**6. Discussion**

Massive weight loss, either achieved using conservative measures or following bariatric surgery, is not without its noticeable side effects (**Figure 6a**–**f**). These patients are left with deflated chest/breast accompanied with redundant, loose and excess skin on face, neck, arms, abdomen, back, knees, upper and lower thighs and often circumferentially. On the other hand, the skin excess on the upper medial thigh can also be associated with generalised ageing process, weight fluctuations or changes seen following pregnancies (**Figures 3** and **4**) or moderate weight loss following conservative measures (**Figure 5a** and **b**). The skin excess or skin fold in upper medial thigh area may also result from overzealous liposuction or liposuction in poorly selected patients (**Figure 7a** and **b**). These iatrogenic deformities also benefit from medial thigh lift for skin excision.

A classification system for the deformities associated with massive weight loss for each area has been devised to grade the scale of these deformities. The system known as Pittsburgh Rating Scale (PRS) divides all these presentations from 0 to 3, zero being normal and 3 being most severe. The grading scale also suggests best operative approach for each grade [10].

The idea and need for rejuvenation of upper medial thigh is not new and with the safety of anaesthesia and postoperative management, techniques have been described in the past [11–13]. However the techniques described were unable to gain popularity among patients and surgeons alike. Inferior scar migration, scar

*Applications and Limitations of Suction Assisted Transverse Medial Thigh Lift DOI: http://dx.doi.org/10.5772/intechopen.100120*

**Figure 4.**

*(a and b). A 45 year old lady who presented with moderate skin laxity on anterior abdominal wall and upper medial thigh (Pittsburgh Rating Scale 2) following pregnancy and age related changes. (c–f) Postoperative views showing results following suction assisted lipo-abdominoplasty and medial thigh lift.*

#### **Figure 5.**

*(a) A 35-year-old female presenting with major upper medial thigh skin excess following considerable weight loss (Pittsburgh Rating Scale 2). She also was not happy from inadequate results following her abdominoplasty elsewhere. (b) Post-operative view following suction assisted medial thigh lift and revision of abdominoplasty and liposuction of flanks.*

#### **Figure 6.**

*(a–c) Preoperative views of a lady following massive weight loss. She was unhappy with the abdominal skin excess and contouring along with skin laxity on upper medial thigh (Pittsburgh Rating Scale 3). (d and e) Postoperative views showing results following suction assisted lipo-abdominoplasty and medial thigh lift as a day case. The improvement was limited to upper medial third only (f).*

stretching, labial distortion or widening exposing labia-minora and recurrence of ptosis were to name the few. The precise anatomical description and introduction of superficial fascial system suspension by Lockwood provided a new impetus and vigour to perform these surgeries. The renewed knowledge and detailed anatomy of the superficial fascial system helps to restore trunk and limb anatomy resulting in its rejuvenation following massive weight. Lockwood technique of restoring this system has given remarkably improved and longer lasting results with elimination of the drawbacks attached with thigh lifts procedures described earlier [1, 14, 15].

Recent colour Doppler studies following liposuction to the abdominal wall has changed the concepts, horizon, and application of the procedure to various body contouring procedures including medial thigh lift. Doppler Flowmetry studies, performed by Dr. Graf, showed that there was no damage to the abdominal skin perforator system arising from the deep epigastric system and on the contrary, there was an increase of

*Applications and Limitations of Suction Assisted Transverse Medial Thigh Lift DOI: http://dx.doi.org/10.5772/intechopen.100120*

**Figure 7.**

*(a) A 29-year young lay who presented with medial thigh skin excess and laxity following aggressive suction assisted liposuction. (b) Three months following suction assisted medial thigh lift as a day case.*

56% blood flow through these perfortaors [16]. The report of the results have changed previously held concepts of abdominal blood supply that discouraged anterior abdominal wall liposuction combined with abdominoplasty [17, 18]. Honeycombing of the subcutaneous layer of fat resulting from suction assisted liposuction allows anterior abdominal wall to get pulled down without the need of extensive undermining of abdominal wall skin or dissection and preserving anterior wall vascularity at the same time [2, 4, 16]. The concept was extended to liposuction assisted brachioplasty and medial thigh lift with safety, reproducibility and acceptable results [5–8].

Suction assisted medial thigh lift can be performed using a transverse incision with or without vertical element. The procedure can also be performed on its own, or it can be combined with other procedures. When performed on its own, it can be performed as a single stage day case procedure. Some surgeon still prefers to do the liposuction first and skin resection as a second stage procedure, about six months or so later. By staging the procedure, the idea is to add safety to the skin flap, as it is generally believed that liposuction combined with medial thigh lift may result in higher local complication rate including skin flap necrosis. However, staging the procedure needs two hospitalisations each at an extra cost, with two sets of recovery periods and each procedure may have its own complications. Additionally, liposuction does result in subcutaneous scarring and quite often makes the tissue dissection and resection difficult, which may increase the incidence of local complication rate on its own [6]. On the contrary, complications rates following liposuction assisted medial thigh lifts are few and gives an added benefit of performing it as a day case. Vascularity of the skin flaps, due to undisturbed perforators, prevents skin necrosis or wound dehiscence secondary to ischemia. Honeycombing of the underlying tissue allows skin approximation without creating a dead space or putting any pressure on the skin edges resulting in good healing. Absence of dead space complemented by intact venous and lymphatic system prevent seroma formation and surgery can be performed without drains [6, 8]. Liposuction assisted transverse medial thigh lift have shown no skin flap necrosis, wound dehiscence or other major complications when compared with en bloc excision [8].

In personal experience of the author, all patients have shown a good and early recovery with no wound breakdown or skin flap necrosis. However and for adequate results, patient selection is extremely important. The transverse resection procedure should ideally be limited to PRS Scale 1–2 [10]. Drawback or disadvantage of suction assisted transverse medial thigh lift is the extent of improvement expected. This improvement is normally limited to upper medial third mostly (**Figure 6a**–**f**). When a patient presents with massive weight loss (PRS Scale 3), a vertical component must be added to transverse resection for an adequate circumferential results unless patient is not prepared to have an extensive scars on the inside of the thigh. Patient must be informed that, when transverse skin excision is performed, improvements are limited to upper third of the inside of the thigh only and no change is expected to lower two thirds of the inner aspect of the thigh or to other parts of the thigh including buttock area (**Figure 6a**–**f**). Last but not least, a proper history and physical examination, thorough informed consent and appropriate selection of patient is mandatory for a beneficial outcome and is the key to a happy patient.
