Gusenoff, Jeffrey A. M.D.; Coon, Devin M.D.; Nayar, Harry M.D., M.B.E.; Kling, Russell E. B.A.; Rubin, J. Peter M.D.

The acceptance of bariatric surgery as an effective and durable means of treating obesity has fueled a precipitous rise in individuals seeking body contouring following massive weight loss. It has also revealed a relative paucity of objective outcome data regarding regional contouring procedures following weight loss. Although it is well established that thigh rejuvenation can have a profoundly positive functional and aesthetic impact after massive weight loss, there remains controversy over the most appropriate methods for achieving favorable outcomes.¹

The medial thighplasty can be designed to treat the varying amount of skin laxity of the inner thigh. For patients with laxity limited to the upper third of the thigh, a horizontal excision may be sufficient. For patients with laxity extending to the middle third of the thigh, a short-scar vertical thighplasty can be performed. For laxity extending down to the knee, a full-length vertical thighplasty may be required. Techniques vary and can be adjusted to eliminate the T-point if desired.¹,²

Despite the many technical variations of medial thighplasty, there are very few studies investigating objective outcomes and complications in the massive weight loss population. Because of movement, moisture, and a potential T-point in the groin crease, complication rates may be high. We hypothesize that medial thighplasty in the massive weight loss population is safe but has the potential to have a high minor complication rate. We present the largest series of medial thighplasty massive weight loss patients to date to aid in patient counseling before surgery.

PATIENTS AND METHODS

One hundred six medial thighplasty subjects were identified retrospectively from our Life After Weight Loss database. Our study was approved by the Institutional Review Board of the University of Pittsburgh (PRO12090401). Procedures were performed between March of 2003 and April of 2012. Thigh procedures were defined as horizontal incision, short-scar vertical thighplasty, and full-length vertical thighplasty. Massive weight loss was defined as weight loss greater than 50 pounds. Other patient factors collected included age, sex, body mass indices [maximum body mass index, current body mass index, and delta body mass index (maximum body mass index − current body mass index)], type of weight loss (surgical or self-weight loss), time from weight loss to body contouring, follow-up time, comorbidities (i.e., tobacco use, diabetes, hypertension, steroid use, anemia, hypothyroidism, and anticoagulation status), and intraoperative data. All procedures were performed by the two senior authors (J.P.R. and J.A.G.).

Horizontal thighplasty markings are routinely performed by means of the pinch test while the patient is in the frogleg position. Short-scar vertical thighplasty is marked the same way; however, after the horizontal component is marked, the thigh tissues are mobilized medially and then laterally to estimate the vertical component, making sure that the resection lines are drawn from the level of the adductor magnus proximally to the desired distance distally in the midthigh. The full-length vertical thighplasty is marked in the same fashion as the short-scar vertical thighplasty, but the estimated resection is carried all the way to the knee if necessary. Suspension of the superficial fascial system in the thigh to the Colles fascia in the groin is performed using 2-0 absorbable braided suture.

Complications assessed were seroma, wound dehiscence (defined broadly as any size wound separation, including superficial skin breakdown), bleeding, infection (included superficial infections), and edema. Edema was further categorized by duration less than 12 weeks and greater than 12 weeks. Concomitant use of liposuction was recorded. Operative revisions for complications and aesthetic revisions were noted.

Descriptive statistics were calculated, including frequencies for categorical and ordinal variables and means, and standard deviations and ranges for continuous variables. All statistical analysis was performed using Stata/SE version 12.0 (StataCorp, College Station, Texas). Univariate logistic regression was used to examine the impact of individual factors on particular outcomes, with multivariate regression then used to control for possible confounders. The Fisher’s exact test was used for analysis of low-frequency dichotomous variables. All statistical tests were two-sided, with equal variance, and significance was set to the level of p < 0.05.

RESULTS

Demographics

One hundred six patients were analyzed. Fourteen (13 percent) underwent horizontal thighplasty, 24 (23 percent) underwent short-scar vertical thighplasty, and 68 (64 percent) underwent full-length vertical thighplasty. The average follow-up time was 119 ± 139.7 months for the horizontal incision group, 93.4 ± 138.7 months for the short-scar incision group, and 70.2 ± 82.6 months for the full-length vertical incision group (p = 0.95). Ninety patients (85 percent) were women and 16 (15 percent) were men, with an average age at the time of surgery of 45.1 ± 10.2 years. Eighty-eight subjects (83 percent) lost weight by surgical methods and 18 (17 percent) lost weight with diet and exercise. The average time interval between massive weight loss and thighplasty surgery was 30.3 ± 21.2 months. The mean maximum body mass index was 52.4 ± 9.1 kg/m², the mean current body mass index was 29.3 ± 4.3 kg/m², and the mean delta body mass index for the series was 23.1 ± 6.9 kg/m². Body mass indices were not statistically different between the three groups (p > 0.05). Table 1 summarizes the key patient characteristics.

Table 1

Complications

Seventy-two subjects (68 percent) had at least one complication. Complications included wound dehiscence (51 percent), seroma (25 percent), infection (16 percent), and hematoma (6 percent) (Table 2). Overall, 23 subjects (22 percent) developed lower extremity edema. Twenty-one patients in the full-length vertical group developed edema, with resolution in 11 patients by 12 weeks and resolution in another eight patients by 12 months. Two patients developed prolonged edema that was unresolved after 12 months despite lymphedema therapy. Two patients who underwent short-scar vertical thighplasty developed prolonged edema, with one patient resolved by 12 weeks and the other by 12 months. No patients with a horizontal excision experienced prolonged edema. All cases of edema resolved or improved by 12 months postoperatively. Six patients (6 percent) required reoperation for a complication and 15 patients (14 percent) underwent revision surgery to improve aesthetic results. Ten of these patients had full-length vertical thighplasty and five had short-scar vertical thighplasty. Forty-nine subjects (47 percent) underwent concomitant liposuction of the thigh at the time of thighplasty; 37 had liposuction of the thigh outside the area of resection, whereas 12 underwent liposuction in all areas of the thigh, including the area of resection.

Table 2

Predictors of Overall Complications

Sex, body mass index, former smoker, diabetes, hypothyroidism, concomitant liposuction (inside versus outside area of resection), and number of other procedures at the time of thighplasty were not associated with an increased overall complication rate (p > 0.05). Anemia and age (p = 0.02) positively correlated with an increased overall complication rate, with 90 percent of anemic patients developing a complication versus 63 percent of nonanemic patients (OR, 5.3; p = 0.03), and a mean age of 46.7 years in patients with a complication versus 41.6 years (OR, 1.29 per 5 years of age; p = 0.02). Horizontal incision thighplasty was associated with a 49 percent complication rate compared with short- (67 percent) and full-length vertical (74 percent) incision thighplasty (p = 0.1).

Predictors of Individual Complications

Hypertension was significantly associated with postoperative seroma formation (OR, 2.9; p = 0.02) and there was a trend toward seroma formation in the full-length vertical incision group (p = 0.06). Age (OR, 1.47 per 5 years of age increase; p = 0.01), hypothyroidism (OR, 4.5; p = 0.01), and liposuction outside the area of resection (OR, 3.8; p = 0.025) were associated with an increased postoperative infection rate. A full-length vertical incision was associated with an increased risk of lower extremity edema (p = 0.007). No factors correlated significantly with need for revision.

DISCUSSION

The massive weight loss population is a fast-growing demographic within plastic surgery and poses unique challenges.³ Massive weight loss individuals present with a wide range of lower extremity deformities. Moreover, impaired wound healing and an increased prevalence of medical comorbidities, including diabetes, hypertension, and cardiopulmonary insufficiencies, are observed in this population.⁴ Despite these considerable challenges, massive weight loss patients also stand to benefit immensely from contouring procedures. With a careful preoperative evaluation, properly selected patients have reported substantial improvements in overall functioning and psychosocial health.⁵,⁶ A key component of body contouring after massive weight loss is managing patient expectations. Understanding the risks of medial thighplasty is important for patient counseling and the informed consent process.

First described by Lewis in 1957, the medial thigh lift became known for several complications, including scar migration, vulvar deformities, and recurrent ptosis.⁷,⁸ Refinements made by Lockwood in 1988 that included fascial anchoring partially alleviated these issues; however, this traditional approach, with its vertical vector of pull, is ill-suited for many massive weight loss patients, as many require a greater degree of excision than is afforded by the Lockwood technique.⁹ To address the needs of massive weight loss patients, a myriad of technical variations to reorient the vector of pull from vertical to horizontal, with and without staging liposuction, have been described.⁸,¹⁰ However, there remains a paucity of objective data regarding outcomes and complications, which are mostly limited to small, retrospective series.

To determine the most appropriate thigh-lift technique, the inner thigh can be divided into three zones (Fig. 1). When contour deformities are confined to the upper third of the thigh, a horizontal thigh lift can be performed. The horizontal thighplasty alone is not a very powerful operation in massive weight loss patients and may offer limited or no improvement of the middle or distal thirds of the thigh. The amount of resected skin in the horizontal vector is not very robust for any of the three procedures. Larger resections can result in pleating of the tissues, inability to close the tissue, or extension of the scar into the gluteal fold, which can create undesired deformities. If skin excess and laxity extend to the middle third but no farther, the short-scar vertical thigh lift is a reasonable choice. However, because of the conical shape of the thigh, the termination of the incision along the middle thigh can lead to a dog-ear deformity (Fig. 2). Simple dog-ear revision may be required after the scar has had sufficient time to settle down (i.e., 6 to 12 months). Patients are educated about this during their preoperative counseling visit. Shermak et al. described a medial thighplasty modification, the anterior proximal extended thighplasty, which is an attractive alternative for patients with limited laxity.¹ This procedure extends the horizontal proximal incision to the infragluteal crease in the anteroposterior direction and anchors the Scarpa fascia to pubic periosteum. This modification conceals the scar and provides greater pull than the traditional Lockwood technique, although disruption of the gluteal fold is common with this procedure. The authors reported acceptable complication rates, most notably, a wound infection rate of 18.6 percent and a lymphedema rate of 8.2 percent. Age was the only significant predictor of wound complications, and the vertical extension thigh lift was significantly associated with lymphedema. The authors did not perform liposuction in the areas of resection.

Fig. 1

Fig. 2

Redundancy to the level of the knee, as is the case with most massive weight loss patients, is best treated by a full-length incision (Fig. 3). The greater contouring power must be weighed against scar visibility, the increased risk of lymphatic disruption, and the problems inherent in a T-point (Fig. 4). Most massive weight loss body contouring patients will accept scar visibility for the functional and contour improvements resulting from greater resection. The T-point is an anatomical junction area prone to wound healing complications, as it is in a moist environment, which is further subject to motion and friction (Fig. 5). Furthermore, the close proximity to the high bacterial burden of the perineum may predispose to wound infection. The T-point can be eliminated by cheating the design more posteriorly to form an L-shaped resection.² To our knowledge, there are no data comparing the two techniques with regard to complications and outcomes. We often use 2-0 polypropylene suture at the T-point to reinforce the closure for 1 to 2 weeks postoperatively. Care should be taken when using permanent suture to secure the superficial fascia to the Colles fascia, as delayed suture extrusion may occur (Fig. 6). The risk of suture extrusion can be reduced using a slowly absorbing suture in this area. Another option to avoid T-point wound healing problems would be to stage the horizontal and vertical components, which may ultimately improve the overall contour and reduce long-term recurrent laxity; however, patients would have to agree to multiple recoveries and increased surgical expense.

Fig. 3

Fig. 4

Fig. 5

Fig. 6

Our complication rates correspond with that observed in the literature for body contouring procedures in the massive weight loss population.¹¹ Wound healing complications—notably, seroma and dehiscence—are predictably high in this population, although most are minor and can be managed in the clinic without need for reoperation. Our finding that older age and anemia lead to an increased rate of total complications is consistent with previous reports.¹ Evaluating and optimizing the micronutrient status of these patients, particularly for iron, calcium, and vitamin B₁₂ levels, could minimize wound healing complications.¹²,¹³ The impact of liposuction on outcomes of medial thigh lift has not been examined previously. We found that concomitant liposuction outside the area of resection has an increased rate of wound infection. This finding may be attributable to tissue trauma with the liposuction cannulas, or residual edema that persists after surgery in a dependent part of the body. Interestingly, however, concomitant liposuction at the time of brachioplasty was recently shown to have no effect on complication rates in a large series of patients.¹⁴ This is likely because liposuction in the arm was limited to the posterior aspect, and was not near the planned resection area. Similarly, in thighplasty, combining liposuction of the saddlebag area or above the knee is likely safe, whereas debulking procedures of the entire thigh involving the resection area pose a higher risk to the patient. A larger sample size may help elucidate these relationships, as there were too few patients undergoing liposuction only in the nonexcised area for us to draw conclusions. Staging of de bulking liposuction and medial thighplasty may be considered, especially in patients who are already undergoing multiple stages of body contouring. Patients with high body mass indices because of a gynoid or pear-shaped morphology may be good candidates for a stage of debulking liposuction first, followed by surgical excision 3 to 6 months later. Patients with high body mass indices that have global adiposity would benefit from further weight loss before any surgical intervention. Studies investigating excision-site lipectomy in the area to be resected are lacking and may provide further information about the utility and safety of liposuction in relation to the risk of seroma and lymphedema. Chronic seromas or lymphoceles that do not resolve with drainage or other methods may require surgical excision (Fig. 7).

Fig. 7

Chronic lymphedema, the vexing complication of the medial thigh lift, has been reported to occur in as many as 30 percent of subjects.¹⁵,¹⁶ In a study using lymphoscintigraphy analysis before and after thigh lift, Moreno et al. reported that a majority of patients develop demonstrable functional and anatomical alterations of the lymphatic network at 6 months postoperatively.¹⁵ The presence of preexisting lymphovascular disease may be underappreciated in the massive weight loss group; therefore, signs and symptoms should be carefully evaluated preoperatively.¹⁷ Patients with preexisting edema and significant varicosities are referred to vascular surgery for evaluation, radiofrequency ablation of the saphenous vein, or other necessary therapies before thigh contouring surgery. Patients with significant disease may not be body contouring candidates. To avoid intraoperative damage to the lymphatics, we maintain a superficial dissection in the area superior to the adductor magnus muscle and stay superficial to the great saphenous vein. In our study, patients undergoing the short- or full-scar thighplasty are wrapped with an elastic bandage for 1 week after surgery and then placed into ankle-length compression garments for 6 weeks. A single drain is used for 1 week or until drainage is less than 30 cc per 24 hours. Ambulation is encouraged and swelling may increase as mobility increases, especially in the first 2 weeks after surgery. Patients are encouraged to use elastic wraps immediately if they notice any foot or ankle swelling. Horizontal thighplasty patients are encouraged to wear compression as well, but these may be compression garments limited to above the knee. Asymmetric swelling of the extremities is worked up for possible deep venous thrombosis. Swelling usually resolves by 6 weeks. If it persists, patients are referred to the lymphedema clinic at our institution. All patients undergoing a medial thighplasty in our practice are informed of the potential risk of chronic lymphedema (or lifelong swelling) with this procedure. Our protocol for management of lower extremity edema in the massive weight loss population has been reported previously.¹⁷

Some observers may question whether a procedure that has a complication rate of at least 68 percent is safe. We argue that it is because most of these complications were minor wound healing issues or transient edema. We broadly define dehiscence as inclusive of small areas of delayed wound healing. Many other authors may regard these small wound healing issues as noncomplications and they may thus be underreported. There were no venous thromboembolic events in our population. Most revisions were for aesthetic concerns and usually because of dog-ears or recurrent skin laxity, conditions that are unpredictable and can be severe in the massive weight loss population (Fig. 8).

Fig. 8

Future prospective studies should help clarify many of the issues that remain unanswered in medial thighplasty. We thought that body mass indices—in particular, delta body mass index—would be correlated to the degree of thigh laxity. However, we did not find this to be true, which may be attributable to sample size. Another explanation may be that thigh laxity after weight loss is more closely related to pre–weight loss body type (gynoid versus android). Other areas to explore include determining whether variations in surgical techniques that avoid a T-point are truly beneficial in decreasing dehiscence, whether excision-site lipectomy really improves preservation of lymphatics and decreases seroma or lymphedema rates, and whether concomitant liposuction outside the excision site truly increases the risk of infection.

CONCLUSIONS

Wound complications in medial thighplasty are common; however, most are minor and can be managed without reoperation. Complications are highest for the full-length vertical thighplasty (74 percent) and less for the short-scar (67 percent) and horizontal (43 percent) procedures. Age, hypothyroidism, hypertension, and liposuction outside of the area of resection may contribute to postoperative complications. Although full-length vertical incisions are associated with the development of edema, most cases resolve acutely. Further prospective studies comparing techniques may help reduce the rate of minor complications in medial thighplasty.

REFERENCES