A woman’s legs are a very important aesthetic feature. Pretty, slim legs increase women's attractiveness a lot. They are regarded as sexy and chic.
Unfortunately, most women's thighs increase in volume, starting from puberty. Taking the contraceptive pill also usually increases the problem. The cause is an increasing local deposition of fat tissue, even in slim women, especially at the inner (medial) sides of the thighs, around the knees and at the outer thighs, mimicking “big bottoms”.
The reason is evolution of mankind itself. Disturbing fat deposits in women are actually found in all females of average weight, with individually varying distribution. In males they will hardly be found. These deposits are induced by female hormonal function and their extension is usually directly related to the amount of hormonal action in the body, especially when taking the pill (ovulation blockers).
The reason for developing those fat deposits is, that our body does not yet recognize that we do not live in the Stone Age period any more, without an adequate enough and regular food supply. During those times, thousands of years ago, the mother of a child had to somehow nourish her child to get it through bad times, especially winter. This was achieved through long-term breast feeding for many years after the birth. Any mother who was able to achieve this, had a clear evolutionary advantage. In order to sustain this, breastfeeding mothers needed reserves of energy, which could last long - even through hunger periods, even though being subjected to starvation themselves. These reserves were provided by hormonally induced fat deposits, which delivered high amounts of energy on one side and were light enough to be easily carried without impairing bodily movement. The above-mentioned deposits are usually located in the area of the inner thighs including the knees, the outer thighs, the hips and the slightly bulging tummy.
Hormonally-related fat deposits were only mobilized during periods of starvation to maintain nutrition of the child, which would seldom survive if the mother was on the verge of starvation. A mother who could not mobilize fat deposits for her child through hunger periods, because of “slimness” had a real nutrition problem and was therefore, at an evolutionary disadvantage. If she did not manage to feed her child through gruelling times, evolution would extinguish the baby or toddler, as callous as it seems to be.
Indeed, I once was consulted by a young, anorexic woman, who was 175 cm tall and only weighed in at 35 kg! She asked me … for liposuction of her outer thighs. Of course I refused to perform the surgical operation which she desired despite her emaciated state.
Another young woman visited me in my practice, a professional fitness instructor, with intense sporting activity for ten hours daily, seven days a week. She also came to the consultation to request liposuction of her thighs, because she was unable to get rid of her undesired fat deposits, despite the excessively high levels of sport.
These typical examples clearly show, that there is hardly any chance for a woman to effectively reduce hormonally induced fat deposits, neither through weight loss nor through sporting activity. The only way that works is long-term periods of breastfeeding or liposuction ...
Liposuction of the thighs can be regarded as some kind of “modular system”. The different regions can be combined with each other or left out. There are several quite important points that can easily lead to major mistakes, however, especially in the case of unexperienced physicians. Therefore, you should be prepared for the first consultation with your doctor:
It is an absolute “no-go” to suction fat deposits underneath your bottom. Several women get nerved by these desposits which resemble “sausages”. However, this local fat tissue is indispensable in supporting tissue to the gluteal region (bottom). It keeps it round and in form. If it is suctioned away, your bottom will droop down and result in a flat, unshaped, hanging “pancake”. You should never allow any doctor to do that!
These problems encountered, if suction of this region has already taken place, are virtually irreversible, because the fat tissue of this part of the body has a unique structure, similar to a scaffolding, that provides support to the tissue above.
There is - as usual - one single exception to the rule: extreme fat deposits underneath the bottom, usually due to overweight, could be taken away only very superficially, right underneath the skin, leaving the deeper supporting tissue behind. In this case too little is better than too much. It is better to reduce fat rather another time than to take away too much fat with the first treatment.
Better think twice, whether you really aim a liposuction of this region, rather make things clear with your plastic surgeon.
Fat tissue of the outer thighs, mimicking “riding breeches”, is a very typical female problem. Women who endure this problem usually complain about their “big bottom”, since they are frequently unaware of the fact that their bottom is not their problem, but their outer thighs. Fat deposits in the thigh area broaden their backside optically, similar to fenders of a car, which can make the car look broader and more effectual to the road. Once suctioned correctly, the bottom will be slimmer and rounder, automatically, without reducing it directly.
Fat deposits of the outer thighs are usually limited to the upper parts of the thighs, although varying in degree between different women. In addition, these fatty deposits can be quite asymmetrical as well, especially due to one-sided leg shortening and consequently, there is misalignment of the pelvis. In these cases the bone sticks out more on the side of the shorter leg, mimicking the appearance of more fat tissue, that is not really there. If this is the case, you should be informed, that liposuction can hardly change the described asymmetry. The aesthetic surgeon can only try to effectively reduce more of the fat in the affected, more prominent side than on the other, less prominent side of the longer leg. Unfortunately, this procedure is very difficult, because during the operation procedure the patient does not stand, but lies on the side, hence the side dissimilarity is not visible. Moreover, the fat deposits virtually “vanish” completely, if you lie on one side. You can test it out at home quite easily. You will see that I am right ...
Experienced aesthetic surgeons know how to discern the problems mentioned above, thus, they respond accordingly to recitfy them, during the operation. Nonetheless, one thing you should never expect post-operatively is that your hips will look perpendicular and straight, no matter whether one leg is shorter or not. You will have to tolerate some degree of roundness of your hips – after all this is feminine; this is attractive and this is appealing.
Only once in my professional life, I have seen a young patient who had undergone liposuction of her outer thighs by a gynaecologist, who must have been quite unexperienced. He must have suctioned down the hips in a sideway lying position so extensively, that the skin came down right to the hip bone, leaving deep and excessively ugly craters in the standing position. Indisputably this patient had experienced a life-long disfigurement as a result of this operation, and the correction or modification of this is a very complicated procedure requiring more than one session.
Each time I operate on broadened hips, I have this abysmal image in my mind. It protects me from suctioning too much, giving me some kind of red signal lamp to watch during the operation. The warning is simply to never ever suction too much! One needs to remember that plastic surgeons are only human beings with a moral and ethical responsibility towards their patients ... As doctors they are not only there to respect all patient wishes – even if they are extreme.
The inner sides of the thighs represent the most frequent fat tissue problem in women. As a man, it took me a long time to understand why. It took prolonged and extensive talks with many patients and lots of physical examinations to make things clear to me. I started to understand, why especially overweight women prefer to wear tight leggings, making other people around them shake their heads about their unaesthetic and unfavourable appearance: The reason is, that by wearing tights, these women were very effectively preventing the rubbing of the inner legs against each other, which otherwise would cause skin erosion and inflammation in this region.
Many women suffer from the rubbing of their inner thighs against each other especially at sport and in summer, when the sweating skin of each thigh rubs against the other when wearing dresses and skirts. In extreme cases this can even lead to reddening and inflammation, and ultimately even open skin wounds. This cannot only be unpleasant, but also very painful. Despite the suffering endured, no medical insurance would ever have noticed nor accepted this problem as a viable medical reason for liposuction. Unfortunately so!
Whilst some suffer, other women simply desire slimmer thighs for aesthetic reasons. Their desired aim is “to be able to look through their closed legs in standing position”. I understood this! Some of them even wanted to be able to read the newspaper through their closed thighs!
Both types of women who suffer from medical or aesthetic issues, want only the one thing: To have the abundant fat tissue between the thighs and knees removed. In these cases we distinguish three zones: the upper zone close to the intimate region which usually is more bulky, the middle zone of the inner thighs and the inner knee zone, which might be quite bulky, too. The latter one actually belongs to the knee zone itself, but usually gets treated together with the inner thighs, in order to achieve an equal and harmonic post-operative look.
All three zones described have totally different consistencies of fat tissue which demands different techniques of liposuction. All areas are also different in sensation. The most sensitive region is the proximal (upper) zone close to the intimate region. It consists of very soft and elastic skin – so utmost care is required to produce a perfect result.
Basically one can say, that liposuction of the inner thighs usually leads to high levels of satisfaction in patients. Nevertheless, one has to postulate a clear dependency of the operative result to the individual quality of skin as well. Young and elastic skin usually shrinks well, so that superficial irregularities of the skin surface, such as unevenness and dimples, hardly appear after the op. Each person would regard their individual case differently. Usually, I am more critical than my patients. But if one focuses more on the details, one will notice slight irregularities before, as well as after the operation.
Middle-aged women can also attain good results quite frequently, if they still have sufficient skin elasticity and if damage through excessive sun and nicotine exposure is not too apparent. This means that relevant post-operative skin irregularities, as well as dimples, usually do not have to be expected. Otherwise, damage through excessive sun and solarium exposure, in addition to chronic nicotine consumption can reduce skin elasticity dramatically, which can lead to reduced skin shrinking post-operatively. This could sometimes result in a compromise, which means a skin tuck is required in a secondary procedure to achieve a smoother skin surface. Each patient gets informed by me pre-operatively about this possibility. In fact, for as long as my practice exists, I have never done any skin tuck to the thighs and upper arms after liposuction. I remember two ladies with terribly damaged skin and huge fat deposits of the inner sides of the thighs. In both cases, I had offered a post-operative skin tuck with scar placement in a well hidden place (groin) to improve their result. Surprisingly, both women refused the skin tuck, because they simply didn’t find it aesthetically necessary. That means that the need of the operation lies always in the eye of the beholder.
The planning of liposuction of the inner thighs needs some close consultation between patient and surgeon. This mainly means the middle part of the inner thighs and the inner parts of the knees. It seems easy, but the only and isolated liposuction of the upper (proximal) parts of the thighs and of the inner sides of the knees does not make sense, for it is technically virtually impossible to equalize both zones “ideally” to the non-suctioned middle zone of the thigh. The same problem results from the inner sides of the knees: It does not make sense to suction the upper thigh to a thin leg and leave a bulky knee behind. This can lead to strange and unwanted optical results.
Therefore, I recommend to always suction the whole upper inner thigh “in one line” to achieve the best possible result.
Furthermore, the consultation between patient and surgeon should claim the wanted extension of liposuction to the thighs. Some women wish for “radical” fat tissue reduction, especially of the proximal side close to the trunk, in order to get rid of the bulky shape underneath the groin. In these cases, I did fulfill some patients’ wishes. However, I did not like the result entirely, because the musculature of the thigh was partially visible through the skin and the thigh tended to look somehow “sceletised”. Otherwise the women treated this way were delighted, whilst I was not. It seems better to me to respect a rest of slight bulkiness of the inner upper thighs, which is regarded as very normal and maintain a smooth, flowing and especially natural and non-operated looking form. “Natural” always does not look blatantly operated on and that is a favourable result. But at the end the patient’s wish counts, as far as I (the surgeon) can still stand behind it.
The amount of suctioned fat tissue can vary excessively.Depending on the patient’s weight and fat deposits, it can vary from under 1.000 ccm to mostly between 1.600 - 2.400 ccm and sometimes up to 3.000 - 4.000 ccm - both legs together. Once I treated a lady with a mega-suction of 11.100 ccm in one 10-hour session, only from the inner thighs and inner knees. This procedure was for medical reasons. Before the operation, the 55 year-old patient could hardly walk. Immediately post-operatively, she could walk faster than her husband, which resulted in more of a problem for him than for her ...
The post-operative scars after liposuction of the thighs can be significantly reduced in our practice based on our years of experience. Nowadays, I usually need one 4 mm scar in the middle of the inner thigh and a second 5 mm scar under the inner side of the knee, to achieve optimal results. Only in special cases is another small scar necessitated. This is much less than usually used in other places.
Three weeks post-operatively the scars first become red, then they fade to white and usually non-visible scars after 12 to 18 months.
The frontal sides (ventral sides) of the thighs are a problem to be considered. They usually contain the same amount of fat tissue as the inner sides. Unusually enlarged frontal thighs disturb one‘s appearance much less, because they hardly create problems with walking and appear less if one looks at them from the front. Quite often the surface of the skin is smooth with hardly any irregularities and dimples, as a result of their enlarged or extended form.
Liposuction to this region, unfortunately, looks less tensed and can give an “empty look”. From the front this looks all right, yet if the patient herself looks from the top - as usual - the tangential view reveals all the slightest irregularities and zones of less post-operative shrinkage, so that even the slightest irregularities could disturb the patient immensely. This may be the result, no matter how precisely or meticulously the surgeon has done his work.
Indeed, I once treated a small-built, but beautiful young woman from South America, who had the frontal sides of her thighs suctioned by me. She was quite happy with the result at first. But after some time she came back to my office and complained, that when she stood in her bathroom undressed with the sun shining in from the side and she looked down at herself and noticed a slight, wave-like irregularity of the skin surface of her frontal thighs. This was something that she did not like.
I learned from this case. Hence, today I make it very clear to my patients with liposuction to the frontal side of their thighs, that they definitely have to be a bit more tolerant than with other regions. Nevertheless, it might turn out to be a very good post-operative result with all over slim thighs and a happy patient. The operative procedure ultimately has to be the patient’s decision. I definitely will do my best about it.
You can read more about this topic under the link: »„Modelling of the Knees“
The back side (posterior side) of the thighs consists of very firm fat tissue that can be stressed much more intensely than other forms of fat tissue. It has to tolerate pressure (from long sitting) and friction (sliding over the edge of a chair), often in excessive amounts. These types of physical forces should not be underestimated and need very specialized forms of fat tissue. It is very similar tissue to underneath the bottom (see there) and an absolute “no-go” for liposuction!
Liposuction of the inner sides of the thighs, as well as the outer sides can regularly be done ambulantly under local anesthesia (so-called “tumescent anesthesia”). Only exceptionally and in high-risk patients, as well in patients with expected extreme amounts of suction may it be necessary to operate in a hospital environment. The operation itself is hardly painful, but one should be prepared for some slight sensitive moments during the operation. We do obviously supervise and support you during the operation and react immediately in case of uncomfortable pain by “drugging you down” to some wellness. General anesthesia is not necessary, and it does not make sense to use this since it leads to worse results, because it would be not possible for you to move your legs and activate muscles during the operation.
We operate on very sensitive structures which demand gentle and careful operative procedures to respect the anatomical structures like nerves and vessels. High sterility is very important to prevent infections of “opened-up” spaces through suction, since this could lead to very unpleasant and dangerous complications.
We make it very clear to ourselves all the time, that there are theoretical risks. This is not wrong. It motivates everybody on the team, including the surgeon, to work more thoroughly and responsibly. We work in our own theatre, which is a closed-up high sterility operation room with lock for personal and patients, as well as a microbiologically multiple-filtered and regularly tested air supply to the operation field and room. This reduces risk of infection drastically – in fact it is to up to now zero since our theatre was established, despite operations which last for up to 10 hours. Strict supervision of hygiene is a regular necessity in our practice.
A technically successful liposuction cannot be done hastily. It usually takes several hours, depending on the suction amounts and the regions. At the end, every single small fat deposit under the skin gets checked and treated in order to achieve the best and smoothest result. Also the borders between the suctioned and non-suctioned regions need to be equalized thoroughly in the best possible way to conceal surgery successfully.
Actually, the liposuction of the inner (medial) sides of the thighs is already big enough. Despite that, this operation can easily be combined with liposuction of the outer thighs, without increasing the risk of operation significantly.
The liposuction of the hips can be added in quite easily when one has healthy patients. But then we talk about a major procedure with operation time of about 6 hours in our practice, if high quality operative results are expected. Nonetheless, the operative risk will still remain minimal to absolutely moderate.
Common liposuction and modelling of upper and lower leg during one operative day is too much and will not be performed in our institution. From the medical side, it would be too much and increase operative risks drastically. So you have to choose, which region you prefer to be dealt with first. The operative gap between both regions should not be smaller than 6 months. I usually advise patients to treat the upper thighs first, being well aware, that most women would prefer the calves treated first. But the intermediate discrepancy between upper and lower legs would be much smaller with the thighs treated first, than visa versa.
The gap between the operations is important to give the lymphatic system enough time to heal and regenerate. Otherwise chronic and unpleasant swelling of the lower legs could result.
There is one basic rule to liposuction: Never operate above and below the belt line at one time! Always do it separately! That means that liposuction of the thighs should ideally not be combined with liposuction of the trunk. No liposuction to the outer sides of the thighs in combination with forming of the waist. If liposuction above and below the belt line is wanted, at least a 6 months time gap should be respected if not more.
It is obvious that I try my very best during operation, with every patient. Liposuction of the legs, as well as liposuction of any other region, has the unbelievable potential of improving the quality of life for any patient, if the result turns out well. Therefore, this form of operation becomes a fantastic instrument in the hands of a surgeon, who is honoured to model and form the perfect shape in order to fulfill the wishes and desires of his patients. Hardly any other form of operation is able to achieve this degree of satisfaction. Even if the operation can sometimes hurt slightly, we have good medical methods to drug you and numb the pain so that pain is hardly any issue to talk about.
Even post-operatively, during the first two days, pain is hardly there. From day three one feels some kind of a “muscle ache”, getting better every day - particularly after day five. Two weeks post-operatively there is hardly any issue or restriction. One just has to avoid sport until the full healing process has occured, which usually takes about 6 weeks post-operatively.
Obviously there are differences in sensitivity between different individuals. That we cannot prevent totally. But we do our best ... as always.
I am exceptionally proud to say, that as long as our practice and operative centre exists, there has never ever been any considerable complication nor problem encountered with liposuction. The rate of secondary correction is lower than 0,1% (two patients with minimal corrections within 16 years). The only “complications” (usually increased bruising) resulted from physical activity too early or leaving out fitted and recommended compression clothing too soon.
If you are willing to follow the medical advice of your plastic surgeon, you had better expect, that happiness with the desired aesthetic result cannot be prevented.
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