Introduction

The increasing global incidence of obesity resulted in a large number of patients undergoing bariatric surgery, which leads to excessive skin and soft tissue and decreased skin tone.¹ Excessive fat and skin accumulation often cause social discomfort, local skin lesions due to friction between the thighs, movement difficulty, discomfort in the patient’s sex life, and self-esteem issues.¹

The first author todescribe thighplasty was Lewis² in 1957. In 1988, Lockwood et al.³ revolutionized thighplasty by anchoring the skin flap to Colles’ fascia,^4,5,6 increasing surgical stability and decreasing complications.⁷ Le Louarn (2004) added the critical role of radical liposuction before avulsion resection to minimize lymphatic complications and reduce edema and seroma formation.⁸

Thigh subcutaneous adipose tissue resection techniques described to date include the J- and T-shaped scar techniques. Longitudinal resection gained prominence for skin traction in longitudinal and transverse directions.^9,10,11 However, these techniques still result in anterior transverse scars at the thigh root and groin (►Fig. 1) that can be conspicuous and stigmatizing, especially in intimate life. Thus, despite the advances in current thighplasty techniques, two points remain unsolved: apparent anterior scar at the thigh root and groin and frequent suture dehiscence in scar angles.¹²

Fig. 1 - Anterior scars from thighplasty techniques

Fig. 1 - Anterior scars from thighplasty techniques

Objective

This study describes a new thighplasty technique with S-shaped skin resection in the posteromedial region of the thigh to further improve the aesthetic outcomes of the procedure by not producing anterior groin scars and angled scars to reduce their dehiscence.

Patient and methods

Inclusion criteria: patients over 18 years old, undergoing post-bariatric thighplasty with weight loss greater than or equal to 30kg, and a body mass index (BMI) below 30. The patients had no comorbidities or risk factors. They read and signed the informed consent form (ICF) authorizing the surgery and data publication for scientific purposes.

For deep vein thrombosis prevention, the patients received enoxaparin, 40mg, for 5 days.

Two female patients underwent post-bariatric surgery thighplasty with S-shaped skin resection. The first subject was 44 years old, weighed 77.5kg, had a BMI of 29.17, and had lost 30kg. The second subject was 39 years old, weighed 70.60 kg, had a BMI of 26.57, and had lost 30kg.

Using a bi-digital maneuver forceps test with tissue invagination, we made a mid-posterior S-shaped marking on the thigh with the patients in the orthostatic position and checked it in the prone position. This S-shaped marking for resection had the upper transverse part of the S in the sub-gluteal groove, and the longitudinal and transverse incisions of the S-shaped skin resection were distributed throughout the thigh (►Fig. 2).

Fig. 2 - Marking of skin resection in black and liposuction in blue

Fig. 2 - Marking of skin resection in black and liposuction in blue

Surgery occurred with the patient in the prone position.

After epidural anesthesia, we performed superficial and deep liposuction of the thighs with a vibro liposuction device radically in the areas for resection.

We performed skin resections by avulsion without detachment to preserve lymphatic circulation. Avulsion resection tends to reduce the incidence of seroma, lymphedema, and hematoma as it spares local circulation^11,12 (►Fig. 3).

Fig. 3 - Skin resection by avulsion

Fig. 3 - Skin resection by avulsion

Results

The surgeries for both patients lasted 4hours each. The patients were discharged from the hospital on the same day and could walk normally. Suture removal occurred after 2 weeks, and the patients were under postoperative monitoring for 6 months. We instructed them not to squat for 2 weeks and to return to physical activities after 1 month.

The surgical technique of posterior medial thighplasty in S considerably reduced excessive skin, improving thigh contour. The mid-posterior resection in S evolved with no complications, including suture dehiscence. In addition, the resulting scar was in the sub-gluteal groove, the posterior region of the body, and the medial region of the thigh, forming a mid-posterior S-shaped scar, sparing the anterior region and the groin. The better scar concealment and the absence of a previous scar are the great achievements of this new technique, which may favor a potential improvement in the personal satisfaction of the patients and an increase in the number of treatments due to a likely greater acceptance by the subjects (►Figs. 4 and 5).

Fig. 4 - Pre- and post-operative period of posterior S-shaped thighplasty

Fig. 4 - Pre- and post-operative period of posterior S-shaped thighplasty

Fig. 5 - Pre- and post-operative period of posterior S-shaped thighplasty

Fig. 5 - Pre- and post-operative period of posterior S-shaped thighplasty

Discussion

Despite advances in thighplasty, the visible anterior scars and high rate of wound dehiscence remain unsolved.¹² The new thighplasty using the S-shaped skin resection described here removes large amounts of excessive skin in the longitudinal and transverse directions without anterior groin scarring. The two cases described by the authors presented no wound dehiscence, probably because the angles were S-shaped, avoiding flaps with acute angles, which are more prone to ischemia and suture dehiscence.

Inelastic scar contractures frequently occur in the longitudinal component of the L and T-shaped scars from other thighplasties, often leading to linear fibrosis and noticeable scars potentially restricting local movement (contracture). In addition, they are more prone to ischemia, increased tension loading, suture dehiscence, and skin necrosis. These undesirable consequences are less likely to occur with S-shaped skin resections, as they do not create right or sharp angles. Furthermore, skin resection with an S-shaped incision on the cylindrical surface of the thigh simultaneously removes excessive longitudinal and transverse skin along the thigh in multiple vectors¹³ without requiring a separate straight-line vector, a step often needed for the T and L-shaped incisions (►Fig. 6).

Fig. 6 - Traction in multiple vectors

Fig. 6 - Traction in multiple vectors

The proposed technique solves the discomfort and aesthetic deficiencies resulting from scars from conventional thighplasties. Since the scars from the new technique are posterior and positioned in the sub-gluteal folds, they are perfectly hidden even with the thighs in abduction. Moreover, the technique may present a lower risk of dehiscence and skin retraction, as the S-shaped scars have no angles. Furthermore, it has the same, or even higher, potential for removing large skin amounts transversely and longitudinally. Lastly, it allows for better traction distribution from the root of the thigh to the knees. (►Figs. 7 and ).

Fig. 7 - Mid-posterior S-shaped scar proposed by the technique

Fig. 7 - Mid-posterior S-shaped scar proposed by the technique

Conclusion

The thighplasty technique presented here is an innovative and unprecedented procedure with an S-shaped resection, without suture angulations, and with better scar tension distribution. This results in better scar concealment since they are in the subgluteal and medial folds of the thigh. In addition, the new technique may reduce the chance of wound dehiscence, allowing extensive skin resection in the transverse and longitudinal directions in multiple vectors.¹³

This case report is the initial step in our studies to scientifically prove the virtues of this new surgical approach.