Surgical and Non-invasive Treatments for Body Contouring - Jayne Joo, MD Director of Cosmetic Dermatology, Department of Dermatology, University
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Surgical and Non-invasive Treatments
for Body Contouring
Jayne Joo, MD
Director of Cosmetic Dermatology, Department of Dermatology, University
of California, Davis
Director of Mohs micrographic surgery, Sacramento VA Medical Center
Disclosure I have no relevant relationship with industry.
Fat is big business
§ United states is the most obese country in the world (35.3% of the
population age 15+)
ú Source: OECD Health Statistics 2015, http://dx.doi.org/10.1787/health-data-en.
§ According to the American Society of Dermatologic Surgery 88% of
Americans report feeling bothered by excess weight on their bodies
§ Improvement in psychosocial function, self-esteem, body image and
quality of life after aesthetic surgery
§ Demand for noninvasive forms of body contouring is increasing
ú Minimally invasive procedures increased by 137% from 2000 to 2012
in US
ú Liposuction has declined from 350,000 (2000) to 198,000 (2009)
§ In 2015, the global market for body shaping platforms and disposables
reached over $1 billion (Medical Insight Inc. “Energy Based Body
Shaping/Skin Tightening.” Medical Insight, Inc. 2016.)
Body contouring after massive weight loss Maia M, Costa Santos D. Body Contouring After Massive Weight Loss: A Personal Integrated Approach. Aesthetic Plast Surg. 2017 May 31.
Non-invasive: the future of fat removal? § Surgical body-shaping procedures down by 14% in 2012 § Advantages: ú Lower risk ú Fewer complications ú Less aftercare ú Faster treatment/healing time ú Less pain ú No need for anesthesia § Disadvantage: ú Tend to require multiple sessions ú Subtler results
Ideal treatment § Safe § Painless § No downtime § Fast § Effective in 1 or few treatments § One size fits all
Non-invasive technologies § Cryolipolysis § Radiofrequency § Laser-based § Light-based § Ultrasound § Injection lipolysis
Cryolipolysis § “Freeze fat” § Based upon concept of popsicle panniculitis § Controlled cooling of adipose tissue to induce adipocyte apoptosis § Reduces fat content by ~20-26% at treatment site § No downtime
Coolsculpting (Zeltiq)
§ FDA approved
§ Suction draws in target tissue into cup-shaped applicators
CoolAdvantage™
with interchangeable contours
§ Tissue is drawn into handpiece under vacuum
§ Treatment duration: 45 to 60 mins
§ # treatment cycles depends on area
§ 1 to 3 treatments spaced 8 weeks apartAdverse effects § Pain § Bruising § Erythema § Numbness § Dysesthesia
Coolsculpting Before After
Coolsculpting Before After
Long Lasting Results
Baseline 2 months 2 years 6 years
Baseline 3 months 5 years 9 years
Bernstein EF. Long-term efficacy follow-up on two cryolipolysis case studies: 6 and 9 years post-treatment. J Cosmet Dermatol. 2016 Dec;15(4):
561-564.Submental Contouring Kilmer SL, Burns AJ, Zelickson BD.. Safety and Efficacy of Cryolipolysis for Non-Invasive Reduction of Submental Fat. Lasers Surg Med. 2016 Jan; 48(1):3-13.
Submental Contouring with Cryolipolysis
Before 12 Week Follow-up
2 CoolSculpting Treatments
Procedure by Brian Zelickson, MD
(-4.5 lbs)Weight
change, 0.05
kg (0.1 lb)
(0.05%) from
baseline.
2 treatment cycles per visit to the lateral and
central submental areas, 2 treatments spaced
6 weeks apart
Bernstein EF, Bloom JD. Safety and Efficacy of Bilateral Submental Cryolipolysis With Quantified 3-Dimensional Imaging of Fat Reduction and
Skin Tightening. JAMA Facial Plast Surg. 2017 Apr 20.Paradoxical adipose hypertrophy
§ Rare, 1:20,000
§ Incidence 0.0051%
§ More common in males
§ Pathogenesis unknown
§ No single, common characteristic has been
identified among affected individuals
§ Onset 2 to 3 months after treatment
§ Does not spontaneously resolve
Jalian HR, Avram MM, Garibyan L, Mihm MC, Anderson RR. Paradoxical Adipose Hyperplasia After Cryolipolysis. JAMA Dermatol. 2014 March ;
150(3): 317–319High intensity focused ultrasound (HIFU) § Generates high-energy acoustic waves (100 to 10,000 W/cm2) that converge at a specific focal point in adipose tissue § Rapidly raises the temperature (to >65°C) around adipose tissue and causes coagulative necrosis § Focal point depth of 1.3 cm § Allows localized destruction of adipose tissue at precise tissue depths without damage to skin surface or surrounding tissue
Liposonix (Solta) § “1 hour, 1 treatment, 1 inch” § Contraindicated in patients with < 1 cm of adipose tissue beyond the focal treatment depth § Liposonix creates a temperature rise above 56°C effectively destroying the targeted adipose tissue without damaging tissue outside of the intended focal zone. § Macrophages are attracted to treated adipose tissue, engulfing free lipids and cellular debris. § Destroyed cells are naturally processed by the body and excreted gradually over 8-12 weeks.
Transducer focuses ultrasonic waves
that converge at a specific depth
Jewell ML, Solish NJ, Desilets CS. Noninvasive body sculpting technologies with an emphasis on high-intensity focused ultrasound. Aesthetic
Plast Surg. 2011 Oct;35(5):901-12.Gross pathology demonstrating
coagulative necrosis and eventual
resorption of treatment zone
Jewell ML, Solish NJ, Desilets CS. Noninvasive body sculpting technologies with an emphasis on high-intensity focused ultrasound. Aesthetic
Plast Surg. 2011 Oct;35(5):901-12.Histology showing adipocyte disruption Jewell ML, Solish NJ, Desilets CS. Noninvasive body sculpting technologies with an emphasis on high-intensity focused ultrasound. Aesthetic Plast Surg. 2011 Oct;35(5):901-12.
Safety, Tolerability, and Efficacy of HIFU
§ Sham-controlled trial, randomized trial
§ 168 patients, ages 18 to 65 years, BMI ≤
30 kg/m2
§ Baseline waist circumference change at
12 weeks post-tx: -2.52 cm (higher
energy) vs -2.10 cm (lower energy) vs
-1.21 cm (sham)
§ 47.5% “satisfied” to “very satisfied” with
treatment results
§ 51.7 to 53.4% “likely” or “very likely” to
pursue additional treatment
§ Adverse effects: mild to moderate
discomfort, bruising and edema
§ Less discomfort at lower energy levels
Jewell ML, Baxter RA, Cox SE, Donofrio LM, Dover JS, Glogau RG, Kane MA, Weiss RA, Martin P, Schlessinger J. Randomized sham-controlled
trial to evaluate the safety and effectiveness of a high-intensity focused ultrasound device for noninvasive body sculpting. Plast Reconstr Surg.
2011 Jul;128(1):253-62.Baseline Post treatment Baseline Post treatment
Decrease of 2.55 cm from baseline wait circumference
Jewell ML, Baxter RA, Cox SE, Donofrio LM, Dover JS, Glogau RG, Kane MA, Weiss RA, Martin P, Schlessinger J. Randomized sham-controlled
trial to evaluate the safety and effectiveness of a high-intensity focused ultrasound device for noninvasive body sculpting. Plast Reconstr Surg.
2011 Jul;128(1):253-62.VASER Liposuction
§ Vibration Amplification of Sound Energy at Resonance
§ Targets unwanted fat using ultrasonic technology
whilst preserving important tissues such as nerves,
blood vessels and collagen and helps with particularly
stubborn areas that will not shift through diet or
exercise and can improve overall shape.
§ Small probe inserted which is used to transmit sound
energy and liquefy fat cells prior to removal through a
suction process
§ Single treatment
§ Improves overall shape and body contour
§ Manual lymphatic drainage (massage to stimulate
lymphatic system) is recommended to encourage of
lymph fluid which helps with recovery and resultsVelashape § Syneron-Candela § Realself worth it rating 57% § For treating cellulite and reducing body circumference § Typically requires 3 treatment session § Combines infrared light, bipolar radiofrequency energy, vacuum and massage, which cause heating of fat cells and surrounding connective tissue/dermal collagen.
Ultrashape (Syneron-Candela) § The UltraShape Power system works by emitting acoustic waves of focused ultrasonic energy (200 ± 30 KHz frequency) that converge into a confined focal volume underneath the skin, thereby, targeting only subcutaneous fat at a controlled depth. Unlike traditional ultrasound technology, UltraShape Power’s energy transmits pulsed ultrasound, allowing control over temperature elevation. § 3 treatments, 2 weeks apart
Ultrashape
Photos: Ruthie Amir, MD
Photos: Eun Hee Kang, MD
Radiofrequency (RF)
§ Used for skin tightening >> fat/cellulite reduction
§ Causes thermal injury using electrical energy
§ Passing of energy creates heating
§ Monopolar vs multipolar
§ Monopolar RF:
ú Energy is passed from single electrode into the tissues
and directed to a return pad
§ Multipolar RF:
ú Two or more electrodes within the same handpiece are
positioned at different points on the skin so that the
waves pass between them to create a heating effect.Radiofrequency §.
EndyMed 3Deep § For body contouring and cellulite reduction § Multisource RF technology that delivers controlled, focused RF energy deep into the skin § Uses an array of several electrodes and a sophisticated algorithm that manipulates the phase of current flowing between each pair of electrodes. The multiple electrical fields created repel each other, leading to the ideal combination of energy directed to a deeper skin layer. The repelling forces between adjacent electromagnetic fields drive energy vertically into the target tissue, reducing the amount of energy flowing through skin surface and alleviating the need for cooling.
Venus Freeze § Venus Freeze is an FDA-approved, non-invasive treatment for cellulite and loose skin on the face, neck, and body. § Uses radio frequency and magnetic pulses to stimulate the generation of new collagen and elastin fibers over time. There is a recommended six sessions for the face/neck and eight to 10 for the body).
Inmode BodyFX § Radio-Frequency provides precise and optimal heating of the skin for reduction, contraction and body shaping § Negative Pressure Massage applies gentle vacuum pressure allowing for maximal depth treatment § Clinical studies show 30% adipocyte (fat cell) apoptosis at a 2.5 cm depth and new collagen synthesis (neocollagenesis) of 13.7%
BodyFX
BTL Vanquish § Uses patented Selective RF technology to cause selective healing of adipose tissue, leading to adipocyte shrinkage and elimination § No BMI limit § Contactless (hovers)
BTL Exilis § Combines RF and ultrasound to tighten skin
BTL Cellutone § For cellulite reduction and skin texture improvement § Can be used to enhance postop recovery after liposuction § Uses targeted high frequency mechanical vibrations § Enhance microcirculation and oxygen supply in affected area resulting in increased blood supply and removal of excess interstitial fluid.
Low level laser therapy (LLLT) § Non-thermal ablation of adipocytes § Primary phase: absorption of red and near infrared light ú Red diode laser 635 nm ú Green diode laser 532 nm § Secondary phase: biological cascade § LLLT excites cytochrome c oxidase (photoreceptor target), which upregulates ATP synthesis à activates transcription factors/gene expression à alters permeability of adipocytes § May adversely affect lipid profile and have effect on endocrine system and metabolism § Requires multiple treatments § Results are modest at best
SculpSure § Diode laser § Hyperthermic: 42 to 47C § Active cooling epidermis and dermis to protect skin § 1060 nm diode, large spot size for treatment § FAST: 25 minutes treatment cycles § Non-suction § 4 treatment areas simultaneously § FDA Cleared: Abdomen and Flank § Side effects: Induration. No PAH seen § On market almost one year § Results seen in 6 to 12 weeks
1060 nm Diode Heating of Fat
Rise in temperature from baseline
+4°C
+8°C +12°C 2.5 cm
Fat destruction zone
Feathering of heat
BaselineSculpsure Treatment Results
Courtesy of B. Katz, MD
FLANK TREATMENT
SIDE VIEW
Areas 1 and 2 treated on both flanksZerona (Erchonia Medical) § Low level diode laser with multiple heads § Uses low level laser therapy at 635 nm which promotes liberation of stored intracellular fat § Laser liberated fatty debris is thought to be eliminated from the treated area via lymphatics
§ Double-blind, randomized, controlled trial
§ 67 volunteers, ages 18-65, BMI 25-30 kg/m2
§ 3 treatments/week x 2 weeks
Jackson RF, Dedo DD, Roche GC, Turok DI, Maloney RJ. Low-level laser therapy as a non-invasive approach for body contouring: a randomized,
controlled study. Lasers Surg Med. 2009 Dec;41(10):799-809.Jackson RF, Dedo DD, Roche GC, Turok DI, Maloney RJ. Low-level laser therapy as a non-invasive approach for body contouring: a randomized, controlled study. Lasers Surg Med. 2009 Dec;41(10):799-809.
Injection lipolysis § Injection of fat reducing substance to localized areas of adiposity
KYBELLA™ (Allergan)
§ Nonhuman nonanimal formulation of
deoxycholic acid
§ Deoxycholic acid is an endogenous
secondary bile acid that normally solubilizes
dietary fat, contributing to its breakdown
and absorption within the gut
§ Cytolytic agent
§ Causes destruction of adipocytes
§ Once the aesthetic response is achieved, re-
treatment is not expected.
Georgesen C, Lipner SR. The development, evidence, and current use of ATX-101 for the treatment of submental fat. J Cosmet Dermatol. 2017
Apr 21.KYBELLA™
§ First and only FDA-approved
injectable drug that contours and
improves the appearance of
submental fullness associated
with fat
§ KYBELLA™ 10 mg/mL is supplied
in 2 mL, single patient use vials (4
pack)
§ Store at room temperature 20°C
to 25°C (68°F to 77°F)
§ Each vial is for a single patient use
§ Do not dilute or admix KYBELLA™Dosing and administration § 0.2 mL injections spaced 1 cm apart until all sites in the planned treatment area have been injected § Up to 50 injections or 10 mL may be injected in a single treatment § Up to 6 single treatments may be administered at intervals no less than 1 month apart
Treatment area landmarks
Pre-Platysmal Fat
Poor candidates § Excessive skin laxity § Marked superficial wrinkling § Loose skin adherence § Redundant skin § Prominent platysmal bands § Too much submental fullness
Common adverse reactions § Edema/swelling § Hematoma/bruising § Pain § Numbness § Erythema § Induration
Precautions § Marginal mandibular nerve injury § Difficulty swallowing (dysphagia) § Injection site hematoma/bruising § Do not inject into or near (within 1 to 1.5 cm) salivary glands, lymph nodes and muscles
Kybella
Combining modalities
Male Body Contouring
Post-pregnancy body
Lipedema
How to pick the right body contouring
for your practice
§ Patient demographics
§ Clinic size/space
§ Staff
ú Resource intensive?
§ Budget
ú Capitol cost of device
ú Cost of consumables
§ Treatment protocolWhen purchasing a device 1. Do your due diligence ú Attend meetings ú Speak to others who have device 2. Don’t fall for before/after marketing photos 3. Ask for evidence from clinical trials ú FDA clearance? 4. Try before you buy ú Ask for loan period 5. Be careful of cheap no-name devices, especially unproven devices from unknown manufacturers ú Ask about warranty/service ú Manufacturer support ú Continuous training
Preparation § Marketing plan § Price strategy § Information brochures § Posters § Before and after photos
Realself worth it ratings
§ Coolsculpting 81% § Sculpsure 73%
§ Liposonix 67% § Cellulaze 62%
§ Laser lipo 84% § Kybella 80%
§ Bodytite 71% § Vaser Lipo 91%
§ Velashape 57%
§ Ultrashape 85%
§ Zerona 70%
§ BTL Vanquish 70%
§ Endymed 56%
§ Venus Freeze 28%Liposuction § Gold standard for body contouring § Expensive and invasive § More downtime § Less sought by most patients § Newer technologies: ú Ultra-sound assisted ú Power-assisted ú Laser-assisted ú Radiofrequency-assisted
Complications § Abnormal body contour § Nerve damage § Fibrosis § Perforations § Seroma § Fat embolism § Deep vein thrombosis § Pulmonary embolism
Liposuction
Submental liposuction
Klein’s recipe for tumescent anesthesia
§ Lidocaine
ú 500 mg (50 ml of 1% lidocaine solution)
§ Epinephrine
ú 1 mg (1 ml 1:1,000 epi solution)
§ Sodium bicarbonate
ú 12.5 mEq (12.5 ml of 8.4% NaH2CO3 solution)
§ Normal saline
ú 1,000 ml of 0.9% NaCl solution
Lidocaine 0.05%, Epinephrine 1:1,000,000
Klein JA. The tumescent technique. Anesthesia and modified liposuction technique. Dermatol Clin. 1990 Jul;8(3):425-37.Benefits of tumescent technique
§ Minimizes risks of postop irregularities/distortions of
the skin
§ Decreases surgical risk
§ Minimizes fluid shift
§ Decreases blood loss (12 ml whole blood per liter of fat
extracted)
§ Decreases anesthetic risk (lidocaine toxicity)
ú Maximal safe dose of lidocaine for liposuction: 45 mg/kg
§ Peak plasma lidocaine levels occur 12 hours after initial
injection
§ Local anesthesia persists for up to 18 hoursLaser-assisted liposuction
§ Variation on traditional liposuction
§ Involves fiberoptic delivery of laser energy to
target tissues
§ Laser energy liquefies fat before removal
through a cannula
§ Makes fat easier to remove
§ Less aggressive/traumatic
§ May offer faster recovery timelineCellulaze (Cynosure) § Uses 1440 nm laser with side-firing fiber inserted subcutaneously to thermally subcise fibrous septae
Smart Lipo/Laser Lipo
BodyTite™ (Invasix Ltd, Israel)
§ Radiofrequency-assisted liposuction
§ Uses bipolar device to deliver radiofrequency
energy that is converted into heat which melts
fat, making it easier to remove
§ Also improves hemostasis and skin tightening
§ Need to be cautious of cannula tip location
§ Complication rate 14.6%
ú infection, seroma, burn, medication reaction
Theodorou SJ, Paresi RJ, Chia CT. Radiofrequency-Assisted Liposuction Device for Body Contouring: 97 Patients under Local Anesthesia. Aesth
Plast Surg (2012) 36:767–779BodyTite Theodorou SJ, Paresi RJ, Chia CT. Radiofrequency-Assisted Liposuction Device for Body Contouring: 97 Patients under Local Anesthesia. Aesth Plast Surg (2012) 36:767–779
BodyTite
82-85% patient satisfaction
89% would recommend procedure
58.% had good to excellent skin tightening
Majority reported minimal to no discomfort
Theodorou SJ, Paresi RJ, Chia CT. Radiofrequency-Assisted Liposuction Device for Body Contouring: 97 Patients under Local Anesthesia. Aesth
Plast Surg (2012) 36:767–779Liposculpture § Liposuction that involves removing or leaving fat in specific areas to create the appearance of muscle definition § Creates illusion of abdominal 6-pack by leaving behind small amounts of fat to mimic muscle fullness (“abdominal etching”)
Cellfina § Uses subcision
Cellfina
Abdominoplasty Pre Post
Abdominoplasty
Abdominoplasty
Patient selection
§ Thorough history (diet and exercise)
§ Reason for seeking treatment
§ Expectations
§ Weed out patients with BDD
§ BMI < 30
Underpromise, overdeliverBody dysmorphic disorder (BDD) § Characterized by a distressing and obsessive preoccupation with an imagined or slight defect in appearance § Associated with significant distress, disability (including social isolation and occupational dysfunction), cosmetic surgery and suicidality § Prevalence in general population: 1.7 – 2.4% § Prevalence in dermatology settings: 8.8-14%
Body dysmorphic disorder
questionnaire (BDDQ)
§ Validated, self screening questionnaire
§ Derived from DSM-IV diagnostic criteria for
BDD
§ Modified from version used in psychiatric
setting
§ Highly effective screening tool in cosmetic
dermatology setting
ú 100% sensitivity, 93% specificity
Dufresne RG, Phillips KA, Vittorio CC, Wilkel CS. A screening questionnaire for body dysmorphic disorder in a cosmetic dermatologic surgery
practice. Dermatol Surg. 2001 May;27(5):457-62.Sample questions to screen for BDD § Are you very concerned about the appearance of some part of your body, which you consider especially unattractive? Y or N § Do you think about these concerns a lot and find it hard to stop thinking about them? Y or N § How much has your defect caused you distress, torment or pain? 1 to 5 (1 = none, 5 = extreme) § How much has your defect caused impairment in social, occupational or other important areas of functioning? 1 to 5 (1 = none, 5 = extreme)
Summary § Non-invasive or minimally invasive alternative to liposuction
References
§ Song AY, Rubin JP, Thomas V, Dudas JR, Marra KG, Fernstrom MH. Body image and quality of life in post massive
weight loss body contouring patients. Obesity (Silver Spring). 2006 Sep;14(9):1626-36.
§ Klassen A, Jenkinson C, Fitzpatrick R, Goodacre T. Patients' health related quality of life before and after aesthetic
surgery. Br J Plast Surg. 1996 Oct;49(7):433-8.
§ Maia M, Costa Santos D. Body Contouring After Massive Weight Loss: A Personal Integrated Approach. Aesthetic Plast
Surg. 2017 May 31.
§ Dufresne RG, Phillips KA, Vittorio CC, Wilkel CS. A screening questionnaire for body dysmorphic disorder in a cosmetic
dermatologic surgery practice. Dermatol Surg. 2001 May;27(5):457-62.
§ https://aestheticsjournal.com/hub/Body%20Contouring
§ Klein JA. The tumescent technique. Anesthesia and modified liposuction technique. Dermatol Clin. 1990 Jul;8(3):425-37.
§ Jewell ML, Baxter RA, Cox SE, Donofrio LM, Dover JS, Glogau RG, Kane MA, Weiss RA, Martin P, Schlessinger
J. Randomized sham-controlled trial to evaluate the safety and effectiveness of a high-intensity focused
ultrasound device for noninvasive body sculpting. Plast Reconstr Surg. 2011 Jul;128(1):253-62.
§ Jewell ML, Solish NJ, Desilets CS. Noninvasive body sculpting technologies with an emphasis on high-
intensity focused ultrasound. Aesthetic Plast Surg. 2011 Oct;35(5):901-12.
§ Avram MM, Harry RS (2009) Cryolipolysis for subcutaneous fat layer reduction. Lasers Surg Med 41:703–708
§ Kilmer SL, Burns AJ, Zelickson BD.. Safety and Efficacy of Cryolipolysis for Non-Invasive Reduction of
Submental Fat. Lasers Surg Med. 2016 Jan; 48(1):3-13.
§ Bernstein EF, Bloom JD. Safety and Efficacy of Bilateral Submental Cryolipolysis With Quantified 3-
Dimensional Imaging of Fat Reduction and Skin Tightening. JAMA Facial Plast Surg. 2017 Apr 20.
§ Jalian HR, Avram MM, Garibyan L, Mihm MC, Anderson RR. Paradoxical Adipose Hyperplasia After
Cryolipolysis. JAMA Dermatol. 2014 March ; 150(3): 317–319
§ Jackson RF, Dedo DD, Roche GC, Turok DI, Maloney RJ. Low-level laser therapy as a non-invasive approach for
body contouring: a randomized, controlled study. Lasers Surg Med. 2009 Dec;41(10):799-809.References cont’ § Georgesen C, Lipner SR. The development, evidence, and current use of ATX-101 for the treatment of submental fat. J Cosmet Dermatol. 2017 Apr 21.
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