With a seemingly endless stream of technological advancements, enhancements, additions and upgrades, as well as the development and introduction of brand-new technology and treatment options, consumer interest in nonsurgical body shaping is staying steady. With that, patient expectations are also growing – demanding increased efficacy and greater outcomes without surgery, at a reasonable cost and with fewer side effects. Fortunately, today’s physicians have an abundance of devices and tools to effectively combat patient concerns such as fat reduction, skin tightening and muscle strengthening.

Recent body contouring advancements include revolutionary treatments like radial pulse wave technology to reduce the appearance of cellulite and acoustic shock wave therapy to tighten skin. Other innovative treatments include cellulite reduction with injectables and ultrasound, as well as threads to lift and tighten skin anywhere on the body. Indeed, creativity and ingenuity continue to propel the aesthetic market forward and allow physicians to provide patients with their desired outcomes.

Treatments for Fat Reduction and Cellulite

Nonsurgical options dominate today’s treatments for both fat reduction and the appearance of cellulite, including cryolipolysis, acoustic wave therapy and injectables.

Fat reduction is a prominent segment of body contouring services, and a variety of treatments are available to address individual concerns. Despite recent events, cryolipolysis still stands out to treat small areas of stubborn fat. Carolyn Jacob, MD, founder and director of Chicago Cosmetic Surgery and Dermatology (Chicago, Ill.) provides a comprehensive spectrum of cosmetic services at her practices, including Coolsculpting ® from Allergan Aesthetics, an AbbVie Company (Irvine,Calif.). “Coolsculpting has been around for over a decade and can be used to target small areas of fat, such as the submental area, arms and love handles,” she explained. “Most areas get a series of two treatments spaced two months apart, with a 20% to 25% reduction of fat.”

According to Dr. Jacob,“Devices to treat cellulite include EmTone® from BTL (Marlborough, Mass.), which uses acoustic shockwave therapy with simultaneous radiofrequency for skin tightening.

“Another cellulite treatment may include the recently launched injectable Qwo® from Endo Pharmaceuticals (Malvern, Pa.), which is an injection of collagenase clostridium histolyticum. It works by dissolving the fibrous bands that pull down the skin, creating the dimple,”Dr. Jacobs continued.Bianca Paraison, RN, owner of The Luxe Dose (Belmont, Mass.), incorporates her advanced nursing and aesthetics skills to provide a combination of healthy lifestyle practices with body contouring services. She is also a fan of injectables.

“My go-to treatment for fat reduction is Kybella® (Allergan), which works to break down fat cells that are then removed by the body’s lymphatic system. I have seen the most success with this for contouring jawlines, love handles and saddle bags,” she reported. “I always encourage lymphatic drainage massage as part of the procedure to encourage as much breakdown and lymphatic drainage as possible. I inject Kybella in two to three sessions, usually about four vials per area, per session. Kybella does require generous amounts to be effective. Once fat is dissolved, we look at PDO threads and laser for skin tightening.

”High Intensity Focused Electromagnetic (HIFEM) Energy is the next generation of innovative technologies for optimized outcomes in circumference reduction and body sculpting. EmSculpt® (BTL) combines two therapies into one procedure to strengthen muscles and create fat destruction. In a study of 22 patients who received four abdominal treatments each, results showed an average 18.6% reduction of adipose tissue thickness and 15.4% increase in abdominal muscle thickness, as well as an average of 3.8 cm of sub umbilical circumference reduction.¹

Dr. Jacob uses this innovative technology in her practice. “EmSculpt and EmSculpt NEO (BTL) are the best studied devices with MRI,ultrasound and histology to show how much fat reduction can be expected at three- and six months post-treatment,” she explained. “NEO adds on radiofrequency energy in a synergistic, patented technology, to provide even further fat reduction and muscle definition, and has been approved for multiple areas besides the abdomen, such as the calves, arms and thighs.”

Edward M. Zimmerman, MD, medical director at Aesthetic Revolution Las Vegas (Las Vegas, Nev.) incorporates similar protocols to treat the appearance of cellulite in his practice. “I currently use Qwo and then Zimmer acoustic shockwave therapy (ASWT) sessions afterwards for cellulite treatment. Adding ASWT improves patient outcomes, decreases bruising time and separates us from the competition."

 

According to Dr. Zimmerman, fat reduction treatments such as targeted laser energy are best for patients with a BMI under 30. “For nonsurgical fat reduction, we utilize the new EON™ non-touch, computer-controlled 1064 laser system from Dominion Aesthetic Technologies (Houston, Texas). Minimal staff supervision is required and results and pricing to patients are about the same as similar lipolysis treatments,” he explained. “This appears to offer a win-win – a new presentation of a proven technology for nonsurgical fat reduction, and the right patient can expect to drop a belt size. That said, these devices are best utilized on patients with a BMI of less than 30, otherwise, it takes multiple treatments and becomes more expensive than surgery. That cutoff supports my liposuction practice, so I am able to offer patients optimized, customized results with the biggest bang for their dollar.”

Liposuction – Still the Gold Standard for Fat Loss

Reducing fat is a top concern for many pa-tients and according to Dr. Zimmerman, liposuction continues to be a popular procedure for any part of the body. “For surgical body contouring we move to our state licensed surgical suite,” he explained. “We offer twi-light sedation, tumescent anesthesia and liposculpting using our rotary power cannula that allows for precise sculpting with less trauma than manual liposculpting. Then we add Renuvion^® helium plasma from Apyx Medical (Clearwater, Fla.) for subdermal skin and tissue tightening as needed.”

Dr. Zimmerman’s very specific liposuction protocol involves first marking patients while awake in a standing position, then incorporating movement such as twisting and bending to create a topographical map of the body. “Sedation, not general anesthesia, and excellent tumescence are required to be able to sculpt most artistically,” he explained. “Then follow with RF tissue tightening, and the first lymphatic drainage massage before the patient is dressed in their compression garment. Follow this with massages every two to three days for at least a week to achieve contour improvement and a quicker return to activities.”

While tumescent liposuction is a technique that may address large areas of adipose tissue with less trauma and a quicker recovery time, it does have limitations and requires skill for ideal outcomes. As Dr. Zimmerman pointed out, “Liposuction is art, anatomy, science and strict attention to detail in prep, performance and post-op follow-up. It is best to think of this treatment as a contouring tool, not a treatment for elevated BMI.”

Dr. Jacob shared that they also offer tumescent liposuction at her practice to trim, shape and contour the body. “I doliposuction as well for more thorough removal of fat. My plastic surgeon does liposuction in the ambulatory surgical center and uses the J Plasma ® device for skin tightening intraoperatively.” She mentioned that they may also incorporate RF skin tightening following liposuction surgery.

Thread Lifts for the Entire Body

Thread lifts have recently enjoyed a resurgence in the aesthetic arena, and are often used for the treatment of sagging skin. With a little creativity, Ms. Paraison incorporates a combination of techniques to address body contouring for precise results. “We use PDO Max™ threads from PDO Max (Liverpool, N.Y.)for all our thread procedures because they are great for mild diffuse cellulite or large pockets of cellulite.

“I favor 29x50 for skin tightening and collagen production for the body, mainly for the abdomen and above knees,” Ms. Paraison continued. “The technique will vary depending on the goal of the procedure with some results that can be seen right away, and the best results within two to three months. Most common areas for cellulite treatment are the back of the thigh and buttocks. If there are heavily indented areas of cellulite, we may use Sculptra^® (Galderma Aesthetics; Fort Worth, Texas) in combination with PDO threads, but we do not place Sculptra and threads in the same visit.”

Augmentation with fillers offer less invasive treatments than surgical procedures. Injectables can act as a standalone procedure, or,as Ms. Paraison explained, they can help correct issues from previous surgeries, as well. “The Brazilian Butt Lift (BBL) and ‘hip dip’treatments are really popular at my office. I use a combination of Sculptra and Radiesse^®(Merz Aesthetics, Raleigh, N.C.), which is done over two to three visits. Radiesse offers immediate visible improvement and Sculptra offers longer-term collagen production. The combination creates amazing results. We also use this protocol to treat patients that have had surgical BBLs and have some irregularities.”

Treatments that Lift and Tighten

Body contouring also includes treatments that can lift and tighten the skin, with a host of time-proven procedures that can address individual needs and concerns. Some of these treatments include microneedling and devices that incorporate microfocused ultrasound (MFU) to boost collagen. In fact, MFU is FDA cleared to lift the neck, chin and brow skin, while RF microneedling continues to impress by reducing skin laxity due to aging.³

Dr. Zimmerman takes advantage of a combination of procedures to provide ideal patient outcomes in his practice. “In addition to Renuvion helium plasma for subdermal or external tightening, we utilize RF microneedling devices including Vivace^® (Aesthetics Biomedical; Scottsdale, Ariz.), Scarlet RF (Viol; Korea), Sylfirm X (BENEV; Mission Viejo,Calif.) and Agnes RF (Agnes Medical; Torrance,Calif.). Downtime and results can be customized to patient requirements and augmented by use of their own platelet-rich plasma (PRP), or umbilically-derived stem cell and exosome products that may improve speed of healing and overall results.” He did caution about claims as peer reviewed discussions are ongoing, and FDA surveillance means use of these materials should be offered without guarantees and attention to consent details.

Improved Healing and Less Bruising

Nonsurgical devices and products are often efficacious additions that can improve surgical outcomes. Lymphatic drainage, either manual, or with devices that utilize acoustic shock wave therapy, as well as low-level lasers with computer-guided systems can lessen inflammation and bruising for quicker healing. Dr. Jacob also shared that supplements such as Vitamedica® offer pre-and post-op packages that reduce inflammation and bruising with ingredients such as bromelain and arnica.

Ms. Paraison utilizes nonsurgical devices to optimize both post-surgical outcomes and injections. “We offer lymphatic drainage massage using Vanity Technologies’ (Ontario, Canada) Revitasculpt™ cupping technology for our patients after procedures such as liposuction,” she shared. “This is also what we offer to our Kybella patients post-procedure to optimize results. It can also be used to assist in reduction of toxins and excess water weight in the body.”

Innovative Devices in the Spotlight

As the first automated device,EON has introduced real-time monitoring of skin proximity and temperature protocols for patient safety and “smarter body contouring”. It is an FDA-cleared, 1064 nm laser used for non-invasive body contouring, programmed with touchless, robotic technology that uses smart sensors to scan and map the patient’s topography prior to treatment.

Jennifer Walden, MD, plastic surgeon and founder of Jennifer L. Walden, MD, PLLC Cosmetic Surgery and Laser Center (Austin,Texas) incorporates this device for the comfort and touchless feature. “In the COVID era, patients respond well to anything that is touchless or allows social distancing of the provider,” she noted. Technology in this space is constantly evolving, and EON is ahead of the game, and its results speak for itself.”

Using a patented Compressive Microvibration®technology, the innovative Endosphères Therapy from Artemis Distribution (Rye Brook, N.Y.) is a game-changer. It improves cellulite, muscle tone, skin laxity, excess fibrous tissue, toxin/fluid retention, pain, signs of aging and athletic recovery, and is completely non-invasive.

Abiola Oladoke, PhD, owner of O & A Wellness Group, Inc. (Arroyo Grande, Calif.) shared how she utilizes this technology in her practice,“I added Endosphères Therapy to our medspa and weight loss clinic and our clients love it,” she stated. “We see immediate tone, skin tightening, smoothness and lift with our body and facial treatments. We use the device by itself and as a complement to our other services. Our clients love their results, and we love the technology.”

According to the manufacturer, this impressive technology is backed by the world’s largest cellulite study in the aesthetic device industry, with clinical observation of 656 subjects, across 24 medical centers. The results showed a 39% improvement in the appearance of cellulite and reported a 97.8% patient satisfaction rating.

Aslı Taşdeviren Sağlam, founding director of Cocomaje Beauty Center (Istanbul, Turkey), is a fan of the Smart Technology evolution by Medixsysteme (Ruggell, Liechtenstein) that incorporates sonography, Body Composition Analysis (BCA) and MRI. The UltraCountour^®NG is an ultrasonic energy-based platform that provides body contouring solutions with quick results. This innovative hands-free technology combines an automated Ultrasonic Mechanical Drainage Effect (UMD) with a triple pulsed fractionated sequence to effectively stimulate fat cells and collagen production while promoting lymphatic drainage.

“UltraContour NG is distinguished from other devices because it is a painless, comfortable application in one, quick treatment,” Ms. Taşdeviren Sağlam advised. “It makes a very clear improvement in fat reduction in the ap-plied area with visibly increased elasticity. Positive results make our patients smile, and implementing successful processes satisfies us and our patients. We are very happy to work with UltraContour NG, as it helps us make a difference in getting ahead of the other clinics within the same sector.”MTF Biologics (Edison, N.J.) is a global non-profit organization that saves and heals lives by honoring donated gifts, serving patients and advancing science. They offer a comprehensive portfolio of aesthetic medicine solutions for providers and patients worldwide including the LipoGrafter®, an all-in-one system for autologous fat grafting.

For Daniel Murariu, MD, a plastic surgeon at the Allegheny Health Network (Pittsburgh,Pa.), this technology is essential to his practice. “Having tried many other fat harvesting techniques and equipment, I have settled on the LipoGrafter for several reasons. First, it is a closed loop system so the fat harvested is never exposed to air or other impurities that may come with rolling on gauze. Second, the fat is harvested in an atraumatic fashion allowing for consistent high viability of cells. Third, but not least, the system is efficient as it easily changes from harvest to injection mode. The entire process can be performed by the surgeon with assistance needed during the harvest only. I am extremely pleased with the design of the device and the consistent results I am able to achieve case after case.”

The evolution of aesthetics has resulted in a multitude of tools and a variety of providers who are empowered to answer the needs of their patients, whether it be for targeted treatments, or the ability to improve multiple areas for complete body transformation. Dr. Zimmerman believes this new paradigm rewards patients and practices. “The patient benefits by having their outcome optimized, safely and economically, and the practice benefits by continuing to exist and offer guests a variety of other aesthetic services available. We endeavor to help educate and supply aesthetic solutions to the patient throughout their lifetime rather than episodically!”

References:

1. Kinney BM, Lozanova P. High intensity focused electromagnetic therapy evaluated by magnetic resonance imaging: Safety and efficacy study of a dual tissue effect based non-invasive abdominal body shaping. Lasers Surg Med. 2019 Jan;51(1):40-46. doi: 10.1002/lsm.23024. Epub 2018 Oct 10. PMID: 30302767; PMCID: PMC6585690.

2. Fabi SG, Joseph J, Sevi J, Green JB, Peterson JD. Optimizing patient outcomes by customizing treatment with microfocused ultrasound with visualization: gold standard consensus guidelines from an expert panel. J Drugs Dermatol. 2019;18(5):426-432.

3. Yu V, Juhász MLW, Mesinkovska NA. Subcutaneous Radiofrequency Microneedling for the Treatment of Thigh Skin Laxity Caused by Weight Loss: A Case Study. J Clin Aesthet Dermatol. 2019;12(6):60-62.

 

Microneedling represents a cosmetic dermatology treatment with multiple uses. Originally touted as a collagen-inducing therapy for wrinkles and skin tightening, microneedling has evolved into an effective modality for treating acne, acne scars, and hyperpigmentation.

My love affair with microneedling began in 2008 while it was still a new and under-explored treatment. It proved safe on my primary demographic – skin of color – when few rejuvenating options were available. I performed treatments on all skin colors and skin types. The results suggested that this therapy safely harmonized the primary dermal cells involved in skin rejuvenation: keratinocytes, melanocytes, fibroblasts, and sebocytes, on all skin tones.

Aesthetic dermatology thrives on the synergies of multimodal treatments, hence the further evolution of my microneedling treatments. I now utilize various techniques and have also begun using rejuvenation secrets gained from my South Korean colleagues.

Acne scars are prevalent on skin of color. Unfortunately, effective treatments such as CO₂ laser resurfacing are not viable options for darker Fitzpatrick skin types IV-VI. CO₂ laser resurfacing carries a risk of melanocyte hyperstimulation, resulting in undesirable post-inflammatory hyperpigmentation (PIH) on darker skin tones. My current treatment protocol for darker skin revolves around a systematic and stepwise approach that combines microneedling with subdermal fiber dissection, radiofrequency (RF) cellular stimulation, dermal fillers and polydioxanone (PDO) thread lifting techniques.

Each of these treatments individually reduces acne scar depth, but my combined approach achieves a synergistic bilayer improvement in acne scar rejuvenation. Both the epidermis and the dermis are maximally stimulated with mechanical and energy-based devices, which ensures minimal risk of melanocyte stimulation.

Pretreatment

Baseline photography should be done prior to the first treatment. Before embarking upon any skin rejuvenation program on skin of color, it is recommended that the skin be conditioned for at least two weeks. I suggest my patients use a superficial chemical peel and a skincare regimen that consists of retinoids, 4% hydroquinone, and a hydroxy acid for home use.

Patient expectations need to be managed prior to treatment. It is important to have a discussion on a realistic timeline for visible results. A series of three treatments is normally the minimum, spaced approximately two weeks apart. Most patients experience an appreciable improvement within the first month of treatment.

Treatment Session One:

The first treatment involves microneedling followed by subdermal scar dissection (sub-cision) with an 18-gauge Nokor™ needle attached to a 1 mL syringe. Energy treatments may also be employed during this session. Local anesthesia will be required for the targeted areas, which can be administered either via infiltration or local blocks. Edema and tenderness are common post-treatment and can be managed with NSAIDs.

Treatment Session Two:

This session focuses on the targeted placement of smooth PDO threads for the further encouragement of neocollagenesis. Topical anesthesia suffices for this treatment.

Treatment Session Three:

Patient response will be assessed during the third session. Each patient will present with a different clinical response; therefore, meticu-lous photographs should be taken. The patient’s skin should be palpated to assess the degree of scar softening and the breakdown of dermal scar tissue. At this appointment, dermal fillers are placed in localized areas re-quiring greater scar rejuvenation. Microneedling is also often performed during this appointment, to aid with the improvement of the epidermal surface texture.

Not all patients will follow the three-session rule. For example, patients presenting with shallower rolling and box scars respond well to the typical three sessions outlined above. Patients with icepick and deeper scars will pres-ent the greatest challenge. With such cases,you can consider a second subcision surgery at session three, concurrently injecting dermal filler through your Nokor needle for large scar areas. A fourth session with PDO threads and microneedling may be performed one month later. Other treatments such as TCA CROSS (trichloroacetic acid chemical reconstruction of skin scars) can also be incorporated into your treatment regime, especially on Fitzpatrick types  I-IV.  Microdermabrasion has also proven to aid epidermal resurfacing and smooth the skin texture.

Treatment Pearls: Thinking Out of the Box

Managing PIH & Skin TextureHaving over a decade of experience with microneedling on dark skin has taught me a great deal. Through experience, I have learned that microneedling on skin of color is not without risk, and PIH development is possible in a few cases. My clinic relies on skin conditioning protocols based on mandelic acid, our choice of hydroxy acid for skin color. We combine this with tretinoin and hydroquinone and have found a superior patient response with mandelic acid over glycolic acid-based skin conditioning protocols. Skin texture and skin tone are also greatly improved with this method.

The Dermal / Epidermal Connection Traditional microneedling treatments still represent a relatively superficial epidermal treatment and should be combined with deeper  stimulation  modalities.  For example, RF can be used to achieve enhanced fibroblastic and dermal stimulation. Acne scars are primarily a dermal concern, therefore greater focus should be applied to dermal plumping and dermal stimulatory treatments. Hence the reason for my focus on PDO treatments for greater predictability of fibroblastic stimulation and dermal fillers for volume enhancement.

The Time Factor

Neocollagenesis and acne scar rejuvenation both require time and patience. Some clients may not see results until three months post-treatment. At this stage, comparison photos can be made. Physicians who utilize cosmeceuticals to improve skin condition and tone will appreciate the three months mark. At this point, the skin becomes a canvas. Not only should light reflection and shadowing be less pronounced with acne scar combination treatments, but the skin should also appear clearer and healthier.

Final Thoughts

Microneedling as a treatment is here to stay for acne scars. Clinicians that can venture deeper with surgical scar treatments and utilize the power of smooth PDO threads will enjoy enhanced treatment results. The combination of in-depth microneedling and PDO threads will provide patients with higher levels of satisfaction and fewer treatment complications

 

About the Author

Dr. Destang is a dual qualified physician from St. Lucia, who has spent the last 25 years aesthetically enhancing her patients. She is a qualified specialist in both orthodontics and aesthetic dermatology. Dr. Destang possesses the ability to not only appreciate ideal facial aesthetics and modify jaw structures, but also recognizes the importance of harmonizing facial balance. Her unique education and experience enable her to be a valuable contributor, innovator, lecturer and educator in aesthetics.

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