The superficial anatomy of the thigh is highly relevant to thigh-lift procedures, and knowledge and understanding of Colles’ fascia is particularly important. Colles’ fascia is a thick, strong fascial layer found deep to the subcutaneous fat of the thigh. It attaches to the ischiopubic rami of the bony pelvis, Scarpa’s fascia of the abdominal wall, and the posterior border of the urogenital diaphragm. It has a particularly strong area at the junction of the perineum and medial thigh, where it defines the perineal thigh crease. The Colles’ fascia is relevant to medial thigh lift, as it is used to resuspend the elevated soft tissues.1–3 Thigh skin thickness differs according to anatomic location and is thinner medially than laterally. The medial skin also contains fewer hairs. The thigh has two distinct fat layers and between the two is a weak superficial fascial system also relevant to thigh-lift procedures. The femoral nerve travels in the femoral triangle (not adjacent to it) and provides some sensation to the thigh through its branches. The medial femoral cutaneous nerve supplies most of the medial thigh (L1–L2). The proximal aspect of the medial thigh close to the groin crease is supplied by the ilioinguinal nerve (L1). The genitofemoral nerve (L1 component) supplies the skin over the femoral triangle. The lateral aspect of the thigh is supplied by the lateral cutaneous nerve of the thigh (L2–L3) and this may be damaged during an abdominoplasty over the anterior superior iliac spine (ASIS; Fig. 121.1). Ilioinguinal Lateral femoral cutaneous Lateral cutaneous Medial femoral cutaneous Obturator Genitofemoral Saphenous Sural Superficial peroneal Deep peroneal Iliohypogastric Medial femoral cutaneous Iliohypogastric Lateral femoral cutaneous Lateral cutaneous Posterior femoral cutaneous S1, 2, 3 L1, 2, 3 Saphenous Sural Tibial Fig. 121.1 Dermatomes of the lower limb.
2. Lockwood TE. Fascial anchoring technique in medial thigh lifts. Plast Reconstr Surg 1988;82(2):299–304
3. Armijo BS, Campbell CF, Rohrich RJ. Four-step medial thighplasty: refined and reproducible. Plast Reconstr Surg 2014;134(5):717e–725e ANATOMY OF THE FEMORAL TRIANGLE 2. What marks the medial border of the femoral triangle? The femoral triangle is bounded by three structures: the medial border of the sartorius (laterally), the medial border of the adductor longus (medially), and the inguinal ligament superiorly (Fig. 121.2). The triangle contains the femoral vessels and nerve and lymphatic channels. It is relevant to a medial thigh lift, in that it should not be violated to avoid damage to these structures. Its anatomy is also relevant to other areas of plastic surgery including groin dissection and management of necrotizing fasciitis of the groin and medial thigh.1 Fig. 121.2 Boundaries of the femoral triangle. Inguinal ligament Inguinal ligament Femoral nerve Femoral nerve Femoral artery Femoral artery Femoral vein Femoral vein Femoral triangle Sartorius muscle Adductor longus muscle Adductor longus muscle
The approach to medial thigh lift is both straightforward and logical. If there is excess fat, then liposuction or further weight loss is required. If there is excess skin, then resection is required. If both fat and skin excess are present, a combination of the two is required. If skin excess is confined to the upper third of the thigh, then a horizontal excision is performed in the groin crease, if skin excess affects the majority of the thigh, then a vertical excision is performed on the medial thigh itself. In some cases, such as in this scenario, both horizontal and vertical excisions are combined to create a T or L-shaped excision. If there are other areas that need to be addressed, such as the abdomen, back, and lateral thighs, then these are generally performed first. If there is severe fat excess, then the procedure may be staged with liposuction first and then skin resection is performed secondarily.1–3
The patient in this scenario has only fat excess without a need for skin resection. Assuming that her weight is stable, she is best managed with liposuction to target both medial and lateral thigh areas. As her skin is in good condition, it should tighten satisfactorily over time. There may be other options for nonsurgical treatment with cryolipolysis which uses extreme cold to breakdown fat cells noninvasively. It does have Food and Drug Administration (FDA) approval for the thighs as well as the abdomen, hips, buttock, and arms. More than one treatment would be expected to give a noticeable result. Alternative noninvasive options are laser treatment and ultrasound which each can also breakdown fat.1–3
This is a massive weight loss patient who is likely to benefit from medial thigh surgery to reduce the residual excess skin and fat present in the thigh. As she has both skin and fat excesses, the approach should include skin resection with liposuction. A more traditional approach is to perform liposuction followed by blade or monopolar skin and subcutaneous fat excision. More recently, combining aggressive liposuction with avulsion of excess skin has become a recognized alternative approach.1 In this technique, the liposuction is performed to leave very little subcutaneous tissue on the underside of the dermis, which is then excised around the periphery and avulsed using a pair of Kocher forceps or similar in a proximal to distal direction. The key proposed advantage of this technique is that the underlying lymphatics are preserved resulting in reduced problems with subsequent lymphedema and lymphocele formation. In addition, because sensory nerves and connective tissue are preserved, wound healing issues and sensory nerve problems should also be reduced. Supplementary liposuction may be performed to other areas of the thigh to further improve overall contour, and this would be performed in a far less aggressive manner to more gently recontour the areas where no skin resection is planned. This approach to medial thigh lift is unproven to significantly affect surgical duration or downtime. This is more likely to be affected by surgeon experience and patient factors. This approach can still lead to contour deformities and these again will most likely be dependent on surgeon experience and characteristics of the patient thighs. There is no reason why this approach should affect venous thromboembolism risk and patients should still be risk assessed to guide chemoprophylaxis.
When marking a patient for a medial thigh lift, it is important to perform this with them standing upright with knees apart. This should be performed in the presence of a chaperone of the same sex as the patient, given the intimate nature of the markings. It is important to do these markings with the patient standing, as it more reliably allows assessment of the location and extent of excess soft tissue. Where necessary, subtle refinements may be made on table to these markings.1–3
When marking a patient for a medial thigh lift, it is best to assess the amount of excess skin that can safely be removed by performing a pinch test. This is done by gently grasping the soft tissues and lifting them toward the thigh crease. The exact amount that can be taken is patient dependent, but on average 5 to 7 cm is excised. A further 3 to 5 cm of lift is achieved secondary to anchoring of the skin flap to the Colles’ fascia. The approach to a medial thigh lift will be guided by skin and soft-tissue excess. A standard approach for the patient described involves a transverse incision placed in the medial thigh crease, passing from the pubic tubercle to the perineal thigh crease. It is not necessary to extend the incision all the way posterior to the buttock crease. A vertical extension is required only where skin laxity extends beyond the upper third of the thigh, and is therefore not required in this case. When performing a fascio-fascial suspension technique, the transverse incision may be placed parallel to and 6 to 7 cm below the inguinal crease, but not in a classic thigh lift.1
Patients undergoing classic medial thigh lift should normally be positioned supine in a frog-leg position.1 Stirrups were previously used but are no longer needed because the incision ends at the perineal crease without extension to the buttocks. A prone position is unnecessary for the same reason and is less favorable from an anesthetic perspective. Lateral positioning would entail changing position and redraping intraoperatively when moving from one side to the next. This would have implications on surgical timings which would naturally be increased. Some authors describe performing this procedure with the patient supine on leg boards so that the legs are flat but abducted. This can offer some advantages with regard to surgeon comfort and minimizing repositioning of the patient intraoperatively.2 1088 Part VII ■ Aesthetic Surgery
It is important to carefully preserve the soft tissue that lies between the mons pubis and femoral triangle to prevent damage to the lymphatics and subsequent lymphedema.1 Lymphedema is difficult to manage, and medial thigh lift carries a small risk of this and must be discussed during the preoperative consent process. The risk of nerve damage is low and the risk of infection is not affected. Hypertrophic scarring is not common at this site and a small volume resection of this soft tissue is unlikely to significantly distort the vulva.
examination, the patient has type V lipodystrophy, with moderate residual fat excess in the medial thigh. The This patient has a significant horizontal excess of skin, and this requires a longitudinal (vertical), elliptical excision pattern. The addition of a short transverse upper incision will likely be required to avoid formation of a dog-ear. Because the vector of lift is horizontal instead of vertical, it is not necessary to anchor the skin flap to Colles’ fascia. Stirrups are not required in this case. A similar approach to a brachioplasty should be adopted, where excision and closure are staged to minimize the effects of soft-tissue swelling and the risk of over-resection. This may not hold true if an avulsion technique is being used. The long saphenous vein should be identified and preserved. Injury to it can result in prolonged swelling of the lower extremity. A compression garment should be used after surgery for 2 to 4 weeks.1–3
The fascio-fascial suspension technique was described by Candiani et al1 as an alternative to a classic medial thigh lift. It employs a transverse skin excision with a vertical vector of pull. Instead of relying on anchoring of the Colles’ fascia, the technique relies on the strength of overlap between the gracilis and the adductor longus muscles. Instead of making an incision in the medial thigh crease, it is made 6 to 7 cm below the inguinal crease. The skin and fat are undermined down to the fascia of the adductor longus and gracilis muscles. The fascia between the two muscles is then overlapped and closed to support the lift and allow skin closure under minimal tension.1