COSMETIC

Medial Thigh Lift in the Massive Weight Loss

Population: Outcomes and Complications
Jeffrey A. Gusenoff, M.D.
Devin Coon, M.D.
Harry Nayar, M.D., M.B.E.
Russell E. Kling, B.A.
J. Peter Rubin, M.D.
Pittsburgh, Pa.; and Baltimore, Md.
Background: Complication profiles of medial thighplasty in the massive weight
loss population are not well described. The authors present their experience
with these procedures in the massive weight loss population.
Methods: Thighplasty patients from 2003 to 2012 were assessed. Variables in-
cluded age, sex, body mass index, method of weight loss, comorbidities, and
smoking status. Outcomes included seroma, dehiscence, infection, hematoma,
edema, and revision. Statistical analysis was performed as appropriate.
Results: One hundred six subjects (90 women and 16 men) underwent thigh-
plasty. Fourteen patients underwent horizontal thighplasty, with a complication
rate of 43 percent; 24 underwent short-scar thighplasty, with a complication rate
of 67 percent; and 68 underwent full-length vertical thighplasty, with a compli-
cation rate of 74 percent. Seventy-two subjects (68 percent) had at least one
complication. Complications included dehiscence (51 percent), seroma (25 per-
cent), infection (16 percent), and hematoma (6 percent). Overall, 25 patients (23
percent) developed edema, which did not resolve in two patients by 12 months.
Hypertension was significantly associated with postoperative seroma (p = 0.02).
Age (p = 0.01), hypothyroidism (p = 0.01), and liposuction outside the area of
resection (p = 0.025) were associated with postoperative infections. A full-length
vertical incision was associated with increased lower extremity edema (p = 0.007).
Conclusions: Medial thighplasty has a high rate of minor wound healing
problems. Full-length vertical thighplasty is associated with prolonged edema.
Concomitant liposuction may also increase complications. Patients should be
counseled appropriately about the potential for minor wound healing prob-
lems. (Plast. Reconstr. Surg. 135: 98, 2015.)
CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

T
he acceptance of bariatric surgery as an effec-
tive and durable means of treating obesity
has fueled a precipitous rise in individuals
seeking body contouring following massive weight
loss. It has also revealed a relative paucity of objec-
tive outcome data regarding regional contouring
procedures following weight loss. Although it is
well established that thigh rejuvenation can have
a profoundly positive functional and aesthetic
From the Department of Plastic Surgery, University of Pitts-
burgh Medical Center; and the Department of Plastic and
Reconstructive Surgery, Johns Hopkins Hospital.
Received for publication November 20, 2013; accepted May
13, 2014.
Presented at the 88th Annual Meeting of the American So-
ciety of Plastic Surgeons, in San Diego, California, October
11 through 15, 2013; and the 30th Annual Meeting of the
Northeastern Society of Plastic Surgeons, in Washington,
D.C., September 19 through 22, 2013.
Copyright © 2014 by the American Society of Plastic Surgeons
DOI: 10.1097/PRS.0000000000000772
impact after massive weight loss, there remains
controversy over the most appropriate methods
for achieving favorable outcomes.1
The medial thighplasty can be designed to treat
the varying amount of skin laxity of the inner thigh.
For patients with laxity limited to the upper third of
the thigh, a horizontal excision may be sufficient.
For patients with laxity extending to the middle
third of the thigh, a short-scar vertical thighplasty
can be performed. For laxity extending down to
the knee, a full-length vertical thighplasty may be
required. Techniques vary and can be adjusted to
eliminate the T-point if desired.1,2
Despite the many technical variations of medial
thighplasty, there are very few studies investigat-
ing objective outcomes and complications in the
massive weight loss population. Because of move-
ment, moisture, and a potential T-point in the
Disclosure: The authors have no financial interest
to declare in relation to the content of this article.

98 www.PRSJournal.com
6OLUME.UMBERs4HIGHPLASTYAFTER-ASSIVE7EIGHT,OSS
groin crease, complication rates may be high. We
hypothesize that medial thighplasty in the massive
weight loss population is safe but has the potential
to have a high minor complication rate. We pres-
ent the largest series of medial thighplasty massive
weight loss patients to date to aid in patient coun-
seling before surgery.
PATIENTS AND METHODS
One hundred six medial thighplasty subjects
were identified retrospectively from our Life After
Weight Loss database. Our study was approved by
the Institutional Review Board of the University of
Pittsburgh (PRO12090401). Procedures were per-
formed between March of 2003 and April of 2012.
Thigh procedures were defined as horizontal inci-
sion, short-scar vertical thighplasty, and full-length
vertical thighplasty. Massive weight loss was defined
as weight loss greater than 50 pounds. Other
patient factors collected included age, sex, body
mass indices [maximum body mass index, cur-
rent body mass index, and delta body mass index
(maximum body mass index − current body mass
index)], type of weight loss (surgical or self-weight
loss), time from weight loss to body contouring,
follow-up time, comorbidities (i.e., tobacco use,
diabetes, hypertension, steroid use, anemia, hypo-
thyroidism, and anticoagulation status), and intra-
operative data. All procedures were performed by
the two senior authors (J.P.R. and J.A.G.).
Horizontal thighplasty markings are routinely
performed by means of the pinch test while the
patient is in the frogleg position. Short-scar verti-
cal thighplasty is marked the same way; however,
after the horizontal component is marked, the
thigh tissues are mobilized medially and then lat-
erally to estimate the vertical component, making
sure that the resection lines are drawn from the
level of the adductor magnus proximally to the
desired distance distally in the midthigh. The full-
length vertical thighplasty is marked in the same
fashion as the short-scar vertical thighplasty, but
the estimated resection is carried all the way to
the knee if necessary. Suspension of the superfi-
cial fascial system in the thigh to the Colles fascia
in the groin is performed using 2-0 absorbable
braided suture.
Complications assessed were seroma, wound
dehiscence (defined broadly as any size wound
separation, including superficial skin break-
down), bleeding, infection (included superficial
infections), and edema. Edema was further cate-
gorized by duration less than 12 weeks and greater
than 12 weeks. Concomitant use of liposuction
was recorded. Operative revisions for complica-
tions and aesthetic revisions were noted.
Descriptive statistics were calculated, including
frequencies for categorical and ordinal variables
and means, and standard deviations and ranges
for continuous variables. All statistical analysis was
performed using Stata/SE version 12.0 (StataCorp,
College Station, Texas). Univariate logistic regres-
sion was used to examine the impact of individual
factors on particular outcomes, with multivariate
regression then used to control for possible con-
founders. The Fisher’s exact test was used for anal-
ysis of low-frequency dichotomous variables. All
statistical tests were two-sided, with equal variance,
and significance was set to the level of p < 0.05.
RESULTS
Demographics
One hundred six patients were analyzed.
Fourteen (13 percent) underwent horizontal
thighplasty, 24 (23 percent) underwent short-
scar vertical thighplasty, and 68 (64 percent)
underwent full-length vertical thighplasty. The
average follow-up time was 119 ± 139.7 months
for the horizontal incision group, 93.4 ± 138.7
months for the short-scar incision group, and
70.2 ± 82.6 months for the full-length vertical
incision group (p = 0.95). Ninety patients (85
percent) were women and 16 (15 percent) were
men, with an average age at the time of surgery
of 45.1 ± 10.2 years. Eighty-eight subjects (83 per-
cent) lost weight by surgical methods and 18 (17
percent) lost weight with diet and exercise. The
average time interval between massive weight loss
and thighplasty surgery was 30.3 ± 21.2 months.
The mean maximum body mass index was 52.4
± 9.1 kg/m2, the mean current body mass index
was 29.3 ± 4.3 kg/m2, and the mean delta body
mass index for the series was 23.1 ± 6.9 kg/m2.
Body mass indices were not statistically different
between the three groups (p > 0.05). Table 1 sum-
marizes the key patient characteristics.
Complications
Seventy-two subjects (68 percent) had at least
one complication. Complications included wound
dehiscence (51 percent), seroma (25 percent),
infection (16 percent), and hematoma (6 per-
cent) (Table 2). Overall, 23 subjects (22 percent)
developed lower extremity edema. Twenty-one
patients in the full-length vertical group devel-
oped edema, with resolution in 11 patients by 12
weeks and resolution in another eight patients by
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Table 1. Patient Characteristics resection, whereas 12 underwent liposuction in all

areas of the thigh, including the area of resection.
Characteristic Value
Sex, no. Predictors of Overall Complications
Female 90
Male 16 Sex, body mass index, former smoker, dia-
Age ± SD, yr betes, hypothyroidism, concomitant liposuction
Mean ± SD 45 ± 10
Range 21–66 (inside versus outside area of resection), and
Maximum BMI, kg/m2 number of other procedures at the time of thigh-
Mean ± SD 52 ± 9 plasty were not associated with an increased over-
Range 36–78
Current BMI, kg/m2 all complication rate (p > 0.05). Anemia and age
Mean ± SD 29 ± 4 (p = 0.02) positively correlated with an increased
Range 21–41 overall complication rate, with 90 percent of
Delta BMI, kg/m2
Mean ± SD 23 ± 7 anemic patients developing a complication ver-
Range 10–45 sus 63 percent of nonanemic patients (OR, 5.3;
Weight loss method p = 0.03), and a mean age of 46.7 years in patients
Surgery 88
Diet/exercise 18 with a complication versus 41.6 years (OR, 1.29
Time from to initiation of weight loss to per 5 years of age; p = 0.02). Horizontal incision
thighplasty surgery, mo thighplasty was associated with a 49 percent com-
Mean ± SD 30 ± 21
Range 11–120 plication rate compared with short- (67 percent)
Follow-up, mo and full-length vertical (74 percent) incision
Mean ± SD 82 ± 107 thighplasty (p = 0.1).
Range 29–603
BMI, body mass index.
Predictors of Individual Complications
Hypertension was significantly associated
12 months. Two patients developed prolonged with postoperative seroma formation (OR, 2.9;
edema that was unresolved after 12 months despite p = 0.02) and there was a trend toward seroma for-
lymphedema therapy. Two patients who under- mation in the full-length vertical incision group
went short-scar vertical thighplasty developed (p = 0.06). Age (OR, 1.47 per 5 years of age increase;
prolonged edema, with one patient resolved by 12 p = 0.01), hypothyroidism (OR, 4.5; p = 0.01), and
weeks and the other by 12 months. No patients liposuction outside the area of resection (OR,
with a horizontal excision experienced prolonged 3.8; p = 0.025) were associated with an increased
edema. All cases of edema resolved or improved postoperative infection rate. A full-length vertical
by 12 months postoperatively. Six patients (6 per- incision was associated with an increased risk of
cent) required reoperation for a complication lower extremity edema (p = 0.007). No factors cor-
and 15 patients (14 percent) underwent revision related significantly with need for revision.
surgery to improve aesthetic results. Ten of these
patients had full-length vertical thighplasty and DISCUSSION
five had short-scar vertical thighplasty. Forty-nine
subjects (47 percent) underwent concomitant The massive weight loss population is a fast-
liposuction of the thigh at the time of thighplasty; growing demographic within plastic surgery and
37 had liposuction of the thigh outside the area of poses unique challenges.3 Massive weight loss
individuals present with a wide range of lower
extremity deformities. Moreover, impaired wound
Table 2. Postoperative Complications by Thighplasty healing and an increased prevalence of medi-
Type cal comorbidities, including diabetes, hyperten-
sion, and cardiopulmonary insufficiencies, are
Vertical Short Horizontal observed in this population.4 Despite these con-
(%) (%) (%)
siderable challenges, massive weight loss patients
No. of patients with
complications 50 (74) 16 (67) 6 (43) also stand to benefit immensely from contouring
Complication procedures. With a careful preoperative evalua-
Dehiscence 37 (54) 11 (46) 6 (43) tion, properly selected patients have reported sub-
Seroma 20 (29) 7 (29) 0
Infection 10 (15) 6 (25) 1 (7) stantial improvements in overall functioning and
Hematoma 4 (6) 2 (8) 0 psychosocial health.5,6 A key component of body
Return to the contouring after massive weight loss is managing
operating room 4 (6) 2 (8) 0 patient expectations. Understanding the risks of

100
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medial thighplasty is important for patient coun-
seling and the informed consent process.
First described by Lewis in 1957, the medial
thigh lift became known for several complica-
tions, including scar migration, vulvar deformi-
ties, and recurrent ptosis.7,8 Refinements made by
Lockwood in 1988 that included fascial anchoring
partially alleviated these issues; however, this tradi-
tional approach, with its vertical vector of pull, is
ill-suited for many massive weight loss patients, as
many require a greater degree of excision than is
afforded by the Lockwood technique.9 To address
the needs of massive weight loss patients, a myriad
of technical variations to reorient the vector of
pull from vertical to horizontal, with and without
staging liposuction, have been described.8,10 How-
ever, there remains a paucity of objective data
regarding outcomes and complications, which are
mostly limited to small, retrospective series.
To determine the most appropriate thigh-lift
technique, the inner thigh can be divided into
three zones (Fig. 1). When contour deformities
are confined to the upper third of the thigh, a
horizontal thigh lift can be performed. The hori-
zontal thighplasty alone is not a very powerful
operation in massive weight loss patients and may
offer limited or no improvement of the middle or
distal thirds of the thigh. The amount of resected
skin in the horizontal vector is not very robust for
any of the three procedures. Larger resections can
result in pleating of the tissues, inability to close
the tissue, or extension of the scar into the gluteal
Fig. 1. Horizontal thighplasty for laxity limited to the upper third of the thigh. (Left) Preoperative view. (Center) Marking for hori-
zontal thighplasty. (Right) Four-month postoperative view demonstrating limited improvement in the middle third of the thigh.
fold, which can create undesired deformities. If
skin excess and laxity extend to the middle third
but no farther, the short-scar vertical thigh lift is a
reasonable choice. However, because of the coni-
cal shape of the thigh, the termination of the inci-
sion along the middle thigh can lead to a dog-ear
deformity (Fig. 2). Simple dog-ear revision may
be required after the scar has had sufficient time
to settle down (i.e., 6 to 12 months). Patients are
educated about this during their preoperative
counseling visit. Shermak et al. described a medial
thighplasty modification, the anterior proximal
extended thighplasty, which is an attractive alter-
native for patients with limited laxity.1 This pro-
cedure extends the horizontal proximal incision
to the infragluteal crease in the anteroposterior
direction and anchors the Scarpa fascia to pubic
periosteum. This modification conceals the scar
and provides greater pull than the traditional
Lockwood technique, although disruption of the
gluteal fold is common with this procedure. The
authors reported acceptable complication rates,
most notably, a wound infection rate of 18.6 per-
cent and a lymphedema rate of 8.2 percent. Age
was the only significant predictor of wound com-
plications, and the vertical extension thigh lift was
significantly associated with lymphedema. The
authors did not perform liposuction in the areas
of resection.
Redundancy to the level of the knee, as is
the case with most massive weight loss patients,
is best treated by a full-length incision (Fig. 3).
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Fig. 2. Short-scar vertical thighplasty. (Above, left) Preoperative view. (Above,

right) Markings demonstrate horizontal and vertical components. The vertical
component is limited to reduce the ultimate length of the scar. (Below, left) Mark-
ings demonstrate the wedge effect of the short-scar technique and the risk for
dog-ear formation. (Below, right) Five-month postoperative view after short-scar
technique with residual dog-ear deformity.

The greater contouring power must be weighed complications, as it is in a moist environment,

against scar visibility, the increased risk of lym-
phatic disruption, and the problems inherent in
a T-point (Fig. 4). Most massive weight loss body
contouring patients will accept scar visibility for
the functional and contour improvements result-
ing from greater resection. The T-point is an ana-
tomical junction area prone to wound healing
which is further subject to motion and friction
(Fig. 5). Furthermore, the close proximity to
the high bacterial burden of the perineum may
predispose to wound infection. The T-point can
be eliminated by cheating the design more pos-
teriorly to form an L-shaped resection.2 To our
knowledge, there are no data comparing the two

102
6OLUME.UMBERs4HIGHPLASTYAFTER-ASSIVE7EIGHT,OSS
Fig. 3. Full-length vertical thighplasty. (Left) Preoperative view. (Center) Markings for the full-length vertical thighplasty, demon-
strating the small horizontal component and the vertical component extending down to the knee. (Right) Three-month postop-
erative view showing improvement all the way to the knee.
Fig. 4. Delayed wound healing at the T-point, the most common
site of wound dehiscence in full-length vertical thighplasty.
techniques with regard to complications and out-
comes. We often use 2-0 polypropylene suture at
the T-point to reinforce the closure for 1 to 2 weeks
postoperatively. Care should be taken when using
permanent suture to secure the superficial fascia
to the Colles fascia, as delayed suture extrusion
may occur (Fig. 6). The risk of suture extrusion
can be reduced using a slowly absorbing suture in
this area. Another option to avoid T-point wound
healing problems would be to stage the horizon-
tal and vertical components, which may ultimately
improve the overall contour and reduce long-term
recurrent laxity; however, patients would have to
agree to multiple recoveries and increased surgi-
cal expense.
Our complication rates correspond with that
observed in the literature for body contouring
procedures in the massive weight loss popula-
tion.11 Wound healing complications—notably,
seroma and dehiscence—are predictably high in
this population, although most are minor and can
be managed in the clinic without need for reoper-
ation. Our finding that older age and anemia lead
to an increased rate of total complications is con-
sistent with previous reports.1 Evaluating and opti-
mizing the micronutrient status of these patients,
particularly for iron, calcium, and vitamin B12
levels, could minimize wound healing complica-
tions.12,13 The impact of liposuction on outcomes
of medial thigh lift has not been examined previ-
ously. We found that concomitant liposuction out-
side the area of resection has an increased rate of
wound infection. This finding may be attributable
to tissue trauma with the liposuction cannulas,
or residual edema that persists after surgery in a
dependent part of the body. Interestingly, how-
ever, concomitant liposuction at the time of bra-
chioplasty was recently shown to have no effect on
complication rates in a large series of patients.14
This is likely because liposuction in the arm was
limited to the posterior aspect, and was not near
the planned resection area. Similarly, in thigh-
plasty, combining liposuction of the saddlebag
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 Plastic and Reconstructive Surgerys*ANUARY
Fig. 5. (Left) Dehiscence at the T-point and horizontal incision. (Right) Healed wound managed with conser-
vative dressing changes.
area or above the knee is likely safe, whereas deb-
ulking procedures of the entire thigh involving the
resection area pose a higher risk to the patient. A
larger sample size may help elucidate these rela-
tionships, as there were too few patients undergo-
ing liposuction only in the nonexcised area for us
to draw conclusions. Staging of debulking liposuc-
tion and medial thighplasty may be considered,
especially in patients who are already undergoing
multiple stages of body contouring. Patients with
high body mass indices because of a gynoid or
pear-shaped morphology may be good candidates
for a stage of debulking liposuction first, followed
by surgical excision 3 to 6 months later. Patients
with high body mass indices that have global
adiposity would benefit from further weight loss
before any surgical intervention. Studies inves-
tigating excision-site lipectomy in the area to be
resected are lacking and may provide further
information about the utility and safety of liposuc-
tion in relation to the risk of seroma and lymph-
edema. Chronic seromas or lymphoceles that do
not resolve with drainage or other methods may
require surgical excision (Fig. 7).
Chronic lymphedema, the vexing complica-
tion of the medial thigh lift, has been reported to
occur in as many as 30 percent of subjects.15,16 In
a study using lymphoscintigraphy analysis before
and after thigh lift, Moreno et al. reported that a
majority of patients develop demonstrable func-
tional and anatomical alterations of the lymphatic
network at 6 months postoperatively.15 The pres-
ence of preexisting lymphovascular disease may
be underappreciated in the massive weight loss
group; therefore, signs and symptoms should be
carefully evaluated preoperatively.17 Patients with
preexisting edema and significant varicosities
104
are referred to vascular surgery for evaluation,
radiofrequency ablation of the saphenous vein, or
other necessary therapies before thigh contouring
surgery. Patients with significant disease may not
be body contouring candidates. To avoid intraop-
erative damage to the lymphatics, we maintain a
superficial dissection in the area superior to the
adductor magnus muscle and stay superficial to
the great saphenous vein. In our study, patients
undergoing the short- or full-scar thighplasty are
wrapped with an elastic bandage for 1 week after
surgery and then placed into ankle-length com-
pression garments for 6 weeks. A single drain is
used for 1 week or until drainage is less than 30
cc per 24 hours. Ambulation is encouraged and
swelling may increase as mobility increases, espe-
cially in the first 2 weeks after surgery. Patients
are encouraged to use elastic wraps immediately
if they notice any foot or ankle swelling. Horizon-
tal thighplasty patients are encouraged to wear
compression as well, but these may be compres-
sion garments limited to above the knee. Asym-
metric swelling of the extremities is worked up for
possible deep venous thrombosis. Swelling usu-
ally resolves by 6 weeks. If it persists, patients are
referred to the lymphedema clinic at our institu-
tion. All patients undergoing a medial thighplasty
in our practice are informed of the potential risk
of chronic lymphedema (or lifelong swelling) with
this procedure. Our protocol for management of
lower extremity edema in the massive weight loss
population has been reported previously.17
Some observers may question whether a proce-
dure that has a complication rate of at least 68 per-
cent is safe. We argue that it is because most of these
complications were minor wound healing issues or
transient edema. We broadly define dehiscence as
6OLUME.UMBERs4HIGHPLASTYAFTER-ASSIVE7EIGHT,OSS
Fig. 6. Suture extrusion near both T-points. (Above) The patient
presented 1 year after surgery with bilateral suture granulomas.
(Center) The granuloma was excised in the office. (Below) The
suture can be seen in the granulation tissue.
inclusive of small areas of delayed wound healing.
Many other authors may regard these small wound
healing issues as noncomplications and they may
thus be underreported. There were no venous
thromboembolic events in our population. Most
revisions were for aesthetic concerns and usually
because of dog-ears or recurrent skin laxity, condi-
tions that are unpredictable and can be severe in
the massive weight loss population (Fig. 8).
Future prospective studies should help clarify
many of the issues that remain unanswered in
medial thighplasty. We thought that body mass
Fig. 7. Lymphocele excision after full-length vertical medial
thighplasty.
indices—in particular, delta body mass index—
would be correlated to the degree of thigh laxity.
However, we did not find this to be true, which
may be attributable to sample size. Another expla-
nation may be that thigh laxity after weight loss is
more closely related to pre–weight loss body type
(gynoid versus android). Other areas to explore
include determining whether variations in surgical
techniques that avoid a T-point are truly beneficial
in decreasing dehiscence, whether excision-site
lipectomy really improves preservation of lymphat-
ics and decreases seroma or lymphedema rates,
and whether concomitant liposuction outside the
excision site truly increases the risk of infection.
CONCLUSIONS
Wound complications in medial thighplasty
are common; however, most are minor and can be
managed without reoperation. Complications are
highest for the full-length vertical thighplasty (74
percent) and less for the short-scar (67 percent)
and horizontal (43 percent) procedures. Age,
hypothyroidism, hypertension, and liposuction
outside of the area of resection may contribute to
postoperative complications. Although full-length
vertical incisions are associated with the develop-
ment of edema, most cases resolve acutely. Fur-
ther prospective studies comparing techniques
may help reduce the rate of minor complications
in medial thighplasty.
Jeffrey A. Gusenoff, M.D.
Department of Plastic Surgery
University of Pittsburgh Medical Center
3380 Boulevard of the Allies, Suite 180
Pittsburgh, Pa. 15213
gusenoffja@upmc.edu
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Fig. 8. Residual deformities or recurrent skin laxity may occur after medial
thighplasty. These can usually be treated with minor procedures of liposuction
or reexcision. (Left) Preoperative photograph. (Right) Two-month postoperative
photograph; red circle delineates residual skin laxity in the upper thigh.

REFERENCES aesthetics and safety in lower extremity contouring. Ann

1. Shermak MA, Mallalieu J, Chang D. Does thighplasty for
upper thigh laxity after massive weight loss require a vertical
incision? Aesthet Surg J. 2009;29:513–522.
2. Hurwitz DJ. Medial thighplasty. Aesthet Surg J. 2005;25:180–191.
3. American Society of Plastic Surgeons. 2012 plastic surgery
statistics report. Available at: http://www.plasticsurgery.
org/News-and-Resources/2011-Statistics-.html. Accessed
September 30, 2013.
4. D’Ettorre M, Gniuli D, Iaconelli A, Massi G, Mingrone G,
Bracaglia R. Wound healing process in post-bariatric patients:
An experimental evaluation. Obes Surg. 2010;20:1552–1558.
5. Modarressi A, Balagué N, Huber O, Chilcott M, Pittet-
Cuénod B. Plastic surgery after gastric bypass improves long-
term quality of life. Obes Surg. 2013;23:24–30.
6. Bruschi S, Datta G, Bocchiotti MA, Boriani F, Obbialero FD,
Fraccalvieri M. Limb contouring after massive weight loss:
Functional rather than aesthetic improvement. Obes Surg.
2009;19:407–411.
7. Lewis JR Jr. The thigh lift. J Int Coll Surg. 1957;27:330–334.
8. Labardi L, Gentile P, Gigliotti S, et al. Medial thighplasty:
Horizontal and vertical procedures after massive weight loss.
J Cutan Aesthet Surg. 2012;5:20–25.
9. Lockwood TE. Fascial anchoring technique in medial thigh
lifts. Plast Reconstr Surg. 1988;82:299–304.
10. Kolker AR, Xipoleas GD. The circumferential thigh lift and
vertical extension circumferential thigh lift: Maximizing
Plast Surg. 2011;66:452–456.
11. Nemerofsky RB, Oliak DA, Capella JF. Body lift: An account
of 200 consecutive cases in the massive weight loss patient.
Plast Reconstr Surg. 2006;117:414–430.
12. Koltz PF, Chen R, Messing S, Gusenoff JA. Prospective
assessment of nutrition and exercise parameters before
body contouring surgery: Optimizing attainability in
the massive weight loss population. Plast Reconstr Surg.
2010;125:1242–1247.
13. Agha-Mohammadi S, Hurwitz DJ. Enhanced recovery
after body-contouring surgery: Reducing surgical compli-
cation rates by optimizing nutrition. Aesthetic Plast Surg.
2010;34:617–625.
14. Bossert RP, Dreifuss S, Coon D, et al. Liposuction of the arm
concurrent with brachioplasty in the massive weight loss
patient: Is it safe? Plast Reconstr Surg. 2013;131:357–365.
15. Moreno CH, Neto HJ, Junior AH, Malheiros CA. Thighplasty
after bariatric surgery: Evaluation of lymphatic drainage in
lower extremities. Obes Surg. 2008;18:1160–1164.
16. Ellabban MG, Hart NB. Body contouring by combined
abdominoplasty and medial vertical thigh reduction:
Experience of 14 cases. Br J Plast Surg. 2004;57:222–227.
17. Katzel EB, Nayar HS, Davenport MP, Bossert RP, Rubin JP,
Gusenoff JA. The influence of preexisting lower extremity
edema and venous stasis disease on body contouring out-
comes. Ann Plast Surg. 2014;73:365–370.

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