Comparative evaluation of traditional, ultrasonic, and pneumatic assisted lipoplasty: analysis of local and systemic effects, efficacy, and costs of these methods

Complications of Aesthetic Liposuction Performed in Isolation: A Systematic Literature Review and Meta-Analysis

Introduction: Aesthetic liposuction represents one of the most commonly performed cosmetic procedures worldwide. The purpose of this article is to examine and synthesize reported complication rates and explore the analytical prospect of possible patient or procedure-related predictive factors associated with specific complications. Methods: A systematic review was performed using the Pubmed, Cochrane, and Embase databases in line with specific criteria set to ensure an accurate assessment of complication rates; extracted data was synthesized through a random-effects model and meta-analysis of proportions. Results: A total of 60 studies were included in the meta-analysis, representing 21,776 patients undergoing aesthetic liposuction. Most studies followed an observational design. The overall complication rate was 12% (95% confidence interval [CI] 8%, 16%). When stratifying according to specific complications, the incidence of contour irregularities was determined to be 2% (95% CI 1%, 2%), seroma 2% (95% CI 1%; 2%), hematoma 1% (95% CI 0%, 1%), surgical site infection 1% (95% CI 1%, 2%), fibrosis or induration 1% (95% CI 1%, 2%), and pigmentary changes 1% (95% CI 1%, 1%), among others. A meta-regression to identify patient- or procedure-related factors associated with greater complication rates proved infeasible given the nature of the available data. Conclusion: Overall, liposuction demonstrated a relatively low complication rate profile, however, a considerable degree of heterogeneity exists within the examined literature preventing the recognition of predictive risk factors. While this calls for efforts to establish consensus on unified methods of outcomes reporting, the present meta-analysis can serve to provide practitioners with an evidence-based reference to improve informed consent and inform clinical guidelines, specifically pertaining to the incidence of commonly encountered complications in aesthetic liposuction, of which presently available survey studies and database queries remain devoid.

From the SAFE to the SAFEST Liposuction: Combining PAL and RFAL Technology in Body Contouring Procedures

BACKGROUND

The SAFE liposuction technique is a worldwide extended method used to achieve great and reproducible results after the surgical aspiration of fat. We propose an evolution of the technique to address one of the major limitations of liposuction, loose skin. The SAFEST liposuction technique combines PAL and RFAL to achieve skin tightening and fat reduction with minimal added morbidity.

METHODS

Patients treated with the SAFEST liposuction technique between December 2019 and February 2022 were included in the study. Demographic and surgical data were collected retrospectively. Photographs and satisfaction interviews were conducted preoperatively and 12 months postoperatively in every case.

RESULTS

Sixty-five patients (58 female and 7 male) were included in the cohort, and a total of 169 anatomical areas were treated with the SAFEST liposuction technique (abdomen, arms, back, flanks and thighs). Globally, satisfaction at 12 months follow-up was of 94.1% and complications only presented in 4.7% of the treated areas. 6 of the 38 treated abdomens (18.4%) presented a complication (4 seromas and 2 access point infections) and 2 of the 38 treated flanks (5.3%) presented one (2 seromas). The rest of the treated anatomical areas (arms, back and thighs) showed no complications and high satisfaction rates.

CONCLUSIONS

The SAFEST liposuction technique achieves outstanding and satisfying results with minimal complications by safely combining the advantages of two different technologies, PAL and RFAL. The main advantages of the presented technique are the skin tightening, the body ligament contraction, the coagulation and the reduction of the operative time.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Outpatient-Based High-Volume Liposuction: A Retrospective Review of 310 Consecutive Patients

BACKGROUND

Currently, the definition of large-volume liposuction is the removal of 5 L or more of total aspirate. Higher volumes of lipoaspirate come into consideration with higher BMIs, because more than 5 L is often required to achieve a satisfactory aesthetic result. The boundaries of what lipoaspirate volume is considered safe are based on historical opinion and are constantly in question.

OBJECTIVES

Because to date there have been no scientific data available to support a specific safe maximum volume of lipoaspirate, the authors discuss necessary conditions for safe high-volume lipoaspirate extraction.

METHODS

This retrospective study included 310 patients who had liposuction of ≥5 L over a 30-month period. All patients had 360° liposuction alone or in combination with other procedures.

RESULTS

Patient ages ranged from 20 to 66 with a mean age of 38.5 (SD = 9.3). Average operative time was 202 minutes (SD = 83.1). Mean total aspirate was 7.5 L (SD = 1.9). An average of 1.84 L (SD = 0.69) of intravenous fluids and 8.99 L (SD = 1.47) of tumescent fluid were administered. Urine output was maintained above 0.5 mL/kg/hr. There were no major cardiopulmonary complications or cases requiring blood transfusion.

CONCLUSIONS

High-volume liposuction is safe if proper preoperative, intraoperative, and postoperative protocols and techniques are employed. The authors believe that this bias should be modified and that sharing their experience with high-volume liposuction may help guide other surgeons to incorporate this practice with confidence and safety for better patient outcomes.

LEVEL OF EVIDENCE: 3

A 16-Year Review of Clinical Practice Patterns in Liposuction Based on Continuous Certification by the American Board of Plastic Surgery

BACKGROUND

The American Board of Plastic Surgery has collected data on cosmetic surgery tracers as part of the Continuous Certification process since 2005. The current study was performed to analyze evolving trends in liposuction from the American Board of Plastic Surgery database.

METHODS

Tracer data from 2005 through 2021 were reviewed and grouped into an early cohort (EC) (2005-2014) and a recent cohort (RC) (2015-2021). Fisher exact tests and two-sample t tests were used to compare patient demographics, techniques, and complications.

RESULTS

A total of 2810 suction-assisted liposuction cases were included (1150 EC, 1660 RC). In-office procedures increased (36% EC versus 41% RC). The use of general anesthesia remained the same (63% EC versus 62% RC). The use of power-assisted liposuction increased (24% EC versus 40% RC) and use of ultrasound-assisted liposuction decreased (5% versus 2%). With respect to body areas treated, liposuction of the abdomen (64% EC versus 69% RC), flanks (60% EC versus 64% RC), and back (22% EC versus 34% RC) increased; treatments of thighs (36% EC versus 23% RC), and knees (8% EC versus 5% RC) decreased. Intraoperative position changes are more common (30% EC versus 37% RC), as is liposuction of multiple areas in one case (28% EC versus 36% RC). The volume of lipoaspirate also increased (1150 cc EC versus 1660 cc RC).

CONCLUSIONS

This study highlights evolving trends in liposuction over 16 years. Liposuction is becoming more common as an outpatient procedure performed concomitantly with other procedures. Despite multiple emerging technologies, the popularity of power-assisted liposuction is increasing. Although adverse events have not significantly increased with these changes, the authors stress careful preoperative evaluation of patients to identify factors that increase the risk of complications.

Safety and Efficacy of Third-Generation Ultrasound-Assisted Liposuction: A Series of 261 Cases

BACKGROUND

The introduction of third-generation ultrasound-assisted liposuction (3rd UAL) allows for a less invasive modality of both deep and superficial lipectomy while offering improved skin retraction and reduced rate of complications. This study examined the efficacy and safety profile of this technology over 15 years of clinical experience.

METHODS

A consecutive series of patients treated from 2005-2020 by the senior author were reviewed for demographic and anthropometric measurements, intraoperative settings, surgical outcomes, and complications via retrospective chart review. Body-Q survey was used to assess patient satisfaction.

RESULTS

A total of 261 patients underwent 3rd UAL in 783 areas. There were 238 female and 23 male patients with an average age of 43.5 years and BMI of 27.4 kg/m². The most frequently treated areas were the trunk and lower limbs. An average of 2840 mL of wetting solution was used with an average of 2284 mL of lipocrit aspirate. About 65% of the cases were done in conjunction with another procedure. Overall complication rate was 4.6%, contour irregularity (1.9%), seroma (0.8%), cellulitis (0.8%), pigmentation changes (0.4%), and electrolyte imbalance (0.4%), with a minimum follow-up of 6 months. 78% of patient would undergo the procedure again and 86% would recommend it.

CONCLUSION

Third-generation ultrasound-assisted liposuction can be used effectively and safely, either alone, or in conjunction with other plastic surgery procedures. VASER liposuction allows surgeons to address superficial fat plane and enhanced skin tightening. Rate of complications are lower than that of traditional liposuction with equivalent or higher patient satisfaction.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

High-Definition Lipoplasty in Male Patients: A Systematic Review of Surgical Techniques and Outcomes

BACKGROUND

Lipoplasty has undergone a series of refinements since its inception. It is now possible to apply superficial suction to enhance the outline of a muscle in order to improve the results of aesthetic lipoplasty.

OBJECTIVES

The aim of this study was to summarize the available evidence on the techniques and surgical outcomes of high-definition lipoplasty (HDL) in male patients.

METHODS

A systematic search across PubMed MEDLINE, Web of Science, Ovid MEDLINE In-Process & Other Non-Indexed Citations, and SCOPUS was performed in accordance with the PRISMA guidelines. Data regarding the surgical techniques, outcomes, and complications were extracted.

RESULTS

Thirteen studies comprising 1280 patients fulfilled the inclusion criteria. The age of patients ranged from 18 to 71 years. The average BMI was 26.5 kg/m2. The follow-up ranged from 2 weeks to 10 years. The liposculpting concepts reported were abdominal etching, high-definition, muscular sculpture, and dynamic definition. Four studies used conventional liposuction, 3 used VASER-assisted HDL, and 6 studies used power-assisted liposculpting. Eight studies reported the use of fat grafting. All studies reported the use of postoperative garments and a well-established wound treatment protocol. Overall satisfaction ranged from 84% to 100%. The most common complications reported were fluid collection, hyperpigmentation, contour irregularities, anemia, and port dehiscence.

CONCLUSIONS

A wide variety of techniques are available to perform HDL with a variable degree of definition. Careful patient selection is critical for successful results because HDL is not suitable for every patient. Finally, proper training and adequate knowledge of abdominal anatomy is necessary to avoid complications.

LEVEL OF EVIDENCE: 4

High Definition Liposculpture in Male Patients Using Reciprocating Power-Assisted Liposuction Technology: Techniques and Results in a Prospective Study

BACKGROUND

High-definition liposculpture (HDL) consists of techniques developed to emulate an athletic and attractive surface anatomy.

OBJECTIVES

The aim of this study was to describe our experience, including techniques and postoperative outcomes, when performing HDL with power-assisted liposuction (PAL) technology in male patients.

METHODS

In this prospective study PAL was used for fat extraction and to perform HDL. Intraoperative data were collected and the techniques used were recorded. Postoperatively, photographs were taken, and data were collected regarding the use of compression garments and pain medication, return to work and full activity, and satisfaction levels.

RESULTS

All patients were males, with an average age of 32.3 years and a body mass index of 26.45 kg/m2; the follow-up period averaged 7.6 months. Intraoperatively, all patients received HDL of the chest, abdomen, back, and upper arms, and fat transfer to the chest. The average operative time was 3.4 hours. None of patients had drains left intraoperatively. Postoperatively, all patients were completely off their pain medications by postoperative day 9. They received, on average, 3.7 sessions of lymphatic massage and wore compression garments for an average of 3 weeks. They returned to work 6.1 days after surgery and were back to full activity in 3.2 weeks. Minor complications were reported in 2 patients. Patient satisfaction was on average 9.8 (on a scale of 1-10) at 6 months.

CONCLUSIONS

HDL with PAL technology is a safe procedure that delivers reproducible natural-looking results with high patient satisfaction rates, low risk of complications, and a relatively short and tolerable recovery process.

LEVEL OF EVIDENCE: 4

Evaluation of Glandular Liposculpture as a Single Treatment for Grades I and II Gynaecomastia

BACKGROUND

Gynaecomastia is a benign enlargement of the male breast, of which the psychological burden on the patient can be considerable, with the increased risk of disorders such as depression, anxiety, and social phobia. Minimal scarring can be achieved by liposuction alone, though it is known to have a limited effect on the dense glandular and fibroconnective tissues. We know of few studies published on "liposuction alone", so we designed this study to evaluate the outcome of combining liposuction with glandular liposculpturing through two axillary incisions as a single treatment for the management of grades I and II gynaecomastia.

METHODS

We made a retrospective analysis of 18 patients with grade I or II gynaecomastia who were operated on by combined liposuction and glandular liposculpturing using a fat disruptor cannula, without glandular excision, during the period 2014-2016. Patient satisfaction was assessed using the Breast Evaluation Questionnaire (BEQ), which is a 5-point Likert scale (1 = very dissatisfied; 2 = dissatisfied; 3 = neither; 4 = satisfied; 5 = very satisfied). The post-operative aesthetic appearance of the chest was evaluated by five independent observers on a scale from 1 to 5 (5 = considerable improvement).

RESULTS

The patient mean (SD) overall satisfaction score was 4.7 (0.7), in which 92% of the responders were "satisfied" to "very satisfied". The mean (SD) BEQ for all questions answered increased from 2.1 (0.2) "dissatisfied" preoperatively to 4.1 (0.2) "satisfied" post-operatively. The observers' mean (SD) rate for the improvement in the shape of the front chest wall was 4.1 (0.7). No haematomas were recorded, one patient developed a wound infection, and two patients complained of remnants of tissue. The median (IQR) body mass index was 27.4 (26.7-29.4), 11 patients had gynaecomastia grade I, and 7 patients grade II. The median (IQR) volume of aspirated fat was 700 ml (650-800), operating time was 67 (65-75) minutes, 14 patients had general anaesthesia, and hospital charges were US$ 538 (481-594).

CONCLUSIONS

Combined liposuction and liposculpturing using the fat disruptor cannula resulted in satisfied patients and acceptable outcomes according to the observers' ratings. It could be a useful alternative with an outcome that corresponds to that of more expensive methods.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Separation, Aspiration, and Fat Equalization: SAFE Liposuction Concepts for Comprehensive Body Contouring

BACKGROUND

Separation, aspiration, and fatty equilibration (SAFE) liposuction uses a process approach to body contouring and minimizes injury to surrounding structures. The multistep process allows for (1) fat separation, (2) lipoaspiration, and (3) fat equalization. The purpose of this study was to review both outcomes and complications of primary SAFE liposuction.

METHODS

Retrospective chart review was completed of patients undergoing SAFE liposuction from January of 2006 to January of 2011. Patient selection was limited to those undergoing liposuction alone with no adjuvant excisional procedures. Data were collected regarding demographics, body mass index, operative details, and outcomes.

RESULTS

Seven hundred thirty-four patients were identified as having undergone SAFE liposuction. One hundred twenty-nine patients were found to have been treated with liposuction alone. Patient age ranged from 18 to 42 years and body mass index ranged from 18 to 42 kg/m (mean, 26.3 kg/m). Seven patients (5.4 percent) underwent treatment of the face and neck, six patients (4.7 percent) underwent treatment of upper extremities, 13 patients (10.1 percent) underwent treatment of the chest, 20 patients (15.5 percent) underwent treatment of lower extremities, 32 patients (24.8 percent) underwent treatment of the circumferential trunk, and 51 patients (39.5 percent) underwent treatment of circumferential trunk and additional area(s). No major complications occurred. Five of the 129 patients (3.87 percent) developed the minor complication of seroma formation.

CONCLUSIONS

SAFE liposuction is a multistep process approach to body contouring consisting of (1) fat separation, (2) lipoaspiration, and (3) fat equalization. The results of this study show such technique to be safe and effective.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Current trends of liposuction in India: Survey and Analysis

Background:

Liposuction is the commonest aesthetic procedure performed by Indian plastic surgeons. However, there exists substantial disparity amongst Indian surgeons about guidelines concerning liposuction. To address this disparity, a nationwide email survey (Association of Plastic Surgeons of India [APSI] database) was started in December 2013 and continued for 5 months.

Material and Methods:

The survey was developed with software from www.fluidsurveys.com. The study was designed to cover most aspects of patient selection, perioperative management, technical considerations, postoperative management and complications. This is the first survey to be conducted in India for an extremely popular procedure. It is also one of the most exhaustive surveys that have been conducted in terms of the topics covered.

Results and Conclusions:

One hundred and eighteen surgeons (including a majority of the cosmetic surgery stalwarts in the country) completed the survey. As expected, the results show a disparity in most parameters but also consolidation on some issues. Liposuction is considered extremely safe (86.1%). The majority of surgeons (70.3%) aspirated >5 L at onetime. The majority (80.2%) felt that the limits for liposuction should be relative and not absolute. The survey highlights lack of standardization with respect to infiltration solutions. The commonest complications observed were contour irregularities, followed by seroma and inadequate skin redrape. The amount of aspirate is the only factor, which achieves statistical significance with respect to major complications. A review of the current evidence and recommendations has been incorporated, along with an in depth analysis of the survey.

Power-Assisted Liposuction Versus Tissue Resection for the Isolation of Adipose Tissue-Derived Mesenchymal Stem Cells: Phenotype, Senescence, and Multipotency at Advanced Passages

BACKGROUND

Adipose tissue-derived mesenchymal stem cells (ASCs) can be isolated from subcutaneous fat harvested by tissue resection or liposuction.

OBJECTIVES

The authors compared ASCs isolated by tissue resection or power-assisted liposuction (PAL) to determine whether either surgical procedure yielded ASCs with improved purity and competence that was preserved for several passages.

METHODS

For this experimental study, ASCs were isolated from fat harvested by tissue resection or PAL from six patients who underwent abdominoplasty. ASCs were counted to determine cell yields, and viabilities were assessed with an amine-reactive dye and by fluorescence-activated cell sorting (FACS). Cell phenotypes were determined by immunostaining and FACS, and doubling times were calculated. Senescence ratios of the cells were detected by gene profiling and by assaying β-galactosidase activity. Multipotency was evaluated by induced differentiation analyses.

RESULTS

No significant differences were observed in cell numbers or viabilities of ASCs isolated following either surgical method of fat harvesting. Both populations of cultured ASCs expressed markers of mesenchymal stem cells and preserved this expression pattern through the third passage. PAL and tissue resection yielded ASCs with similar division rates, similar senescence ratios into the fourth passage, and similar capacities to differentiate into osteocytes or adipocytes.

CONCLUSIONS

Fat harvested by PAL or tissue resection yielded uniform cultures of ASCs with high division rates, low senescence ratios, and multipotency preserved into passages 3 and 4. Because PAL is less invasive, it may be preferable for the isolation of ASCs.

Surgical treatment of multiple symmetric lipomatosis with ultrasound-assisted liposuction

Multiple symmetric lipomatosis (MSL) is a rare disease of unknown etiology, characterized by the presence of multiple, symmetrical, noncapsulated lipomas, mostly in the neck and upper trunk. To date, there is no effective medical treatment of MSL. Surgical treatment is based on 2 options, namely, lipectomy and/or liposuction. In this retrospective study, we compare traditional lipectomy with ultrasound-assisted liposuction. Our initial experience demonstrates that the ultrasound-assisted liposuction procedure can be applied to patients with MSL, allowing simultaneous treatment of multiple areas in a single session and the removal of a substantial amount of fat, thus improving aesthetic results. If lipomas are circumscribed and isolated, traditional lipectomy is probably to be preferred.

Unfavourable outcomes of liposuction and their management

Liposuction is one of the most popular cosmetic surgery procedures currently performed by plastic surgeons around the world. It must be clear at the outset that liposuction is not primarily a modality for weight loss, it is meant to be a body contouring procedure and therefore the inherent limitations and safety issues related to this must always be respected if complications and unfavourable results are to be avoided as far as possible.

Avoiding unfavourable outcomes in liposuction

The origin of liposuction can be traced to an adverse event by Dujarrier in 1921 when he used a uterine curette to remove fat from the knees of a ballerina ending in an amputation secondary to damage of the femoral artery. The history of liposuction since then has been one of avoiding complications and optimising outcome. After this adverse event, liposuction was abandoned until the 1960's when Schrudde revived the practice using small stab incisions and sharp curettage with the secondary suction to aspirate the freed tissue. This technique was associated with a high incidence of complications especially seroma and skin necrosis. Illouz then replaced the curette with a blunt cannula connected to vacuum pump thus avoiding the complications of a sharp curette. Despite the presence of various techniques for liposuction, suction assisted liposuction (SAL) is still the standard technique of liposuction. This article aims to discuss literature regarding the various aspects of liposuction (SAL) and to highlight the salient points in the literature and in the senior author's experience in order to avoid unfavourable outcomes in liposuction. A literature review on avoiding complication is in liposuction including some of the seminal papers on liposuction. Liposuction is generally a safe procedure with reproducible outcome. Just like any surgical procedure it should be treated with the utmost care. Illouz published 10 commandments for liposuction in 1989 and we review these commandments to demonstrate how liposuction has evolved.

Evidence-based medicine: liposuction

LEARNING OBJECTIVES

After reading this article, the participant should be able to: 1. Perform preoperative assessment and patient selection for liposuction surgeries. 2. Explain the differences among the various types of anesthesia and wetting solutions used in liposuction. 3. Identify the available literature about skin-tightening procedures. 4. Convey to patients the complication profile for various modalities of liposuction. 5. Recall important ASPS consensus guidelines when discussing liposuction.

SUMMARY

The article was prepared to feature recent evidence-based publications pertaining to liposuction. The authors placed special emphasis on the most clinically relevant data. In addition, they highlighted current data regarding liposuction-related fields, including autologous fat transfer and minimally invasive skin tightening.

Advances in liposuction: five key principles with emphasis on patient safety and outcomes

SUMMARY

Since Illouz's presentation of a technique for lipoplasty at the 1982 Annual Meeting of the American Society of Plastic and Reconstructive Surgeons, liposuction has become one of the most commonly performed aesthetic surgery procedures. The evolution of liposuction has seen refinements in technique and improvement of patient safety-related standards of care. Based on long-term experience with body contouring surgery, 5 principles of advanced liposuction are presented: preoperative evaluation and planning, intraoperative monitoring-safety measures, the role of wetting solutions and fluid resuscitation, circumferential contouring and complication prevention, and outcomes measurement.

Nonexcisional tissue tightening: creating skin surface area reduction during abdominal liposuction by adding radiofrequency heating

BACKGROUND

Recent publications show that heat-mediated tissue tightening is a promising treatment for the lax abdomen and may provide better long-term outcomes than traditional suction-assisted liposuction (SAL).

OBJECTIVES

The author evaluates the degree and duration of skin surface area contraction, as well as the influence of anatomic location of the treatment region on the degree of tissue tightening, in a study comparing SAL alone vs SAL plus radiofrequency-assisted liposuction (RFAL).

METHODS

In this prospective, randomized, split abdominal study, 12 consecutive patients were treated with SAL alone on 1 side and with SAL plus RFAL on the other side. Each patient had 4 (3 × 3-cm) squares-2 per treatment type-tattooed in the lower abdominal region (2 on the right and 2 on the left). The surface area of these squares was measured with the Vectra computerized measurement system (Canfield, Inc, Fairfield, New Jersey) at pretreatment, at 6 weeks posttreatment, and at 1 year posttreatment. All measurements were subjected to statistical analysis using predictive analytic software and were evaluated for statistical significance.

RESULTS

In regions treated with SAL alone, there was a 10.4% mean skin surface area contraction at 6 weeks and 8.3% at 1 year posttreatment. The mean skin surface area reduction was 25.8% in regions treated with radiofrequency plus SAL at 6 weeks and at 1 year. The anatomic location of each square (medial vs lateral) did not statistically correlate with more or less tissue tightening.

CONCLUSIONS

Radiofrequency-assisted tissue tightening, when applied in conjunction with SAL, is effective in achieving greater skin surface area reduction.

Dynamic definition mini-lipoabdominoplasty combining multilayer liposculpture, fat grafting, and muscular plication

BACKGROUND

There is a select group of women for whom mini-abdominoplasty techniques combined with 3-dimensional liposculpture and fat grafting can effectively correct postpartum deformities.

OBJECTIVE

The authors describe a multilayer and 360-degree approach, dynamic definition mini-abdominoplasty (DDM), to create athletic definition and contour and to restore a feminine appearance postpartum.

METHODS

A total of 181 consecutive women ages 20 to 56 years underwent DDM between January 2005 and May 2012. Patients who were a minimum of 6 months postpartum and in good health, with a body mass index below 30, were considered for inclusion in the study. Fat grafting was performed in select cases in the buttocks, deltoids, and/or calves. A satisfaction index (SI) was estimated based on patient survey responses.

RESULTS

An overall SI of 91.5% was achieved. No major complications were reported. Twenty-nine minor complications included postoperative anemia, seroma, and infection in the surgical wound. In most patients, the postpartum abdomen was restored to an aesthetic and even athletic appearance. Athletic definition to the rectus, arms, trunk, thighs, and buttocks was also achieved. No burns or flap necrosis were reported.

CONCLUSIONS

Dynamic definition mini-abdominoplasty is safe and reproducible. It serves as a viable alternative to a full abdominoplasty in selected cases and for women who wish to restore an athletic and feminine appearance after childbirth.

LEVEL OF EVIDENCE

4.

Arm dynamic definition by liposculpture and fat grafting

BACKGROUND

The contour of the arm is determined by muscular shape and volume. Liposuction in this area is challenging due to the difficulties of achieving symmetry and the high risk of contour irregularities due to fat structures in the region.

OBJECTIVE

The authors describe a new technique to achieve muscular definition in the arm.

METHODS

From January 2005 to December 2011, a total of 651 arm-sculpting procedures were performed in consecutive patients. Patients with body mass index (BMI) >30 kg/m(2) and/or severe skin laxity were excluded. Fat grafting was performed in the deltoid area in selected cases. The areas of fat extraction and grafting were specific to gender: in men, an athletic, muscular look was preferred, whereas in women, a slimmer and less-defined shape was desired.

RESULTS

Of the 651 patients, 158 were men (24.3%) and 493 were women (75.7%). Most patients (98.3%) were satisfied with the results in arm dynamic definition. All patients underwent other body contouring procedures at the time of arm enhancement. Complications (n = 21) included 1 soft tissue abscess in the posterior arm, 2 unilateral hematomas, and 3 unilateral seromas that required puncture, along with 15 cases of minor asymmetry. Transitory hardening of the skin of the posterior arm was frequent (n = 104) due to superficial fat extraction, but all cases resolved within 6 months.

CONCLUSION

The authors were able to achieve natural results with this new procedure in arm contouring. The technique is safe and effective with reproducible results when performed through multilayer fragmentation and liposuction with an anatomical extraction. Fat grafting can be performed for contouring with no additional complications.

Dynamic-definition male pectoral reshaping and enhancement in slim, athletic, obese, and gynecomastic patients through selective fat removal and grafting

BACKGROUND

One of the most appealing characteristics of an athletic male body is a well-defined pectoral area. For decades, implants have been the gold standard method for the treatment of this area, but it is not suitable for every case. The goal was to design a mixed technique combining autologous fat extraction and grafting in an anatomically guided fashion to produce a highly athletic contour in the male pectoral.

METHODS

The patient criteria included a body mass index (BMI) lower than 30 kg/m(2), adequate skin tone, and general good health. A three-phase procedure was performed, beginning with infiltration of tumescent solution and followed by fragmentation of extra fat in an anatomic fashion using internal third-generation ultrasound; extraction that blends deep, intermediate, and superficial fat removal; and multilayer fat grafting in the pectoral area. In the presence of gynecomastia, a selective pull-through technique was used in an anatomic manner.

RESULTS

In a series of 154 consecutive male patients, the minor complications (n = 15) included asymmetries (n = 10) and residual gynecomastia (n = 5). The major complications (n = 3) included unilateral hematoma (n = 2), and abscess that required sonographic-guided removal (n = 1). An appealing muscular contour was produced in most patients, and the satisfaction rate was very high.

CONCLUSION

Implants are no longer the only option for defining and augmenting the male chest. Combining fat grafting in a multilayer fashion with precise anatomic fat and gland removal achieved a contoured and athletic male pectoral in a safe and reproducible manner.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article.

1,000 consecutive cases of laser-assisted liposuction and suction-assisted lipectomy managed with local anesthesia

BACKGROUND

Advances in suction-assisted lipectomy (SAL) include improved instrumentation, better understanding of fluid dynamics, and an improved concept of appropriate indications. The tumescent technique uses subcutaneous injection of isotonic fluid containing vasoconstrictive and analgesic agents and is proved to be safe, with low morbidity and mortality rates. Laser-assisted liposuction (LAL) using local infiltration of an anesthetic and no general anesthesia or sedation has been developed, with claims of fat destruction and skin tightening. This study aimed to review 1,000 consecutive cases of LAL and SAL performed with the patient under local anesthesia and to determine whether this represents a safe technique with few complications.

METHODS

During a period of 22 months, 581 consecutive patients (486 females and 95 males) underwent 1,000 LAL/SAL operations, 545 of whom had multiple procedures performed. None of the patients had a body mass index (BMI) higher than 30 kg/m2. The patients ranged in age from 18 to 62 years. The fat aspirate ranged from 50 to 1,400 ml. Patients were given an oral sedative, an antibiotic, and an analgesic. Ringer's lactate solution containing lidocaine and epinephrine was injected into the subcutaneous space. The 1,064-nm and/or 1,320-nm neodymium:yttrium-aluminum-garnet (Nd:YAG) laser was used for laser lipolysis followed by SAL using standard and/or power-assisted liposuction (PAL) cannulas. The treated areas included the neck, triceps, male breast, midback, flanks, axilla, abdomen, mons pubis, thighs, presacrum, and knees. No patient was administered intravenous sedation or general anesthesia.

RESULTS

The average number of areas treated was 1.8, and no major complications or mortalities were observed. There were three burns, two infections, one hematoma, and one seroma. A total of 73 secondary procedures were performed (7.3%). No tertiary procedures were required.

CONCLUSION

For appropriately selected patients, comparable results can be obtained with an excellent safety profile and short recovery period using LAL and SAL with the patient under local anesthesia. The awake patient is able to participate in body positioning and to provide physiologic monitoring. No major complications occurred in this series. The burn and hematoma complications occurred in the first 25 cases and may have been related to a learning curve. One case of cellulitis occurred in the triceps region, and a second infection occurred in the abdomen. Both responded to antibiotics. Altogether, 73 touch-up procedures (7.3%) were performed. The amounts of fat removal were comparable with the volumes obtained using traditional liposuction. In conclusion, this series demonstrated that LAL/SAL using local anesthesia is a safe procedure for selected patients, with acceptably low morbidity and revision rates.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors at www.springer.com/00266.

Body-contouring with radiofrequency-assisted liposuction

Liposculpturing is the most frequently performed procedure in the aesthetic clinical practice. The techniques have evolved into significant modification during the past few decades with introduction of several new devices, leading to superior outcome. Radiofrequency-assisted liposuction (RFAL) have revolutionised body contouring techniques by providing simultaneous fat liquefaction, coagulation of blood vessels, and skin tightening in the tissues. In this study we discuss our preliminary experience with RFAL in treating patients for aesthetic body contouring and patients with HIV-related lipohypertrophy. Forty-two patients were treated with RFAL for cosmetic concerns, and eight were treated for HIV-related lipohypertrophy after unsuccessful outcome with other techniques. Significant reduction of adipose tissue with marked tightening of the skin was noted in all the patients. Clinical results were impressive in terms of pain, recovery, and patient satisfaction. Remarkable improvement was observed in patients with HIV-related cervical lipohypertrophy and gynaecomastia with fibrous fatty tissue. Two patients suffered superficial burns and were managed conservatively. Our experience suggests that controlled application of radiofrequency power for liposculpturing may open up a new horizon of non-excisional lipectomy in the future.

Surgical correction of gynecomastia in thin patients

BACKGROUND

Gynecomastia refers to a benign enlargement of the male breast. This article describes the authors' method of using power-assisted liposuction and gland removal through a subareolar incision for thin patients.

METHODS

Power-assisted liposuction is performed for removal of fatty breast tissue in the chest area to allow skin retraction. The subareolar incision is used to remove glandular tissue from a male subject considered to be within a normal weight range but who has bilateral grade 1 or 2 gynecomastia.

RESULTS

Gynecomastia correction was successfully performed for all the patients. The average volume of aspirated fat breast was 100-200 ml on each side. Each breast had 5-80 g of breast tissue removed. At the 3-month, 6-month, and 1-year follow-up assessments, all the treated patients were satisfied with their aesthetic results.

CONCLUSIONS

Liposuction has the advantages of reducing the fat tissue where necessary to allow skin retraction and of reducing the traces left by surgery. The combination of surgical excision and power-assisted lipoplasty also is a valid choice for the treatment of thin patients.

The American Society for Aesthetic Plastic Surgery (ASAPS) survey: current trends in liposuction

BACKGROUND

The emergence of new technologies necessitates a study of current trends in liposuction and other methods for fat removal.

OBJECTIVE

The American Society for Aesthetic Plastic Surgery (ASAPS) conducted a survey of its members to gain valuable information from Board-certified plastic surgeons about their experience with new technologies for fat removal and managing complications after liposuction.

METHODS

The ASAPS Current Trends in Liposuction Survey was emailed to 1713 ASAPS members. Data were tabulated and examined to determine current trends in liposuction and other fat removal techniques performed by ASAPS members.

RESULTS

The response rate for the survey was 28.7% (n = 492). Most ASAPS respondents reported performing between 50 and 100 liposuction procedures annually. Most plastic surgeons currently employ or have previous experience with suction-assisted lipectomy/liposuction (SAL), ultrasound-assisted liposuction (UAL), and power-assisted liposuction, but fewer reported experience with laser-assisted liposuction (LAL), mesotherapy, or external, noninvasive devices. SAL was the preferred method of fat removal for 51.4%. UAL, LAL, and SAL were most commonly associated with complications. Only 10.5% of ASAPS members employ LAL; 38% have treated a patient with complications secondary to LAL.

CONCLUSIONS

Valuable information about current trends in liposuction and other fat removal techniques has been gained from this survey. Although many studies have been published that review issues related to safety, morbidity, aesthetics, and recovery after different methods of fat removal, more prospective studies with standardized objective outcome measures comparing these techniques, particularly newer modalities, are needed to continue improving safety-related standards of care.

Water-assisted liposuction for body contouring and lipoharvesting: safety and efficacy in 41 consecutive patients

BACKGROUND

Water-assisted liposuction (WAL) is a new technique for body contouring and fat harvesting that relies on a fan-shaped jet of tumescent solution to anesthetize fatty for liposuction and grafting. As with any new technology, safety and efficacy are paramount.

OBJECTIVE

The author evaluates the technique and outcomes for small-to-moderate volume liposuction cases treated with WAL in an office setting.

METHODS

Forty-one consecutive patients were treated with WAL (Body-Jet; Human Med, Eclipse Ltd., Dallas, Texas) in the author's private practice for mild-to-moderate body contouring. Patients were given local anesthesia (standardized tumescent solutions) during all three phases of the surgery. During the latter two phases, irrigation of tumescent solution was accompanied simultaneously by suction aspiration. Fat harvesting was accomplished by collecting and separating the aspirated adipose tissue in a sterile container, without need for washing or centrifugation. Fat grafting by microdroplet technique was performed within two hours of collection. Fat aliquots from five randomly-selected patients were assessed with a trypan blue dye exclusion test within one hour and again six to eight hours after collection.

RESULTS

A total of 37 females and four males underwent WAL in this series; average body mass index (BMI) was 25.5. Among the 41 patients, 166 areas involving twelve anatomic sites were treated. Patients were divided into two groups based on the volume of treatment: Group 1 contained 19 patients with small-volume WAL and Group 2 had 22 cases of moderate-volume WAL. All patients experienced uneventful recovery periods with minimal side effects and no significant complications. Although large volumes of tumescent solution were required during the three phases of the technique, the total volume of infiltration almost equaled the final volume of aspiration. The average infiltration-to-aspiration ratio was 1.1 to 1.0 in all cases over both groups. On the other hand, the average infiltration-to-fat ratio was 2.8 to 1.0 in Group l and 2.4 to 1.0 in Group 2. Lidocaine dosage averaged 10.5mg/kg in Group 1 and 20.0mg/kg in Group 2. Patients were monitored for at least 24 hours without adverse signs or symptoms that required fluid resuscitation, blood transfusions, or interventional treatments for lidocaine side effects or toxicity. Twenty-three patients elected to save their fat for autologous fat grafting in nine anatomical sites with thirty-nine procedures. The augmented sites were clinically assessed between three and eight months postoperatively. Trypan blue dye exclusion testing indicated that about 90% of adipocytes expelled the dye after one hour of extraction, while an estimated 10% of cells per patient were observed to be free of dye six to eight hours after removal.

CONCLUSIONS

The amount of instilled tumescent fluid, lidocaine dosage, and aspiration volumes appeared to be safe, with minimal blood loss in small and moderate volume liposuction cases. The early experience with fat grafting was encouraging, but requires more sophisticated evaluation, longer follow-up, and a larger number of cases.

Liposuction: a review of principles and techniques

For one of the most commonly performed aesthetic procedures, liposuction has a somewhat mixed reputation. This may result from suboptimal technical comprehension and/or poor patient selection. It has also attracted strong commercial pressure from manufacturers of new, sometimes less assiduously-evaluated, technologies. Liposuction is not a panacea for obesity and patients are not always cognisant of this. On the other hand, it can produce highly satisfactory outcomes for well-selected patients and anatomical areas when performed by appropriately-trained operators using properly selected technologies. Although introduced by the Europeans, liposuction was enthusiastically adopted by the North Americans, yet seems to have excited little scientific interest in the UK, despite widespread use. Given the numerous techniques and recent advances, a review may be timely.

Tissue harvest by means of suction-assisted or third-generation ultrasound-assisted lipoaspiration has no effect on osteogenic potential of human adipose-derived stromal cells

BACKGROUND

Human adipose-derived stromal cells readily undergo osteogenic differentiation in vitro and in vivo. Thus, interest in their potential role in skeletal tissue engineering continues to escalate. Very little is known regarding the effects that energy delivered by means of third-generation ultrasound-assisted lipoaspiration may have on the osteogenic potential of these cells. The authors investigated whether differences in adipose-derived stromal cell yield, and the in vitro proliferation and osteogenic potential of these cells obtained by suction-assisted lipoaspiration or third-generation ultrasound-assisted lipoaspiration, exist.

METHODS

Adipose-derived stromal cells were harvested from lipoaspiration specimens of patients undergoing elective suction-assisted lipoaspiration and third-generation ultrasound-assisted lipoaspiration. Harvested cells were seeded to evaluate proliferative capacity and in vitro osteogenic potential. Alkaline phosphatase and alizarin red staining were performed to evaluate early and terminal osteogenic differentiation, respectively. Quantitative real-time polymerase chain reaction analysis was used to examine osteogenic gene expression patterns of RUNX2/CFBA1 (early differentiation) and osteocalcin (late differentiation).

RESULTS

No significant differences in the proliferative capacity (n = 3), alkaline phosphatase staining (n = 3), or extracellular matrix mineralization (n = 3) of suction-assisted lipoaspiration- or third-generation ultrasound-assisted lipoaspiration-derived cells were appreciated. Transcript levels of markers of early and terminal osteogenic differentiation were not significantly different (n = 3).

CONCLUSIONS

These findings suggest that exposure of adipose-derived stromal cells to ultrasound energy during tissue harvest by means of third-generation ultrasound-assisted lipoaspiration does not impart a negative consequence toward their proliferative capacity or osteogenic potential. Thus, the cells harvested using third-generation ultrasound-assisted lipoaspiration are comparable to those obtained by means of suction-assisted lipoaspiration for use in the study of osteogenic differentiation and skeletal tissue engineering.

New advances in liposuction technology

Although suction-assisted liposuction under tumescent anesthesia remains the traditional method for body sculpting, newer technologies promise to increase efficiency, decrease surgeon fatigue, and minimize complication. Power-, ultrasound-, and laser-assisted devices are ideal in large volume cases and in areas of fibrous tissues as an adjunct to traditional liposuction. Although skepticism remains chemical lipolysis, more commonly termed mesotherapy or lipodissolve may be an alternative to surgical treatment of localized fat. This article reviews the recent advancements in the field of liposuction and the current literature which support their use.

Power-assisted lipoplasty versus traditional suction-assisted lipoplasty: comparative evaluation and analysis of output

Power-Assisted lipoplasty (PAL) is a new method introduced to simplify and standardize surgical results of traditional suction-assisted lipoplasty (SAL). Comparative studies already have demonstrated PAL to be a handy, atraumatic, time- and fatigue-sparing technique. The authors performed a pilot study to compare the output capacity of PAL and SAL in 15 healthy female patients. The general and the specific per area outputs over 1 min from symmetrical areas were assessed. The results confirmed the efficiency of PAL (17.41% increase in average specific area output, as compared to SAL) and the distribution of fat in major "fat storage" areas such as the abdomen and the anterior thigh. Specific per area output indicated a higher suction capacity for PAL in all areas except the inner thigh. The efficiency of PAL seemed to be less influenced than that SAL by fat distribution.

Ultrasound-assisted liposuction for the removal of siliconomas

In the past, the traditional methods of removing siliconomas have been excision of the affected tissues or suction of the injected silicone. Unfortunately siliconomas are often found in exposed areas, where it is undesirable to leave visible scars, and suction is technically difficult and often unsuccessful because the affected tissues are so hard. Because we have used ultrasound-assisted liposuction for other procedures since 1984, it seemed logical to find out whether this technique would be useful to remove siliconomas. We have used it in three such patients, ranging in age from 36 to 84 years. Our mean follow up is 38 months (range 18 months-4 years). We have found that it results in improvement in all patients. The only problem was a minor burn at the entrance port in one patient.