The safety and effectiveness of low-level light therapy (LLLT) with light-emitting diode (LED) bed system and a novel topical anti-cellulite gel on grades 1-2 thigh/buttock cellulite: a randomized, comparative-controlled split-thigh/buttock IRB study.

BACKGROUND: Cellulite of the upper lateral and posterior thighs and lower buttocks represents a common unwanted condition. OBJECTIVES: The author sought to comparea LLLT-LED bed therapy and a novel topical anti-cellulite gel on one thigh/buttock cellulite vs light therapy for cellulite to the opposite side. METHODS: Eight healthy female subjects were randomly treated with a LLLT-LED bed twice weekly for 20 minutes in prone/supine positions with twice daily application of a novel anti-cellulite gel to one randomized thigh/buttock. RESULTS: At the end of the 3-month trial, skin elasticity increased after combined therapy on one thigh but decreased with only LLLT-LED bed treatments on the opposite thigh. Thighs treated with active gel and LLLT-LED bed, were downgraded to a lower cellulite grade, while monotherapy did not demonstrate any change from their baseline cellulite grading. Changes in thigh circumference did not correlate with either treatments regimens.Subject and investigator questionnaire evaluations at month-3 were assessed as "satisfactory" results. There were no adverse reactions to treatments. CONCLUSIONS: The use of LLLT-LED bed therapy and an anti-cellulite gel demonstrated an efficient alternative in the treatment of cellulite-involved thighs/buttocks over similarly affected thighs/buttocks that were treated only with LLLT-LED bed therapy.

Clinical Use of Extracellular Vesicles in the Management of Male and Female Pattern Hair Loss: A Preliminary Retrospective Institutional Review Board Safety and Efficacy Study.

Background: Pattern hair loss is a common disorder in female and male patients. Objectives: To assess the safety, efficacy, and satisfaction of a single extracellular vesicle (EV) treatment over 6 months. Methods: A retrospective open-label study among 22 female and 9 male patients who demonstrated early stages of alopecia or were in remission from previous medical and surgical treatments. The amount of undiluted or diluted volumes of EV solution used was determined by the extent and degree of alopecia. Global photography, Patient Global Aesthetic Improvement Scale (PGAIS) and Investigator Global Aesthetic Improvement Scale (IGAIS) questionnaires, and trichoscan measurements were compared at baseline and 6 months in 3 response categories. Results: Frequent growth responses were observed: older aged females and younger aged males, shorter history of alopecia, earlier stages of hair loss, larger and undiluted volumes of XoFlo, previous positive responses to medical and surgical treatments, and absence or control of disease factors affecting the hair. Global photography, trichoscan for density, follicle diameter, terminal: vellus ratio, and PGAIS/IGAIS satisfaction questionnaires at baseline and 6 months were useful in assessing clinical efficacy. No significant adverse reactions were observed. Conclusions: Intradermal injections with varying doses of EVs were safe and effective among indicated alopecic female and male patients. Findings suggest that the presence of positive factors, absence of conditions known to negatively affect hair growth, and administration of larger volumes of XoFlo may have a significant influence on the use of this new cell-free therapy.

The Effects of Lower vs Higher Cell Number of Platelet-Rich Plasma (PRP) on Hair Density and Diameter in Androgenetic Alopecia (AGA): A Randomized, Double-Blinded, Placebo, Parallel-Group Half-Scalp IRB-Approved Study.

BACKGROUND: Androgenetic alopecia (AGA) is a common disorder in both males and females and may be improved by platelet-rich plasma (PRP) treatment. OBJECTIVES: The aim of this study was to compare safety, efficacy, and satisfaction following treatment with a lower or higher number of platelets over 6 months. METHODS: This was a prospective randomized, double-blinded, placebo, parallel-group, half-scalp IRB-approved study involving 8 subjects with moderate AGA. Participants received intradermal PRP injections (baseline and Month 3), according to 2 treatment protocols (high vs low platelet numbers) to the frontal and crown portions of the hemiscalp and normal saline to control sites. Phototrichoscans were recorded at baseline and at 6 months, and global photography and subject and investigator satisfaction questionnaires were obtained at baseline, 3, and 6 months. RESULTS: At the end of 6-month evaluation period, both groups demonstrated absolute increases in total hair density, follicle diameter, and terminal hair density, as well as absolute and percentage changes at the frontal and crown targeted sites compared with baseline. These improvements tended to occur more often in areas treated with higher platelet numbers than with lower numbers. Vellus hair densities did not exhibit any significant changes with either PRP dosages. The investigator and 6 of the subjects were "satisfied" with the results at 3 months and no adverse reactions were associated with the treatments. CONCLUSIONS: Intradermal injections with 2 therapeutic quantities of platelets were equally safe and efficacious for treating men and women with AGA. Higher numbers of platelets may have a greater effect than lower numbers of platelets in regard to hair density, follicle diameter, and terminal hair density but exhibited minimal effects on vellus hair densities at the 6-month evaluation point. Further studies are required to determine whether any significant advantages occur when delivering either lower or higher numbers of platelets in AGA treatments as long as therapeutic levels are administered.

The Significance of Trans-Epidermal Water Loss After Microneedling and Microneedling-Radiofrequency Procedures: Histological and IRB-Approved Safety Study.

BACKGROUND: Microneedling (MN) and microneedling-radiofrequency (MN-RF) result in skin rejuvenation and skin exposure to pathogens. OBJECTIVES: The aim was to determine histopathological changes of needle-depth injuries in preauricular skin and measure time-dependent repair of transepidermal water loss (TEWL) in subjects. METHODS: MN and MN-RF procedures were performed at 0.5- and 1.5-mm needle depths on preauricular skin strips from a facelift patient. In 10 subjects, MN and MN-RF procedures were performed at 0.5-mm needle lengths on 6 marked opposing face and body sites. MN and MN-RF at 1.5-mm needle lengths were also carried out on each subject's midface skin lateral to the nasolabial fold. TEWL measurements were recorded with a calibrated DermaLab Cortex device (Hadsund, Denmark). RESULTS: Histological examination confirmed that the penetration depths of microchannels closely approximated the 0.5- or 1.5-mm needle lengths. In addition, MN-RF exhibited zones of coagulation injury at the distal end of the channel. After MN or MN-RF at 0.5-mm needle length, TEWL values were greatest immediately after needling to scalp, midface, neck, chest, arm, and thigh sites and remained slightly higher than baseline throughout the 48-h evaluation period. TEWL measurements after MN or MN-RF at 1.5-mm needle length resulted in the highest- and longest-lasting values throughout the 2-day observation period. CONCLUSIONS: MN and MN-RF devices are novel devices that require further investigation into optimal treatment parameters and protocols, patient selection, and protection against intrusion of external pathogens and reactive cosmeceutical ingredients with barrier repair.

Review of Human Hair Follicle Biology: Dynamics of Niches and Stem Cell Regulation for Possible Therapeutic Hair Stimulation for Plastic Surgeons.

Plastic surgeons are frequently asked to manage male- and female-pattern hair loss in their practice. This article discusses the epidemiology, pathophysiology, and current management of androgenetic alopecia and emphasizes more recent knowledge of stem cell niches in hair follicles that drive hair cycling, alopecia, and its treatment. The many treatment programs available for hair loss include newer strategies that involve the usage of growth factors, platelet-rich plasma, and fat to stimulate follicle growth. Future research may clarify novel biomolecular mechanisms that target specific cells that promote hair regeneration.Level of Evidence V 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 .

A Preliminary Clinical Trial Comparing Split Treatments to the Face and Hand With Autologous Fat Grafting and Platelet-Rich Plasma (PRP): A 3D, IRB-Approved Study.

BACKGROUND: Numerous methodologies have been suggested to enhance fat graft survival, but few long-term studies are available. OBJECTIVES: The authors of this institutional review board-approved study investigated the safety and efficacy of utilizing platelet-rich plasma (PRP). METHODS: Each of 10 patients received equal volumes of syringe-harvested, centrifuged fat to opposing midfaces with a lateral submuscular aponeurotic system-plication or no face lift and hands that were combined with equal volumes of either concentrated PRP or normal saline. Comparable assessments of fat retention/baseline values by 3D Vectra Analysis, VISIA, and Cortex facial skin analyses were performed. Clinical results were judged on a visual analogue scale. RESULTS: The average percent change in mean volume assessments at the fat/PRP sites from baseline values, as profiled by 3D Vectra Analysis, demonstrated a higher, but statistically nonsignificant value over 1 year than the percent value changes at the fat/normal saline sites in the opposing face or hand. Three independent evaluators were able to assess volume restorations to the malar fat pad, naso-jugal groove, and nasolabial fold as well as to intermetacarpal hollowness with reduction of visible veins and tendons in the anterior midface and hands with both treatments. No adverse events were observed over the year-long study. Perioperative edema, erythema, bruising, and tenderness lasted up to 1 to 2 weeks at most. CONCLUSIONS: Autologous fat grafting continues to be a safe and effective adjunct in facial and hand aesthetic surgery. This study will require more patients and longer follow-up periods to determine whether PRP has a potential role to increase fat graft retention in aesthetic patients.

A Split Face Study to Determine the Significance of Adding Increased Energy and Treatment Levels at the Marionette Folds.

BACKGROUND: Microfocused ultrasound with visualization (MFU-V) has become a safe and effective means to tighten skin and subdermal structures by optimizing the amount of joule energy and treatment tissue planes for improved customization for the individual patient. To date, there have been an absence of split treatments to verify algorithms. OBJECTIVES: The aims of this institutional review board-approved investigation and clinical experience were to clarify the safety and efficacy of current treatment guidelines. METHODS: This split-face investigation quantified tissue displacement at the marionette folds after single treatments of 2 different treatment densities or number of lines and 2 vs 3 planes of treatment with matched-orientation photography, elasticity measurements, subjective assessments by patient (SGAIS), and blinded-investigator global investigation (IGIAS) analyses at baseline, 180 days post treatment (D180), and 360 days post treatment (D360). Clinical studies, utilizing these algorithms to treat regional areas of the forehead, periorbitum, face, neck, and décolleté, were analyzed by (IGIAS) assessment, pain scoring, and incidence of complications and side effects at D180 and D360. RESULTS: Post hoc analyses at D180 and D360 in pilot studies 1 and 2 demonstrated greater tissue displacements, elasticity measurement, and pain scores, supported by SGAIS and IGAIS assessment with the use of higher amounts of joule energy and treatment planes than those used on the contralateral reference marionette folds at D180 and D360. Pain scores after use of each transducer or at the end of the procedure showed variability at different regional areas with more discomfort noted with treatments at the deepest and most superficial tissue planes. There were no major adverse reactions and minimal short-termed side effects in the entire study. CONCLUSIONS: Optimization, customization, and safety were observed with the use of current MFU-V algorithms as clarified by the findings in this investigation. Further investigations with multiple sessions will be required to advance this unique noninvasive technology for tissue lifting. LEVEL OF EVIDENCE: 3.

Micro-Needling Depth Penetration, Presence of Pigment Particles, and Fluorescein-Stained Platelets: Clinical Usage for Aesthetic Concerns.

BACKGROUND: Aesthetic micro-needling (MN) has demonstrated skin permeability to cosmeceutical ingredients and platelet-rich plasma by creating reversible micro-channels in the skin. OBJECTIVES: The purposes of this study were to determine: (1) actual needle depth-penetrations by adjusting needle lengths in a disposable tip of an electric MN device; (2) time-dependent passage of pigment and platelets; and (3) safety and efficacy profiles in patients. METHODS: Excised micro-needled pre-auricular skin was used to determine actual depths of tissue penetration with six needle lengths, and the presence of massaged pigment particles (histological examination) and fluorescein-labeled platelets (confocal laser microscopy) in 1 mm depth micro-channels over an hour. Patients were treated for wrinkles and skin laxity, scars, and alopecia with cosmeceuticals and plasma-rich platelets. RESULTS: Actual needle penetrations closely matched settings up to 1.0 mm, but were less consistent at settings from 1.5 to 2.5 mm. The optimal time for massaging pigment particles and labeled platelet-rich plasma (PRP) down 1.0 mm micro-channels was between 5 to 30 minutes after MN. Patients treated in the Skin Care Center (cosmeceuticals, 0.25-1 mm depth) and Surgical Center (PRP, 0.25-2.5 mm) demonstrated statistically significant improvements (P ≤ .05) in wrinkle effacement, skin laxity, scar softening, and hair growth by Patient and Observer Satisfaction Scores at 12 months. The average hair count in a 10 mm spot size at baseline (88.3 ± 22.5) increased at the 12 month evaluation period (133.6 ± 13.8). All patients experienced minimal side-effects. CONCLUSIONS: MN alone or in combination therapy resulted in safe and effective treatments from implemented guidelines. LEVEL OF EVIDENCE: 3 Therapeutic.

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.

The Safety and Efficacy of Cell-Assisted Fat Grafting to Traditional Fat Grafting in the Anterior Mid-Face: An Indirect Assessment by 3D Imaging.

BACKGROUND: Numerous methodologies and algorithms have been suggested to enhance fat graft survival, including the usage of stromal vascular fraction (SVF) and platelet-rich plasma (PRP), but no long-term studies are available. OBJECTIVES: This single-center prospective, case-controlled study investigated the safety and efficacy of combining a modified Baker-designed lateral SMASectomy or plication face lift with simultaneous anterior mid-face grafting into site-specific compartments by (1) conventional Coleman's technique or (2) Yoshimura's cell-assisted lipografting technique. METHODS: On the voluntary principle, candidates selected one of four techniques for volumization of their mid-face: conventional fat grafting; PRP-assisted fat grafting; SVF-assisted fat grafting; and PRP/SVF- assisted fat grafting. For comparison data, comparable fat volumes, SVF volumes and nucleated cells, and PRP volumes and platelet concentrations were injected into each designated group. Indirect volume retentions were determined by standardized Vectra 3D analyses up to 1 year. RESULTS: PRP, SVF, and PRP/SVF cell supplementation of processed fat resulted in statistically significant percent mean graft retention over their baseline control at 12 months (p < 0.01). The use of either PRP or SVF alone resulted in almost equal outcomes. Combining cell populations provided no additional advantage over single cellular therapy. Complications were negligible. CONCLUSIONS: Autologous fat grafting continues to be a viable adjunct in facial aesthetic surgery. With refinements in the entire grafting process and the potential benefits of autologous cell approaches with SVF and PRP, future evidence-based controlled studies under regulatory approval may improve graft survival in a safe and effective manner. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Cryolipolysis for fat reduction and body contouring: safety and efficacy of current treatment paradigms.

BACKGROUND: Cryolipolysis is a nonsurgical technique for localized fat reduction. With the increased risk of complications from more invasive methods such as liposuction, cryolipolysis presents a promising method for nonsurgical body contouring. This study presents a systematic review of the available clinical data, with an emphasis on the efficacy, methods, safety, and complications of cryolipolysis. METHODS: To identify clinical studies that assessed outcomes of cryolipolysis, a systematic review of the MEDLINE and Cochrane databases was performed with the search algorithm cryolipolysis OR cool sculpting OR fat freezing OR lipocryolysis. RESULTS: The primary literature search returned 319 articles. After inclusion criteria were applied and additional articles were idenfied via manual review of article references, 19 studies were selected for review. Average reduction in caliper measurement ranged from 14.67 percent to 28.5 percent. Average reduction by ultrasound ranged from 10.3 percent to 25.5 percent. No significant impact on lipid levels or liver function tests after cryolipolysis treatments was noted in any study. Only mild, short-term side effects, such as erythema, swelling, and pain, were noted. Paradoxical adipose hyperplasia was described in one patient. CONCLUSIONS: Cryolipolysis is a promising procedure for nonsurgical fat reduction and body contouring and presents a compelling alternative to liposuction and other, more invasive methods. This procedure appears to be safe in the short term, with a limited side effect profile, and results in significant fat reduction when used for localized adiposities. It remains unclear whether posttreatment manual massage and multiple treatments in the same anatomic area enhance the efficacy of cryolipolysis.

Noninvasive selective cryolipolysis and reperfusion recovery for localized natural fat reduction and contouring.

BACKGROUND: Cryolipolysis is a contemporary method of reducing fat by controlled extraction of heat from adipocytes. OBJECTIVES: The authors recorded temperature profiles during a single cryolipolysis treatment/recovery cycle (with and without massage) and report on the clinical safety and efficacy of this procedure. METHODS: In the pilot study group (PSG), the abdomens of 6 patients were treated with cryolipolysis and subdermal temperatures were recorded. In the clinical treatment group (CTG), 112 patients were treated without temperature recordings and results were evaluated through matched comparison of standardized photographs, caliper measurements, ultrasound imaging, and global assessments. RESULTS: Thirty minutes into the cooling phase, subdermal temperatures of patients in the PSG declined precipitously from pretreatment levels and remained low until the end of treatment. During recovery, subdermal temperatures of the only subject who received massage returned faster and to higher levels than the temperatures of subjects who did not receive massage. Patients in the CTG who were available for follow-up measurements at 6 months (n = 85) demonstrated an average fat reduction of 21.5% by caliper measurements; 6 random patients from this group also showed an average of 19.6% fat reduction by ultrasound imaging at 6 months. Global assessments were highest for the abdomen, hip, and brassiere rolls. Minimal side effects were observed, and patients experienced no significant downtime. CONCLUSIONS: Noninvasive cryolipolysis results in a predictable and noticeable fat reduction within 6 months and does not cause skin damage. Profiling of subdermal temperatures may provide additional insights for improving clinical effectiveness and safety. LEVEL OF EVIDENCE: 3.

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 .

Tissue restructuring by energy-based surgical tools.

Energy-based noninvasive surgical tools can be used for ablative bio-stimulation (eg, collagen production) or tissue restructuring functions (eg, tightening or lifting) and are the subject of this review. The authors present the various methods and tools for noninvasive cosmetic surgery (ultrasound, radiofrequency, cryolipolysis, and lasers) and present the clinical outcomes of each. They summarize techniques and methods and their indications, physical parameters and tissue target, and consistency.

Early clinical experience with the 1440-nm wavelength internal pulsed laser in facial rejuvenation: two-year follow-up.

This article reports on the early experience with the 1440-nm wavelength, using a specially designed side-firing fiber, in a four-step approach, primarily to the lower third of the midface and neck. The author presents the clinical protocol, procedure steps, outcomes, and adverse events of use of the laser. Outcomes are described at 3 months, 6 months, and 18 months.

Clinical efficacy and safety of focused-image ultrasonography: a 2-year experience.

BACKGROUND: Focused-image ultrasonography produces controlled waves that image dermal and subdermal structures in real time, with precise thermal coagulation points in a linear pattern, for eventual nonsurgical lifting. OBJECTIVES: The authors evaluate the effectiveness of single and dual planes of ultrasound treatment by varying the directions of treatment lines, depths, and cumulative joule energies and compare the safety and efficacy of treatment with these variations. METHODS: In this prospective, 2-part study, patients were treated by single- or dual-treatment depth with differing directions of treatment lines while the number of treatment lines and amount of energy delivered to brows or marionette lines remained constant (Study 1) or with lower or higher joule energy to opposing areas while the dual depths and number of vectored lines remained constant (Study 2). Lifting was measured using the matched-orientation function of specific mirroring software. Clinical outcomes were assessed with global aesthetic improvement scales. RESULTS: Vertical vectoring of 15 treatment lines in both tissue depths produced significant lifting over the 15 horizontally-placed treatment lines in the opposing brows and marionette lines. Sites with more treatment lines and higher joule energy at dual depths resulted in significantly greater lifting (Study 2). Side effects were minimal. CONCLUSIONS: Focused-imaged ultrasound therapy to facial tissues is safe and effective when performed as described.

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

BACKGROUND: Water-assisted liposuction (WAL) is a new technique for body contouring and fat harvesting that relies on a fan-shaped jet of tumescent solution to anesthetize fatty for liposuction and grafting. As with any new technology, safety and efficacy are paramount. OBJECTIVE: The author evaluates the technique and outcomes for small-to-moderate volume liposuction cases treated with WAL in an office setting. METHODS: Forty-one consecutive patients were treated with WAL (Body-Jet; Human Med, Eclipse Ltd., Dallas, Texas) in the author's private practice for mild-to-moderate body contouring. Patients were given local anesthesia (standardized tumescent solutions) during all three phases of the surgery. During the latter two phases, irrigation of tumescent solution was accompanied simultaneously by suction aspiration. Fat harvesting was accomplished by collecting and separating the aspirated adipose tissue in a sterile container, without need for washing or centrifugation. Fat grafting by microdroplet technique was performed within two hours of collection. Fat aliquots from five randomly-selected patients were assessed with a trypan blue dye exclusion test within one hour and again six to eight hours after collection. RESULTS: A total of 37 females and four males underwent WAL in this series; average body mass index (BMI) was 25.5. Among the 41 patients, 166 areas involving twelve anatomic sites were treated. Patients were divided into two groups based on the volume of treatment: Group 1 contained 19 patients with small-volume WAL and Group 2 had 22 cases of moderate-volume WAL. All patients experienced uneventful recovery periods with minimal side effects and no significant complications. Although large volumes of tumescent solution were required during the three phases of the technique, the total volume of infiltration almost equaled the final volume of aspiration. The average infiltration-to-aspiration ratio was 1.1 to 1.0 in all cases over both groups. On the other hand, the average infiltration-to-fat ratio was 2.8 to 1.0 in Group l and 2.4 to 1.0 in Group 2. Lidocaine dosage averaged 10.5mg/kg in Group 1 and 20.0mg/kg in Group 2. Patients were monitored for at least 24 hours without adverse signs or symptoms that required fluid resuscitation, blood transfusions, or interventional treatments for lidocaine side effects or toxicity. Twenty-three patients elected to save their fat for autologous fat grafting in nine anatomical sites with thirty-nine procedures. The augmented sites were clinically assessed between three and eight months postoperatively. Trypan blue dye exclusion testing indicated that about 90% of adipocytes expelled the dye after one hour of extraction, while an estimated 10% of cells per patient were observed to be free of dye six to eight hours after removal. CONCLUSIONS: The amount of instilled tumescent fluid, lidocaine dosage, and aspiration volumes appeared to be safe, with minimal blood loss in small and moderate volume liposuction cases. The early experience with fat grafting was encouraging, but requires more sophisticated evaluation, longer follow-up, and a larger number of cases.