Medial Thigh Surgery

The medial thigh aesthetic deformity presents a challenging problem to the surgeon performing body contouring. Skin laxity of the medial thigh is frequently the earliest sign of aging in the thighs and is one of the first signs of significant ptosis in the body.1 The skin in the medial thigh is quite thin and inelastic, resulting in early relaxation with age and poor retraction after liposuction. Liposuction of moderate to severe fat deposits in the medial thigh often leads to skin laxity, especially after the age of 30. Skin laxity requires excisional surgery to produce consistent improvement in medial thigh contours. Factors resulting in early gravitational descent of the medial thigh tissues include a heavy fat deposit supported by thin and weak fibrous structures—the superficial fascial system (SFS)2 and the skin—along with a loosening of the two anchors of the anteromedial thigh. First, the perineal-thigh crease descends inferiorly with age because of loosening of its fibrous attachments to the perineal SFS (Colles’ fascia).1 This results in the flat vulvar contour of older women along with medial thigh ptosis. The importance of a second anchor of the anteromedial thigh tissues has been noted since the development of the high lateral-tension abdominoplasty.3 Relaxation of the lower abdominal and inguinal tissues results in laxity of the anteromedial thighs. A strong lift of the lateral abdominalinguinal region will provide an indirect lift of the anteromedial thigh. In the second and third decades of life the medial thigh deformity consists primarily of a localized fat deposit that can be adequately managed in most cases by liposuction. Even some degree of skin laxity may be noted after liposuction. Patients should understand the anatomic limitations in this region and the possible need for a medial thigh lift in the future. This discussion should help prevent unrealistic expectations in medial thigh contouring. In the fourth decade of life actual or potential skin laxity of the medial thigh generally appears in most women and continues to progress thereafter. Medial thigh flaccidity may be isolated but more commonly is associated with laxity of the lower abdominal and inguinal regions. Patients with significant laxity isolated to the medial thigh, with or without a localized fat deposit, will require medial thigh lifting and, if necessary, liposuction. Ted Lockwood, MD Kansas City, KS Ted Lockwood, MD Kansas City, KS For patients with laxity of both the lower anterior trunk and upper anteromedial thighs, I now recommend the high lateral-tension abdominoplasty as the initial procedure in most cases. This provides a modest lift of the anteromedial thigh tissues, which is often enough to allow simultaneous liposuction of any upper medial thigh fat deposits. Patients should understand that medial thigh lifting may be required in the future for optimal medial thigh contour. Patients with moderate to severe medial thigh laxity will definitely require medial thigh lifting at the time of abdominoplasty or at a later stage. Performing an effective medial thigh lift in the presence of inguinal/pubic tissue laxity will result in an unaesthetic folding of these tissues over the anterior portion of the incision. This can be readily demonstrated to patients while they are standing in front of a full-length mirror. Patients can also visualize the improvement in anteromedial thigh contours with a strong lift of the lateral abdominal/inguinal regions. Whereas standard medial thigh lift techniques were often plagued with widened and migrating scars, vulvar distortion, and ineffective lifts, the Colles’ fascial anchoring technique reduced the risk of such complications, producing more consistent and long-lasting results.1 Since originally describing the anchoring technique 9 years ago, numerous technical refinements have been developed to enhance safety, predictability, and aesthetics. Colles’ fascia is a distinct, strong fascial layer that attaches to the periosteum of the ischiopubic rami of the bony pelvis and defines the perineal-thigh crease. It is continuous with Scarpa's fascia in the pubic area and has subcutaneous fascial extensions that help form the buttock fold posteriorly. All of these subcutaneous connective tissues are part of the SFS and all are used to anchor the medial thigh lift procedure. The medial thigh lift design has changed significantly since the original description because of a better understanding of thigh aesthetic deformities. Because most skin laxity in this area occurs at the juncture of the anterior and medial thighs, the standard surgical resectional pattern has rotated anteriorly, allowing the entire procedure to be performed in the supine position. In contrast to previous descriptions, the incision should not extend into the buttock fold posteriorly. For most aesthetic deformities the incision leaves the perineal-thigh crease at the pubic tubercle and courses vertically along the lateral margin of the mons pubis, staying within bikini lines. For milder cases, the medial thigh lift incision is more limited, extending anteriorly to just beyond the pubic tubercle. Preoperative markings are made in the standing position with the knees apart. The extent of medial thigh fat deposits is marked and an estimate of the amount of skin redundancy is determined. The actual skin resection has become more conservative over the years, averaging 5 to 7 cm of stretched skin at the anteromedial corner of the thigh. Anchoring the perineal-thigh crease into Colles’ fascia provides an additional 3 to 5 cm of lift. More conservative resection has decreased wound complications from overresection while providing consistent contour improvements. The patient is placed in the supine position with the hips flexed 30 degrees. Stockinettes with elastic wraps are placed to the knees, so that the thighs can be repositioned during surgery. The excision of redundant tissue and the subsequent repair are performed with the patient's knees shoulder-width apart (rather than in the semi-frogleg position) to avoid undercorrection. The thigh can be abducted for exposure as needed. Initial deep liposuction after infusion with dilute epinephrine in lactated Ringer's solution is followed by skin-only incision along the superior resection line. Posteriorly, the incision extends only to the far posterior perineal-thigh crease. Anteriorly, the incision leaves the perineal-thigh crease at the pubic tubercle (origin of adductor longus muscle) and courses vertically along the lateral aspect of the mons pubis to varying degrees, defining the new lateral limits of the pubic hair pattern (Figure 1). Standard medial thigh lift resectional pattern lifts maximally at the anteromedial juncture of the thigh, averaging 5 to 7 cm of stretched skin. The resection courses vertically along the lateral mons pubis to a variable degree, depending on the extent of the aesthetic deformity. The thigh flap is undermined 3 to 4 cm in most cases (cross-hatched area). Standard medial thigh lift resectional pattern lifts maximally at the anteromedial juncture of the thigh, averaging 5 to 7 cm of stretched skin. The resection courses vertically along the lateral mons pubis to a variable degree, depending on the extent of the aesthetic deformity. The thigh flap is undermined 3 to 4 cm in most cases (cross-hatched area). Undermining the thigh flap posterior to the pubic tubercle is performed superficial to the adductor muscle fascia. Undermining extends 3 to 4 cm beyond the planned line of resection. Anterior to the pubic tubercle, the undermining is more limited and is superficial (8 to 10 mm subdermally) over the soft tissue bundle that extends from the pubis to the femoral triangle. Preserving these external pudendal blood and lymphatic vessels reduces the risk of lymphatic complications (Figure 2). The soft tissue bundle between the femoral triangle lymphatic vessels and the mons pubis is preserved, sparing the external pudendal vessels to decrease lymphatic complications. Limited superficial undermining over this bundle is performed. The soft tissue bundle between the femoral triangle lymphatic vessels and the mons pubis is preserved, sparing the external pudendal vessels to decrease lymphatic complications. Limited superficial undermining over this bundle is performed. Colles’ fascial roll is now identified by blunt gauze finger dissection over the adductor muscle fascia, pushing superiorly until the ischiopubic ramus is palpated at the fingertip. Do not dissect beyond this level; attempts to overly define this vague superficial fascial roll may lead to disruption of the fibrous elements anchoring Colles’ fascia to the ischiopubic ramus. Retracting the skin and superficial fat of the vulva medially will expose Colles’ fascial roll at the deepest and most lateral aspect of the vulvar soft tissues. Permanent anchoring sutures from Colles’ fascia to the thigh flap SFS are now used for all patients (0-braided nylon, dipped in povidone iodine [Betadine®], taper needle) (Figure 3). Anterior to the pubic tubercle, Scarpa's fascia is used for the deep anchor after bluntly dissecting through the preserved soft tissue bundle. Posteriorly, the buttock fold SFS anchors the medial thigh flap to prevent scar descent out of bikini lines. To hold the thigh flap in position more securely, the braided nylon anchoring suture is now placed into the thigh SFS and dermis instead of in the dermis alone as initially reported.1 The actual incisional closure line is forced onto the relaxed vulvar tissues to decrease the risk of scar widening or migration. Permanent anchoring sutures of 0-braided nylon are placed into Colles’ fascia in the central half of the wound, forming a fascial roll. Scarpa's fascia and the buttock fold SFS anchor at each end. The anchoring suture is placed into the thigh flap SFS instead of the dermis alone as reported in the original description. Permanent anchoring sutures of 0-braided nylon are placed into Colles’ fascia in the central half of the wound, forming a fascial roll. Scarpa's fascia and the buttock fold SFS anchor at each end. The anchoring suture is placed into the thigh flap SFS instead of the dermis alone as reported in the original description. No drains are used. Light gauze dressings are applied and changed as needed. Dressings are removed in 1 to 2 days. The incisions are cleaned with peroxide or soap and water twice a day and then coated with a thin layer of silver sulfadiazine (Silvadene®) cream to reduce bacterial growth in the perineal-thigh crease. No compression garments are used. In conclusion, the surgical principles of the medial thigh lift have evolved to allow more accurate patient selection, individualized operative planning, and standardized surgical technique. “Surgical Strategies” focuses on refinements in aesthetic surgical techniques. Contributors are Aesthetic Society members or other recognized experts.