In a society where undertaking beautifying enhancements no longer holds the stigma it once did, more people are claiming their right to a personalized aesthetic ideal. And as the market for cosmetic procedures grows exponentially, increasingly advanced nonsurgical technologies are providing safer treatments. While surgical liposuction is also growing in popularity, albeit more slowly, less invasive, energy-based body shaping is sharply on the rise.
In the March 2019 preview of its 2018 annual statistics, the American Society of Plastic Surgeons (ASPS) reported an upsurge in new trends in body shaping procedures this past year, with a spike in non-invasive fat reduction. In 2017, the American Society for Aesthetic Plastic Surgery (ASAPS) listed nonsurgical fat reduction, which included procedures that employ energy-based devices, up 24.7%.
Leading technologies
Prevalent energy-based body shaping technologies include radiofrequency (RF), laser and ultrasound, including high-intensity focused ultrasound (HIFU), as well as cryolipolysis, electromagnetic energy, radial shockwave and more.
“Currently, cryolipolysis is king,” expressed Suzanne Kilmer, MD, a dermatologist and founder of the Laser and Skin Surgery Center of Northern California (Sacramento, Calif.), clinical professor at the University of California, Davis and past president of the American Society for Laser Medicine and Surgery (ASLMS).
“While RF is up-and-coming, ultrasound energy and 1064 nm lasers are vying for popularity,” she continued. “More recently, we have seen high-intensity focused electromagnetic (HIFEM) technology emerge as a great adjunctive treatment.”
Cryolipolysis, by virtue of Allergan’s CoolSculpting device, is perhaps the most well-known fat reduction and body shaping technology right now. “The CoolSculpting method is effective on many patients,” noted Michael Somenek, MD, a facial plastic surgeon in Washington, D.C. “In addition, while most people tolerate the cold, after the treatment there is some massage, which can be quite painful, at times.”
To deal with pain associated with the massage, some practitioners have incorporated Z Wave radial shock-wave technology from Zimmer MedizinSystems, (Irvine, Calif.), as an adjunct therapy. It works with non-invasive lipolysis devices, enhancing the effect and providing a more consistent outcome, as well as relieving associated pain. The company also markets a cryolipolysis-based body shaping device, ZLipo.
As reported by Marc J. Salzman, MD, a plastic surgeon in Louisville, Ky., and assistant clinical professor of plastic surgery at the University of Louisville, “We combine cryolipolysis with acoustic soundwave therapy because it increases the amount of apoptosis that you can achieve. The sound waves break up the cells that are hanging on that would otherwise survive.”
Among other types of energy-based modalities that have found favor in aesthetic practices, for Dr. Salzman, “the possibilities with RF are quite interesting. We have come up with excellent ways of using RF under the skin, and now we have injectable RF via microneedling. The design of how to apply the RF is limited by the three keys of skin tightening. First, the temperature you have to reach, followed by the time you have to be at that temperature to achieve a therapeutic effect and then the patient’s tolerance.”
A recently released example of an RF-based body shaping system, truSculpt® iD, from Cutera® (Brisbane, Calif.), offers distinctive handpiece and placement location versatility and customizable 15-minute protocols to treat the full abdomen or multiple body areas simultaneously. This powerful, non-invasive monopolar RF platform adapts to patients’ individual needs and features real-time temperature control for clinically proven results, safety and patient comfort.
Another new standard in RF-based contouring that boasts effective, 15-minute treatments is InMode’s AccuTite device, which delivers precision heating via the company’s proprietary radiofrequency assisted lipolysis (RFAL) technology, which uses thermal energy to promote skin tightening and remove unwanted fat, inducing collagen production for firmer skin. AccuTite’s efficacy is backed by a number of clinical studies and peer-reviewed publications.
RF-based aesthetic platforms that offer multiple modalities have grown in acceptance, as well. For instance, the Thermi® line of devices, from Thermi, a Celling Biosciences Company (Dallas, Texas), which includes ThermiTight® for body shaping, are controlled via the firm’s A RVATI™ system. This new technology regulates the emission of continuous RF waves and features an enhanced 50W capacity, as well as intelligent software with electrode recognition, improved treatment speed and advanced temperature-control technology.
Non-invasive HIFEM® is new on the aesthetic scene, although it is established in the urology and gynecology fields. As an electromagnetic field passes through the body, it intermingles with motor neurons, which then trigger supramaximal muscle contractions. The exposure of muscles to these contractions leads to their strengthening. This technology addresses fat to an extent, but mostly provokes muscle contractions that result in muscle building and body sculpting effects.
The first device of this type marketed to aesthetic practices, EMSCULPT®, from BTL Aesthetics (Marlborough, Mass.), “Does not so much reduce fat as it helps sculpt the body from a muscle standpoint,” stated Dr. Kilmer. “We have used it in conjunction with other devices, where HIFEM increased muscle toning and fat loss.”
In a more traditional realm, laser-based lipolysis and specifically the 1064 nm wavelength has been shown to be effective in body contouring procedures, with many devices in the marketplace capable of heating larger areas of subcutaneous tissue while yielding a smaller thermal effect on neighboring dermal tissue.
For instance, TightSculpting®, from Fotona (Dallas, Texas), is a unique, dual-wave-length, non-invasive laser treatment for sculpting and tightening skin on all body areas. And, the SculpSure® laser, from Cynosure/Hologic (Westford, Mass.), offers a unique applicator system that can work on multiple body areas simultaneously, utilizing a 1060 nm wavelength to treat fat tissue and contour the body.
“For a select group of the patient population, there is still a place for laser lipolysis,” said Dr. Salzman. “Sciton has one called ALLURA™ Body, and I’m doing more and more of that treatment because it causes visible tightening. Most laser-based lipolysis procedures are minimally invasive with very little downtime.”
Ultrasound has a place in the body shaping realm as well, although modern aesthetic platforms that employ ultrasound tend to combine it with RF-based technologies. A recent example, Alma Beauty Reform, from Alma Lasers (Buffalo Grove, Ill.), combines the two in a single platform – an RF applicator for skin tightening and an ultrasound applicator for fat reduction and body contouring. The two energies can also be found in generically branded ultrasound cavitation devices, which have appeared mostly in medspas as second tier energy-based systems for body contouring procedures.
HIFU technology is also employed for body shaping procedures, as in Ultralipo, from Wontech Co., Ltd. (Daejeon, South Korea), in which focused ultrasound energy delivers heat from 60° C to 80° C to the target body area, destroying fat tissues without damaging the surface of the skin.
HIFU-based devices are more frequently found in Asia, less so in the U.S., opined Dr. Salzman. “It works, but if you are creating enough heat to cause acute fat necrosis thermally, with some kind of injury, it is going to hurt. Apoptosis, which is produced by enough heat to cause cells to emit their intercellular fat, is a safer way to go,” he said.
Combination techniques
Combining energy sources, such as hybrid platforms that support both ultrasound and RF modalities, with adjunctive treatments like HIFEM, are today’s trends in body shaping procedures.
“The goal is to create an optimal result for the patient. Sometimes, that means doing a combination treatment of non-invasive fat reduction and adding some device that can potentially improve skin tone and tighten the skin,” Dr. Somenek pointed out.
Furthermore, “part of the follow-up plan with the patient concentrates on their physical health, emphasizing a good diet plan, exercise and a continuing skincare regimen,” he added.
“We often do treatments in combination,” Dr. Kilmer shared. We will apply one device in one area, another device in another area, and then use body creams to enhance the efficacy of the result. In body shaping, the missing link is that once we’ve sculpted then how best to smooth out any cellulite? I don’t have any products in hand that do a good job of that, although there are some new approaches coming down the pipeline.
”Personalized combination therapies are already de rigueur at Dr. Salzman’s clinic. “Say the patient has some adiposity. We will start with an RF-based body sculpting treatment and that will thin them out. They might want skin tightening or more definition, or a little more fat reduction. These are very common combinations using different devices.”
Beyond technology & technique
No matter the energy source or technique involved, “Efficacy, ease of use, length of treatment time and patient comfort during treatment are all important criteria for selecting an energy-based body shaping system,” noted Dr. Kilmer.
Length of treatment always plays a role, Dr. Somenek agreed. “How long is each treatment going to take and how many treatments does the patient need in order to see a result?” he asked.
“Being able to demonstrate results is probably the most important thing, because if you have a device that shows very mild improvement then it is not worth it to me. I like a device that actually does what the manufacturer claims and demonstrates some improvement for the patient in a very easy-to-use manner,” Dr. Somenek expressed.
“Patient comfort and tolerance of the procedure is also a top concern,” he continued. “A device that is technician independent is very attractive. You want to be able to put the applicators on, turn on the machine and let it act on the surface of the skin.”
Designing for the future
While these technologies and combination treatment techniques are the state-of-the-art, what will the uture hold for body shaping techniques?
First, the technology needs to be perfected, Dr. Salzman stated. “You need to get to at least 55° C to incite neocollagenesis that will tighten the skin; 43° does not work.”
“And the relationship between time and temperature is logarithmic,” he explained. "You may need ten seconds at 55° to obtain the equivalent amount of tightening that may be one million seconds at 43°, or whatever that logarithmic relationship might be. “Hence, the necessity for multiple treatments with these outside-in RF devices,” Dr. Salzman continued. “I know people who are working on microwaves to treat more than underarm sweating. You want to target the fat and break it up sonically, so that it doesn’t hurt and doesn’t require numbing. That is the holy grail.”
DEKA Medical, Inc. (El.En. Group, Firenze, Italy) offers the Onda system that uses microwave-based energy at 2.45 GHz, a frequency that heats deeper subcutaneous cells rather than the two outermost layers of skin. Reportedly, this body contouring approach has been found to be effective for abdominal circumference reduction.
For Dr. Somenek, future devices need to be able to target fat more effectively. “Most of these non-invasive devices have limitations. They are called non-invasive for a reason; namely, they do not deliver a surgical result,” he said. “It is important to keep that in mind and be truthful about it. However, at the same time I think that there will be an evolution in technologies in which we can more effectively target the fat in one or two treatments, but at more than the 20% – 24% reduction per treatment we are seeing now with conventional devices.”
Both now and in the future, physicians need to maintain a realistic perspective about which patients are good body shaping candidates, stated Jason Emer, MD, a cosmetic surgeon and dermatologist in West Hollywood, Calif. “The patient has to be a good candidate for good results.
“The bottom line is surgery is the gold standard,” Dr. Emer continued. “Nonsurgical improvements are the second-best option. Anyone who comes to you and says CoolSculpting didn’t work wasn’t a good candidate or didn’t get enough treatments. In general, all of those devices and modalities can work; they just have to be paired right. Typically, they don’t work that well by themselves and need to be done in combination.”
A thorough review of any long-term clinical study data associated with a device is critical, as well, Dr. Emer added.
“You have to be an astute physician and really press back on the manufacturers to make sure that they are being truthful about the results,” he noted. “Also, talk to the people that have done the studies. Take the time to do the research. There are a lot of energy-based systems in the marketplace, and just because something is new doesn’t mean it is better.
