Body Contouring Flankoplasty and Thigh Lift

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 midbuttock to conceal the scar beneath normal clothing.[6]

Flankoplasty rarely is performed alone. It is most often combined with abdominoplasty and thigh plasty procedures (see the image below). Somalo first described the circumferential dermolipectomy.[7] Gonzalez-Ulloa first described the belt lipectomy in 1960, adding a vertical wedge resection.[8] Whereas belt lipectomy is usually indicated for obesity or excess skin from massive weight loss, partial belt lipectomies can produce dramatic results.

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 lymphatic vessels.[10] As Regnault indicates, the problem is more a resection of redundant skin and subcutaneous fat rather than a resection to cure obesity.

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

Excisional thigh and buttock surgery is technically difficult, can result in significant blood loss, and produces significant scarring. Postoperative morbidity is significant. Suction-assisted lipectomy (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.[11] Hunstad notes that “excision contouring in the obese patient is appropriate in virtually all areas previously discussed for nonexcisional (SAL) patients.”[12]

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.

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. Addressing the superficial fascial system (SFS), as described by Lockwood, appears to be the best way to do this.

The following are indications for performing thigh and buttock plasty:

• Localized excess of fat and skin

• Generalized excess of fat and skin

• Skin redundancy with or without excess subcutaneous fat

Many physicians prefer 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. Patients with poor skin tone are best served by excision.

Flankoplasty (see the image below), 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 surgical procedure 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 the patient’s future commitment to avoiding weight gain. The patient must have realistic ideas of what can be accomplished, must be cognizant of the location of scars, and must be aware of the amount of postoperative care required.

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[13] :

• Heavy thighs and/or general obesity

• Trochanteric lipodystrophy[14, 15]

• Medical skin and fat excess with redundancy

• Buttock ptosis with redundancy

• Cellulite

Regnault and Daniel classify lower extremity deformities by dividing them into regional and general.[16] 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.

Some types of cellulite can be improved by excisional or liposuction surgery. It has been demonstrated that one type of cellulite is the result of extrusion of subcutaneous fat into the reticular dermis. The pattern of connective tissue differs between males and females, with women having a diffuse pattern of a regular and discontinuous connective tissue immediately below the dermis and men having a smooth and continuous pattern.

Cellulite may be removed by direct excision of the involved area. Its tethering effect can be improved using a subcision technique. Other irregularities may be improved by adipose autografts.

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

Major resections are contraindicated in patients who are massively obese, especially those with comorbid factors (eg, cardiovascular disease, diabetes mellitus, cancer, and decreased pulmonary function). They are also contraindicated in patients with massive weight loss and multiple metabolic derangements from previous surgery.

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

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

Distribution of fat also differs between genders. Whereas women tend to accumulate fat in the hips and thighs, men tend to accumulate fat in the 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.[17] At approximately the onset of 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.

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 (see the image below). 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 effacement of the gluteal fold.

The skin overlying the greater trochanter is also thick, but there is less subcutaneous fat. This skin 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.

Knowledge of the cutaneous circulation is important, especially with regard to avoiding skin necrosis when large areas of skin are being undermined.[18]

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 originating in the quadriceps supply the skin of the anterior thigh. Fasciocutaneous perforators from the quadriceps and 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.

As with all major surgical procedures, a complete history and a thorough physical examination are important.

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. Carefully document previous surgical procedures, especially gynecologic, orthopedic, vascular, or cutaneous.

In particular, be sure to inquire into the patient’s use of medications. Patients are often reluctant to volunteer information regarding certain drugs they are taking (eg, prescription or nonprescription [homeopathic, over-the-counter] weight loss drugs, drugs that can promote obesity), so question them carefully and document the answers meticulously.

The physical examination should be thorough. In particular, be alert for signs of peripheral vascular disease and lymphatic disease.

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. Carefully measure both lower extremities and note any significant discrepancies between them. Determine the circumference and record the patient’s weight on the weighing scales in the clinic. Self-reported weights are not accurate.

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. Patients should be told to look straight ahead during the placement of the marks. Otherwise, they are likely to twist their body to the left to watch you place the marks on the left side of their body. When they turn to the right side to observe your marks, they may turn a lesser amount. This can give rise to asymmetric marks, which, in turn, can lead to an asymmetric result.

Perform a complete laboratory workup. Obtain a complete blood count, a complete metabolic panel, and an electrocardiogram (ECG). Carefully investigate any abnormal value before surgery.

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. Spend a significant amount of time obtaining informed consent.

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.

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. 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. As with thigh and buttock surgery, deep venous thrombosis and pulmonary embolism are rare but real considerations.

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.

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.[16] The major problem with the early techniques was wide, unsightly scars that migrated because of excess tension on the wound. Numerous maneuvers, including deepithelialization 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.[19] Lockwood described suturing Colles’ fascia in both superior and inferior thigh flaps. He explained this concept with his description of the superficial fascial system (SFS) in the trunk and extremities.[20]

Lockwood 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.”

Surgical manipulation of the SFS 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 use of the SFS in abdominoplasties, thigh and buttock lifts, back and flank lifts, medial thigh lifts, inframammary fold reconstructions, and augmentation mammoplasty.[21, 22, 23]

Equally important, Lockwood also described certain “zones of adherence” that must be released to obtain a long-lasting result. These zones differ in men and women. By releasing the SFS at these zones of adherence, lifting forces can be transmitted to the distal thigh, the upper abdomen, the trunk, and the buttocks. This can be accomplished through incisions placed entirely within the bathing suit line.

In a second article, Lockwood described his technique.[24] The patient’s skin is marked preoperatively so that the incision line falls within the bikini area (see the images below).

Areas to be excised and areas to be undermined are marked as well. Once the resection and undermining have been carried out, the wounds are closed by using braided permanent sutures in the SFS, subdermal polydioxanone sutures, and intracuticular polypropylene sutures.

Lockwood notes that the SFS lift has the following advantages:

• It prevents invasion of the gluteal vascular territory and the consequent reduced circulation to the inferior flap

• It prevents tight wound closure of the skin, which produces painful wide scars that often migrate

• It prevents flattening of the buttock crease, which increases the appearance of age

A study by Gusenoff et al found a high rate of minor wound-healing problems in patients who, following massive weight loss, underwent medial thigh plasty. Of 106 patients in the study, 72 of them (68%) experienced at least one complication, among which were dehiscence (51%), seroma (25%), edema (24%), infection (16%), and hematoma (6%). The investigators also reported an association between hypertension and postoperative seroma; in addition, they found age, hypothyroidism, and liposuction outside the resection area to be linked with postoperative infection.[25]

A study by Bertheuil et al, however, indicated that medial thigh plasty can improve the quality of life in patients who have undergone a massive weight loss, although the report, on 21 individuals, did not find that the surgery improved the quality of subjects’ sex lives.[26]

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.”[16] This frequently leads to a multistage approach. Regnault and Daniel based their approach on the location of the major redundancy. If the redundancy is anterior, an abdominoplasty is performed. If it is anterolateral, a “batwing torso lipectomy that incorporates a thoracobrachioplasty is performed” (see the image below).

A circular deformity requires a sloping ring belt lipectomy (see the image below).

In patients with less excess skin, Baroudi describes elliptical excisions of the excess skin that can be joined in the back if necessary.[5] Baroudi also describes a meticulous wound closure, including the subcutaneous tissue (to close dead space), dermis, and an intracuticular suture.

Vilain reported on 300 belt lipectomies.[27] 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.

Complications

Potential complications of thigh and buttock plasty include the following:

• Hematoma

• Infection

• Wound dehiscence

• Widened scars

• Scar migration

• Sensory nerve damage

• Lymphedema

• Deep vein thrombosis (DVT)

• Pulmonary fat embolism syndrome (PFES)

Although these complications are rare, they can be quite troublesome. Before the advent of the superficial fascial system (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.

A study by Weber et al indicated that in patients who undergo medial thigh plasty, prolonged postoperative administration of antibiotics may reduce complications. Those patients who were treated with 2 weeks of oral postoperative antibiotics experienced a lower total number of complications than did individuals who did not receive this treatment. For the latter, the odds ratio for total complications was 3.5; for major complications, 4; and for wound infections, 6.8. The investigators found evidence, however, that the ability of prolonged antibiotic administration to reduce the incidence of major infections was affected by change in body mass index.[28]

Potential complications of flankoplasty include the following:

• Hematoma

• Seroma

• Infection

• Wound dehiscence or marginal necrosis

• Widened scars

• Scar migration

• Sensory nerve damage

• 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).