Complications Associated With Medial Thigh Lift: A Comprehensive Literature Review

INTRODUCTION

Medial thighplasty is an intervention to reduce excess skin and fat in the medial part of the thighs. Because of the changes which occur with age and weight loss, the skin and subcutaneous tissue of the medial thigh region show relaxation and redundancy from the loss of tone and elasticity, with inevitable ptosis of the tissues[1] [Figure 1]. The Pittsburgh Rating Scale[2] is a validated measure of contour deformities after bariatric weight loss. In this study, the authors rated body areas most frequently demonstrating skin and soft-tissue laxity and ptosis (arms, breasts, abdomen, flank, mons, back, buttocks, medial thigh, hips/lateral thighs, and lower thighs/knees). A four-point grading system was designed to describe the most common medial thigh deformities [Table 1]. For each rating, the indicated surgical procedures were outlined. This scale has applications in preoperative planning and evaluating surgical outcomes. When evaluating a patient for thigh rejuvenation, a critical assessment must be made of the quality, location, degree, and extent of skin excess. If the patient has a moderate to significant amount of fat in the medial thigh, the patient will require liposuction. If the skin quality is good and there is not a significant amount of skin excess, liposuction is performed without skin resection. When the skin quality prohibits liposuction alone, liposuction is initially performed followed by excisional surgery after a minimum of 6 months.[3] Medial thighplasty represents one of the most commonly performed plastic surgical procedures. The very first description of thigh lift for aesthetic purpose dates back to 1957.[4] Today, its popularity is growing. During the last few years, there has been a significant increase in the number of patients who undergo this surgery because of redundant skin due to prior bariatric surgery.

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Figure 1

Typical skin-fat excess in the medial thigh

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Table 1 Medial thigh derformities classification using the Pittsburgh Rating Scale

Unfortunately, this type of surgery can lead to a high percentage of postoperative complications [Figure 2]. The most frequent complications are scar migration, wound dehiscence, scar infection, hematoma, lymphedema, and gaping vulva.[567] Over the years, new surgical techniques have been proposed to minimize these complications.

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Figure 2

Wound dehiscence

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Our aim has been to consider the studies in literature that describe the experience of medial thigh lift, with particular reference to the complications occurred.

MATERIALS AND METHODS

In order to verify the complications of medial thighplasty techniques, we selected the studies dealing with the use of this kind of surgery for the treatment of excessive amount of soft tissue and skin.

A systematic literature search of the PubMed database was carried out using the key words “medial thighplasty,” “medial thigh lifting,”; and “technique.” Additional articles were selected reviewing the references of the papers identified using the abovementioned key words.

Inclusion criteria among these papers were:

• The paper was a case study, case report, clinical trial, open label prospective study, case series, or retrospective study.

• Medial thighplasty was used as a surgical therapy.

Exclusion criteria were:

• The paper does not treat medial thighplasty under a surgical point of view

• The paper was a review of the literature

• Complications related to medial thighplasty were not specified.

The entire PubMed database was considered without restrictions of time. Both English and non-English language papers were included. Each article was tabulated as follows: authors, year of the study, number of patients, location, demographic data, surgical technique, follow-up time, and complications.

All kinds of medial thighplasty techniques were considered. We included patients regardless of the cause that drove the patient to this surgical procedure; it was not only postbariatric patients who were included.

The publications were screened manually and reviewed to identify reports for medial thighplasty techniques. Three investigators independently reviewed and extracted data from the papers according to the predetermined criteria.

RESULTS

We identified 48 full-text articles; 32 did not meet inclusion criteria, leaving 16 studies available from 1988 to 2015 [Table 2].

Table 2 Overview of clinical studies on medial thigh lift

One was a case report and 15 were retrospective studies. Overall, 447 patients (age: 24-77 years) were treated in the 16 studies. Different surgical techniques were used for thighplasty: fascial anchoring,[89] concentric medial lift,[10] T-shaped technique,[511] double triangle technique,[12] scarpa lift,[13] vertical lift,[6714] horizontal lift,[67] L-shaped technique,[15] and personal technique. Follow-up ranged from 0.5 month to 112 months.

The postoperative outcome was satisfactory, with most of the performed techniques. In general, almost all of the patients were satisfied with the dramatic improvement in their medial thigh contour.

Pooling the data, complications were observed in 191/447 patients (42.72%). The most frequent complications were: wound dehiscence (82/447 patients, 18.34%)[56891012171819] seroma (36/447 patients, 8.05%),[5691318] wound infection (21/447, 4.96%)[6111518] hypertrophic scarring (11/447 patients, 2.4%),[7891015] and scar migration (16/447 patients, 3.57%).[7101618] Rare complications were partial skin necrosis (one patient)[18] and lymph fistula (one patient).[11]

No major complications, such as thromboembolism and sepsis, were observed. In all the studies, the surgical revision rate was 0-18%, with residual contour deformity and hypertrophic scarring representing the most common causes for revision.

Gusenoff[6] reported the highest complication rate (68%, 72/106 patients) during 1-year follow-up. Wound dehiscence was the most frequent complication; a full-length vertical incision was associated with the highest number of complications.

DISCUSSION

Bariatric surgery for extreme obesity continues to grow in popularity. Massive weight loss following bariatric surgery frequently results in an excess of overstretched skin causing physical discomfort and negatively affecting the quality of life, self-esteem, body image, and physical functioning.[20] Patients often cannot imagine the degree of dissatisfaction they will experience from the sagging skin that comes with weight loss.[21] Patients who express unrealistic expectations may be more likely to express disappointment and dissatisfaction with their postoperative result, even if the surgeon believes that the result is acceptable[22] [Figure 3].

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Figure 3

Clinical outcomes 6 months after medial thighplasty

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Appropriate psychiatric screening and management of these patients is believed to play an important role in successful postoperative outcomes.

Body contouring surgery produces significant improvements in different aspects of body image, self-esteem, quality of life, physical functioning, social life, working conditions, and general psychopathology after bariatric surgery. However, these psychosocial benefits appear to be limited to the first few postoperative years,[22] and the quality of the sex life of the patient does not seem to improve by this operation.[23]

There is a significantly increased risk of postoperative complications after body contouring surgery in postbariatric patients as compared to nonbariatric patients; malnutrition, malabsorption may be a possible explanation.[2425]

Postbariatric surgery body contouring treatment represents a high cost for the patient or public health system. The severe complications increase by 2.96 times the average cost per patient.[26]

Fischer,[27] in 2013, analyzed a total of 1,797 patients who underwent body contouring. The most common area of intervention was the trunk region, with 1,652 patients (91.9%) receiving abdominal contouring and/or contouring of the hips and buttocks. Minor wound complications occurred in 114 (6.3%) individuals, 122 (6.8%) patients suffered a major surgical morbidity, and 40 (2.2%) patients experienced a medical complication. Multiple comorbidities, presence of bleeding disorder, preoperative albumin level, and malnutrition were associated with increased odds of minor wound complications. Inpatient procedures and functional status were associated with increased odds of major surgical morbidity.

Coon[28] analyzed data of 609 massive weight loss patients who underwent body contouring procedures. The author concluded that minor complication rates were higher in concomitant procedures than in single-procedure cases.

Body mass index (BMI) before medial thighplasty should be taken into consideration for patients willing to undergo a body-contouring procedure. High BMI before massive weight loss and before medial thighplasty were associated with a higher risk of developing a postoperative complication.[18]

The most common complication observed in our review was wound dehiscence. Also, Bertheuil[18] in a retrospective case series found wound dehiscence as the most frequent complication with a very similar complication rate (39.6% of the patients experienced at least one complication).

The analysis of the studies showed no uniformity between the performed surgical techniques. The time of follow-up was not specified in 5/16 studies and the demographic data were not reported in 3/16 studies.

In our review, the second most common complication was seroma.[5691318] Superficial lymphatic structures and the great saphenous vein and its branches require special attention while performing a medial thigh lift. The thigh lift changes lymphatic drainage in the lower extremities according to lymphoscintigraphy analyses.[29] Lymphocele treatment requires percutaneous drainage and surgical excision in multiple recurrent cases.[30] Understanding the topographic anatomy of the limbs [Figure 4] may help explain body-contour deformities and provide the anatomic basis for a successful surgical correction.[3132]

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Figure 4

Colles’ fascia (superficial perineal fascia); it is important to recognize and preserve this anatomical structure during dissection of the overlying skin-fat layer

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The main limits of this analysis were the high heterogeneity of the study populations. Selection bias and lack of common outcome measures were some of the problems that prevented a proper meta-analysis. Although this review is not a meta-analysis, we critically assessed the literature and tried to identify high-quality studies. Moreover, many of the technique papers showing favorable results are biased by authors promoting their preferred techniques.

CONCLUSIONS

Medial thigh lift is a satisfying procedure because it provides aesthetic improvement in terms of skin excess and laxity. Complications are frequent but life-threatening complications have not been reported. The use of a vertical incision (wider than the horizontal one) is related to a higher risk of complication. Performing more concomitant surgical procedures on the same patient and a high preoperative BMI of the patient are related to a higher risk of complications.