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
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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
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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
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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.
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Figures 5-9
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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.
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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.
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TED LOCKWOOD
OPERATIVE TECHNIQUE
TED LOCKWOOD
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.
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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.
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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.
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REFERENCES
TED LOCKWOOD