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Medial Thigh Lift in the Massive Weight Loss

Population: Outcomes and Complications
Jeffrey A. Gusenoff, M.D.
Background: Complication profiles of medial thighplasty in the massive weight
Devin Coon, M.D.
loss population are not well described. The authors present their experience
Harry Nayar, M.D., M.B.E.
with these procedures in the massive weight loss population.
Russell E. Kling, B.A. Methods: Thighplasty patients from 2003 to 2012 were assessed. Variables in-
J. Peter Rubin, M.D. cluded age, sex, body mass index, method of weight loss, comorbidities, and
Pittsburgh, Pa.; and Baltimore, Md. smoking status. Outcomes included seroma, dehiscence, infection, hematoma,
edema, and revision. Statistical analysis was performed as appropriate.
Results: One hundred six subjects (90 women and 16 men) underwent thigh-
plasty. Fourteen patients underwent horizontal thighplasty, with a complication
rate of 43 percent; 24 underwent short-scar thighplasty, with a complication rate
of 67 percent; and 68 underwent full-length vertical thighplasty, with a compli-
cation rate of 74 percent. Seventy-two subjects (68 percent) had at least one
complication. Complications included dehiscence (51 percent), seroma (25 per-
cent), infection (16 percent), and hematoma (6 percent). Overall, 25 patients (23
percent) developed edema, which did not resolve in two patients by 12 months.
Hypertension was significantly associated with postoperative seroma (p = 0.02).
Age (p = 0.01), hypothyroidism (p = 0.01), and liposuction outside the area of
resection (p = 0.025) were associated with postoperative infections. A full-length
vertical incision was associated with increased lower extremity edema (p = 0.007).
Conclusions: Medial thighplasty has a high rate of minor wound healing
problems. Full-length vertical thighplasty is associated with prolonged edema.
Concomitant liposuction may also increase complications. Patients should be
counseled appropriately about the potential for minor wound healing prob-
lems. (Plast. Reconstr. Surg. 135: 98, 2015.)

he acceptance of bariatric surgery as an effec- impact after massive weight loss, there remains
tive and durable means of treating obesity controversy over the most appropriate methods
has fueled a precipitous rise in individuals for achieving favorable outcomes.1
seeking body contouring following massive weight The medial thighplasty can be designed to treat
loss. It has also revealed a relative paucity of objec- the varying amount of skin laxity of the inner thigh.
tive outcome data regarding regional contouring For patients with laxity limited to the upper third of
procedures following weight loss. Although it is the thigh, a horizontal excision may be sufficient.
well established that thigh rejuvenation can have For patients with laxity extending to the middle
a profoundly positive functional and aesthetic third of the thigh, a short-scar vertical thighplasty
can be performed. For laxity extending down to
the knee, a full-length vertical thighplasty may be
From the Department of Plastic Surgery, University of Pitts- required. Techniques vary and can be adjusted to
burgh Medical Center; and the Department of Plastic and eliminate the T-point if desired.1,2
Reconstructive Surgery, Johns Hopkins Hospital. Despite the many technical variations of medial
Received for publication November 20, 2013; accepted May thighplasty, there are very few studies investigat-
13, 2014. ing objective outcomes and complications in the
Presented at the 88th Annual Meeting of the American So- massive weight loss population. Because of move-
ciety of Plastic Surgeons, in San Diego, California, October
11 through 15, 2013; and the 30th Annual Meeting of the
ment, moisture, and a potential T-point in the
Northeastern Society of Plastic Surgeons, in Washington,
D.C., September 19 through 22, 2013. Disclosure: The authors have no financial interest
Copyright © 2014 by the American Society of Plastic Surgeons to declare in relation to the content of this article.
DOI: 10.1097/PRS.0000000000000772


groin crease, complication rates may be high. We was recorded. Operative revisions for complica-
hypothesize that medial thighplasty in the massive tions and aesthetic revisions were noted.
weight loss population is safe but has the potential Descriptive statistics were calculated, including
to have a high minor complication rate. We pres- frequencies for categorical and ordinal variables
ent the largest series of medial thighplasty massive and means, and standard deviations and ranges
weight loss patients to date to aid in patient coun- for continuous variables. All statistical analysis was
seling before surgery. performed using Stata/SE version 12.0 (StataCorp,
College Station, Texas). Univariate logistic regres-
sion was used to examine the impact of individual
factors on particular outcomes, with multivariate
One hundred six medial thighplasty subjects regression then used to control for possible con-
were identified retrospectively from our Life After founders. The Fisher’s exact test was used for anal-
Weight Loss database. Our study was approved by ysis of low-frequency dichotomous variables. All
the Institutional Review Board of the University of statistical tests were two-sided, with equal variance,
Pittsburgh (PRO12090401). Procedures were per- and significance was set to the level of p < 0.05.
formed between March of 2003 and April of 2012.
Thigh procedures were defined as horizontal inci-
sion, short-scar vertical thighplasty, and full-length RESULTS
vertical thighplasty. Massive weight loss was defined
as weight loss greater than 50 pounds. Other Demographics
patient factors collected included age, sex, body One hundred six patients were analyzed.
mass indices [maximum body mass index, cur- Fourteen (13 percent) underwent horizontal
rent body mass index, and delta body mass index thighplasty, 24 (23 percent) underwent short-
(maximum body mass index − current body mass scar vertical thighplasty, and 68 (64 percent)
index)], type of weight loss (surgical or self-weight underwent full-length vertical thighplasty. The
loss), time from weight loss to body contouring, average follow-up time was 119 ± 139.7 months
follow-up time, comorbidities (i.e., tobacco use, for the horizontal incision group, 93.4 ± 138.7
diabetes, hypertension, steroid use, anemia, hypo- months for the short-scar incision group, and
thyroidism, and anticoagulation status), and intra- 70.2 ± 82.6 months for the full-length vertical
operative data. All procedures were performed by incision group (p = 0.95). Ninety patients (85
the two senior authors (J.P.R. and J.A.G.). percent) were women and 16 (15 percent) were
Horizontal thighplasty markings are routinely men, with an average age at the time of surgery
performed by means of the pinch test while the of 45.1 ± 10.2 years. Eighty-eight subjects (83 per-
patient is in the frogleg position. Short-scar verti- cent) lost weight by surgical methods and 18 (17
cal thighplasty is marked the same way; however, percent) lost weight with diet and exercise. The
after the horizontal component is marked, the average time interval between massive weight loss
thigh tissues are mobilized medially and then lat- and thighplasty surgery was 30.3 ± 21.2 months.
erally to estimate the vertical component, making The mean maximum body mass index was 52.4
sure that the resection lines are drawn from the ± 9.1 kg/m2, the mean current body mass index
level of the adductor magnus proximally to the was 29.3 ± 4.3 kg/m2, and the mean delta body
desired distance distally in the midthigh. The full- mass index for the series was 23.1 ± 6.9 kg/m2.
length vertical thighplasty is marked in the same Body mass indices were not statistically different
fashion as the short-scar vertical thighplasty, but between the three groups (p > 0.05). Table 1 sum-
the estimated resection is carried all the way to marizes the key patient characteristics.
the knee if necessary. Suspension of the superfi-
cial fascial system in the thigh to the Colles fascia Complications
in the groin is performed using 2-0 absorbable Seventy-two subjects (68 percent) had at least
braided suture. one complication. Complications included wound
Complications assessed were seroma, wound dehiscence (51 percent), seroma (25 percent),
dehiscence (defined broadly as any size wound infection (16 percent), and hematoma (6 per-
separation, including superficial skin break- cent) (Table 2). Overall, 23 subjects (22 percent)
down), bleeding, infection (included superficial developed lower extremity edema. Twenty-one
infections), and edema. Edema was further cate- patients in the full-length vertical group devel-
gorized by duration less than 12 weeks and greater oped edema, with resolution in 11 patients by 12
than 12 weeks. Concomitant use of liposuction weeks and resolution in another eight patients by

Plastic and Reconstructive Surgerys*ANUARY

Table 1. Patient Characteristics resection, whereas 12 underwent liposuction in all

areas of the thigh, including the area of resection.
Characteristic Value
Sex, no. Predictors of Overall Complications
Female 90
Male 16 Sex, body mass index, former smoker, dia-
Age ± SD, yr betes, hypothyroidism, concomitant liposuction
Mean ± SD 45 ± 10
Range 21–66 (inside versus outside area of resection), and
Maximum BMI, kg/m2 number of other procedures at the time of thigh-
Mean ± SD 52 ± 9 plasty were not associated with an increased over-
Range 36–78
Current BMI, kg/m2 all complication rate (p > 0.05). Anemia and age
Mean ± SD 29 ± 4 (p = 0.02) positively correlated with an increased
Range 21–41 overall complication rate, with 90 percent of
Delta BMI, kg/m2
Mean ± SD 23 ± 7 anemic patients developing a complication ver-
Range 10–45 sus 63 percent of nonanemic patients (OR, 5.3;
Weight loss method p = 0.03), and a mean age of 46.7 years in patients
Surgery 88
Diet/exercise 18 with a complication versus 41.6 years (OR, 1.29
Time from to initiation of weight loss to per 5 years of age; p = 0.02). Horizontal incision
thighplasty surgery, mo thighplasty was associated with a 49 percent com-
Mean ± SD 30 ± 21
Range 11–120 plication rate compared with short- (67 percent)
Follow-up, mo and full-length vertical (74 percent) incision
Mean ± SD 82 ± 107 thighplasty (p = 0.1).
Range 29–603
BMI, body mass index.
Predictors of Individual Complications
Hypertension was significantly associated
12 months. Two patients developed prolonged with postoperative seroma formation (OR, 2.9;
edema that was unresolved after 12 months despite p = 0.02) and there was a trend toward seroma for-
lymphedema therapy. Two patients who under- mation in the full-length vertical incision group
went short-scar vertical thighplasty developed (p = 0.06). Age (OR, 1.47 per 5 years of age increase;
prolonged edema, with one patient resolved by 12 p = 0.01), hypothyroidism (OR, 4.5; p = 0.01), and
weeks and the other by 12 months. No patients liposuction outside the area of resection (OR,
with a horizontal excision experienced prolonged 3.8; p = 0.025) were associated with an increased
edema. All cases of edema resolved or improved postoperative infection rate. A full-length vertical
by 12 months postoperatively. Six patients (6 per- incision was associated with an increased risk of
cent) required reoperation for a complication lower extremity edema (p = 0.007). No factors cor-
and 15 patients (14 percent) underwent revision related significantly with need for revision.
surgery to improve aesthetic results. Ten of these
patients had full-length vertical thighplasty and DISCUSSION
five had short-scar vertical thighplasty. Forty-nine
subjects (47 percent) underwent concomitant The massive weight loss population is a fast-
liposuction of the thigh at the time of thighplasty; growing demographic within plastic surgery and
37 had liposuction of the thigh outside the area of poses unique challenges.3 Massive weight loss
individuals present with a wide range of lower
extremity deformities. Moreover, impaired wound
Table 2. Postoperative Complications by Thighplasty healing and an increased prevalence of medi-
Type cal comorbidities, including diabetes, hyperten-
sion, and cardiopulmonary insufficiencies, are
Vertical Short Horizontal observed in this population.4 Despite these con-
(%) (%) (%)
siderable challenges, massive weight loss patients
No. of patients with
complications 50 (74) 16 (67) 6 (43) also stand to benefit immensely from contouring
Complication procedures. With a careful preoperative evalua-
Dehiscence 37 (54) 11 (46) 6 (43) tion, properly selected patients have reported sub-
Seroma 20 (29) 7 (29) 0
Infection 10 (15) 6 (25) 1 (7) stantial improvements in overall functioning and
Hematoma 4 (6) 2 (8) 0 psychosocial health.5,6 A key component of body
Return to the contouring after massive weight loss is managing
operating room 4 (6) 2 (8) 0 patient expectations. Understanding the risks of


medial thighplasty is important for patient coun- fold, which can create undesired deformities. If
seling and the informed consent process. skin excess and laxity extend to the middle third
First described by Lewis in 1957, the medial but no farther, the short-scar vertical thigh lift is a
thigh lift became known for several complica- reasonable choice. However, because of the coni-
tions, including scar migration, vulvar deformi- cal shape of the thigh, the termination of the inci-
ties, and recurrent ptosis.7,8 Refinements made by sion along the middle thigh can lead to a dog-ear
Lockwood in 1988 that included fascial anchoring deformity (Fig. 2). Simple dog-ear revision may
partially alleviated these issues; however, this tradi- be required after the scar has had sufficient time
tional approach, with its vertical vector of pull, is to settle down (i.e., 6 to 12 months). Patients are
ill-suited for many massive weight loss patients, as educated about this during their preoperative
many require a greater degree of excision than is counseling visit. Shermak et al. described a medial
afforded by the Lockwood technique.9 To address thighplasty modification, the anterior proximal
the needs of massive weight loss patients, a myriad extended thighplasty, which is an attractive alter-
of technical variations to reorient the vector of native for patients with limited laxity.1 This pro-
pull from vertical to horizontal, with and without cedure extends the horizontal proximal incision
staging liposuction, have been described.8,10 How- to the infragluteal crease in the anteroposterior
ever, there remains a paucity of objective data direction and anchors the Scarpa fascia to pubic
regarding outcomes and complications, which are periosteum. This modification conceals the scar
mostly limited to small, retrospective series. and provides greater pull than the traditional
To determine the most appropriate thigh-lift Lockwood technique, although disruption of the
technique, the inner thigh can be divided into gluteal fold is common with this procedure. The
three zones (Fig. 1). When contour deformities authors reported acceptable complication rates,
are confined to the upper third of the thigh, a most notably, a wound infection rate of 18.6 per-
horizontal thigh lift can be performed. The hori- cent and a lymphedema rate of 8.2 percent. Age
zontal thighplasty alone is not a very powerful was the only significant predictor of wound com-
operation in massive weight loss patients and may plications, and the vertical extension thigh lift was
offer limited or no improvement of the middle or significantly associated with lymphedema. The
distal thirds of the thigh. The amount of resected authors did not perform liposuction in the areas
skin in the horizontal vector is not very robust for of resection.
any of the three procedures. Larger resections can Redundancy to the level of the knee, as is
result in pleating of the tissues, inability to close the case with most massive weight loss patients,
the tissue, or extension of the scar into the gluteal is best treated by a full-length incision (Fig. 3).

Fig. 1. Horizontal thighplasty for laxity limited to the upper third of the thigh. (Left) Preoperative view. (Center) Marking for hori-
zontal thighplasty. (Right) Four-month postoperative view demonstrating limited improvement in the middle third of the thigh.

Plastic and Reconstructive Surgerys*ANUARY

Fig. 2. Short-scar vertical thighplasty. (Above, left) Preoperative view. (Above,

right) Markings demonstrate horizontal and vertical components. The vertical
component is limited to reduce the ultimate length of the scar. (Below, left) Mark-
ings demonstrate the wedge effect of the short-scar technique and the risk for
dog-ear formation. (Below, right) Five-month postoperative view after short-scar
technique with residual dog-ear deformity.

The greater contouring power must be weighed complications, as it is in a moist environment,

against scar visibility, the increased risk of lym- which is further subject to motion and friction
phatic disruption, and the problems inherent in (Fig. 5). Furthermore, the close proximity to
a T-point (Fig. 4). Most massive weight loss body the high bacterial burden of the perineum may
contouring patients will accept scar visibility for predispose to wound infection. The T-point can
the functional and contour improvements result- be eliminated by cheating the design more pos-
ing from greater resection. The T-point is an ana- teriorly to form an L-shaped resection.2 To our
tomical junction area prone to wound healing knowledge, there are no data comparing the two


Fig. 3. Full-length vertical thighplasty. (Left) Preoperative view. (Center) Markings for the full-length vertical thighplasty, demon-
strating the small horizontal component and the vertical component extending down to the knee. (Right) Three-month postop-
erative view showing improvement all the way to the knee.

agree to multiple recoveries and increased surgi-

cal expense.
Our complication rates correspond with that
observed in the literature for body contouring
procedures in the massive weight loss popula-
tion.11 Wound healing complications—notably,
seroma and dehiscence—are predictably high in
this population, although most are minor and can
be managed in the clinic without need for reoper-
ation. Our finding that older age and anemia lead
to an increased rate of total complications is con-
sistent with previous reports.1 Evaluating and opti-
mizing the micronutrient status of these patients,
Fig. 4. Delayed wound healing at the T-point, the most common particularly for iron, calcium, and vitamin B12
site of wound dehiscence in full-length vertical thighplasty. levels, could minimize wound healing complica-
tions.12,13 The impact of liposuction on outcomes
of medial thigh lift has not been examined previ-
techniques with regard to complications and out- ously. We found that concomitant liposuction out-
comes. We often use 2-0 polypropylene suture at side the area of resection has an increased rate of
the T-point to reinforce the closure for 1 to 2 weeks wound infection. This finding may be attributable
postoperatively. Care should be taken when using to tissue trauma with the liposuction cannulas,
permanent suture to secure the superficial fascia or residual edema that persists after surgery in a
to the Colles fascia, as delayed suture extrusion dependent part of the body. Interestingly, how-
may occur (Fig. 6). The risk of suture extrusion ever, concomitant liposuction at the time of bra-
can be reduced using a slowly absorbing suture in chioplasty was recently shown to have no effect on
this area. Another option to avoid T-point wound complication rates in a large series of patients.14
healing problems would be to stage the horizon- This is likely because liposuction in the arm was
tal and vertical components, which may ultimately limited to the posterior aspect, and was not near
improve the overall contour and reduce long-term the planned resection area. Similarly, in thigh-
recurrent laxity; however, patients would have to plasty, combining liposuction of the saddlebag

Plastic and Reconstructive Surgerys*ANUARY

Fig. 5. (Left) Dehiscence at the T-point and horizontal incision. (Right) Healed wound managed with conser-
vative dressing changes.

area or above the knee is likely safe, whereas deb- are referred to vascular surgery for evaluation,
ulking procedures of the entire thigh involving the radiofrequency ablation of the saphenous vein, or
resection area pose a higher risk to the patient. A other necessary therapies before thigh contouring
larger sample size may help elucidate these rela- surgery. Patients with significant disease may not
tionships, as there were too few patients undergo- be body contouring candidates. To avoid intraop-
ing liposuction only in the nonexcised area for us erative damage to the lymphatics, we maintain a
to draw conclusions. Staging of debulking liposuc- superficial dissection in the area superior to the
tion and medial thighplasty may be considered, adductor magnus muscle and stay superficial to
especially in patients who are already undergoing the great saphenous vein. In our study, patients
multiple stages of body contouring. Patients with undergoing the short- or full-scar thighplasty are
high body mass indices because of a gynoid or wrapped with an elastic bandage for 1 week after
pear-shaped morphology may be good candidates surgery and then placed into ankle-length com-
for a stage of debulking liposuction first, followed pression garments for 6 weeks. A single drain is
by surgical excision 3 to 6 months later. Patients used for 1 week or until drainage is less than 30
with high body mass indices that have global cc per 24 hours. Ambulation is encouraged and
adiposity would benefit from further weight loss swelling may increase as mobility increases, espe-
before any surgical intervention. Studies inves- cially in the first 2 weeks after surgery. Patients
tigating excision-site lipectomy in the area to be are encouraged to use elastic wraps immediately
resected are lacking and may provide further if they notice any foot or ankle swelling. Horizon-
information about the utility and safety of liposuc- tal thighplasty patients are encouraged to wear
tion in relation to the risk of seroma and lymph- compression as well, but these may be compres-
edema. Chronic seromas or lymphoceles that do sion garments limited to above the knee. Asym-
not resolve with drainage or other methods may metric swelling of the extremities is worked up for
require surgical excision (Fig. 7). possible deep venous thrombosis. Swelling usu-
Chronic lymphedema, the vexing complica- ally resolves by 6 weeks. If it persists, patients are
tion of the medial thigh lift, has been reported to referred to the lymphedema clinic at our institu-
occur in as many as 30 percent of subjects.15,16 In tion. All patients undergoing a medial thighplasty
a study using lymphoscintigraphy analysis before in our practice are informed of the potential risk
and after thigh lift, Moreno et al. reported that a of chronic lymphedema (or lifelong swelling) with
majority of patients develop demonstrable func- this procedure. Our protocol for management of
tional and anatomical alterations of the lymphatic lower extremity edema in the massive weight loss
network at 6 months postoperatively.15 The pres- population has been reported previously.17
ence of preexisting lymphovascular disease may Some observers may question whether a proce-
be underappreciated in the massive weight loss dure that has a complication rate of at least 68 per-
group; therefore, signs and symptoms should be cent is safe. We argue that it is because most of these
carefully evaluated preoperatively.17 Patients with complications were minor wound healing issues or
preexisting edema and significant varicosities transient edema. We broadly define dehiscence as


Fig. 7. Lymphocele excision after full-length vertical medial


indices—in particular, delta body mass index—

would be correlated to the degree of thigh laxity.
However, we did not find this to be true, which
may be attributable to sample size. Another expla-
nation may be that thigh laxity after weight loss is
more closely related to pre–weight loss body type
(gynoid versus android). Other areas to explore
include determining whether variations in surgical
techniques that avoid a T-point are truly beneficial
in decreasing dehiscence, whether excision-site
lipectomy really improves preservation of lymphat-
ics and decreases seroma or lymphedema rates,
and whether concomitant liposuction outside the
excision site truly increases the risk of infection.

Wound complications in medial thighplasty
are common; however, most are minor and can be
managed without reoperation. Complications are
Fig. 6. Suture extrusion near both T-points. (Above) The patient
highest for the full-length vertical thighplasty (74
presented 1 year after surgery with bilateral suture granulomas.
percent) and less for the short-scar (67 percent)
(Center) The granuloma was excised in the office. (Below) The
and horizontal (43 percent) procedures. Age,
suture can be seen in the granulation tissue.
hypothyroidism, hypertension, and liposuction
outside of the area of resection may contribute to
inclusive of small areas of delayed wound healing. postoperative complications. Although full-length
Many other authors may regard these small wound vertical incisions are associated with the develop-
healing issues as noncomplications and they may ment of edema, most cases resolve acutely. Fur-
thus be underreported. There were no venous ther prospective studies comparing techniques
thromboembolic events in our population. Most may help reduce the rate of minor complications
revisions were for aesthetic concerns and usually in medial thighplasty.
because of dog-ears or recurrent skin laxity, condi-
tions that are unpredictable and can be severe in Jeffrey A. Gusenoff, M.D.
Department of Plastic Surgery
the massive weight loss population (Fig. 8). University of Pittsburgh Medical Center
Future prospective studies should help clarify 3380 Boulevard of the Allies, Suite 180
many of the issues that remain unanswered in Pittsburgh, Pa. 15213
medial thighplasty. We thought that body mass

Plastic and Reconstructive Surgerys*ANUARY

Fig. 8. Residual deformities or recurrent skin laxity may occur after medial
thighplasty. These can usually be treated with minor procedures of liposuction
or reexcision. (Left) Preoperative photograph. (Right) Two-month postoperative
photograph; red circle delineates residual skin laxity in the upper thigh.

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