Body Contouring Flankoplasty and Thigh Lift Technique

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).