Journal of Cosmetic Surgery

Effects of Pulsed Electro-Magnetic Field (PEMF) Technology on Post-Liposuction Ecchymosis and Recovery - A Case Series

Abstract

Our case series aims to determine the effects of Pulsed Electro-Magnetic Field (PEMF) on liposuction patients after surgery. The effects we focus on during the recovery period is ecchymosis (bruising), which is a common sign and symptom after liposuction surgery.

PEMF technology has been used in various specialties in the medical field for its non-invasive benefits in aiding the speed of recovery after surgeries and injuries. Applying this knowledge to our post-liposuction patients, it was found that PEMF hastened the entire process of bruising by at least a week. Brusing was shortened from an average of 3-4 weeks to 1-2 weeks, resulting in a faster recovery altogether. Patients also experienced less soreness and therefore required less pain medications. While this case series focused on effects of pulsed electromagnetic field (PEMF) treatment on bruising, it would be beneficial to investigate further the benefits of PEMF and Radiofrequency (RF) on post-surgical swelling.

Keywords

Pulsed electromagnetic field, Liposuction recovery, Bruising healing, Radiofrequency

Introduction

Pulsed Electro-Magnetic Field (PEMF) Technology was first introduced as a medical treatment in the specialty of osteology, focusing on bone tissue and osteogenesis [1]. It is an external, non-invasive device that can be placed directly on skin, generating short bursts of electrical current in injured tissue without interfering with nerve or muscle function [2].

The mechanism behind PEMF has been long discussed, but in its regard to controlling growth factors and inflammation, PEMF relies on an increase in calcium (Ca ²⁺ ) binding to calmodulin (CaM) [2], resulting in a nitric oxide (NO) cascade. Which is synthesized by nitric oxide synthase (NOS) [3]. NOS has multiple isoforms, but endothelial and neuronal nitric oxide synthase isoforms (eNOS and nNOS) in particular, release NO in short bursts which relaxes blood and lymph vessels instantly [4]. The short burst of NO further promotes production of cyclic guanosine monophosphate (cGMP) thereby driving growth factor production [5]. Increased growth factor production stimulates cell growth and therefore tissue repair [6]. These combined effects result in angiogenesis, tissue regeneration, and remodeling.

PEMF treatment has been used in many different specialties of medicine as it is a non-invasive and safe treatment that effectively aids in recovery of trauma and injury [7]. A major clinical application of PEMF is treatment of breast cancer patients suffering from lymphedema, a clinical trial found that PEMF aided in reducing pain and was able to reduce lymph swelling in conjunction with exercise therapy [8]. Clinical applications of PEMF in plastic surgery are applied in surgeries such as breast augmentation and abdominoplasty, with improvements to patient pain, healing and recovery. The focus of this case series is the cosmetic surgery applications of PEMF, particularly the use of PEMF on ecchymosed skin at the site of liposuction. Liposuction surgery is the removal of adipose tissue with a suction machine from the subcutaneous space [9].

The anticipated post-surgical reactions include swelling, bruising, and pain. Our protocol for swelling control is wearing compression garments for a period of 4-6 weeks. Ecchymosis is generally observed immediately after surgery and can take up to 4 weeks to gradually improve, but in certain cases bruising is persistent - such as patients who are on blood thinners [10]. Ecchymosis may not cause patients extreme pain, but it can cause discomfort in the recovery process and may result in a reliance on pain medications. Another reason to shorten bruising time is to minimize risk of hemosiderin staining to the overlying skin with prolonged bruising, which poses an aesthetic concern for patients.

As such, the use of PEMF to reduce the amount and time of bruising greatly lessens patients’ discomfort and allows for a smoother recovery. Our case series will aim at demonstrating potential positive effects of PEMF on bruising, in liposuction patients during the recovery period. Furthermore, this study aims determine whether there is an avenue for further research into quantifying the effects of PEMF, and if PEMF technology can be standardized to ease patient recovery.

Methods

Patients who had undergone Liposuction surgery through our aesthetic clinician practice, between October 2022 and October 2024, were selected for this case series. Patients enrolled consented for their photos to be published, and/or for their data to be published. Patients who did not consent to be part of this study still received PEMF treatments after liposuction as part of our aftercare protocol.

Patients were consulted twice before undergoing surgery at one of two accredited day hospitals in Sydney Australia, then returning to our clinic for follow-up appointments. All liposuction procedures were performed by one practitioner, Dr Charlotte Ying, and all received liposuction with tumescent solution with varying amounts of infiltration depending on the surgical area, under general anaesthesia. All tumescent bags consisted of normal saline 1 litre, lignocaine 200 mg, adrenaline 1 mg. The liposuction technique used was suction-assisted liposuction (SAL). All patients were discharged the same day with a garment in-situ, with 5 days of oral pain medications (paracetamol 500 mg and codeine phosphate hemihydrate 30 mg) and oral antibiotics (cephalexin 500 mg). None of the patients in this case series had any medications, herbal tablets or supplements for bruising treatment, for example, Arnica tablets, Arnica creams, and/or tranexamic acid.

All patients had the same schedule of follow-up appointments: Day 2, Day 7, Day 14, 6 weeks, 6 months and 1 year. At the day 2 follow-up appointment patients underwent a change of dressings with wound review and cleaning. If there was bruising present, PEMF treatment was immediately applied. In addition to these follow-up appointments, one extra PEMF treatment was added on day 4 if there was extensive bruising. On day 7 patient had wounds cleansed and reviewed, then sutures removed. If the patient presented with any residual bruising on day 7, we proceeded with another PEMF treatment, if there wasn’t any bruising low power lymphatic drainage treatment through radiofrequency (RF) was utilized. This was repeated on day 14 with PEMF and RF treatment for lymphatic drainage. For reviews at weeks 4, 6 and 8, RF treatment was used to soften fibrosis and aid lymphatic drainage. Patients who did not present with bruising on day 2 did not receive PEMF treatments.

Our routine protocol for bruising treatment is direct application of the Venus Bliss™ machine’s (Multi-Polar2) RF applicator onto bruised skin for 5 minutes. This is performed on each bruise, or the area of the applicator (if the bruise is larger than the applicator’s range).

The PEMF and RF technology utilized in our study is from Venus Aesthetic Intelligence. The exact machine used was the Venus Bliss ^TM device, which uses (MP) ² technology - a combination of Multi-Polar RF and PEMF in one applicator. The (MP) ² applicator has a maximum RF output power of 150 Watts and a frequency of 1 MHz. The constant magnetic field is at 15 Gauss and the magnetic pulse frequency is at 15 Hz. The applicator has 4 suction levels of strength when RF is utilized. The settings of the machine were adjusted to each patient's pain tolerance and comfort. For PEMF treatments the RF setting was turned off. Unlike RF treatments where heat is usually generated, Pulsed Electromagnetic Field does not generate heat. It is therefore safe and comfortable to directly place the PEMF applicator onto intact ecchymosed skin, without the need of using any conducting medium.

Pictures were taken at each follow-up appointment, if treatment was conducted pictures were taken before and after. All photos were taken using a Sony Alpha A6000 with the same lighting, all photos were uploaded directly from the camera to patient files - no editing in any way was conducted on photos. Levels of bruising were graded using figure 1 [11].

Results

A total of 16 patients were enrolled in this case series, all of whom consented usage of their data for publication. Ten patients consented for both their photos and data to be published, while six denied permissions for photos to be published. Fourteen patients (87.5%) needed one PEMF treatment in their recovery period for bruising to subside within 7 days. Two patients (12.5%) had two PEMF treatments within one week due to the severity of bruising (on day 2 and day 4). Full resolution of bruising for one of these two patients was reached by day 14, and day 16 for the second patient. The average time for bruising resolution was 8 days. No pain or discomfort was reported during the PEMF treatments, and there were no complications from the PEMF treatments.

Figure 2A and 2B (Age: 49) underwent liposuction surgery on the abdomen and flanks. The patient accidentally took a dose of aspirin for pain on day 1 against our aftercare protocol, resulting in extensive bruising. Figure 2A shows mixed stage 1 and 2 bruising and deep bruising in the lower abdomen and the left and right iliac regions on day 2. Light stage 4 bruising in the middle and upper regions of the abdomen are also noted. PEMF was applied on the entire abdominal area, 5 minutes of PEMF on each region of bruising. Figure 2B shows no evidence of bruising at any stage on day 7. The skin discoloration is from a self-tanning product the patient applied the day before.

Figure 3A and 3B (Age: 44) had liposuction surgery of the outer thighs and flanks. As seen in figure 3A, stage 2 bruising is present in the upper right flank region as well as stage 4 in the middle of the lateral right thigh. PEMF was applied for 5 minutes on each bruise. Figure 3B, at day 7, bruising in the upper right flank region is no longer seen and only slight discolouration is evident. Furthermore, the bruise present in the centre on the lateral right thigh had progressed to a stage 2 bruise and become smaller.

Figure 4A and 4B (Age: 48) received liposuction surgery on flanks and inner thighs. Figure 4A shows stage 3-4 bruising at day 2 postoperative in the lumbar and sacral regions. PEMF was applied for 5 minutes on each region of bruising. In Figure 4B the bruising in the lumbar and sacral regions has completely resolved. Note that there is extensive bruising on her inner and posterior thighs as this region was not treated on day 2 postoperative. The improvement of bruising is clearly from PEMF treatment.

Figure 3C and 3D (Age: 56) underwent liposuction surgery to the thighs and knees. Figure 3C shows stage 2-3 bruising concentrated in the outer thigh region on day 7. PEMF treatment was applied for 5 minutes to each bruise region. In Figure 3D it is shown that a week later at day 14, the patient’s bruising has subsided completely. No PEMF treatment was applied on day 2 as the patient had no bruising evident at this time.

Figure 5A and 5B (Age: 21) had liposuction surgery of the arms. In figure 5A bruising of stage 4 is seen throughout the tricep region as well as the elbow area on day 7. PEMF treatment was applied for 5 minutes on each bruise. Seen in figure 5B, there is no bruising evident at day 14 appointment. Of note this patient had very minimal bruising on day 2, no PEMF was applied then.

Figure 2C and 2D (Age: 59) underwent liposuction surgery to abdomen and flanks. In figure 2C, bruising is evident in the right and left iliac regions at stage 2 on day 2. PEMF treatment was applied for 5 minutes on each region. In figure 2D the patient's bruising is completely resolved at the day 7 appointment.

Figure 4C and 4D (Age: 59) had liposuction surgery on abdomen and flanks. Figure 4C shows swelling in the lower abdomen on day 7. This patient received PEMF and low RF treatment to the lower abdominal region for lymphatic drainage, and PEMF to the bruise on the hip region. Immediately after the treatment, as shown in figure 4D, the patient’s abdominal swelling reduced significantly, with slight lightening of her bruising. The patient’s bruising was fully resolved a week after PEMF treatment.

Figure 5C and 5D (Age: 49) received liposuction to the arms. Figure 5C shows at day 2 the patient experienced stage 3 bruising. PEMF treatment was applied for 5 minutes on each bruise. In figure 5D, bruising is no longer present anywhere on the arm at day 7.

Figure 2E and 2F (Age: 75) underwent fat harvest surgery for stem cells using liposuction to the abdomen. Shown in figure 2E, the patient experienced extreme bruising of various stages to the entire abdominal region on day 2. PEMF treatment was applied for a total of 20 minutes. An additional PEMF treatment was performed on day 4 due to the intensity of bruising. Figure 2F shows bruising almost completely resolved by day 14. There is slight discolouration and a bruise of stage 4 in the left iliac region.

Discussion

PEMF treatment has been widely used in the medical field as a non-invasive and safe therapy for patients recovering from trauma and injury. PEMF treatment is not revolutionary, it has long been used benefiting patients with pre-existing conditions or as post-trauma/postoperative treatment. Current evidence of PEMF in orthopedic specialties has found that patients with osteoarthritis after receiving PEMF treatment experience a reduction in pain and increased physical function, creating an effect of reduced medication usage and improved quality of life [12].

Clinical evidence based on plastic surgery cases have found PEMF beneficial for managing postoperative pain, swelling and wound repair for surgical scars. One author suggested that PEMF treatment “may well play a large role in treatment of otherwise intractable wounds” as it is cost-effective and has no adverse effects [2].

It is evident from our observations that PEMF technology significantly reduces bruising duration after liposuction surgery. 87.5% of cases in our study had complete resolution of bruising following one PEMF treatment. It is also common for bruising to migrate distally due to effects of gravity. In our case series, we demonstrated that PEMF minimized this migration. The average bruising time from this case series was found to be 8 days, which is significantly shorter than the average of 21-28 days [10]. We recorded one case of hemosiderin staining from bruising in our study, which suggests that prolonged bruising can negatively impact aesthetic results and patient expectation of the liposuction procedure.

An interesting effect of PEMF that was discovered during our study was its benefit in pain management. Figure 2E and 2F experienced the most bruising in our case series on day 2 (Figure 2E), it is noted that this patient also experienced swelling and tenderness. Immediate pain relief and swelling reduction were reported with this patient after one combined PEMF and RF treatment. The patient also reported that there was no pain unless applying hard pressure on their abdomen after the second PEMF treatment on day 4. This reduction in pain is found to be consistent throughout our study and in our clinical practice, resulting in reduced prescription pain medications (Codeine) and earlier conversion to milder pain relief medications (paracetamol only).

In our practice prior to utilization of PEMF, the average number of days that a liposuction patient required prescription medication (paracetamol 500 mg and codeine phosphate hemihydrate 30 mg) was 4 days postoperative. We were able shorten this to 2 days after incorporating PEMF in our recovery protocol post-liposuction. The reduction in pain resulted in decreased prescriptions of pain medications, minimizing patients’ reliance on pain relief drugs. However, pain is subjective, and patients may relate discomfort to pain. Therefore, a systematic way for patients to grade their pain must be implemented in future studies.

Despite typical protocol of using compression garments to reduce and resolve swelling, it seems that RF treatment should be further explored to be implemented in postoperative recovery of liposuction surgery, due to its powerful lymphatic draining properties [13]. Our PEMF device, the Venus Bliss ^TM device by Venus Aesthetic Intelligence, has an RF option which greatly benefited our patients to target swelling and fibrosis once bruising was resolved. It does not seem that PEMF had a major effect on swelling compared to the significant benefit on bruising, but it was found that using low level Radiofrequency as a lymphatic drainage technique was more efficient for our patients to reduce swelling.

The length of PEMF treatment time was 5 minutes on each bruise. For larger bruises, duration of treatment is determined by applicator size, as larger bruises may need a longer treatment time to cover the whole area. It is, however, clear that even 5 minutes of PEMF treatment greatly benefited patients in reducing bruising - further study may be needed to determine the most effective time of treatment. Current clinical applications of PEMF treatment in the osteology specialty focus on healing fractures. It was found that patients who received PEMF treatment for ≥ 9 hours a day healed ~76 days earlier, than patients that received PEMF treatment for ≤ 3 hours a day [14]. Previous applications suggest that longer PEMF treatment time improves efficiency of the healing process.

In future case series, a larger cohort will further demonstrate the efficacy of PEMF treatment, and daily monitoring of bruising evolution after liposuction will provide a more detailed timeline of results. Comparison of a range of treatment times must also be measured to determine the most effective time of PEMF treatment for liposuction recovery. It would be beneficial to include treatment control areas on the same patient, i.e. treating one side of a body area affected by bruising and not the other on the same patient, to provide a better comparison of the effects of PEMF and its results. Another factor to consider is the type of Liposuction surgery each patient underwent and in further research to separate results to compare how bruising evolved in different post-surgical areas.

To develop our research past this preliminary case study, our plans are to outline an experimental method that can quantify our results with a larger cohort so that statistics can be incorporated into our study. This preliminary case study does not have any statistics as it would not be accurate nor consistent with only sixteen patients, as different areas and conditions were being treated. As such in the future, we will be expanding our research by quantifying evolution of bruising through measurements, to record minimizing and migration of ecchymosis, as well as a numeric scale of color changes throughout bruising evolution (in addition to taking pictures). Further developments in research would also include statistics of the ease of recovery on patients through mental and physical tests or questionnaires, to better indicate benefits of PEMF technology directly through patient perspective.

In conclusion, our case study demonstrates that PEMF treatment safely and significantly reduces bruising time after liposuction and alleviates postoperative pain. This treatment, together with RF lymphatic drainage treatment, can greatly reduce our patient’s recovery time after liposuction surgery in our clinical practice, and has become the gold standards in our post-surgical management protocol. We also incorporate this technology in our post-injectable bruising, whereby we apply PEMF (without RF) directly onto a bruise from hyaluronic acid filler or Botulinum toxin, immediately after the injections when a bruise becomes apparent. Further research is heavily required as while this may be a standard in our post-surgical protocol, it would be beneficial if our future research could assist other surgeons in easing patient recovery after Liposuction surgery or other treatments.

Disclosures

The PEMF technology is incorporated within the Venus Bliss ^TM device Machine by Venus Aesthetic Intelligence, which is owned by Dr Charlotte Ying. Conflict of Interest: Dr Charlotte Ying is a Key Opinion Leader of Venus Aesthetic Intelligence. There was no financial profit nor benefits received from Venus Aesthetic Intelligence for the research and publication of this paper. The Venus Bliss ^TM device machine is used at our clinic for profited treatments, however in this case series patients did not pay extra for PEMF treatments. Patients did not receive any discounts or benefits from participating in this case series and in no way incentivized. Patient photos taken and published in this paper were used with the patient’s explicit permission.

References

1. Punt BJ, den Hoed PT, Fontijne WPJ (2008). Pulsed electromagnetic fields in the treatment of nonunion. European Journal of Orthopaedic Surgery & Traumatology 18: 127-133.
2. Strauch B, Herman C, Dabb R, et al. (2009) Evidence-based use of pulsed electromagnetic field therapy in clinical plastic surgery. Aesthet Surg J 29: 134-143.
3. Bruckdorfer R (2005) The basics about nitric oxide. Mol Aspects Med 26: 3-31.
4. Hagendoorn J, Padera TP, Kashiwagi S, et al. (2004) Endothelial nitric oxide synthase regulates microlymphatic flow via collecting lymphatics. Circ Res 95: 204-209.
5. Korhonen R, Lahti A, Kankaanranta H, et al. (2005) Nitric oxide production and signaling in inflammation. Curr Drug Targets Inflamm Allergy 4: 471-479.
6. Park JW, Hwang SR, Yoon IS (2017) Advanced growth factor delivery systems in wound management and skin regeneration. Molecules 22: 1259.
7. Flatscher J, Loriè EP, Mittermayr R, et al. (2023) Pulsed electromagnetic fields ( PEMF)-physiological response and its potential in trauma treatment. Int J Mol Sci 24: 11239.
8. Anuja P (2018) Comparison of conventional physiotherapy with pulsed electromagnetic field therapy in breast cancer patients with lymph-edema. International Archives of BioMedical and Clinical Research.
9. Wu S, Coombs DM, Gurunian R (2020) Liposuction: Concepts, safety, and techniques in body-contouring surgery. Cleve Clin J Med 87: 367-375.
10. Dixit VV, Wagh MS (2013) Unfavourable outcomes of liposuction and their management. Indian J Plast Surg 46: 377-392.
11. Sherris D (2019) Bruising after eyelid surgery - How long will it last? Facial Plastic Surgery.
12. Cianni L, Di Gialleonardo E, Coppola D, et al. (2024) Current evidence using pulsed electromagnetic fields in osteoarthritis: A systematic review. J Clin Med 13.
13. O'Brien JG, Chennubhotla SA, Chennubhotla RV (2005) Treatment of Edema. American Family Physician 71: 2111-2117.
14. Hu H, Yang W, Zeng Q, et al. (2020) Promising application of Pulsed electromagnetic fields ( PEMFs) in musculoskeletal disorders. Biomed Pharmacother 131.