Thighlift After Bariatric Body Contouring Surgery

by Michele Shermak, MD, FACS

Dr. Shermak is Chief of Plastic Surgery, Johns Hopkins Bayview Medical Center in Baltimore, Maryland.

Introduction

While massive weight loss (MWL) after bariatric surgery improves overall health status, significant skin redundancy often results, indiscriminately affecting the whole body. Many patients seek treatment to alleviate the functional symptoms associated with excess skin in the thigh, including intertrigo, rubbing and irritation, and impaired physical functioning. Thigh skin excess is visible in bathing suits and clothing above the knee, including shorts and skirts, resulting in cosmetic deformity and deflated body image.

Management of the thigh presents a significant challenge. There is great variability in presentation of patients who demonstrate different degrees and qualities of skin and fat excess, varicosities, body mass index (BMI), and previous medical and surgical history. There is little written on treatment. There are risks associated with such a challenging area for healing. Intraoperative positioning and safety issues are extremely important to consider as well. Techniques in thighlifting must be varied in order to address variability in patient presentation and desire.

Techniques in Surgical Management of the Thigh

When presented with a MWL patient seeking correction of the thigh, the surgeon must consider the components of the thigh, including the skin, fat, varicosities and scars, medical and surgical history, and BMI. Patients with limited upper thigh excess and good skin quality require a very different operation than patients with significant skin excess and poor skin quality. Furthermore, many patients present with BMI greater than 35 with significant subcutaneous lipodystrophy, and these patients also require a different approach.

The literature describing techniques in thighlifting is sparse. Lockwood has written the most about thighlift, but he primarily focused on the cosmetic, non-massive weight loss patient.[1,2] In his papers, he discussed resection of anteromedial proximal thigh skin with suspension to Colles fascia in the pubic crease after undermining was performed. He recommended limiting the degree of skin excision to 7cm, and would not extend the incision posteriorly into the infragluteal fold. Such limitations in excision limit the applicability of this technique to the MWL patient. Recent literature has more directly addressed the MWL patient, with greater skin removal, liposuction and discussion of vertical excision of skin.[3,4] Thighlift is currently a technique in evolution, so little has made it to press yet.

Surgical management of the thigh includes secondary lift with treatment of adjacent body regions; anteromedial thighlift; vertical thighlift; and staged procedure with liposuction followed by excisional surgery.

Secondary Lift without Direct Excision

Patients who have sustained MWL have excess skin involving multiple body regions, and alleviating the torso excess is the often the focal interest of the patient. The belt lipectomy is becoming increasingly popular as the power of the technique is realized.[5-11] In performing an abdominoplasty or a belt lipectomy with skin excision extending to the back, secondary inner thigh lift will result, most notable in patients with a minimal degree of proximal laxity. Belt lipectomy results in excellent lift of the outer thigh with more subtle lift in the inner thigh. In patients with good skin quality and minimal skin excess or in patients who do not prioritize the thigh or will return for second stage surgery, secondary lift of the inner thigh with adjacent lifting of the abdomen or back is worth considering, understanding results are conservative. (Figures 1a and 1b) Pain and mobility limitations are associated with recovery from thighlift, so if the thigh is not high priority, a “watch and wait” attitude may be the best option.

Extended Anteromedial Thighlift

Lockwood’s thighlift technique may be extended, continuing the anterior excision into the abdominoplasty and the posterior excision into the infragluteal fold, to broaden the axis and degree of lift and the amount of skin that may be removed. (Figures 2a and 2b) This technique must be limited to patients who have good skin quality with skin excess limited to the upper half of the thigh. This technique relies on suspension to the ischial periosteum as well as the pubic periosteum to avoid gravitational scar migration and labial spread that might result with inadequate suspension.

Intraoperative positioning requires a prone to supine approach. Standard techniques must be followed in protecting patient safety in prone and supine positioning.[12] Goggles and a foam pillow are applied to the head and neck, which must remain in neutral position. (Figures 3a-c) The arms are bent no greater than 90 degrees at the axilla and elbow. Gel bumps are placed under the clavicles and lumbar region and eggcrate padding is applied to all pressure points.
With this technique patients get nice improvement in the upper inner thigh, particularly when the procedure is paired with a belt lipectomy. (Figures 4a-c)

Postoperative pain must be managed for approximately 4 to 6 weeks and a pain pump may be considered. Patients must ambulate within 24 hours of surgery to reduce the risk of venous thromboembolism. A Foley catheter may be maintained for five days to avoid difficulty with toileting.

Vertical Thighlift

Many patients have skin with poor elasticity after massive weight loss, and patients will often present with inner thigh skin excess with poor skin quality and skin excess involving the entire thigh. Patients have also had the anteromedial thighlift with inadequate correction, with results limited by the hidden scar, and desire improved skin tightening. Patients with this presentation who desire improvement in thigh contour and who does not mind exchanging scar for contour are the best candidates for vertical thighlift. Pull in vertical thighlift is primarily horizontal in direction avoiding the need for periosteal suspension of the skin closure, so the axis is opposite to that of the extended inner thighlift.

Positioning with the vertical thighlift is entirely supine, and is best performed with the legs placed on spreader bars. (Figures 5a and 5b) The knees should be gently flexed and sequential compression devices must be applied to to reduce the risk of venous thromboembolism. Excision is performed in a step-wise fashion to avoid over-resection and difficulty in closure. The surgeon needs to avoid injury to the saphenous vein and lymphatic structures to reduce the risk of postoperative lymphedema. Drains are placed and exited distally. The incisions are dressed with Dermabond glue (Ethicon, Somerville, NJ), and compressive dressings are not placed. Dilated varicose veins are best addressed prior to performing the thighlift.

Staged Management

Patients who are still morbidly obese with BMI greater than 35 often request excisional contouring of the inner thigh. Excisional thighlift is best avoided in patients who are still morbidly obese who have a great deal of subcutaneous fat. (Figure 6) These patients are at higher risk for venous thromboembolism and healing problems, including seroma, dehiscence, infection and lymphedema.[13] It is safer to perform two staged procedure, with first stage involving diffuse liposuction of the thigh to decompress the skin. In a second stage the inner thigh excess may be resected. It is best to have varicose veins addressed by a vascular surgery colleague prior to liposuction as invasion of these thin-walled, dilated vessels is easy and will limit the liposuction that can be performed due to bleeding.

Tips on Optimizing Outcomes

With greater experience in body contouring for MWL, techniques have evolved to optimize outcomes. Patient safety is ultimately the foremost concern in this surgery.

First, we utilize a two team approach in order to expedite progression of the case and minimize blood loss. These cases often include multiple portions, and, while present throughout the entire case, the senior surgeon can benefit from assistance in dissection and closure in order to more effectively treat the patient.

Venous thromboembolism (VTE) precautions are critical as MWL patients often have significant risk factors for VTE, including obesity, general anesthesia for surgery, and history of varicose veins. Having the thighlift with postoperatively decreased mobility leads to stasis in the venous system, which exacerbates risk of VTE. Some patients have had a prior episode of VTE.[14] Noninvasive, conservative prophylactic measures against VTE such as sequential compression devices; perioperative prophylactic dosing of unfractionated (UFH) or low molecular weight (LMWH) heparin; and ambulation, often enforced with the help of the physical therapist, effectively reduce the risk of VTE. Counseling patients about immobility and the risk of VTE is also useful. In high risk patients, preoperative Greenfield filter, and postoperative anticoagulation need to be carefully considered. Greenfield filters may be placed temporarily for up to 6 weeks, which covers the high risk perioperative period while avoiding long-term filter risks.

Lymphatic and venous injury are best avoided to protect against postoperative lymphedema. When working in the mid to distal thigh, saphenous vein injury should be avoided and dissection should be kept at the level of Scarpa’s fascia. In the groin excision must only include the skin, leaving lymphatic and venous structures intact. Lymphedema often results after thighlift procedures and needs to be addressed with patients. Leg elevation and compression hose are helpful.

Low salt diet is recommended to avoid fluid retention. In more severe cases, consultation with physical therapist for lymphatic massage and compressive wrapping may be useful. Diuretics need to be prescribed very carefully as hypokalemia and dehydration may result, particularly in the perioperative period.

Deep venous thrombosis cannot be ruled out in cases of remarkable lymphedema, particularly if only unilateral, so Duplex venous ultrasound must be performed urgently for such patients (Figure 7).

Scarring irregularities with scar malposition and migration may result in the anterior thighlift, and irregular posterior fullness pulled anteriorly may result in vertical thighlift. (Figure 8) Periosteal suspension in the proximal thighlift protects against migration. A smooth contour must be seen on the table in vertical thighlift, particularly if irregular fullness is seen after closing. Revisions may be necessary due to unpredictable scar position and the patient must understand this. Relapse of skin laxity is another related issue that must be discussed with the patient prior to surgery.

Many patients have thigh skin excess that extends distal to the knee and this is difficult to treat. Patients may have a “Popeye” deformity with a well-contoured thigh and a calf, which is similar or larger in dimension, leading to a disproportionality in scale.

Importantly, limiting surgery for patients with notable comorbidities must be followed. The thigh presents a challenge with wound healing, infection, and swelling possible, so patients who are morbidly obese, have uncontrolled endocrine dysfunction such as diabetes or hypothyroidism, who smoke, or who might not be adherent with postoperative instruction are not good candidates for excisional thighlift.

We perform our surgery in an inpatient hospital with the full complement of adjunctive services available, including a team of anesthesiologists, general surgeons and intensivists. Patients are generally admitted for at least one night. Prior to discharge it is assured patients are hemodynamically stable; can eat, walk and urinate adequate volumes; and understand postoperative care necessary for home. Home care nursing may be arranged to assure patients do well after leaving the supervised environment of the hospital.

Conclusion

Patients who successfully achieve MWL after bariatric surgery while enjoying an improved health profile may be distracted by negative body image and physical impairment resulting from skin redundancy. Thigh management presents surgical challenges, and can help massive weight loss patients achieve a more complete result and improved body image.

References
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