Over the past two decades, liposuction has grown from a procedure that facilitates small or spot reductions to become an irreplaceable tool in the aesthetic surgery armamentarium in the neck, breast, and circumferential body contouring. Several vital innovations and modifications to the standard suction-assisted liposuction (SAL) have progressively refined the procedure.
Patients present for thigh contouring to take care of obesity, fat collection, skin laxity, etc. The ideal patient for liposuction is the one who has localized areas of fat in the thigh but is otherwise fit and does not have skin laxity. Patients may also present with deformities after a prior attempt at thigh lift, or thigh liposuction elsewhere will benefit from thigh fat injection.
Lower extremity liposuction treats lymphedema that is not entirely resolved with nonsurgical measures. There is a risk of contour deformity and skin laxity. Liposuction in the knee and thigh, therefore, must be conservative. Based on the experience of Prof Moawad for the last 20 years, he prefers syringe liposculpture for small thighs and the external ultrasound power-assisted liposuction for large ones.
Who is the Right Candidate for Thigh Liposuction?
It is helpful to classify patients based on the three types of fatty tissue deposits and skin redundancy:
- Type I: localized fatty tissue deposits. Often younger patients with good skin tone and minimal skin irregularities.
- Type II: generalized fatty tissue deposits. These patients tend to have slightly diminished skin tone with some skin irregularities and circumferential fatty tissue deposits throughout their trunk and extremities.
- Type III: skin redundancy and fatty tissue deposits. Patients display significant skin redundancy that would be more amenable to excisional surgical techniques to improve shape and contour. Liposuction may be a valuable adjunct to achieve an optimal result if necessary.
Liposuction patients often present with a variety of expectations, concerns, and complaints. As a rule, liposuction is performed in healthy patients who maintain realistic goals and expectations.
A successful body contouring patient must satisfy four key elements to achieve and maintain optimal results:
- Lifestyle change
- Regular exercise
- Well-balanced diet
- Body contouring.
Appropriate candidates for thigh liposuction are not morbidly obese, are of stable weight, and have incorporated the above lifestyle changes into their preoperative regimen. Preoperative consultation with a dietician may prove beneficial for long-term patient satisfaction.
Thigh Liposuction is contraindicated in patients who are pregnant or in poor general medical health. Patients with morbid obesity, cardiopulmonary disease, body image perception issues, unrealistic expectations, wound healing difficulties, or who have extensive or poorly located scars should be excluded from consideration for liposuction.
Preoperative assessment of Thigh Liposuction
During this initial interaction, the cosmetic surgeon must assess the patient’s goals of surgery and be able to determine if the patient has realistic expectations regarding the outcome and postoperative body image.
- It may be helpful to have the patient prioritize the body regions they are most concerned with while focusing on specific complaints within these areas.
- A detailed medical history should be obtained, including any medications, allergies, and tobacco use. Critical are notations in the medical history of diabetes, massive weight loss, previous surgery, previous liposuction, and a complete detailed list of medications and supplements.
- Any concerns about a patient’s medical suitability to undergo anesthesia and an operative procedure should result in a referral for preoperative time clearance with either an internist or cardiologist.
- The patients need to be asked specifically about herbal and over-the-counter medications because these are frequently omitted. Non-essential medications should be discontinued at least three weeks before surgery
- preoperative evaluation by a primary care doctor, internist, or cardiologist may be warranted in selected patients. This typically includes anyone with a significant medical history or patients older than 50 years of age.
Massive weight loss patients should undergo the preoperative evaluation and clearance for liposuction for any excisional-type body contouring procedure (including nutrition, hemoglobin, iron, vitamin B12, etc.). It is safest to refrain from operations until these lab results are normalized. Herbal remedies and supplements, including bleeding or hypercoagulability, should be avoided in the perioperative period.
Avoiding aspirin, NSAIDs, and hormonal therapy can help prevent such complications as well. Of course, suppose there is a medical indication and necessity for these drugs. In that case, I should complete a consultation with the primary physician or appropriate specialist before discontinuation of the medical therapy. We strongly recommend that oral contraceptives and estrogen these medications be discontinued a month before the operative procedure.
Physical exam of Thigh Liposuction
A detailed physical exam is performed at the first visit and consultation. Specific attention to prior scars, presence or absence of hernias, evidence of venous insufficiency, and presence of pre-existing asymmetry or contour irregularity should be discussed and noted in the chart.
During the initial and subsequent visits, height and weight with calculating body mass index (BMI) are paramount for safety and observation of long-term trends during follow-up. For liposuction candidates, six key elements are documented.
- Evaluation of areas of fatty tissue deposits and contour deformities
- Skin tone and quality
- Dimpling and cellulite
- Myofascial support
- Zones of adherence.
The physical exam is best performed before a full-length mirror, allowing an open dialogue between patient and physician. High-quality medical images should be obtained with anterior, posterior, lateral, and oblique views, documenting the results and objective evaluation of outcomes by both patient and physician. I should point out any cellulite areas to the patient and note a specific discussion of the expected outcome in these areas.
Professional medical photography can be helpful for accurate and consistent pre-and postoperative documentation. Findings may be challenging to interpret in more prominent individuals, males, or patients with multiple scars.
If superficial thigh liposuction or “liposculpture” is planned, a detailed exam of the subcutaneous fat distribution is essential. I must pay attention to “gender ideal” muscular shape/ mass and fat distribution. Additionally, dynamic areas must be examined and marked in the full range of muscular contraction to yield natural results.
A follow-up visit is typically scheduled 2–3 weeks after the initial consultation. During this visit, computer images are reviewed, which allows the patient to establish realistic expectations. These true-to-life images portray the advantages, disadvantages, and limitations of body contouring surgery. The second visit allows further dialogue between the patient and physician so that all questions may be answered and issues addressed.
Patient Education and Informed Consent of Tigh Liposuction
The patient has sufficient information about the procedure, postoperative course, and long-term results to make a truly informed decision. The patient and physician should discuss the procedure, alternative liposuctions, financial obligations (including further surgeries if required), and complications and risks.
Informed consent is vitally important in evaluating and managing liposuction patients to protect the surgeon and the patient from unexpected outcomes or patient dissatisfaction. The operative surgeon should perform this vital process (not a nurse or staff) and be documented in the medical record.
Operative considerations of Thigh
Preoperative marking Tigh Liposuction
Marking the thigh is done in front of a mirror. The patient should confirm what will be addressed during the procedure. Areas to be suctioned are marked with a circle; areas of adherence and avoidance are marked with hash marks. Access incisions are also marked at this setting.
I use a topographic type of marking with more circles in areas that will need more suction. The central ring is where the most liposuctioned is and at a deep level; as I move to the peripheral ring, the aspirate is less and more superficial to blend nicely with the surrounding areas.
Males and females have varied distributions of fat in the thigh region. Women accumulate fat in a diffuse, circumferential manner or substantial amounts medially and laterally. Standard terms for deformities related to the thigh and hips include saddlebag (a thigh bulge lateral to buttock crease); banana folds, and violin deformity (female contour of the narrow waist, full hips, full lateral thighs, and depression in the zone of adherence between the hips and thighs).
The lateral thigh with saddlebag deformity is a high-risk area susceptible to depression. This depression is the distal extent of the high hip and the proximal extent of the lateral thigh. A straightforward way to evaluate the area of depression is to have the patient laterally separate the leg in the upright standing position. There is no area where the surgical markings are more critical than the junction between the butt and lateral thigh area called the G point.
In general, men accumulate more compact fat in the proximal thighs. The fatty layer tends to be more fibrous. Cellulite may also be seen in women, as are superficial irregularities and contour problems.
It is necessary to describe areas as a complete unit rather than separate areas. I must evaluate the woman from the waistline to the knee. The degree of contouring of specific regions of the thigh is dependent on the analysis and needs of each patient.
In many instances, patients undergoing thigh liposuction of the thigh are best suited for a circumferential approach in the prone/supine position. However, patients may present with an isolated medial or lateral deformity.
Anesthesia and Location of Thigh Liposuction
It is up to the surgeon to determine the optimal surgical setting for each patient undergoing thigh liposuction. Factors influencing this decision are the expected lipoaspirate, length and extent of the procedure, patient positioning, operating surgeon preference, anesthesiologist preference, and overall patient health.
Awake thigh liposuction is performed in MSI- an office-based setting with a tumescent technique. Small-volume liposuction cases can be performed with local anesthesia, with or without mild sedation. Complex, large-volume liposuction, and combined cases should be performed under general anesthesia. At MSI prefer IV anesthesia for most cases.
Maintaining Core Body Temperature.
The patient is placed in a warming blanket 30–60 min before the procedure. The local anesthesia (tumescent) solutions should be warmed and not administered cold. Additionally, calf compression is also applied to the lower legs.
Each area is treated with the body in a specific position on the operating table. With the patient in the lateral position, the flanks and lateral thighs, the buttock fold, and the “banana” fold are treated. We treat the dorsal region, arms, flanks, dorsal and medial thighs, and the knees in the prone position. The abdomen, medial thighs, calves, ankles, and axillary region are treated in the supine position. By bending and separating the patient’s knees, the liposuction of the medial thighs, calves, and ankles is
Local Anesthesia (tumescent)
Four different terms describe wetting techniques: dry, wet, superwet, and tumescent. These terms are based on the volume of infiltrating as a ratio of the volume suctioned. We wait 30-45 minutes before suctioning to ensure that local infiltration is optimum. We use either superwet or mostly tumescent infiltration technique.
Thigh Liposuction Techniques options
Factors that influence selecting a particular type of thigh liposuction include surgeon preference, target area, expected aspirate, and history of the previous liposuction. The traditional SAL remains the most common and popular modality for liposuction.
Suction-assisted liposuction (SAL) uses a two-stage technique. Advantages of this technique include ease of use, malleable cannulas, a wide variety of cannulas, and decades of experience and results.
Power-assisted liposuction uses an externally powered cannula, variable in size and flex, and oscillates in a 2–3-mm reciprocating motion at four thousand–six thousand cycles/ min. PAL is best used for large volumes, fibrous areas, and revision liposuction. Because the PAL cannula breaks up fibrous fat much more readily, the procedure is significantly faster and less labor-intensive for the surgeon than traditional SAL.
Syringe liposuction is an artistic, three-dimensional, architectural body contouring technique. It uses a cannula attached to a 10-60 ml syringe. The cannula moves in a fan shape, with the opening of the cannula facing downward.
IMPORTANT NOTES FOR THOSE WHO ADVOCATE THE USAGE OF THERMAL INJURY TO REMOVE FAT
Various technologies have been introduced over the past three decades to facilitate fat removal and avoid the above-described dose-response curve in liposuction. Many of these have used thermal injury. The thermal energy introduced with ultrasound-assisted, laser-assisted, and radiofrequency-assisted liposuction creates injury to fat cells, therefore facilitating aspiration.
However, the thermal load imparted the creation of additional fibrosis, scarring, and contour irregularities. Therefore, using thermal devices designed to eliminate liposuction complications compounds the problem.
External Ultrasound or U-PAL (My Technique)
A non-invasive external ultrasound method decreases localized fat cells by increasing the intracellular volume and rupturing the cellular membrane. The main indication for external ultrasound isolation with no suction is the non-invasive liposuction of localized fat deposits of volume smaller than 300 ml.
For volumes more significant than 300 mL, we can combine external Ultrasound with either syringe liposculpture in small cases or power-assisted in large ones.
Superficial (Liposculpture) vs. Deep Liposuction and Macro vs. Micro cannulas
Superficial fat can be found throughout most of the body. There are two types of fat removal with aspiration. One is liposuction, which uses a large diameter cannula (3.0–3.7) and usually aspirates fat in middle and deep planes. On the other side, Liposculpture uses microcannulas (less than 2.7mm) and removes superficial fatty layers for better skin tightening.
It is much thicker in such areas as the abdomen, hips, thighs, and buttocks. Below the knee and elbow, the deep layer of fat phases out, and only the superficial layer remains. Twenty-five years of experience performing liposuction has convinced me that I need to be able to work superficially and in the deeper plane if I am to obtain optimum results.
The one area in which I first worked superficially is the inner thigh. Thigh liposuction begins using the syringe for harvesting fat for later grafting. Once enough fat is obtained, liposuction is performed on the deeper fat using the vacuum pump. In the deeper planes, -mm cannulas are usually used.
Once the deeper fat has been reduced, then one can move superficially. Liposuction can be accomplished with the hand in the flat position or by pinch maneuvering around the cannula to ensure a similar position to the skin and underlying muscles. On the other hand, it is necessary always to be in contact with the tip of the cannula. The liposuction must be performed initially in the deeper planes when treating the hips. The surgeon can then move more gradually to the more superficial planes.
Hips, Lateral Thigh, and Thigh depression Areas Liposuction
One of the areas most requested for liposuction is the lateral thigh. Sculpturing of the lateral thighs needs to be blended into the hips, buttocks, and waist to recapture the lateral figure from the waistline to the knee. Autologous fat grafting and liposhifting may be required to obtain optimum results.
Unfortunately, the lateral thighs are one of the most unforgiving body areas. The lateral thighs are very susceptible to irregularity, especially if there is significant skin flaccidity. Suctioning the lateral thigh is done in the prone position or occasionally in the lateral decubitus position.
The prone position allows the operating physician to work on both sides and assess for symmetry. Incisions are often placed in the lateral buttock crease. Occasionally, a patient may benefit from a mid-lateral incision.
The subcutaneous infiltration of the tumescent fluid is then carried out. Over infiltration is indicated in this area, especially if there is flaccidity. I believe that tumescent infiltration should be carried out in this area until the tissue has firmness and a slight “orange peel” appearance, which will help stabilize the tissue during the liposuction phase.
The surgeon needs to make a smooth transition between the hip, the buttocks, the lateral thigh, the back, and the waist. Most of the time, the skin in this area is quite thick, and it contrasts nicely. I might require superficial liposuction for patients who have lax skin and excessive fat in this area.
The lateral thigh is amenable to all forms of liposuction; both the intermediate and deep planes can be suctioned. Final contouring or transitioning from lateral to anterior is often performed in the supine position to remove any “shelf” following the prone position.
The 10-ml or the 60-ml Luer-lock syringe with a small amount of saline and Coleman needles are used to harvest the fat for later use. I attempt to obtain at least 2–3 times the amount of fat I believe will be required. Then the deep phase of Liposculpture is accomplished.
The tunnels are made in a crisscross fashion but always in the vertical plane. Vertical tunnels tend to contract in the horizontal plane, whereas horizontal tunnels will contract vertically and leave waviness and irregularity. Refinement is carried out in the superficial plane using small 2.0-mm or smaller cannulas. At present, I use power-assisted cannulas.
Autologous fat grafting and liposhifting may be required to obtain optimum results. Sculpturing of the lateral thighs needs to be blended into the hips, buttocks, and waist to sculpt the lateral figure from the waistline to the knee.
Buttocks and Banana Fold Deformity
Many patients will come for consultation stating that their “butt” is too large. Most of the time, the enlargement is in the high posterior hips and lateral thighs that give the impression of more prominent buttocks.
A flaccid buttock will accumulate fat in its lower third and present depression in the buttock thigh depression area (banana folds). One needs to work deeper laterally until the desired reduction has been achieved and then work around cautiously underneath the buttocks in the superficial plane. Fine cannulas are used, and slow conservative liposuction is needed.
If the banana fold is too long, the lower third of the buttock is liposuctioned, and the banana fold area is reduced and treated with superficial suction. The liposuction below the buttock fold can yield a dropping of the buttocks and create a worse or even double banana roll.
Fine irregularities are handled with the Toledo “pickle fork” cannula and fat injection. Fat grafting done in multiple tunnels is an efficient and safe procedure to correct or enhance contour deformities of the lower limbs. Injecting fat into the thigh depression region (thigh depression) produces the illusion of an elevation of the buttock. In some cases, removing excess fat from the lateral and posterior thigh will shorten the sub buttock fold and create a more gracious look. The combination will shorten the buttock fold and create an illusion of an elevation of the buttock. The leg looks longer when there is a continuation of the buttock with the thigh.
Overzealous liposuction in the deep or superficial plane may result in buttock ptosis. I can achieve a uniform reduction of the buttock by cautiously treating the intermediate layer resulting in a lower buttock projection. Often, patients requesting buttock contouring desire increased shape and projection and will require augmentation and fat transfer.
Liposuction of the posterior thigh should be approached with caution. In many patients, the skin is adherent to the underlying tissues lacking fatty tissue. Overzealous suctioning in this area results in loss of the adherent zone, rolling, and skin redundancy. This area can be challenging to correct, requiring either autologous fat transfer or skin excision. In females, over liposuction of this area may elongate the buttock fold, masculinizing the female silhouette.
Medial Thigh Liposuction
In my view, the medial thigh is the most unpredictable and difficult area to treat. Patients often present with complaints of legs rubbing together when walking or difficulty with clothing in the medial upper thigh. Fat in the medial thigh is loose and soft, and the overlying skin is thin and often lax.
Thighs’ loose areolar fat and the fragile skin of the inner thigh make this one of the challenging areas to treat without leaving “divots.” It is easy to over resect because this fat does not contain much fibrous tissue. The markings are essential, delineating the highest fat point and reducing the margins.
The plane of suctioning is intermediate fat, and smaller cannulas such as 3.0 mm and 2.4 mm are utilized. It would help if you established realistic expectations with the patient, and I should review certainly the possibility of skin redundancy or laxity.
After the tumescent fluid has been introduced, I start to collect fat for later fat injection if needed. I use 3mm multiholes cannula. I will determine the plan of liposuction according to the amount of fat collected. Most of the posterior fat can be reduced through an incision in the inner thigh at the mid-thigh.
Positioning is essential, and one must be careful if suctioning with the legs in a “frog-leg” position. For this reason, most of the resection should be done with the assistant holding the leg straight and slightly adducted. Blend the upper medial thigh into the mid-thigh. Wearing a garment is essential to mold the inner thigh. External Ultrasound postoperatively helps smooth minor irregularities.
Anterior thigh Liposuction
The anterior thigh is characterized by compact fat of limited thickness. Patients often have more fullness proximally compared with the distal anterior thigh. Contouring of this area helps eliminate step-off or transition points from the medial and lateral thighs.
It helps decrease the projection of the thigh in the posterior-to-anterior view. I can often address the anterior medial thigh through the same access site as the medial thigh. Laterally, we often make an accessory access incision on the proximal anterior thigh. Fine cannulas should be used in this area as it is compact and thin. Irregularities can frequently occur in inexperienced hands.
Most patients have a small area that will need to be reduced on the medial side just below the knee to obtain the most admirable result. The amount of fat removed is minimal, but the results are often quite impressive. Fatty tissue deposits around the knees are usually confined to the medial and anterior leg. I should avoid the posterior knee. I recommend a straight leg position. Phase the knee resection into the mid-thigh without a “step-off.”
The liposuction of the calves and ankles remains challenging and requires more prolonged recovery. Patients may complain of a lack of definition and poor tapering from the bulkier calf to the ankle. Patients must be aware of the increased morbidity associated with the liposuction of this region.
Postoperative Care of Thigh Liposuction
After surgery, liposuction patients are placed in a compression garment, customized based on surgeon preference and the procedure performed. Some compression foam may also be used under the garment for the first week to assist in contouring; this also helps diminish bruising and edema in our hands.
She will wear the garment 24 h per day, removing it only to shower for the first week. The postoperative care includes foam padding and a compression girdle. The garment and the padding are left in place until the fourth postoperative day.
At the end of the first week, she will return to the office for external ultrasonic therapy if it is necessary. The garment will then be worn for the second week, 18 h per day, and for the third week, 12 h per day. Ultrasonic therapy will be continued as needed for irregularity and ecchymosis.
Patients are asked to ambulate on the day of the surgery, and sequential compression devices are placed on the patient in the preoperative holding area and continued until discharge.
Patients are allowed to shower as early as 1 or 2 days postoperatively and are instructed to keep the compression garment 24 h a day for two weeks. The patient may remove the compression garments for bathing.
Initial postoperative visits are scheduled for 5–7 days. The return to activity/work can occur as early as 3–4 days or two weeks, depending on the procedure. Walking is encouraged immediately, and light activity is allowed two weeks after surgery.
Patients should expect to gain weight; due to volume shifts and postoperative swelling. Swelling peaks from 3 to 5 days after surgery. Bruising should be minimal and dissipate by 7–10 days after surgery.
Patients should begin to see contour changes in their waist by two weeks, and at six weeks should be able to appreciate significant changes in their shape. As patients’ activity levels improve and necessary lifestyle changes proceed, you may notice further changes. Depending on the patient, the final aesthetic result can be seen 3–6 months after surgery.
Postoperative lymphatic massage is encouraged to help with swelling and induration. It started before surgery and resumed shortly after the procedure.
Complications of Thigh Liposuction
Postoperative complications occur in three different windows. These are the perioperative period (0–48 h), early postoperative period (days 1–7), and late postoperative period (1 week to 3 months).
Perioperative complications of thigh liposuction can include anesthesia and cardiac complications, cannula trauma to the skin and internal organs, and volume loss/overload from bleeding or excess fluid administration. Cannula injury to blood vessels, bowel, and other solid intra-abdominal organs has been reported.
Liposuction of the thigh, especially when it involves multiple areas, places the patient at risk for hypothermia. Preventative measures include warming the wetting solutions and prep, increasing the ambient room temperature, and use of preoperative and intraoperative warming.
Prewarming the patient for one h has also been shown to reduce the incidence of hypothermia significantly and should be considered, particularly for longer body contouring cases and those involving multiple areas.
In the perioperative period of thigh liposuction, fluid shifts occur, which, if improperly managed, can lead to hypovolemia or volume overload. We require our patients to obtain preoperative medical clearance over 50 years of age or have any concomitant risk factors, such as cardiopulmonary disease.
Careful management of intraoperative and postoperative fluids and an intraoperative datasheet helps prevent volume-related complications from liposuction.
Other early postoperative complications include venous thromboembolism, infection, and skin necrosis. The incidence of DVT in liposuction has been reported at <1%, but a marked increase in this percentage is demonstrated when liposuction is combined with other surgery.
Wound infections, including necrotizing fasciitis, are serious complications known to occur in liposuction. Fortunately, these types of complications are rare. Complaints of persistent postoperative fevers or cellulitis should be closely monitored and aggressively treated.
As a preventative measure, first-generation cephalosporins are administered perioperatively within 30 min of the incision. There is no indication for routine postoperative antibiotics after the perioperative dose in standard liposuction.
Late liposuction complications of thigh liposuction include delayed seroma formation, edema and ecchymosis, paresthesia, hyperpigmentation, and contour irregularities. A loose closure of cannula sites, postoperative compression garments, and expression of residual fluid over liposuction areas at the end of the procedure can potentially reduce the incidence of seroma formation.
Postoperative edema and ecchymosis occur to a varying extent in all patients. Significant ecchymoses may result in hemosiderin deposition and hyperpigmentation. This can be challenging to eliminate. Prolonged edema can occur up to 3 months post-surgery and is best treated with supportive care and lymphatic massage.
Postoperative paresthesia/dysesthesia can occur in all forms of liposuction. The sensory changes are usually reversible and can take up to 10 weeks to recover.
Thigh Liposuction Outcomes
Regarding aesthetic outcomes, the most common late postoperative complication from thigh liposuction is contour deformity or irregularities. Up to 20% of patients can present or will complain of some contour irregularity.
Once a contour deformity is identified, it is best to define the etiology. Mild irregularities of thigh liposuction are often present after suctioning and are treated conservatively with lymphatic massage as swelling and edema resolve. Once a proper assessment of the etiology is made, thigh liposuction can either be directed at re-injecting the fat in the over-resected region or suctioning the adjacent areas to reduce the prominence of the concavity and blend the adjacent areas.
Conclusion: Thigh Liposuction
Over the past three decades, the procedure of thigh liposuction has evolved and has consistently become one of the most popular cosmetic procedures performed around the world. thigh Liposuction is based on scientifically sound principles, but the optimal results depend on the eye to visualize and the skill to create the desired symmetry and contour artistically. Thigh Liposuction approaches will vary since each patient has different anatomy, emotions, and expectations. Superficial thigh liposuction combined with liposuction in the deep or traditional planes is necessary if one is to create a sculpture rather than remove fat.
Prof. Moawad is confident that liposuction will remain one of the most popular procedures performed in the years to come. We must thus remain committed to the common goals of patient safety and improved aesthetic outcomes.