**4. Anaesthesia, positioning, infiltration and technique**

All procedures are performed under full general anaesthesia. All patients have endotracheal intubation for a secured airway. All patients receive intravenous antibiotics and intermittent pneumatic decompression device for DVT prophylaxis. Catheterisation of patients is not required due to short nature of the procedure unless the procedure is carried out simultaneously with another procedure. Low molecular weight heparin is given in selected cases of medial thigh lift unless the procedure is combined with other procedures. For a better intraoperative position and patient handling, procedure is performed in two separate positions. This allows access to the upper medial thigh without abducting or spreading the legs and I prefer to operate first in a prone position. Steps involve infiltration, liposuction and excision of the posterior half of crescenetric markings before turning them to supine position to complete the surgery. Infiltration fluid is prepared using 1,000 cc of normal saline, 30 ml of 1% lidocaine plain and 1 mg of adrenaline (1:1,000). Measured and equal infiltration is performed using Luer Lock 50 cc syringes with 2 mm blunt tipped infiltration needles. On average 250 to 300 cc fluid is used on each side. Suction assisted lipectomy (SAL) is performed first using 4 mm suction cannula with patient in prone position. Agrresive liposuction is predominantly limited to the marked area to ensure viability of adjacent skin (**Figure 1a**). A conservative liposuction is also performed to an adjacent area on the thigh just below the proposed line of excision. This allows flexibility, thinning and, honeycombing of the skin flap. Honeycombing allows a better mobilisation of skin flaps and harmony in tissue thickness when approximated. Usually the skin flaps thickness up to 1.5–2 cm is ideal to keep lymphatic system secured. The liposuction plane is superficial to deep fascia that prevents injury to all important neurovascular bundles tucked well under the deep fascial layer. Starting from the lateral to medial from gluteal crease, skin is incised along the upper marked margin and up to midpoint of the marked crescent. The honeycombing allows risk free dissection of skin and defatted subcutaneous layer in downward direction and under direct vision. An inferiorly based flap is raised and once the dissection has reached to the lower

**Figure 1.** *Intraoperative pictures showing resection of the posterior half of the skin of left medial thigh, in prone position. (a) Liposuction of the posterior thigh. (b) Incision of the upper and lower margins of the posterior crescenteric markings. (c) Lateral to medial dissection of the flap above deep fascia using finger-switch point diathermy on cutting mode. (d) Deep closure along with restoration of superficial suspensory ligament. (e) Posterior half of the medial thigh skin closure completed on both sides with an inch wide adhesive dressing.*

margin of the marked crescent, proposed excision margin is approximated for a tension free closure. Adjustments are made if necessary. Skin is now incised along the lower margin and extended medially to the midpoint of the crescent (**Figure 1b**). The dissection and the separation of skin is performed using finger-switch point diathermy, closer to the skin flap and under direct vision which facilitates prospective haemostasis in a more secured way without disruption of lymphatic network (**Figure 1c**). Once excision of the posterior half of skin crescent is completed, superficial fascial system is restored using 2–0 vicryl sutures from dermis of the upper and lower skin margins and sutured to Colle's fascia [9], fascia over the adductor muscle and periosteum of the pubic bone (**Figure 1d**). Skin closure is performed using 3–0 vicryl subcutaneous and 4–0 monocryl intradermal sutures and selfadhesive dressing (**Figure 1e**). Wound is dressed and patient is turned into supine position and the procedure is repeated on the anterior aspect to complete the medial *Applications and Limitations of Suction Assisted Transverse Medial Thigh Lift DOI: http://dx.doi.org/10.5772/intechopen.100120*

**Figure 2.**

*Stages of anterior part of the suction assisted liposuction and medial thigh lift on the anterior aspect of right side. (a) Measured infiltration of fluid using 50cc Luer lock Syringe mounted with 2 mm infiltration blunt needle. (b) Suction assisted lipectomy using 4 mm cannula. (c) Skin incision in perineal thigh junction. (d) Inferiorly based flap with underlying muscle neurovascular bundle protected by deep fascia. Flap is pulled up to check and ensure a tension free closure before the skin belt is excised. (e) Lateral to medial skin flap dissection on the anterior aspect of right upper medial thigh. (f) Skin closure in layers.*

thigh lift (**Figure 2a**–**f**). Dissection in the anterior part has to be done carefully to avoid injury to great saphenous vein and lymphatic system. Skin and fascial system closure is achieved as above. A single drain is used on each side and subsequently removed next day. Sutured area is wiped with Povidone Iodine, sprayed with an adhesive aerosol and an inch wide adhesive linear paper dressing applied. Light absorbent gauze dressing is placed and a surgical pressure garment applied.

#### **4.1 Postoperative instructions**

Patients stay in the clinic for at least 6–8 hours. Early postoperative ambulation is encouraged and elasticated compression stockings are applied until patient is well mobilised. Once they have passed urine, pain free and able to eat and drink without nausea or vomiting, they are allowed home with a supply of oral antibiotics and oral analgesia. Soft dressings can be taken down after two or three days and patients are encouraged to have sitz bath for localised cleansing and hygiene.

### **5. Results**

All patients were females in the series and mostly done as day cases (**Figures 3**–**7**). There was no skin loss, wound breakdown, labial distortion, deep venous thrombosis, seroma, pulmonary embolism or motor nerve damage. Postoperatively all patients retained sensation of the distal limbs and there was no lymphedema noticed in any of the patient in the group.

#### **Figure 3.**

*(a–c) Preoperative views of a 38 year female model with minor skin excess of upper medial thigh (Pittsburgh Rating Scale 1). (d–g) Postoperative views two weeks following abdominoplasty and suction assisted medial thigh lift.*
