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 apart
 Adverse 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): 317–319
High 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 results
 Velashape
§  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
Baseline
Sculpsure Treatment Results

Courtesy of B. Katz, MD
FLANK TREATMENT
SIDE VIEW
Areas 1 and 2 treated on both flanks
 Zerona (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 protocol
 When 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 hours
 Laser-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 timeline
 Cellulaze (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) 36:767–779
 BodyTite

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) 36:767–779
 Liposculpture
§  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, overdeliver
 Body 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.