Massive weight loss (MWL) patients, both thoselosing weight through diet and exercise pro-grams and those who have undergone gastric

bypass surgery (GBS), represent a growing population,particularly as weight loss surgery continues to becomemore safe and effective. Many of these patients presentto plastic surgeons seeking to reduce skin excess andlaxity resulting from MWL. The thigh is one of the morecomplex regions to address in MWL patients because ofthe differing degree, location, and quality of skin excessand fatty tissue, as well as surgical risk factors.

Lockwood1,2 popularized thighlifting in contempo-rary literature; however, he did not specifically addressMWL patients. In his technique, he performed conser-

vative skin resection in combination with underminingand liposuction, and he was able to create a scar hid-den in the groin crease. Lifting was accomplished byapproximating the superficial fascia of the thigh toColle’s fascia in the groin, achieving a vertical pull. Heincorporated thighlift into his lower body lift, includingabdominoplasty and lower backlift. He cautionedagainst extending the thighlift scar into the infraglutealfold and suggested that surgeons limit skin resection to5 cm to 7 cm. While he showed great results, the appli-cability of his procedure to MWL patients was inade-quate because of limited skin removal and the risk ofscar migration from dependence upon attenuated tis-sue, leading to the potential risk of labial spread andthe subsequent need for revisions.

Because of the limited applicability of the Lockwoodthighlift to MWL patients, more surgeons have turned tovertical extended thighlift.3-6 This technique involves the

Body Contouring

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Background: After massive weight loss (MWL), many patients present with concerns about skin excess andlaxity. The thigh is one of the more complex regions to address in MWL patients because of the differingdegree, location, and quality of skin excess and fatty tissue, as well as surgical risk factors.Objective: The authors describe a technique called the anterior proximal extended (APEX) thighlift to effec-tively treat upper thigh skin excess with a hidden scar while also enhancing adjacent body regions.Methods: A review was performed of 97 MWL patients who underwent thighlift surgery between March 1998and October 2007. Eighty-six women and 11 men, with average weight loss of 146 lb and average body massindex (BMI) at contouring of 29.8, were included in the study. The risk factors that were assessed included age,gender, medical conditions, tobacco use, BMI, weight of skin excised, and surgery performed. The outcomesthat were assessed included wound healing and lymphedema. Extended vertical thighlift was performed in11 patients and anterior superior thighlift in 86 patients.Results: Complications of thighlift included wound healing problems (n � 18; 18.6%); lymphedema (n � 8;8.3%); cellulitis (n � 7; 7.2%); seroma (n � 3; 3.1%); and bleeding (n � 1; 1%). On multivariate statisticalanalysis, age and BMI were found to impair healing in the entire thighlift group. For patients with a BMI greaterthan or equal to 35, the odds ratio (OR) for a wound healing complication was 13.7 (P � .03). Hypothyroidismwas strongly associated with lymphedema, with an OR of 23 (P � .06). Extended thighlift trended toward lym-phedema (OR � 16.7; P � .08).Conclusions: Thighlift can be a satisfying procedure for both the patient and surgeon because it provides aes-thetic improvement in terms of skin excess and laxity. The APEX thighlift is a new technique that expands uponthose previously described in the literature to effectively treat upper thigh laxity with a hidden scar after MWL.(Aesthet Surg J; 29:513-523.)

Dr. Shermak and Ms. Mallalieu are from the Division of PlasticSurgery, Johns Hopkins Bayview Medical Center, and Dr. Changis from the Department of Surgery, Johns Hopkins School ofMedicine, Baltimore, MD.

Does Thighplasty for Upper Thigh LaxityAfter Massive Weight Loss Require a

Vertical Incision?Michele A. Shermak, MD; Jessie Mallalieu, PA-C; and David Chang, PhD, MPH, MBA

514 • Volume 29 • Number 6 • November/December 2009 Aesthetic Surgery Journal

removal of medial thigh tissue from the groin to the kneethrough a vertical incision, converting the axis of pullfrom vertical to horizontal. There is no reliance on thesuspension of tissues that might fail because of attenua-tion, nor is there limitation of the degree of skin removal,such as that required in patients with significant skin lax-ity and poor skin quality extending to the knee. Inexchange for the dramatic results, the patient receives avisible scar with risk of irregularity in the junctionbetween the anterior and posterior thigh, and the accom-panying risks of lymphedema and lymphoceles.3,7,8

While the authors appreciate the greater power of thevertical extended medial thighlift, many MWL patients donot have poor skin quality or exaggerated skin redundancyalong the length of the thigh meriting a visible scar withpotential injury to venous and lymphatic structures. Wehave worked to extend the Lockwood medial thighlift toimprove its relevance to the MWL population. To that end,we have extended the anterior inguinal crease incision pos-teriorly into the infragluteal fold with suspension of poste-rior thigh skin to the ischial periosteum, and have extendedthe superior portion of Lockwood’s incision to merge intothe abdominal incision. Our technique has been named theanterior proximal extended (APEX) thighlift. The APEXthighlift has increased the degree of skin excision and pullbeyond that of Lockwood’s technique, while maintaining ascar that is hidden in revealing clothing. A secondaryadvantage of this technique is improved gluteal aesthetics,which results when skin is removed from the inner thighand infragluteal area that would otherwise blunt the aes-thetic contour of the medial inferior buttock.9,10

METHODSThe operating room census between March 1998 andOctober 2007 was reviewed, as were the patient databaseand clinic notes of the primary plastic surgeon (MAS)performing surgery on MWL patients at an academicteaching institution. Ninety-seven patients who had

undergone thighlift were identified. Potential risk factorsassessed included age, gender, comorbid medical condi-tions, tobacco use, body mass index (BMI), weight ofskin excised, and surgery performed.

APEX thighlift required prone to supine positioning,preferably using spreader bars to allow easier access tothe medial thigh. The patient was placed in the proneposition (Figure 1, A) and a hemiellipse of skin wasremoved from the upper posterior thigh, with the superiorportion of the incision at the infragluteal crease.Dissection occurred superficial to muscle fascia and sub-cutaneous tissue was maintained over the ischium. Theamount of skin removal that could be performed wasassessed and completed. Closure began with approxima-tion of the Scarpa fascia of the thigh to the ischialperiosteum, with no. 1 braided permanent interruptedsutures to retain the infragluteal fold and provide strongsuspension. The skin was then approximated using der-mal closure with buried monofilament absorbable sutureand intracuticular suturing with monofilamentabsorbable suture. The incision was dressed withDermabond (Ethicon, Somerville, NJ) to provide furtherstrength of closure and protection of the wound. If per-formed in conjunction with lower backlift and/or outerthigh liposuction, thighlift occurred after backlift andliposuction because preoperative markings may haverisen with elevation of the buttock.

The patient was then carefully turned into the supineposition (Figure 1, B). If necessary, completion of theanterior thighlift took place after abdominoplastybecause of secondary medial thighlifting with abdomino-plasty and the potential need to modify the markings. Acontinuous incision from the posterior medial closurewas created symmetrically along the inguinal crease, orwithin the lateral mons pubis if there was a large monsthat required narrowing. The thighlift resection proceededfrom the posterior medial aspect superiorly in a step-wisefashion to avoid overresection. Elevation of the medial

Aesthetic Surgery Journal

A B

Figure 1. A, The surgeon begins with the patient in the prone position, performing lower backlift with autologous gluteal augmentation and lateralthigh liposuction before the posterior thighlift. B, The patient is then turned to the supine position and abdominoplasty is followed by completionof the anterior portion of the thighlift. Suspension to the pubic periosteum is performed and the incision is extended superiorly and laterally,merging into the abdominoplasty incision and providing further pull and tissue removal in the anterior superior thigh.

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thigh skin was performed just under the Scarpa fascia,with avoidance of injury to venous and lymphatic struc-tures; the plane of elevation was superficial. The Scarpafascia of the thigh was suspended to the pubic perios-teum with no. 1 braided permanent suture. The resectioncontinued superiorly along the lateral pubis, leaving asuperior triangle (“dogear”) of thigh skin that wasexcised and blended into the abdominoplasty incision,allowing a second directional axis of pull on the centralsuperior thigh in a more vertical orientation. No drainswere used and the anterior skin was dressed withDermabond (Ethicon, Somerville, NJ); gauze dressings ortape were not necessary. While no liposuction was per-formed on tissue in the region of resection, lateral thighliposuction complements this procedure nicely. The pre-operative markings and preoperative/postoperative com-parison views of the patient featured intraoperatively inFigure 1 can be seen in Figures 2 and 3.

Perioperative intravenous antibiotics were begunbefore the start of surgery and continued until dischargefrom the hospital. A urinary catheter was placed at thebeginning of the case. We recommended that the patientmaintain the catheter for up to five days postsurgery, butthe catheter was removed the day after surgery if that

was the patient preference. The patient was maintainedin thromboembolic deterrent hose and sequential com-pression devices throughout surgery and until discharge.Prophylactic subcutaneous unfractionated heparin or lowmolecular weight heparin was administered after surgery.Most patients saw a physical therapist within 18 hours ofsurgery to ensure satisfactory ambulation.

Outcomes for all techniques were recorded and multi-ple logistic regression analysis was performed to deter-mine the association between risk factors andcomplication outcomes. Complications recorded includedwound healing problems, lymphedema, cellulitis, seroma,and bleeding. Lymphedema diagnosis was made througha physical examination indicating a swollen calf andmay have been identified by the patient. The primarydependent variables included wound healing and lym-phedema. Independent variables included age, gender,medical conditions (hypertension, diabetes, hypothy-roidism, asthma, sleep apnea, osteoarthritis, cardiac dis-ease, autoimmune disease, reflux disease,thromboembolism, and tobacco use), and weight of skinexcised. Statistical analysis was performed in Stata MP(version 10; StataCorp, College Station, TX). P � .05 wasconsidered statistically significant.

A B

Figure 2. A, Preoperative inner thigh crescent markings. The degree of excision is measured with a pinch test and no commitment is made untilthe surgeon is assured that closure is possible through step-wise excision and closure. B, Inner thigh crescent markings. Also planned is a lowerbacklift with autologous gluteal augmentation.

RESULTS

The thighlift patient population included 97 individu-als (86 women and 11 men). The average age was 39years (range 22 to 57 years). Existing medical condi-tions included (alone or in combination): osteoarthri-tis (n � 13), hypertension (n � 14), reflux disease(n � 10), hypo thyroidism (n � 8), asthma (n � 9),

diabetes (n � 7), cardiac disease (n � 2), sleep apnea(n � 2), auto immune disease (n � 2), and venousthrombo embolism (VTE) history (n � 1). There were12 active smokers.

Weight loss was achieved by open (n � 58) orlaparoscopic (n � 26) GBS, or diet and exercise (n �

13). The average weight loss was 146 lb. The average

C D

516 • Volume 29 • Number 6 • November/December 2009 Aesthetic Surgery Journal

A B

Figure 3. A, C, Preoperative views of a 41-year-old woman who lost 167 lb after laparoscopic gastric bypass surgery, reaching a body mass indexof 22.6. She desired a lower body lift. This same patient is featured in Figures 1 and 2. B, D, Two months after thighlift with the anterior proximalextended thighlift (APEX) technique.

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BMI at contouring was 30 (range 21 to 45), with astandard deviation of 4.78.

Thighlift was performed with an APEX thighlift(n � 86; 89%) or through extended vertical thighlift(n � 11; 11%) technique. Four patients had previousthighlift surgery. Two of these had proximal thighliftsrevised with the APEX thighlift; the other two hadproximal thighlifts revised with extended verticalthighlift. The average skin resection per thigh was 275 g(range 40 to 980 g). Body contouring proceduresincluded work on the abdomen (n � 86; 99%), back(n � 48; 55%), arm (n � 42; 48%), and chest/breast(n � 25; 29%; Table 1).

The average length of hospital stay was two days. Ofthese patients, 75 (77.3%) had an uneventful recovery.The average follow-up was 14.8 months (median eightmonths; range one to 107 months). The following com-plications occurred and, in some cases, more than onetype of complication occurred in patients undergoingthighlift: wounds (n � 18; 18.6%), lymphedema (n � 8;8.2%), infection (n � 7; 7.2%), lymphocele/seroma(n � 3; 3.1%), and bleeding requiring return to theoperating room (n � 1; 1%). Lymphedema diagnosiswas based on clinical examination and patient com-plaint; calf measurements were not taken before andafter surgery. In all cases, lymphedema was temporary

and responded well to compression hose and elevation,resolving within two months of surgery. There were nothromboembolic complications, confirmed by minimallyinvasive venous Doppler ultrasound studies in patientswith lymphedema (Table 2).

No patients suffered from urinary tract infectionsfrom the urinary catheter. There were no problems withlabial spread. With the use of large braided nylonsutures for suspension, temporary palpability or discom-fort was experienced by some patients. One patientrequired unilateral removal of a suture at the junction ofthe pubis and ischium because of continued tenderness.Surgery to remove this painful suture revealed a methi-cillin-resistant Staphylococcus aureus infection. Thepatient healed well with appropriate oral antibiotic ther-apy, without subsequent labial spread.

Upon multiple logistic regression analysis (controllingfor patient age, gender, BMI, and comorbidities includ-ing, diabetes, hypothyroidism, and tobacco use), it wasfound that age significantly impacted healing complica-tion, with a BMI greater than or equal to 35 showing atrend for wound healing complication. Each one-yearincrease in age was associated with a 9% increase inrisk of a wound healing complication (P � .037). Therewas a trend toward increased risk of wound healingcomplications for patients with BMI greater than orequal to 35 (odds ratio [OR] � 5.2; P � .056; Table 3).Vertical thighlift, hypothyroidism, and male gendershowed significant associations with lymphedema. HighBMI was less likely associated with lymphedema (OR �0.62; P � .025), which is probably related to the factthat lymphedema is more difficult to diagnose in obeseindividuals (Table 4).

DISCUSSIONWhile MWL has catalyzed growing interest and increasedpublications regarding thighlift, elements of current con-cepts (such as vertical thighlifting or Lockwood’s proxi-mal anteromedial technique) may be traced back to earlierliterature. Lewis advocated for wide elliptical excision ofthe medial thigh along the inguinal crease with verticalextension in the 1950s and 1960s.11,12 In 1958, Pitanguy13

performed extensive dermatolipectomy for the correctionof trochanteric lipo dystrophy and the ptotic inner thigh,bringing an incision from the lateral buttock at the fascia

Table 1. Demographic information of the study cohort*

No. of patients 97

Ratio of females:males 86:11

Age, y, mean (range) 39 (22–57)

Average BMI at body contouring (range) 30 (21–45)

Average weight loss, lb 146

Method of weight loss, n (%)

Open GBS 58 (60%)

Laparoscopic GBS 26 (27%)

Diet and exercise 13 (13%)

Thighlift techniques, n (%)

APEX 86 (89%)

Extended vertical 11 (11%)

Contouring procedures in conjunction with thighlift, n (%)

Abdomen 86 (99%)

Back 48 (55%)

Arm 42 (48%)

Chest/breast 25 (29%)

Abdomen and back (circumferential) 46 (47%)

Average weight of thigh skin excised at plastic surgery, g (range) 275 (40–980)

Average length of hospital stay, days 2

APEX, anterior proximal extended thighlift; BMI, body mass index; GBS,gastric bypass surgery.*Cohort taken from massive weight loss patients who underwent thighliftsurgery between March 1998 and October 2007.

Table 2. Thighlift complications

Complication n (%)

Wounds 18 (18.6%)

Lymphedema 8 (8.2%)

Infection 7 (7.2%)

Lymphocele/seroma 3 (3.1%)

Postoperative bleed 1 (1%)

Thromboembolism 0 (0%)

Uneventful recovery 75 (77.3%)

518 • Volume 29 • Number 6 • November/December 2009 Aesthetic Surgery Journal

lata across the gluteal fold, ending anteriorly in the medialthigh. This technique was further elaborated upon byHoffman and Simon.14 Schultz and Feinberg15 describedmedial thighlift from the inguinocrural crease to thegluteal crease. Vilain and Dardour16 also used anapproach from the anterior medial thigh into the glutealcrease, without suspension.

A review of the literature affords the benefit of bor-rowing components from various techniques to createan approach that may be individualized and therebyimprove upon surgical results for a specific patientpopulation.17,18 The APEX thighlift is the product ofsuch a review and we present a solution for MWLpatients who have laxity in the upper half of the thighand ptosis throughout the lower body. The APEXthighlift takes advantage of the hidden scar describedin earlier techniques, using an incision along themedial thigh inguinal crease (or inside that if thinningof a widened pubis is desired) that extends posteriorlyinto the infragluteal fold (Figure 4). The power of thistechnique is granted through the lengthened antero-posterior scar and the suspension along both thepubic periosteum and the ischial periosteum at theinfragluteal fold, which creates strong reinforcing ele-vation. Whereas Lockwood’s thighlift techniqueproved frustrating in patients who have experiencedMWL, the APEX thighlift has led to far more satisfyingresults because of the greater suspension and anincreased degree of skin removal. As stated, in thesepatients, the pelvic periosteal suspension from front

to back is what makes this technique more powerful.Earlier in our experience, we saw less successful out-comes and had some problems with scar wideningand migration, particularly at the junction of thepubis and ischium. However, with greater attention toproper periosteal suspension, we have seen greatersuccess in outcomes. We now prefer this technique tothe one described by Lockwood.

The ideal candidates for APEX thighlift are MWLpatients who have a redundancy extending no furtherdistally than the midportion of the medial thigh withgood skin quality, and who have a BMI less than orequal to 30 (Figure 5). While patients with significantskin redundancy to the knee and poor skin quality arebetter candidates for vertical thighlifting techniques,patients understanding the limited distal reach of theAPEX lift but who desire a hidden scar are also goodcandidates. While vertical thighlift after MWL has beenwell described in the contemporary literature, tech-niques directed toward MWL patients using a hiddenproximal scar have not.3,5,6 Our description of theAPEX thighlift fills this void.

We have more recently seen a surge in publicationsabout gluteal aesthetics and contouring. Moving fromimplants, liposuction, and fat grafting, we are now look-ing at high-volume fat grafting and vascularized fat andfascia for autologous gluteal augmentation.10 Someauthors have also developed an expanded understandingof the elements contributing to an aesthetically pleasinggluteal region, breaking it into aesthetic units for stan-

Table 3. Multiple logistic regression statistical analysis: Wound healing

Odds ratio P 95% Confidence interval

Age 1.088305 .037 1.005317–1.178145

Female 0.4692815 .518 0.0472313–4.662691

Diabetes 0.6689345 .726 0.0703636–6.359445

Hypothyroidism 0.5896583 .676 0.0495365–7.019005

Tobacco use 0.2395721 .249 0.021119–2.717686

Body mass index ≥ 35 5.212932 .056 0.9581134–28.36267

Vertical incision 0.9224911 .933 0.1394985–6.100351

Weight of skin resected 0.305849 .533 0.0073685–12.69514

Multiple logistic regression statistical analysis of variables impacting wound healing after thighlift was performed using Stata SE (version 9).

Table 4. Multiple logistic regression statistical analysis: Lymphedema

Odds ratio P 95% Confidence interval

Age 0.97277 .706 0.8429502–1.122583

Female 0.0097107 .049 0.0000954–0.9880769

Hypothyroidism 22.57808 .041 1.132561–450.1035

Body mass index at body contouring 0.6233759 .025 0.4126393–0.9417366

Vertical incision 28.68875 .016 1.893706–434.621

Weight of skin resected 0.0855721 .329 0.0006153–11.90098

Multiple logistic regression statistical analysis of variables impacting wound healing after thighlift was performed using Stata SE (version 9).

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A B

Figure 4. A, Preoperative view of a 46-year-old woman who lost 100 lb after open gastric bypass surgery. B, Six months after lower body lift,including abdominoplasty, lower back lift, and an anterior proximal extended (APEX) thighlift. Her overall buttock aesthetics are markedlyimproved, with a reduction of the excess tissue of the waist and hip, infragluteal region, and medial thigh.

A B

Figure 5. A, Preoperative view of a 49-year-old woman who lost 120 lb after open gastric bypass surgery seven years before this procedure. Shealso underwent circumferential bodylift and Lockwood thighlift five years before these photographs. She has laxity involving the upper inner thigh.B, Twenty-one months after anterior proximal extended (APEX) thighlift.

520 • Volume 29 • Number 6 • November/December 2009 Aesthetic Surgery Journal

C

D

A

B

Figure 6. A, B, Preoperative views of a 42-year-old woman who lost 135 lb after laparoscopic gastric bypass surgery. Her body mass index at con-touring was 27. C, D, Seven months after anterior proximal extended (APEX) thighlift in addition to surgery on her abdomen, lower back, andmastopexy, showing an improvement in the mons, infragluteal regions, and the inner thigh.

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dardization.9,19 A small waist, a flat and well-definedsacral triangle, a contoured lateral thigh, and a reducedinner thigh and posterior infragluteal thigh—in combina-tion with a rounded buttock—all contribute to an aes-thetically pleasing result.19 The APEX thighliftcontributes to an improved aesthetic appearance in thegluteal region of the MWL patient because of the result-ing reduction of the inner thigh and infragluteal region(Figure 6). Surgery in adjacent territories, such as theabdomen and lower back, can further contribute togluteal aesthetic improvement associated with APEXthighlifting. The abdomen, back, and thighlift surgery allcomplement one another.

Looking at our outcomes analysis, advanced ageand BMI greater than or equal to 35 negativelyimpacted wound healing. We have previously reportedon our complications with BMI.20,21 Other authors22,23

have reported their experience with high BMI impair-ing outcomes. More advanced age and accompanyinghormonal changes have been reported in the literatureas detrimental to wound healing.24-28 Generally, weapproach patients with high BMI (particularly in themorbidly obese range) and older patients with cau-tion, leaning toward more conservative surgical therapyfocused on improving function or no surgical therapyat all.

While hypothyroidism, male gender, and vertical thigh-lift were associated with lymphedema, obesity was lessoften associated with clinical lymphedema. We have pre-viously reported that hypothyroidism impairs wound heal-ing in an outcomes analysis of MWL patients.20 There arepapers in the literature reporting hypothyroidism as a fac-tor exacerbating lymphedema.29-31 The high prevalence ofhypothyroidism and the documented effects of hypothy-roidism on wound healing and lymphedema make this anarea worthy of further focused investigation.

Vertical thighlifting has a known risk of temporaryor permanent injury to the venous and lymphatic sys-tem, traveling from the knee to the inguinal region.We have seen a greater prevalence of lymphedema inthe calf, borne out by our analysis. With careful atten-tion to maintaining the saphenous vein and to remain-ing superficial to the fascia overlying venous andlymphatic structure, we have found this lymphedemato be temporary and it responds well to conservativemanagement, including compression hose, leg eleva-tion, and a low-salt diet.

The negative relationship between obesity and lym-phedema might indicate that higher BMI impairs VTEdiagnosis. This is interesting, because more obesepatients are increasingly prone to VTE.21,32,33 If thereis any suspicion of deep vein thrombosis (DVT)—including calf pain, swelling, or pulmonary embolismwith shortness of breath or dyspnea—the possibilityof VTE must be ruled out. In the case of workup forDVT, a Duplex scan of the legs is the optimal test,while the best test for pulmonary embolism workup isa spiral computed tomographic scan of the chest.

Patients with a BMI greater than 35 must approachsurgery with caution; we tend to discourage thighliftsurgery in patients who are still morbidly obese.

Male gender has been reported to be associated withmore complications in various plastic surgery proce-dures, including most (if not all) areas of the body. Wefound this in a previous outcomes study investigatingpostbariatric body contouring surgery.20 In this study,male gender may be associated more with hypertension,varicose veins, greater noncompliance, or other issuesthat exacerbate lymphedema after thighlift.

CONCLUSIONSThigh contouring presents a significant challenge to theplastic surgeon. As more experience is gained with aes-thetic analysis of the thigh and its adjacent regions, and assurgical therapeutic options and experience broaden, theoutcomes are improved and surgical results are becomingmore dramatic. We are also better able to match any num-ber of procedures available to a given presentation, allow-ing for greater customization in the treatment ofpostbariatric contour deformities. The APEX thighliftallows us to effectively treat upper thigh laxity with a hid-den scar in patients who have undergone MWL. ◗

DISCLOSURES

The authors have no financial interest in and receive no compensa-tion from manufacturers of products mentioned in this article.

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Accepted for publication May 22, 2009.

Presented at the American Association of Plastic Surgeons Meeting inBoston, MA, May 2008.

Reprint requests: Michele A. Shermak, MD, Division of Plastic Surgery,Johns Hopkins Bayview Medical Center, 4940 Eastern Ave., Ste. A518,Baltimore, MD 21224. E-mail: masherma@jhmi.edu.

Copyright © 2009 by The American Society for Aesthetic Plastic Surgery, Inc.

1090-820X/$36.00

doi:10.1016/j.asj.2009.09.001