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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_511_Библиотеки_им_академика_М_И_Перельмана
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cutaneous
external
of med.
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lateral
femoral
nerve
inguinal
lig.
deep
circumfl.
iliac art.
femoral
nerve
deep
femoral
art.
Tensor
fasciae
latae
femoral
artery
Rectus
femoris
Sartorius
femoral nerve
iliac art.
external iliac vein
hypogastric art.
*
Peclineus
great saphenous vein ×
femoral
vein
Adductor
longus
Gracilis
Iliopsoas
femoral
nerve
lat. circumflex
femoral art.
(ascend br.)
Sartorius ×
deep femoral
art.
descen-
ding br.
of lat.
circumfl.
art.
obturator nerve
femoral artery
obturator
art. (ante-
rior br.)
Pectincus ×
obturator nerve
(anterior br.)
*
deep br. of med.
circumfl.fem.art.
superf.br.
circumfl.fem.art.
femoral vein
femoral artery
cutaneous br. of
obturator nerve
saphenous
nerve
Vastus
lateralis
Vastus medialis
branch of genu
superior art.
patellar rete
patellar lig.
Rectus femoris
muscular branch
adductor canal
Vastus medialis
branch of genu
superior artery
Gracilis
saphenous nerve
Sartorius ×
Fig. 27.2 Major arteries and veins of the thigh. (Anterior view of the thigh. An anatomical illustration from Sobotta’s Human Anatomy 1908)
414
Medial
genitofemoral nerve
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Fig. 27.3 Femoral triangle
(Craig Hacking, Radiopaedia.
org, 2019)
E. J. Nuveen
Pelvis
Inguinal ligament
Sartorius
Femoral branch of
Lateral
femoral artery
femoris artery
Femur
Femoral nerve
Common
femoral artery
Superficial
Profunda
Profunda
femoris vein
Femoral sheath
Femoral ring
Femoral canal
Common femoral
vein
Adductor longus
Femoral vein
Greal saphenous
vein
27.2 Examination
The physical examination should include photographs and
documentation of the skin quality, degree of soft tissue
excess and vertical and horizontal skin laxity. Use of the
Pittsburgh Scale [7] enables systematic reproducible classication into 0—ideal, 1—mild, 2—moderate, 3—severe. This
enables proper preoperative diagnosis and consideration of
the appropriate surgical techniques. Additional consideration
should be made for the evaluation of lymphedema and deep
venous thrombosis.
27.2.1 Types ofThigh Lift
Lifting and tightening of the thigh skin can be achieved
through various techniques which are based on the presence
of adiposity as well as the extent of skin laxity. Pittsburg
scale 1 and 2 are basically patients with mild or moderate fat
deposits along with good skin tone. Presence of skin folds
automatically takes them to Pittsburg scale 3. For those in the
rst and second level, only a lipocontouring with or without
the use of skin tightening technology such as VASER® or
Bodytite® will provide very good results and not require skin
excision (Fig.27.4).
1. Upper horizontal medial thigh lift—(Fig. 27.5a–c) is used
to reduce sagging in the upper part of the inner thigh. In
people who do have skin laxicity with folds of skin limited to the upper thigh will not need tightening of the
entire thigh rather will only need tightening of a small
portion of the upper third of the thigh. This procedure is
not indicated in patients who have a BMI of more than
30. This limited excision is almost always associated with
liposuction which extends beyond the boundaries of distal ap undermining.
2. The vertical medial thigh lift (Fig.27.6a–c)—It is usually
undertaken in patients who have excess skin is in a
horizontal vector, especially where excess skin is all over
the medial thigh. While an inner thigh lift focuses on the
upper area, this kind of thigh lift treats the middle and
lower sections of the thigh, too. The good result may not
even require xation of the dermal layer to the Colle’s
fascia, because the tension is achieved in a horizontal
vector during suturing and disperses throughout the
medial thigh.
ac
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Fig. 27.4 (a) Mild adiposity
of the thighs with good skin
tone and minimal skin laxity.
(b) Postmedial and lateral
thigh lipoaspiration which has
allowed skin shrinkage as
well as does not need any skin
excision
a
b
b
Fig. 27.5 (a) Moderate medial and lateral thigh adiposity with upper medial skin laxity which is primarily in the vertical axis. (b) Abdominoplasty
with medial thigh horizontal lift and lipoaspiration (c) Illustration showing the extent of skin excision and undermining
In a medial vertical thigh lift, the rst consideration is
to preserve the femoral triangle. If the lymphatic system
in the femoral triangle is injured, prolonged edema and
lymphatic collection may occur. Therefore, the femoral
triangle should be demarcated in the process of preoperative design in order that it may not be dissected mistakenly. In this case, more signicant and noticeable scarring
is left behind. While the scars from an upper medial thigh
lift will be hidden, these scars are more obvious. These
scars are only visible when the thighs are opened and the
inner thighs are exposed and are usually seen as a
T-shaped scar.
3. The spiral thigh lift (Fig.27.7a–g) is effective when people present with excess skin and ptosis on the lateral hip
(trochanteric area) and buttocks along with loose skin
along the medial thigh. This is the only procedure that
targets the entire thigh. It treats areas at the front, back,
and sides, as well as up and down the length of the thigh.
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a
Fig. 27.6 (a) Severe weight loss causing skin excess in the vertical and horizontal direction. (b) Abdominoplasty along with vertical medial thigh
lift. (c) Illustration showing the extent of dissection and skin removal
a
b
b
c
Fig. 27.7 (a, b) Generalized skin laxity seen circumferentially in the
thigh and extending onto the inner aspect of the knee. There is associated buttock ptosis and deation. (c, d) A Spiral lift is marked extending
from the superior aspect of the buttocks which will help with the but-
tock lift, onto the upper extent of the lateral thigh for a lateral thigh lift,
into the groin and medial thigh to achieve a slimmer lifted thigh. (e–g)
Immediate postoperative result (1week) of lipoaspiration, spiral thigh
lift with vertical skin excision to below the knee
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c
e
d
f
Fig. 27.7 (continued)
As a result, it’s sometimes referred to as a “total thigh
lift” or a “360 degree lift.” This procedure can be utilized
to augment the buttocks at the same time. Although
extensive scars are left behind, most of them are hidden.
In the case of the spiral thigh lift, the inferior skin ap
is xed to nonmovable tissues such as the Colles’ fascia,
g
the inguinal ligament and the periosteum of the anterior
superior iliac spine, which makes it possible to lift the
buttocks, the lateral hip, and the medial thigh without
worrying for further ptosis. This procedure gives a dramatic shape to the thigh making them smaller, smoother,
and much tighter.
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27.3 Techniques Currently Considered
forThigh Reshaping
1. Suction-assisted lipectomy without skin excision.
2. Elliptical horizontal skin excision.
3. Vertical skin excision.
4. Combined horizontal and vertical skin excision, with or
without liposuction.
5. Circumferential lower body lift (spiral lift).
27.4 Preoperative Markings
Marking is always done when the patient is in the standing
relaxed position and places his/her weight on both legs. Use
of a permanent surgical marker is made to identify and mark
the groin crease starting from the anterior superior iliac spine
along the inguinal crease medially to move posteriorly to the
lateral most extent of the infragluteal crease. In the case of
excess adiposity alone, the inferior, anterior, and posterior
extent of the fat bulges should be delineated. In the case of
skin excess, the skin should be manually moved superiorly,
and a parallel line drawn at the point of redundancy using a
pinch test. This line should be 4–6.0cm inferior to the groin
crease. If this skin is in excess of 6.0cm vertically, the consideration should be made for combining a vertical with a
horizontal excision. The extent of vertical incision can be
minimized by combining lipoaspiration with the horizontal
skin excision of up to 6.0cm. When marking the skin excision for a vertical skin wedge removal, the anterior thigh skin
should be moved medially in such a way that the suture line
is positioned on the inner aspect of the thigh. As with all
areas of surgery, particular care and technique must be used
to minimize skin breakdown at this juncture of the vertical
and horizontal incision. Widespread regional lipoaspiration
below the supercial fascial system also allows mobility of
the segments and more tension free suspension at Colles’
fascia.
27.5 Operative Technique (Horizontal
andVertical Thigh Lift)
1. Anesthesia—In collaboration with our anesthesia col-
leagues, we recommend intubation for a secure airway
and general anesthesia as change of position is commonly required, prone to supine repositioning. CDC
recommended course of presurgical antibiotics and steroids are given (Ancef 1.0 g and Decadron 8.0 mg).
Foam rolls are placed beneath the knees and the heels
are padded. The arms are abducted and placed on padded arm boards. Warm air blankets are placed over the
lower extremities. Usually no urinary catheters are used
in these surgeries. The duration of this procedure is
scheduled for one hour. The patient is surgically
prepped and draped in the standing position and laid on
sterile towels and drapes. If the procedure is to remain
above the knee, sequential compression garments and
TED hose are applied and veried functioning prior to
induction of anesthesia.
2. Inltration—The subcutaneous skin is injected along
lines of planned incision with high concentration of local
anesthesia. Supercial and deep layers of adipose tissue
are inltrated with tumescent solution (1:1,000,000
Epinephrine, 250 mg lidocaine, 1.0 L Normal Saline)
maintaining limits of 35mg/kg at all times.
3. Lipocontouring—Judicious but complete lipoaspiration
is then performed to a desired cosmetic goal checking for
uniform thickness of the skin ap. Conscientious removal
of skin is then perform as preoperatively planned. Special
care must be taken not to be overly aggressive as skin
mobility is usually greater after liposuction than the
preoperative examination and adjustment of the sound
preoperative markings may be a fool’s errand.
4. Surgical skin excision—(Fig. 27.8a–e) The thigh is kept
abducted and with the surgeon sitting in between the
thighs, a full-thickness incision using a #10 bard parker
blade is made along the inguinal crease and carried to the
level of the deep fascia overlying the muscle.
Electrocautery is used throughout for hemostasis.
Penetrating towel clamps are used for tissue repositioning
in order to reduce tension on skin during suture approximation. The previously marked excess skin is excised
horizontally as well as vertically and hemostasis achieved.
Care should be taken that the tissue dissection in the femoral triangle should be very supercial so as not to injure
the lymphatics and vessels. Similarly, during the vertical
skin excision pattern care should be taken of the saphenous vein as it traverses along the medial aspect of the
lower third of thigh. We use 0-0 Nurilon suture for suspending and deep reapproximation of supercial fascia to
Colles’ fascia. The second layer of closure is deep dermal
and we use 2-0 PDS suture for this followed by 4-0
Monocryl subcuticular. Consideration for external retention sutures is often made after the above closer, especially at the T of vertical and horizontal closure. Skin
adhesive glue is applied in order to seal the incision line
and allow for a more ideal scar outcome.
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a
c
b
d
e
Fig. 27.8 (a) Extent of skin excision marked for a combination of ver-
tical and horizontal axis skin tightening of the thigh. This has been
assessed using a pinch technique in the standing position. (b) The incision has been deepened and the marked tissue is excised taking care of
the hemostasis. (c) The inferior ap is sutured to the Colle’s fascia and/
or the periosteum of the ischiopubic rami. The point of suspension is
In utilizing a horizontal only excision, it is common to
transition the patient to the prone position for lipoaspiration
and skin resection from the infragluteal and upper-inner
thigh region.
In some patients specially who have undergone massive
weight loss secondary to Bariatric surgery or through calorie
marked as a yellow arrow and the pubic tubercle as a green star. (d) The
two edges of the incision are now sutured in such a way so as to prevent
dog-ears. Please note that the inferior edge is not suspended on the
superior skin ap as a result the introitus remains intact. (e) Complete
closure of the incision line has been achieved
restricted diet, the skin laxity may not be limited to just the
inner thigh. A circumferential or total thigh lift will be
required which will lift the medial thigh, lateral thigh as well
as the buttocks (Fig. 27.9a–f). This procedure has been
described as a “Spiral Lift” in another chapter of this book.
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a
c
b
d
e
Fig. 27.9 (a, b) Lady who has undergone massive weight loss leading
to circumferential laxity of her thigh skin. She also had ptotic buttocks
as well as loose abdomen skin. (c, d) The inguinal incision for the anterior thigh lift has been made and the excess thigh skin has been removed.
f
The opposite side is being shown to be sutured. (e, f) The vertical component of the medial thigh lift is being initiated and the aps are suspended to the “Colle’s fascia”
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27.6 Postoperative Care
Post operatively, all patients are placed in compressive garments or ace wraps and 24-h follow-up evaluations are performed on all patients. Patients are encouraged to elevate
their legs in order to minimize edema for the rst three
weeks. Secondary stage garments are also provided as is a
comprehensive scar management protocol for every patient.
27.7 Complications
Complications occur frequently in thighplasty. A recent
review of current published research reveals a range (23–
74%) [4, 6, 8] Some authors have recommended staged performance of the medial thigh lift in order to reduce
complications. Some have also recommended liposuctionassisted skin resection without deep plication as a method to
reduce tension, dehiscence, and scar displacement [6].
Others have advocated to go for a total body lift in one stage,
suggesting an advantage associated with circumferential vertical elevation being to minimize the thigh lift tension [8].
When appropriate, we suggest the more aggressive one-stage
vertical elevation using a circumferential BodyLift (Buttocks
lift, complete abdominoplasty, and circumferential spiral
thigh lift) to minimize the need for vertical medial thigh incision and to reduce incisional tension associated with the isolated medial thigh lift.
Expertise in wound management is imperative prior to
undertaking these procedures. Dehiscence is common and
may require negative pressure wound therapy options for
most rapid secondary closure. Adjunctive methods to promote expedited wound closure include traditional sharp and
chemical debridement, use of sound balancing matrices such
as Promogran® or Prisma®, Silver ion gel and traditional
moist to dry dressing for weeks or months. Scar revision may
also be a necessity in 6–12months as well. Optimizing the
patient’s body mass index, exposure to smoking, nutritional
status, and proper wound care management requires a welleducated participant during this time of recovery.
Lipoedema is a very common nding in lower extremity
massive weight loss patients. Although treatment with
lipoaspiration with or without laser, ultrasonic or Renuvion
are viable options, none completely remove the disorder [9].
These patients routinely require repeated treatments for ideal
results and this is best discussed in painstaking detail with
the patient during the consent process (Figs. 27.10 and
27.11).
Fig. 27.10 (a, b)
Preoperative photograph of a
lady who is interested in a
thigh lift. She has undergone
an abdominoplasty before. (c,
d) She underwent a vertical as
well as a horizontal
component thigh lift.
Photographs taken 3weeks
after the surgery
a
b
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Fig. 27.10 (continued)
Fig. 27.11 (a, b)
Preoperative photographs of a
lady who has massive weight
loss with circumferential
thigh laxity. (c, d)
Postoperative anterior and
posterior view after spiral
thigh and buttocks lift with
medial thigh lift
c
a
d
b
c
d
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