Original Contribution

Journal of Cosmetic Dermatology, 13, 202--207

Effect of low-intensity, low-frequency ultrasound treatment on

anthropometry, subcutaneous adipose tissue, and body composition
of young normal weight females
Chiara Milanese, BSc, Valentina Cavedon, BSc, Francesco Piscitelli, BSc, & Carlo Zancanaro, MD
Laboratory of Anthropometry and Body Composition, Department of Neurological and Movement Sciences, University of Verona, Verona, Italy

Summary Background Low-intensity, low-frequency ultrasound is increasingly being used for

noninvasive, external body contouring as an alternative to liposuction or laser
treatments.
Objectives To evaluate the effect of chronic localized treatment with a novel
ultrasound device on subcutaneous adipose tissue thickness and fat mass in young,
normal weight women.
Methods Twenty-eight females (mean age = 25.5  0.66 [SE] year, mean
BMI = 22.1  0.37 kg/m2) underwent a 10-week bilateral treatment with the device in
the gluteus–buttock–thigh area (Lipolysis program: ultrasound frequency = 150 kHz;
power = 1.65 W/cm2), 48 min per session, two sessions a week. Subcutaneous
adipose tissue thickness and fat mass were evaluated before and after treatment with
ultrasound and dual-energy X-ray absorptiometry, respectively.
Results Treatment was well tolerated by all participants. At the end of treatment,
statistically significant reduction of subcutaneous adipose tissue thickness was found
bilaterally at the gluteus and thigh site ( 2.03  2.79%). Trunk and lower limb
fat mass were reduced as well ( 3.48  3.97%).
Conclusions A 10-week, low-intensity, low-frequency localized external ultrasound
treatment is effective in reducing adipose tissue in females.
Keywords: low-intensity ultrasound, low-frequency ultrasound, DXA, fat, esthetic

is similar to that for car accidents (16 per 100 000).1

Introduction
A growing number of people, especially females, desire
to improve body contours, seeking for cosmetic solutions
for the removal of excess subcutaneous fat tissue. While
surgical procedures such as liposuction allow the
removal of excess fat tissues in specific body areas, these
procedures have limitations and possible complications.
It has been claimed that the death rate from liposuction
Correspondence: C Zancanaro, Department of Neurological and Move-
ment Sciences, Strada Le Grazie, 8. I-37134 Verona, Italy. E-mail: carlo.
zancanaro@univr.it
Accepted for publication June 5, 2014
Complications can include embolism, changes in sensa-
tion, infections, visceral perforations, swelling, scars,
and contour irregularities.2 Cost is also an issue.
A wide range of nonsurgical technologies such as ra-
diofrequency ablation,3 cryolipolysis,4 injection lipoly-
sis,5 external low-level lasers,6 and laser ablation7 are
currently available to perform esthetic body sculpting.
Each of these treatments can be administered in an
outpatient setting with little or no need for anesthesia
or analgesia and typically result in fewer complications
than liposuction.
Ultrasound (US) is a mechanical compression wave
with a frequency above the range of human hearing

202 © 2014 Wiley Periodicals, Inc.


(>20 kHz) which is characterized by intensity,
expressed in W/cm2, and frequency, expressed as kilo-
hertz (kHz) or megahertz (MHz).8 Ultrasonic waves
penetrate through tissue losing energy as they are
reflected, scattered, or absorbed by the tissues they
encounter. US is widely used in medicine for diagnostic
applications. Diagnostic US typically generates waves
of low intensity (range 0.1–3 W/cm2) and high fre-
quency (range 1–20 MHz). Therapeutic US is less
widely used, although it can induce a range of biologi-
cal effects at very different acoustic parameters. US
used for physical therapy generate high-frequency
(1–3 MHz), low-intensity (0.5–3 W/cm2) ultrasonic
waves.9 US is increasingly being used in esthetic medi-
cine to induce external lipolysis in subcutaneous adi-
pose tissue, thereby reducing the local fat deposits; the
involved procedures are safe and well tolerated.10,11
US devices use either high-intensity (>3 W/cm2) US
working primarily through a thermal mechanism or
low-intensity US working primarily through a nonther-
mal (mechanical) mechanism, creating repeated com-
pressions and rarefactions in target tissues.10
This work is aimed at verifying the effect of chronic
localized US treatment on subcutaneous adipose tissue
thickness and fat mass in young, normal weight
women using a novel device exploiting low-intensity,
low-frequency US delivery. Obtaining a significant
reduction of fat at the total body or regional level
would be of use to many people experiencing reduced
physical activity and weight gain.
Material and methods
Twenty-eight healthy active female volunteers from
the Sports and Exercise School of the University of Ve-
rona were enrolled in this study upon signed informed
consent. The protocol was in accordance to the Hel-
sinki Declaration (2008 revision) and was approved by
the local institutional review board. Inclusion criteria
were age >18 year <30 year, a record of moderate
physical activity, no pharmaceutical drug intake affect-
ing body composition in past 3 months, and no signs/
symptoms of disease. Exclusion criteria were over-
weight (body mass index [kg/m2], BMI > 25), ongoing
hypocaloric diet, and agonistic sport activity. All sub-
jects were asked not to change alimentary habits or
level of physical exercise during treatment.
Body mass was taken at the nearest 0.1 kg with an
electronic scale (Tanita electronic scale BWB-800 MA
[Wunder SA.BI. Srl], max 200 kg); stature was mea-
sured with a Harpenden stadiometer (Holtain Ltd., Cry-
mych, UK) at the nearest mm.
© 2014 Wiley Periodicals, Inc.
Ultrasound reduction of adipose tissue . C Milanese et al.
Subcutaneous adipose tissue thickness was measured
with a Chinson 600M (2009 version) Ultrasound Sys-
tem (Chinson Medical Imaging Co. Ltd., Wuxi City,
China), equipped with display-screen and freeze-frame
capacity. A 7.5-MHz linear array (detecting depth
≥80 mm; lateral resolution ≤1 mm [depth ≤60 mm];
axial resolution ≤1 mm [depth ≤80] according to the
manufacturer) was used while capturing the image in
B-mode, and a transmission gel was applied to the
array of the transducer. Measurements were taken at
two sites (thigh and gluteus) on both sides of the sub-
ject excluding skin thickness. The sites and the position
measurements were as follows: gluteus, mid-point
between the great trochanter and the coccyx, mea-
sured in prone decubitus; and thigh, mid-point
between the great trochanter and the mid-thigh, mea-
sured in lateral decubitus. Each site was marked with
a ballpoint pen, and the transducer was then held
manually on the marked site without depression of the
dermal surface. To assure accurate depth readings, the
transducer was held in a vertical position, perpendicu-
lar to the tissue interfaces at each site. Three indepen-
dent measurements were taken at each site (for a total
of 12 images/subject). All measurements were per-
formed by one operator (VC) to ensure consistency.
The standard error of measurement for triplicate mea-
surements in ten subjects was 0.817 mm and
0.615 mm at the gluteus and thigh site, respectively.
Total body and regional fat mass were evaluated by
means of dual-energy X-ray absorptiometry (DXA)
using a total body scanner (QDR Explorer W, Hologic,
MA, USA; fan-bean technology, software for Windows
XP version 12.6.1) according to the manufacturer’s
procedures. All analyses were performed by one opera-
tor (VC) to ensure consistency. For the regional body
composition estimations, Hologic software readings
divide the body into up to eight regions. In this work,
we identified two regions namely the trunk and the
lower limb as depicted in Figure 1.
For US treatment, the Lipozero G39 pro, a CE class I
device featuring a maximal power of 3 W/cm2 (Glob-
usItalia, Codogne, Treviso, Italy) was used. US delivery
was by direct contact to the skin with the aid of a
proper conductive gel. US was delivered by the subject
herself upon proper instruction from a researcher
according to the Lipolysis program CAVI-MAX
150 kHz already implemented in the device. US fre-
quency was 150 kHz, power was 1.65 W/cm2, and
emission was pulsed (1 Hz) with a 60% duty cycle. US
was delivered at the thigh–buttock–gluteal area bilater-
ally for a total of 48 min/session (24 min each side).
Subjects had two sessions per week for 10 weeks.
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Ultrasound reduction of adipose tissue . C Milanese et al.
Safety parameters evaluated included adverse events,
local skin reaction, and pain. Efficacy parameters eval-
uated included comparison of before and after thick-
ness of subcutaneous adipose tissue, fat mass, and
percent fat mass.
Normality of data was assessed with the Kolmogo-
rov–Smirnov test. Changes in the anthropometry and
body composition parameters after treatment were
investigated by paired-samples t-test. Correlation was
tested calculating the r (Pearson’s) correlation coeffi-
cient. Predictivity was explored using linear regression
analysis. For all analyses, the SPSS for Windows ver-
sion 15.0 (SPSS Inc., Chicago, IL, USA) was used. Data
Figure 1 Representative DXA whole-body scan. Lines are drawn
according to the manufacturer’s instructions to identify several
body regions. The two regions considered in this work are
labeled: T, trunk region; and L, lower limb region
204
are reported as means  standard error of the mean
(SEM).
Results
The 28 subjects participating in this study had mean
age 25.5  0.66 year, mean stature 166.6  1.05 cm,
mean body mass 61.4  1.10 kg, and mean BMI
22.1  0.37 kg/m2.
The treatment was well tolerated by all participants.
At the end of each session, the involved skin region
presented modest rubor. Participants did not refer dis-
comfort or pain during or after delivery of US.
In comparison with baseline values, mean body mass
and BMI were slightly reduced after treatment
( 0.55%), the difference being not significant.
Whole-body DXA analysis showed that fat mass and
percent fat mass significantly reduced after treatment
(Figs 2 and 3) ( 3.48%, t = 2.797, P = 0.009;
0.79%, t = 3.044, P = 0.005, respectively). Regional
DXA analysis showed significant reduction of fat mass
and percent fat mass after treatment (Figs 2 and 3) in
the trunk ( 3.97%, t = 2.440, P = 0.022; 0.72%,
t = 2.369, P = 0.025, respectively), left leg ( 3.86%,
t = 3.424, P = 0.002; 0.89%, t = 3.450, P = 0.002,
respectively), and right leg ( 2.62%, t = 2.269,
P = 0.032; 0.83%, t = 2.833, P = 0.009, respec-
tively).
Subcutaneous adipose tissue thickness measured
with US at the gluteal and thigh site showed signifi-
cant bilateral reduction after treatment (Figs 4 and 5)
(right gluteus: 2.03%, t = 4.696, P < 0.001; left glu-
teus 1.86%, t = 4.142, P < 0.001; right thigh:
2.79%, t = 4.853, P < 0.001; left thigh: 2.78%,
t = 4.360, P < 0.001).
Figure 2 Regional and total body DXA-measured fat mass at
baseline (dark gray) and after (light gray) a 10-week treatment
with low-frequency, low-intensity external ultrasound. *P < 0.05,
**P < 0.01
© 2014 Wiley Periodicals, Inc.

Figure 3 Percent regional and total body DXA-measured fat
mass at baseline (dark gray) and after (light gray) a 10-week
treatment with low-frequency, low-intensity external ultrasound.
*P < 0.05, **P < 0.01
Figure 4 Ultrasound measured thickness of subcutaneous adi-
pose tissue at baseline (dark gray) and after (light gray) a 10-
week treatment with low-frequency, low-intensity external ultra-
sound. ***P < 0.001
Significant correlations (r = 0.613  0.815, P <
0.001 for all) were found between US-measured subcu-
taneous fat thickness at the gluteal and thigh site and
the corresponding DXA-measured regional (trunk and
leg) fat parameters (fat mass and percent fat mass) both
Figure 5 Left panel: representative picture showing application of ultrasound treatment in the thigh region. Middle and right panel:
ultrasound imaging of the thigh skin and subcutis before and after treatment, respectively. Note reduction in the thickness of subcutane-
ous fat after treatment
© 2014 Wiley Periodicals, Inc.
Ultrasound reduction of adipose tissue . C Milanese et al.
before and after treatment. Significant correlations
(r = 0.382  0.780, P = 0.045  0.0001) were found
between bilateral (dx + sin) change (post minus pre) in
US-measured subcutaneous adipose tissue thickness at
the gluteal and thigh site and the corresponding DXA-
measured regional (trunk and lower limbs) change in
fat mass and percent fat mass.
Linear regression analysis showed that bilateral
(dx + sin) change (post minus pre) in US-measured
subcutaneous adipose tissue thickness at the gluteal,
and thigh site is a significant predictor DXA-measured
fat parameters (fat mass and percent fat mass) change
in the corresponding regions (trunk fat mass: adjusted
coefficient of determination (R2) = 0.113, P = 0.045;
percent trunk fat: adjusted R2 = 0.184, P = 0.022;
lower limbs fat mass: adjusted R2 = 0.504,
P = 0.0001; lower limbs percent fat: adjusted
R2 = 0.512, P = 0.0001).
Discussion
Results of this work show that a 10-week treatment
(two 48 min sessions per week) with localized low-fre-
quency, low-intensity, pulsed US is able to reduce sub-
cutaneous adipose tissue thickness and regional fat
mass in young nonobese female.
In recent years, a trend emerged toward less invasive
body contouring procedures as a possible alternative to
liposuction. US has been used in esthetic body contour-
ing dates since the late 1980s.12 However, usage of
early ultrasound devices for use in body contouring
was associated with complications, probably due to the
high ultrasonic energy output associated with these
devices.13 To date, a number of noninvasive devices in
use for body contouring are ultrasonic energy based. In
2011, about 300 000 noninvasive contouring or tight-
ening procedures were reported in the United States.14
While data on thermal ablation of adipose tissue with
US are rather abundant,15 information on the effects of
US exploiting mechanical US ablation (cavitation) is
205
Ultrasound reduction of adipose tissue . C Milanese et al.
scarce. In the past, this kind of US has typically been
used for US physiotherapy16 receiving FDA approval.17
As cavitation does not work primarily through heating,
it may be appropriate for the long-term treatment of
nonobese subjects with localized adiposity.
To the best of our knowledge, this is the first work
using the current gold standard three-compartment for
body composition, that is, DXA to assess the effect of
low-frequency, low-intensity external US delivery on
body fat. Considering body regions currently used in
regional DXA analysis (trunk, lower limb, see Fig. 1),
we showed that a 10-week treatment with low-fre-
quency, low-intensity external US is associated with
significant reduction of fat mass and percent fat in the
trunk and the limbs.
Interestingly, significant correlations were found
between regional DXA-measured fat parameters and
US-measured subcutaneous adipose tissue thicknesses.
This suggests that easy-to-measure US variables reflect
fat mass changes assessed with the accurate and repro-
ducible DXA technology, which is costly and demand-
ing in terms of facilities. Accordingly, we found that
US-measured change in adipose tissue thickness at the
gluteus and thigh sites is able to significantly predict
DXA-measured changes in fat mass in the correspond-
ing regions. The explained variance of the dependent
variable was limited (11–50%); however, it should be
taken into account that the treated area was a limited
surface of each region, and in the trunk, a large
amount of fat is visceral. We refrained from using DXA
data from smaller regions because of precision con-
cerns.18
A limit of this work is that we did not directly inves-
tigate the mechanism(s) of adipose tissue reduction. A
recent histological and biochemical work in pigs19
showed that acute nonfocused external US treatment
with a device emitting an ultrasound frequency of
1 MHz at 5–7 W/cm2 was associated with increase of
free lipids in the lymph, the lymph nodes, and the
extracellular space without cell necrosis; the authors
concluded that the device has a reduction effect on adi-
pose tissue by altering the permeability of the adipo-
cytes. Accordingly, work is in progress to investigate
blood lipids after acute and chronic treatment with
low-frequency, low-intensity external US delivery as
well as the morphology of subcutaneous fat by means
of needle biopsy and electron microscopy.
Acknowledgments
The authors thank the women who volunteered in this
study for kind cooperation and Globus s.r.l for kindly
206
supplying the LipozeroG39pro devices used in this
work at no cost. This study was supported by a grant
from the University of Verona (Joint Projects 2010) to
CM. FP and VC are in the PhD program “Multimodal
Imaging in Biomedicine” at the University of Verona.
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