eMedicine Specialties > Plastic Surgery > Body Contouring

Body Contouring, Flankoplasty and Thigh Lift

Author: Keith M Robertson, MD, LRCSI, LRCPI, FACS, Consulting Staff, Whitfield Clinic, Cork Road, Waterford, Ireland.
Coauthor(s): Bruce G Freeman, MD, PhD, Chief, Section of Plastic Surgery, Associate Professor, Department of Surgery, Section of Plastic Surgery, West Virginia University School of Medicine
Contributor Information and Disclosures

Updated: Jun 24, 2009

Introduction and History

Localized and generalized accumulations of lower extremity fat have tested the skills of plastic surgeons for decades. Patients with localized fat accumulations often desire removal for aesthetic reasons, whereas patients with large, especially circumferential, accumulations desire removal for functional as well as aesthetic reasons. Kelly was one of the first to recognize the possibility of direct excision of excess skin and fat of the abdomen.¹ This led to direct excision of localized fat on the lower extremities.

Lewis first described the circumferential excision of thigh skin and fat with a vertical closure.² Farina performed direct lateral excision that, while improving the contour of the lateral thigh, produced huge, highly visible scars.³ Pitanguy was the first to describe a thigh lift incision that was hidden within the bathing suit line.⁴ This resection also was the first to address inner and outer thigh skin and fat excess and to correct buttock ptosis.

Over the years, thigh plasty has evolved from variations on this theme. Major variations dealt with the location of the lateral scar. Baroudi kept his lateral incisions low.⁵ Regnault et al brought the incision higher, onto the buttock. Finally, Grazer and Klingbeil raised the incisions to the level of the mid buttock to conceal the scar beneath normal clothing.⁶

McCraw first described multiple procedures on a patient with massive weight loss, combining abdominoplasty, brachioplasty, mastopexy, and thigh lift.⁹ Zook was able to standardize the procedure by describing the following individual procedures and their sequence: patient marking (in the standing position), long S-shaped incisions, and preservation of veins and lymphatics.¹⁰ As Regnault indicates, the problem is more a resection of redundant skin and subcutaneous fat rather than a resection to cure obesity.

Definition of the Problem

The etiology of this problem may be obesity, weight loss, aging, congenital defect, or a posttraumatic defect.

Patients who seek thigh and buttock plasty most often report excess skin and fat as the reason that they desire the procedure. They may also notice a cottage cheese–like appearance over the lateral thigh region and ptosis of the lower buttock. Some comment that they can see the lower part of their buttocks between their thighs when looking in the mirror. Hoffman and Simon describe the problem as the following:¹¹

1. Heavy thighs and/or general obesity
2. Trochanteric lipodystrophy
3. Medical skin and fat excess with redundancy
4. Buttock ptosis with redundancy
5. Cellulite

Regnault and Daniel classify lower extremity deformities by dividing them into regional and general.¹² Regional deformities are those of the medial thigh, buttock, and trochanter. They treat these areas with a "single crescent excision" or a "semicircular approach." A vertical height of 20 cm is excised in some cases. Generalized deformities are treated with a circumferential resection with or without a vertical component.

Pathophysiology

Body fat distribution is determined by gender, age, degree of physical activity, nutritional habits, and in some circumstances, drugs. In men, percent body fat may increase from 20% in young men to 25% in older men. For women, the percentages are 30% and 35% for young and old, respectively. At all ages after puberty, women have a higher percentage of body fat than men.

Distribution of fat also differs between genders. Women tend to accumulate fat in their hips and thighs, while men tend to accumulate fat in their abdomen and flanks.

As humans age, fat is redistributed. Muscle mass declines, tissues lose their elasticity, and the percentage of body fat increases. Sjöstrom notes that from infancy until approximately puberty, adipose tissue develops by multiplication of fat cells.¹³ Approximately at puberty, fat cell division ceases and further increase in adipose tissue volume is caused by an increase in the size of individual fat cells.

Most flankoplasty procedures are performed on patients who are mildly-to-morbidly obese or who have lost a large amount of weight. However, about 15% of the author's patients are of a normal weight but have very poor skin tone.

An estimated 30-50% of the variability in body fat is determined genetically. Environmental and nutritional factors also are important determinants of body fat stores. Drugs, including phenothiazines, antidepressants, antiepileptics, steroids, antiandrogens, and antihypertensives, have been associated with increased body weight.

Indications

The following are indications for performing thigh and buttock plasty:

1. Localized excess of fat and skin
2. Generalized excess of fat and skin
3. Skin redundancy with or without excess subcutaneous fat

Many physicians prefer suction-assisted lipectomy (SAL) for localized fat. SAL alone is usually not adequate in the presence of excess and/or redundant skin. However, for patients with fair-to-moderate skin tone, a surprising amount of skin contraction can be performed by using superficial liposuction (see Procedure). Patients with poor skin tone are best served by excision.

Flankoplasty, combined with other procedures, is indicated for patients who are moderately obese with loose skin or who have lost massive amounts of weight. In patients who have undergone bariatric surgery, weight should remain stable for at least 18 months. Patients with massive weight loss frequently have large amounts of excess skin, leading to chronic hygiene problems, especially suppurative intertrigo. Excisional surgery often is the only way to correct these problems.

This surgery is not for an unmotivated patient because of the extensive nature of the recovery and the need for frequent follow-up. Large amounts of skin and subcutaneous fat are excised, leaving long, occasionally wide, and permanent scars. The physician must understand the patient's motivation and aesthetic goals and assess their future commitment to not gaining weight. The patient must have realistic ideas of what can be accomplished, the location of scars, and the amount of postoperative care that is required.

Contraindications and Relevant Anatomy

Contraindications

Contraindications to this surgery include unrealistic patient expectations, inability to deal with major unpredictable scarring, peripheral vascular disease (arterial, venous), and lymphatic disease. Note any previous surgery that may impact on the venous or lymphatic drainage of the lower extremity. This includes pelvic exenteration and gynecologic procedures leading to inguinal lymph node dissections. Patients who have had varicose vein stripping or saphenous vein harvest probably are not good candidates. The author does not perform this procedure on people who smoke.

Major resectional surgeries are contraindicated in patients who are massively obese, especially those with comorbid factors (eg, cardiovascular disease, diabetes mellitus, cancer, decreased pulmonary function). They also are contraindicated in patients with massive weight loss and multiple metabolic derangements from previous surgery. For more information on obesity, visit Medscape’s Obesity Resource Center.

Relevant anatomy

The anatomy of the skin and subcutaneous tissue of the lower extremity varies greatly. The skin over the buttock is thick and covers a thick layer of subcutaneous fat. Multiple diffuse fibrous septa traverse from the gluteal fascia to the skin. They are especially dense in the area of the gluteal fold. Cutting these during a buttock lift leads to an "effacement" of the gluteal fold.

The skin overlaying the greater trochanter also is thick but with less subcutaneous fat. It is densely adherent to the deep tissues and is recognized as an area that may need to be released during thigh lifts.

Medial thigh skin is thinner than lateral thigh skin and is attached more loosely to the underlying fascia. It also is more prone to rhytid formation, especially after weight loss or as the patient ages.

The buttock skin is supplied from vertical perforators that originate in the gluteal muscles. The superior and inferior gluteal arteries supply the gluteal muscles. Fasciocutaneous perforators that originate in the quadriceps muscles supply the skin of the anterior thighs. Fasciocutaneous perforators from the quadriceps muscles and the tensor fascia lata muscles supply the skin of the lateral thigh. Finally, the skin of the medial thigh is supplied through fasciocutaneous perforators from the femoral artery and perforators from the adductor magnus and the gracilis muscles. Knowledge of cutaneous circulation is important, especially when undermining large areas of skin to avoid skin necrosis.

Workup

As with all major surgical procedures, perform a thorough history and physical examination.

• Specifically investigate dietary habits, history of weight gain or loss, and family history regarding venous problems or lymph edema.
• Note medical problems, especially diabetes, as well as smoking habits and drug use (prescription, nonprescription).
• Carefully document previous surgical procedures, especially gynecologic, orthopedic, vascular, or cutaneous.
• The physical examination should be thorough. Aside from the standard physical examination, take particular care to exclude signs of peripheral vascular disease and lymphatic disease.
• Carefully measure both lower extremities and note discrepancies. Measure the circumference and record the patient's weight on the weighing scales in the clinic. Self-reported weights are not accurate.
• Conduct detailed discussions with the patient regarding areas of concern and the patient's aesthetic goals. Give the patient a realistic idea of whether the deformity can be treated with a local resection or whether a regional resection would be better. Emphasize the location and expected quality of the scars.
• Counsel the patient regarding postoperative care. Discuss the presence of drains (if any) and the possibilities of hematoma, infection, wound dehiscence, and their treatment. Patients with poor skin tone are at high risk for recurrent seroma. Discuss difficulties that the patient will have with walking and sitting for up to 3 weeks. The patient should be shown beforehand how to get out of bed and how to use the bathroom with minimal flexion of the torso.
• Schedule a second and, if necessary, a third consultation to ensure that the patient understands the magnitude of this operation.

Flankoplasty

As for all major procedures, a complete history and physical examination is important.

• Perform a thorough medical history with particular emphasis on medications. Patients frequently do not volunteer information regarding certain drugs they are taking (prescription or nonprescription [eg, homeopathic, over-the-counter] weight loss drugs, drugs that can promote obesity), so carefully question them and meticulously document the answers.
• Note previous surgery.
• Examine the patient without clothing in the standing position. Note the location of any previous surgical scars and the presence of multiple skin folds and rolls.
• Assess the elasticity of the skin.
• If possible, a full-length mirror should be available. Draw the planned excisions and locations of the scars on the patient while the patient observes.
• Obtain a complete laboratory workup. Obtain a complete blood count, complete metabolic panel, and ECG. Carefully investigate any abnormal value prior to surgery.
• Spend a significant amount of time obtaining informed consent. Impress the magnitude of this operation upon the patient. Thoroughly discuss postoperative complications. Inform the patient where scars will be located and that these scars almost assuredly will not fade into fine white lines. Wound healing problems, marginal skin necrosis, and seromas occur at least 50% of the time. As with thigh and buttock surgery, deep venous thrombosis and pulmonary embolism are rare but real considerations. Patients should be aware that skin that has been stretched severely by obesity has lost much of its elasticity. Therefore, tight, smooth contours cannot be obtained with these procedures, especially if the patient gains weight or continues to lose weight, which is why the patient's weight should remain stable for at least 18 months before surgery. Inelastic stretched skin continues to age, frequently requiring revisional or "touchup" surgery. This is true in most patients.

Procedure

Numerous designs exist for thigh plasty. Until 1988, almost all thigh plasties involved either partial or total circumferential skin excision and direct closure. Regnault and Daniel call for minimal undermining to prevent seromas and hematomas.¹² The major problem with the early techniques was wide, unsightly scars that migrated because of excess tension on the wound. Numerous maneuvers, including de-epithelialization of the lower flap, were attempted. The problem with these designs is that they called for minimal undermining and skin closure alone.

Not until Lockwood described fascial anchoring in medial thigh lifts did reproducible results in thigh plasty and buttock plasty become routine.¹⁴ Lockwood describes suturing Colles fascia in both the superior and inferior thigh flaps. Lockwood explained this concept with his description of the superficial fascial system (SFS) in the trunk and extremities. He described the SFS and, equally importantly, certain "zones of adherence" that must be released to obtain a long-lasting result.

In a second article, Lockwood describes his technique. Mark the patient preoperatively so that the incision line falls within the bikini area.

1. Invasion of the gluteal vascular territory as described in previous procedures, thereby reducing circulation to the inferior flap
   
   

   

   Trunk and lower extremity.

   [ CLOSE WINDOW ]

   

   Trunk and lower extremity.

2. Tight wound closure of the skin, which produces painful wide scars that often migrate
3. Flattening the buttock crease, thereby increasing the appearance of age

Flankoplasty

According to Regnault and Daniel, the "fundamental principle of total body contouring is the excision of as much redundant tissue as possible with minimal undermining and moderate tension."¹² This frequently leads to a multistage approach. Regnault and Daniel based their approach on the location of the major redundancy. If it is anterior, perform an abdominoplasty. If anterolateral, a "batwing torso lipectomy that incorporates a thoracobrachioplasty is performed."

Vilain reported on 300 belt lipectomies.¹⁵ Unlike most authors, he performs extensive undermining of both the superior and inferior flaps.

Zook published an excellent article describing some technical details of these procedures.¹⁰ First, "sinuous" incisions are performed rather than straight incisions, especially if the incision crosses one or more joints. Zook also promotes preservation of veins and lymphatics, especially in the extremities.

With regard to the length of incisions, Zook emphasizes the need to carry the incisions to the length of the deformity regardless of their location. This principle is sound, for adequate excision and lifting cannot be obtained without dissection of the deformity. This must be discussed with the patient preoperatively.

Flankoplasty remained virtually unchanged until Lockwood described the SFS. He studied the anatomy of the SFS in 12 cadavers (fresh and embalmed) and in 20 patients. He found that the SFS consists of horizontal fascial sheaths separated by fat that are interconnected by vertical fibrous septa. According to Lockwood, its function is to "encase, support, and shape the fat of the trunk and extremities and to hold the skin onto the underlying tissues." The surgical manipulation of this system allows more aggressive lifting by increasing the pulling power of the deep soft tissues and decreasing the tension on the skin. Lockwood has described the SFS and its use in abdominoplasties, thigh and buttock lifts, back and flank lifts, medial thigh lifts, inframammary fold reconstructions, and augmentation mammoplasty.

Lockwood also describes "zones of adherence" that must be released to achieve a more normal appearance. These zones differ in men and women.

Complications and Future and Controversies

Thigh and Buttock Plasty

Complications

1. Hematoma
2. Infection
3. Wound dehiscence
4. Widened scars
5. Scar migration
6. Sensory nerve damage
7. Lymphedema
8. Deep vein thrombosis (DVT)
9. PFES

While these complications are rare, they can be quite troublesome. Prior to the advent of the SFS suspension, widened scars and scars that migrated were quite common. Lymphedema is quite rare. Paresthesia secondary to cutaneous nerve injury rarely is mentioned but can be quite troublesome.

Future and controversies

Buttock and thigh lifting continue to be relatively rarely performed procedures for a number of reasons.

• SAL has gained great acceptance because of the relative ease with which it may be performed. Some authors are extending the boundaries in its use for treating obesity. Hunstad notes that "excision contouring in the obese patient is appropriate in virtually all areas previously discussed for nonexcisional (SAL) patients."¹⁶
• Excisional thigh and buttock surgery is technically difficult, can result in significant blood loss, and produces significant scarring. Postoperative morbidity is significant.

The future may rest in developing combinations of the 2 techniques. This is not without risk. In certain areas, performing aggressive superficial liposuction and combining it with wide undermining is not safe. However, with experience and small cannulas (<3 mm), dramatic results may be obtained.

Flankoplasty

Complications

1. Hematoma
2. Seroma
3. Infection
4. Wound dehiscence and/or marginal necrosis
5. Widened scars
6. Scar migration
7. Sensory nerve damage
8. Lymphedema

Complications occur in 20-25% of patients who have undergone massive weight loss; the heavier the patient, the greater the risk. For this reason, the author rarely operates on someone who weighs more than 90 kg (200 lb).

Future and controversies

The future of flankoplasty depends on the surgeon's ability to restore normal body contour with the least possible scarring. Certainly, SAL has provided a powerful tool to remove fat. SAL does not treat skin laxity and can worsen truncal deformity. The main goal should be to improve the quality of scars. This can be accomplished by relieving the tension on them. The SFS appears to be the best way to do this.

Multimedia

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Media file 1: Trunk and lower extremity.

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Media file 2: A circular sloping ring belt lipectomy.

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Media file 3: Batwing torsoplasty.

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Media file 4: Preoperative markings, lateral view.

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Media file 5: Preoperative markings, anterior and posterior views.

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Media file 6: Incisions placed entirely within bathing suit line.

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Media file 7: Flankoplasty and thigh lift.

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Media file 8: Anatomy of the superficial fascial system in males and females.

Keywords

thigh lift, thigh plasty, batwing torsoplasty, buttock ptosis, dermolipectomy, belt lipectomy, obesity, excess skin, massive weight loss, abdominoplasty, brachioplasty, mastopexy, flankoplasty, lower extremity fat, excess abdominal fat, abdominal skin, localized fat, local fat removal, circumferential fat, fat excision

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