From Cellulite to Post-liposuction Skin Irregularities: A Proposal for Definition and Classification

J Clin Aesthet Dermatol. 2024;17(4):24–27.

by Stefania Guida, MD, PhD; Nicola Zerbinati, MD; Claudio Conforti, MD; Alessia Paganelli, MD, PhD;
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. Zerbinati is with the Department of Medicine and Surgery at University of Insubria in Varese, Italy. Dr. Conforti is with the Dermatology Clinic at Maggiore Hospital of Trieste in Trieste, Italy. Dr. Paganelli is with UOC Dermatologia, IRCCS-AUSL Reggio Emilia in MIlan, Italy. Dr. Pellacani is with the Department of Clinical Internal Anesthesiologic Cardiovascular Sciences at Sapienza University of Rome in Rome, Italy. Dr. 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 have no conflicts of interest relevant to the contents of this article.

ABSTRACT: Background. Post-liposuction skin irregularities (PLSI) represent a complication of liposuction, even though literature does not report specific data on their characteristics.

Objective. Considering the expanding request of treatment of PLSI and their similarities to cellulite, the aim of this study is to provide a definition or classification of their appearance according to a previously described cellulite scale and to highlight eventual novel features, in patients undergoing previous liposuction and a control group.

Methods. A total of 47 women, of which 47 percent performed a previous liposuction, were included in this study. Pictures of gluteal area and postero-lateral thighs were analyzed according to number and depth of depressions, skin laxity, asymmetry and v-sign by three investigators. The correlation between parameters and previous liposuction was explored with statistical analysis.

Results. Our results show good to excellent intraobserver agreement and moderate to good agreement between the evaluators. Additionally, we showed that PLSI can appear as marked cellulite signs (depth of evident depression) or as specific previously not reported features including asymmetry and v-sign.

Conclusion. Our findings provide information about the previously unreported morphology of PLSI. Further studies will apply validated features of PLSI proposed herein to clinical practice.

Keywords: Cellulite, liposuction, post-liposuction skin irregularities

Introduction

Cellulite is a common concern, with over 90 percent of women being affected.¹ Many different therapeutic approaches have been described.^2,3 Before the diffusion of mechanical or chemical subcision techniques, liposuction, one of the most performed aesthetic surgical procedures, was considered a potential treatment.^2,4 However, this application has been debated due to divergent results obtained, leading either to an improvement of or worsening of cellulite.^5,6 One of the potential risks include necrosis coming from a superficial liposuction that may lead to an increased appearance of cellulite.⁷ 

Post-liposuction skin irregularities (PLSI) or overcorrection have been reported as the most common complication of liposuction.⁸ The rising incidence of these complications has been related to irregular fat aspiration of both areolar and lamellar fat layers.⁹ While a global consensus for the treatment of these irregularities is still lacking, many authors reported management of these irregularities through intra-operative lipo-shifting and autologous fat transfer.^9–13 

Recently, the use of fillers with biostimulatory activities, aiming at the increase of neocollagenesis,^14–16 has been proposed as an off-label treatment of skin laxity of the body.^17–21

PLSI may resemble cellulite. However, a definition and classification of PLSI is currently missing. According to the clinical experience of the authors, it is possible to observe these PLSI in patients with cellulite signs on the gluteal area and thighs. This study aims to evaluate the distribution of previously described cellulite features and identify eventual novel parameters on the gluteal area and postero-lateral aspect of thighs in two groups of subjects, those who underwent previous liposuction (PL) and those who did not (NoL).

Methods

This was a retrospective study that included 47 women, consecutively enrolled. Photographic images of the gluteal area and posterior-lateral thighs were collected at a single centre, in the same room, by the same investigator. All procedures performed in the current study involving human participants were in accordance with the Declaration of Helsinki and later amendments or comparable ethical standards. 

Photographs were evaluated by three doctors. The first evaluator created the adapted criteria for the current study. The other two evaluators received specific training and were unfamiliar with the parameters before the current study. 

This study included a quantitative assessment of the number and depth of visible depressions and skin laxity. Specifically, quantitative evaluations of parameters were performed according to previous scales^22,23 as follows for number of visible depressions (either circular or linear): 0=absent, 1=1 to 4 depressions, 2=5 to 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.

Novel and additional qualitative parameters were taken into account to identify potential differences between PL patients and NoL subjects. After the revision of the pictures, two parameters were identified: asymmetry between the two sides and v-sign. Specifically, asymmetry was graded as: 0=absent, 1=mild, 2=moderate, and 3=severe while the v-sign, defined as the presence of V-shaped skin retractions (mimicking the passage of the liposuction cannula), was considered as absent or present (Supplemental Figure 1).

A statistical analysis was performed with Spss 24.0 (IBM, Armonk, New York, USA).

To validate evaluations, the intraclass correlation coefficients (ICCs), estimating the intra-observer reliability of the same physician evaluating at different times, and inter-observer reliability, measuring the concordance between the three evaluators, were calculated to determine whether evaluations were consistent. The level of agreement was classified according to the scale applied by Koo and Li²⁴ as poor (<0.50), moderate (≥0.50 to <0.75) good (≥0.75 to <0.90), and excellent (≥0.90).

Additionally, based on the evaluations of the expert evaluator, the distribution and grade of features were evaluated according to the presence/absence of a history of previous liposuction, and compared to highlight potential markers of PLSI. The chi-square test (of Fisher for values <5 in the 2×2 table) was employed to compare differences between groups. Multivariate analysis was then performed taking into account variables that resulted significantly in the univariate analysis.

A p-value <0.05 was considered significant. 

Results

This study involved 47 women with an average age of 39.3 ± 9.5 years (range, 20–60). A total of 25 out of 47 (53%) belonged to the NoL group and 22 (47%) to the LP group.

The intra- and inter-observer reliability analyses were reported in Tables 1 and 2, highlighting mostly a good to excellent intraobserver agreement and moderate to good agreement between the evaluators.

Additionally, assessments highlighted the correlation between previous liposuction and increased depth of evident depressions, increased asymmetry, and the presence of v-sign (Table 2, Figure 1). Specifically, depth was graded as medium and deep in all PL patients, as compared to 52 percent of NoL ones (p=0.002). Moderate and severe asymmetry was observed in 64 percent of PL patients, as compared to 4 percent of NoL subjects (p<0.001). Interestingly, the v-sign was specifically observed in PL patients only (p=0.012), Table 3.

Multivariate analysis revealed that asymmetry was significantly associated with PL (p=0.002), Table 3.

Discussion

Passing years, weight variations, and lifestyle interact with the genetics of an individual to determine the appearance and severity of cellulite, such as number, type, and depth of evident depressions, skin laxity, and asymmetry on the body. However, the contribution of liposuction in these processes has been not defined yet, despite liposuction has been established as the most common surgical procedure sought out by women.⁴ There currently exists no official definition and/or grading of PLSI, despite being the most common complication of liposuction.

In the present study, starting from previously reported cellulite scores, we developed and validated a novel scale for the classification of PLSI. Our results show a good to excellent intraobserver agreement and moderate to good agreement between the evaluators.

We found that PL patients have a significantly higher depth of evident depression severity, as compared to NoL subjects (p=0.002 in the univariate analysis). Therefore, despite the depth of evident depressions cannot be considered a specific PL sign, since they are also evident in cellulite,^22,23 they show an increased severity in the PL group. 

Importantly, we proposed herein two previously unreported parameters in the evaluation of cellulite scales, which are asymmetry and v-sign. These parameters were significantly associated with previous liposuction in the univariate analysis. The v-sign was observed in PL patients only, therefore suggesting that the v-sign can be considered a specific sign of liposuction. We hypothesize that this sign might be related to retraction following cannula movement during liposuction. Of note, we observed that asymmetry was the only variable significantly associated with PL in the multivariate analysis (p<0.001), with 64 percent of PL patients showing moderate to severe asymmetry as compared to 4 percent in the NoL group. 

Conclusion

Taken together, our results show that PLSI can appear as marked cellulite signs (depth of evident depression) or as specific previously not reported features including asymmetry and v-sign.

Limitations. The current study is limited by the small number of patients evaluated, the retrospective design of the study, and the lack of information concerning lifestyle and weight history. However, the overall good correlation and consistency of agreements observed in the current study can be extended to more evaluators at multiple sites for further validation in the context of different cohorts or the evaluation of treatment outcomes for PLSI.

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