Body contouring breakthroughs and directions

 Flank shown before (left) and 6 months after (right) one SculpSure treatment. Photo: Bruce Katz, M.D.

Medicine has seen remarkable advances in the last several years, and cosmetic dermatology is no exception. At the 2015 American Society for Dermatologic Surgery’s annual meeting, Vic. A. Narurkar, M.D., of Bay Area Laser Institute, San Francisco, co-moderated a session about body contouring, providing participants with valuable information on the latest devices, agents, and approaches for non-invasive fat reduction.

 “Non-invasive contouring, primarily the treatment of fat, has really evolved over the past five years since CoolSculpting, the first FDA-approved device,” was introduced, says Dr. Narurkar. “CoolSculpting itself has transformed the practice and the landscape in general to being a very viable option to treating unwanted fat. We now have long-term experience-and I’m a little biased because we use CoolSculpting in the practice-we have a lot of experience and now new devices are coming in to provide modalities for treating fat. When CoolSculpting first came out, we were doing one-session treatments with one adapter to treat the flanks. It’s now evolved to multiple adaptors and multiple indications for non-invasive fat reduction. Now we can treat the flanks, the abdomen, the thighs, and most recently, submental fat.”

Read: When CoolSculpting goes wrong

Dr. Narurkar notes that the rigorous FDA trials the CoolSculpting procedures faced were invaluable, but also cites the enormous value of clinical experience, including “treatment to transformation.” He says a primary element in the evolution has been the change from one session to multiple session treatments, and also the use of multiple adaptors. 

“We now know that it takes more than one treatment session to get the desired results,” he explains. “Now, we have long-term experience using CoolSculpting-it’s the only device that’s been on the market over five years-and I’ve personally seen patients that the fat is gone even after five years out. We can now say from clinical experience that it provides long-term fat reduction.”

Bruce E. Katz, M.D. discussed invasive and non-invasive approaches for using fat to optimize outcomes. Dr. Katz is clinical professor, Icahn School of Medicine at Mt. Sinai; director, Juva Skin & Laser Center; and director, Cosmetic Surgery & Laser Clinic, Mt. Sinai Hospital, New York.

Like Dr. Narurkar, Dr. Katz cites CoolSculpting’s influence. Additionally, Dr. Katz mentions UltraShape, which uses ultrasound to break up fat cells. “The ultrasound is very nice. It does require three treatments and a technician moving a transducer over the area. There’s also radio frequency, a device called Vanquish which is really just for the abdomen. The newest approach is SculpSure – this is a laser treatment which I think has been the most effective because you can treat four areas in one procedure. So half the time and it’s very cost effective for patients. There’s no downtime; patients can go right back to work afterwards.” 

Also read: SculpSure turns up the heat in noninvasive fat reduction

Another non-invasive, Kybella, is an injectable for fat removal, says Dr. Katz. This method “injects deoxycholic acid which is actually in the bile that the body uses to breakdown fat in the body. It’s approved for use in the neck, usually someone with a double chin and puffiness there, and we do a series of two or three injections over a few weeks and it melts the fat away.”

Dr. Katz cites ThermiRF for radio frequency, a minimally invasive “where we insert a probe under the skin and melt the fat and tighten the skin. It tightens the skin and removes the fat. You can do big areas or small areas, abdomens, upper arms, thighs.” The patient is awake, there’s a very quick recovery. He also discusses LipoEase, using laser liposuction under the skin to melt fat and tighten the skin. “It’s like the ThermiRF,” he says, “but using lasers instead of radio frequency.”

NEXT: Economy of evolution

Flank shown before (left) and 6 months after (right) one SculpSure treatment. Photo: Bruce Katz, M.D.

Economy of evolution

What should physicians do to balance incorporating new technologies into their practices, ensuring quality and safety, and assuring their patients that they have the training and know-how? Physicians should, “go to ASDS meetings, or the International Society for Dermatologic Surgery-we lecture on these technologies at all these meetings,” Dr. Katz says. “They should ask the product company to let them observe and get some hands-on experience before they start to practice on patients.” 

There’s some skill to finding the balance in an established practice, deciding how adding new technology will influence that balance and return on investment. 

Read: Will soaking in a hot tub prior to CoolSculpting help improve results?

“For me,” Dr. Narurkar says, “I wanted to make sure the technology really works. Having long-standing clinical info helps support that and get the patients to buy in.” This creates an audience whose positive experience with your practice makes them more likely to invest in additional procedures. 

For his practice, Dr. Katz says SculpSure is often the most effective approach. “You can do four areas in a half hour. The technologies have evolved.”

Dr. Narurkar is quick to point out that the key for success with all these devices is proper patient selection. “With some of these newer technologies, we still don’t know how areas might behave in areas beyond which they’ve been approved for.” Time and additional studies will have to show how that evolves. 

Next: Who is the best candidate?

Flank shown before (left) and 6 months after (right) one SculpSure treatment. Photo: Bruce Katz, M.D.

Who is the best candidate? 

To be a good candidate for body contouring, “the patient must have pinchable fat, good skin quality, fit in the adaptor, and have a reasonable BMI,” Dr. Narurkar says. “They have to have stubborn areas of fat that diet and exercise alone won’t solve. A bad patient is someone with poor skin quality, someone with visceral fat, or who is morbidly obese, or excessive loose skin.”

Pain management and understanding possible side effects is still important, Dr. Narurkar says. “In all these technologies there’s always a degree of discomfort. But the discomfort with procedures like CoolSculpting we generally manage with NSAIDs or something like gabapentin, but the pain does resolve. The main side effect is numbness that lasts a few weeks.”

Also read: The nurse's role in body contouring

Where does this leave conventional liposuction? “In the dust,” says Dr. Katz. “We have lasers and radiofrequency that melt the fat,” eliminating most of the need for conventional liposuction with general anesthesia. 

One exception would be paradoxical hyperplasia, where you see more fat, says Dr. Narurkar. And although this happens in less than 1% of cases, “It’s a real potential side effect and is seen with the large adaptors. If we encounter that, we’ll address it with liposuction and/or other tightening technologies.”

NEXT: What lies ahead for the technology?

Flank shown before (left) and 6 months after (right) one SculpSure treatment. Photo: Bruce Katz, M.D.

What lies ahead for the technology? 

“With CoolSculpting we now have a technology with over five years of experience,” Dr. Narurkar says. “So the gold standard now with over 2 million cycles performed is cryolipolysis. We know it works and we have a proven way to treat unwanted fat. So we use that experience to learn how to treat areas that cryolipolysis doesn’t treat. We’re refining what CoolSculpting has already presented.”

New adaptors can provide treatment for gynecomastia and clinicians are learning their application for knee fat and bra fat. “Those are all areas we’ve found respond well,” Dr. Narurkar says, “so it really gives us the option for total body CoolSculpting. Also, we’ve found in clinical experience that after a series of CoolSculpting there is secondary skin tightening, so after the fat is gone there’s also retraction of the skin. Some companies say you can’t get that, but in our experience there’s collateral improvement in the skin laxity.”

Read: Laser and light devices: What's trending?

How will this affect practice for cosmetic dermatologists in the near and far future? Dr. Katz says new technologies will have a significant effect on practices, “because we’ll be able to treat significant areas of fat that we couldn’t do before in a noninvasive fashion and more cost effectively. It will have a great influence,” including patients needing incidental medical dermatologic treatment. 

With the new technologies available, the future is bright. What’s ahead? Dr. Katz sums it up. “The sky’s the limit!”

Drs. Katz and Narurkar report no relevant disclosures.