Real- vs High-Definition Ultrasound-Assisted Liposuction in Men: Long-Term Outcomes and the Role of Helium Plasma Skin Tightening.

[BACKGROUND] Male body contouring has evolved from conventional debulking to high-definition liposuction (HDL) etching and, more recently, a "real-definition" c (RDL) approach emphasizing natural contours. The role of helium-plasma skin tightening (HPST) as an adjunct remains uncertain.

[OBJECTIVES] To compare long-term patient-reported outcomes, complications, and revision rates between RDL and HDL in men undergoing ultrasound-assisted liposuction (UAL), and to evaluate the selective role of HPST in improving skin quality.

[METHODS] A retrospective analysis was performed on 743 male patients who underwent primary UAL between 2008 and 2024. Patients were grouped by era: conventional (2008-2011), HDL (2011-2014), RDL (2015-2019), and RDL with HPST (2019-2024). Outcomes included BODY-Q satisfaction, complication severity, and revision rates. Regression, mediation, and propensity-score matching analyses were applied to identify predictors of durable satisfaction and recommendation.

[RESULTS] Mean satisfaction improved across eras: 59.3 (2008-2011), 57.7 (2011-2014), 66.8 (2015-2019), and 73.8 (2019-2024). HDL patients showed the lowest durable scores despite high early ratings and were most associated with self-reported "fake abs," which correlated with reduced BODY-Q domains. RDL produced more stable outcomes, particularly in men with BMI ≤25 and ≥4 exercise sessions/week. Sports frequency predicted higher satisfaction directly and indirectly via lower body mass index (BMI). Clinically meaningful complications declined from 15.4% to 4.6% across eras. Helium-plasma skin tightening was offered mainly to older, higher-BMI men and, after adjustment, was not independently associated with improved skin quality. RDL was linked to a lower revision risk (odds ratio (OR) 0.32, = .029).

[CONCLUSIONS] Real-definition liposuction provided natural, durable outcomes and fewer revisions than HDL. Over-etching increased unnatural contours and dissatisfaction. Careful patient selection-BMI ≤25, consistent exercise, and weight stability-is critical, while HPST may be reserved for older men with mild laxity.