Commentary

Shermak et al describe their anterior proximal extended (APEX) thighlift technique, a variant of the Lockwood horizontal thighlift,1, 2 which in its excision spans anteriorly from the abdominoplasty scar to the infrabuttocks crease posteriorly. They conclude that APEX thighlift is the most appropriate thighlift for massive weight loss (MWL) patients with redundancy extending no further than the midportion of the medial thigh. While I am in agreement with the authors that the infrabuttocks area should be addressed more frequently in the MWL patient, I disagree that APEX should be the preferred methodology for patients with proximal thigh excess.

The thighs act like “stretch pants” during the weight gain and weight loss process, with most of the stretching occurring in the horizontal plane. After the deflation of weight loss, the resultant excess is, again, mostly horizontal in nature. It may appear vertical because the skin–fat envelope of the thigh is more adherent to the underlying musculoskeletal anatomy on the outer half of the thigh cylinder than it is on the medial half. With the medial skin-fat envelope being more free to descend, the thighs will present with the appearance of vertical excess, when in reality horizontal excess is the primary culprit. In designing an operation to reverse this problem, it is therefore more logical to eliminate horizontal excess with a vertical excision rather than the horizontal excision recommended by Shermak et al.

Furthermore, my major concern regarding APEX thigh reduction is its potential complications, including labial spreading and poor aesthetic results. Labial spreading is a very difficult, if not impossible, complication to eradicate.1, 2 In describing their technique, the authors state that “the Scarpa fascia of the thigh was suspended to the pubic periosteum with no. 1 braided permanent suture.” As I see it, the problem with the anchoring process of horizontal-only thigh reductions is not what you anchor to superiorly, but what you attach to inferiorly. Even if one were to drill holes in and pass sutures through the pubic bone, the problem is in what the suture attaches to inferiorly (which, in this case, is thigh Scarpa fascia). My experience is that upper thigh Scarpa fascia is weak at best and can be quite flimsy in many patients, especially in patients with MWL. When you combine this with the relatively heavy weight of the tissue being suspended in MWL patients and the ever-changing vector tensions of walking, a spectrum of problems—from scar migration to labial spreading—may occur. The authors claim that none of their patients experienced labial spreading, but looking at their outcomes—specifically Figure 6, part B, which I assume is representative of average results—it would take very little active contraction of the scars to lead to labial spreading.

Two potential aesthetic problems—blunting of the perineal crease and migration of scar onto the thighs—can occur with a horizontal-only, APEX-type thigh reduction. The mons pubis is a triangular-shaped subunit that has the perineal creases as its lateral boundaries. These should be areas of depression, rather than flat surfaces. Procedures that blunt the creases and/or migrate the scar onto the thigh violate that subunit and create a “pasted on” appearance, which is unattractive and artificial (again, see Figure 6, B). I believe that a vertical thigh reduction scar, limited to the proximal one-third of the thigh, is more hidden and superior in appearance to the scars created by the APEX technique. It can be argued that vertical thigh reductions do not address the mons pubis, which they do not, but I believe the answer to that problem is better addressed by labia majora reductions rather than the lateral excisions associated with APEX-type reductions.

In conclusion, I congratulate the authors for addressing the growing need for literature discussing infrabuttocks crease deformities in the MWL patient, but I feel that the APEX technique can potentially lead to labial spreading and unaesthetic results.