Biostimulatory Fillers to Treat Post-liposuction Skin Irregularities

J Clin Aesthet Dermatol. 2025;18(3):39–41.

by Stefania Guida, MD, PhD; Ilaria Proietti, MD; Claudio Conforti, MD; Carmen Cantisani, MD; Nicola Zerbinati, MD; Giovanni Pellacani, MD; and Hassan Galadari, MD

Dr. Guida is with the School of Medicine at Vita-Salute San Raffaele University in Milan, Italy, and the Dermatology Clinic at IRCCS San Raffaele Hospital in Milan, Italy. Dr. Proietti is with the Dermatology Unit at Daniele Innocenzi, A. Fiorini Hospital in Terracina, Italy. Dr. Conforti is with Istituto dermopatico dell’Immacolata, IDI-IRCCS, Dermatological Research Hospital in Rome, Italy. Prof. Cantisani is with the Dermatology Department of Clinical Internal Anesthesiologic Cardiovascular Sciences at the Sapienza University of Rome in Rome, Italy. Prof. Zerbinati is with the Department of Medicine and Surgery at the University of Insubria in Varese, Italy. Prof. Pellacani is with the Dermatology Department of Clinical Internal Anesthesiologic Cardiovascular Sciences at the Sapienza University of Rome in Rome, Italy. Prof. Galadari is with the College of Medicine and Health Sciences at United Arab Emirates University in Al Ain, United Arab Emirates.

FUNDING: No funding was provided for this article.

DISCLOSURES: The authors report no conflicts of interest relevant to the content of this article.

ABSTRACT: Background: Treatment of post-liposuction skin irregularities (PLSI), a complication of liposuction, can be challenging. Objective: Considering the increasing request of treatment of PLSI, the aim of this study is to evaluate the efficacy and safety of CaHA diluted/hyperdiluted to PLSI. Methods: A retrospective study on a total of eight PLSI areas in six women treated with CaHA diluted/hyperdiluted was performed. Efficacy was estimated on pictures of affected areas collected before and four months after treatment, according to the recently validated PLSI scale and Student’s t-test for paired samples was performed to analyze data. Eventual adverse events were used to evaluate safety. Results: Our results showed a statistically significant improvement of number and depth of depressions and a trend toward reduction of skin laxity. Conclusion: This study reported the efficacy and safety of CaHA diluted/hyperdiluted for PLSI treatment. Larger studies are encouraged to support the results of this pilot study.

Keywords: Post-liposuction skin irregularities, calcium hydroxyapatite, biostimulation, liposuction, PLSI scale

Introduction

Post-liposuction skin irregularities (PLSI) are a common concern that affect both patients and doctors alike. The condition, where such irregularities occur weeks to months after surgery, has recently been given a proper definition with a proposal for the classification has recently been published in the literature.¹

PLSI occurs after liposuction due to irregular fat aspiration of both areolar and lamellar fat layers.^2,3 Despite it being a growing concern, a global consensus for the treatment of these irregularities is still lacking. Intra-operative lipo-shifting and autologous fat transfer have been suggested as possible alternatives.^2–7 These approaches may be limited by the need for a donor site, as well as requiring specific expertise and equipment. 

Due to similarities between PLSI and cellulite, the use of fillers with biostimulatory activities, aiming at the increase of neocollagenesis, can been hypothesized to treat PLSI of the body.^8–11 Calcium hydroxyapatite and carboxymethylcellulose (CaHA/CMC) have been described as an effective treatment for cellulite but no data is currently available about its use for PLSI. This study aims to present clinical cases of patients presenting with mild to severe PLSI, treated with biostimulatory fillers with satisfactory results.

Methods 

Participants. This retrospective study included six female patients who were treated with diluted/hyperdiluted CaHA for PLSI, and who did not receive any other treatment in the previous six months. Patients who underwent treatment did not have any illness or active inflammatory skin lesions or were using drugs that might impede wound healing or cause immune system suppression. Baseline information concerning age, sex, area of treatment, treatment strategy, and number of years after liposuction were retrieved.All procedures performed in the study involving human participants were in accordance with the Helsinki Declaration and its later amendments or comparable ethical standards. All patients provided informed written consent before undergoing the treatment.

Treatment protocol. Given the biostimulatory activity of the CaHA, we treated our patients with its diluted/hyper-diluted form. With the patient in a standing position, the area to be treated was identified and marked. Patients with skin irregularities were assessed according to the recently validated PLSI scale.¹ Briefly, quantitative evaluations of parameters included the following: number of visible depressions (either circular or linear): 0=absent, 1=1–4 depressions, 2=5–9 depressions, 3=≥10 depressions; for depth of depressions: 0=absent, 1=superficial depressions, 2=medium depth depressions and 3=deep depressions; skin laxity severity: 0=absent, 1=slight draped appearance, 2=moderate draped appearance and 3=severe draped appearance.^1,14,15 Additionally, the presence/absence of v-sign was evaluated.¹ The treatment strategy was based on the depth of the areas: Depths 1 and 2 were treated with hyperdiluted CaHA1:2, while Depths 2 and 3 were treated with CaHA 1:1. For a 1:1 dilution, every 1.5mL of CaHA syringe was diluted with 1.5mL solution (0.5mL 1% lidocaine and 1mL 0.9% saline solution) while for 1:2 hyper-dilution each 1.5mL CaHA syringe was mixed with 3mL solution (0.5mL 1% lidocaine and 2.5mL 0.9% saline solution).^10,12,13

To achieve a homogeneous solution, the mixture was prepared using two 5mL syringes, connected with a female-to-female Luer lock connector, and, as per guidelines, at least 20 passes were performed.^10,12,13

The total amount of the reconstituted solution was injected into the PLSI area, through a 27G 19-mm needle the areas of skin retraction were subcised and the solution was injected, employing a cross hatch technique. The area was well-massaged to ensure proper distribution.

Evaluation of efficacy. Pictures before (T0) and four months after treatment (T1) of 6 PLSI in female patients were collected and evaluated according to the recently published and validated PLSI scale1. Furthermore, patients’ level of satisfaction was assessed according to a five-point satisfaction questionnaire, from very unsatisfied to very satisfied at T1.

Evaluation of safety. Patients were asked to rate pain according to a validated 10-point scale, scoring from 1 (no pain) to 10 (maximum pain). The possible occurrence of swelling, bruising, or improper distribution of the solution was monitored for 30 minutes after treatment. During follow-up visits, patients were asked about the eventual appearance of nodules, dyspigmentation, and scars.

Statistical analysis. Statistical evaluation was performed with SPSS version 24 (IBM Corp, Armonk, New York). Quantitative variables were described as mean ± standard deviation (SD) with range interval and compared with the student’s T-test while qualitative variables were reported as frequencies. A p-value ≤0.05 was considered a statistically significant result.

Results

Baseline characteristics of female patients and techniques employed were reported in Table 1. The mean age of six patients was 45±7 (range 38–58); the mean number of years after liposuction was 4±4 (range 2–15). Half of PLSI areas were located on the postero-lateral thighs, 25 percent on the abdomen and the two remnants were located on the arm and inner thigh.

Efficacy. The number and depth of depressions were significantly decreased after treatment (Table 2). The mean severity of the number of depressions was 2±0.8 at T0 and decreased to 1.1±1.1 at T1 (p=0.006). The depth of depressions was 2±0.6 at T0 and decreased to 0.9±0.6 at T1 (p=0.002) (Figure 1). A trend toward improvement of skin laxity was also observed, although not significant (p=0.17). In addition, an improvement of the v-sign can be observed (Figure 2). In addition, 33 percent (n=2) of patients reported being very satisfied, 50 percent (n=3) reported being satisfied, and 17 percent (n=1) reported being neither satisfied nor dissatisfied.

Safety. Treatment-induced minor adverse events, including redness, swelling, and bruising, were observed. All these events were self-limiting, resolving within 2 to 14 days, without any sequelae. The main pain intensity was 2.3±0.5 (range 2–4).

Discussion

Post-liposuction skin irregularities (PLSI) can be related to technical issues during liposuction, as well as to underlying skin retraction due to fibrosis. Given the ability of steroids to modulate fibrosis, intralesional steroids have been used after liposuction to prevent such issues.¹⁶ However, this procedure may be limited by possible adverse events such as atrophy, therefore intra-operative lipo-shifting and autologous fat transfer have been suggested as possible alternatives.^2–7

Previous studies supported the role of biostimulatory fillers in cellulite treatment with different modalities. In a single case report, a 1:2 CaHA hyper-dilution technique was employed,¹⁷ involving ≥20 patients, 1:1 CaHA diluted was used.^18,19 Furthermore, good results in terms of efficacy and safety were observed with CaHA alone or in association with microfocused ultrasound with visualization.^18,19 

Considering that cellulite shares some features with PLSI, such as the presence of depressions and possible association with skin laxity,¹ we reported herein the efficacy and safety of a single session of CaHA diluted/hyper-diluted in PLSI treatment. Specifically, a significant reduction in the number and depth of depressions was revealed. A trend toward improvement of skin laxity was observed, although not significant. Taken together, these results support the application of CaHA diluted/hyperdiluted in PLSI treatment, suggesting another potential indication for CaHA biostimulatory treatment involving different areas of the body.

Different CaHA dilution/hyperdilution have been associated to different levels of collagen stimulation, with a direct relation between CaHA concentration and collagen expression.²⁰ Therefore, according to the number and depth of depressions it is possible to personalize the treatment protocol, for instance, in case of a single deep depression CaHA should be more concentrated to provide more collagen stimulation. Additionally, repetitions of CaHA sessions or combination with other techniques can also be considered.

Limitations. This study is limited by the low number of patients enrolled; therefore, further studies should be performed on larger cohorts and provide follow-up data to elucidate the most appropriate treatment schedule.

References

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