Fat distribution under the human skin is uneven (Fig. 34.1). There is an almost uniform superficial layer, where lobules are organized in a “vertical” manner, perpendicular to the skin surface. In these areas, the fascia superficialis is fused with the deep, premuscular fascia. In some areas, there is another layer, deep to the fascia superficialis, where the fat is organized in a “horizontal”, lamellar fashion, parallel to the skin surface. Liposuction allows for the elimination of most of the fat in the different layers, achieving not only volume reduction but also skin release. Skin retraction is best in those areas of deep fat, as retraction of the superficial, “vertical” fat layer often leads to surface irregularities.

FIG. 34.1 Fat layers, fascia superficialis and lymphatic vessels.

Lymphatic Distribution

The lymphatic vessels of the skin (Fig. 34.1), after collecting from the surface, join into vessels situated just deep to the fascia superficialis. Therefore, in areas where there is deep fat, it is of the utmost importance that dissection stays superficial, in order to avoid any impairment of the lymphatic drainage. In some anatomical areas this boundary is not particularly obvious, for example in the outer thigh. Nevertheless, due to the frequently described lymphatic complications,⁷ dissection should stay superficial.

Skin Particularities

The skin of the upper inner thigh is very thin. Its blood supply will not tolerate excessive tension, which will subsequently lead to wound dehiscence or necrosis. Deep anchorage will prevent not only excessive tension on the suture line, but also secondary deformity, such as scar migration or vulvar dehiscence.⁸

Surgical Technique

Marking of the Incisions (Fig. 34.2A, B)

Markings are performed with the patient standing in order to avoid any excessive tension. The area of lipodystrophy is identified and marked, and, if necessary, gentle pinching of the skin allows for appreciation of the maximum possible tension between the inner thigh and the pubic tubercle. The pull is vertical at this medial aspect, and at a 45° angle for the anterior aspect, realizing a rotation towards the pubis.

FIG. 34.2 (A, B) Preoperative markings.

Preparation and Positioning

The operation can be performed under general, spinal or local anesthesia with IV sedation, according to the patient’s needs and requirements. After anesthesia, the patient is placed supine on the operating table, legs are positioned on a gynecologic rest, abducted at 45 ° in the frog leg position. Pressure socks or compression devices are mandatory. Sterile stockinettes or drapes cover the lower leg to allow for positioning the thighs as requested for liposuction and skin resection.

The incision line should avoid the inguinal crease, where there is a major risk of impairment of the lymphatics.^2,⁹^–¹¹ Our incision is vertical within the pubis, starting from below the hairline, medial to the groin crease, 3 to 4 cm away from the midline on either side. Another reason for a pubic positioning is that superficial dissection in the groin region to preserve lymphatic vessels will result in a very thin skin flap, which will not tolerate any tension. The incision is then extended vertically toward the pubic tubercle along the labia majora. If the amount of skin resection is major, it seems preferable, as advocated by Le Louarn,¹¹ to extend the marking of the incision to the inner part of the buttock toward the ischial tuberosity and the anal margin. This is a superior incision line as opposed to the gluteal fold, as this area is very prone to hypertrophic and painful scarring and is technically difficult to correct.

Skin Release

Extensive liposuction allows for a very thin skin flap (Fig. 34.3); the fascia superficialis is kept deep to undermining, preserving the lymphatic vessels’ integrity; skin elevation is limited to the planned resection.

FIG. 34.3 Extensive liposuction allows for a very thin skin flap, fascia superficialis kept deep to undermining, preserving integrity of lymphatic vessels, skin elevation limited to planned resection.

Skin resection does not go beyond the elevated flap (Fig. 34.4); the risk of skin necrosis is reduced to a minimum.

FIG. 34.4 Skin resection does not go beyond elevated flap, risk of skin necrosis reduced to a minimum.

After infiltration with the following solution (1 liter saline, 40 ml of 1% lidocaine and 1 mg of epinephrine (adrenaline)), extensive liposuction will allow for volume reduction and associated skin tension release. This will effectively free the superficial dermal layers with preservation of deep fibrous and vascular attachments, as originally analysed in 1992 by Le Louarn ⁵ and subsequently by Illouz.¹² Surgical undermining becomes therefore unnecessary, apart from the zones to be removed; all fat there should be removed. The skin incision is superficial to the subcutaneous tissue. The margin is hooked and lifted, to undermine as superficial to the fascia superficialis as possible, as it is fairly easy to identify after removal of all fat. The excised skin is therefore extremely thin.

Skin Resection

Skin resection limits are not set. It is a “mark as you go” procedure. First, the previously identified maximum tension point is controlled and eventually adjusted, with an upward vertical traction. Undermining could eventually be extended for a few millimeters beyond the defatted flap, but in all cases it should be kept strictly superficial.

This point is anchored to Colles’s fascia with 2-0 Vicryl sutures. Two or three other anchoring points are then defined on either side, the superior flap being rotated medially towards the pubis with deep stitches grasping the deep fascia and the muscle insertion at the ischial tuberosity. The periosteum should be avoided, as this can be painful. Skin resection is performed step by step, only on the excess skin thus defined. Closure is achieved in two layers with 3-0 Vicryl sutures. No drainage is required, as there is no dead space. Figure 34.5 shows the closure of the incisions on the first side. Note, that despite the thigh position and vertical component, there is no deformation of the genital fold line. Note tension in the subgluteal fold; the scar will remain invisible posteriorly.

FIG. 34.5 Closure of the incisions on the first side.

Note, despite position and vertical component, no deformation of genital fold line. Note tension in the subgluteal fold; scar will remain invisible posteriorly.

Optimizing Outcomes

Simple points to note are the following:

• Any surgical approach should stay superficial to the fascia superficialis, or premuscular fascia, whether perpendicular to the surface (skin incisions) or parallel to it (undermining), to preserve all lymphatic vessels.

• Undermining should be minimal in its extension so as to avoid impairment of blood supply.

• Tissue release should be maximal to allow for easy resection of excess skin and fat, and closure without tension.

• Deep anchorage with fixation to strong structures is mandatory.

• Incisions should be positioned in areas hidden and not prone to hypertrophic scarring.

Postoperative Care

Suture lines are covered with iodoform gauze and maintained with surgical glue (collodion). Protective gauzes are positioned before applying a pressure garment. Patients are allowed to walk the following morning, and advised to refrain from sitting with thighs abducted. Pressure garments are worn for at least 3 to 4 weeks. Daily cleaning after each stool or urine passing is done in a shower to avoid extension and abduction of the thighs.

Complications and Their Management

Lymphatic Drainage and Lymphocele

Some authors have advocated the risks of seroma or lymphocele formation associated with liposuction. In 1990 Ersek et al ⁷ reported that liposuction associated with undermining in nine cases of abdominolipectomies led to seroma and pseudo bursa formation. This results in uneven skin retraction and unsightly aspect and he advocates waiting for 6 weeks after suction for resection. In 1995, Candiani et al⁹ operated on 18 patients for medial thigh lift with a full thickness undermining including the premuscular fascia, “cautious lipoaspiration when it was really necessary” and deep fasciofascial anchoring to Colles’s fascia. They observed three bilateral seromas requiring repeat aspirations. In their 2008 report on seroma development, Shermak et al¹³ found only 4% of seroma formation in thigh lifts. However, in 2009 Bruschi¹⁴ performed 11 liposuctions on 35 cases of thighplasty, and did not report any case of a lymphatic problem. In 25 cases, over a 2-year period, Le Louarn and Pascal in 2004,¹¹ while preserving fascia superficialis, had no cases of lymphatic edema or seroma formation. In 2006, Espinosa-de-los-Monteros et al¹⁵ noted only two seromas in 60 cases of abdominoplasty with extensive liposuction, but preserving Scarpa’s fascia of the lower abdomen. Since introducing extensive liposuction, superficial dissection and no undermining, we have had no cases of lymphorrhea or lymphocele.

Skin Necrosis

This been reported mainly in cases with large undermining in an attempt to fixate the skin to solid grounds.² None have been reported with the liposuction/no undermining/deep fixation techniques.

Acute Anemia

Bruschi et al ¹⁴ reported that this occurred in 43% of their cases. None have been reported by other authors or in our cases.

Clinical Cases

Case 1: Preoperative (Fig. 34.6A, B) and postoperative views (Fig. 34.6C, D) of the same patient, after bodylift and thighplasty with extensive circumferential liposuction of the thighs. A fair result.

Case 2: Preoperative (Fig. 34.7A–C) and postoperative views (Fig. 34.7D–F): in this early result, correction is satisfactory, but scar placement, due to extent of skin resection, could not allow for proper fixation on the deep planes, therefore allowing for downward scar migration. Nevertheless, no vulvar dehiscence occurred.

Case 3: Preoperative (Fig. 34.8A) and postoperative views (Fig. 34.8B): a very difficult condition. No indication for a vertical thigh approach, as the excess skin is limited to the upper third of the thigh. Extensive circumferential thigh liposuction should probably have been performed to allow for a better rotation of the anterior skin towards the pubis. No vulvar dehiscence despite the extreme vertical skin resection.

Case 4: Fig. 34.9A, B: a good result with the described technique, although today the vertical pubic scar would be slightly more medially placed.