Boris M. Ackerman, MD

The total thigh lift is ideal for the well-motivated and educated patient

The field of body contouring surgery has been evolving for many years. In the past 2 decades, the understanding and study of human anatomy as it applies to surgical intervention has evolved significantly. This understanding has advanced the evolution of new and pioneering techniques in body contouring. Some of the old ideas and techniques that were used were abandoned because of the less than satisfactory results that have been revisited with modifications based on new anatomical studies. The total thigh lift is growing in popularity because of this fusion of traditional techniques with more advanced and innovative thinking.

The field of bariatric medicine has become more popular and the number of patients requesting various body contouring procedures has increased. The procedures have evolved and expanded in their indications. Significant contributions to this field have been offered by a number of surgeons, most notably Ted Lockwood, MD. The total thigh lift procedure evolved from the field of body contouring performed on significant weight loss patients, but now the procedure is being offered to patients that do not fit the typical post-bariatric-surgery patient profile. The impetus for this procedure started a few years ago when I saw a patient who had had multiple liposuction procedures over the course of a few years. The patient's weight had always been within the normal range, so the procedures were apparently being done to simply correct some of the contours of her thighs as well as the iatrogenic postliposuction problems. The patient showed me what she wanted by lifting her leg and using her hands to point out the problem areas. By combining the lower body-lift procedure with the medical thigh lift, I was able to surgically re-create what the patient demonstrated with her hands, which was to lift the entire circumference of the thigh.

The typical candidate for the total thigh lift has evolved in my practice from the significant weight loss patient to the dissatisfied postliposuction patient, and now to a more "normal" looking patient in his or her 30s or 40s that has some settling of the thighs and buttocks. This is typically a result of a few pregnancies or premature tissue aging and settling. These patients have a great motivation to regain the youthful thigh and buttocks contour that they enjoyed in their earlier years. They typically are not overweight, but are quite motivated, exercise regularly, and lead very healthy lifestyles. The patients are seen in consultations on at least two occasions prior to the surgery. The final surgical scar location is marked out on their body and thighs. Various bikini-line options are discussed in terms of being able to hide the surgical scar in a bathing suit. The patients understand that they are choosing to trade somewhat droopy thighs and buttocks without a scar for a more lifted and youthful body with a rather large scar.

The total thigh-lift procedure is a combination of two well-described procedures, which include the lower body lift and the medial thigh lift. In the past, similar procedures left more visible scaring in the buttocks crease, and were therefore less desirable for wearing bathing suits. With the total thigh lift, the preoperative surgical markings are paramount. The patient wears a bikini bottom of her choice and is told that the final scar most likely will be hidden within the bikini bottom, although it is not a guarantee. The perimeter of the bathing suit area is outlined and the garment is removed. Next, the location of the final surgical incision is marked out, assuring symmetry. On the posterior aspect, the final incision forms an open "V" extending laterally then curving gently along the inguinal crease into the medial thigh crease. The superior incision is estimated at approximately 2 to 3 inches above the final closure line, depending on the superior tissue's mobility and redundancy. The inferior incision line is significantly lower from the final closure line, and is estimated by superiorly displacing the entire buttocks and lateral thigh complex and estimating the redundancy. Only the superior incision line is "set in stone." The amount of excised tissue is determined on the operating table, and the inferior line of excision is marked out only as a guide. As part of the total thigh lift, the patient might need either some adjunct liposuction of the inner or outer thigh or, on occasion, some fat grafting to the buttocks for some volume augmentation. Appropriate topographical markings are done with the patient in a standing position at the same time as the excision markings.

I perform the procedure on an outpatient basis, with most of the patients being discharged to a recovery retreat. The procedure is performed under general anesthesia. All the surgical sites are infiltrated with an adequate amount of tumescent solution. I prefer to perform this procedure in three positions, with each one requiring a new prep and drape. The procedure starts with the patient in a supine position. At this time, if needed, the medial thigh liposuction is performed. Next, the incision is made in the medial thigh crease extending posteriorly into the perineal crease, stopping short of the visible portion.

Total thigh lift of the buttocks crease. The flap is raised just above the adductor muscle fascia inferiorly beyond the proposed line of excision. Some discontinuous undermining with a blunt instrument, such as a liposuction cannula, can be helpful, especially if no concomitant liposuction is being done. The amount of redundant tissue is estimated and amputated. Historically, the closure of this wound was fraught with complications such as wound dehiscence and perineal tissue distortion. These complications can be avoided with judicious tissue excision and attention to proper closure.

It is important to identify the deeper layer of superficial fascia in the perineum and the superficial fascia in the thigh flap. An Alice clamp is used to grasp Colles' fascia in the perineum, approximately three to four sutures are preplaced evenly along the perineal fascia and the entire thigh flap is suspended on these sutures, thereby correcting the thigh laxity. The wound is closed in layers with polyglactic acid sutures and with absorbable monofila-ment sutures in subcuticular fashion. The anterior portion of the incision is left open for the time being.

Next, the patient is placed in a lateral decubitus position with the thigh abducted past the neutral position at approximately 20° to 30°. The patient is secured with the aid of beanbag pillows and foam padding. At this time, again, any needed liposuction of lipografting is performed. Incision is continued along the superior markings. The thigh flap is raised just above the muscle fascia. Again, some discontinuous undermining is performed. Dedicated marking clamps are used to estimate the redundancy of the flap. The closure relies on some preplaced sutures that are evenly distributed within the superficial fascia. These sutures support the entire thigh/buttocks complex. The wound is closed in layers as in the medial thigh lift. I do not use any drains. The patient is placed into a dedicated postliposuction garment.

Postoperative Recovery

Postoperative recovery is quite remarkable. Typically there is only mild to moderate pain associated with this type of procedure. The patients are ambulated the next day and are advised to avoid extreme amounts of flexion and extension of their hip joints. They can sit on the toilet the next day and bathe in a shower in 48 hours. The garment is worn for approximately 3 weeks. Most patients return to work within 10 to 14 days. Some physical exercise is permitted after 2 weeks, and no restrictions on any physical activities are needed after 6 weeks. There is usually only mild to moderate swelling noted, and only for 2 to 3 weeks. I routinely employ silicone strips on the incisions in all of the patients, which starts approximately 2 to 3 weeks after surgery.

Conclusion

In summary, the total thigh lift is a worthwhile procedure for a well-motivated and educated patient. The results are evident immediately after surgery and seem to be quite long lasting. The complication rate has been extremely low; so far, there have been no incidents of infections or keloids, and all incisions have remained flat with only occasional mild widening. On occasion there is some dehiscence, never more than a 1/2 inch, seen in the sacral region, which heals rather rapidly. The overall satisfaction rate of this procedure is quite high both for the patient and the surgeon.

Boris M. Ackerman, MD, is a board-certified plastic surgeon, who graduated from MIT and Dartmouth Medical School. He is currently in private practice in Newport Beach, Calif. His area of expertise is deep structure facial rejuvenation surgery and major body countouring surgery, and he was one of the first plastic surgeons in the United States to use lasers. He can be reached via his Web site at www.doctorackerman.com