Incorporation of the UGRAFT Technique to High-definition Liposuction

Summary:

High-definition liposuction is now a reliable procedure that provides more athletic results. It is a trend among plastic surgeons and patients. The ultrasound-guided rectus abdominis fat transfer (UGRAFT) technique has expanded the range of patients who can benefit from rectus abdominis fat grafting, including those without skin laxity. Its advantage over isolated high-definition liposuction is a more natural-looking result because it increases muscle volume and provides a contoured abdomen even during movement, regardless of the patient’s position. In this article, we describe one patient undergoing the UGRAFT technique after high-definition liposuction, versus one patient undergoing only high-definition liposuction. We determined that the use of the UGRAFT technique provides greater muscle definition over those in which this technique has not been performed. The UGRAFT technique opens the possibility of developing more complete body structures regarding definition, providing volume to muscular areas. The more muscle mass and less body fat, the greater the body definition in a liposuction. The less muscle mass and more body fat, the less definition a patient will have in a liposuction. Under these principles, we improve the result by increasing the volume of muscle mass.

Liposuction is one of the most frequently performed cosmetic procedures worldwide. In 1976, Fisher first described liposuction for cosmetic purposes.¹ Subsequently, since traditional liposuction in the 1980s by Illouz gained popularity, many technical improvements and technological modifications have been introduced.² Today, it is the second most commonly performed cosmetic procedure after augmentation mammoplasty.³ Over time, new concepts and techniques were introduced. The first reference of liposuction as a technique to improve musculature, also known as “muscle etching,” came from Mentz et al⁴; later, Hoyos and Millard⁵ in 2007 systematized and expanded the technique, introducing the concept of high-definition (HD) liposculpture by adding the systematic use of ultrasound to achieve a better retraction of tissue. In most people with a normal body mass index, an athletic and toned appearance can be created through HD body sculpting by removing fat and highlighting the major muscle groups.⁵

HD liposuction is nowadays a reliable procedure that provides more athletic results. It is a trend among plastic surgeons and patients. However, despite its popularity, this technique has certain limitations and disadvantages. Danilla⁶ obtained more natural results when performing rectus abdominis fat grafting in patients undergoing lipoabdominoplasty. Viaro et al⁷ in 2020 published for the first time information about the Ultrasound-Guided Rectus Abdominis Fat Transfer (UGRAFT) technique, which consists of fat grafting in the rectus abdominis muscle under direct visualization with ultrasound in patients who are not suitable for abdominoplasty, to obtain a more natural abdominal contour.

An important feature of adipose tissue is that it contains a large amount of mesenchymal stem cells compared to bone marrow. This is relevant not only because these cells can differentiate into different tissues such as bone, nervous, skin, muscle, and others, but also because they produce growth factors that help to repair these tissues.⁸ We have the knowledge and evidence that they work as ideal stem cells for regenerative medicine, and in this particular case, for skeletal muscle regeneration.⁹

Nowadays, the UGRAFT technique has expanded the range of patients who can benefit from rectus abdominis fat grafting, including those without skin laxity. Its advantage over isolated HD liposuction is a more natural result because it increases the muscle volume and provides a flatter abdomen even during movement, independent of the patient’s position. This article documents the first cases performed in Mexico with this technique.

PATIENTS AND METHODOLOGY

Two male patients, 33 and 28 years old, respectively, are included in the present study. The first patient underwent only HD liposuction using our already established technique, and the second patient underwent HD liposuction with the addition of the UGRAFT technique. Supplementary Digital Contents 1 and 2 show the number of patients who have currently undergone HD liposuction and HD liposuction plus the UGRAFT technique correspondingly, noting the analogy of the characteristics between both groups, sex, age, body mass index, surgery time, same evolution time (2 months) and amount of fat infiltrated in the rectus abdominis muscle. [See table, Supplemental Digital Content 1, which shows the data of the 9 patients (5 men and 4 women) treated with HD liposuction, http://links.lww.com/PRSGO/C131.] [See table, Supplemental Digital Content 2, which shows the data of the 9 patients (6 men and 3 women) treated with the UGRAFT technique, http://links.lww.com/PRSGO/C132.]

Liposuction was started using our established technique, which consists of infiltration of Hartmann’s solution as follows: 1000 ml solution + 1 epinephrine vial (1 mg/ml) + 1 amikacin vial (500 mg/2 ml) + 1 clindamycin (600 mg/4 ml). This solution was infiltrated in all the areas to be liposuctioned (most commonly abdomen, back, arms, and lumbar), and deep liposuction was performed in these areas. Once the fat to be liposuctioned was obtained, the UGRAFT technique was performed to increase the rectus abdominis as its name indicates. The fat was decanted removing the liquid components. After this decantation was done, microfragmentation of the fat was performed through the 2-mm diffusers. Once the fat had been infiltrated, the 2.5-mm cannula was introduced under ultrasonography-guided vision. The anterior abdominal wall was penetrated over the desired muscle belly and being sure of the position of the cannula in the intramuscular layer, the fat infiltration was performed. (See Video 1 [online], which demonstrates the UGRAFT technique in a 28-year-old male patient.)

Video 1. This video demonstrates the UGRAFT technique in a 28-year-old male patient. The procedure was originally performed by the author of this article for which the SONOSITE EDGE ultrasound was used.

Download video file ^{(52.5MB, mp4)}

RESULTS

In this case report article, we present two cases: the first was a 33-year-old male patient, with a body mass index of 25, and a duration of his surgery of 4 hours, with a recovery time of 2 weeks. It was decided to take preoperative and postoperative photographs at 3 months postoperative, as a cutoff point to assess the evolution (Fig. 1A, B). The second case was a 28-year-old male patient, body mass index of 23, duration of the procedure of 6 hours, with postoperative recovery time of 2 weeks, submitted to HD liposuction with the incorporation of the UGRAFT technique. Preoperative and 3-month photographs were taken to assess the patient’s progress (Fig. 2A, B). We clearly observed that muscle definition was higher in patients operated on with the UGRAFT technique than those in whom only HD liposuction was performed.

Fig. 1.

Liposuction technique. A, Presurgical view of a 33-year-old male patient undergoing HD liposuction. B, Postoperative view 3 months after HD liposuction.

Fig. 2.

UGRAFT technique. A, Presurgical view of a 28-year-old male patient who underwent the UGRAFT technique. B, Postoperative view 3 months after UGRAFT technique.

DISCUSSION

Since body contouring surgery is one of the most performed procedures worldwide, it is of the utmost importance to have an understanding of the transformation that this procedure undergoes, which is why plastic surgeons must have anatomical knowledge of fat deposits to sculpt in high definition. Today, the UGRAFT technique represents a valid option that can be incorporated into an HD liposuction to improve the results. Currently, there is knowledge about the function of fat grafts in the different clinical uses in plastic surgery; however, their usefulness has increased to optimize the muscles, emphasizing that this technique can be replicated in any muscle group with the purpose of surpassing the results obtained by previous definition techniques.

CONCLUSIONS

The UGRAFT technique offers the possibility of developing body structures with better definition, since it gives volume to important muscular areas in HD liposuction, such as the rectus abdominis. A fundamental principle in this procedure is accomplished: the more muscle mass and less body fat, the greater definition a body will have in liposuction (HD liposuction) and the less muscle mass and more body fat, the less definition a patient will have in liposuction. Today, under these principles, we can improve or increase the results of a definition liposuction by increasing the volume of muscle mass.

But this does not end there. Although muscle lipoinfiltration using the UGRAFT technique is unique to the rectus abdominis, the fundamental principle of this technique, ultrasound as a visual guide of fat infiltration, is what helps us to infiltrate fat in muscles—such as deltoids, pectorals, biceps, triceps, among others—in which previously lipotransfers were performed, in a safer and more reliable way. In this sense, new muscular areas inaccessible until now are being explored, to improve the definition generated by the volume of these muscles, as well as by the problematic areas generated by the principle of liposuction, creating more natural body contours with better defined results. The course has been traced out; the principle of this technique is the future of body contouring surgery.