The Clinical Problem ( Fig. 39.1 )
The lower extremities, and especially the thighs, are one of the most typical surgery consultations in Argentina. Most patients with massive weight loss desire a better-looking shape of the thighs because they look deflated and have poor skin tone.
Deformities in the thigh region vary according to age, degree of skin laxity, and distribution of adipose tissue. Patient dissatisfaction with surgery can be associated with poor wound healing, seroma, inguinal scar migration, and poor contouring requiring revisional surgery.
The surgeon’s major challenge is how to restore the skin and redistribute the fat in the upper inner thigh to good effect. Inner thigh laxity can be classified according to the vectors of tissue ptosis in the inner thigh.
Surgical Preparation and Technique
Surgical assessment of the thigh involves understanding the ideal anatomic shape, ideal skin envelope, and ideal fat distribution. The inner thighs ideally have the shape of an inverted cone, wider proximally and narrowing gradually toward the knees. This inverted cone appearance is affected by thigh skin laxity and adipose tissue under the influence of gravity ( Fig. 39.2 ). The thigh can be anatomically divided into three zones ( Fig. 39.3 )—inguinal zone, medial inner thigh, and upper knee section.
Objectives in Inner Thigh Reduction
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Improvement of contour in medial thigh section
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Adequate resection to improve skin tension
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Predictable scar placement
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Decrease complication rate
Preoperative Evaluation
Evaluate skin laxity and lipodystrophy in different areas. Note placement of the inguinal and medial scars. Ask about the presence of lymphedema or vascular disease and history of deep vein thrombosis.
Typical patients for an inner thigh reduction show postbariatric deflation. There is skin laxity in patients, who are typically 30 to 60 years of age. They are not concerned about scars but complain about the bulky area in their inner middle thigh.
Planning Inner Thigh Reduction
Patients will have mild to severe skin laxity and fat in different areas. Care must be taken for patients with inguinal scars. Avoid patients with an BMI more than 34 and those who are heavy smokers. Avoid patients with massive localized lymphedema.
Critical decisions in inner thigh reduction include the following:
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How much skin and fat should be removed?
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Is liposuction in other areas required first or should it be delayed?
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Where should the scars be placed?
Technique
Skin Laxity
Use the pinch test, and determine skin laxity with the patient in standing position. Assess potential elevation of the horizontal (subinguinal) vector. Determine if the need for excision reaches or passes the knee.
Scar Placement
The inguinal scar should be placed in the inguinal crease. The vertical incision should not be too anterior or posterior. With the patient in standing position, there should be no visible scars.
Use of Liposuction
It should be used only in areas that will not be excised. Lipocutaneous undermining helps advance skin flaps at closure. Try to stage this with other procedure, such as abdominoplasty.
Factors to Consider in Inner Thigh Reduction
The amount of skin resection is often smaller than that which was originally thought. No undermining reduces complications. With longer surgery time, there will be more swelling and more tension in closure. The patient should be given information about postoperative complication.
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