INTRODUCTION
Inner and Outer Thighs
Plastic surgeons consider the inner and outer thighs separately. The outer thighs may be lifted with the buttocks in an operation called an “outer thigh lift.” This may be done at the same time as an abdominoplasty. The combined procedure (outer thigh/buttock lift and abdominoplasty) is called a “lower body lift.” This operation is becoming more popular as more patients are losing large amounts of weight after bariatric surgery.
The inner thighs have been a source of frustration for patients and plastic surgeons. The traditional technique makes use of an incision that parallels the groin crease, on the skin of the upper inner thigh. This incision placement would seem to make sense, hiding it in the groin crease. However, problems include limited effectiveness for the lower inner thigh (it only tightens the skin of the upper half of the inner thigh) and possible tension affecting the perineum, which may pull across the groin, even pulling on the vagina.
A different approach, similar to the arm lift, is more effective – a longitudinal excision of excess skin from the inner thighs. This method leaves a scar down the inseam of the thigh. It is very effective in removing extra unwanted skin which is distributed around the circumference of the thigh. For patients with very loose skin, particularly after massive weight loss, the trade-off is favorable.
The outer thigh lift makes use of an incision that courses around the hip and back, almost 360 degrees, lifting the buttocks and outer thighs.
Although this surgery is often done in the setting of massive weight loss, it is also helpful in patients (usually women) who have lost skin tone (genetic factors, aging, and gravity) and find that no amount of exercise can help tighten their droopy buttocks or skin in the saddlebag areas.
PHOTOS OF PATIENTS WITH A LOWER BODY LIFT
SS 52.
Procedure: Lower body lift, medial thigh lift, liposuction of the abdomen, flanks,
outer thighs, and knees, and buttock fat transfer.
Before, 4 months.
KL 56.
Procedure: Lower body lift, liposuction of abdomen and flanks, and secondary medial thigh lifts.
Before, 4 months.
PHOTOS OF PATIENTS WITH AN INNER THIGH LIFT
AJ 62.
Procedure: Inner thigh lifts and liposuction of inner thighs and knees. previous abdominoplasty and liposuction.
Before, 3 months.
Inner Thigh Lift (also called Medial Thigh Lift)
The excess skin of the inner thigh is marked before surgery. The marking is wider at the top and tapers at the bottom. The upper end is marked so it will join the groin crease as an inverted J. This avoids a “T” junction, which can be associated with healing problems.
This 50-year-old woman who did not have a history of massive weight loss presented with laxity of the skin of the thighs. The markings show the pattern used to remove the extra skin. She is shown 16 days after surgery. The scar is positioned to lie along the inseam of her inner thigh. There is no downward traction on the perineum.
Outer Thigh Lift
The extra tissue is marked before surgery. The excess tissue is removed at the level of the waist. In the past, excisions have been tried lower on the thigh, at the level of the buttock crease, but this leaves unfavorable scars. It is better to place the scar up high so as not to interfere with the normal gluteal crease, which is impossible to reproduce surgically. This also happens to coincide with the level of the abdominoplasty scar. The excess skin and fat is removed and the tissues of the outer thigh and buttock are elevated and sutured at a higher level. The buttocks may be injected with fat simultaneously. This can be helpful for patients who have lost a lot of weight and have flat buttocks.
In most patients, the incision does not need to go all the way around the back. The small of the back is an attractive part of the body and if a scar can be avoided, so much the better. Preservation of a skin bridge minimizes the risk of elongation of the gluteal cleft3 (plumber’s crack deformity) and avoids placing an incision directly over a pressure point.
This 66-year-old woman without a history of massive weight loss presented for a lower body lift. The planned incisions are marked. The resection is near-circumferential, sparing the midline of the back. Her before and after photos are included in the photo section.
Swanson E. Near circumferential lower body lift: A review of 40 outpatient procedures. Plast Reconstr Surg Glob Open 2019;7:e2583.
Fortunately the discomfort associated with thigh and buttock lifts is not as severe as might be imagined, particularly in view of the extent of the surgical dissection. Patients do notice the tightness of the buttocks and thighs and are gratified by this. They have to be careful not to stress the wounds by flexing the hips too much My experience is that patients who have a lower body lift (abdominoplasty + outer thigh/buttock lift) have a recovery experience that is not much different from an abdominoplasty alone. There is little extra discomfort from the outer thigh/buttock lift.
I do not routinely use drains in performing thigh and buttock lifts. I limit undermining and avoid cutting electrocautery, which I believe reduces the risk of seromas (fluid collections) after surgery. Nevertheless, seromas do commonly occur and need to be drained by inserting a needle in the office. As the lymphatics regenerate, the fluid collection gradually gets smaller and eventually stops.
Seromas
Seromas are relatively common because large areas are often undermined, particularly when done with an abdominoplasty.
Infection
Any increased redness, purulent drainage or fever can signal an infection. Any drainage is cultured and antibiotics are prescribed.
Dehiscence
There is some tension intentionally placed on the deep fascia to help correct the tissue sagging, which of course is the objective of surgery. Occasionally, the wound may partially open (“dehiscence”). If this is a small opening, it is allowed to heal in on its own. Larger openings may be closed surgically.
Delayed Wound Healing
Skin loss along the incision line may result from compromised circulation. This is typically due to old scars that reduce skin circulation or smoking.
Contour Deformity
If the deep connective tissue layer (“deep fascia”) is not adequately repaired, or comes loose after surgery, there may be a depression along the incision line that can be corrected with a subsequent surgical revision.
Scar Deformity
As in other locations, the scar may spread and benefit from a later revision. At least 6 months are allowed for healing prior to a scar revision.
Asymmetry
Symmetry is the goal but complete symmetry is impossible to achieve. It is not unusual for patients to return for a touch-up liposuction or revision of a scar to raise it or lower it, or simply to make it less conspicuous.
Deep Venous Thrombosis
Patients undergo ultrasound scans to detect any blood clots that may develop in the first week after surgery.
- The dressings come off when you return to the office the day after surgery.
- Bruising and swelling are normal.
- Leave the Steri-Strips in place. They come off about a week after surgery.
- Start bathing normally again the day after surgery, after the dressings are removed.
- At first, there is some normal gathering and irregularity along the incision. This smooths out on its own.
- Vigorous physical activities should be deferred for about a month. Normal day-to-day activities may be resumed right away.
Q: Will the surgery correct my cellulite?
A: Often there is an improvement. However, dimpling may persist. Fat injection of the buttocks can help with this.
Q: Can you keep the incision hidden in the groin?
A: No. This does not allow sufficient skin tightening of the thigh and can cause distortion of the perineum. However, a scar down the inseam is well-accepted by patients as a favorable trade for saggy, loose skin.
Q: Does the scar go all the way around?
A: Usually it does not. I perform a near circumferential lift and preserve a bridge of skin in the midline of the back. This avoids any unusual appearance of the butt crack.
Q: Can you do a tummy tuck at the same time as the outer thigh/buttock lift?
A: Yes, and this is called a lower body lift.
Q: Does a lower body lift include an inner thigh lift?
A: No, but it can be done at the same time.