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

Abstract

Background

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

Objectives

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

Methods

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

Results

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

Conclusions

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

Level of Evidence: 4

Since Schrudde et al in 1972 published preliminary reports in which subcutaneous fat was removed by means of sharp lipectomy assisted by uterine curettes, lipoplasty has undergone a series of refinements.^1,2 Currently, we continue to adhere to the principles of blunt suction-assisted lipectomy (SAL) described by Arpad and Giorgio Fischer and further improved by Illouz and Fournier, who extended the application of liposuction to enable contouring of the whole body.^1,3,4 Later, as pressure garments and infiltrating solutions with local anesthetic and epinephrine were employed, the problems of bleeding and prolonged recovery were overcome while expanding liposuction to several anatomic areas with more predictable results.^5-7 In fact, it is now possible to apply superficial suction to improve the appearance of flaccid skin and to sculpt 3-dimensional shapes of muscular units by means of aesthetic lipoplasty.^8-10

According to the Plastic Surgery Procedural Statistics of 2019 from the American Society of Plastic Surgeons (ASPS), liposuction is the second most common procedure performed in the United States and the third most common cosmetic surgery in male patients. In fact, cosmetic male liposuction has shown an increase of 3% in comparison to the previous year.¹¹ Remarkably, since Mentz et al presented the technique of “abdominal etching” with the aim of enhancing the details of the anterior abdominal wall musculature through the use of differential liposuction, many techniques have being reported to provide liposuction with the aim of outlining the superficial abdominal anatomy with high definition.^12-14 Therefore, the purpose of this study was to summarize the available literature on the methods used for aesthetic high-definition lipoplasty (HDL) in male patients in terms of surgical technique and outcomes.

METHODS

Systematic Literature Search

This review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement.^15,16 A review protocol was conceived and accepted by all authors a priori. A comprehensive search was conducted by J.M.E. across PubMed MEDLINE (United States National Library of Medicine, Bethesda, MD), Web of Science (Clarivate, Philadelphia, PA), SCOPUS (Elsevier, Amsterdam, the Netherlands), and Ovid MEDLINE In-Process & Other Non-Indexed Citations through February 2021 for the following Medical Subject Headings and keywords: “male,” “men,” “suction-assisted lipectomy,” “lipoabdominoplasty,” “body contouring,” “abdominal etching,” “high-definition liposuction,” “liposculpture,” and “abdominal body shaping” (Supplemental Table 1, available online at www.aestheticsurgeryjournal.com, displays the search strategy for the different databases).

Inclusion and Exclusion Criteria

Observational cohort studies, case-control studies, and case series reporting outcomes of HDL in cis-male patients for aesthetic indications written in English were included. Studies including transgender patients or solely reporting the management of gynecomastia, or chest or limb liposculpting were excluded. Preclinical studies, survey studies, conference presentations, abstracts, and case reports were also excluded.

Selection of Articles and Data Extraction

After removal of duplicates, a double-screening process was conducted by 2 reviewers (J.M.E. and O.J.M.). First, studies were reviewed based on title and abstract and then a full-text assessment was performed. The remaining studies fulfilling the inclusion criteria were incorporated into the following phase of data extraction. All discrepancies were resolved by consensus-forming discussions between the 2 investigators. The reference list of each study was inspected manually to identify relevant studies.

Data extraction was performed independently by 2 authors (J.M.E. and O.J.M.). Data regarding the author and year, number of patients, age, BMI, preoperative markings, tumescent solution, types of cannulas, liposuction technique, lipoaspirate volume, fat-grafting technique, closure of incisions, surgical outcomes and complications, postoperative wound treatment protocol, and follow-up were extracted. Cumulative estimates of the patients’ clinical and demographic characteristics were calculated as weighted means.

Quality Assessment

Two independent reviewers used the Oxford Centre for Evidence-Based Medicine (OCEBM) protocol to appraise the level of evidence of the included studies (Supplemental Table 2, available online at www.aestheticsurgeryjournal.com).¹⁷ The Newcastle-Ottawa Scale (NOS) was deemed suitable for evaluating the methodologic quality of cohort studies (Supplemental Table 3, available online at www.aestheticsurgeryjournal.com); and the tool for evaluating the methodological quality of case reports and case series (TMQCR/CS) developed by Murad et al was applied to assess the methodologic quality of case series (Supplemental Table 4, available online at www.aestheticsurgeryjournal.com).^18,19 Disagreements were resolved through consultation with a third reviewer (K.S.V.).

RESULTS

Included Study Characteristics

The initial search provided 920 citations. After duplicates were removed, 744 articles were then screened for title and abstract. Subsequently, 77 articles were eligible for full-text review, from which 9 fulfilled the inclusion criteria and were prepared for qualitative analysis.^{1,9,10,12,20-24} Four additional studies were added manually after reviewing the reference lists and authors’ names of the included articles.^25-28 A total of 13 studies were included in this systematic review (Figure 1).^{1,9,10,12,20-28} Four studies were case series, 6 were single-arm retrospective cohort studies, 2 were single-arm prospective cohort studies, and 1 was a 2-arm prospective cohort study. An overview of the characteristics of included studies is summarized in Table 1. Overall, 1284 male patients were included; only 1 study did not specify a sample size (7.6%). The mean age was not ubiquitously reported but ranged from 18 to 71 years. The average BMI was 26.5 kg/m² (range, 18.8-38 kg/m²), reported in 5 studies (38.46%). The follow-up was reported in 11 studies (84.6%) and ranged from 2 weeks to 10 years.

Quality Assessment

The NOS and OCEBM scores are shown in Table 1. With the NOS instrument, 5 studies scored 5, 2 scored 4, 1 scored 3, and 1 scored 1 (Figure 2). Quality assessment with the TMQCR/CS resulted in 3 studies with a score of 4 and 1 scoring 3. All studies had a level of evidence of 4 according to the OCEBM protocol (100%) (Table 1).

Surgical Planning

Preoperative markings were performed exclusively in the standing position in 10 studies, whereas 2 series reported preoperative markings performed in different positions.^9,24 One study did not specify the patients’ position.²⁶ Preoperative markings and surgical planning were limited to the linea alba, linea semilunaris, the flanks, and the transverse inscriptions of the rectus muscle in 6 studies (anterior abdominal wall).^{1,12,20-22,28} Preoperative markings beyond liposculpting of the anterior and lateral abdominal wall muscles were reported in 7 studies (Table 2). In these articles, liposculpting was performed over the abdomen, the chest (n = 5),^{9,10,23,24,27} upper and lower back (n = 6),^{9,10,23-25,27} gluteus and lower extremity (n = 4),^10,23,26,27 and upper extremity (n = 6) (Table 2).^{9,10,23,25-27}

Liposculpting Concept

Abdominal Etching

Mentz et al and Niddam et al used differential lipoplasty to detail the abdominal musculature, specifically the rectus abdominis muscles, between the linea alba and the linea semilunaris, while also addressing the horizontal tendinous inscriptions.^12,22 This concept was limited to patients with a low total body fat percentage (≤15%).⁹ Ersek et al performed conventional liposuction to generate a smooth and even contour of the abdomen and flanks. Precision etching was then performed with a special semisharp beveled cannula over the tendinous inscriptions and linea alba above the umbilicus until a defatted groove was noted (Figure 3).¹

Agochukwu-Nwubah and Mentz described a “modified abdominal etching” and a “full abdominal etching” technique. Both techniques were performed to detail the abdominal musculature but the latter involved a more aggressive deep and superficial liposuction performed along the linea semilunaris and over the transverse rectus inscriptions in comparison to the former (Table 2).²⁰

HDL

Initially presented by Hoyos, HDL elevated the concept of abdominal etching to a 3-dimensional approach encompassing the impact of other muscle groups and the effect of bony structures over the superficial anatomy to integrate the entire torso, the arms, legs, and back (Figure 4).^9,23-25,27 In this approach, the concept of body contouring by sectors was abolished and liposuction was also extended to patients with a higher percentage of total body fat (>15%).⁹

Saad et al proposed a classification of 3 levels of definition based on the extent of superficial fat liposculpting, and the difference in skin height and projection between treated and untreated areas of the superficial fat layer. These classifications were as follows: mild definition (MiD), 3 to 5 mm; moderate definition (MoD), 5 to 7 mm; and high definition (HD), 7 to 9 mm.²⁷

Monarca and Rizzo reported a muscle sculpture technique that extrapolated concepts of HDL to overweight and previously obese patients. This technique also included excision of subcutaneous tissue and fat grafting selectively to muscles when increased volume was desired, giving a bodybuilder-like effect (Table 2).²⁶

Dynamic Definition

The Hoyos Dynamic Definition (HD²) technique involves the aforementioned principles of HDL. However, the dynamic component incorporates a muscular definition that follows the pattern of particular muscle movements by creating “dynamic zones” at specific anatomic landmarks, predicting the form of the muscles in motion (Figure 5). Therefore, with HD², multilayer liposuction and fat grafting were based on muscular motion and biomechanics.¹⁰ In addition, HD² takes into consideration the natural succession of the body sculpting process of muscular units and the different anatomic groups (endomorph, ectomorph and mesomorph) to choose an adequate treatment plan according to the BMX (Basic, Moderate, eXtreme) algorithm (Table 2).¹⁰

Incisions and Infiltration Solution

An overview of the incisions performed for liposculpting and the use of infiltrating solution is shown in Table 3. Four studies used tumescent solution with diluted epinephrine,^9,10,22,26 whereas 9 studies used tumescent solution diluted with local anesthetic and epinephrine. The amount of tumescent fluid injected was reported in 4 studies and ranged from 300 to 14,400 mL.^10,20,21,25 The infiltration-aspiration ratio ranged from 1:1 to 2:1, reported in 3 studies.^9,10,20 Remarkably, Hoyos and Millard reported a detailed infiltration in areas with skin laxity and areas that were treated more superficially (Table 3).⁹

Surgical Technique and Technology

VASER-Assisted HDL

Hoyos et al reported an initial stage of fat emulsification. After the wetting solution was infiltrated, the superficial subcutaneous fat was treated in VASER (vibration amplification of sound energy at resonance) mode with a 2.9- or 3.7-mm, 3- or 2-grooved probe using an amplitude of 80% (Solta Medical, Bothell, WA).^9,10 Energy was augmented to 90% or an alternative probe was selected if unwarranted resistance was experienced. Then, continuous mode was used to emulsify the deeper fat.¹⁰ The duration of VASER treatment was 60 to 90 seconds per 100 mL of infiltration.¹⁰ Taha et al reported emulsifying fat with VASER at 70% in pulsed mode immediately after infiltration of the wetting solution (Table 4).²⁴

As described by Hoyos et al, once emulsification was finished, debulking was accomplished in the deep fat layer with 3.7- or 4.6-mm cannulas and then the superficial plane was treated with a 3.0-mm cannula (Sound Surgical Technologies, Louisville, CO).^9,10 Controlled irregularities were crafted over the preoperative markings to sculpt the muscle anatomy. HDL was accomplished by means of small cannulas, removing almost all of the fat in the subdermal layer to define muscle groups.¹⁰ Finally, Hoyos and Millard also reported a transitioning phase accomplished by debulking some of the remaining fat over muscles, while smoothing the surface overlying the creases at the mid-lamellar layer with 3.7- or 4.6-mm cannulas (Table 4).⁹

Power-Assisted Liposculpture

Boeni performed all-layer reciprocating power-assisted liposuction (PAL) (MicroAire Surgical Instruments, Charlottesville, VA) with straight and bent 4-mm flared Mercedes cannulas, starting from deep to superficial, to subdermal liposuction.²⁵ Agochukwu-Nwubah and Mentz initially performed “cross-tunneling” over all areas, and then performed both superficial and deep PAL with 4- and/or 5-mm basket cannulas (MicroAire).²⁰ Husain et al performed PAL of the deep fat layer over the abdomen and flanks with a Mercedes cannula no. 5 (MicroAire); and then, with a blunt-tip cannula, superficially sculpted the linea alba, semilunaris, and iliac crest lines, placing the cannula superficially next to the dermis and limiting the cannula passes to a maximum of 10.²¹ Steinbrech and Sinno also reported the use of PAL or standard traditional SAL.²⁸

Saad et al initially used the vibratory energy of PAL (MicroAire) without suction power to maximize the interaction between the tumescent fluid components and the fat tissue by continuously passing the cannula while no suctioning was performed. Then, superficial and deep fat harvesting was done with 5-mm (straight and bent) PAL HD cannulas (MicroAire). Superficial fat liposculpting consisted of a detailed liposuction over the superficial fat layer to enhance the underlying musculoskeletal structures.^23,27 Fat equalization (vibration without suction) was reported by Saad et al and Boeni after HDL to ensure smooth blending of the skin in the infraumbilical areas (Table 4).^23,25,27

Conventional Liposuction

Mentz et al commenced with superficial liposuction in the marked areas with a 2- or 3-mm flat Becker-style cannula until the desired groove was created.¹² Deep liposuction with a small MicroAire Mercedes cannula (1.5-2.5 mm) was then performed, leaving a thicker fat pad in the islands where muscular enhancement was required.¹²

Niddam et al used conventional contouring liposuction before abdominal etching when needed with a 4-mm cannula. Abdominal etching was subsequently carried out with a 4-mm 3-hole cannula along the drawings, mostly in the superficial planes but also in the deep plane.²² Monarca and Rizzo reported a similar technique to that of Niddam et al. However, they added a final step with residual adipose tissue homogenization by cannula which avoided irregularities over the treated areas (Table 4).²⁶

Fat Grafting

Nine articles reported the use of fat grafting as an adjunct to liposuction to improve outcomes of aesthetic lipoplasty.^{9,10,21,23,25-28} Monarca and Rizzo described fat grafting in the lower and upper extremities where greater projection was required to achieve a more athletic appearance.²⁶ Steinbrech and Sinno reported selective fat grafting to the rectus muscle and serratus anterior in an attempt to enhance the muscular contour.²⁸ Husain et al delivered fat to the deltoids and biceps.²¹ Hoyos et al described a multilayered fat-grafting technique in which small amounts of fat were delivered into the subcutaneous and intramuscular planes as the cannula moved in retrograde manner over the deltoids and pectoralis.¹⁰ In comparison to Hoyos et al, Saad et al performed fat grafting solely in the subcutaneous pectoral area, similar to Boeni.²⁷ In the gluteal area fat was solely grafted in the subcutaneous layer (Table 5).¹⁰

Wound Closure and Drains

Ersek and Salisbury, Mentz et al, and Saad et al and closed the puncture sites with 5-0 nonabsorbable or absorbable sutures.^1,12,27 Hoyos et al reported the use of open drains in the inguinal area, and also stated that some puncture sites were left open for lymphatic drainage in slope points. The rest were closed with inverted deep dermal sutures.¹⁰ Taha et al inserted drains in the inguinal region and left some incisions open to drain.²⁴ In 4 studies incisions were left open without additional drains (Table 5).^20,21,25,28

Postoperative Protocol

The majority of studies used abdominal compression garments for 2 to 6 weeks and adhesive foam strips over the superficially sculpted regions for 2 to 7 days. Niddam et al reported the use of 4-mm custom plastic rods positioned along the superficial liposculpted areas for 10 days.²² Postoperative lymphatic drainage and massage therapy started during the first postoperative week was reported in 5 studies.^{9,24,25,27,29} Exercise was allowed on postoperative days 5 or 14; ^12,20 however, heavy exercise was delayed until 4 weeks postoperatively.²¹ Boeni reported the administration of vitamin C (1000 mg) per os to limit methemoglobinemia caused by local anesthetics (Table 6).²⁵

Outcomes

Overall satisfaction ranged from 84% to 100%. Mentz et al reported a satisfaction of 100%, and results were above or at preoperative expectations in 87.5%.¹² Husain et al reported a 95% satisfaction rate and most patients said that would have the procedure performed again.²¹ Saad et al reported an average satisfaction score of 9.2/10 at 1.5 months postoperatively, which increased to 9.8/10 over a period of 6 months.²³ Niddam et al reported a satisfaction above 95%, whereas Hoyos et al reported a satisfaction index of 92%, considering “above expectations” and “good” as optimum results (Table 7).^10,22

The mean operative time was 191.7 minutes (range, 155-230 minutes), reported in 2 articles.^23,27 The average lipoaspirate was reported in 9 articles.^{1,10,12,20-22,27} The average lipoaspirate with abdominal etching was 3325 mL (range 100-10,200 mL) and the mean lipoaspirate following HDL and HD² was 4925.77 mL (range of means, 500-9700 mL) (Table 7).^{1,10,12,20-22,27}

Complications

Reported complications are shown in Table 7. Complications were not reported in 1 study,²⁶ and were not explicitly reported for male liposuction in 1 article.⁹ Fluid collection or seroma formation was the most common complication, reported in 60 patients, followed by hyperpigmentation (n = 53), contour irregularities (n = 11), revision surgery (n = 11), anemia (n = 7), port dehiscence (n = 6), and hematoma or bruising (n = 5). Other complications reported were severe pain (n = 1), an exaggerated groove at the level of the umbilicus (n = 1), an oil cyst (n = 1), erratic skin adhesion or fibrosis (n = 3), and necrosis (n = 2). An additional indentation at the level of the umbilicus turned out to be an exaggerated groove as a result of sitting. The authors were unable to completely correct the groove by repeated fat injections and liposuction.¹

Taha et al reported a seroma rate of 52% in a standard group in comparison to 16% in patients treated with draining procedures (evacuation of the infiltrate through the incision sites at the end of the procedure, cannula sites left open to help drainage, early ambulation, compressive garments, and silicone drains at the inguinal and iliac regions).²⁴

DISCUSSION

Subcutaneous adipose tissue (SAT) differs anatomically and functionally from intra-abdominal visceral fat, but is nevertheless still deleterious to health and generates a dissonant and amorphous appearance of the body.^26,30 SAT in males tends to accumulate in the anterior abdominal region where the topographic anatomy of the abdominal musculature cannot be visualized, even with an adequate muscle volume if the total body fat is beyond 15%.¹² Additionally, the chest acquires a gynecoid semblance and the SAT of arms and legs does not undergo hyperplastic changes in the same proportion as the torso, giving a thin appearance to the limbs.²⁶

Traditional SAL integrates wet techniques and deep lipoplasty while preserving a quantity of subcutaneous fat to avoid contour irregularities and wrinkling.^9,26,31 Nonetheless, this approach is not comprehensive and does not offer athletic-build results.^26,31 In 1993 Mentz et al described the technique of “abdominal etching,” which aimed to enhance the details of the abdominal wall musculature by applying differential liposuction.¹² However, this technique was limited to the anterior abdominal wall. In 2003, Hoyos presented the technique of “high-definition liposculpture” at the Colombian National Congress where lipoplasty was not only performed to remove fat but to outline the superficial anatomy of the body.³² This technique was further developed and improved with the inclusion of VASER-assisted liposuction to perform HDL with a precision technique for abdominal etching with the integration of a 3-dimensional multilayer concept of body contouring for the entire torso, lower and upper extremities, and back.⁹ Finally, the latest concept of HD² not only includes the concept of the body as a whole homogeneous unit described with HDL, but incorporates a finely detailed definition of musculature based on the pattern of precise muscle movements by creating “dynamic zones,” predicting the form of muscles during physical activity.^13,14

All the aforementioned concepts include abdominal etching by creating controlled irregularities at the linea alba, the linea semilunaris bilaterally, as well as the inscriptions of the rectus abdominis muscles.^22,26 Remarkably, the transverse inscriptions can be arranged as an intersection in a transverse direction, extending perpendicular to the linea alba; in an oblique fashion; a biphasic type of inscription; or in a stair-step configuration, in which the levels of the intersections can differ from side to side by several millimeters in the vertical axis.^12,22,28,33 Therefore, this asymmetry should be respected because the purpose of abdominal HDL is to accentuate a natural result and normal anatomy.²²

Regarding the lowest insertion at the level of the umbilicus, several authors recommended avoiding horizontal liposuction at or below this point because it creates an exaggerated and artificial appearance of such lines.¹ Moreover, the linea alba should mainly be visible and marked above the umbilicus and not below in order to achieve more natural outcomes.²² Finally, several authors mentioned it was also necessary to etch a 2- to 3-cm radius around the umbilicus to prevent a periumbilical “doughnut.” ²⁰

A common challenge faced during HDL or HD² is artificial or unrealistic results, which occur when the surgeon does not identify the patient biotype and mistakenly applies HDL as a standardized procedure to every patient.¹⁰ In response to this, Hoyos et al implemented a BMX algorithm in which an endomorphic (overweight) biotype, or patients who desire moderate definition receive basic (mild) to moderate HDL mainly to extract a significant volume of fat and etch the underlying musculature; whereas patients with mesomorphic or ectomorphic biotypes receive a moderate to extreme (aggressive) HDL, focused mainly on reproducing an athletic appearance.^10,13,14 Saad et al reported a similar approach in which the extent of definition was decided through a consensus between the patient and the surgeon, taking into consideration the patient’s body habitus, anatomy, and expectations.²⁷ Although these approaches provide a clear and explanatory algorithm,^10,27 the reproducibility in terms of surgical outcomes for less-experienced surgeons remains a critical concern due to the limited number of studies.

Regarding the different technologies, VASER-assisted HDL has a more measured learning curve and is more time-consuming than traditional lipoplasty. However, several authors have reported better outcomes, with a low complication rate, by never letting the skin become warmer than the hand of the surgeon and limiting the cannula to a maximum of 10 passes in the subdermal plane.⁹ The fragmentation of all the deep, intermediate, and subdermal lamellae SAT is gentle and precise, avoiding the morbidity associated with multilayer techniques. In addition, the superficial emulsification addresses the subcutaneous plane, thus allowing augmented skin retraction in areas of muscle or fascial laxity.^9,34 On the other hand, PAL is an intensification of SAL that involves a rapidly reciprocating cannula tip, which replicates the “back-and-forth” motion of the surgeon’s arm but at an amplitude of 3 mm. In previous series, PAL has been shown to reduce vascular injury, increase the overall efficiency, and provide a favorable cost-benefit ratio in comparison to SAL and vibration-assisted liposuction.^23,35 However, due to the divergent methodologic protocols applied in the included studies and the lack of a control group or a comparative cohort, pairwise comparison in terms of outcomes, effectiveness, and complications remains uncertain among surgical technologies, hindering the formulation of further recommendations in favor of a particular technique.^36,37

Niddam et al avoided injecting fat in the rectus abdominis muscles or in the deep layers of the skin to increase the volume of the rectus abdominis because of the associated morbidity and the eccentric appearance. Instead, they found that the regions of gluteus maximus muscle, the deltoid muscle, or the pectoralis major muscle were more suitable for fat injection to increase volume in a more natural fashion.²² Hoyos et al did not include rectus abdominis fat grafting because most of the patients did not desire a fat-grafted appearance over the abdominal musculature.²¹ In comparison, Steinbrech and Sinno reported superior abdominal contouring results when they performed selective lipocontouring with fat grafting, specially over the rectus abdominis and the serratus anterior to provide a bodybuilder-like appearance.²⁸

In this setting, if muscle expansion is still desired in the rectus abdominis, ultrasound-guided rectus abdominis fat transfer has been described as a safe approach for this purpose.³⁸ With this modality, fat is administered below the anterior rectus sheath, avoiding a posterior approach where the inferior epigastric vessels are located.³⁸ Additionally, the bolus injection technique is preferred because the ultrasound image becomes distorted once fat injection is started, preventing fat from being delivered in a precise and safe way if the cannula is in motion.³⁸

Interventions directed to decrease seroma and hematoma formation are extremely important in HDL because minor seromas can have devastating consequences.²¹ Therefore, seromas are managed with aggressive aspiration and compression to preclude the obliteration of sculpted regions.⁹ Some authors left open (<1.5 cm) the stab incisions to allow for drainage and prevent seroma/hematoma formation. Nevertheless, when excessive drainage was expected, drains were sometimes used.²¹ In these cases, the incidence of seroma dramatically decreased with the use of drains in the inguinal area in male patients.⁹ In addition to drains, evacuation of all the infiltrate through the incision sites at the end of the procedure, tight dressings applied over superficially treated areas, pressure garments applied immediately after the procedure and worn for 6 weeks, early ambulation, and massage therapy for 4 weeks, were shown to significantly reduce the incidence of seroma (P < 0.007) in comparison to nondraining interventions.²⁴ However, further studies with an increased sample size are required to increase the strength of these recommendations for HDL and to adequately ascertain the benefits of these postoperative protocols.³⁹

Other common minor complications of liposuction include bruising or pigmentation, and contour deformities; more serious complications include infection, lidocaine toxicity, anemia, hypovolemic shock, thromboembolism, and death.^21,40 Skin laxity, particularly above the umbilicus, caused postoperative wrinkling in older and sun-damaged patients; issues with waviness usually occurred below the umbilicus.²⁰ This highlights the importance of evaluating skin features and laxity preoperatively and assessing the thickness irregularities intraoperatively.²⁰

Finally, patient selection for this procedure is paramount because preservation of long-term results is reliant on patient motivation, adherence to a diet, and an exercise regimen.^9,20 Conversely, weight gain can negatively impact long-term results and reduce the definition of the abdominal wall musculature.²⁰ In fact, patients who receive this procedure and gain weight eventually require further SAL but are likely to have an evident deformity with an artificial etched 6-pack over an obese abdomen.²⁰

Limitations

Quantitative analysis was limited due to the sample size of some studies. Complications were not reported ubiquitously. Most studies had a OCEBM score of 4 and were limited to single-arm cohort studies or were case series, which limited comparability among surgical techniques. Satisfaction was not reported according to standardized scales in the majority of studies.

CONCLUSIONS

A wide variety of techniques are available to perform HDL to achieve various degrees of definition. However, careful patient selection is critical for successful results; the concept of “one type of definition fits all” must unequivocally be abandoned.^10,27 The different liposuction techniques are technically moderate/complex; therefore, proper training with a straightforward learning curve and adequate knowledge of the superficial anatomy of bodies are necessary to avoid complications and achieve optimum results.

Disclosures

The authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article.

Funding

The authors received no financial support for the research, authorship, and publication of this article.

REFERENCES