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Stepwise thighs

Article-Stepwise thighs

Key iconKey Points

  • Aesthetic resection of excess skin in post-surgical MWL patients with significant skin excess may result in lymphorrhea, scarring and significant long-term pain
  • However, one expert shares a two-step surgical procedure, which may achieve better aesthetic results and minimal complications

Claudio Cannistra, M.D., Ph.D.
PARIS — Obese patients treated surgically for weight reduction have significant skin excess after they have lost 30 kg to 90 kg (approximately 66 lb to 198 lb). Aesthetic resection of this excess skin can prove to be very challenging, as classical techniques often times result in lymphorrhea, unsightly scarring as well as significant long-term pain. According to one French expert, a fresh, new technique to resect this excess skin in a two-step surgical procedure can greatly benefit the patient and can achieve optimal aesthetic results with minimal complications and significantly decreased risk of lymphorrhea.

"In the past, our gold standard of treatment was the Pitanguy technique for our obese patients who required a thigh and buttock lift following massive weight loss," says Claudio Cannistra, M.D., Ph.D., of the Unit of Plastic Surgery at C.H.U. Bichat C.B., Paris, France. "Unfortunately, this procedure often resulted in unsatisfactory aesthetic results for buttock ptosis and significant pain from scars. Due to these less-than-optimal surgical results, we decided to treat these regions using an innovative two-step procedure."

SIX-MONTH INTERVAL In step one, Dr. Cannistra performs an abdominal lipectomy and lipoaspiration of the thigh's medial and lateral aspect. Six months later, in step two, the buttock thigh lift is performed using a heart-shaped incision traced previously from the perianal region on the inguinal fold anteriorly and spread on to the iliac crest and down to the intergluteal fold posteriorly.

Between 1999 and 2004, Dr. Cannistra performed this novel procedure in 15 patients who had lost 30 kg to 90 kg after surgical treatment for obesity. To date, none of the patients who underwent this new procedure has experienced any complications, such as infections or painful scarring, and, importantly, there are no reports of lymphorrhea. The procedure lasts approximately three-and-a-half hours and no patient required blood transfusions.

"In patients who have undergone massive weight loss, there is an abundance of excess skin at the level of the thigh's anterior and internal aspect," Dr. Cannistra tells Cosmetic Surgery Times . "In this technique, we prefer to first homogenize the subcutaneous fat layer by lipoaspiration approximately four to five months before any follow-up procedure. The superficial lipoaspiration on the inner aspect of the thigh makes the second intervention of a groin lift easier because the subcutaneous fat layer is homogenized and it is not necessary to perform the dissection and subdermic lipectomy in this region."

In his two-stage approach to the buttock and thigh lift for formerly obese patients, Dr. Cannistra first performs an abdominal lipectomy and lipoaspiration of the thighs. Six months later, excess skin is resected via a heart-shaped incision. The patient above had lost 40 kg and is shown pre-step one, and six weeks following the second stage of the technique. (Photo credit: Claudio Cannistra, M.D., Ph.D.)
Further, he explains that it is of paramount importance to preserve the superficial lymphatic vessels in the groin area. To accomplish this, Dr. Cannistra dissects down to the scarpa fascia, preserving the superficial aponeurosis and the lymphatic vessels, very similar to the Avelar procedure.

INELEGANT BUT EFFECTIVE When dissecting the skin, without touching the superficial aponeurosis, Dr. Cannistra pulls off the skin flap with force thus anatomically isolating the skin flap from the superficial scarpa fascia.

"This way, we can preserve and cause only minimal trauma to the lymphatic vessels. I believe that this [is] one of the main reasons why we see a decreased risk in infectious complications and lymphorrhea with this intervention," Dr. Cannistra says.

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