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Talent & Techniques: Surgery in a syringe: My minimally invasive alternative to surgical liposuction

Talent & Techniques: Surgery in a syringe: My minimally invasive alternative to surgical liposuction

Among the available nonsurgical cosmetic procedures, body contouring treatments, and the use of injectables for aesthetic improvement, continue to gain popularity. As a modality for reducing unwanted adipose tissue, injection adipocytolysis, is an approach to body contouring that accommodates the growing patient inclination toward minimally invasive treatments. 

ATX-101 injection (deoxycholic acid injection 10 mg/mL), from Allergan, Inc., known as Kybella in the U.S, and Belkyra in Canada, is the first FDA-approved pharmaceutical therapy for injection adipocytolysis.

Indicated for the treatment of submental fullness, ATX-101 acts to permanently destroy fat cells on contact due to the cytolytic nature of its active ingredient, deoxycholic acid. Deoxycholic acid is a naturally occurring bile acid involved in dietary fat emulsification and is capable of inducing adipocyte lysis by irreversibly disrupting the cell membrane. 

While ATX-101 injections to the subcutaneous submental fat have proven to be effective in reducing adipose tissue, there are limited publications assessing the results of treatment to non-submental regions. 

In 2017, I conducted the first studies evaluating the efficacy and safety of ATX-101 injection to non-submental areas. The study involved ATX-101 injection to more than 200 patients on over 15 distinct anatomic fat compartments. The results demonstrated improved contour in nearly all patients after one to two treatments.   

Based on meticulous clinical research and the results achieved at my personal practice, I developed Surgery in a Syringe – an approach to body contouring that accommodates patient proclivity for minimally invasive treatments. Surgery in a Syringe is a nonsurgical procedure that involves precise injection of ATX-101 to areas of unwanted fat. Commonly targeted treatment areas include: submental, jowls, upper arms, anterior and posterior periaxillary, upper and lower abdomen, pubis, inner and outer thighs, knees, calves and ankles. 

The patient in Figure 1 is a 49-year-old male who presented for a chief complaint of body contour deformity related to the abdomen. He was displeased with the appearance of contour irregularity and excess fat in the abdominal region. The patient had previously undergone liposuction to the abdomen with another physician and was unhappy with the remaining fat. He was not interested in liposuction or cosmetic surgery and requested a nonsurgical procedure. After discussing the available treatment options and reviewing the advantages and disadvantages of each option, the patient elected for Surgery in a Syringe to the abdomen. 

Prior to treatment, consent was obtained, risks were disclosed, and we discussed the treatment protocol, which included the likelihood of needing two to four treatments at six-week intervals. Following physical examination, the patient was marked to define the treatment zone and the 1.0 cm injection grid (recommended for use with submental ATX-101 injections) was applied to the area. To enhance patient comfort, lidocaine with epinephrine was injected in the treatment area. 

In total, 94 cc of ATX-101 was administered to the abdomen using a 32 gauge, 0.5 inch needle. 47 cc of ATX-101 was injected into the left abdominal region and 47 cc was injected into the right abdominal region, from cephalad to caudal. Injections were administered perpendicular to the skin’s surface and midway into the subcutaneous fat (0.2 mL per injection site to achieve a dose of 2 mg/cm2). 

At follow-up, the patient was very pleased with the results we achieved. He noticed dramatic improvement in cellulite and excess fat of the abdomen. He also observed improvement in skin quality. Based on the results of treatment, the patient scheduled an appointment for ATX-101 injections to the submental and jowl regions at follow-up. The patient is pictured before treatment and five months after his first and only treatment.

While further clinical trials and explicit indications for non-submental ATX-101 injection are imperative, treatment has shown to be effective and unaccompanied by significant adverse events at early follow-up. In the treatment of patients with large areas of undesired fat, the use of deoxycholic acid for body contouring is, undoubtedly, limited by cost. Considering current product cost, favorable applications for non-submental ATX-101 injection involve small treatment zones. 

With proper patient selection, Surgery in a Syringe represents an attractive minimally invasive alternative to surgical liposuction and other forms of injection lipolysis for body contouring.

About the author

Sachin Shridharani, M.D.
Dr. Shridharani is a renowned, board certified plastic surgeon and founder of LUXURGERY, located on Manhattan's famed Fifth Avenue. His firm commitment to excellence has earned him several accolades and he has authored over 100 publications. Dr. Shridharani is recognized as an international authority on aesthetic plastic surgery treatments and technique. He serves as an international opinion leader and has lectured around the world. Dr. Shridharani is frequently featured in national media outlets including The New York Times, New York Post, Cosmopolitan Magazine, Harper's Bazaar, NBC, FOX, and ABC. He also serves as the cosmetic surgery expert and is a recurrent contributor on the topic of plastic surgery and beauty for Haute Living Magazine.

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