Short vertical scar medial thigh lift

Published on 23/05/2015 by admin

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Chapter 36 Short vertical scar medial thigh lift

James D. Frame

Key Points

• Patient selection is helped by thorough discussion of the possible outcome, risks and benefits.

• Understanding the anatomy is vital.

• The excision and lipomobilization are described.

• Closure of the wound is described.

• The prevention and management of complications.

Introduction

Lax tissues in the upper thigh can be a concern to many people, particularly where there has been significant weight loss.¹ Rubbing inner thighs can cause sores and hygiene problems. The esthetic consequences of redundant skin can be a major psychological disability and destroy interpersonal relationships.

Understanding the anatomical changes is hugely important in deciding the best method of correction. A short medial scar inner thigh lift is indicated where there is a vertical descent of tissue immediately beneath the groin crease as it extends into the perineum and thence into the buttocks. The temptation is simply to excise an ellipse of skin and fat and hitch up the distal tissues onto the adductor tubercle and fascia using nonabsorbable sutures.

In my experience, there is an inevitable gravitational drag on tissue that is undergoing repair and if the holding suture fails and an excessive amount of “thigh lift” has been performed, then the labia majora is pulled down, causing an open introitus and a severe problem with underwear and hygiene.² Whilst there may be a good initial result, it becomes certain that an undesirable scar occurs below the bikini line. The presence of labial skin in the inner thigh is a major disaster.

In essence, it is important to remember that the thigh is an inverted cone, and gravity, plus loosening of tissues, loss of volume, and reduced elasticity is causing the problem. Merely pulling the cone upwards increases the vertical force downwards and thus gives the unsatisfactory result over time.

Adding a vertical limb to the inner thigh lift effectively narrows the diameter of the thigh and allows the tissues to “cling” into a better position. The scars are vertical (i.e., “antigravity”) and there is no drag downwards of the introitus.

Applied Anatomy

The mons pubis is held in an elevated position by fibrous suspensory attachments, but these generally loosen off with ageing and weight loss. The descent of the mons and tissues immediately above the inguinal ligament starts the cascade that results in soft tissue redundancy at a level usually at the apex of the femoral triangle. Simply lifting the mons, as occurs in some forms of abdominoplasty, can improve the appearance of the inner thigh. For a long-lasting effect though, a vertical narrowing of the base of the cone is required and this can be achieved in a number of ways (Fig. 36.1). In the tissues over the femoral triangle there are a significant number of important structures that should be maintained if possible.

FIG. 36.1 The short vertical scar medial thigh lift.

The long saphenous vein passes upwards from a point one hand’s breadth behind the medial border of the patella, to a point two fingers breadth below and two fingers breadth lateral to the pubic tubercle. The vein then turns 90° through the cribriform fascia, so joining the femoral vein at the saphenofemoral junction. The vein passes beneath the Scarpa’s fascia in its vertical ascent and is superficial to deep fascia (Fig. 36.2).

FIG. 36.2 The anatomy of the upper thigh – transverse section.

Superficial lymphatics in the thigh travel alongside the saphenous vein as trunks, before separating from the vein to enter the femoral ring and passing through a complex of lymph nodes, the most well known being Cloquet’s gland. Superficial lower leg lymph vessels follow the long saphenous vein medially and are larger and more numerous than the lower leg lateral lymphatics that pass deeply into the popliteal fossa. The medial thigh lymphatics ascend to the lower group of inguinal lymph nodes. Superficial lymphatics around the posterior thigh and buttocks pass medially and anteriorly to the front of the thigh and terminate in the upper group of inguinal nodes. By restricting the depth of resection, the undermining of tissues and the extent of the wound, there is less likelihood of lymphatic damage and subsequent collection of lymph with subsequent morbidity. The excisional plane, therefore, must be superficial to the long saphenous vein. Contrary to common procedure, it is important to preserve bulk to the thigh whilst performing the lift. For example, in the Brazilian abdominoplasty ³ there is preservation of all tissues above Scarpa’s fascia and there is no incidence of seroma or lymphocele. Similarly, in the groin, if lymphatics are preserved by using lipomobilization techniques, there is no dead space available to create a problem with fluid collections in the thigh (Fig. 36.3).

FIG. 36.3 Principle of mobilization.

If there is a minimal undermining of tissue there is no possibility of wound edge necrosis as was commonly seen after groin dissection without a 2 cm skin edge resection for malignancy.⁴ As the skin is approximated, the deeper tissues tighten under compression (Fig. 36.4). This will loosen eventually but still leave a better result than after a major debulking of the medial thigh tissues.

FIG. 36.4 Scarpa’s fascia and closing the post-excisional deep space to avoid seroma.

Preoperative Preparation

It is wise to consult patients on at least two occasions preoperatively, and to show photographs of average outcomes for the proposed surgery. If the scars do not discourage the enthusiasm of the patient, then a complete analysis of the benefits and risks must be discussed to ensure correct patient selection. Once surgery has been performed there is no turning back. It is important to have a stable weight pattern over a period of time. Weight loss after a skin tightening procedure creates problems. Weight gain improves the esthetics but subsequent weight loss results in further skin redundancy.

A preoperative nurse assessment, including measurements for support garments, and in-depth social and medical assessments are extremely helpful in predicting psychological outcome. Any medical issues are investigated and acted upon. Obviously, smoking, obesity, diabetes, hypertension and other medical problems need to be addressed pre-operatively.

Surgical Technique

Immediately prior to surgery the patient is marked in a standing position and the problem area is addressed (Figs 36.5 and 36.6). Scars are limited in vertical length within the medial aspect of the thigh then curve anteriorly to follow the groin crease for a few centimeters, before ascending vertically again into the mons pubis in cases where there is significant mons ptosis and redundancy, the skin markings are as in Fig. 36.1. The surface marking of the long saphenous vein is noted and the proposed skin excision is marked accordingly. In the short vertical scar inner thigh lift the skin paddle excision will extend to a thigh level just distal to the apex of the femoral triangle. Variances to the scar are created by several choices of design in the skin paddle excisions. In general, a horizontal groin crease scar will drop and widen unless there is a vertical element above it, or if the horizontal scar can be restricted. Not all vertical scar thigh lifts require an extension into the mons pubis.

FIG. 36.5 Patient standing – front view.

FIG. 36.6 Oblique inner thigh view – standing.

Skin Marking: Erect and Supine Positions

1. Mark from the adductor tuberosity to the medial condyle of the knee, vertically.

2. Surface mark the course of the long saphenous vein.

3. Using the palm of the hand, slide the soft tissue situated posterior to this line anteriorly and re-mark the vertical. The apex of the marked triangle should only extend 1.5 hand’s breadth below the adductor tuberosity.

4. Using the palm of the hand, slide the tissues anterior to this vertical line posteriorly with a slight upward elevation. Re-mark the vertical.

5. The patient lies supine. The breadth of the skin ellipse marked is equalized and made symmetrical to the opposite side.

6. An oblique line is drawn along the groin crease and the potential dog-ear is marked for excision. In cases of excessive skin redundancy a vertical line continues into and lateral to the pubic hairline of the mons. Further skin markings to plan the excision of redundant skin, the sliding advancement of the skin edges with no undermining, and comfortable skin closure are added.

The patient is supine on the operating table with full exposure of groins and thighs to knees; skin preparation is with Betadine^TM and spirit. A “frog-leg” position (Fig. 36.7) is adopted for the surgery but both thighs are kept potentially mobile to assess symmetry of scars. Thromboembolic stockings, warming blankets and Flotrons^TM are used. The original skin markings, from the erect position, may be modified in the GA supine frog leg position (Figs 36.8–36.10). Incisions are made in the skin to mid-dermal level, closely following the skin marking. Angles and junctions are marked to align the wound edges symmetrically. The dermis and underlying fat in the layers superficial to Scarpa’s fascia are elevated and put under traction, thence dissecting with electrocautery. Using traction and counter-traction forces, the dissection is easy and leaves the intact long saphenous vein and lymphatics. After reflecting the composite tissues, the wound is repaired by closing the space superficial to Scarpa’s fascia, using 2-0 and 4-0 Vicryl Plus^TM (Fig. 36.11). By catching (quilting) the Scarpa’s layer in the wound depths, all dead spaces are closed (Fig. 36.4). Tissues are therefore bulked, effectively causing a skin tightening maneuver. In the event of excessive tightness in closure, gentle lipomobilization techniques, using PAL technology, can help mobilize the tissues and aid in closure. Eventually all the premarked areas are excised. Except in very thin-skinned people, where staples may help, all wounds are carefully closed in layers, and dead spaces eradicated. To achieve and maintain a vertical lift, in addition to the circumferential tightening, it is important to “hitch stitch” the Scarpa’s fascia to the fascia immediately over the proximal adductor origin. The adductor tubercle must not be caught by the stitch and the adductor muscle must be unviolated. Exposure to the adductor fascia is via a small pocket direct dissection, breaking open the Scarpa’s fascia to allow a 2-0 Prolene^TM, or 2-0 Ethibond^TM, suture to grip and maintain the lift. An intradermal subcuticular 5-0 Vicryl Plus^TM closes the skin edges (Figs 36.12 and 36.13), and Dermabond^TM or Prineo^TM tape (Ethicon^TM), with or without Steri-strips^TM and loose dressings (i.e., not taped), are used to occlude the sutured wound. Local anesthetic may be used for postoperative pain relief but the experienced anesthetist is invaluable in providing the correct environment for patient safety and comfort postoperatively. Blood loss should be minimal and the excision is continued as the wound is closed. The emphasis is on closing and plicating the spaces above Scarpa’s fascia. No drains are required. Even at 3 months some scars can be very acceptable (Figs 36.14–36.16) and complications are rare.