A journey through liposuction and liposculture: Review

Comparative Analysis of the Effectiveness of Tranexamic Acid in Controlling Surgical Blood Loss in Patients Undergoing Liposuction

BACKGROUND

Liposuction is one of the most popular plastic surgeries, and blood loss is one of its major complications. Tranexamic acid (TXA), an antifibrinolytic drug, has been shown to reduce blood loss in many surgeries. In this prospective study, the effect of TXA on blood loss in patients, who underwent three different procedures including suction-assisted lipoplasty, vibrational amplification of sound energy at resonance (VASER)-assisted lipoplasty and LipoSaver, was compared.

METHODS

Thirty-five patients were enrolled in the study. Patients who underwent VASER2.2 technology were assigned to group 1 (n = 12), patients who underwent LipoSaver2000 technology were assigned to group 2 (n = 12), and patients who underwent SAL were assigned to group 3 (n = 11). For each patient, demographic data, tumescent solution and aspirate volumes, and hemoglobin and hematocrit values in the aspirate were compared.

RESULTS

There was no difference in tumescent volume between the groups, but the aspirate volume from group 3 was significantly higher than the aspirate volume of group 1 (p = 0.001). No difference was detected in terms of Hgb and Hct values in each liter of aspirate, both in terms of the applied liposuction method and TXA application. Additionally, no correlation was observed between gender, age, total inflated volume, total aspirate volume and device use time and Hgb and Htc values in the aspirate.

CONCLUSION

No significant differences were determined between lipoaspirate, VASER, LipoSaver and SAL in terms of blood loss, and TXA application did not significantly change the Hgb and Htc values in lipoaspirate.

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 .

Successful Abdominal Wall Reconstruction Following Liposuction Catastrophe: A Case Report and Literature Review

BACKGROUND

Devastating abdominal injuries may result from liposuction, which can lead to necrotizing fasciitis and loss of abdominal domain. This may necessitate reconstructing the abdominal wall to improve the patient's quality of life.

OBJECTIVES

The study aims to raise awareness among the readers of this catastrophic complication. Guidelines for preoperative assessment, and intraoperative measures to reduce abdominal complications along with the importance of early recognition, diagnostic tools, and treatment strategies were provided.

METHODS

We reported a patient who underwent abdominal wall reconstruction following liposuction-inflicted abdominal injury and necrotizing fasciitis. Subsequently, a literature search was conducted to review abdominal wall reconstructive techniques following liposuction-inflicted abdominal injuries. Algorithms for patient safety followed this.

RESULTS

The patient developed necrotizing fasciitis due to liposuction cannula bowel perforation leading to loss of abdominal domain. This was reconstructed with a transversus abdominis release trial with mesh followed by bilateral pedicled neurotized anterolateral thigh flaps with vastus lateralis. The review of the literature included 10 papers describing different techniques of abdominal reconstruction. Common treatment techniques following liposuction-inflicted abdominal injuries were negative pressure wound therapy and skin grafting.

CONCLUSIONS

Anterolateral thigh flaps are an excellent option that provides functional and structural repair. Neurotization of the muscle helps protect the muscle from atrophy. The review of the literature showed a lack of abdominal wall reconstruction using musculocutaneous flaps following liposuction-inflicted abdominal injuries.Communicating symptom awareness to patients and the medical team is essential for quickly identifying potential visceral injury after liposuction, ensuring prompt management and improved outcomes.

An Analysis of Industry Payments Toward Physicians in the United States-Cryolipolysis

Background: Cryolipolysis has emerged as a nonsurgical fat reduction alternative to liposuction. Industry payments may impact how physician authors view medical devices in the literature. Under-reporting financial conflicts of interest has raised concerns about full transparency between industry and physicians. Objectives: We aim to determine the impact industry payments to physicians have on the cryolipolysis literature and whether there is under-reporting of financial conflicts of interest in the literature. Methods: We collated all articles that cite the pivotal trial in the Food and Drug Administration approval of a cryolipolysis device. Articles were read independently and coded as favourable or neutral. A separate researcher screened the Centers for Medicare & Medicaid Services Open Payments database for direct or in-kind payments and recorded financial conflicts of interest. Results: A total of 19 articles met the inclusion criteria. This included 37 unique authors across multiple specialties. Eighteen (95%) published articles had at least one author who received industry payment. Payments totalled $1,476,564.16. Twelve (63%) articles were positive, and 7 (37%) neutral. Of the 31 authors who received payments, 11 (35%) did not report a conflict of interest. The majority of industry payments assessed were for consulting fees, which totalled $980,334.86 (66.4%). Conclusions: We found the majority of published opinions on cryolipolysis from the United States were written by physicians who received industry payments. We also found financial conflicts of interest around cryolipolysis devices are under-reported in the literature.

Global Analysis and Latest Research Hot Spots of Lipoedema/Lipodystrophy Investigation and Management: A Bibliometric Analysis and Visualized Review

BACKGROUND

Lipodystrophy presents clinical management challenges due to its varied expression and low incidence. Despite the clinical importance, there has been no systematic evaluation of the research output in terms of geographical distribution, institutional contributions, or emerging trends. This study aims to fill that gap by conducting a comprehensive bibliometric analysis of the global research landscape on lipodystrophy.

METHODS

Utilizing the Web of Science core collection, studies from 2010 to 2024 were analyzed. Bibliometric indicators were processed using VOSviewer to identify trends through graphical co-occurrence mapping.

RESULTS

A total of 826 studies from 57 countries were included. The USA led with 259 publications (30.51%). The most productive institutions were the National Institute of Diabetes and Digestive and Kidney Diseases with 43 publications (14.98%). Among 166 journals, the Journal of Clinical Endocrinology and Metabolism had the highest publications (43, 25.90%) and citations per publication (58). The most co-cited article was The Diagnosis and Management of Lipodystrophy Syndromes (2016), which was referenced 290 times.

CONCLUSION

This analysis highlights research trends and collaborative networks, areas for future investigation, and identifies the gaps and emerging trends that will inform future research directions.

NO LEVEL ASSIGNED

This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. 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 .

Literature Review and Evidence-Based Comparative Analysis of Traditional Suction-Assisted Lipectomy (SAL) vs. Ultrasound-Assisted Liposuction (UAL) Reported Outcomes

BACKGROUND

Over the past two decades, liposuction techniques have significantly evolved. Methods aimed at improving safety, efficiency, and cosmetic outcomes have been developed. Energy-based devices (EBD) that generate heat capable of fragmenting fat and inducing skin retraction are the most advertised and marketed as a possible alternative to invasive surgical skin excision. Third-generation ultrasound-assisted liposuction (UAL), vibration amplification of sound energy at resonance (VASER) is at present employed in approximately 20% of liposuction cases. Whether it has truly advanced the field or offers only a marketing advantage with negligible benefits, or whether any benefits, if present, outweigh the costs, remains a subject of debate. In an evidence-based perspective, the current review is intended to critically analyze reported outcomes of UAL compared to suction-assisted lipectomy SAL.

METHODS AND MATERIALS

A PICO literature search was conducted across the MEDLINE, PubMed, and EMBASE databases RESULTS: Only 5 studies that specifically compared ultrasound-assisted liposuction with traditional liposuction techniques were identified and included in this review.

CONCLUSION

In spite of well-documented clinical efficiency, relative safety, decreased incidence of postoperative anemia, and less physician effort, there are at present little convincing long-term data to confirm UAL superior aesthetic outcomes and skin tightening. Offering this technology to patients with excessive fat or skin flaccidity or redundancy for whom more invasive surgery is indicated, on the promise that it will meet their expectations of optimal body contouring and skin tightening without visible scarring, may be somewhat misleading. 1. UAL is known for its clinical effectiveness, safety, lower rates of postoperative anemia, and reduced physician fatigue. 2. Currently, there are insufficient convincing long-term data to validate that UAL delivers better aesthetic results and skin tightening compared to SAL. 3. UAL should be offered to specific patients to ensure satisfactory results.

LEVEL OF EVIDENCE III

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 .

Tranexamic Acid in Liposuction: A Systematic Review of Literature and Meta-Analysis

BACKGROUND

Tranexamic acid (TXA) is increasingly employed in plastic surgery to reduce perioperative hemorrhage. This systematic review assesses TXA's impact on blood loss, bruising, and fat graft survival following liposuction.

METHODS

A PRISMA-compliant systematic review was conducted. PubMed, Google Scholar, and Cochrane Library were searched using relevant keywords. Adult liposuction patients, receiving "intravenous TXA", "topical TXA", or "placebo", were categorized into "treatment" or "control" groups. Randomized controlled trials, prospective or retrospective cohort studies, and case-control studies were included, while uncontrolled observational studies, systematic reviews, letters, animal studies, and conference abstracts were excluded. Data on blood loss and bruises severity were synthetized into Excel spreadsheets. Study quality was independently assessed by two reviewers. Statistical analysis was accomplished employing forest plots for Hedge's G effect sizes and standardized mean differences, I2 heterogeneity, and publication bias using Egger's regressions and trim-and-fill funnel plots.

RESULTS

Seven studies encompassing 457 patients were analyzed. Findings suggest that intravenous and topical TXA may contribute to blood loss reduction and a potential decrease in bruises severity following liposuction. No thromboembolic or serious complications were reported, suggesting a favorable safety profile for its routine use. TXA's impact on fat graft survival remains unknown.

CONCLUSIONS

This meta-analysis suggests that TXA might be beneficial in reducing blood loss and bruising after liposuction, but the results are not definitive due to study limitations. Larger randomized controlled trials with standardized protocols of TXA administration, and better-designed measurement instruments are needed to confirm these findings.

LEVEL OF EVIDENCE II

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 .

Outcome of Liposuction for Limb Lymphedema in Men Compared with Women

Objectives

Liposuction effectively reduces limb volume in cases of advanced fat-dominant lymphedema. This study compares surgical outcomes between men and women using Brorson's liposuction for lymphedema protocol.

Methods

A total of 11 men and 11 women with unilateral limb lymphedema who underwent liposuction were matched based on preoperative volume difference (Vol Diff) and percentage volume difference (%Vol Diff) between the affected and unaffected limbs. Individuals were secondarily matched for age, body mass index, and lymphedema duration. The volume of fat aspirated was compared to preoperative Vol Diff to calculate a percentage (%) aspirate volume. The preoperative %Vol Diff and postoperative %Vol Diff at two-time intervals over 12 months were recorded. Differences between the groups were assessed for significance.

Results

Preoperative male group mean %Vol Diff of 35.1% matched the female group mean %Vol Diff of 34.8% (p = 0.928). The surgical male mean %aspiration volume of 80.4% was significantly less than the female group of 119% (p = 0.004). The reduction in male mean %Vol Diff was significantly less at the two postoperative time intervals. At 3-6 months, the mean %Vol Diff for men was 20.7% and 3.8% for women (p = 0.009). At the 9-12 months, the mean %Vol Diff was 13.2% for men and 4.2% for women (p = 0.006).

Conclusions

The male group matched for preoperative volume with a female group had a lower %aspiration volume and higher postoperative %Vol Diff which was most likely due to sex-based fat differences.

Lipedema: Complications in High-Volume Liposuction Are Linked to Preoperative Anemia

Background: Lipedema is a subcutaneous adipose tissue disorder mainly affecting women. Its progressive nature often requires high-volume liposuction for efficient pain reduction. However, aspiration volumes of more than 5 L within a single session may lead to a variety of complications. Thus, we examined the effect of high-volume liposuctions on lipedema patients and the incidence of associated complications. Methods: We analyzed perioperative differences in lipedema patients undergoing low- or high-volume liposuctions. Statistical analyses were performed, investigating postoperative complications and the correlation of patients' BMI, total amount of aspiration, duration of surgery, hospital stay and hemoglobin alterations. Complications were investigated according to the Clavien-Dindo Classification. Patients were divided in two groups based on the volume aspirated at liposuction (low-volume vs. high-volume liposuction). Results: Overall, 121 sessions were investigated. Mean total volume of aspiration was 8227.851 mL ± 3643.891. Mean preoperative hemoglobin levels were 13.646 g/dL ± 1.075 g/dL. Preoperatively, 7.44% of patients were anemic (Hb < 12 g/dL). Mean postoperative hemoglobin was 10.563 g/dL ± 1.230 g/dL. Postoperatively, 90.10% of patients showed Hb levels below 12 g/dL. Hemoglobin loss differed significantly between the two groups (p = 0.001). Significant correlations between pre- (p = 0.015) and postoperative (p < 0.001) hemoglobin levels and pre- (p < 0.001) and postoperative (p < 0.001) anemia with Class II complications were also seen. The total volume of aspiration did not correlate with complication rates (p = 0.176). Conclusions: Complication rates in high-volume liposuctions are hemoglobin-dependent rather than volume-associated. Preoperative anemia was the most influential for the occurrence of postoperative complications. To safely conduct high-volume liposuctions in lipedema patients, adequate patient selection and preoperative patient preparation are imperative.

Gluteal Augmentation: A Historical Perspective on Aesthetic Practice

Buttock augmentation has emerged as a significant focus in cosmetic surgery, driven by advancements in techniques and increasing patient interest in body contouring. The evolution of this field, from early pioneering methods to modern, diverse approaches, highlights the need to understand the specific characteristics of each technique and their implications for aesthetic outcomes. The author aims to provide a detailed review of 4 major buttock augmentation techniques: gluteal implants, Brazilian butt lift (BBL), intramuscular polymethylmethacrylate (PMMA), and deep subcutaneous hyaluronic acid fillers. The goal is to assess the benefits and limitations of each method, helping practitioners and patients make informed decisions tailored to their preferences and needs. A comprehensive literature review was conducted, incorporating clinical studies, case reports, and expert opinions on these 4 techniques. Evaluation criteria included effectiveness, safety, recovery time, and patient satisfaction. Data were synthesized to provide a comparative analysis of each method. Gluteal implants offer predictable volume but involve surgical risks and lengthy recovery. The BBL, using autologous fat, delivers natural results and body contouring benefits but carries risks such as fat embolism and fat reabsorption. Intramuscular PMMA fillers provide permanent results with minimally invasive application but are challenging to remove. Hyaluronic acid fillers are reversible and minimally invasive but require periodic maintenance and may present risks like material migration. In this review, the author highlights the advantages and drawbacks of each technique, emphasizing individualized assessments and practitioner expertise. By outlining these methods, the author supports informed decision making in buttock augmentation.

Level of Evidence 5 Therapeutic

From Quackery to Super-Specialization: A Brief History of Aesthetic Surgery

From time immemorial, human beings have always tried to decorate themselves to look more beautiful and attractive to an onlooker, in turn improving their own self-esteem. Thus, Ayurveda in India and Ebers Papyrus in Egypt, written thousands of years ago, mention a variety of cosmetics being used for the same. However, operative interventions were mainly reconstructive and any improved aesthetics was a by-product only (e.g., restoration of amputated nose). The surgery for purely cosmetic reasons started less than 150 years ago after the availability of anesthesia and antisepsis. Initially, the medical profession and the common man were skeptical of these interventions and even ridiculed the patient and the clinician. The pioneers were labeled as quacks and working against the law, and some of them had to even commit suicide, while the patients were labeled as "psychiatric." The past 50 years have seen aesthetic procedures, both surgical and nonsurgical, being performed by highly qualified superspecialists. This article attempts to trace this change.

Correlation between BMI, amount of aspirated fat and post-operative complications in VASER liposuction: A single centre experience

Background

Vibration amplification of sound energy at resonance (VASER) liposuction is an innovative technique that allows surgeons to selectively remove fat and shape desired areas of the body, resulting in more precise and controlled outcomes compared to traditional liposuction techniques. VASER liposuction offers several advantages, including targeted action that reduces trauma to the surrounding tissues, limiting pain, swelling and recovery time.

Purpose

This study compared the complication rates among patients who underwent VASER liposuction in relation to their body mass index (BMI) and the amount of fat aspirated.

Methods

The authors reviewed the medical records of all patients who underwent VASER liposuction at Scalera Clinic in Naples, dividing them into two groups: the first with BMI < 24.9 kg/m2 and second with BMI >25.0 kg/m2.

Results

The authors examined 117 patients who were operated on within a year (2022/2023), with 48 of them having BMIs < 24.9 kg/m2 and 69 showing BMIs >25.0 kg/m2. In patients with a BMI >25 kg/m2, the most common complications were contusion, hematomas and abnormal skin retraction, whereas no complications were observed in the patients with normal-weight.

Conclusions

To minimise post-operative complications and maximise results, it is advisable to select patients based on their BMI assessment, the anatomy of the treated body area and the volume of fat to be removed. This approach aims to ensure that the patients are suitable for the procedure and the achieved results align with their aesthetic expectations.

Advancements in Face and Neck Contouring: Integrating Radiofrequency-Assisted Liposuction with FaceTite and Buccal Fat Pad Excision for Facial Slimming

BACKGROUND

The integration of neck liposuction with FaceTite Manipulus Radiofrequency (RF) technology and buccal fat pad excision for enhanced neck rejuvenation promise heightened precision and efficacy in sculpting the neck and jawline. Neck liposuction, coupled with RF technology, provides controlled thermal energy for adipose tissue treatment and collagen remodeling, while buccal fat pad excision offers refined contouring of the lower face and neck. This integrated approach aims to optimize patient outcomes and advance the field of esthetic plastic surgery.

METHODS

A prospective study was conducted from 2016 to 2023 on 80 consecutive patients who presented to the author's private clinic and required neck remodeling surgery for esthetic purposes. Patients were monitored and clinic appointments were scheduled at intervals of 0, 1, 3, 6 and 12 months post-treatment for evaluation. A tape measure recorded submental length at 1 and 6 months, and a satisfaction survey was administered one week before surgery and after six months. Physicians assessed improvement using a five-point scale for patient satisfaction and a four-point scale for overall improvement.

RESULTS

All patients underwent successful RFAL treatment, consistently achieving satisfaction with the outcomes. The average reduction in submental length measured 23 mm during the 6-month follow-up period. Additionally, the removal of buccal fat pads played a pivotal role in facial slimming and enhancing the esthetics of the upper cheek region.

CONCLUSIONS

The integration of neck liposuction with FaceTite RF technology and buccal fat pad excision offers a promising approach for enhanced neck rejuvenation and facial contouring. This combined method demonstrates heightened precision and efficacy in sculpting the neck and jawline, aiming to optimize patient outcomes and advance the field of esthetic plastic surgery.

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 .

The role of adipose tissue-derived stromal cells, macrophages and bioscaffolds in cutaneous wound repair

Skin healing is a complex and dynamic physiological process that follows mechanical alteration of the skin barrier. Under normal conditions, this complex process can be divided into at least three continuous and overlapping phases: an inflammatory reaction, a proliferative phase that leads to tissue reconstruction and a phase of tissue remodeling. Macrophages critically contribute to the physiological cascade for tissue repair. In fact, as the inflammatory phase progresses, macrophage gene expression gradually shifts from pro-inflammatory M1-like to pro-resolutive M2-like characteristics, which is critical for entry into the repair phase. A dysregulation in this macrophage' shift phenotype leads to the persistence of the inflammatory phase. Mesenchymal stromal cells and specifically the MSC-derived from adipose tissue (ADSCs) are more and more use to treat inflammatory diseases and several studies have demonstrated that ADSCs promote the wound healing thanks to their neoangiogenic, immunomodulant and regenerative properties. In several studies, ADSCs and macrophages have been injected directly into the wound bed, but the delivery of exogenous cells directly to the wound raise the problem of cell engraftment and preservation of pro-resolutive phenotype and viability of the cells. Complementary approaches have therefore been explored, such as the use of biomaterials enriched with therapeutic cell to improve cell survival and function. This review will present a background of the current scaffold models, using adipose derived stromal-cells and macrophage as therapeutic cells for wound healing, through a discussion on the potential impact for future applications in skin regeneration. According to the PRISMA statement, we resumed data from investigations reporting the use ADSCs and bioscaffolds and data from macrophages behavior with functional biomaterials in wound healing models. In the era of tissue engineering, functional biomaterials, that can maintain cell delivery and cellular viability, have had a profound impact on the development of dressings for the treatment of chronic wounds. Promising results have been showed in pre-clinical reports using ADSCs- and macrophages-based scaffolds to accelerate and to improve the quality of the cutaneous healing.

Comprehensive Evaluation of the BeShape One Device: Assessing Thermal Safety in Noninvasive Body Contouring Using Advanced Techniques

OBJECTIVES

This study aims to assess the thermal safety profile of the BeShape One Device, a noninvasive, high-intensity, non-focused ultrasound device designed for reducing waist circumference. This device possesses several features that distinguish it from other commercial ultrasound-based fat reduction devices. The study focuses on evaluating temperature-related physiological changes through thermal safety analysis and histopathology in a swine model.

MATERIALS AND METHODS

The study utilized three types of applicators-active, demo, and modified-to comprehensively assess the device's impact on various skin layers. Five female Large White X Landrace swine were involved in the study, and the BeShape One Device was applied to designated treatment sites using a specific treatment protocol. The assessment included clinical observations, skin reaction evaluations, gross pathology, histopathological analyses, and advanced temperature measurement techniques, including needle thermocouples, thermal cameras, COMSOL modeling, and CEM43 analysis.

RESULTS

Clinical observations indicated the animals' overall well-being throughout the study. Skin reactions, including erythema, edema, bruising, and crust formation, were temporary and resolved over time. Gross pathology revealed no treatment-related pathologies, except for a discoloration related to a tattoo procedure. Histopathological analyses at 30 and 90 days posttreatment demonstrated an absence of heat-related lesions in skin layers. Needle thermocouples and thermal camera measurements supported the device's ability to maintain consistent thermal homogeneity. COMSOL modeling and CEM43 analysis predicted no thermal damage to the skin, confirming the safety of the BeShape One Device.

CONCLUSIONS

Under the experimental conditions, the BeShape One Device demonstrated a favorable safety profile. Clinically and histopathologically, no adverse effects were observed. The device's ability to achieve thermal homogeneity in skin layers was validated through advanced temperature measurement techniques. COMSOL modeling and CEM43 analysis further supported the conclusion that the device is safe, making it a promising option for noninvasive body contouring procedures.

Diagnosis, treatment and management of lipodystrophy: the physician perspective on the patient journey

BACKGROUND

Lipodystrophy syndromes are a heterogeneous group of rare, life-limiting diseases characterized by a selective loss of adipose tissue and severe metabolic complications. There is a paucity of information describing the experiences and challenges faced by physicians who have seen and treated patients with lipodystrophy. This study aimed to provide a better understanding of the physician's perspective regarding the patient journey in lipodystrophy, including diagnosis, the burden of disease, and treatment approaches.

METHODS

Thirty-three physicians from six countries who had seen or treated patients with lipodystrophy were interviewed using a semi-structured questionnaire. Interviews were transcribed, anonymized, and analyzed for themes and trends. Four main themes were developed: (1) the diagnostic journey in lipodystrophy including the disease features or 'triggers' that result in the onward referral of patients to specialist medical centers with experience in managing lipodystrophy; (2) the impact of lipodystrophy on patient quality of life (QoL); (3) the use of standard therapies and leptin replacement therapy (metreleptin) in lipodystrophy, and (4) barriers to metreleptin use.

RESULTS

Participants reported that, due to their rarity and phenotypic heterogeneity, lipodystrophy cases are frequently unrecognized, leading to delays in diagnosis and medical intervention. Early consultation with multidisciplinary specialist medical teams was recommended for suspected lipodystrophy cases. The development and progression of metabolic complications were identified as key triggers for the referral of patients to specialist centers for follow-up care. Participants emphasized the impact of lipodystrophy on patient QoL, including effects on mental health and self-image. Although participants routinely used standard medical therapies to treat specific metabolic complications associated with lipodystrophy, it was acknowledged that metreleptin was typically required in patients with congenital generalized lipodystrophy and in some acquired generalized and partial lipodystrophy cases. A lack of experience among some participants and restrictions to access remained as barriers to metreleptin use.

CONCLUSIONS

To our knowledge, this is one of the first studies describing the qualitative experiences of physicians regarding the diagnosis and management of lipodystrophy. Other physician-centered studies may help increase the awareness of lipodystrophy among the wider medical community and support clinical approaches to this rare disease.

Liposuction as a Treatment for Lipedema: A Scoping Review

Background

Lipedema is the progressive symmetrical deposition of subcutaneous fat and fluid in the lower body, ordinarily sparing the trunk, upper limbs, face, and neck. It may follow an autosomal dominant inheritance pattern. The gold standard treatment for lipedema is complete decongestive therapy, consisting of manual lymphatic drainage and compression garments. This scoping review assessed the existing literature on the effectiveness of liposuction as an alternative treatment for lipedema.

Methods

A scoping review of electronically available literature within PubMed, Scopus, and Cochrane focused on liposuction as a treatment for lipedema considering the following inclusion criteria: human studies, case series of 10 or more, controlled trials, randomized controlled trials, patient-reported outcome measurement studies, survey analyses, descriptive studies, retrospective analyses, recurrence included, follow-up of 6 months or more, age 18 years or older, and treatment modality being liposuction.

Results

Thirteen studies were selected. Nine studies reported decreased compression therapy use among patients following liposuction. No studies reported a long-term increase in compression therapy following liposuction. Studies found self-reported improvements in pain, mobility, bruising, and overall quality of life for patients following liposuction, many of whom had previously been on compressive therapy. Studies reported low rates of serious adverse events following liposuction, including deep vein thrombosis, pulmonary embolism, and infection.

Conclusions

These results suggest that liposuction can be a viable treatment alternative to compression therapy for lipedema in patients whose compression therapy has not been helpful. However, there is not enough evidence to say whether liposuction is as effective as compression for patients first presenting with lipedema.

Risks and Complications Rate in Liposuction: A Systematic Review and Meta-Analysis

Liposuction is a surgical procedure used to remove localized excess adipose tissue. According to The Aesthetic Society's latest annual report, liposuction is the most commonly performed cosmetic procedure. Despite its popularity, the existing literature lacks a unified understanding of the risks associated with liposuction. The aim of this study was to measure complications of liposuction. A systematic review and meta-analysis was reported according to PRISMA guidelines and registered on the PROSPERO database (CRD42023471626). The primary outcome was overall complication rate. The absolute risk for individual complications was also assessed. From 2957 articles, 39 studies were selected for analysis. In total, 29,368 patients were included, with a mean age of 40.62 years and mean BMI of 26.36 kg/m2. Overall, the rate of any complication was 2.62 (95% CI, 1.78-3.84). The most common complication was contour deformity, with a prevalence of 2.35% (95% CI, 1.05%-5.16%). The prevalence of hyperpigmentation was 1.49% (95% CI, 1.12%-1.99%), seroma 0.65% (95% CI, 0.33%-1.24%), hematoma 0.27% (95% CI, 0.12%-0.60%), superficial burn 0.25% (95% CI, 0.17%-0.36%), allergic reaction 0.16% (95% CI, 0.050%-0.52%), skin necrosis 0.046% (95% CI, 0.013%-0.16%), generalized edema 0.041% (95% CI, 0.0051%-0.32%), infection 0.020% (95% CI, 0.010%-0.050%), venous thromboembolism 0.017% (95% CI, 0.0060%-0.053%), and local anesthesia toxicity 0.016% (95% CI, 0.0040%-0.064%). Liposuction is a safe procedure with low complications, of which contour deformity is the most common. Raising awareness of specific risks can enhance surgical outcomes and improve patient-physician understanding.

LEVEL OF EVIDENCE: 3

The Critical Blood-Sparing Effect of Tranexamic Acid (TXA) in Liposuction: A Systematic Review and Meta-Analysis

Introduction

Tranexamic acid (TXA) has been used to improve bleeding outcomes in many surgical procedures. However, its blood-sparing effect in liposuction is not well established.

Methods

A systematic literature search was performed using PubMed, Embase, Cumulated Index to Nursing and Allied Health Literature (CINAHL), Cochrane Central, ClinicalTrials.gov, and WorldWideScience.org databases from their inception to October 8, 2021, according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The authors focused on 3 main topics: 1) TXA, 2) liposuction, and 3) complications. We included articles evaluating the potential blood-sparing effects of TXA in liposuction. Studies were excluded if they were systematic review articles or protocol papers, animal studies, conference abstracts, survey studies, or non-English publications.

Results

A total of 711 articles were identified, with 1 retrospective and 4 prospective (3 randomized) studies meeting our inclusion criteria. TXA was used in various forms: administered intravenously either on induction or after the procedure, mixed into the tumescent solution, or infiltrated into the liposuction sites after lipoaspiration. A significantly smaller reduction in hematocrit was noted in the TXA group compared with that in the non-TXA group (p<0.001) despite a significantly greater amount of lipoaspirate removed in the TXA group (p<0.001). Patients in non-TXA cohorts experienced adverse effects (such as seroma and need for transfusion) that were not seen in TXA cohorts.

Conclusion

TXA use in patients undergoing liposuction seems to be associated with a beneficial blood-sparing effect, which may enhance safety in this population. Future studies should aim to determine the optimal route and dosing for TXA in liposuction.

Evidence Based Medicine

Level IV.

Evaluating the effect of glycerol on increasing the safety and efficiency of hyperthermic laser lipolysis

This study aimed to investigate the effect of glycerol as an Optical Clearing Agent on the temperature profile of the skin during HyperThermic Laser Lipolysis using computer simulation. In this study, a three-layer model of the skin was used to simulate HyperThermic Laser Lipolysis. The Monte Carlo MCML code was used to investigate the propagation of laser photons inside skin tissue. The energy absorbed from photons is used as a heat source to determine the increase in temperature and assess thermal damage in the layers of the skin. The finite element method in COMSOL software was used for calculation. The simulation of single-pulse radiation exposure with and without applying glycerol to the skin model was investigated to assess the impact of glycerol. Glycerol decreases the temperature and thermal damage to the epidermis layer while increasing the temperature of the fat layer. Moreover, the presence of glycerol increases the depth of fat cell destruction. Glycerol, as a supplement, significantly improves the efficacy of HyperThermic Laser Lipolysis.

Multi-Functional Polymer Nanoparticles with Enhanced Adipocyte Uptake and Adipocytolytic Efficacy

Multi-functional polymer nanoparticles have been widely utilized to improve cellular uptake and enhance therapeutic efficacy. In this study, it is hypothesized that the cellular uptake of poly(D,L-lactide-co-glycolide) (PLG) nanoparticles loaded with calcium carbonate minerals into adipocytes can be improved by covalent modification with nona-arginine (R9 ) peptide. It is further hypothesized that the internalization mechanism of R9 -modified PLG nanoparticles by adipocytes may be contingent on the concentration of R9 peptide present in the nanoparticles. R9 -modified PLG nanoparticles followed the direct penetration mechanism when the concentration of R9 peptide in the nanoparticles reached 38 µM. Notably, macropinocytosis is the major endocytic mechanism when the R9 peptide concentration is ≤ 26 µM. The endocytic uptake of the nanoparticles effectively generated carbon dioxide gas at an endosomal pH, resulting in significant adipocytolytic effects in vitro, which are further supported by the findings in an obese mouse model induced by high-fat diet. Gas-generating PLG nanoparticles, modified with R9 peptide, demonstrated localized reduction of adipose tissue (reduction of 13.1%) after subcutaneous injection without significant side effects. These findings highlight the potential of multi-functional polymer nanoparticles for the development of effective and targeted fat reduction techniques, addressing both health and cosmetic considerations.

Assessment of the Efficacy of Cryolipolysis on Abdominal Fat Deposits: A Prospective Study

BACKGROUND

Cryolipolysis is a non-invasive and efficacious procedure for body contouring. The effectiveness of cryolipolysis has been demonstrated on multiple areas of the body, but on a limited number of subjects. The aim of this study is to demonstrate the effectiveness and the safety of cryolipolysis in the lower abdomen adipose tissue thickness reduction.

METHODS

A prospective study on 60 healthy women was carried out using CryoSlim Hybrid device. Each patient underwent two cryolipolysis sessions centered on the abdominal area. The primary endpoint was to decrease the thickness of the abdominal fat deposits. The change in the abdominal circumference and the thickness of the subcutaneous fat layer were assessed. Patient satisfaction and tolerance of the procedure were also taken into account.

RESULTS

A significant reduction of the abdominal circumference and subcutaneous fat layer thickness was observed. The mean decrease in abdominal circumference was 2.10 cm (3.1%) 3 months after the procedure and 4.03 cm (5.8%) 6 months after the procedure. The mean decrease in fat layer thickness was 1.25 cm (43.81%) 3 months after the procedure and 1.61 cm (41.73%) 6 months after the procedure. No major adverse events were noted. All patients were very satisfied, and minimal pain was reported.

CONCLUSIONS

Cryolipolysis is an effective technique to treat abdominal localized fat deposits. No major adverse events have been described for this procedure. Our promising results should encourage further studies aimed at optimizing the efficacy of the procedure without a considerable increase in the risks.

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 http://www.springer.com/00266 .

Use of Radiofrequency-Assisted Liposuction (BodyTite) for Upper Arms Lifting

BACKGROUND

Body contouring surgery is increasingly requested by patients, both for aesthetic and post-bariatric purposes. There has also been a rapid increase in demand for noninvasive aesthetic treatments. While brachioplasty is burdened by numerous complications and unsatisfactory scars, and conventional liposuction is unsuitable for all patients, nonsurgical arm remodeling performed with radiofrequency-assisted liposuction (RFAL) allows to effectively treat most of patients, regardless of the amount of fat and ptosis of the skin and avoiding surgical excision.

METHODS

A prospective study was conducted on 120 consecutive patients who presented to the author's private clinic and required upper arm remodeling surgery for aesthetic purposes or after weight loss. Patients were classified according to the modified classification of El Khatib and Teimourian. Pre- and posttreatment upper arm circumferences were taken after 6 months of follow-up to assess the degree of skin retraction obtained by treating the arm with RFAL. A satisfaction questionnaire regarding the appearance of the arms (Body-Q upper arm satisfaction) was administered to all patients before surgery and after 6 months of follow-up.

RESULTS

All patients were effectively treated with RFAL, and no cases required conversion to brachioplasty. The average reduction in arm circumference was 3.75 cm at 6 months follow-up, and patients' satisfaction increased from 35 to 87% posttreatment.

CONCLUSIONS

Radio frequency is a valid tool to treat most patients with upper limbs skin laxity, with significant aesthetic results and a high degree of patient satisfaction, regardless of the degree of skin ptosis and lipodystrophy of the arm.

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 .

Procedural dermatology and its unmet need

Procedural dermatology includes invasive conventional dermatologic surgeries which involve significant use of knife and suture, minimally invasive procedures and device-based procedures. Device-based procedures are the easiest to learn and are less prone to human errors due to automation but can lead to monotony, while conventional surgeries require significant skill, craftsmanship and interest. There has been a recent shift in the approach to procedural dermatology as a therapeutic option with complementary and combination models replacing the conventional hierarchical model in which procedures were last in the step-ladder approach. The demand for both conventional dermatologic surgeries and minimally invasive cosmetic procedures is increasing. Unfortunately, this demand has not been met with adequate supply. Consequently, the number of trained professionals with expertise in these procedures is very limited; they are far outnumbered by unqualified practitioners. A limited number of dermatologic surgeons practicing conventional surgeries has resulted in huge waiting lists for vitiligo surgeries, inappropriate excisions for skin cancers and poor cosmetic outcomes of excisions without proper knowledge of flaps and grafts. Increasingly procedures are being performed by inadequately trained personnel, resulting in complications. There is also an absence of good quality research on the subject of procedural dermatology, which has resulted in a lack of standardisation of various procedures and knowledge about the efficacy of various drug-procedure and procedure-procedure combinations. An increasing variety of gimmicky but costly procedures are being offered to the public without much evidence of efficacy. Individual institutional and broad policy directives are needed to address these issues. Special emphasis is required on formal hands-on procedural dermatology training during residency and beyond it.

Evolution of the Push-2-Spin Fat Graft Processing Device: Enhancing Efficiency and Reducing Risk of Contamination

Background

Small-volume fat graft efficiency is a critical determinant of the cost and material effectiveness of aesthetic fat grafting in the clinical space. Recent development of devices, such as the Push-2-Spin (P2S) system (Pittsburgh, PA), has improved upon the process by yielding a rapid, handheld, multi-use system to minimize operative time and mess.

Objectives

In this study, the authors describe further technical innovations on the P2S prototype that improve operative ease of use, time, and safety.

Methods

Abdominoplasty samples were obtained as discarded tissue. Lipoaspirate was collected utilizing a 3.0 mm liposuction cannula and processed through centrifugation (Coleman technique), gauze (telfa) rolling, mesh straining, the tabletop P2S device (prototype), or the P2S handheld (P2S-H) device. Operative processing time, spin time, oil fraction, stromal vascular fraction (SVF) yield and viability, and adipocyte viability were assessed to compare the efficacy and viability of each device/technique. Blood agar smears of lipoaspirate were performed to assess for risk of contamination.

Results

The P2S-H device outperformed its prior iteration in rotary and processing speed and was significantly faster than each other technique assessed. Furthermore, the use of an inline system offered significant advantages over open-air techniques in terms of resistance to contamination. Serial use characteristics were assessed; under these conditions, oil yield as well as adipocyte and SVF number and viability was similar between all techniques.

Conclusions

The technical advancements to the P2S system which enable single-unit, handheld operation significantly improve operative time and minimize space requirements. This operative quality of life improvement comes at no cost to the efficacy of oil extraction, cellular yield, or cell viability.

Level of Evidence 3

A Case of Acute Opioid Withdrawal after Liposuction Surgery in a Patient on Extended-release Buprenorphine

BACKGROUND

The US Food and Drug Administration approved the once-monthly injectable extended-release buprenorphine product to treat moderate-to-severe opioid use disorders. The patient in our case report had a liposuction procedure and immediately started having opioid withdrawal symptoms after the procedure.

CASE DESCRIPTION

The patient is a 27-year-old African-American woman who injects drugs and has morbid obesity. She enrolled in a medications for addiction treatment program and opted to get treated with extended-release buprenorphine monthly injections. She tolerated them well for a span of 6 months. In one clinic visit, she reported opioid withdrawal symptoms and started purchasing and using sublingual buprenorphine from her acquaintances. On review of history, she underwent liposuction surgery and this triggered the opioid withdrawal symptoms. Examining her abdomen revealed surgical scars at the site of the buprenorphine injection and the residual buprenorphine depot was not palpable.A subcutaneous injection of 300-mg extended release buprenorphine was administered in the right periumbilical area in this clinic visit. The following week, she was doing well and denied any withdrawal symptoms.

DISCUSSION

This is a unique case of "iatrogenic opioid withdrawal" after a fairly common surgical procedure. The extended-release buprenorphine formulation solidifies when it comes into contact with bodily fluids forming a depot. The depot and surrounding adipose tissue may have been removed during the patient's liposuction procedure, causing an immediate drop in buprenorphine levels leading to acute opioid withdrawal.This case report highlights the precautions that need to be taken before patients go for a surgical procedure like liposuction.

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.

Treatment with selective transcatheter arterial embolization of a ruptured profunda artery perforator after internal thigh liposuction: a case report

BACKGROUND

Hemorrhage is an uncommon complication of liposuction that may be trauma-induced by the cannula on the subcutaneous perforators. It usually resolves spontaneously with external compression and results in mild to moderate ecchymosis on the liposuction site. However, in sporadic cases, active bleeding may persist and require urgent intervention for hemostasis.

CASE PRESENTATION

We report the case of a 60-year-old White female who developed a massive hematoma in the hour following liposuction of the right internal thigh, with active bleeding in the subcutaneous plane reported on contrast-enhanced computed tomography. The initial angiogram was conducted in the right common femoral artery and showed active bleeding from a profunda artery perforator. After careful selective catheterization of the feeding artery using a 2.0-French microcatheter, 0.3 mL of Onyx 34 was injected. Control angiography showed no immediate complication and confirmed the exclusion of the pseudoaneurysm. No postoperative event occurred. Blood pressure and hemoglobin levels remained stable throughout the episode.

CONCLUSIONS

Although liposuction is a very common procedure in plastic surgery, hemorrhagic complications may occur and require urgent hemostasis. This case suggests a vital place for interventional radiology in the management of hemorrhagic complications after liposuction.

Enhanced osteogenesis of human urine-derived stem cells by direct delivery of 30Kc19α-Lin28A protein

Urine-derived stem cells (USCs) are a promising source for regenerative medicine because of their advantages such as easy and non-invasive collection from the human body, stable expansion, and the potential to differentiate into multiple lineages, including osteoblasts. In this study, we propose a strategy to enhance the osteogenic potential of human USCs using Lin28A, a transcription factor that inhibits let-7 miRNA processing. To address concerns regarding the safety of foreign gene integration and potential risk of tumorigenicity, we intracellularly delivered Lin28A as a recombinant protein fused with a cell-penetrating and protein-stabilizing protein, 30Kc19α. 30Kc19α-Lin28A fusion protein exhibited improved thermal stability and was delivered into USCs without significant cytotoxicity. 30Kc19α-Lin28A treatment elevated calcium deposition and upregulated several osteoblast-specific gene expressions in USCs derived from multiple donors. Our results indicate that intracellularly delivered 30Kc19α-Lin28A enhances the osteoblastic differentiation of human USCs by affecting the transcriptional regulatory network involved in metabolic reprogramming and stem cell potency. Therefore, 30Kc19α-Lin28A may provide a technical advancement toward developing clinically feasible strategies for bone regeneration.

The Incident of Multiple Skin Necrosis and Unilateral Vision Loss Post Liposuction: A Case Report

For many years, people with excess weight around specific body parts who wanted to improve their shape or establish symmetry to achieve their ideal body image chose liposuction. As with any intervention, there is a chance of complications and unfavorable outcomes with liposuction. As a late result of the procedure, skin necrosis, infection, and hematoma are some of the known complications of such a procedure. Other known complications include damage to surrounding structures like nerves, vasculature, or perforating body viscera. This study aimed to report an eventful and unwanted result of a common and relatively safe cosmetic procedure. A 31-year-old Saudi female presented to the emergency room (ER) with right unilateral vision loss, bruises, and burning pain involving the upper limbs, thighs, abdomen, back, and flanks after having liposuction and rhinoplasty two weeks ago in a private clinic overseas. Multiple investigations were obtained to investigate her blindness, which showed a right upper branch of retinal vein occlusion. She was treated conservatively with daily wound dressings and analgesics. After five days, the patient returned with infected wounds and clinical deterioration, necessitating multiple excisions, debridement, and grafting. She eventually recovered and was discharged in good health. Herein, we report a rare case of unilateral blindness and multiple skin necrosis following liposuction of the abdomen and thigh. Debridement and skin grafting were the ideal treatment strategies.

Dental Pulp Stem Cells for Salivary Gland Regeneration-Where Are We Today?

Xerostomia is the phenomenon of dry mouth and is mostly caused by hypofunction of the salivary glands. This hypofunction can be caused by tumors, head and neck irradiation, hormonal changes, inflammation or autoimmune disease such as Sjögren's syndrome. It is associated with a tremendous decrease in health-related quality of life due to impairment of articulation, ingestion and oral immune defenses. Current treatment concepts mainly consist of saliva substitutes and parasympathomimetic drugs, but the outcome of these therapies is deficient. Regenerative medicine is a promising approach for the treatment of compromised tissue. For this purpose, stem cells can be utilized due to their ability to differentiate into various cell types. Dental pulp stem cells are adult stem cells that can be easily harvested from extracted teeth. They can form tissues of all three germ layers and are therefore becoming more and more popular for tissue engineering. Another potential benefit of these cells is their immunomodulatory effect. They suppress proinflammatory pathways of lymphocytes and could therefore probably be used for the treatment of chronic inflammation and autoimmune disease. These attributes make dental pulp stem cells an interesting tool for the regeneration of salivary glands and the treatment of xerostomia. Nevertheless, clinical studies are still missing. This review will highlight the current strategies for using dental pulp stem cells in the regeneration of salivary gland tissue.

A Comparative Analysis to Dissect the Histological and Molecular Differences among Lipedema, Lipohypertrophy and Secondary Lymphedema

Lipedema, lipohypertrophy and secondary lymphedema are three conditions characterized by disproportionate subcutaneous fat accumulation affecting the extremities. Despite the apparent similarities and differences among their phenotypes, a comprehensive histological and molecular comparison does not yet exist, supporting the idea that there is an insufficient understanding of the conditions and particularly of lipohypertrophy. In our study, we performed histological and molecular analysis in anatomically-, BMI- and gender-matched samples of lipedema, lipohypertrophy and secondary lymphedema versus healthy control patients. Hereby, we found a significantly increased epidermal thickness only in patients with lipedema and secondary lymphedema, while significant adipocyte hypertrophy was identified in both lipedema and lipohypertrophy. Interestingly, the assessment of lymphatic vessel morphology showed significantly decreased total area coverage in lipohypertrophy versus the other conditions, while VEGF-D expression was significantly decreased across all conditions. The analysis of junctional genes often associated with permeability indicated a distinct and higher expression only in secondary lymphedema. Finally, the evaluation of the immune cell infiltrate verified the increased CD4+ cell and macrophage infiltration in lymphedema and lipedema respectively, without depicting a distinct immune cell profile in lipohypertrophy. Our study describes the distinct histological and molecular characteristics of lipohypertrophy, clearly distinguishing it from its two most important differential diagnoses.

Ant Waist Surgery: Aesthetic Removal of Floating Ribs to Decrease the Waist-hip Ratio

Decreasing waist circumference has become an essential feature in modern body contouring surgery owing to the attractiveness of hourglass body shapes. Traditionally, this can be achieved through lipomodeling and abdominal musculature strengthening techniques. An adjunctive procedure for ideal shaping of the waistline is resection of the 11th and 12th ribs, referred to as floating ribs. This study aimed to report and analyze clinical outcomes and self-reported patient satisfaction after "ant waist" surgery (floating rib removal) for aesthetic reasons. We retrospectively reviewed the medical records of five patients who had undergone bilateral 11th and 12th rib resections at a single institute in Taiwan in an outpatient setting. The mean lengths of the resected left and right 11th ribs were 9.1 and 9.5 cm, respectively. The mean lengths of the resected left and right 12th ribs were 6.3 and 6.4 cm, respectively. The mean waist-to-hip ratio decreased from 0.78 preoperatively to 0.72 postoperatively, with a mean decrease of 7.7%. No adverse events were reported. Generally, all patients reported being satisfied with the operation. Floating rib resection proved useful and effective in decreasing the waist-to-hip ratio using a safe, simple, and reproducible technique without significant complications. Although preliminarily, the authors' comprehensive demonstration of this ant waist surgery supports further studies focusing on waistline contouring.

Techniques and Applications of Lower Extremity Feminization and Masculinization

Background

Significant differences exist between feminine and masculine lower extremities, and this region contributes to gender dysphoria in transgender and nonbinary individuals.

Methods

A systematic review was conducted for primary literature on lower extremity (LE) gender affirmation techniques as well as anthropometric differences between male and female lower extremities, which could guide surgical planning. Multiple databases were searched for articles before June 2, 2021 using Medical Subject Headings. Data on techniques, outcomes, complications, and anthropometrics were collected.

Results

A total of 852 unique articles were identified: 17 met criteria for male and female anthropometrics and 1 met criteria for LE surgical techniques potentially applicable to gender affirmation. None met criteria for LE gender affirmation techniques specifically. Therefore, this review was expanded to discuss surgical techniques for the LE, targeting masculine and feminine anthropometric ideals. LE masculinization can target feminine qualities, such as mid-lateral gluteal fullness and excess subcutaneous fat in the thigh and hips. Feminization can target masculine qualities like a low waist-to-hip ratio, mid-lateral gluteal concavity, calf hypertrophy, and body hair. Cultural differences and patient body habitus, which influence what is considered "ideal" for both sexes, should be discussed. Applicable techniques include hormone therapy, lipo-contouring, fat grafting, implant placement, and botulinum toxin injection, among others.

Conclusions

Due to lack of existing outcomes-based literature, gender affirmation of the lower extremities will rely on application of an array of existing plastic surgery techniques. However, quality outcomes data for these procedures is required to determine best practices.

Adipocytolytic Polymer Nanoparticles for Localized Fat Reduction

The demand for body fat reduction is increasing. However, conventional lipolytic approaches fail to control adipose tissue reduction and cause severe side effects in adjacent nonadipose tissues. A strategy to specifically reduce subcutaneous fat using adipocytolytic polymer nanoparticles in a minimally invasive manner is reported here. The polymer nanoparticles are designed to generate carbon dioxide gas when selectively absorbed by adipocytes. The carbon dioxide gas generated within late endosomes/lysosomes induces adipocytolysis, thereby reducing the number of cells. Localized injection of the adipocytolytic nanoparticles substantially reduces subcutaneous fat in a high-fat diet-induced obese mouse model, without significant changes in hematological or serum biochemical parameters. The adipocytolytic efficacy of the nanoparticles is also evaluated in a porcine model. This strategy addresses the need to develop safe and effective adipocytolytic agents using functional polymer nanoparticles.

Adipose Tissue Transfer in Dynamic Definition Liposculpture PART III. The Arms: Biceps, Triceps, and Deltoids

Arm contouring usually represents a challenge for the surgeon due to zones with high risk of irregularities/asymmetries, the variable degree of skin laxity, and the differences between patient/gender preferences. In men, the bigger and muscular the arms the better, while women tend to prefer a slim and soft silhouette.

Methods

We performed arm cadaveric dissections and also searched our records for patients who underwent fat grafting of the arm in addition to HD2, from January 2016 to May 2022 at a single center in Bogotá, Colombia.

Results

Two hundred eighty-nine consecutive patients (275 men and 14 women) underwent high-definition lipoplasty/HD2 plus fat grafting of the biceps (72 muscles), the triceps (46 muscles), the deltoids (426 muscles), or a combination of them. Mean age was 39 and 36 years for men and women, respectively. Range of the fat graft volume was 30-150 ml. No major complications were reported. Follow-up period ranged from 2 to 24 months. Most patients were satisfied with the results.

Conclusions

Men usually seek an overall well-toned and muscular extremity, while women tend to prefer a slim but also athletic contour. Such outcomes can be achieved through intramuscular fat grafting of the biceps, triceps, and deltoids. The proper recognition of the pedicles and a precise surgical technique will ensure both its safety and the reproducibility of the results.

Abdominal Visceral Injury, a Devastating Consequence of Abdominal Liposuction: A Case Report and Literature Review

Abdominal liposuction is a commonly performed cosmetic procedure. However, as with any procedure, it can be associated with complications. One of the life-threatening complications of this procedure is visceral injury and bowel perforation. This complication is very rare, nevertheless general, and acute care surgeons must be aware of its possibility, its management, and its possible sequelae. We report a case of a 37-year-old female who underwent abdominal liposuction which was complicated by bowel perforation and was transferred to our facility for further care. She underwent an exploratory laparotomy in which multiple perforations were repaired. The patient then underwent multiple surgeries including stoma creation and had a long postoperative course. A literature review reveals the devastating sequelae of reported similar visceral and bowel injuries. The patient eventually did well and her stoma was reversed. This patient population will require close intensive care unit observation and a low threshold of suspicion for missed injuries during initial exploration. Further down the line, they will need psychosocial support and the mental health implications of this outcome must be cared for. The long-term aesthetic outcome is yet to be addressed.

Plumping up a Cushion of Human Biowaste in Regenerative Medicine: Novel Insights into a State-of-the-Art Reserve Arsenal

Major breakthroughs and disruptive methods in disease treatment today owe their thanks to our inch by inch developing conception of the infinitive aspects of medicine since the very beginning, among which, the role of the regenerative medicine can on no account be denied, a branch of medicine dedicated to either repairing or replacing the injured or diseased cells, organs, and tissues. A novel means to accomplish such a quest is what is being called "medical biowaste", a large assortment of biological samples produced during a surgery session or as a result of physiological conditions and biological activities. The current paper accentuating several of a number of promising sources of biowaste together with their plausible applications in routine clinical practices and the confronting challenges aims at inspiring research on the existing gap between clinical and basic science to further extend our knowledge and understanding concerning the potential applications of medical biowaste.

ECG Changes Occurring During Chest Liposuction for Gynecomastia - Artifacts or a Cause for Concern?

Currently, liposuction alone or combined with various methods of gland excision has become the standard of care in the surgical management of gynecomastia. Although liposuction is considered a safe and straightforward method of body contouring, serious complications related to the procedure, including deaths, have been reported in the literature. We report the occurrence of ECG artifacts intra-operatively while performing chest liposuction under general anesthesia. Patients may receive unnecessary and potentially dangerous therapeutic interventions if these ECG artifacts are not identified correctly. A careful and rational evaluation of the patient and the ECG by the clinician can accurately identify these pseudo-abnormalities and avoid unnecessary therapies.

Lipedema: Insights into Morphology, Pathophysiology, and Challenges

Lipedema is an adipofascial disorder that almost exclusively affects women. Lipedema leads to chronic pain, swelling, and other discomforts due to the bilateral and asymmetrical expansion of subcutaneous adipose tissue. Although various distinctive morphological characteristics, such as the hyperproliferation of fat cells, fibrosis, and inflammation, have been characterized in the progression of lipedema, the mechanisms underlying these changes have not yet been fully investigated. In addition, it is challenging to reduce the excessive fat in lipedema patients using conventional weight-loss techniques, such as lifestyle (diet and exercise) changes, bariatric surgery, and pharmacological interventions. Therefore, lipedema patients also go through additional psychosocial distress in the absence of permanent treatment. Research to understand the pathology of lipedema is still in its infancy, but promising markers derived from exosome, cytokine, lipidomic, and metabolomic profiling studies suggest a condition distinct from obesity and lymphedema. Although genetics seems to be a substantial cause of lipedema, due to the small number of patients involved in such studies, the extrapolation of data at a broader scale is challenging. With the current lack of etiology-guided treatments for lipedema, the discovery of new promising biomarkers could provide potential solutions to combat this complex disease. This review aims to address the morphological phenotype of lipedema fat, as well as its unclear pathophysiology, with a primary emphasis on excessive interstitial fluid, extracellular matrix remodeling, and lymphatic and vasculature dysfunction. The potential mechanisms, genetic implications, and proposed biomarkers for lipedema are further discussed in detail. Finally, we mention the challenges related to lipedema and emphasize the prospects of technological interventions to benefit the lipedema community in the future.

Description of a Novel Web-Based Liposuction System to Estimate Fat Volume and Distribution

BACKGROUND

Pre-operative planning for liposuction is vital to ensure safe practice and patient satisfaction. However, current standards of fat assessment before surgery are guided by subjective methods such as visual inspection, skin-pinch tests, and waist circumference measurements.

OBJECTIVES

This study aimed to develop an inexpensive software-based tool that utilizes ultrasound (US) imaging and an online platform to accurately simulate regional subcutaneous adipose tissue (SAT) distribution and safe volume estimation for liposuction procedures.

METHODS

The authors present a web-based platform with integrated two-dimensional (2D) and three-dimensional (3D) simulations of SAT to support liposuction planning and execution. SAT-Map was constructed using multiple sub-applications linked with the python framework programming language (Wilmington, DE).

RESULTS

The SAT-Map interface provides an intuitive and fluid means of generating patient-specific models and volumetric data. To further accommodate this, an operational manual was prepared to achieve consistent visualization and examination of estimated SAT content. The system currently supports static 2D heatmap simulation and 3D interactive virtual modelling of the SAT distribution. Supplementary clinical studies are needed to evaluate SAT-Map's clinical performance and practicality.

CONCLUSIONS

SAT-Map revolutionizes the concept of pre-operative planning for liposuction by developing the first combined web-based software that objectively simulates fat distribution and measures safe liposuction volume. Our software approach presents a cost-efficient, accessible, and user-friendly system offering multiple advantages over current SAT assessment modalities. The immediacy of clinically accurate 3D virtual simulation provides objective support to surgeons towards improving patient conversation, outcomes, and satisfaction in liposuction procedures.

Intravenous Versus Wetting Solution Magnesium Sulphate to Counteract Epinephrine Cardiac Adverse Events in Abdominal Liposuction: A Randomized Controlled Trial

Background

The increased frequency of liposuction has resulted in more complications being reported. Adding epinephrine to the wetting solution could induce some cardiac adverse effects, some of which may be fatal. For instance, magnesium sulfate (MgSO₄) is known for its cardioprotective effects.

Objectives

This study aimed to evaluate the efficacy of intravenous (IV) versus wetting solution containing MgSO₄ in decreasing such cardiac adverse events during abdominal liposuction.

Methods

This randomized controlled study included 129 adult cases undergoing abdominal liposuction under general anesthesia. The participants were divided into 3 groups: Group I (control group) was only subjected to the injection of the wetting fluid (1 mL 1/1000 epinephrine added to every 1000 mL of normal saline), group II was subjected to IV MgSO₄ (40 mg/kg over 1 minute) at the same time of installing the wetting solution, and group III was subjected to MgSO₄ (40 mg/kg) added to the wetting solution.

Results

Intraoperative isoflurane consumption, intraoperative heart rate (HR), mean arterial pressure (MAP), and postoperative pain scores were significantly lower in the MgSO₄ groups (groups II and III) than group I. Cardiac adverse events (sinus tachycardia and premature ventricular contractions (PVCs)) were also significantly less frequent in groups II and III compared to group I.

Conclusions

Adding MgSO₄, either through IV or subcutaneous routes, is associated with lower intraoperative HR, MAP, and postoperative pain scores and a remarkable decrease in epinephrine-induced cardiac adverse events during liposuction.

The Impact of Abdominal Liposuction on Abdominally Based Autologous Breast Reconstruction: A Systematic Review

Prior abdominal liposuction can be viewed as a relative or absolute contraindication to abdominally based autologous breast reconstruction given concerns for damaged perforators and scarring complicating intraoperative dissection. This systematic review aims to explore the outcomes of abdominally based breast reconstruction in patients with a history of abdominal liposuction. A Preferred Reporting Items for Systematic Reviews and Meta-Analyses-guided literature search was conducted using PubMed, Scopus, and Web of Science from the earliest available date through June 2020. Deep inferior epigastric perforator, muscle-sparing transverse rectus abdominis musculocutaneous (TRAM), superficial inferior epigastric artery, and pedicled TRAM flaps were included for evaluation. Complications included total or partial flap loss, fat necrosis, seroma, delayed wound healing, and donor site complications. After inclusion criteria were applied, 336 nonduplicate articles were screened, yielding 11 for final review, representing 55 flaps in 43 patients. There was no instance of total flap loss, eight (14.5%) flaps developed partial loss or fat necrosis, three (5.4%) flaps had delayed wound healing, and two (4.6%) patients had donor site complications. Most authors (8/11) utilized some type of preoperative imaging. Doppler ultrasonography was the most used modality, and these patients had the lowest rate of partial flap loss or flap fat necrosis (8%), followed by those without any preoperative imaging (10%). In conclusion, this review supports that patients undergoing abdominally based autologous breast reconstruction with a history of abdominal liposuction are not at an increased risk of flap or donor site complications. Although preoperative imaging was common, it did not reliably decrease complications. Further prospective studies are needed to address the role of imaging in improving outcomes.

The use of Liposuction to treat significant contour abnormalities associated with Lipomyeloeningocoele

INTRODUCTION

Since 1972 when first pioneered, liposuction has developed and is now one of the commonest aesthetic procedures performed worldwide. Evidence of its application in aesthetic lipomodelling is widely known, but there are scant reports in the literature on the use of liposuction in more unusual cases. We report its use as a safe and successful method of contour correction in two cases of lipomyelomeningocoele (LMMC), a form of spina bifida. To our knowledge, this has never been reported before.

METHOD

A prospective review was performed and both cases were followed up during the treatment period. Both patients were treated at the Royal Belfast Hospital for Sick Children. Patient charts were reviewed and magnetic resonance imaging was used.

RESULTS

Two patients, aged 11 and 17 years, had a large LMMC over the lumbosacral area. Preoperative imaging was obtained in each case to ensure the procedure could safely avoid the underlying spinal cord structures. The use of the Microaire© suction device allowed precise fat extraction. Postoperative images demonstrate reduction of lipomatous bulk and improved contour.

CONCLUSION

We have shown that when used with caution liposuction is a safe and effective technique for volume reduction of a LMMC in carefully selected cases.

Perforation of Abdominal Viscera Following Liposuction: A Systemic Literature Review

BACKGROUND

Liposuction is among the most popular esthetic procedures worldwide. With growing demand and popularity, reports of serious complications accumulate. Despite being a rare complication of the procedure, visceral perforation is associated with morbidity and severe debilitation.

METHODS

The authors conducted a literature search for reported cases of perforation of abdominal viscera following liposuction procedures in the electronic databases of PubMed, Scopus and Cochrane Library databases.

RESULTS

The authors found 22 publications; 19 cases case reports and three studies, reporting a total of 49 cases of visceral perforation following abdominal liposuction procedures. Average age of patients was 50 years (range 24-72). Twenty-seven patients (73%) were female, and 10 were male (27%). Forty (81%) patients underwent isolated liposuction, and nine (19%) had multiple procedures carried out in a single surgery. Twenty patients (42%) had undergone previous abdominal surgery, 13 (27%) suffered abdominal wall weakness or deformities, and 7 (14%) suffered from obesity. 25 (52%) ileal perforations occurred, 6 jejunal (12.5%), 5 colic (10%) and 2 (4%) each of splenic and hepatic. Seven patients (14%) died during their hospitalization, 20 (41%) were discharged with no sequelae complications, and 22 (45%) developed complications after discharge.

CONCLUSIONS

Liposuction is a popular esthetic procedure that underwent numerous changes over the past century since its introduction. Despite its widely accepted reputation of a safe procedure with minimal complications, a growing number of reports on visceral perforation following liposuction have emerged. Scrupulous pre-operative evaluation and high index of suspicion are crucial for avoiding complications and unfavorable outcomes.

LEVEL OF EVIDENCE III

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 .

Vodder manual lymphatic drainage technique versus Casley-Smith manual lymphatic drainage technique for cellulite after thigh liposuction

Introduction

Cellulite is one of the complications post liposuction. Cellulite causes changes in the lymphatic system. Manual lymphatic drainage is utilized as an effective treatment for enhancing cellulite.

Aim

To compare between Vodder Manual Lymphatic Drainage (MLD) Technique and Casley-Smith MLD Technique for cellulite after liposuction.

Material and methods

Thirty female patients with cellulite grade 3 after thigh liposuction participated in the study, and they were randomly divided into two equal groups: Group (A) that received Vodder MLD Technique and Bandage and Group (B) that received Casley-Smith MLD Technique and Bandage. The duration of the intervention was 8 weeks per participant, and each participant received 3 sessions per week.

Results

The results revealed that there was a significant improvement in both groups by using two different methods of treatment (p < 0.001), but there was no significant difference between the two study groups (p > 0.05).

Conclusions

Both Vodder technique and Casley-Smith technique are effective in treatment of cellulite after thigh liposuction but there is no difference between them, hence any technique of MLD is recommended to achieve better improvement in this case.

Liposuction Assisted Gynecomastia Surgery With Minimal Periareolar Incision: a Systematic Review

BACKGROUND

This study aims to analyse the quality of studies and revisit the liposuction assisted gynecomastia surgery performed through minimal incision.

METHODS

A systematic review, based on the literature in the PubMed, Scopus, Science Direct, and Cochrane, to the treatment of Simon's grade I and II gynecomastia was conducted using keywords "gynecomastia" AND "liposuction." Study appraisal was performed using MINORS to assess the methodological quality of the paper.

RESULTS

There were 18 out of 415 studies eligible to review. A total of 244 out of 1628 patients with the average age of 23.13 years. Liposuction facilitated the easy handling to remove the breast tissue via small incisional design; showed consistent improved quality of life in terms of satisfaction after surgery. However, the measuring method of satisfaction rate varied, resulting in difficulties to interpret the results. Complication rates were inconsistent throughout the studies, ranging from 0.06 to 26.67%. Reoperation rate of liposuction-assisted surgery is between 0.6 and 25%. There are only two studies of a total 25 patients that are considered as good in quality. The two studies, which discuss laser-assisted liposuction technique, show minor complication of seroma in two patients. While one study shows high patient's satisfaction rate; both studies indicate high surgeon's satisfaction rate.

CONCLUSION

Small incisional design for breast parenchymal removal in gynecomastia assisted by liposuction showed a good technical approach for consistent improvement in quality of life. However, only 2 studies reported good quality methods of non-randomized case series urging for a better quality of studies in the future.

LEVEL OF EVIDENCE III

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 .

Treatment Options for Lipodystrophy in Children

Lipodystrophy includes a heterogeneous group of rare diseases characterized by different amounts of adipose tissue loss and several metabolic complications, including hypertriglyceridemia, steatohepatitis and particularly insulin resistance, that may lead to severe morbidity and, sometimes, mortality. Therefore, therapy for lipodystrophy primarily consists of a conventional approach that involves standard treatments of metabolic abnormalities. Given the evidence of leptin deficiency in lipodystrophy syndromes, leptin replacement therapy has been considered as a treatment option. Long-term studies on the use of therapy with a methionylated analog of human leptin, metreleptin, first on animals and subsequently on human patients, demonstrated enormous improvements of patients' clinical features and metabolic conditions. Recently, metreleptin was approved by Food and Drug Administration (FDA) for the treatment of generalized lipodystrophy and by European Medicines Agency (EMA) for the treatment of both generalized and partial lipodystrophy. However, further research is being conducted for new and different therapeutic agents, especially helpful for the treatment of patients with partial lipodystrophy, as some of them do not have access to metreleptin therapy or show poor response.

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