Thighplasty

Anatomy and Physiology

Thighplasty was initially introduced in the 1950s and was not widely accepted for many years due to high complication rates. The scar migration and vulvar deformities resulting from early thighplasty were secondary to an incomplete understanding of the anatomy of the thigh.[7][8] As this understanding has evolved, knowledge of the anatomy of the thigh has become crucial in maximizing cosmetic outcomes while minimizing patient morbidity.

In both phenotypic sexes, the medial thigh is associated with a skin-fat envelope less tightly adherent to the underlying fascia; the dermal component is especially thin.[9] This anatomy makes the medial thigh compartment more susceptible to redundancy and laxity, resulting in ptosis of the skin, which can extend to the knee level in severe cases. This anatomy is also why medial thighplasty has gained favor over a lateral or posterior approach. 

The femoral triangle, located adjacent to the intertriginous fold of the inguinal crease, is an important anatomical landmark denoting the transition from the pelvis to the leg. The femoral artery, vein, nerve, and sheath pass through the femoral triangle, with the femoral sheath acting as a potential space for displaced abdominal contents and a resulting femoral hernia. A significant disruption of the lymphatics in this region can increase the incidence of complications after thighplasty. It is imperative to remain superficial when performing thighplasty, as the purpose of the procedure is to remove excess lipodermal tissue without disrupting crucial underlying structures.[10] 

The great saphenous vein and its branches are found in the medial thigh tissue; this vein ascends along the medial aspect of the thigh and confluences with the femoral vein at the saphenofemoral junction just caudal to the femoral triangle.[7] Intraoperative preservation of the great saphenous vein is crucial to reduce the risk of postoperative venous insufficiency. However, there are reports of concurrent saphenous vein stripping or ligation during thighplasty performed on patients with preoperative venous insufficiency and ultrasonographic evidence of saphenous reflux.

Other critical anatomical structures to consider when performing thighplasty are the superficial lymphatics. These lymphatics are concentrated in the medial thigh, converge at the femoral triangle, and run deep to the great saphenous vein.[9] Significant damage to the superficial lymphatics can have severe sequelae such as lymphocele or postoperative lymphedema. Maintaining a relatively superficial dissection during thighplasty has resulted in successful outcomes while reducing lymphatic-associated morbidity.[11]

Historically, thighplasty was associated with high rates of untoward scar migration. Lockwood introduced a method anchoring the inferior flap in a transverse incision, or anterior flap in a vertical incision, to the peritoneal membranous superficial fascia, otherwise known as the deep membranous layer of the superficial fascia or the Colles fascia.[8][12] This fascial layer is contiguous with the Scarpa fascia anteriorly and attaches to the ischiopubic ramus proximally and fascia lata distally. Originally thought of as a durable aponeurotic plane suited for anchoring tissue, most recent studies have demonstrated that the variability in the composition of the Colles fascia leads to inconsistent long-term outcomes and associated morbidity.[13]

Indications

Classically known as a cosmetic procedure, the increased prevalence of thighplasty has mirrored that of weight loss surgery. Patients with massive weight loss and lipodystrophy may benefit from thighplasty as a functional procedure. The severity and distribution of lipodystrophy, redundancy, or ptotic skin of the thighs can lead to multiple functional complaints, including skin irritation or infection, decreased mobility, pain, aesthetic concerns, and difficulty finding correctly fitting clothes.

The Pittsburgh Rating Scale (PRS) is a validated rating system to classify skin contour deformities following massive weight loss.[14] The PRS evaluates 10 anatomical regions using a four-point grading scale ranging from 0, normal, to 3, severe. The PRS may be used as a preoperative tool to assist in planning and anticipating surgical outcomes for thighplasty. Less severe skin contour deformities may benefit from minimally invasive approaches like liposuction. In contrast, those with a more severe deformity require more extensive procedures such as excision, considerable undermining, and tissue repositioning.

Thighplasty has improved mobility and functionality in patients after lower extremity amputation by improving prosthesis fit.[3] Thighplasty is an affordable and practical solution for patients with obesity who have undergone transfemoral amputation when compared with repeated iterations of sockets to mold an amputation stump.

Wounds caused by genitoperineal defects caused by infection, trauma, or neoplasm have led to increased versatility of thighplasty with the expectation of closing a gruesome wound with an excellent cosmetic and functional outcome.[15] For example, hidradenitis suppurativa is a chronic inflammatory disease frequently involving the moist skin creases of the axillae and groin. Medically refractory cases of hidradenitis suppurativa complicated by recurrent abscesses may require radical excision, often combining thighplasty with regional or free tissue transfer to augment the tissue loss and allow for healing by primary intention.[16] Thighplasty has a wide breadth of indications and is an adaptable procedure with the foundational purpose of restoring appearance and functionality.

Contraindications

While there are no absolute contraindications to thighplasty, modifiable and nonmodifiable relative contraindications exist. The treatment of specific medical comorbidities such as diabetes mellitus, cardiovascular disease, renal insufficiency, anemia, and pulmonary disease should be optimized in the preoperative period to maximize success. A thorough preoperative evaluation assessing for the presence of peripheral vascular or lymphatic disease can help achieve a favorable outcome and mitigate complications.

Lymphedema is an incurable chronic debilitating diagnosis; management is focused on limiting secondary complications.[17] The symptoms of lymphedema include aching, a sensation of heaviness, pitting edema, and recurrent infections in the affected limb. Lymphedema can easily be confused with excess lipodermal tissue, and patients may warrant further investigation with lymphoscintigraphy if the diagnosis is uncertain. Further disruption of the lymphatic channels in a patient who already suffers from poor lymphatic drainage may cause rapid progression of the disease process and associated complications. Before performing a thighplasty, it is essential to conduct a thorough evaluation to assess the presence of lymphedema.

The prevalence of chronic venous insufficiency in patients with obesity is increasing; a thighplasty could lead to superficial venous disruption and progression of venous insufficiency.[18]

Patients electing to undergo thighplasty will benefit from maintaining a stable preoperative weight. While no data cite an ideal timeframe for weight stability, many practitioners advocate delaying thighplasty until the patient has demonstrated a stable weight for 1 year.[19] Preoperative weight stability helps to define the extent of lipodystrophy and optimizes tissue resection. 

Expectations regarding the outcome of thighplasty need to be clearly defined, reasonable, and mutually agreed upon. If the surgeon and the patient cannot agree on the expected result, then there needs to be a genuine consideration of the appropriateness of the procedure. The prevalence of body dysmorphic disorder in aesthetic plastic surgery practices has been reported to be up to 40%, and a high index of suspicion is warranted.[20]

Equipment

The equipment needed for thighplasty includes the following:

• Sterile marking pen
• Liposuction system with or without ultrasound
• Monopolar and bipolar electrocautery
• Basic plastic surgery instrument tray
• Absorbable and nonabsorbable suture
• Dressing supplies including Xeroform gauze
• Compression leggings

Personnel

Essential personnel needed for thighplasty typically includes the following:

• Surgeon
• Surgical first assistant
• Circulator or operating room nurse
• Surgical technician or operating room nurse
• Anesthetist

Preparation

The preoperative evaluation is essential to a thighplasty and must include a discussion of the surgical technique, possible complications, and expected outcomes. A thorough evaluation of the location of skin ptosis, subcutaneous fat distribution, and skin quality, laxity, and thickness must accompany a comprehensive physical examination to assess for signs of peripheral arterial disease, venous insufficiency, lymphedema, and other comorbidities. The medical history and physical examination will inform the choice of surgical technique.

A surgeon-led marking in the preoperative holding area allows for surgical planning and is crucial to the outcome of the procedure.[21] The patient should be marked while standing upright with legs abducted and in recumbent body and limb positions; this allows complete visualization of the extent of the excess tissue. Importance should be placed on the lipodermal tissue laxity and anticipated scar location, as well as the traction that will be placed on the horizontal incision and its proximity to the labia majora or scrotum to reduce any potential distortion.

Thighplasty is performed under general anesthesia with the patient in the lithotomy position. Lithotomy positioning distorts tissue positioning; the preoperative identification and marking of tissue to be resected are imperative. Sequential compression devices are placed, and venous thromboembolism chemoprophylaxis is given to reduce the risk of deep venous thrombus formation.[2]

Technique or Treatment

Various surgical techniques can address lipodystrophy and excess lipodermal tissue in the thigh, including isolated liposuction, a horizontal or transverse lift, a vertical lift, a combined lift, which can be further differentiated into the T-shaped or L-shaped lift, and a double triangle. All of these procedures can be performed with or without concomitant liposuction.[22] The preoperative evaluation will guide the choice of the appropriate technique.

Isolated liposuction is reserved for patients with a low PRS score or isolated excess subcutaneous tissue; the lack of skin ptosis makes thighplasty an unfavorable approach in these individuals. Liposuction is tolerated with good results in appropriately selected patients.[23] Unfortunately, isolated liposuction does not address the excess skin in patients with ptotic skin and may exacerbate symptoms and increase complications.

A horizontal thighplasty utilizes an incision created in the intertriginous folds of the groin, approximately 1 cm caudal to the inguinal crease, extending from the femoral triangle to the middle of the infrabuttock crease.[9] This technique is employed to lift the tissue cephalad, most commonly to address skin ptosis over the proximal thigh. An essential step in this technique is anchoring the inferior flap to the Colle fascia to limit caudal migration of the resulting scar.[21]

The vertical thighplasty, established to reduce circumferential skin laxity in patients with excess lipodermal tissue extending to the knee level, creates an incision extending down the medial aspect of the thigh to hide the scar when viewed from the front. An elliptical incision is planned along the medial part of the thigh extending from 3 cm caudal to the labia majora or scrotum to slightly above the medial condyle of the knee.[9] The width of the incision is determined using the "pinch test" to estimate the amount of redundant skin to excise. The cephalad portion of the incision is typically extended along the infra-buttock crease to address resulting tissue redundancy.

A combined horizontal and vertical approach is frequently the best technique for patients with abundant lipodermal tissue involving the entirety of the thigh, who require circumferential tissue reduction in addition to elevation. A T-shaped lift has the vertical incision coming off the middle of the transverse incision and running down the medial thigh. The L-shaped lift, a slight variation, has the vertical incision originating off the posterior aspect of the horizontal incision. The planned vertical incision has a gentle curve, coursing back down the middle of the thigh for preferred scar placement. The resultant scar is in the formation of an inverted "T" or "L." The double triangle thighplasty addresses excess tissue in the mons region and the medial thigh.[24]

When considering adjunctive liposuction, there is no consensus on whether this should be accomplished as a staged or simultaneous approach. However, using liposuction to thin the skin envelope and reduce fat deposits has improved incisional planning and estimations of skin resection and scar location, resulting in more desirable outcomes in some series.[21][7] If liposuction is pursued simultaneously, the superficial subcutaneous layers of the medial and anterior thigh compartments are infiltrated with a tumescent solution, and liposuction is performed. Repeat evaluation of excess skin and planned incisions should be performed as it is typical for extra skin removal to be required after liposuction.[25] Any additional modifications should be adjusted from the anterior line, as the anterior compartment of the thigh is more mobile when compared to the posterior.[26] 

In all techniques, it is crucial to remain superficial to the fascia lata to limit disruption of the superficial lymphatic system and vessels coursing along the medial thigh.[22] Using penetrating towel clamps or permanent sutures can help approximate skin edges before the closure of the wound to ensure the wound will close with acceptable tension and produce the optimal scar.

Complications

Unfortunately, thighplasty is a procedure associated with high morbidity, with recent studies citing around a 42% complication rate.[22] The anatomical location is an environment that is humid, moist, and under repeated friction, contributing to poor healing parameters.[7] The complication rate for thighplasty remains relatively high despite evolving surgical techniques to mitigate the associated complications. Patients must be made aware of these potential complications before pursuing thighplasty. 

The complications of thighplasty range from simple and easily handled, such as an asymptomatic seroma, to severe and debilitating, such as vulva displacement or lymphedema. Wound-specific complications include but are not limited to dehiscence, infection, and necrosis. Other common complications include the development of a seroma, hematoma, or lymphocele, scar migration, and hypertrophic scarring.[27][28] Debilitating complications include thrombophlebitis and lymphedema. However, recent series have been published describing complication rates of zero after isolated thighplasty.[22] 

Despite relatively high overall complication rates, severe complications requiring reoperation are rare. Complications of thighplasty that are most likely to require reoperation include scar migration, hypertrophy or widening of scars, and procedures to remove residual excess skin.

Studies have cited higher complication rates in patients with higher preoperative body mass index, undergoing more technically advanced or concomitant procedures, and those with more underlying comorbidities, specifically diabetes mellitus and tobacco use.[22][28] 

Although not a technical complication, patient dissatisfaction is a potentially severe and relatively common outcome.[29] Establishing a shared understanding of realistic expectations is fundamental to successful outcomes following thighplasty.

Clinical Significance

The increased prevalence of weight loss surgery and the number of patients who have undergone massive weight loss has increased demand for body contouring procedures, including thighplasty. Thighplasty has evolved and adapted to improve technical efficiency and patient outcomes while mitigating associated complications.[30] Associated complications are often outweighed by an enhanced quality of life resulting from increased aesthetics, functionality, and mobility and reduced pathologic disease burden related to redundant, ptotic skin in appropriately selected patients.[31] Indications for thighplasty have extended beyond cosmetic benefits to include the repair of wounds caused by trauma or excision of genitoperineal disease and improved prosthesis fit.[3][15]

Enhancing Healthcare Team Outcomes

Thighplasty is a procedure requiring an interprofessional management approach for optimal outcomes.[15][32] Patients undergoing thighplasty require a team with expertise in surgical techniques, management of comorbidities, wound and pain management, and complete perioperative care.

While the reconstructive surgeon determines the surgical approach to thighplasty and guides treatment plans that consider patient preferences, goals, and medical requirements, a team-driven approach can help control associated comorbidities and minimize complications. Patients undergoing thighplasty may require input from vascular surgeons, internists, bariatric surgeons, or mental health professionals. 

The clinical nursing staff plays a vital role throughout the perioperative period. In addition to monitoring the patient, nursing staff provide expertise in wound management and drain care, patient education regarding pain management and postoperative activities, and facilitate patient outcomes by promoting patient advocacy.[9]

Pharmacists contribute to patient care by ensuring appropriate medication management, evaluating potential drug interactions, and educating patients on medication use. They assist in the formulation of a multimodal pain regimen to mitigate pain-related complications or addiction. The appropriateness of chemoprophylaxis should also be considered depending on the preoperative risk, a task best suited for the pharmacy to assist.[2]

Nutritionists can implement a dietary plan to reduce the recurrence of postoperative weight gain and optimize protein intake to enhance recovery. Physical therapists may be utilized in the perioperative period to establish and assist with goals for movement and recovery. 

By integrating these considerations into the care of patients undergoing thighplasty, healthcare professionals can work collaboratively to enhance patient-centered care, improve outcomes, prioritize patient safety, and optimize team performance.