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32 Spiral Lift
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Fig. 32.13 The Lockwood underminer is used on the lateral thigh to
stretch the skin attachments so that adequate lateral thigh lift can be
achieved. (Image taken from Ted E.Lockwood, MD, Lower-Body Lift,
Aesthetic Surgery Journal, Volume 21, Issue 4, July 2001, Pages 355–
369, https://doi.org/10.1067/maj.2001.118028)
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Fig. 32.14 Excess lateral thigh tissue is marked
a
Fig. 32.15 (a) Suspending of the lower ap using permanent Ethibond sutures to the deep muscle fascia and the periosteum of the iliac crest. (b)
Closure of the skin in multiple layers
32.8.2 Posterior Medial Thigh Lift (this Part
oftheProcedure May Not BeRequired
forall Patients. It Is Also Not Required if
aVertical Medial Thigh Lift Is
Undertaken asShown intheSteps
Below)
b
of the infragluteal crease should be made in the standing
position. The excess tissue is pinched and reconrmed as tissues do move after a buttock and a lateral thigh lift
(Fig.32.16b).
Incision is rst made along the inferior gluteal crease
(Fig.32.17a) and dissection is carried out inferiorly over the
fascia (subcutaneous plane) using a cautery (Fig. 32.17b).
The previously marked posterior, medial wedge of tissue is
now taken up for excision. This is part of the medial thigh lift
that has to be done with the patient in the prone position. The
markings are reconrmed (Fig.32.16a). It is important that
the infragluteal crease is not violated and hence the marking
The extent of dissection at the subcutaneous plane should be
beyond the estimated excision of the skin (Fig. 32.17c).
Once adequate dissection and undermining has been completed, the skin to be excised is estimated by moving the
thigh ap toward the superior incision. It is important to note
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a
Fig. 32.16 (a) Markings for posterior medial thigh lift reconrmed. (b) Extent of tissue removal is reconrmed with pinch test
a
b
b
c
Fig. 32.17 (a) Incision is made along the inferior gluteal crease. (b)
Suprafascial dissection is accomplished taking care of the deeper muscles and nerve. (c) Extent of the pocket dissection is checked. (d) Skin
d
laxity and removal is checked by moving the thigh skin toward the
infragluteal incision
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499
a
a
b
b
Fig. 32.18 (a) Once the excess skin has been removed, the inferior
ap is suspended to the periosteum of the ischial tuberosity using permanent sutures so that on the nal closure (b) there is no drag on the
gluteal skin and the skin closure is tension free
that the superior incision is not brought or moved toward the
thigh ap, else more skin will be excised and the buttock will
lose its shape (Fig.32.17d). Once the excess skin has been
removed, the inferior ap is suspended to the periosteum of
the ischial tuberosity (Fig.32.18a) using permanent sutures
so that on the nal closure (Fig.32.18b) there is no drag on
the gluteal skin and the skin closure is tension free.
32.8.3 Lateral, Anterior, andMedial Thigh Lift
The patient is then turned over to continue the surgery
toward the anterior thigh and medial thigh incisions. The
operation is continued in a supine position with the lower
extremities abducted so as to expose the medial thigh.
Depending on the extent of skin laxity, the incision is continued on the anterior side dissecting toward the thigh
through the supercial fat layer, which is above the supercial fascia system, in order not to injure the major vessels.
Fig. 32.19 (a) Assessing the skin laxity in the anterior thigh. (b)
Suspension of the thigh ap to the periosteum along the anterior superior iliac spine, inguinal ligament, and medially to the Colles’ fascia
The most important requirement is to protect the structures
of the femoral triangle. The Lockwood underminer was
used for limited undermining of the anterior thigh in an inferior fashion deep to the supercial fascial system. The
medial thigh was not undermined. The excision amount is
determined by pinching using a demarcator or by moving
the thigh skin toward the lower abdomen incision and checking for skin laxity (Fig. 32.19a). Thereafter, a crescent of
redundant skin and fat was resected at the superior medial
thigh, spiraling anteriorly to the ank and posteriorly to the
infragluteal fold, thus joining the previous ank and infragluteal excision sites.
Multiple incisions were made perpendicularly to the incision line dividing the tissue to be excised. The dissection was
continued along the inguinal ligament, the anterior superior
iliac spine, and the lateral hip connecting it with the lower
body lift and buttock lift from the back (Fig.32.19b).
The inferior skin ap then was suspended from the
supercial fascial system to Colles’ fascia of the perineum
medially, to the inguinal ligament anteriorly, and to the
periosteum of the anterior superior iliac spine laterally with
polydioxanone sutures. Next, the superior and inferior
edges were approximated in a layered fashion with subdermic running absorbable polyglactin 910 (3-0 Vicryl) and
subcutaneous running absorbable 3-0 Monocryl sutures.
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Fig. 32.20 (a) A vertical
incision being made on the
inner thigh along the medial
axis. (b) The thickness of the
subcutaneous layer required
to maintain the vascularity of
the skin ap. (c) The aps are
overlapped and checked for
adequacy of excision. (d)
Extra skin removed and
closure done
a
c
b
d
32.8.4 Medial Thigh Having Vertical asWell
asHorizontal Laxity
When there is laxity in the horizontal direction as well and
when skin can be pinched in the vertical axis, a T excision of
the medial thigh skin may be required for the best result
(Fig.32.20a–d).
32.9 Postoperative Care
Compression garment is applied immediately after termination of the procedure and patients are encouraged to keep
them on for at least six weeks. Ambulation is essential for
several reasons including prevention of deep vein thrombosis, hematomas, and seromas, and to enhance drainage.
Surgical drains are removed three to four days postoperatively. Pain control and opioid counseling is provided.
Avoid exercise for six weeks. Avoid heavy lifting for eight
weeks and intercourse for three weeks.
32.10 Complications
Cosmetic dissatisfaction is an obvious nearly expected complication of any cosmetic surgery procedure. Pertinent to the
inner thighs, the location is a high risk for several complications. The inner thigh and buttocks can be a harbor of bacteria and yeast infections, due to the warm and moist
environment. The intertriginous skin is fragile and wound
dehiscence is possible. In addition, the proximity of the anal
area can increase the risk of wound infections.
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Scars can be less than ideal, due to the high tension caused
by suture placement and scar retraction that may cause vulvar deformation. Lymphatic vessels and the supercial
venous system are supercially located; therefore there is a
higher risk of lymphedema.
32.11 Pearls
• Thin skin 1cm ap is essential superiorly. The preserved
pedicle will be used as an open-book fashion down into
the buttocks, which will give a nice aesthetic fullness
superiorly. Avoid liposuction of the lower back as it will
be used as a pedicle.
• For the medial thigh markings and incision, do not invade
the femoral triangle; otherwise there is an increased risk
of involving the lymphatic system resulting in lymphedema and lymphoceles.
• Avoid excessive undermining as it may result in increased
risk of seromas or hematomas.
• Avoid excessive tension on the actual wound and possible
skin necrosis by anchoring with Ethibond sutures to the
Colles’ fascia medially, to the periosteum of the anterior
superior iliac spine laterally, and to the inguinal ligament
anteriorly.
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References
1. Hurwitz DJ, Agha-Mohammadi S, Ota K, Unadkat J. A clinical
review of total body lift surgery. Aesthet Surg J. 2008;28(3):294–303.
2. Kim SW, Han HH, Seo JW, Lee JH, Oh DY, Ahn ST, Rhie JW.Two
cases of lower body contouring with a spiral and vertical medial
thigh lift. Arch Plast Surg. 2012;39(1):67–70.
3. Sozer SO, Agullo FJ, Palladino H.Spiral Lift: Medial and lateral
thigh Lift with buttock Lift and augmentation. Aesthetic Plast Surg.
2008;32(1):120–5.
4. Pitanguy I.Evaluation of body contouring surgery today: a 30-year
perspective. Plast Reconstr Surg. 2000;105:1499–514.
5. Baroudi R.Body contour surgery. Clin Plast Surg. 1989;16:263–77.
6. Lewis JR Jr. Correction of ptosis of the thighs: the thigh lift. Plast
Reconstr Surg. 1966;37:494–8.
7. Di Pietro V, Gianfranco MC, Cervelli V, Gentile P, Medial thigh
contouring in massive weight loss: A liposuction-assisted medial
thigh lift. World J Plast Surg. 2019;8(2):171–80.
8. Pitanguy I.Surgical reduction of the abdomen, thigh, and buttocks.
Surg Clin North Am. 1971;51:479–89.
Liposuction Assisted Body Lift
Lipo-Abdominoplasty: Critical Elements
Excellent Safety Profile
Dissection with liposuction
Vascular supply preserved
Pre-excision skin measurement
Incredible SPEED
1000 ml/min aspiration
Large cannulas
Bloodless
Postop analgesia
Courtesy of Le Belle Vie Surgery Centers.
https://t.me/medicina_free
inaPatient withMassive Weight Loss
E.AntonioMangubat
33
33.1 Introduction [1, 2]
The lipo-bodylift is a signicant extension of our lipoabdominoplasty technique published in 2008 where we
described the essential elements to deliver exceptional results
safely. It is a single procedure and a combination of three
major procedures combined into a single setting: (1) posterior buttock lift, (2) lateral thigh lift, and (3) abdominoplasty.
This procedure is usually required in patients who have
undergone massive weight loss due to bariatric surgery or
through diet (Figs.33.1 and 33.2).
Fig. 33.1 The steps that are
critical elements in
performing a safe and
successful
lipo-abdominoplasty
We introduced the lipo-bodylift at the January 2008,
American Academy of Cosmetic Surgery Annual Meeting in
Orlando, Florida, and published our experience in 2011. We
extended the capabilities of original lipo-abdominoplasty
technique rst described by Avelar [3]. We described our
lipo-abdominoplasty technique in 2008 with signicant evolution from the original description in 2000. The full description of these procedures can be found in the cited manuscripts.
The purpose of the chapter is to describe each step to better
help you understand navigating my personal methods and
provide you with a path to prociency and safety offering
Abdominoplasty
Avelar concept
Supplementary Information The online version contains supplementary
material available at [https://doi.org/10.1007/978- 981- 19- 4997- 5_33].
E. A. Mangubat (*)
Director- La Belle Vie Cosmetic Surgery Center, Tukwila, Seattle,
WA, USA
e-mail: tony@mangubat.com
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022
M. Thomas, J. D’silva (eds.), Manual of Cosmetic Surgery and Medicine, https://doi.org/10.1007/978-981-19-4997-5_33
Liposuction w/ Fat Disruption
Tumescent fluid infusion
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Fig. 33.2 Body of a patient who has undergone massive weight loss
showing an abdominal pannus, loose inner and outer thigh skin, as well
as a ptotic buttock
these procedures. It is worth repeating that acquiring procedure prociency is a journey that requires more than this
book; it requires a mentor to guide hands-on learning and
proper execution. Please do not consider this publication as
sole source of education, but rather as the initial source to
begin understanding the operations.
I chose to share the videos describing my lipo-bodylift
technique from our Procedure Prociency Program (P3,
offered through World Academy of Cosmetic Surgery). It
offers a step by step video demonstration of the technique
and allows surgeons to evaluate their skills in preparation for
learning the procedure. The other surgeon scrubbed with me
is my surgical fellow, Dr. Geoffrey Stiller, who currently is in
private practice in Spokane, WA, USA.
The video contains chapter markers so you can immediately nd segments of interest. This is especially useful for a
detailed review. The chapters are supported by many (but all)
video-players (e.g., QuickTime, VLC Media Player, iTunes,
are among the many platforms that support the chapters).
33.2 Preoperative Markings
Posterior markings are undertaken rst because they are the
most variable and it is easiest to establish them rst before
joining them with the anterior marking. Identify the superior
iliac crest (SIC) and anterior iliac spine (AIS; Fig.33.3a–f).
E. A. Mangubat
These are important in estimating the nal location of
the incision and the amount of skin to be excised. Identify
the superior edge of the gluteus maximus and draw the
curved line outlining the upper border of the gluteus muscle beginning at the gluteal cleft that will be the desired
location of the posterior incision. With the patient bent forward, manually push the skin upward in the mid-gluteal
line to estimate how much skin can be elevated and how
much can be pushed inferiorly to the desired incision position and produce a plan of estimated skin excision posteriorly and laterally to the mid-axillary line (Figs. 33.4a–c
and 33.5a–e).
Anterior incisions are similar to the lipo-abdominoplasty
described in the previous chapter but there are signicant differences (Figs. 33.6 and 33.7). Note that this patient had
prior abdominal surgery (open gastric bypass) and assessment of all prior abdominal procedures are critical to a safe
operation. Vertical midline scars are not typically an issue
because they leave the rectus perforators intact. Transverse
incisions that cut across the rectus (e.g., Kocher cholecystectomy, splenectomy) are a major disruption of the vascular
supply for abdominoplasty. In fact, lipo-abdominoplasty is
perhaps the only safe procedure for patients with transverse
abdominal incision because the vascular supply is preserved.
Performing a traditional abdominoplasty would likely lead
to ap necrosis.
In this patient we begin by repairing the epigastric incision hernia developed as a result of her open gastric bypass.
The video of the hernia repair is beyond the scope of this
chapter and is included briey. The anterior superior incision’s most superior point is at the umbilicus and marks
the superior limit of the skin excision in most cases
(Fig.33.6a). Only in severe excess do we excise skin above
the umbilicus. A line is drawn horizontally joining the posterior superior excision line. The anterior inferior line
requires precision. Measure 6cm superiorly from the vulvar commissure and mark it in the midline (Fig.33.6b);
this ensures that enough pubic hair is retained to maintain
proper vulvar proportions and appearance. Then draw a
best estimate line beginning superior to the vulvar marking
from the midline to estimate the inferior limits of excision,
joining the line to the posterior inferior excision line
(Fig. 33.6d). Draw vertical meridian lines that mark the
re-approximation locations of the superior and inferior
aps once the skin is excised (Fig.33.7d). This completes
the estimated excision lines of our bodylift. The nal excision line will be determined with greater precision intraoperatively that will allow ne-tuning the position and
symmetry of the incision and maximizing the amount of
skin excision without excessive tension.
The areas of liposuction will include the entire abdomen,
waist, anks, and lateral thighs to enhance the lateral thigh
lift (Fig.33.7a–c).
ab
ef
33 Liposuction Assisted Body Lift inaPatient withMassive Weight Loss
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dc
507
Fig. 33.3 (a) Marking of the anterior superior iliac spine (left index
nger). (b, c) Moving the thigh skin superiorly to check for the extent
of skin removal possible. (d) Moving the ank skin inferiorly to assess
the extent of excision possible. (e) Marking of the superior and inferior
extent in the mid-axillary line. (f) Marking the outline of the innerwear
so that the scar is kept within its connes
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