Clinical Implications of Fat Grafting in the Posterior Calf: A Dynamic Cadaver-based Study.

BACKGROUND: Intramuscular fat grafting in extremity muscles, especially the gastrocnemius, has become increasingly popular. However, while safety in truncal muscle fat grafting has been well-studied, research on extremity muscles is lacking. OBJECTIVES: This study aims to explore the anatomy of the gastrocnemius muscle and adjacent structures concerning intramuscular and subcutaneous recipient sites. Additionally, it seeks to analyze pressure/volume relationships and fat migration patterns during posterior calf grafting. METHODS: Eight cadaveric lower extremities were examined. A prosection was performed to better understand the vascular complex as it exists about the gastrocnemius. Ultrasound-guided fat injections were then performed into both the subcutaneous and intramuscular layers; dynamic pressures were measured with a manometer. Lastly, dyed-injectate was injected subcutaneously to better elucidate subcutaneous anatomy. RESULTS: Anatomic prosection demonstrated the proximity of the gastrocnemius muscle to the popliteal venous system which arborized (>1mm) intramuscularly. In the three specimens that underwent intramuscular fat grafting, the peak intramuscular pressures plateaued at 21mmHg (19.5-23mmHg); there was no observed extra-fascial migration of the injectate. With subcutaneous injectate into one specimen, pressures in the subcutaneous space increased (125mmHg) with additional injectate (240cc) while pressures in the intramuscular space remained relatively constant (4mmHg). CONCLUSIONS: Intramuscular gastrocnemius fat grafting should be done with caution: its proximity to critical veins and sustained increased intramuscular pressures following grafting increases risk of embolus and thrombosis, respectively. Subcutaneous injection may be safer in that increased pressures are not communicated to deep structures. Lastly, we present a novel description of posterior calf subcutaneous compartments that may better allow surgeons to direct and predict subcutaneous injectate.

Aesthetic Rib Cage Remodeling with Osteosynthesis: Body Structural High-Definition Reshaping (RIBOSS).

BACKGROUND: Rib cage remodeling has shown promising aesthetic results as a new technique for body contouring yet risks and complications associated with the procedure have not been well established. The aim of our study is to assess safety, efficacy and patient satisfaction rate associated with a new surgical technique for waistline definition. METHODS: We looked into our records for patients who underwent waist narrowing through a new rib remodeling procedure with osteosynthesis of the 11th and 12th ribs; from October 2022 to June 2023. Follow up was carried out at 1 and 3 months after surgery. Outcomes were evaluated based on waist and hip measures, body images, pain and a patient satisfaction survey. RESULTS: A total of 27 consecutive patients were included in the analysis. Our technique resulted in a significant reduction in waist circumference, as evidenced by a decrease of 12.1 cm and 13.0 cm at the first and third month respectively (p<0.005). A reduction of hip circumference of 6.2 cm and 8.7 cm was also reported. A high patient satisfaction rate was reported. Postoperative complications included only one case of wound dehiscence and one case of mild pain. Pain levels were also reduced, with a mean pain score of 2.4 at week 1 and 0.26 at month 1. CONCLUSION: Rib osteotomy with osteosynthesis emerges as an innovative, safe, and reliable approach for waist narrowing. Our results suggest that this technique can be applied to a wide variety of patients and presents might entail significant advantages compared to those from other techniques. TYPE OF STUDY: Retrospective cohort. Level of Evidence: III.

Ultrasonic- and Ultrasound-assisted Improvement of Silhouette of the Torso: Bone Structure High-definition Remodeling (Part I).

Background: High-definition liposculpture allowed plastic surgeons to achieve better aesthetic results by carving the underlying muscles and contours in a new way. Several authors have improved the original technique by adding other procedures and new technologies. We designed a new improvement by incorporating bone transformation surgery to overcome the lack of silhouette at the waist and, as a result, optimize the breast-waist-hip ratios. Methods: We carried out a prospective multicenter study, with five different surgeons performing the same rib remodeling technique for waist definition. We used an ultrasonic piece for costal corticotomy and real-time ultrasound imaging to perform green-stick fractures over the last two or three floating ribs. Ours is a new technique based on the prior one described by Kudzaev. Results: We reported 131 consecutive patients who were enrolled in this study. Waistline diameter decreased an average of 8 cm after surgery (P < 0.05). Most patients were women (n = 125, 95.4%). No major complications were reported. Most common complication was prolonged pain, with only three cases of contour asymmetry, all of which were attributable to noncompliance of constantly wearing the corset + compressive garments. Patients reported a high satisfaction rate and fast recovery (Body-QoL survey). Conclusions: Ultrasonic- and ultrasound- assisted indentation surgery of the thorax is a safe and reliable technique for waistline definition, with a high satisfaction rate, almost-invisible scars, and minimal risk for complications. Incorporation of high-definition liposculpture to rib remodeling opens up a new horizon for bone structure modification surgery (S-high-definition remodeling) that can be safely performed for patients who seek better aesthetic outcomes in body contouring.

Effectiveness of Tranexamic Acid in the Postoperative Period in Body Contour Surgery: Randomized Clinical Trial.

Background: Tranexamic acid (TXA) is used to reduce bleeding in body contouring procedures; however, there are no studies that show the effectiveness of TXA when it is also used in the immediate postoperative period. Methods: A controlled, randomized, parallel, and open-label clinical trial was carried out in adult patients undergoing liposculpture and/or abdominoplasty. A control group administering presurgical TXA and a study group with presurgical and postsurgical TXA were formed. The decrease in hemoglobin and the incidence of blood transfusions between both groups were compared as well as the possible adverse effects of TXA. Results: Four hundred twenty-seven subjects were included, 208 (48.7%) in the control group and 219 (51.3%) in the study group. The median age was 34 years (interquartile range 28-42). Median postoperative hemoglobin levels at 24 hours were similar in both groups (study 11.3 g/dL versus control 11.1 g/dL, P = 0.07); however, at 72 hours, postoperative hemoglobin was higher in the study group versus control (10.8 versus 10.0 g/dL, P ≤ 0.001). The incidence of transfusions at 72 hours was 1.8% in the study group and 8.6% in the control group, for a risk ratio of 0.21 (95% confidence interval 0.07-0.61). There were no adverse or thromboembolic events. Conclusion: TXA proved to be more effective in reducing intra- and postsurgical bleeding and the need for transfusions, when used preoperatively and continued for 48 hours after surgery, than when used only preoperatively, without reporting adverse or thromboembolic effects.

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.

Adipose Tissue Transfer in Dynamic Definition Liposculpture Part II. The Lower Limb: Gastrocnemius, Vastus Medialis, Vastus Lateralis, and Rectus Femoris Muscles.

One big challenge of body contouring surgery is the liposculpture of the lower limbs, probably because of the imperative symmetry and the risk of contour irregularities. We are reporting our experience in fat grafting of the thighs and calves for men and women undergoing dynamic definition liposculpture. Methods: We did cadaveric dissections of the vastus lateralis, vastus medialis, rectus femoris, and gastrocnemius muscles and identified each of their primary pedicles. We also performed fat grafting of these muscles in the contralateral virgin cadaveric specimen. We searched our records for patients who underwent fat grafting of the lower extremity in addition to dynamic definition liposculpture, from January 2016 to May 2022 at a single center in Bogotá, Colombia. Results: Seventy-three consecutive patients met the inclusion criteria (26 men and 47 women). We grafted 102 gastrocnemius muscles, 86 vastus medialis muscles, 98 vastus lateralis muscles, and 22 rectus femoris muscles. Mean age was 34 and 41 years for men and women, respectively. Range of the fat graft volume was 50-200 mL. No complications were recorded related to fat grafting. Almost all patients were satisfied with the procedure (89%). Follow-up period ranged from 2 to 36 months. Conclusions: Fat grafting of the lower limb muscles should be considered an alternative operative technique to enhance volume and athletic appearance of this body segment. Based on cadaveric dissections and clinical evidence, our technique is considered reliable and reproducible with remarkable outcomes and a very low complication rate.

Adipose Tissue Transfer in Dynamic Definition Liposculpture-PART I. Back: Latissimus Dorsi and Trapezius Muscles.

The aesthetics for the male posterior torso remain a topic not fully studied in body contouring surgery, neither the lipoinjection of its muscles have been considered before. As a result, we carried out a retrospective cohort study including patients who underwent fat grafting of either the trapezius or the latissimus dorsi muscles as part of dynamic definition liposculpture (HD2). Methods: We performed cadaveric dissections to support the fat grafting technique for both the trapezius and the latissimus dorsi muscles. We also searched our records for patients who underwent fat grafting of these muscles in addition to HD2 from January 2016 to November 2021 at a single center in Bogotá, Colombia. Results: Thirty-five consecutive patients met the inclusion criteria. In total, 22 (63%) and 7 (20%) of 35 underwent fat grafting at the trapezius and the latissimus dorsi muscles alone, respectively, and 6 out of 35 (17%) of both. Mean age is 39 years (range = 22-63). All patients were men. No complications were recorded related to fat grafting. Almost all patients were satisfied with the procedure (97%). Follow-up period ranged from 2 to 48 months. Conclusions: Liposuction might not be enough to achieve the ideal V-shape of the men's back in some cases; hence, fat grafting of the power muscles becomes the best option. Recognition of the main neurovascular pedicle, proper preoperative markings, and a correct surgical technique ensure both the safety and the reproducibility of the technique.

High-Definition Liposculpture 18-Year Evolution: Patient Safety and Aesthetic Outcomes.

BACKGROUND: High-definition liposculpture (HDL) emerged as an innovative surgical technique that allowed plastic surgeons to achieve improved aesthetic results with a natural and athletic appearance using minimal incisions and with imperceptible scarring. Its targets are high aesthetic standards and patient safety. PURPOSE: This article summarizes the evolution of HDL by explaining upgrades to the original technique and comparing the complication rates among them. METHODS: The authors retrospectively reviewed records from four private medical centers (Evolution Medical Center, Santa Barbara Medical Center, and Dhara Clinic in Bogota and FOSCAL in Bucaramanga, Colombia) of patients who underwent HDL performed by the senior author (A.E.H) over an 18-year period (2002 through 2019). Patients were classified into three groups: suction-assisted lipoplasty (period 1), vibration amplification of sound energy at resonance-assisted HDL (period 2), and dynamic definition liposculpture (period 3). RESULTS: The authors established a cohort of 5052 patients (4300 women and 752 men): 923 in period 1, 1272 in period 2, and 2857 in period 3. The most common complications included seroma, bruising, hematoma, acute anemia, hyperchromia, wrinkled skin, wound dehiscence, and local infections. CONCLUSIONS: HDL and dynamic-definition liposculpture procedures are safe and reproducible techniques to achieve an athletic and natural body contour. Complication rates, especially those related to bleeding, decreased as the technique evolved. These procedures are aimed toward patient safety to provide higher aesthetic outcomes using extensive medical, anatomic, artistic, and technological knowledge. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

H-Wing Neoumbilicoplasty: A New Technique for Advanced Abdominoplasty and Umbilical Zones by Gender.

BACKGROUND: Multiple umbilicoplasty techniques have been described, even more after the advent of full tummy tuck procedures and the neoumbilicoplasty (X-shaped incision) described by the authors in a previous report. The authors decided to upgrade the technique (H-wing incision) because the former procedure is associated with relatively common complications. The authors report a case series of an upgraded technique for neoumbilicoplasty (H-wing technique), comparing its outcomes with their previous standard procedure (X-shaped incision). METHODS: The authors reviewed their records for neoumbilicoplasties performed between January of 2014 and December of 2019. The authors divided the procedures according to the surgical technique and performed a detailed analysis regarding timing, complications, uses, and quality standards according to patients' opinion through a nonstandardized survey. RESULTS: A total of 407 procedures were distributed between two techniques: X-shaped incision, 179 procedures; and H-wing technique, 228 procedures. The former was performed from January of 2014 to October of 2016 and the latter from September of 2016 to December of 2019. High satisfaction indexes were found for both procedures; however, fewer complications were seen in the H-wing group. The X-shaped incision is thought to generate a greater force of tension over the flaps compared to that from the H-wing technique, which consequently increased the risk of flap necrosis and flattening. CONCLUSIONS: The H-wing technique for neoumbilicoplasty decreases the risk of postoperative complications such as dehiscence, skin necrosis, and navel flattening, and maintains high aesthetic standards and satisfaction indexes among patients. The technique can be used after either lipoabdominoplasty or secondary procedures.

Decision-Making Algorithm for Advanced Excisional Body Contouring: Dynamic Definition Solutions for Skin Laxity.

BACKGROUND: Excisional body contour surgery is the cornerstone treatment for skin laxity. Decision-making can be challenging when selecting the procedure. Dynamic definition liposculpture allows the surgeon to carve the underlying anatomy and provide more natural results, in which umbilical shape and position play a crucial role. The authors describe their experience using a decision-making algorithm as a tool to ease surgical planning for advanced excisional body contouring. METHODS: Following the algorithm designed by the senior author regarding excisional body contouring procedures, the authors searched their database for patients who were classified according to skin laxity and navel location to undergo one of the following procedures: mixed technologies plus umbilical mobilization, mixed technologies plus sliding mini-abdominoplasty, mini-tummy tuck with muscular plication, full abdominoplasty, reverse bridge abdominoplasty, or reverse full abdominoplasty. RESULTS: A total of 563 women were consecutively operated on from February of 2014 to January of 2020. The six-procedure model algorithm helped the authors achieve very good results with low complication rates in patients with some grade of abdominal skin laxity. Most complications were reported as minor (9.6 percent). Major complications (3.9 percent) included three localized infections, four abnormal skin retractions, two cases of skin flap necrosis, and 13 cases of postoperative anemia. CONCLUSIONS: This algorithm helped the authors choose the best excisional technique based on patients' anatomical features by following skin geometry to enhance aesthetic outcomes. Further studies are needed to support the algorithm validation and aesthetic outcomes. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Use of Tranexamic Acid in Liposculpture: A Double-Blind, Multicenter, Randomized Clinical Trial.

BACKGROUND: Intraoperative hemostasis should be performed with great caution because bleeding is a huge enemy of patient safety during surgery. Tranexamic acid is a lysine synthetic derivate that inhibits fibrinolysis and diminishes the bleeding by blocking the five lysine-binding sites for plasminogen. The authors compare the efficacy of tranexamic acid versus placebo as a hemostatic agent in liposculpture procedures. METHODS: The authors conducted a multicenter, double-blind, randomized, controlled clinical trial in patients who were scheduled for liposculpture in three plastic surgery centers (Colombia and Mexico) between January of 2019 and February of 2020. One hundred forty-one patients were randomly assigned into three groups: intravenous (1 g of tranexamic acid), subcutaneous (1 g of tranexamic acid), and placebo (normal saline). Forty-seven patients were assigned to each group. There were 30 male patients and 111 female patients. The main outcome was to evaluate the amount of postoperative bleeding between groups. The primary outcome was measured by the hemoglobin point loss at day 1 (preoperative hemoglobin minus hemoglobin at day 1 postoperatively) and the hemoglobin (in milligrams per deciliter) point loss at day 5 (preoperative hemoglobin minus hemoglobin at day 5 postoperatively). RESULTS: The authors found the intravenous intervention group to have a greater hemoglobin level than the other two groups on both the first postoperative day ( p = 0.0001) and the fifth postoperative day ( p = 0.001). There were no statistical differences in hemoglobin values between the placebo and the subcutaneous intervention groups. CONCLUSION: Intravenous tranexamic acid is a good therapeutic choice to implement on liposculpture procedures to decrease postoperative bleeding. CLINICAL RELEVANCE STATEMENT: The preoperative use of intravenous tranexamic acid not only decreases the bleeding rate after liposuction procedures, but also allows greater lipoaspirate volumes when performing high-definition liposculpture. Further studies are required to support the effectiveness of tranexamic acid within the infiltration solution. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, I.

TULUA Male High-Definition Abdominoplasty.

BACKGROUND: Abdominoplasty is a surgical technique for body contouring that has been shown to improve the patient's quality of life. It has become more common among male patients, so clear differences between procedures for men and women have to be stated. The authors present their experience with high-definition lipoabdominoplasty with transverse plication in men. METHODS: Records of male patients undergoing transverse plication full abdominoplasty in addition to high-definition liposculpture were analyzed. A total of 24 consecutive cases were found between January of 2017 and June of 2019. Patient ages ranged from 24 to 60 years. Patients aged 18 years or younger were excluded. Body mass index ranged from 25 to 33 kg/m2. Photographic records were taken before and during follow-up at 2 days and 1, 3, 6, and 12 months after surgery. RESULTS: Male TULUA (transverse plication, no undermining, full liposuction, neoumbilicoplasty, and low transverse abdominal scar) with high-definition lipoabdominoplasty was successfully achieved in 24 cases. No major complications were reported. Six minor complications were reported (25 percent). Rectus abdominis diastases are less common in men compared to women, as pregnancy is the most determining factor in its development. Fat distribution is also a key difference when performing lipoabdominoplasty for the male or the female patient. The authors recommend a transverse plication of the abdominal wall, instead of a vertical one, as flap viability is preserved and enhanced muscular definition can be accomplished. CONCLUSIONS: Combining transverse plication with high-definition lipoabdominoplasty (transverse plication, no undermining, full liposuction, neoumbilicoplasty, and low transverse abdominal scar plus high-definition lipoabdominoplasty) is a safe and reproducible technique for the male patient. It offers higher aesthetic results in line with modern beauty ideals. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Safety Comparison of Abdominoplasty and Brazilian Butt Lift: What the Literature Tells Us.

BACKGROUND: Although abdominoplasty is a mainstay of the plastic surgeon, the safety of the Brazilian butt lift (BBL) has been questioned, effectively being prohibited in some countries. The central rationale for the safety concern over the BBL stems from a publication stating a mortality rate of one in 3000. The question remains: What is the real safety of these procedures? METHODS: Focusing on mortality, literature searches were performed for BBL and for abdominoplasty. The 2017 Aesthetic Surgery Education and Research Foundation survey data and publication were examined and analyzed. Additional data from the American Association for Accreditation of Ambulatory Surgical Facilities were obtained independently. RESULTS: Abdominoplasty and BBL appear to have similar safety based on mortality; however, the nature of their mortalities is different. Although most abdominoplasty deaths are secondary to deep venous thrombosis/pulmonary embolism-inherent circulatory thrombotic abnormality-BBL mortality is associated with iatrogenic pulmonary fat embolism. BBL mortality rates from more recent surveys on BBL safety demonstrate a mortality of one in 15,000. CONCLUSIONS: Although deep venous thrombosis/pulmonary embolism will always remain an abdominoplasty risk, intraoperative BBL pulmonary fat embolism has the potential to be reduced dramatically with a better understanding of dynamic anatomy, surgical instrumentation, and technique. The authors are now presented with a better lens with which to view a more accurate safety profile of BBL surgery, including its place among other commonly performed aesthetic procedures.

The 100 Most-Cited Articles in Liposuction: A Bibliometric Analysis.

BACKGROUND: Liposuction is one of the most common cosmetic surgical procedures performed worldwide. Despite previous citation analyses in plastic surgery, the most-cited works in liposuction have not yet been qualitatively or quantitatively appraised. We hypothesized that use of validated outcome measures and levels of evidence would be low among these articles. Thus, we performed a bibliometric analysis aiming to comprehensively review the most-cited liposuction literature, evaluating characteristics and quality of the top 100 articles. METHODS: The 100 most-cited articles in liposuction were identified on Web of Science, across all available journals and years (1950-2020). Study details, including the citation count, main subject, and outcome measures, were extracted from each article by 2 independent reviewers. The level of evidence of each study was also assessed. RESULTS: The 100 most-cited articles in liposuction were cited by a total of 4809 articles. Citations per article ranged from 602 to 45 (mean, 92). Most articles were level of evidence 4 (n = 33) or 5 (n = 35), representative of the large number of case series, expert-opinion articles, and narrative reviews. Ten articles achieved level of evidence 3, 22 articles achieved level of evidence 2, and none reached level 1. The main subject was operative technique in 63 articles, followed by outcomes in 32 articles. Five articles assessed the metabolic effects of liposuction. Only 1 article used a validated objective cosmetic outcome measure, and none used validated patient-reported outcome measures. CONCLUSIONS: This analysis provides an overview of the top cited liposuction literature. Overall, level of evidence was low, and no articles achieved the highest level of evidence. Improving the quality of literature requires prioritization of better-designed studies and incorporation of validated outcome measures, which will increase patient satisfaction and ensure provision of excellent, reproducible clinical care.

Gynecomastia Treatment through Open Resection and Pectoral High-Definition Liposculpture.

BACKGROUND: Male chest definition surgery and patients complaining of breast tissue overgrowth have been increasing in recent decades. After the authors' first report of pectoral etching in 2012, patients and surgeons became more aware about gynecomastia resection when performing pectoral enhancement. The authors present their experience with pectoral high-definition liposculpture in addition to inverted-omega incision resection for gynecomastia. METHODS: The authors reviewed their records on pectoral high-definition lipo sculpture between January of 2005 and October of 2019 in four surgical centers in Colombia. Inclusion criteria were as follows: men diagnosed with gynecomastia and body mass index less than or equal to 32 kg/m2, adequate skin elasticity, and general good health. Photographs were taken preoperatively and 1, 3, 6, and 12 months postoperatively. Follow-up ranged from 2 months to 3 years. RESULTS: Gynecomastia resection plus high-definition liposculpture was successfully performed in 436 consecutive men (open inverted-omega incision resection, n = 132; liposuction, n = 304). Ages ranged from 18 to 66 years. Fat grafting volume ranged from 50 to 300 cc in each pectoral muscle. Minor complications (3.2 percent) included prolonged swelling, bruising, asymmetries, and residual gynecomastia. Major complications (1.6 percent) included unilateral hematoma and localized infection. No necrosis, systemic infection, or muscle paralysis was reported. A nonstandardized survey showed a very high satisfaction index. CONCLUSION: Gynecomastia treatment combining high-definition liposculpture to male breast tissue resection through a new, almost invisible incision allowed us to achieve an athletic and natural appearance of the male pectoral area with a very low rate of complications. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.