The Buried Guide Suture Method: A Novel Technique to Correct Traumatic Facial Dimples

SUMMARY

Facial dimpling, frequently occurring after blunt trauma, presents as soft-tissue depression, which is particularly apparent during facial expression. The displacement of subcutaneous tissue can be detected and measured by high-frequency ultrasound. Limited surgical methods have been applied in these closed-injury cases. Repositioning the subcutaneous tissue without incisions on unscarred skin is challenging. The authors propose a novel three-dimensional technique to suture and fix the subcutaneous tissue at a distance through a concealed incision. The buried guide suture method was used in the treatment of 22 patients with traumatic facial dimples on the cheek. All patients showed great improvement in their depressed deformity with minor complications. This technique provides an option to correct soft-tissue depression without leaving a visible scar, especially for mimetic rupture caused by blunt trauma.

Innovation of the protocol for the application of cryolipolysis: Effects and mechanisms of action

BACKGROUND

In recent years, aesthetic procedures aiming at body remodeling and have grown exponentially. Cryolipolysis (CLL) has stood out as a noninvasive resource that acts directly on the subcutaneous adipose tissue promoting a significant reduction of adipose tissue through of cooling that could lead to the crystallization cytoplasmic lipids, loss of cellular integrity, apoptosis/necrosis of adipocytes, and local inflammation, producing selective loss of adipose tissue. Thus, the objective of the present study was to evaluate the effects of a specific technique of CLL application on the inflammatory reactions of the target tissue in different post-application times.

METHODS

This is a randomized, blind clinical study that evaluated the tissue sample of six patients after 45, 60, and 90 days of an innovative protocol for the application of CLL, with samples collected through abdominoplasty surgeries. The samples were evaluated by immunohistochemical analyses of several markers.

RESULTS

A significantly greater increase in fibroblasts was observed at 45 days and greater phagocytic action at 60 days. Regarding the apoptosis process, the expression of caspase 3 and cleaved caspase 3 markers varied at different times, with cleaved caspase 3 being higher at 45 and 90 days after CLL application.

CONCLUSION

The protocol of the CLL presented in this study was able to induce inflammatory responses in addition to confirming the selective apoptotic action at the different times studied.

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 .

Cryolipolysis for fat reduction using Cooltech® Define technology: A large-sample retrospective clinical study

BACKGROUND

Cryolipolysis is a noninvasive technique for localized fat reduction, which induces selective apoptosis of the adipocytes using controlled exposure to intense cold. During the past 10 years, this technique has been shown to be safe and effective and its application has significantly increased. In this context, Cooltech® devices have been widely used around the world.

AIMS

The purpose of this retrospective study was to evaluate the efficacy and safety of the removal of localized fatty tissue in different body areas using the new Cooltech® Define controlled cooling system.

METHODS

This single-center study was carried out on 287 patients, both female and male, treated with Cooltech® Define on different body areas for a total of 1118 procedures. Follow-up evaluations were conducted to estimate efficacy and safety. Efficacy was evaluated through plicometry and photographs. Side effects were also reported.

RESULTS

Fold thickness showed a significant reduction (-69.91 ± 12.55%) after cryolipolysis treatment (fold thickness before: 35.33 ± 8.41 mm; fold thickness after: 10.69 ± 5.27 mm). Few side effects were reported, they included posttreatment pain (1.70%) and one case of paradoxical adipose hyperplasia (0.09%).

CONCLUSION

The Cooltech® Define cryolipolysis device is a safe, effective, and well-tolerated nonsurgical procedure for reducing localized fat.

Active Heating following Cryolipolysis Reduces Efficacy and Side Effects: A Randomized Split-Body Trial

BACKGROUND

Cryolipolysis-a popular noninvasive technique for body contouring-has fewer side effects compared with liposuction; however, its effectiveness in terms of reducing local adipose tissue is also lower. This study is, to the authors' knowledge, the first prospective, controlled, investigator-blinded split-body trial to evaluate whether postcryolipolytic heating can increase the efficacy.

METHODS

Twenty-five subjects were treated with one session of cryolipolysis on the lower abdomen and a subsequent heating with a mud pack of a randomized side of the treated region (left or right). Epidemiologic, temperature, edema, erythema, hypesthesia, and pain level data were obtained. Photographs, fat layer thickness (on ultrasound, caliper, and abdominal girth), satisfaction, and side effects were documented over a follow-up period of 12 weeks.

RESULTS

The side effects-edema, erythema, and hypesthesia-faded almost completely with heating, whereas they remained on the nonheated site. However, the mean sonographic reduction of local adipose tissue after 12 weeks was significantly lower on the heated sites than on the control sites (9.6% versus 14.1%; P = 0.0003). The overall satisfaction was high (9.2 of 10 points), even though only 44% of participants had a subjective recognition of fat loss without difference between the sites.

CONCLUSIONS

Active heating following cryolipolysis increases bodily well-being by reducing common side effects, but it reduces the effectiveness of cryolipolysis significantly and should therefore be avoided. Further improvements are necessary to enhance the efficacy of cryolipolysis.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, I.

Cryolipolysis: A promising nonsurgical technique for localized fat reduction

BACKGROUND

Cryolipolysis, also known as fat freezing, is a nonsurgical technique specialized for localized fat reduction. Utilizing targeted cold exposure to adipose tissue, cryolipolysis devices induce cellular apoptosis in adipocytes while sparing surrounding tissues, resulting in the selective disruption of fat cells and subsequent removal of damaged cells by macrophages. A reduction of the fat layer produces a noninvasive cosmetic benefit that provides an accessible alternative to liposuction. Objective and subjective measurements have demonstrated significant reduction in fat volume and high patient satisfaction rates. Cryolipolysis has been proven to be safe with minimal adverse effects. However, further research is needed to fully understand the mechanism of cryolipolysis and its efficacy in different treatment areas. This paper aims to provide a comprehensive overview of cryolipolysis, including its mechanism of action, indications, contraindications, adverse effects, results and outcomes, safety profile, and areas requiring further research.

METHODS

Our primary phase of literature review consisted of a PubMed search looking for all published literature around cryolipolysis. We employed a review approach that examined over 30 papers with the key search terms of "cryolipolysis," "fat-freezing," "cosmetic dermatology," "body contouring," "adverse effects," "adipocyte apoptosis," "Coolsculpting®," "cold panniculitis," and "localized fat reduction." We then analyzed each paper, extracting relevant information to gain a multidimensional understanding of cryolipolysis to provide a comprehensive review.

CONCLUSION

Cryolipolysis, with its ability to target and reduce localized adipose tissue, has emerged as a promising nonsurgical technique in the field of body contouring. It offers patients a valuable option for achieving their desired fat reduction without the need for a lengthy recovery period or major surgery. Cryolipolysis has shown to reduce the number of adipocytes in the treated area, a phenomenon that can be objectively quantified through various means, including fat caliper measurements, ultrasound assessments, and 3D imaging, or subjectively observed through patient satisfaction rates, clinical observations, and investigator assessments. In addition to its effectiveness in reducing localized adipose tissue, cryolipolysis also holds potential in the area of skin tightening. Preliminary studies suggest that cryolipolysis may have a positive impact on skin elasticity and tightening. Further investigation of this mechanism is needed to provide a better understanding of its potential in achieving optimal cosmetic outcomes for patients. By combining the benefits of fat reduction and skin tightening, cryolipolysis has the potential to offer a comprehensive nonsurgical solution for body contouring.

A review of research for a cryolipolysis technology

BACKGROUND

Obesity and excess body fat are known health issues and a major aesthetic concern. Numerous modalities have been developed to address unwanted deposits of adiposity, including the development of various noninvasive methods overcoming the limitations and risks of invasive alternatives. Cryoadipolysis, also known commonly as cryolipolysis, involves the harnessing of selective cryolysis, the selective cold-based damaging of subcutaneous fat cells which die via apoptosis, and are removed naturally by the body over time.

AIMS

To provide a brief but comprehensive summary of the literature supporting two related cryoadipolysis devices that are only available outside of North America, Cooltech and Cooltech Define (Sinclair).

RESULTS/DISCUSSION

Review of 10 available clinical studies evaluating the two devices, specifically, showed both devices to be safe, with side effects profiles comparable to those of similar platforms in the armamentarium. Both operate by non-invasively lowering the temperature of localized subcutaneous fat and maintaining it at or below a threshold that causes disruption of adipocytes via crystallization, inducing apoptosis (programmed cell death). Over time, clinically significant reductions in fat thickness and circumference of the treated area were noted. Patient satisfaction is high. The literature also highlights the necessity of adherence to patient selection and device use guidelines to minimize potential for rare paradoxical adipose hyperplasia and maximize patient satisfaction.

Literature review of adverse events associated with cryolipolysis

BACKGROUND

Cryolipolysis is a noninvasive procedure for localized fat reduction and body contouring. This technique utilizes controlled cooling to induce adipocyte apoptosis without damage to overlying skin and other tissue. Although the procedure was once thought to be relatively harmless, recent studies have shed light on the risks of adverse effects (AEs).

AIMS

The aim of this article was to review AEs in cryolipolysis as published in clinical data.

METHODS

A comprehensive search was performed in PubMed, using relevant keywords such as "cryolipolysis," "CoolSculpting," "adverse effects," "complications," and "side effects" with no set data range. The search was limited to studies published in English. The selected studies encompassed a variety of study designs, including randomized controlled trials, prospective cohort studies, case series, case reports, and reviews.

CONCLUSIONS

Since its FDA approval in 2010, our understanding of the potential risks and complications associated with cryolipolysis has grown significantly, and shown that the procedure may not be as harmless as once thought. Continued post-market surveillance of cryolipolysis devices combined with documenting of AE cases help providers better understand the true risks associated with this procedure. As "cryolipolysis" and "CoolSculpting" are often used interchangeably, further research is needed to understand if AEs such as paradoxical adipose hyperplasia (PAH) that occur both inside and outside the United States are CoolSculpting cases or linked to other devices. Additionally, further studies are needed to understand the pathophysiology of such sequelae as PAH, and to better recognize the risks and potential complications associated with cryolipolysis so that we can more accurately inform patients.

Cryolipolysis: The future of cryolipolysis

BACKGROUND

Cryolipolysis has revolutionized the field of cosmetic dermatology as a nonsurgical procedure, utilizing controlled cooling to selectively destroy fat cells.

AIMS AND METHODS

This review article will focus on the future prospects of cryolipolysis, considering advancements in current technology as well as innovations that hold promise for the future. We will explore emerging trends in cryolipolysis, considering novel applicator designs, combination therapies, an innovative injectable treatment approach, and the evolving role of this technology in the field of cosmetic dermatology.

CONCLUSION

The future holds promise for advances in cryolipolysis using both the noninvasive topical cooling approach and the novel injectable ice-slurry technology.

Cryolipolysis in the United States-Review of the clinical data

BACKGROUND

Noninvasive body contouring is becoming more popular in the United States as an alternative to liposuction. The most popular of these methods, cryolipolysis, uses precisely controlled cooling to reduce focal adiposities. The number of cryolipolysis procedures performed annually has experienced rampant growth in United States markets, and the indications have likewise diversified. In light of this change, it is imperative to perform an updated review of available US safety and efficacy data on cryolipolysis.

AIMS

To examine the safety and efficacy of cryolipolysis treatments in the United States using data extracted from research performed exclusively at US-based sites.

METHODS

In order to identify relevant studies, a literature search was conducted on PubMed using the terms "CoolSculpting" OR "cryolipolysis" OR "lipocryolysis." Articles were manually reviewed to exclude literature reviews, research not performed on humans, studies on experimental combinations of techniques, and any studies not performed in the United States.

RESULTS

The initial literature search returned 246 results. Following manual review, a total of 18 studies were selected for data extraction. Mean reduction in fat thickness by ultrasound was 2.0-5.1 mm or 19.6%-32.3%; mean reduction by body caliper was 2.3-7 mm or 14.9%-21.5%. Side effects were mild and transient. Four instances of PAH were documented in 3453 treatment cycles.

CONCLUSIONS

Cryolipolysis is a safe, modestly effective method for reducing focal adiposity. Complications are rare and treatable. However, US-based studies are few in number and often of low power and/or quality. More high-quality research is needed for all aspects of cryolipolysis.

The Use of Autologous Subcutaneous Fat Tissue to Embolize an Infected Iliac Artery Pseudoaneurysm

We describe a patient with a fistula between small bowel and a polyester patch of the common iliac artery. After emergency treatment with an endograft, the patch was replaced by a venous patch. Within 3-week a symptomatic pseudoaneurysm developed. It was decided to embolize the pseudoaneurysm using autologous subcutaneous fat, followed by a femoro-femoral crossover bypass using an allograft. Using this technique, the pseudoaneurysm was successfully excluded. This case shows that subcutaneous fat tissue can be used as an autologous embolic material, also in larger vessel pathology and in cases of ongoing infection, where regular embolization material cannot be used.

Successful treatment of submental fat using a non-focused pulsed ultrasound

BACKGROUND

The prevalence of non-invasive aesthetic treatments is increasing, with patients demanding easier, safer, and more effective non-invasive cosmetic procedures. Submental fat is usually addressed using liposuction, which is associated with significant adverse events and a long recovery. Although newer, non-invasive submental fat treatments are gaining popularity, they are often complex, require frequent injections, or have adverse side effects.

AIMS

Assess the safety and efficacy of vacuum-assisted acoustic wave technology for treating submental.

PATIENTS/METHODS

Fourteen female patients underwent a total of three weekly 15-min treatments using ultrasound with a 40 mm bell-shaped sonotrode. Improvement in submental fat was assessed 3 months after the final treatment using questionnaires for the patients and physicians. Two blinded dermatologists rated each patient using the Clinician-Reported Submental Fat Rating Scale (CR-SMFRS) 5-point scale.

RESULTS

Both physicians rated a significant improvement in all 14 patients. Furthermore, self-evaluation of the 14 patients on a 1 to 5 satisfaction scale averaged 2.14, indicating that most patients were somewhat satisfied.

CONCLUSION

This study demonstrates that a three-treatment course with an acoustic wave ultrasound applicator with 1-week intervals leads to a significant reduction in submental fat and can be used as a novel, efficient treatment paradigm.

Metabolic aspects of surgical subcutaneous fat removal: An umbrella review and implications for future research

Although obesity is a preventable disease, maintaining a normal body weight can be very challenging and difficult, which has led to a significant increase in the demand for surgical subcutaneous fat removal (SSFR) to improve physical appearance. The need for SSFR is further exacerbated because of the global rise in the number of bariatric surgeries, which is currently the single most durable intervention for mitigating obesity. Fat tissue is now recognized as a vital endocrine organ that produces several bioactive proteins. Thus, SSFR-mediated weight (fat) loss can potentially have significant metabolic effects; however, currently, there is no consensus on this issue. This review focuses on the metabolic sequelae after SSFR interventions for dealing with cosmetic body appearance. Data was extracted from existing systematic reviews and the diversity of possible metabolic changes after SSFR are reported along with gaps in the knowledge and future directions for research and practice. We conclude that there is a potential for metabolic sequelae after SSFR interventions and their clinical implications for the safety of the procedures as well as for our understanding of subcutaneous adipose tissue biology and insulin resistance are discussed.

Experimental evaluation of high intensity focused ultrasound for fat reduction of ex vivo porcine adipose tissue

PURPOSE

The present study was stimulated by the continuous growth of commercially available high intensity focused ultrasound (HIFU) systems for fat reduction. Herein, HIFU was utilised for fat ablation using a single-element ultrasonic transducer operating in thermal mode.

METHODS

The custom-made concave transducer that operates at 1.1 MHz was assessed on excised porcine adipose tissue for its ability to reduce fat. Ultrasonic sonications were executed on the adipose tissue utilising acoustical power between 14 and 75 W and sonication time in the range of 1-10 min. The mass of the adipose tissue sample was weighed afore and after ultrasonic sonications and the effect of the sonication on the mass change was recorded.

RESULTS

Mass change was linearly dependent with either increasing acoustical power or sonication time and was in the range of 0.46-1.9 g. High acoustical power of 62.5 W for a sonication time of 1 min and a power of 75 W for a sonication time of 5 min, respectively resulted in the formation of a lesion or possible cavitation on the piece of excised adipose tissue.

CONCLUSION

The study demonstrated the efficacy of the proposed transducer in achieving a reduction of excised fat tissue. The present findings indicate the potential use of the transducer in a HIFU system indicated for the reduction of subcutaneous adipose tissue where increased values of acoustical power can result in increased amounts of fat reduction.

Non-invasive system delivering microwaves energy for unwanted fat reduction and submental skin tightening: Clinical evidence

BACKGROUND

Cervicomental contour represents an important aesthetic problem.

AIMS

This research evaluates the safety and the efficacy of a new non-invasive system delivering microwave energy for the treatment of submental skin laxity and fat.

METHODS

Forty-eight subjects underwent submental treatment with the device at hand at Poliambulatorio San Michele, Reggio Emilia, Italy. The treatment was performed on the submental area starting from 1.5 cm below the lower border of the mandible up to the hyoid bone. Treatment consisted of 6 sessions of 10 min, with a 2-week interval between each session. At the baseline and upon follow-up 12 weeks from the last treatment, the following evaluations were performed: Photographic evaluation, Clinician-Reported Submental Fat Rating Scale (CR-SMFRS), Submental Skin Laxity Grade (SMSLG), Five-Point Likert Scale Questionnaire (LSQ) for Skin Laxity, Patient-Reported Submental Fat Rating Scale (PR-SMFRS) and Numeric Rating Scale (NRS) for pain evaluation.

RESULTS

Mean submental fat and laxity scores evaluation significantly decrease respectively from 3.4 ± 0.5 and 3.7 ± 0.5 at baseline to 1.7 ± 0.6 and 2.4 ± 0.6 (p < 0.01) at 12-week follow-up after the last treatment. The treatment was well-tolerated according to the NRS results. Out of the 47 participants (70.2%), 33 were very satisfied or satisfied. Most patients denied experiencing any discomfort during and after the treatment with the non-invasive device delivering microwaves. The submental subcutaneous fat reduction, the improvement of submental skin tightening, and aesthetic results are confirmed also by photographic evaluation. No side effects were observed.

CONCLUSIONS

Our results showed the potential microwaves role in the treatment of localized submental subcutaneous adiposities and skin laxity.

A Systematic Review of Subsurface Radiofrequency Treatments in Plastic Surgery

BACKGROUND

Subsurface radiofrequency (RF) treatments produce skin contraction by causing coagulation of the underlying subcutaneous fat. This method is marketed to fill a treatment gap for patients who do not wish to have surgery. A systematic review of this subject has not been previously published.

METHODS

An electronic search was performed using PubMed to identify the literature describing subsurface RF treatments.

RESULTS

Thirty articles were evaluated. An InMode device was used in 23 studies, and a Thermi device was used in 6 studies, with or without liposuction. Treatment areas included the face, neck, body, breasts, and labia. Most studies relied on patient satisfaction scores and physician review of photographs. The most frequent complications were induration and nodules. Most patients experienced prolonged swelling and numbness. Several studies reported marginal mandibular neuropraxias. The skin response after treatment of the abdomen was poor, and seromas were common. The incidence of burns improved after modification of the InMode device. Breast treatment did not appear to be effective in treating ptosis. Patient satisfaction scores were modest. Most studies (77%) were published by authors with a known conflict of interest. In some studies, the photographs did not accurately depict the treatment result. Institutional review board approval and disclosure of off-label regulatory status were often missing.

DISCUSSION

Thermal treatment of the subcutaneous tissue introduces extra risks without a compensatory benefit. Comparisons in terms of safety, cost, recovery time, results, and complications do not favor energy-based devices. A treatment gap may be fictitious; properly informed patients may be treated with existing surgical procedures at all ages.

CONCLUSIONS

Little evidence supports the efficacy and safety of subcutaneous RF treatments as an improvement over results that may be obtained using traditional surgical methods such as submental lipectomy, liposuction, and abdominoplasty. Photographic integrity is often lacking. Financial conflict of interest is pervasive. Marketing precedes the science. Plastic surgeons need to be aware of these serious limitations and the off-label regulatory status of these devices, before purchasing expensive equipment and recommending subsurface RF treatments to patients.

High Participant Satisfaction Achieved Using Cryolipolysis for Fat Reduction of the Abdomen and Flanks

BACKGROUND

Patient-reported outcome (PRO) data evaluating the physical and psychosocial impact of cryolipolysis (CoolSculpting) treatment are limited.

OBJECTIVES

The aim of this study was to assess, by means of PRO instruments, multidimensional aspects of satisfaction following cryolipolysis treatment of the flanks and abdomen.

METHODS

This was a multinational, prospective, single-cohort, interventional study. The primary endpoint was the proportion of participants stating they were "satisfied" or "very satisfied" with treatment at 12 weeks post final treatment. Secondary endpoints included satisfaction categorized by treatment area, total number of treatment cycles, baseline BMI, and fat volume reduction measured by 3-dimensional photography at 12 weeks post final treatment. Exploratory endpoints assessed the physical and psychosocial impacts of treatment. Safety was monitored throughout the study.

RESULTS

Of 112 participants who were treated, 74.1% were female. The mean age and BMI were 42.5 years and 24.9 kg/mg2, respectively. Of the 106 evaluable participants, 89.6% were "satisfied" or "very satisfied" with treatment results. Satisfaction was high regardless of body area(s), total number of treatment cycles, or baseline BMI. Mean [standard deviation] fat volume reduction was 264.8 [411.4] mL. Overall, 90.6% reported "noticeable" or "very noticeable" fat reduction, 89.6% were "likely" or "very likely" to treat additional areas, and 93.4% would recommend cryolipolysis to a friend. Twenty-four (21.4%) participants reported treatment-emergent adverse events; 23 (20.5%) reported these as adverse device effects. No serious device-related or unanticipated adverse effects occurred.

CONCLUSIONS

Cryolipolysis (CoolSculpting) for fat reduction of the flanks and/or abdomen was well-tolerated and associated with high levels of satisfaction across multidimensional PROs.

LEVEL OF EVIDENCE: 4

Efficacy and safety of a novel combined 1060-nm and 635-nm laser device for non-invasive reduction of abdominal and submental fat

The aim of this study was to evaluate the safety and efficacy of combined 1060-nm diode laser and 635-nm low-level laser therapy (LLLT) device for non-invasive reduction of the abdominal and submental fat. Forty-two healthy subjects received single laser treatment on both the abdomen and submental area. Ultrasound images measuring the thickness of abdominal and submental fat were taken at baseline, follow-up at 4, 8, and 12 weeks after treatment. Waist circumference and body weight were also measured at all visits. Adverse events were recorded at all visits. Subjects completed a satisfaction questionnaire at the end of the trial. Twelve weeks after a single treatment with the investigational device, ultrasound images showed statistically significant (P < 0.0001) reductions in abdominal and submental fat by 18.62 and 26.4%, respectively. In addition, significant (P < 0.0001) reduction in waist circumference was observed. Ninety-six percent of subjects rated that they were satisfied. Noted side effects were transient mild to moderate tenderness which subsided within 1 to 3 weeks. No serious treatment-related adverse events were reported. The dual wavelength device combining 1060-nm diode laser with 635-nm LLLT was safe and effective for non-invasive reduction of both abdominal and submental fat.

Increase apparent penile length by cryolipolysis in the reduction of male suprapubic fat

The buried or hidden penis in adults is troublesome in males, whereas the length of the penile shaft is buried under the skin surface of the suprapubic fat to a degree that reveals the concept of a little penis. We aimed to assess a new modality of treatment to increase the apparent penile length by using the cryolipolysis in the reduction of male suprapubic fat as a noninvasive procedure. This prospective study was performed on 46 male patients complaining of buried short apparent small size penis. All patients were subjected to full medical history, body mass index and examination of penile (length, size and abnormalities). The measures of the apparent penile length from the skin to the tip of the glans penis and suprapubic skin fold thickness using (adipometer) were recorded before the three consecutive suprapubic cryolipolysis sessions. The mean apparent stretched penile length at session 1, 2 and 3 were 12.1 ± 0.5 cm, 12.66 ± 0.48 and 12.88 ± 0.72, respectively, with a statistically significant increase between three sessions (p < .001), whereas the mean skin fold suprapubic fat at session 1, 2 and 3 was 2.99 ± 0.49 cm, 2.37 ± 0.48 and 2 ± 0.37, respectively, with a statistically significant decrease (p < .001). The cryolipolysis of suprapubic fat is a safe, effective, noninvasive and applicable procedure that successfully decreases the suprapubic fat in males and increases the apparent length of the buried penises.

Liposuction Treatment of a Subacute Morel-Lavallée Lesion: A Case Report

INTRODUCTION

A Morel-Lavallée lesion (MLL) is a rare and aesthetically concerning condition caused by a shearing force between subcutaneous fat and underlying fascia. Subsequent seroma formation occurs after the initial trauma of a crush injury, ligamentous sprain, or abdominal liposuction. Misdiagnosed lesions lead to inadequate treatment and are a source of chronic pain.

CASE REPORT

The case of a 33-year-old woman who presented with a large, painful subacute MLL of the left thigh after being run over by a truck 3 weeks prior is reported. Physical examination revealed severe hyperesthesia and fluctuance of the left thigh. After confirmation of the fluid collection by X-ray and computed tomography angiogram, the authors performed liposuction of the cavity and seroma wall to evacuate and treat the lesion. Postoperative care consisted of a temporary drain, thigh compression, and oral antibiotics. Immediate reduction in size was appreciated intraoperatively with no reaccumulation of fluid at postoperative visits on week 1 and week 6. The pathology report confirmed seroma etiology, and all cultures of the fluid returned negative. At the end of her postoperative course, the patient reported a reduction in pain and no recurrence of her symptoms.

CONCLUSIONS

This case of MLL was diagnosed early and successfully treated with liposuction, resulting in an acceptable cosmetic outcome. It is the authors' hope that this case report will lead to earlier diagnosis and proper treatment of MLLs.

Subcutaneous Fat Reduction with Injected Ice Slurry

BACKGROUND

Cryolipolysis is a noninvasive method for removal of subcutaneous fat for body contouring. Conventional cryolipolysis with topical cooling requires extracting heat from subcutaneous fat by conduction across the skin, thus limiting the amount and the location of the fat removed. The authors hypothesized that local injection of a physiological ice slurry directly into target adipose tissue would lead to more efficient and effective cryolipolysis.

METHODS

Injectable slurries containing 20 percent and 40 percent ice content were made using common parenteral agents (normal saline and glycerol), then locally injected into the subcutaneous fat of swine. Ultrasound imaging, photography, histological, and gross tissue responses were monitored before and periodically up to 8 weeks after injection.

RESULTS

Fat loss occurred gradually over several weeks following a single ice slurry injection. There was an obvious and significant 55 ± 6 percent reduction in adipose tissue thickness compared with control sites injected with the same volume of melted slurry (p < 0.001, t test). The amount of fat loss correlated with the total volume of ice injected. There was no scarring or damage to surrounding tissue.

CONCLUSION

Physiological ice slurry injection is a promising new strategy for selective and nonsurgical fat removal.

The short-term and long-term effects of bariatric/metabolic surgery on subcutaneous adipose tissue inflammation in humans

CONTEXT

The mechanisms mediating the short- and long-term improvements in glucose homeostasis following bariatric/metabolic surgery remain incompletely understood.

OBJECTIVE

To investigate whether a reduction in adipose tissue inflammation plays a role in the metabolic improvements seen after bariatric/metabolic surgery, both in the short-term and longer-term.

DESIGN

Fasting blood and subcutaneous abdominal adipose tissue were obtained before (n=14), at one month (n=9), and 6-12months (n=14) after bariatric/metabolic surgery from individuals with obesity who were not on insulin or anti-diabetes medication. Adipose tissue inflammation was assessed by a combination of whole-tissue gene expression and flow cytometry-based quantification of tissue leukocytes.

RESULTS

One month after surgery, body weight was reduced by 13.5±4.4kg (p<0.001), with improvements in glucose tolerance reflected by a decrease in area-under-the-curve (AUC) glucose in 3-h oral glucose tolerance tests (-105±98mmol/L * min; p=0.009) and enhanced pancreatic β-cell function (insulinogenic index: +0.8±0.9pmol/mmol; p=0.032), but no change in estimated insulin sensitivity (Matsuda insulin sensitivity index [ISI]; p=0.720). Furthermore, although biomarkers of systemic inflammation and pro-inflammatory gene expression in adipose tissue remained unchanged, the number of neutrophils increased in adipose tissue 15-20 fold (p<0.001), with less substantial increases in other leukocyte populations. By the 6-12month follow-up visit, body weight was reduced by 34.8±10.8kg (p<0.001) relative to baseline, and glucose tolerance was further improved (AUC glucose -276±229; p<0.001) along with estimated insulin sensitivity (Matsuda ISI: +4.6±3.2; p<0.001). In addition, improvements in systemic inflammation were reflected by reductions in circulating C-reactive protein (CRP; -2.0±5.3mg/dL; p=0.002), and increased serum adiponectin (+1358±1406pg/mL; p=0.003). However, leukocyte infiltration of adipose tissue remained elevated relative to baseline, with pro-inflammatory cytokine mRNA expression unchanged, while adiponectin mRNA expression trended downward (p=0.069).

CONCLUSION

Both the short- and longer-term metabolic improvements following bariatric/metabolic surgery occur without significant reductions in measures of adipose tissue inflammation, as assessed by measuring the expression of genes encoding key mediators of inflammation and by flow cytometric immunophenotyping and quantification of adipose tissue leukocytes.

Neck Contouring and Treatment of Submental Adiposity

There have been many recent and significant innovations to the cosmetic physician's repertoire for addressing excess submental fat and improving patients' neck contour. These new techniques include submental cryolipolysis, injectable chemical lipolysis, percutaneous radiofrequency, laser techniques, and liposuction with or without laser or power assistance. These modalities range from completely non-invasive to surgical procedures. Each technique has its own unique advantages, and limitations and as such, aesthetic practitioners should be familiar with the various indications to use each technique. Additionally, cost to the practice and patient are similarly varied across the different techniques. By increasing familiarity with the new procedures addressed herein, practices can better present a diverse range of treatment options for excess submental fat and neck fullness to the cosmetic patient. <em>J Drugs Dermatol. 2017;16(1):54-57.</em>.

"Hands-Free" Noninvasive Body Contouring Devices: Review of Effectiveness and Patient Satisfaction

The demand for body contouring is increasing rapidly and has generated the need for a variety of non-invasive body contouring devices. This review concentrates on three popular "hands-free" body contouring devices and analyzes their mechanism of action, as well as their evidence of safety and ef cacy. It also addresses some issues of usability from both the operators' and patients' point of view. <em>J Drugs Dermatol. 2016;15(11):1402-1406.</em>.

Transconjunctival Lower Blepharoplasty

There is no secret to achieving successful results with lower belpharoplasties; as is the case with any surgical procedure, proper patient evaluation and development of a comprehensive, anatomic-based treatment plan are prerequisites for success. For situations in which a patient has little lid laxity and pseudoherniated periorbital fat, transconjunctival lower blepharoplasty is the treatment of choice. Transconjunctival lower blepharoplasty enables the surgeon to reposition fat, effectively blending the lid-cheek junction and filling the tear trough deformity. In order to better enable clinicians to achieve optimal outcomes, the authors advocate an anatomic-based approach for patient evaluation and treatment planning.

Content of Soluble Factors and Characteristics of Stromal Vascular Fraction Cells in Lipoaspirates from Different Subcutaneous Adipose Tissue Depots

BACKGROUND

Although fat grafting has emerged as a major force in plastic, reconstructive, and aesthetic surgery, some questions regarding its reliability and regenerative potential remain unanswered.

OBJECTIVES

The authors examined the influence of three anatomic areas on various lipoaspirate properties to identify the most appropriate harvest site for fat-grafting procedures.

METHODS

Lipoaspirates from 25 healthy patients were harvested from the abdomen, inner thigh, and knee. The authors measured the content of soluble factors in the lipoaspirate followed by the assessment of the yield, adipogenic differentiation, proliferation of stromal vascular fraction (SVF) cells, and the percentage of adipose-derived stem cells (ASC) in the SVF. The results also were correlated with the age and body mass index of the donors.

RESULTS

Lipoaspirates from the abdomen showed significantly higher concentrations of matrix metalloproteinase (MMP)-9 compared with the knee. The content of basic fibroblast growth factor (b-FGF), platelet-derived growth factor (PDGF)-BB, and insulin-like growth factor (IGF)-1 tended to be highest in the abdomen but did not reach statistical significance. Vascular endothelial growth factor (VEGF)-A and bFGF-2 contents both correlated negatively with age in lipoaspirates from at least two different anatomic areas.

CONCLUSIONS

The authors' results indicate that the abdomen may be a slight favorite over the inner thigh and knee because of its richer content of soluble factors. However, because only the difference of MMP-9 content actually reached statistical significance and because no differences in SVF characteristics were observed, a decision primarily based on other criteria appears to be justifiable.

Total Composite Flap Facelift and the Deep-Plane Transition Zone: A Critical Consideration in SMAS-Release Midface Lifting

BACKGROUND

Recent anatomic studies suggest the superficial musculoaponeurotic system (SMAS) layer attenuates in the midface. This led the author to switch from a bilamellar high SMAS dissection to a "total composite flap" technique, preserving skin and SMAS/platysma as one layer in a critical "deep-plane transition zone" (DTZ) lateral to the zygomaticus major muscle. This allows traction on the SMAS to translate to the malar fat pad via a "cantilever bridge" effect, which is lost when skin is undermined in the DTZ.

OBJECTIVES

This paper attempts to answer the question of whether the composite flap or bilamellar technique better lifts the midface, comparing groups where the DTZ was undermined: (1) only at a sub-SMAS level; or (2) at both subcutaneous and sub-SMAS levels.

METHODS

Thirty-five patients underwent bilamellar facelifts with skin and SMAS separated in the DTZ. Midfacial elevation was measured using size-matched preoperative and 18-month (average) postoperative photographs for the 70 hemi-midfaces. The same analysis was done for 35 patients undergoing total composite flap facelift, maintaining skin and SMAS as one layer in the DTZ. The two groups were compared.

RESULTS

In the bilamellar group, the mean percentage of midfacial elevation at 18 months postoperative was 5.5% (range, 0.0%-17.8%). In the composite flap group, the percentage was 11.7% (range, 0.1%-32.3%). The difference was statistically significant.

CONCLUSIONS

Maintaining skin-SMAS attachments in the DTZ improves midface elevation during SMAS facelifting, exploiting a "cantilever bridge" effect of the skin transferring traction on the SMAS to the malar fat pad.

SMAS Fusion Zones Determine the Subfascial and Subcutaneous Anatomy of the Human Face: Fascial Spaces, Fat Compartments, and Models of Facial Aging

BACKGROUND

Fusion zones between superficial fascia and deep fascia have been recognized by surgical anatomists since 1938. Anatomical dissection performed by the author suggested that additional superficial fascia fusion zones exist.

OBJECTIVES

A study was performed to evaluate and define fusion zones between the superficial and the deep fascia.

METHODS

Dissection of fresh and minimally preserved cadavers was performed using the accepted technique for defining anatomic spaces: dye injection combined with cross-sectional anatomical dissection.

RESULTS

This study identified bilaminar membranes traveling from deep to superficial fascia at consistent locations in all specimens. These membranes exist as fusion zones between superficial and deep fascia, and are referred to as SMAS fusion zones.

CONCLUSIONS

Nerves, blood vessels and lymphatics transition between the deep and superficial fascia of the face by traveling along and within these membranes, a construct that provides stability and minimizes shear. Bilaminar subfascial membranes continue into the subcutaneous tissues as unilaminar septa on their way to skin. This three-dimensional lattice of interlocking horizontal, vertical, and oblique membranes defines the anatomic boundaries of the fascial spaces as well as the deep and superficial fat compartments of the face. This information facilitates accurate volume augmentation; helps to avoid facial nerve injury; and provides the conceptual basis for understanding jowls as a manifestation of enlargement of the buccal space that occurs with age.

A Multicenter Study for Cellulite Treatment Using a 1440-nm Nd:YAG Wavelength Laser with Side-Firing Fiber

BACKGROUND

Treatment of cellulite using a 1440-nm YAG wavelength laser with side-firing fiber has proven safe and effective, lasting at least 6 months.

OBJECTIVES

The authors evaluate the safety and efficacy of a single, subdermal procedure to treat the underlying structure of cellulite for at least 1 year.

METHODS

Fifty-seven patients underwent a 3-step cellulite treatment with a 1440-nm Nd:YAG laser with a side-firing fiber and temperature-sensing cannula. Efficacy was measured by the blinded evaluators to distinguish baseline photos from those taken at 12 months posttreatment, with results on a 5-point, 2-category ordinal photonumeric scale when comparing baseline photos to 12 months posttreatment. Subject and physician satisfaction was assessed based on completion of a satisfaction survey. Adverse events (AE) were recorded throughout the study. Twelve month data were analyzed and compared to 6 month data.

RESULTS

Evaluators chose baseline photographs 97% on average from 6 (-1, +2) months and 91% from the 12 (-3, +2) months posttreatment photographs. At 6 (-1, +2) months, the average improvement score was 1.7 for dimples and 1.1 for contour irregularities. At 12 (-3, +2) months, the average improvement score was 1.4 for dimples and 1.0 for contour irregularities. The average satisfaction score for the physician was 5.6 and the patient was 5.3 on a 6-point scale.

CONCLUSIONS

A single, 3-step, minimally invasive laser treatment using a 1440-nm Nd:YAG laser, side-firing fiber, and temperature-sensing cannula to treat the underlying structure of cellulite proved to be safe and maintained effectiveness at least 1 year post treatment. LEVEL OF EVIDENCE 2: Therapeutic.

Facilitated long chain fatty acid uptake by adipocytes remains upregulated relative to BMI for more than a year after major bariatric surgical weight loss

OBJECTIVE

This study examined whether changes in adipocyte long chain fatty acid (LCFA) uptake kinetics explain the weight regain increasingly observed following bariatric surgery.

METHODS

Three groups (10 patients each) were studied: patients without obesity (NO: BMI 24.2 ± 2.3 kg m(-2) ); patients with obesity (O: BMI 49.8 ± 11.9); and patients classified as super-obese (SO: BMI 62.6 ± 2.8). NO patients underwent omental and subcutaneous fat biopsies during clinically indicated abdominal surgeries; O were biopsied during bariatric surgery, and SO during both a sleeve gastrectomy and at another bariatric operation 16 ± 2 months later, after losing 113 ± 13 lbs. Adipocyte sizes and [(3) H]-LCFA uptake kinetics were determined in all biopsies.

RESULTS

Vmax for facilitated LCFA uptake by omental adipocytes increased exponentially from 5.1 ± 0.95 to 21.3 ± 3.20 to 68.7 ± 9.45 pmol/sec/50,000 cells in NO, O, and SO patients, respectively, correlating with BMI (r = 0.99, P < 0.001). Subcutaneous results were virtually identical. By the second operation, the mean BMI (SO patients) fell significantly (P < 0.01) to 44.4 ± 2.4 kg m(-2) , similar to the O group. However, Vmax (40.6 ± 11.5) in this weight-reduced group remained ~2X that predicted from the BMI:Vmax regression among NO, O, and SO patients.

CONCLUSIONS

Facilitated adipocyte LCFA uptake remains significantly upregulated ≥1 year after bariatric surgery, possibly contributing to weight regain.

Male Body Contouring

Men are increasingly turning to dermatologists and plastic surgeons to request procedures that correct or enhance physical features. With the advent of this emerging new patient population, alterations in preexisting aesthetic techniques, gender-specific uses of existing devices and overall approaches need to be revisited and adapted to obtain results that are suitable for the male patient. Recently, body contouring has become one of the most sought out procedures by men. Although the majority of clinical studies involving body contouring esthetics are performed with female patients, gains from such studies can be extrapolated to men. Body contouring can be broadly classified as non-invasive or invasive, depending on the modality used. Non-invasive contouring is most frequently performed with devices that target subcutaneous adipose with focused electrical or thermal energy, including low-level laser, cryolipolysis, ultrasonography, and radiofrequency. Invasive body contouring modalities useful for male body contouring include liposuction, pectoral and abdominal wall etching, jawline fillers, synthetic deoxycholic acid injections, and solid silicone implants. The purpose of this review is to bring attention to the unique aspects, strategies, and modalities used in aesthetic body contouring for the male patient.

Femoral lipectomy increases postprandial lipemia in women

Femoral subcutaneous adipose tissue (SAT) appears to be cardioprotective compared with abdominal SAT, possibly through better triglyceride (TG) sequestration. We hypothesized that removal of femoral SAT would increase postprandial TG through a reduction in dietary fatty acid (FA) storage. Normal-weight (means ± SD; BMI 23.9 ± 2.6 kg/m(2)) women (n = 29; age 45 ± 6 yr) were randomized to femoral lipectomy (LIPO) or control (CON) and followed for 1 yr. Regional adiposity was measured by DEXA and CT. A liquid meal labeled with [(14)C]oleic acid was used to trace the appearance of dietary FA in plasma (6-h postprandial TG), breath (24-h oxidation), and SAT (24-h [(14)C]TG storage). Fasting LPL activity was measured in abdominal and femoral SAT. DEXA leg fat mass was reduced after LIPO vs. CON (Δ-1.4 ± 0.7 vs. 0.1 ± 0.5 kg, P < 0.001) and remained reduced at 1 yr (-1.1 ± 1.4 vs. -0.2 ± 0.5 kg, P < 0.05), as did CT thigh subcutaneous fat area (-39.6 ± 36.6 vs. 4.7 ± 14.6 cm(2), P < 0.05); DEXA trunk fat mass and CT visceral fat area were unchanged. Postprandial TG increased (5.9 ± 7.7 vs. -0.6 ± 5.3 × 10(3) mg/dl, P < 0.05) and femoral SAT LPL activity decreased (-21.9 ± 22.3 vs. 10.5 ± 26.5 nmol·min(-1)·g(-1), P < 0.05) 1 yr following LIPO vs. CON. There were no group differences in (14)C-labeled TG appearing in abdominal and femoral SAT or elsewhere. In conclusion, femoral fat remained reduced 1 yr following lipectomy and was accompanied by increased postprandial TG and reduced femoral SAT LPL activity. There were no changes in storage of meal-derived FA or visceral fat. Our data support a protective role for femoral adiposity on circulating TG independent of dietary FA storage and visceral adiposity.

Evidence of Subcutaneous Tissue Lipolysis Enhancement by Endogenous Cortisol in Critically Ill Patients Without Shock

BACKGROUND/AIM

Cortisol is involved in in many aspects of adipose tissue metabolism. A positive association between plasma cortisol and lipolysis has been observed. Critically ill patients exhibit 'lipemia of sepsis'. The aim of the present study was to study, in septic ICU patients, adipose tissue lipolysis in relation to tissue cortisol using microdialysis (MD).

PATIENTS AND METHODS

We studied 17 mechanically-ventilated patients (9 men; mean±SD age=63±19 years) with a diagnosis of severe sepsis. Upon ICU admission, an MD catheter was inserted under sterile conditions into the subcutaneous adipose tissue of the upper thigh. On days 2, 3 and 4, MD samples were collected six times per day for glycerol (used as an index of lipolysis) and tissue cortisol determinations. The mean of these six collections was used for analysis (normal values for adipose tissue glycerol <200 μmol/l). Statistics were carried-out with analysis of covariance (ANCOVA) and linear regression.

RESULTS

More than half of the samplings (19/31) indicated accentuated lipolysis with above-normal MD glycerol levels. By ANCOVA, MD glycerol (log values) was associated with MD cortisol (log values) (p=0.012) and was not associated with age or day of sampling. Furthermore, MD glycerol (log values) was positively correlated to MD cortisol (log values) (r=0.490, p=0.012).

DISCUSSION

Changes in interstitial/tissue cortisol may not be reflected in (total) plasma cortisol concentration. Thus, it is interesting that we observed, albeit weak, an association between tissue lipolysis (via MD glycerol levels) and MD cortisol, verifying (although modestly so) the well-known association between lipolysis and cortisol.

Suture Closure versus Non-Closure of Subcutaneous Fat and Cosmetic Outcome after Cesarean Section: A Randomized Controlled Trial

INTRODUCTION

To investigate the effect of subcutaneous fat suture closure versus non-closure at cesarean section (CS) on long-term cosmetic outcome.

MATERIAL AND METHODS

Women undergoing planned or unplanned CS were randomized to either subcutaneous fat suture closure or non-closure using a 1∶1 allocation algorithm. Participants and outcome assessors were blinded to group allocation. Scar evaluation was performed after two and six months. Primary outcome measures were Patient and Observer Scar Assessment Scale (POSAS) summary scores six months after surgery. Secondary outcome measures were Vancouver Scar Scale (VSS) summary scores, retraction of the scar below the level of the surrounding skin, duration of surgery, and development of hematoma, seroma, surgical site infection (SSI) or wound disruption. Data were analyzed according to the intention to treat principle.

RESULTS

A total of 116 women were randomized and 91 participants, 47 in the closure and 44 in the non-closure group, completed the trial and were analyzed. There were no differences in patient morphometrics or surgery indications between groups. At two and six months no significant differences were found with respect to POSAS or VSS scores between groups. After two months significantly more women in the non-closure group described their scar as being retracted below the level of the skin (36% vs. 15%, p = 0.02) whereas no difference was observed at six months. There were significantly more hematomas in the non-closure (25%) compared to the closure group (4%) (p = 0.005). There was no difference in duration of surgery, SSI, seroma formation or wound disruption between groups.

CONCLUSIONS

Suture closure of the subcutaneous fat at CS does not affect long-term cosmetic outcome. (Level I evidence).

TRIAL REGISTRATION

ClinicalTrials.gov NCT01542346.

Abdominal wall dynamics after component separation hernia repair

BACKGROUND

The component separation technique (CST) is an important technique now used frequently in complex ventral hernia repair (VHR). Although this technique has demonstrated superior success rates, there is a paucity of research describing how release of the external obliques coupled with rectus myofascial advancement alters the morphology of the abdominal architecture. In this study, we apply the new concept of analytic morphomics to describe the immediate changes in morphology of the abdomen that take place after VHR by CST.

METHODS

We identified 21 patients who underwent VHR by CST and received both preoperative and postoperative computed tomography scans between 2004 and 2009 in our clinical database. The surgical technique involved incisional release of the external oblique muscle lateral to the linea semilunaris with rectus abdominis myofascial advancement in all patients. Using semiautomated morphomic analysis, we measured the pre- and post-operative dimensions of the abdominal wall including the anterior-posterior distance from the anterior vertebra-to-skin and fascia along with the circumferential area of the skin and fascial compartments. Paired Student t-tests were used to compare pre- and post-operative values.

RESULTS

After hernia repair, there was a decrease in the anterior vertebra-to-skin distance (16.6 cm-15.8 cm, P = 0.007). There were also decreases in total body area (968.0 cm(2)-928.6 cm(2), P = 0.017) and total body circumference (113.6 cm-111.4 cm, P = 0.016). The distance from fascia to skin decreased as well, almost to the point of statistical significance (3.3 cm-2.9 cm, P = 0.0505). Interestingly, fascia area and circumference did not decrease significantly after the operation (578.2 cm(2)-572.5 cm(2), P = 0.519, and 89.1 cm-88.6 cm, P = 0.394, respectively).

CONCLUSIONS

Morphomic analysis can be used to compare and pre- and post-operative changes in patients undergoing abdominal surgery. Our study demonstrates that component separation affects the dimensions of the entire abdomen, but leaves the fascia area and circumference relatively unchanged. These changes in the abdominal wall may help explain the muscular changes observed as a result of this operation and demonstrate that this is a functional operation that restores fascial area. By better defining the effects of this procedure, we can better understand the reason for its clinical success.

Defining the fat compartments in the neck: a cadaver study

BACKGROUND

Cervicoplasty is an important component of aesthetic facial and neck surgery, but the fat content in this area has not been described.

OBJECTIVES

The authors identify anatomic compartments of fat in the neck (specifically the areas relevant to surgical management), quantify the fat in each compartment, and describe the relationships between each compartment and the submandibular glands.

METHODS

The skin was removed from 10 fresh cadaver heads. Each compartment of fat was weighed, along with the submandibular gland. Supraplatysmal fat was found between the skin and the platysma muscle, and it was compartmentalized into suprahyoid and infrahyoid fat. Subplatysmal fat was found deep to the platysma and between the medial edges of the anterior digastric in the midline; this fat also fell into suprahyoid and infrahyoid compartments. The "very deep" fat was deep to the anterior digastric muscles and submandibular gland, and adherent to the strap muscles.

RESULTS

On average, supraplatysmal fat represented 44.7% of the fat in the neck, the subplatysmal fat represented 30.7%, and the submandibular gland represented 24.5%. The very deep fat was scant, representing less than 1% of the fat in the neck.

CONCLUSIONS

This anatomic study provides a comprehensive review of fat in the neck, and the results should serve as an additional guide as surgeons approach this challenging area in surgical rejuvenation.

Subcutaneous closure versus no subcutaneous closure after non-caesarean surgical procedures

BACKGROUND

Most surgical procedures involve a cut in the skin that allows the surgeon to gain access to the surgical site. Most surgical wounds are closed fully at the end of the procedure, and this review focuses on these. The human body has multiple layers of tissues, and the skin is the outermost of these layers. The loose connective tissue just beneath the skin is called subcutaneous tissue, and this generally contains fat. There is uncertainty about closure of subcutaneous tissue after surgery: some surgeons advocate closure of subcutaneous tissue, as they consider this closes dead space and leads to a decrease in wound complications; others consider closure of subcutaneous tissue to be an unnecessary step that increases operating time and involves the use of additional suture material without offering any benefit.

OBJECTIVES

To compare the benefits (such as decreased wound-related complications) and consequences (such as increased operating time) of subcutaneous closure compared with no subcutaneous closure in participants undergoing non-caesarean surgical procedures.

SEARCH METHODS

In August 2013 we searched the following databases: Cochrane Wounds Group Specialised Register (searched 29 August, 2013); The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2013, Issue 7); Ovid MEDLINE (1946 to August Week 3 2013); Ovid MEDLINE (In-Process & Other Non-Indexed Citations August 28, 2013); Ovid EMBASE (1974 to 2013 Week 34); and EBSCO CINAHL (1982 to 23 August 2013). We did not restrict studies with respect to language, date of publication or study setting.

SELECTION CRITERIA

We included only randomised controlled trials (RCTs) comparing subcutaneous closure with no subcutaneous closure irrespective of the nature of the suture material(s) or whether continuous or interrupted sutures were used. We included all RCTs in the analysis, regardless of language, publication status, publication year, or sample size.

DATA COLLECTION AND ANALYSIS

Two review authors independently identified the trials and extracted data. We calculated the risk ratio (RR) with 95% confidence intervals (CI) for comparing binary (dichotomous) outcomes between the groups and calculated the mean difference (MD) with 95% CI for continuous outcomes. We performed meta-analysis using the fixed-effect model and random-effects model. We performed intention-to-treat analysis whenever possible.

MAIN RESULTS

Eight RCTs met the inclusion criteria. Six of the trials provided data for this review and all of these were at high risk of bias. Six trials randomised a total of 815 participants to subcutaneous closure (410 participants) or no subcutaneous closure (405 participants). Overall, 7.7% of participants (63/815 of participants) developed superficial surgical site infections and there was no clear evidence of a difference between the two intervention groups (RR 0.84; 95% CI 0.53 to 1.33; very low quality evidence). Only two trials reported superficial wound dehiscence, with 7.9% (17/215) of participants developing the problem. It is not clear whether the lack of reporting of this outcome in other trials was because it did not occur, or was not measured. There was no clear evidence of a between-group difference in the proportion of participants who developed superficial wound dehiscence in the trials that reported this outcome (RR 0.56; 95% CI 0.22 to 1.41; very low quality evidence). Only one trial reported deep wound dehiscence, which occurred in 8.3% (5/60) of participants. There was no clear evidence of a difference in the proportion of participants who developed deep wound dehiscence between the two groups (RR 0.25; 95% CI 0.03 to 2.11; very low quality evidence). Three trials reported the length of hospital stay and found no significant difference between groups (MD 0.10 days; 95% CI -0.45 to 0.64; very low quality evidence). We do not know whether this review reveals a lack of effect or lack of evidence of effect. The confidence intervals for these outcomes were wide, and significant benefits or harms from subcutaneous closure cannot be ruled out. In addition, none of the trials assessed the impact of subcutaneous closure on quality of life, long-term patient outcomes (the follow-up period in the trials varied between one week and two months after surgery) or financial implications to the healthcare provider.

AUTHORS' CONCLUSIONS

There is currently evidence of very low quality which is insufficient to support or refute subcutaneous closure after non-caesarean operations. The use of subcutaneous closure has the potential to affect patient outcomes and utilisation of healthcare resources. Further well-designed trials at low risk of bias are necessary.

Blepharoplastic: essential review

In the periorbital the major aging changes are a drooping of the brow (brow ptosis), excessive accumulation of skin in the upper lid (dermatochalasis), and a prolapse of orbital fat, in the upper and lower lids caused by weakening of the septum and orbital connective tissues. The specific anatomical abnormalities of each individual patients should be identified and the relationship between each other should be identified in order to determine a correct surgical plan. In this review we will analyze different surgical techniques.

Single treatment of grades II and III cellulite using a minimally invasive 1,440-nm pulsed Nd:YAG laser and side-firing fiber: an institutional review board-approved study with a 24-month follow-up period

BACKGROUND

Cellulite represents one of the common topographic alterations to the skin surface and one of the structural changes to the subdermal fat and septal band of the posterolateral thighs. Currently, no treatment exists to address this entity with a multifactorial genesis that produces long-term beneficial outcomes. This clinical study evaluated the safety and efficacy of the 1,440-nm laser and the duration of the clinical benefits during 2 years.

METHODS

Initially, 25 healthy women with thigh cellulite were enrolled in this prospective institutional review board (IRB)-approved study. For grade II cellulite, the laser fiber delivered up to 1,000 J of energy to the undersurface of the entire involved skin. For grade III cellulite, the laser fiber distributed 1,300 to 1,500 J of energy to melt the subdermal fat, subcise the taut septal bands, and heat the reticular dermis. Baseline and posttreatment analyses included standardized high-resolution photography, skin elasticity measurements, ultrasound scanning for dermal thickness, histology, investigator global assessment scores, and recording of adverse events.

RESULTS

Of the 24 subjects who underwent treatment, only 20 were available for the 6-month follow-up assessment. Objective measurements at 2 years demonstrated an increase over the baseline mean skin elasticity (34 %) and mean dermal thickness (11 %), as well as an increase in the average percentage of dermal thickening determined by ultrasound imaging. Independent investigator global assessments were rated higher for grade II subjects than for grade III subjects throughout the 2-year follow-up period. Mild adverse events disappeared by the third month.

CONCLUSIONS

This IRB-conducted clinical trial, as part of a multicenter study for Food and Drug Administration approval, demonstrated the safety and efficacy of a single minimally invasive treatment for grades II and III thigh cellulite during a 2-year follow-up period.

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 .

Ultrasonic incisions produce less inflammatory mediator response during early healing than electrosurgical incisions

As the use of laparoscopic surgery has become more widespread in recent years, the need has increased for minimally-invasive surgical devices that effectively cut and coagulate tissue with reduced tissue trauma. Although electrosurgery (ES) has been used for many generations, newly-developed ultrasonic devices (HARMONIC® Blade, HB) have been shown at a macroscopic level to offer better coagulation with less thermally-induced tissue damage. We sought to understand the differences between ES and HB at a microscopic level by comparing mRNA transcript and protein responses at the 3-day timepoint to incisions made by the devices in subcutaneous fat tissue in a porcine model. Samples were also assessed via histological examination. ES-incised tissue had more than twice as many differentially-expressed genes as HB (2,548 vs 1,264 respectively), and more differentially-expressed proteins (508 vs 432) compared to control (untreated) tissue. Evaluation of molecular functions using Gene Ontology showed that gene expression changes for the energized devices reflected the start of wound healing, including immune response and inflammation, while protein expression showed a slightly earlier stage, with some remnants of hemostasis. For both transcripts and proteins, ES exhibited a greater response than HB, especially in inflammatory mediators. These findings were in qualitative agreement with histological results. This study has shown that transcriptomics and proteomics can monitor the wound healing response following surgery and can differentiate between surgical devices. In agreement with clinical observations, electrosurgery was shown to incur a greater inflammatory immune response than an ultrasonic device during initial iatrogenic wound healing.

Broad overview of a clinical and commercial experience with CoolSculpting

BACKGROUND

Cryolipolysis has been shown to be a safe and effective noninvasive procedure for the reduction of localized subcutaneous fat.

OBJECTIVES

The authors examine the safety, efficacy, and procedural growth of cryolipolysis (via the CoolSculpting device; Zeltiq, Pleasanton, California) in a single plastic surgery practice.

METHODS

A retrospective chart review was conducted for 528 consecutive patients who underwent cryolipolysis treatment from January 2010 to December 2012. The number of patients, the number of treatment cycles, the average number of cycles per patient, all treatment areas, and all procedural complications were recorded and analyzed. Overall practice growth with the device was also analyzed.

RESULTS

Over the study period, 1785 anatomic sites were treated with 2729 cycles, primarily in the lower abdomen (28%, n = 490 cycles), upper abdomen (11%, n = 189), left flank (19%, n = 333), right flank (19%, n = 333), inner thigh (6%, n = 111), outer thigh (5%, n = 87), and back (6%, n = 99). The age distribution for men and women was similar (46.6 ± 12.8 years for women and 46.5 ± 12.3 years for men; overall range, 18-79 years). Only 3 cases of mild or moderate pain/neuralgia were reported and resolved in 4 or fewer days. No adverse events were reported. Procedure volume showed consistent growth, with treatment cycles increasing by 823% by 2012.

CONCLUSIONS

Based on the results in this single plastic surgery practice, cryolipolysis is a safe and effective nonsurgical body contouring method associated with high patient satisfaction that can generate steady, significant business growth.