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LOWER BODY LIFT

TED LOCKWOOD, MD

In the last decade, significant progress has occurred in the understanding of aged aesthetic body deformities,
allowing new body lift designs based on modern surgical principles. Whereas liposuction deals with fat deposits,
body lifts are designed to treat significant skin quality problems causing body contour deformity. Lifts may be used at
the time of initial liposuction or may be required to treat skin laxity and contour irregularities that appear after
liposuction. The lower body lift deals with skin quality problems of the trunk and thighs using an incision hidden in
high-cut bikinis. Depending on the nature of the deformity, the transverse flank/thigh/buttock lift may be combined
with either the medial thigh lift or the high lateral tension abdominoplasty in one stage. Patient selection,
preoperative markings, and operative techniques are presented for the lower body lift procedure. The primary goal of
the lower body lift is to improve body contour in patients with flaccid skin as their primary problem. The lower body
lift produces a dramatic improvement in skin tightness or skin tone that cannot be matched by the skin retraction
occurring after superficial or deep liposuction.
Copyright 9 1996 by W.B. Saunders Company
KEY WORDS: body contouring, abdominoplasty, thigh-buttock lift contouring

In the last decade, significant progress has occurred in


the understanding of aged aesthetic body deformities,
which has encouraged new body lift designs based on
m o d e m surgical principles. 1-7 Whereas liposuction deals
with localized fat deposits and thick subcutaneous fat
layers, s body lifts are designed to treat significant skinquality problems causing body contour deformity. Lifts
may be used at the time of initial liposuction or may be
required to treat skin laxity and contour irregularities that
appear after liposuction.
Aesthetic body contour deformities frequently involve
multiple areas of the trunk and thighs. In these patients,
the ideal surgical plan targets the entire circumferential
trunk and thigh aesthetic unit in one or several stages. 4,7To
develop a surgical plan in patients with multiple body
contour problems, visualize the lower body lift incision on
each patient and use that portion of the lower body lift
incision that adequately treats the aesthetic deformity for
that individual (Fig 1).
The original lower body lift design 4 combined the
transverse flank/thigh/buttock lift3 with the medial thigh
lift 1 to treat laxity of the circumferential trunk and thighs.
In addition, a second lower body lift design combines the
transverse flank/thigh/buttock lift with the high lateral
tension abdominoplasty. 5 Although both lower body lift
techniques deal with laxity of the skin and soft tissues of
the trunk and thighs, the patient's goals and specific
aesthetic deformity are used to outline an overall treatment
plan for each individual.
If there is moderate to severe abdominal laxity, I recomFrom the Department of Plastic Surgery, University of Kansas Medical
School, Kansas City, KS.
Address reprint requests to Ted Lockwood, MD, 10600 Quivira Rd, Ste
470, Overland Park, KS 66215.
Copyright 9 1996 by W.B. Saunders Company
1071-0949/96/0302-000655.00/0

132

mend either an initial high lateral tension abdominoplasty


followed by thigh/buttock lifting at a second stage or a
lower body lift incorporating bilateral transverse flank/
thigh/buttock lifts with the high lateral tension abdominoplasty (Fig 2). This latter combination will produce a
modest degree of anteromedial thigh tightening, although
if the medial thigh problem is more severe a second stage
medial thigh lift will be required.
If the patient has had a previous abdominoplasty or has
a mild to moderate abdominal problem and a moderate to
severe medial thigh problem, I recommend the lower b o d y
lift procedure that I originally described, 4 which combines
bilateral flank/thigh/buttock lifts with bilateral medial
thigh lifts along with a limited suprapubic skin resection
(Fig 3). This produces dramatic lifting of the medial and
lateral thighs, buttocks, and flanks along with moderate
lifting of the abdomen.
This article will describe the technical features of the
original lower body lift design. 4 To combine the highlateral tension abdominoplasty and the transverse thigh/
buttock lift, use the technical description reviewed below
for the posterior half of the body lift and the recentlypublished technical description of the high lateral tension
abdominoplasty for the anterior half. 5 The key technical
difference is the treatment of the anterior segment of the
superficial fascial system (SFS) zone of adherence located
inferior to the inguinal ligament and lateral to the femoral
triangle lymphatics (Fig 4). In the original lower body-lift
design, both the posterior and anterior segments of the SFS
zone of adherence are undermined directly to allow a more
effective thigh lift. In the lower body lift that uses the
abdominoplasty technique anteriorly, the anterior segment
of the SFS zone of adherence is left intact to anchor the high
lateral tension abdominoplasty. A modest medial thigh lift
effect will occur even without this anterior undermining.

Operative Techniquesin Plasticand ReconstructiveSurge~ Vol 3, No 2 (May), 1996: pp 132-144

Fig 1. (A and B) The lower body lift incision concept combines the transverse flank/thigh/buttock and medial thigh lift incisions
within high-cut bikini outlines, Use the appropriate portion of this incision to develop a surgical plan for multiple body-contour
problems,

PHOTOGRAPHIC DOCUMENTATION
Accurate documentation of the degree of skin laxity and its
postoperative improvement is necessary to justify the long
incisional scars of lower body lifts. In addition to nude
photos, photograph the patient with the same dark bikini
underwear before and after surgery to compress the soft,
loose fat and skin, producing "bikini overhang." Use a
moderate to dark background with overhead lighting
without flash (ASA 400 Ektachrome; Eastman Kodak,
Rochester, NY). Replace fluorescent bulbs with Spectralite
bulbs for natural colors. Available light photography most
accurately shows the subtleties of skin contour irregularities, whereas flash techniques fill the shadows and obliterate surface detail. In addition, avoid light-colored backgrounds and bikinis; the backlighting effect produces loss
of surface detail. Never use photo panties for the nude

LOWER BODY LIFT

photos; the position and appearance of the mons pubis and


inguinal areas are part of the aesthetic deformity and must
show.
The lower body lift design is based on a careful analysis
of youthful aesthetic anatomy, as well as both youthful and
aged body contour aesthetic deformities. These body lifts
have proven to be effective and long-lasting with low risk
of significant complications. 3-s Key technical elements of
the lower body lift include:
9 incisions placed in current high-cut bikini lines
9 superficial fascial system (SFS) suspension with permanent sutures
9 direct undermining through SFS zone of adherence for
more distal transmission of lifting forces
9 discontinuous cannula undermining more distally as
needed

133

Fig 2. (A and B) Preoperative markings in a 48-year-old woman with trunk and thigh laxity and trochanteric fat deposits. This
lower body lift design incorporates the bilateral transverse flank/thigh/buttock lift with the high lateral tension abdominoplasty
in one stage and is indicated when there is moderate to severe abdominal laxity associated with thigh/buttock laxity. (C)
Preoperative view, anterior oblique. (D) Postoperative view at 2 months noting total contouring of the trunk and thighs in one
stage. (E) Preoperative view, posterior oblique. (F) Postoperative view, posterior oblique.

MARKINGS
Accurate and symmetrical preoperative markings are critical to the success of lower body lifts because each side of
the thigh/buttock lift is performed without the ability to
reference the opposite side. Markings are made in the
standing position after high-cut bikini margins are outlined. The planned line of closure should always lie within
bikini outlines. First, mark a transverse line in the suprapubic region at a level that corresponds to the top of a lifted,
youthful mons pubis (Table 1).
Next, the short horizontal suprapubic line angles superiorly toward the area of the anterior superior iliac spine
within bikini outlines and then is again horizontal along
the lateral body contour (Fig 5). Posteriorly, the incision
curves gently downward toward the top of the midline
gluteal crease over the sacrum, crossing the midline.
For the medial thigh lift, vertical lines extend inferiorly
from each end of the short horizontal suprapubic line
134

toward the pubic tubercle, defining the new width of the


mons pubis. The incision should hide in bikini outlines,
but I would caution against excessive narrowing of the
mons width. The incision then courses along the perinealthigh crease from the pubic tubercle to the posterior
perineal-thigh crease (Fig 6). Do not extend the incision
into the buttock fold posteriorly; it is unnecessary (because
there is minimal vertical aging descent of the posterior
thigh) and it will always show in current swimwear.
TABLE 1. Aesthetic Guidelines for the Mons Pubis
and Hypogastrium
Mons pubis skin stretches with age and pregnancy: vertical height may
have to be shortened for optimal aesthetics
From umbilicus to external vulvar commissure: 40% hair-bearing, 60%
non-hair-bearing
External vulvar commissure to top of mons pubis: 6 to 8 cm (under tension)
Umbilicus to top of mons pubis: 9 to 12 cm (under tension)

TED LOCKWOOD

Fig 3. (A and B) Original lower body lift pattern combining medial and lateral thigh lifts resects laxity of the lower trunk and
thighs at one stage. Direct undermining beneath the lateral portion of the lower flap (area of horizontal and diagonal lines)
through the SFS zone of adherence (see Fig 4) will allow more distal transmission of lifting forces. Bold line = line of closure;
solid lines = estimated resection lines; horizontal and diagonal lined areas below estimated lower line of resection = direct
undermined areas; horizontal dotted lines = extent of discontinuous undermining with cannula. No undermining is performed
near the gluteal vessels to maintain strong thigh flap vascularity, The high-cut bikini pattern separates the major vascular
territories of the trunk and thighs. Resecting redundant tissue in this region will allow optimal blood flow to both flap edges,

Fig 4. (A and B) The zones of adherence of the superficial fascial system (SFS) are strong connections to the underlying
musculoskeletal system. For the original lower body lift design, direct undermining is performed of the entire transverse SFS
zone of adherence, which extends from the lateral gluteal recess to the femoral triangle. This allows more distal transmission of
lifting forces. The anterior segment of this connection (inferior to the inguinal ligament) is the anchor for the high lateral tension
abdominoplasty and should not be undermined for the lower body-lift design that includes this abdominoplasty.
LOWER BODY LIFT

135

Figures 5-9

136

TED LOCKWOOD

Fig 10, Operative positioning. The patient is in lateral decubitus position with the trunk on a vacuum positioner and foam
padding under the legs. The hip is both abducted and flexed to
produce overcorrection.
Fig 11. (A) An incision is made into skin and subcutaneous fat
along the superior or anchor resection line and is deepened
through the SFS membranous layers until muscle fascia is
exposed. (B) Undermining of the skin-fat-SFS flap is begun
along the lateral contour just superficial to muscle fascia,
staying lateral to the femoral triangle lymphatics. The direct
undermining then sweeps posteriorly in the same plane,
preserving the deeper fat in this area.

Fig 5. Preoperative markings for the lower body lift are made after bikini margins have been outlined and should be made with
the patient in the standing position with the knees 6 inches apart. A short transverse line is marked in the suprapubic area at the
level of the lifted mons pubis. This line then angles superolaterally to stay within bikini outlines.
Fig 6. Vertical lines drop from either end of the short suprapubic line toward the pubic tubercle, defining the new width of the
mons pubis. The incision courses posteriorly in the perineal-thigh crease but does not extend into the buttock fold on the
posterior thigh.
Fig 7. (A and B) The amount of laxity superior to the planned line of closure is now estimated. It is usually 4 to 5 cm along the
lateral body and represents about one-fourth of the vertical excess at that point. This line is termed the anchor resection line,
and it must be symmetrical from side to side.
Fig 8. (A and B) The redundant tissue inferior to the planned line of closure is now estimated and marked. The actual amount of
tissue resection will be determined intraoperatively, but these estimate markings are quite helpful to maintain symmetry.
Fig 9. In the medial thigh, the resectional ellipse can be tapered to end in the posterior perineal-thigh crease because most of
the laxity in this area occurs in the anteromedial corner of the thigh. Do notextend the incisions into the buttock fold.
LOWER BODY LIFT

137

Fig 12. (A and B) Direct undermining extends through the SFS zone of adherence (see Fig 4) into the trochanteric region,
releasing fibrous connections that encircle the deep fat pad or scarring produced by previous liposuction.

Fig 13. (A) Undermining cannula designed for discontinuous undermining into the distal thigh (Courtesy of Byron Medical,
Tucson, AZ). (B) Discontinuous cannula undermining is performed to the knee if laxity extends into the distal half of the thigh.

Fig 14. (A and B) The redundant soft tissue is now resected using flap-splitting techniques and the large Pitanguy or
D'Assumpcao marking clamps. Resect less skin than the underlying SFS and fat to reduce the tension on the skin repair.
138

TED LOCKWOOD

Fig 16. The dermis is closed with subdermal 2-0 or 3-0


polydioxanone and the skin with intracuticular 3-0 polypropylerie. A few staples are also placed in the areas of highest
tension.

Fig 15. (A) A #1-braided nylon (dipped in povidine-iodine


solution) on a large taper needle is used to gather a generous
bite of the entire thickness of the superficial fascial system
without dermis. This is generally 2.5 to 3 cm from flap edge on
each side. (B) The braided nylons are tied with inverted knots
and are placed closely together. This produces an incisional
ridge that will gradually flatten over many weeks.
LOWER BODY LIFT

Fig 17. After completing both transverse thigh/buttock lifts,


the patient is placed in the supine position with knees at
shoulder width and the hips flexed 30 ~. After completing the
medial thigh lifts, the suprapubic skin excess is excised as a
final step.
139

The amount of soft-tissue redundancy superior to the


planned line of closure is now estimated with the knees 6
inches apart (Fig 7). There is usually 4 to 5 cm of redundant
tissue, which represents about one-fourth of the vertical
excess along the lateral body. Anteriorly, the amount of
redundant abdominal tissue is estimated by pulling from
either side. Only a small amount of vertical excess remains
in the suprapubic area for patients with mild to moderate
abdominal aesthetic deformities. This can be removed by
deepithelialization or by block resection at the end of the
procedure. Lower abdominal muscle plication can be
easily performed at this time.
Next, the redundant tissue inferior to the line of closure
is estimated. This generally ranges from 10 to 15 cm
vertically along the lateral contour, producing a total
vertical resection of between 15 and 22 cm of stretched skin
(Fig 8). Finally, the excess in the inguinal and medial thigh
areas is marked. Most of the medial thigh laxity occurs in
its anterior hall and therefore, the resectional ellipse can be
tapered to end in the posterior perineal thigh crease (Fig 9).

the anterosuperior iliac spine, include the underlying


muscle fascia to recreate the SFS zone of adherence in the
inguinal region. The skin is closed with 2-0 or 3-0 subdermal polydioxanone sutures (PDS) and intracuticular 3-0
polypropylene (Fig 16). A few skin staples are also placed
in the wound areas on highest tension. The opposite side is
performed similarly after repositioning, reprepping, and
redraping.
To perform the medial thigh lift, the patient is placed
supine with the knees shoulder-width apart and the hips
flexed 30 ~ (Fig 17). After reprepping and redraping, the
lateral mons pubis and perineal-thigh crease skin incision
is made. Again, the incision should not extend into the
buttock fold posteriorly.
After the initial skin incision, undermining of the inferior flap posterior to the pubic tubercle is performed
superficial to the adductor muscle fascia. In contrast to the
original description, 1in most patients this direct undermining usually extends 3 to 4 cm beyond the planned line of
resection (Fig 18). Anterior to the pubic tubercle, care is
taken to leave the soft-tissue bundle coursing between the
mons pubis and the femoral triangle. Superficial undermin-

OPERATIVE TECHNIQUE

Following the induction of general anesthesia, the patient


is placed in the lateral decubitus position with the trunk on
a vacuum positioner and foam pads under the legs. To
produce an overcorrected resection, the hip is flexed
anteriorly 30 ~ to 45 ~ and the thighs are abducted with foam
blocks to keep the knees 15 inches apart (Fig 10). Liposuction of trochanteric and posterior thigh fat deposits is
performed if needed. An incision is made through the
superior resection line, and undermining is begun along
the lateral contour just superficial to the muscle fascia
(Fig 11), staying lateral to the femoral triangle lymphatics.
This produces a fairly uniform flap thickness of the
skin-superficial fat-SFS unit. The undermining then sweeps
posteriorly over the deep fat of the buttocks.
The direct undermining should extend beneath the flap
to be resected and into the trochanteric region, releasing
the SFS zone of adherence that extends from the lateral
gluteal recess around to the femoral triangle lymphatics
(Fig 12). No direct or discontinuous undermining is performed over the buttocks. Anteriorly, the direct undermining extends only through the SFS zone of adherence, which
lies in the superior 10 cm of the thigh. Next, discontinuous
cannula undermining is performed more distally if the
aesthetic deformity extends into the lower half of the thigh
(Fig 13).
The redundant soft tissue is now resected using flapsplitting techniques and the large Pitanguy marking clamp,
being careful to leave more of the skin of each flap than the
underlying SFS. This allows a minimal-tension skin repair
after SFS-anchoring sutures are placed (Fig 14). Following
soft-tissue resection, two no. 19 French Blake (fluted)
drains are inserted on each side as far distally as possible,
exiting in the mons pubis anteriorly and through the
incision posteriorly above the buttocks.
The wound is repaired in this overcorrected position
with the hip flexed and abducted. A generous bite of the
entire thickness of the SFS without any dermis is made
with a large taper needle (CT-1) using #1-braided nylon
(dipped in povidine-iodine solution) (Fig 15). Anterior to
140

Fig 18. In contrast to the original medial thigh lift description,


the inferior thigh flap is directly undermined for 3 to 4 cm to
allow better placement of the SFS anchoring sutures. Discontinuous undermining toward the knee may be necessary in
selected patients.

TED LOCKWOOD

Fig 19. Superficial undermining over the soft-tissue bundle


between the mons pubis and the femoral triangle preserves
the external pudendal blood and lymphatic vessels, reducing
the risk of lymphatic complications.

Fig 20. Colles' fascial roll is best defined using digital


dissection with a dry gauze sponge. Push superiorly over the
adductor muscles until the tendinous portion is reached and
the bony ischiopubic ramus is at the fingertip.

Fig 21. (A) The redundant tissue of the medial thigh is marked with the knees at shoulder-width. (B) The clamp is placed against
the pubic tubercle and the ischiopubic ramus.
LOWER BODY LIFT

141

Fig 22. (A) In addition to anchoring to Colles' fascia centrally, anchor the posterior wound to the buttock's fold SFS, which is
the extension of superficial fascia from Colles' fascia that helps form the buttock's fold. (B) Retract the superficial vulvar soft
tissue medially to expose the Colles' fascial roll and place anchoring sutures of 0-Nurolon (dipped in povidine-iodine solution
close together.

Fig 23. (A) Next, the sutures are placed in the thigh flap. A generous amount of SFS along with scraping the dermis 1.5 cm from
the wound edge is included in this suture. This forces the actual wound edge onto the relaxed vulva, forming a new
perineal-thigh crease of intact skin. (B) Scarpa's fascia in the region of the mons pubis is a direct extension of Colies' fascia.
Superior to the pubic tubercle anchor to Scarpa's fascia after bluntly spreading through the preserved soft-tissue bundle.
142

TED LOCKWOOD

Fig 24. (A) Preoperative anterior view, 52-year-old woman, with trunk and thigh laxity and isolated mild fat deposits. A dark
bikini is used to show the degree of soft tissue laxity (ie, bikini overhang). (B) Postoperative view at one year after original lower
body lift design, which combines the transverse flank/thigh/buttock and medial thigh lifts in one stage. This is indicated in
patients with multiple body contour problems with mild to moderate abdominal laxity. Note the improvement in skin quality. (C)
Preoperative nude view. (D) Postoperative view at one year after lower body lift with limited liposuction of multiple areas of the
trunk and thighs. The incisions have faded; the body contours are more youthful and aesthetic; and the skin tone is excellent.

LOWER BODY LIFT

143

ing over this bundle (leaving 8 to 10 mm of subdermal fat


and the most superficial membranous layer of the superficial fascia) preserves the external pudendal blood and
lymphatic vessels, reducing the risk of lymphatic complications (Fig 19). Blunt dissection through this soft-tissue
bundle at the mons pubis exposes Scarpa's fascia or
muscular fascia, either of which can be used for anchoring
of the thigh flap in the pubic region.
Once flap undermining is completed, Colles' fascial roll
is identified. It is very important not to overdissect this
fascia because, like all superficial fascia, it tends to be
somewhat vague and indistinct on gross examination.
Attempts to overly-define this fascia will lead to disruption
of the connections between Colles' fascia and the periosteum of the ischiopubic ramus, jeopardizing the strength of
the fascial anchoring technique. Digital dissection using a
dry gauze sponge most reliably preserves Colles' fascia
anatomy (Fig 20). Push superiorly over the adductor
muscles until the tendinous muscle origins are seen and
the bony ischiopubic ramus is palpated at fingertip. Retracting the skin and superficial fat of the vulva medially will
expose the Colles' fascial roll at the deepest and most
lateral aspect of the vulvar soft-tissues.
The redundant tissue of the medial thigh is estimated
and resected with the patient's knees shoulder-width apart
(Fig 21). Permanent anchoring sutures into Colles' fascia
are now used for all patients (0-braided nylon, dipped in
povidine-iodine solution). In addition, Scarpa's fascia is
used as the anchor in the inguinal and pubic areas, and the
buttock fold superficial fascial system (SFS) is used to
anchor posteriorly (Fig. 22). Next, the 0-braided nylon
sutures are placed into the thigh SFS and dermis of the
thigh-flap w o u n d edge (Fig 23). Skin is repaired with 3-0
polydioxanone subdermal sutures and interrupted 3-0
nylon mattress sutures or intradermal polypropylene.
Drains are generally not placed in the medial thigh wound.
Light dressings are applied to all wounds, and no
compression garment is used. Postoperatively, the patient's hips should be kept flexed at 20 ~ to 30 ~ and the
thighs at shoulder-width for I to 2 weeks to reduce w o u n d
tension. At least one lateral-thigh drain on each side is left
for 7 to 10 days. Prophylactic antibiotics (cephlexin) are
continued until after all drains are removed. Any subsequent w o u n d infection is treated with ciprofloxacin until
w o u n d cultures return. Amoxicillin may also be required
for serious or mixed-organism infection.

144

The operative time is generally 6 to 7 hours and requires


1 to 2 units of autologous blood postoperatively and 2 to 4
nights of nursing care. Most patients are back to limited
work in 3 to 4 weeks and full vigorous physical activity in 2
to 3 months (Fig 24).
Complications include delayed w o u n d healing and marginal skin necrosis, which can lead to limited w o u n d
dehiscence, w o u n d infection, suture complications, seromas, hematomas, paresthesias and anesthesia, prominent
or widened scars, and partial recurrence of aesthetic
deformity resulting from underresection. If marginal skin
ischemia is noted, treat initially with silver sulfodiazine
cream twice a day to help prevent full thickness skin loss. If
marginal skin necrosis is minimal, delayed w o u n d healing
should occur uneventfully. If skin necrosis is more significant, then conservative debridement is performed once
w o u n d healing is stable (3 to 5 weeks). Secondary w o u n d
repair with ciprofloxacin prophylaxis is frequently successful after w o u n d debridement is completed and granulations have appeared.
The primary goal of the lower body lift is to improve the
body contour in patients with flaccid skin as their primary
problem. In these patients, ptotic fat should not be removed with liposuction but rather redraped to produce
more youthful and feminine body contours. The lower
body lift produces a dramatic improvement in skin tightness or skin tone that cannot be matched by the skin
retraction occurring after superficial or deep liposuction.

REFERENCES

1. LockwoodT: Fascial anchoring in medial thigh lifts. Plast Reconstr


Surg 82:299-304,1988
2. LockwoodT: Superficialfascial system (SFS)of the trunk and extremities: A new concept. Plast ReconstrSurg 87:1009-1018,1991
3. LockwoodT:Transverseflank-thigh-buttocklift with superficialfascial
suspension. Plast ReconstrSurg 87:1019-1027,1991
4. LockwoodT: Lower body lift with superficial fascial system suspension. Plast ReconstrSurg 92:1112-1122,1993
5. Lockwood T: High-lateral-tension abdominoplasty with superficial
fascial systemsuspension. Plast ReconstrSurg 96:603-615,1995
6. LockwoodT: Brachioplastywith superficialfascialsystem suspension.
Plast ReconstrSurg 96:912-920,1995
7. BaroudiR, Moraes M: Philosophy,technical principles, selection, and
indications in body contouring surgery. Aesth Plast Surg 15:1-18,1991
8. Illouz YG: Body contouring by lipolysis:A 5 year experience in over
3000cases.Plast ReconstSurg 72:591-597,1983

TED LOCKWOOD