Body Contouring Personal Evolution in Thighplasty Techniques for Patients Following Massive Weight Loss

Background: Lockwood described the importance of Colles’ fascia anchoring in medial thighplasty to reduce morbidity associated with the procedure. However, this maneuver may still have complications including traumatic dissection, prolonged edema, and potential wound healing ramifications form increased tension. Alternatively, we suggest orienting tension in medial thighplasty for massive weight loss (MWL) patients in the horizontal vector rather than a vertical direction, negating the need for Colles’ fascia anchoring. Objectives: To compare the morbidities, complications, and outcomes between Colles’ fascia suture fixation (CFSF) and horizontal vector fixation (HVF) in medial thighplasties in MWL patients. Methods: A retrospective chart review was conducted on an Institutional Review Board approved database of MWL patients who had medial thighplasty between October 2004 and March 2014. Patient demographics and surgical outcomes were reviewed between those MWL patients with CFSF and HVF. Results: Of 65 post-MWL patients, 26 (40.0%) patients were in the CFSF group, and 39 (60.0%) patients were in the HVF group. The 2 groups had statistically equivocal preoperative characteristics and comorbidities. Intraoperatively, the HVF group had increased use of barbed suture (92.3% vs 30.6%, P < 0.0001) and liposuction (71.8% vs 26.9%, P < 0.0001). Postoperatively, the HVF group had decreased incidence of infection (5.1% vs 23.0%, P = 0.051) and lymphocele/seroma (10.3% vs 34.6%, P = 0.0257). No statistical differences were observed for dehiscence, necrosis, or hematoma. Conclusions: HVF for medial thighplasty in MWL patients is a safe and effective procedure, with a lower complication profile than CFSF. Furthermore, the incorporation of barbed sutures and/or liposuction may help to achieve optimal results. Level of Evidence: 3 Editorial Decision date: February 17, 2017. Medial thighplasty has undergone significant changes over the course of the last few decades as a result of improved anatomic understanding and surgical technique.1-3 John R. Lewis published the first description of the traditional thigh lift over 50 years ago.1 With strictly a vertical lift and no soft tissue fixation, this approach had a variety of complications and did not gain wide acceptance. Patients suffered wound migration, widening of scars, lateral traction of the vulva, as well as damage to the lymphatics.1 Subsequently, Pitanguy described a dermal sling of the superior flap to secure the thigh lift to the periosteum or muscle fascia with variable skin laxity recurrence and skin Ms Xie is a Medical Student, Dr Stark is a Resident, and Dr Kenkel is a Professor and Chairman, Department of Plastic Surgery, UT Southwestern Medical Center, Dallas, TX. Dr Kenkel is also Associate Editor of Aesthetic Surgery Journal. Dr Small is the Director of Plastic Surgery, New York Bariatric Group, Roslyn Heights, NY. Mr Constantine is a Medical Student, College of Medicine, Texas A&M Health Science Center, Bryan, TX. Dr Farkas is a plastic surgeon in private practice in Paramus, NJ. Corresponding Author: Dr Jeffrey M. Kenkel, Department of Plastic Surgery, Professor and Chairman, UT Southwestern Medical Center, 1801 Inwood Road, Dallas, TX 75390, USA. E-mail: jeffrey.kenkel@utsouthwestern.edu 2 Aesthetic Surgery Journal flap necrosis.2 Alternatively, Lockwood suggested anchoring the distal dermal tissue of the medial thigh to the rigid Colles’ fascia for more stable fixation.4-5 This modification significantly decreased the morbidity associated with this procedure but persistent distal skin laxity remained an issue. Separately, recognizing the lipodystrophic components of the distal thigh, Le Louarn and Pascal advocated circumferential liposuction of the thigh and horizontal skin resection. This approach avoided disruption of the lymphatic and vascular networks to minimize edema but maintained some skin laxity.6 Although thighplasty has had significant modifications over the decades to decrease complications, this procedure remains a challenge, specifically for the massive weight loss (MWL) population. These patients have atrophic dermis and inelastic tissue prone to wound breakdown. Additionally, they have skin laxity throughout the thigh, not just the proximal thigh. In our hands, Lockwood’s vertical lift does not address the symptomatology and extent of skin laxity of this patient population. Because of the quality of the tissues, the vertical lift in massive weight loss patients has a higher risk of extensive traumatic dissection, prolonged edema, recurrent ptosis, and deformity of the labia.7-11 Over the years, the senior surgeon (J.M.K.) has evolved his own technique of addressing the skin laxity in the medial thigh in MWL patients. Instead of anchoring the horizontal incision to Colles’ fascia, the vertical vectors are oriented horizontally transferring tension from the fascia and surrounding structures to the medial aspect of the thigh, distributing tension along the length of the incision.12 This technique maintains fascial support along the entire thigh, and thus disperses the tension of closure more evenly. In addition, the technique avoids disrupting Colles’ fascia and decreases the risk of injuring the inguinal lymphatics, which may help avoid further morbidity. In this retrospective review, we study our evolution of techniques comparing the morbidities, complications, and outcomes.

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