Choosing technologies for noninvasive body contouring depends on what areas they are approved to treat, the local competition and — where available — the data, say experts who presented at The Cosmetic Bootcamp (CBC) in Aspen, Colo., in July.
When investing in equipment, “I’m driven by data,” says Vic Narurkar, M.D. “When I inject a neurotoxin or filler for a patient, I know what each modality can do on its own” and when combined with complementary treatments. He is founder and director of the Bay Area Laser Institute, chairman of dermatology at California Pacific Medical Center, San Francisco, and a CBC cofounder and director.
Dr. Narurkar says he’s passionate about CoolSculpting in particular because it’s unique among FDA-cleared devices for noninvasive fat reduction.
“Long-term data show that it creates apoptosis and kills fat cells.”1 And with FDA clearance for noninvasive treatment of fat bulges in the submentum, thigh, abdomen, flank, bra and back fat, knee bulges and most recently the arms, it offers the most versatility among noninvasive fat treatments, he adds.
A PubMed search reveals more than 75 published CoolSculpting clinical trials and abstracts involving more than 5,000 patients reported during and after 15 years of research and development, he says. This research plus seven years’ commercial experience, including his own clinical experience, shows reproducible results, he says.
“That’s what I like to see: that my CoolSculpting results are the same as others’ CoolSculpting results,” he says.
With the CoolMini applicator, he adds, “The big pearl is that for very bulky submental fat, start with the CoolMini because there’s less swelling than with an injectable. We’ve now started using CoolMini for larger areas followed by Kybella (deoxycholic acid, Allergan) to fine-tune.”
The CoolAdvantage applicator slashes treatment times from 60 minutes to 35 minutes, treating more tissue with greater comfort, without compromising results versus the original applicator.2 Post-treatment, Dr. Narurkar says, “The biggest difference we’ve seen with the CoolAdvantage is less bruising and pain.”
The CoolAdvantage petite addresses the arms, which he said represent the second most-requested treatment area by women seeking noninvasive fat reduction. In the device’s pivotal study, ultrasound measurements showed a mean 3.2 mm reduction here.3
Eric F. Bernstein, M.D., M.S.E., added, “I was one of the early adopters of CoolSculpting, so I’ve had a long experience with it, and what’s most important to me, as I’m quite a conservative doctor, is a high degree of safety and, of course efficacy. CoolSculpting offers both, and it’s only getting better. The new applicators use less suction and provide cooling through the entire cup, resulting in quicker treatments and even greater safety.”4,5 He is a Philadelphia-based dermatologist in private practice.
“What goes where”
When selecting equipment, Jeanine B. Downie, M.D., says, “One of the things I consider is what can go where.”
With the Exilis device (BTL), she commonly treats ankles, upper knees, arms and underarms. She is a Montclair, New Jersey-based dermatologist and a CBC strategic planning board member.
Dr. Downie says she chose Exilis over CoolSculpting because when she evaluated the original CoolSculpting device in 2010, it didn’t result in circumference reductions. The device now works consistently well, she adds.
Often, she couples Exilis with the Futura Fit (Perigee Medical) system, which combines ultrasound and electrical muscle stimulation.
“With the Futura Fit, I’ve seen decreases in patients’ cholesterol and triglyceride levels,” she notes.
The Vanquish’s (BTL) large treatment zone allows for treatment of very large abdomens, she says. Liposonix, SculpSure, UltraShape (Syneron Candela) and CoolSculpting are indicated for long-term reductions; Exilis and Vanquish are cleared for temporary reductions. But Dr. Downie says that after Exilis treatment, “I have patients who have kept off their inches for years at a time. And I have patients who regain what they lost.”
For cellulite in the anterior and posterior thigh, Dr. Downie says, “I like ThermiTight (ThermiGen),” which she chose originally to treat the jawline. If a patient with already flat abs wants to get “ripped,” she adds, “You can do that with the ThermiTight.”
With the concept of injectable radiofrequency, “You’re literally inserting this wand, and you can hear the fibrous bands popping sometimes as you go along. I’ve done tightening with the Exilis in that area. But when patients have true cellulite all the way up the leg, or they generally have cellulite up the back of their leg, it works very well.”
Regarding market exclusivity, “I’ve never believed that anything was exclusive.” Instead, Dr. Narurkar says he focuses on his practice and things he can control.
Just as the plethora of nearby botulinum toxin and filler providers has not hurt his injectable business, he says that practicing in a crowded market has not affected his CoolSculpting business.
“It’s not as easy as putting the applicator on and getting results.” All aesthetic technologies require careful patient assessment and thorough patient education, he says. “My patients are happy because we choose the right patients for this technology.”
Suneel Chilukuri, M.D., swapped his CoolSculpting devices for SculpSure when he moved to a smaller office. At the time, “I wanted the latest and greatest technology. Does it work any better than CoolSculpting? No. In our hands, it works equivalently to CoolSculpting, but with fewer side effects and shorter treatment times. There are no post-treatment neuralgias or paradoxical fat hyperplasia that I saw with CoolSculpting.” He is a Houston-based cosmetic and Mohs surgeon in private practice.
As with any procedure, he says, “It’s all about picking the right patient. We turn away around 50% of the people who come in for body contouring consultations. You must put your hands on the patient and make sure that they have superficial fat, not just visceral fat. Make sure if it’s true laxity, true fat or a combination. You must be able to treat all aspects of that.”
The missing link
What’s missing from body contouring, says Dr. Narurkar, are long-term data from devices other than CoolSculpting, and any comparative studies between technologies claiming to achieve equivalent results, which would allow physicians to make better decisions about which device to incorporate into their practice.
Regarding evaluation of devices for body contouring Dr. Bernstein says, “The best way to evaluate the efficacy of a body contouring device is to treat one side of the body, for example, a love handle, and not the other and compare results— to me that’s the ultimate test.”
1. Bernstein EF. Long-term efficacy follow-up on two cryolipolysis case studies: 6 and 9 years post-treatment. J Cosmet Dermatol. 2016;15(4):561-564.
2. Kilmer SL. Prototype CoolCup cryolipolysis applicator with over 40% reduced treatment time demonstrates equivalent safety and efficacy with greater patient preference. Lasers Surg Med. 2017;49(1):63-68.
3. Carruthers JD, Humphrey S, Rivers JK. Cryolipolysis for reduction of arm fat: safety and efficacy of a prototype CoolCup applicator with flat contour. Dermatol Surg. 2017;43(7):940-949.
4. 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. doi: 10.1001/jamafacial.2017.0102. [Epub ahead of print]
5. Bernstein EF, Bloom JD, Basilavecchio LD, Plugis JM. Noninvasive fat reduction of the flanks using a new cryolipolysis applicator and overlapping, two-cycle treatments. Lasers Surg Med. 2014;46(10):731-5.