resection near the symphysis pubis. Medial thigh excisions are usually 4–6 cm in width at the mid medial thigh.
If there is descent of the mons pubis, correction of this area should be planned at the time of combined medial and lateral thigh lift. The mons is elevated under moderate tension, and the midline is marked 5–7 cm above the anterior vulvar commissure. This midline mark is extended right and left to join the lateral reference lines. The anterior transverse line thus created becomes the reference line in the pubic area. Pinching the pubic and hypogastric skin together permits the surgeon to estimate the amount of skin that should be resected, and a second transverse line above and parallel to the pubic reference line is drawn to mark the planned superior limit of resection in this area.
Symmetry of planned excisions is key and is aided by drawing vertical lines at the front and back mid lines and the left and right mid axillary lines. Prior to beginning surgery, the patient is placed in the supine frog-leg position and the surgeon verifies that his medial thigh estimates of skin resection are achievable in this position as well. The thighs should be flexed at approximately 30 degrees and slightly abducted. Although the actual tissue excised may or may not be congruent with the drawings, the markings are essential references during surgery and help ensure symmetry.
Operation
Under general endotracheal anesthesia, the patient is placed in the left lateral decubitus position while lying on a position maintenance device (Olympic Vac-Pac Olympic Medical Corp., Seattle, WA). A wedge is placed to keep the thighs abducted and the patient is taped to the operating table to ensure stability of position. A small roll in the axilla is mandatory to prevent brachial plexus injury.
After prepping and draping, the right side of the operative field is infiltrated with lidocaine 0.05% with epinephrine 1:1,000,000. Approximately 500–1500 cc is injected into the right hip-thigh-buttock area. Enough solution is injected to cause intense vasoconstriction through the full thickness of subcutaneous tissue from the skin to the deep fascia, but not so much is injected that the tissues become turgid and difficult to mobilize. Lidocaine in the injectate provides postoperative analgesia.
If liposuction is indicated in the subtrochanteric area, it is carried out before starting the thigh lift. After liposuction, the upper resection line is incised. The incision is carried through the superficial layer of subcutaneous fat and fascia down to, but not through, the deep subcutaneous layer of fat and fascia. The deep subcutaneous layer is characterized by a darker, more orange fat and a looser, lamellar arrangement of fascial elements. The deep layer is several centimeters thick in the posterolateral area, but is rudimentary in the anterolateral area, and, for practical purposes, is absent over the external oblique fascia. The level of dissection in the more anterior areas is, therefore, just above the innominate fascia. Once the level of dissection is established, a flap is undermined in a caudal direction extending over the buttocks area, the iliac area, and the groin and anterior thigh. Dissection proceeds at least as far as the planned line of inferior resection. Over the lateral thigh, undermining may extend beyond the area of the greater trochanter. The dissection plane is relatively avascular, and made more so by the preoperative infusion of epinephrine-containing solution. The few perforators to the skin are coagulated.
The flap is pulled in a cephalic direction, and a decision is made regarding how much of the flap should be excised. Usually the entire amount of the premarked area is removed. Additional flap mobility can be obtained by dissecting over the lower buttock and upper thigh distal to the greater trochanter, but as the extent of flap undermining increases, so does the incidence of postoperative seroma formation.
Closure is in layers using interrupted #1 Monocryl in the superficial fascial system, interrupted 2-0 Maxon in the subdermis, and a running 3-0 Monocryl through the cutis. The anterior portion of the closure stops at the anterior superior iliac spine. Posterior closure stops at the midline where a Burow’s triangle is excised.
The patient is then turned to the right lateral decubitus position and the left side is treated in an identical fashion. The operative sites on the right and left side will be joined at the posterior midline where careful tailoring and adjustment of flaps is necessary to create a smooth meeting of excision sites. Closure on each side should be under the same level of tension to achieve symmetry. Accurate, symmetric preoperative markings and their careful observance during the procedure are most helpful in this regard.
Upon completion of the left lateral thigh lift, the patient is turned supine. A Foley catheter is placed, and the patient is prepped and draped again with both lower extremities prepped free and in the field. The tissues are infiltrated with local solution using approximately 500 cc for each groin. The groin incision is begun along the groin crease marking (most cephalic portion of specimen to be excised) and is carried up to the symphysis pubis and then laterally to join the lateral excision. In the groin, the depth of incision is to the fascia lata in the region between the ischial tuberosity and the symphysis pubis. The depth of incision becomes more superficial through the fat over the femoral triangle in order to leave lymphatics intact. As the incision proceeds laterally, its depth is to the innominate fascia just superficial to the external oblique aponeurosis. Undermining of the flap is carried out in a caudal direction at the previously described levels of dissection. With the thighs slightly abducted and the knees flexed at 30 degrees, the skin flap of the upper medial thigh and groin area is put under moderate tension and excised.
Closure in the groin is accomplished by suturing the superficial fascial system of the flap to the Colles fascia along the pubic ramus between the ischium and pubis. Four or five interrupted sutures of #1 Monocryl are placed at this level. All deep sutures in Colles fascia are placed before tying. The deep sutures take all tension off the skin closure and prevent downward migration of the scar and eversion or distortion of the labia majora. The more lateral portions of the flap are also closed with interrupted #1 Monocryl through the superficial fascial system. A subdermal closure with interrupted 2-0 Maxon and intracuticular closure with a running 3-0 Monocryl completes the procedure.
Aftercare
Patients remain 2–3 nights in the hospital. They are maintained in a thighs-abducted position with pillows between the knees and gradually ambulated starting the morning after surgery. The Foley catheter is removed on the first or second postoperative day. Although the patient may be unable to sit comfortably for approximately one week, voiding and bowel movements can be performed in a semi-standing position. Return to sedentary work activities is usually not until two weeks after surgery and sports are prohibited for six weeks.
Complications
Hypertrophic or pigmented scarring is not uncommon, but scars mature over two years and improve with time. Incisions placed too low or too far laterally in the groin may produce scars visible outside of bathing suits or shorts. Asymmetry of scar position is sometimes due to skeletal asymmetries, but it can also be caused by imprecise preoperative measurement and/or unequal surgical excisions. Equal segments of tissue should be removed from right and left sides. Scar revision should not be attempted until one year or more post surgery.
If a hematoma is recognized in the early postoperative period, it should be drained. The frequency of seromas is directly proportional to the extent of undermining. Once the diagnosis of seroma is established by aspiration, the seroma should be permitted to resorb without repeated aspirations, which are unpleasant for the patient and do not hasten resolution, which may take several months.
Minor wound complications can include small areas of dehiscence and persistent suture granulomas. Areas of dehiscence will usually heal spontaneously if kept clean and minimally debrided. Chronically infected sutures should be removed. Even though all of the sutures are absorbable, their large size means they can remain in the wound for many months.
Frank infection should be treated with rest, appropriate antibiotics determined by culture and sensitivity, and drainage, if necessary.