Case Report

Cosmetic
Incorporation of the UGRAFT Technique to
High-definition Liposuction
Emmanuel Armando Flores
González, MD*
Mauricio S. S. Viaro, MD†
Hector Cesar Duran Vega, MD‡
Oliver René Ramírez Guerrero,
MD§
Patricia Brito Toledo, MD¶
Raquel Aracely Vázquez Apodaca,
MD§
Lenin Rendon Jaramillo, MD§
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, ver-
sus 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 defi-
nition 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. (Plast Reconstr Surg Glob Open 2022;10:e4447; doi:
10.1097/GOX.0000000000004447; Published online 26 July 2022.)

L
iposuction 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 pro-
cedure after augmentation mammoplasty.3 Over time, new
concepts and techniques were introduced. The first refer-
ence 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
From the *Hospital Angeles, Clinica Londres, Mexico City, Mexico;
†Private Practice SBCP, Santa Maria, RS, Brazil; ‡Private
Practice, Mérida, Yucatán, Mexico; §Hospital General de Mexico,
“Dr. Eduardo Liceaga,” Mexico City, Mexico; and ¶Private
Practice, Mexico City, Mexico.
Received for publication March 31, 2022; accepted June 1, 2022.
Copyright © 2022 The Authors. Published by Wolters Kluwer Health,
Inc. on behalf of The American Society of Plastic Surgeons. This
is an open-access article distributed under the terms of the Creative
Commons Attribution-Non Commercial-No Derivatives License 4.0
(CCBY-NC-ND), where it is permissible to download and share the
work provided it is properly cited. The work cannot be changed in
any way or used commercially without permission from the journal.
DOI: 10.1097/GOX.0000000000004447
HD liposuction is nowadays a reliable procedure that
provides more athletic results. It is a trend among plas-
tic surgeons and patients. However, despite its popularity,
this technique has certain limitations and disadvantages.
Danilla6 obtained more natural results when perform-
ing 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 mus-
cle 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 con-
tains 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 par-
ticular case, for skeletal muscle regeneration.9
Nowadays, the UGRAFT technique has expanded the
range of patients who can benefit from rectus abdomi-
nis fat grafting, including those without skin laxity. Its
Disclosure: The authors have no financial interest to declare
in relation to the content of this article.
Related Digital Media are available in the full-text ver-
sion of the article on www.PRSGlobalOpen.com.

www.PRSGlobalOpen.com 1
 PRS Global Open • 2022

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 under-
went only HD liposuction using our already established
technique, and the second patient underwent HD lipo-
suction 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 correspond-
ingly, 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 tech-
nique, 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 infil-
trated, the 2.5-mm cannula was introduced under ultraso-
nography-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.)
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 recov-
ery time of 2 weeks. It was decided to take preoperative
and postoperative photographs at 3 months postopera-
tive, 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 tech-
nique. 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.
DISCUSSION
Since body contouring surgery is one of the most per-
formed procedures worldwide, it is of the utmost importance
to have an understanding of the transformation that this

Fig. 1. Liposuction technique. A, Presurgical view of a 33-year-old male patient undergoing HD liposuc-
tion. B, Postoperative view 3 months after HD liposuction.

2
Flores González et al. • UGRAFT Technique and 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.
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 repli-
cated in any muscle group with the purpose of surpassing the
results obtained by previous definition techniques.
CONCLUSIONS
The UGRAFT technique offers the possibility of devel-
oping 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 lipoin-
filtration using the UGRAFT technique is unique to the
rectus abdominis, the fundamental principle of this tech-
nique, 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 previ-
ously 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 lipo-
suction, creating more natural body contours with better
defined results. The course has been traced out; the prin-
ciple of this technique is the future of body contouring
surgery.
Emmanuel Armando Flores González
EMMANUEL FLORES
Plastic and Reconstructive Surgery
Frontera 74, Roma Norte, Cuauhtémoc
Mexico City 06700, Mexico
E-mail: leafg52@gmail.com
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