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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_884_Библиотеки_им_академика_М_И_Перельмана
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10 Thigh and Buttock Lift
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Anatomical Overview (Fig. 10.1)
1. Anterior superior iliac spine
2. Pubic bone
3. Hip bone
4. Long saphenous vein
5. Iliotibial tract
6. Femoral vein
7. Femoral artery
8. M. tensor fascia lata
9. Saphenous opening
10. Inguinal superficial lymph nodes
11. Inguinal ligament
10 Thigh and Buttock Lift
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Anatomical Overview (Fig. 10.2)
1. Gluteal fascia
2. M. gluteus maximus
3. Gluteal fold
4. M. adductor magnus
5. M. biceps femoris
6. M. semimembranosus
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Instruments (Fig. 10.3–10.5)
1 Pump-syringe
2 Sterile centimeter rule
3 Sterile marking pen
4 Scalpel
5 Adson tweezers with plate
6 Surgical tweezers
7 Monopolar electrocoagulation
8 Insulated anatomical tweezers for hemostasis
9 Metzenbaum dissecting scissors
10 Backhaus clamps
11 Sharp four-pr o nged retractor
12 Large Langenbeck retractor
13 Large needle holder
14 Small needle holder
15 Curved forceps for hemostasis
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Fig. 10.3
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Fig. 10.4
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Fig. 10.5
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Duplicate Patient Information
The patient is first given comprehensive information about the objectives and risks of the procedure on the day of the first consultation. A
written record is kept of this.
One day before the surgical procedure, the patient is again given comprehensive information on two separate occasions: once by the surgeon
and once by the surgical resident. All the risks are set down in writing
at this time.
Although one tries to achieve symmetry before the intervention by precisely drawing the areas of skin that are to be removed, after the operation there may still be small differences between the sides. If this is very
unsightly, it is possible to com pensate by making a small extra intervention under local anesthesia without a need to admit the patient.
During the first few weeks after the operation , the scars frequently
move caudally.
If the patient is also given a buttock lift, he/she must be made aware
that the shape is primarily determined by the musculature and cannot
be substantially changed by the intervention.
Preliminary Examinations
䊏
Current preoperative routine laboratory tests, ECG, chest X-ray if the
patient is over 50.
䊏
Clinical examination of the patient.
Photographic Documentation
Overview image: Patient standing
Borders: Ventral: inguinal ligament
Dorsal: gluteal sulcus
Distal: poplit eal region
Medial: perineal fold
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Fig. 10.6
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Surgical Planning
The operation is performed under general anesthesia with endotracheal intuba tion. Before the intervention, the affected area is shaved.
The day before the operation, the surgeon carrying out the operation
discusses with the patient in detail what he/she wants in terms of
changes and how the surgeon can achieve this, and draws the incision
lines and resection boundaries precisely. The patient must be warned
about having unrealistic expectations and be given detailed information about postoperative measures in order to avoid scar formation as
far as possible. Intraoperative single-shot infection prophylaxis with
cefaclor 2 g, treatment in the hospital, Steri-Strip™ dressing, thrombosis (fractionated heparin 1 ampule i.m. preoperatively and 3 days postoperatively) and embolism prophylaxis, special girdle.
10 Thigh and Buttock Lift
If the loss of elasticity and slackness of the skin is confined to the upper
third of the thigh, the operation may be carried out in a half-moon
shaped skin/fat resection in this area (a). The scar is then located in the
groin and runs into the buttock crease. There is no scar on the inner
side of the thigh. This is the operation that is wanted most frequently
andisalsopresentedindetailinthevideo.
If the overstretched and therefore loose skin stretches over the whole
inner side of the thigh as far as the knee, then it is necessary to carry
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out additional vertical removal of skin/fat, depending on the extent of
theskinontheinnersideofthethigh(b). The scar is then located in
the groin and on the inner side of the thigh, depending on how far the
slackness of the skin extends, to just above the knee.
If there is also pronounced wrinkling of skin on the buttock, then a
skin/fatresectionmustbecarriedouthereaswell.Thescarthenwillbe
in the buttock crease and runs forwards into the inguinal region. The
resection lines are drawn before the operation with the patient in a
standing position. It must be kept in mind here that the incision line in
the area of the inguinal fold should be relatively high (two fingerwidths
in the cranial direction), since the scars always descend slightly over
time and then could be visible in the upper leg area.
The incision in the groin, which is at the height of the pubic hair
boundary laterally, generally runs above the inguinal fold to the thighperineal crease and finishes at the innermost part of the buttock crease,
whichislengthenedaccordinglyifthereisalsoabuttocklift.
If only a buttock lift is carried out, then only the resection in the area of
the buttocks is drawn according to the extent desired.
Positioning, Disinfection
䊏
For theoperation, the patient isplaced on the operatingtable in a
supine positionwith the knees as farapart as the shoulders and the
hips flexedat an angle of30°. If extensi v eremoval ofskin is required,
for exam p le,if there has been extremeweight loss, then it may be
necessary to use a urinary catheter both during and shortly after the
operation.
Tumescence (Fig. 10.7)
䊏
After shaving and careful disinfection of the whole operating area, the
tumescence solution (0.9% NaCl 500 ml, 1% prilocaine 250 mg = 25 ml,
epinephrine 0.5 mg, 8.4% NaHCO
5 mEq) is infiltrated into the skin
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area to be resected along the predrawn incision and dissection boundaries. For each side, depending on the extent of the flabby skin, one
needs between 250 and 500 ml of tumescence solution. The tumescence
solution is pumped in manually , until a taut elastic skin tension and the
typical blanching effect are noted.
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Fig. 10.7
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The resection area (a), as in all tightening operations, is only established when, following dissection (b), the exact superfluous skin has
been fixed using key sutures. Consequently, the same basic principle
always applies that before the skin flap is resected, one makes the
incision on the resection line that has been pulled over and only then
carries out the whole dissection.
The dissection boundary is dependent on how far the loose skin
extends.
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