Deoxycholic Acid Injection as an Effective Treatment for Reduction of Posterior Upper Torso Brassiere Strap Adiposity

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Deoxycholic acid was developed into a synthetic form (ATX-101, Kybella) by Kythera Biopharmaceuticals, Inc. (Westlake Village, Calif.) in 2007, leading ultimately to U.S. Food and Drug Administration approval in 2015 for the reduction of submental fat. Interestingly, histologic studies were initially performed in abdominal fat: in a multicenter Phase I study, Kybella was injected into subjects’ abdominal fat pads at different time points before abdominoplasty, and tissue biopsy specimens were then examined microscopically.1
Although subsequent clinical trials assessed the clinical effect of Kybella for submental fat, the off-label use of the treatment for expanded indications at other anatomical sites appears to be gaining traction in the dermatology and plastic surgery communities.2 One such anatomical site is the posterior upper torso brassiere strap region. Fat deposition in this scapular and periscapular region may prove bothersome to women, as fat deposition protrudes outward under external compression when wearing form-fitting dresses or athletic tank tops, creating a “bra-bulge,” with overhang of tissue over the inferior lateral posterior brassiere strap regions. Current treatment options to address this region include traditional suction lipectomy, posterior upper body lift, cryolipolysis, and most recently, off-label use of Kybella. We have had promising results using Kybella injections to treat this region and, in this communication, present our positive experience.
A total of five patients with posterior bra-bulge were treated. Each underwent three total treatment sessions of Kybella (a single 20-mg/2 ml vial per region for a dose of 2 mg/cm2 achieved by means of 0.2-ml injections spaced at 1-cm intervals) every 4 weeks (Fig. 1). Measurements of tissue pinch thickness at the superior and inferior aspects of the treatment areas were taken before each session using a medical skinfold caliper (baseline) and 4 weeks after the final session.
After final treatment, patients experienced an average 5.2-mm reduction (range, 4 to 9 mm) in skin pinch thickness and a 17 percent reduction (range, 10 to 24 percent) in posterior bra-bulge from baseline (Fig. 2). Pain, swelling/edema, and bruising were all minor, and no patients experienced posttreatment contour irregularities. All patients expressed high satisfaction with their final result.
A previous study analyzing the average thickness of the subcutaneous fat layers for the scapular and parascapular region used ultrasound to assess appropriate donor sites for microvascular soft-tissue transfer, and demonstrated the scapular region to have an average thickness of 5.9 mm and the parascapular region to have an average thickness of 6 mm.3 Our results, demonstrating an average 5.2-mm reduction in this region, is consistent with this previous anatomical study, and suggests a favorable application of Kybella in treating aesthetically unappealing localized adiposity in this region.
Of note, the use of Kybella in our practice to treat brassiere strap–associated localized adiposity is limited to the posterior region, because anterior bra-bulge injections could theoretically be associated with fat necrosis and abnormal mammography leading to unnecessary biopsies. We have been able to provide safe and consistent results in using Kybella as an effective treatment for reduction of posterior upper torso brassiere strap adiposity.
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