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The current nonsurgical fat reduction landscape

Dermatology TimesDermatology Times, September 2019 (Vol. 40, No. 9)
Volume 40
Issue 9

Nonsurgical fat reduction device choices are taking the market by storm, with technologies that target fat via cryolipolysis, laser lipolysis or radiofrequency.

Dr. Schlessinger

Dr. Kilmer

Dr. Moore

Dr. Engleman

Dr. Fromowitz

Dr. Rivkin

Statistics released this year by the American Society of Plastic Surgeons (ASPS) reveal high demand for body shaping options, with a spike in noninvasive fat reduction procedures in 2018.

Nonsurgical fat reduction device choices are taking the market by storm, with technologies that target fat via cryolipolysis, laser lipolysis or radiofrequency. To get a pulse on the current state of the noninvasive fat reduction market, we asked providers what they’re using and why.

Cryolipolysis on Top

Nonsurgical fat reduction treatments, like CoolSculpting (Allergan), are taking center stage, while Kybella (deoxycholic acid, Allergan) takes a back seat, according to dermatologist and cosmetic surgeon Joel Schlessinger, M.D.

“While Kybella hasn’t turned out to be the blockbuster that many thought it would be, CoolSculpting has filled the void dramatically. With new treatment heads and protocols, CoolSculpting has significantly improved,” Dr. Schlessinger says.

The most notable change, according to Dr. Schlessinger, has been the benefits of using CoolSculpting’s CoolMini on the chin area.

“I think that’s the gateway procedure for fat reduction for most of my patients. They come in for the chin and submental area and during the conversation express interest in other areas,” Dr. Schlessinger says.

And the updated CoolSculpting treatment protocol has boosted patient satisfaction.

“When CoolSculpting was introduced 10 years ago there were some fairly optimistic expectations for CoolSculpting and fairly minimal approaches to getting these optimistic results. They thought that perhaps one session alone might yield optimal results which was clearly not possible,” he says. “Now we explain to our patients that two and perhaps even three sessions are necessary for the desired result. This allows us to set the expectations more appropriately from the outset.”

Dr. Schlessinger says he has been remarkably satisfied with CoolSculpting’s safety, with one exception.
“The one thing that has occasionally occurred is paradoxical adipose hyperplasia in a few patients. In those patients, we’ve taken one-half of the dollars spent on CoolSculpting and put them toward tumescent liposuction. The patients have been very pleased,” Dr. Schlessinger says.

Evolutions in laser and RF devices

SculpSure (Cynosure) is marketing its “WarmSculpting” approach, using targeted laser energy to noninvasively heat fat cells.
Hologic's Cynosure division announced July 26, 2019, that it launched a petite mask for SculpSure submental treatments, which are FDA cleared for patients with a body mass index (BMI) up to 49 - the highest BMI clearance on the market for submental treatments, according to Cynosure.

But SculpSure isn’t the only device on this block. Dermatology Times recently reported on the FDA-cleared eon FR laser energy (Dominion Aesthetic Technologies) body contouring device for fat reduction of the abdomen. Suzanne L. Kilmer, M.D., founder of the Laser and Skin Surgery Center of Northern California and clinical professor of dermatology at University of California, Davis, conducted studies on the eon and says the device has a non-contact automated articulated arm that hovers over the treated area delivering 1064 nm wavelength energy, while simultaneously cooling the skin with temperature feedback control.

Fat reduction outcomes with the device are comparable to that of other 1064 nm body contouring technologies, at 11% to 13%, according to Dr. Kilmer.

Radiofrequency (RF), devices also have a place in noninvasive fat reduction.

TruSculpt 3D and iD (Cutera) are both monopolar radiofrequency devices for fat reduction.

“TruSculpt is a different technology that uses heat to trigger fat apoptosis and lipolysis, but it also cools skin at the same time, so it protects the skin. It’s very comfortable. And you can apply up to six of these applicators in any way that you want to the abdomen and flanks,” Dr. Kilmer says.

New York City dermatologist Sapna Palep, M.D., says she recommends truSculpt as one of the best options in noninvasive fat reduction technology because it improves skin laxity through the heating of the skin. TruSculpt is best for a weight stabilized patient with stubborn areas resistant to diet and exercise, she says.

Richard Moore, M.D., an aesthetic physician who practices in St. Louis, Mo., says his practice offers three non-invasive devices for fat destruction: CoolSculpting, and RF devices Vanquish Me (BTL) and BodyFX (InMode).

“Vanquish ME is our preferred device in patients who are heavier (BMI of greater than 30) or who have insufficient fat for CoolSculpting to suction up into the applicator,” Dr. Moore says. “Our preference for the overweight or obese individual is based on the need for diffuse fat destruction. These patients may be more prone to having deformities on the edge of the applicators when CoolSculpting is used. With the Vanquish ME large treatment panel size there is virtually no risk of deformities making this our treatment of choice. Vanquish ME is also our treatment of choice for patients who are not good candidates for CoolSculpting on the outer thighs and has the added benefit of treatment of the inner and outer thighs at the same time.”

For patients whose arms have insufficient fat for the CoolSculpting applicator, Dr. Moore’s treatment of choice is BodyFX.

“This is a good treatment for small focal areas of fat that may not be treated with CoolSculpting,” Dr. Moore says.

Muscle-Stimulating Technology Trending

Emsculpt (BTL) has been a game-changer in this arena, not so much for fat reduction but for muscle stimulation, according to Dr. Kilmer.

“You get a butt lift and flattening of the abdomen, with improvement in the look of the muscle. It has some fat reduction by MRI and CT but I think the novelty here is once you get rid of some of that fat, you have improvement in the muscular structure underneath, so that becomes more visible giving more of a six-pack or buttock lift look,” Dr. Kilmer says. 

Dr. Kilmer says Emsculpt’s ability to increase fitness hasn’t been shown in studies yet, but she believes it does and says she plans to do a study on that soon. Dr. Kilmer says her personal experience with Emsculpt treatment to the abdomen is that her abdomen feels tighter, she stands up straighter and can exercise more easily.

“For me personally it has been really helpful for yoga positions, including holding a plank position. After doing Emsculpt, I can do them much longer,” Dr. Kilmer says.

BTL announced in July 2019 that Emsculpt, which uses High Intensity Focused Electro-Magnetic (HIFEM), now is FDA cleared to treat the arms and calves using new small contour applicators.

CoolSculpting’s new CoolTone (Allergan) device is similar to Emsculpt in that it tones muscle on the abdomen, according to Dr. Kilmer.

“I am particularly excited to see how CoolTone integrates with and enhances the CoolSculpting experience. This could be a huge benefit for our patients and increase the flow of patients who could be candidates for fat and laxity treatments,” according to Dr. Schlessinger.

Seattle-based facial plastic surgeon Wayne F. Larrabee, Jr., M.D., M.S.H., says that most patients looking for body contour enhancement, especially in the abdomen, desire body toning as well as fat removal.

“We have evaluated the science behind CoolTone and decided it would be complementary to our practice and benefit many of our CoolSculpting patients. Allergan states that the magnetic muscle stimulation (MMS) of CoolTone is 50% greater than competitors. Although there isn’t good public data to evaluate this, investigators I have spoken to are enthusiastic about the potential of CoolTone,” Dr. Larrabee says.

And not to be overlooked is new muscle sculpting platform from Cutera – TruSculpt flex. This muscle sculpting technology uses Multi-Directional Stimulation and is FDA-cleared for the strengthening, toning, and firming of the abdomen, buttocks and thighs.

Synergistic Fat Reduction

Dr. Kilmer says she will in some cases use CoolTone or Emsculpt in conjunction with CoolSculpting to combine fat reduction with muscle tightening.

New York dermatologist Dendy Engleman, M.D., says her favorite noninvasive fat reduction device is Emsculpt, which she typically uses as a standalone treatment, but she will combine it with another device in some patients.

“While all body types can benefit from Emsculpt, very high BMI patients are not ideal candidates,” Dr. Dendy says. “Despite significant strengthening of their muscles due to treatment, this improvement may stay hidden beneath the patient’s excessive fat deposits. For these patients, I use BTL Vanquish ME first before Emsculpt to reduce the circumference of the entire abdominal area or inner and outer thighs.”

Los Angeles facial cosmetic surgeon Alexander Rivkin, M.D., says he believes that the field of noninvasive fat reduction or noninvasive body contouring is still in an early stage, where each technology cannot yet achieve the reliable, dramatic results that patients are demanding. A single device has not yet proven to be effective enough to dominate the field, Dr. Rivkin says.

“The two most promising modalities are cryolipolysis (CoolSculpting) and transcutaneous magnetic muscle stimulation (CoolTone). My favorite way to achieve fat reduction is to use a combination of these two devices in a synergistic amplification of effect,” Dr. Rivkin says. “CoolSculpting and CoolTone in combination reduce fat in different ways that seem to be synergistic with one another. I think that this will bring patients the best results.”

Boca Raton dermatologist Jeffrey S. Fromowitz, M.D., says he packages two treatments - CoolSculpting and truSculpt, which some call “fire and ice.”

“This allows us to combine the best of both worlds with fat reduction from [CoolSculpting], then we fine tune the treatments with RF truSculpt. The addition of the RF also adds tissue tightening in areas where we have reduced fat pockets,” Dr. Fromowitz says.

San Antonio, Texas, plastic surgeon Thomas T. Jeneby, M.D., says his number one noninvasive fat reduction technology is CoolSculpting, but he, too, uses a fire and ice approach in some patients with CoolSculpting and Vanquish.

“The Vanquish is a no-touch fat melting system that hovers over the body and spins water molecules causing them to heat up and eventually rupture the fat cells by vibration,” Dr. Jeneby says. “So while CoolSculpting uses cold; Vanquish uses heat. We use both back to back…. This gives synergistic fat reduction to people who do not want surgery.”

In the end, different technologies offer different benefits, according to Beverly Hills plastic surgeon Payman Danielpour, M.D., who says that, in his practice, if fat reduction is the sole objective his favorite device is CoolSculpting.

“It has been clearly proven that cryolipolysis works and can be used in multiple areas of the body, even the hard-to-treat areas,” Dr. Danielpour says. “Radiofrequency can be effectively used for circumferential reduction and skin tightening but the fat reduction is not as pronounced. Lastly, Emsculpt… is revolutionary [on] its own because it’s the first machine to effectively build muscle and lose fat.”

The bottom line: Proper patient selection is key when recommending noninvasive fat reduction or body sculpting technologies, according to Dr. Schlessinger.

“As with any technology there are clearly limitations and benefits and it is incredibly important to pick the right candidate for the right procedures. Without this all is lost,” Dr. Schlessinger says. “For example, about 50% of people that come in for CoolSculpting consultations… simply aren’t candidates. Some, however, are candidates for tumescent liposuction or SmartLipo [Cynosure] that we perform in the office, and when they’re good candidates for that we explain the opportunities and options. For those who are not candidates for either one, we’re just as clear and politely explain the fact that they aren’t a candidate for anything at this time. Many of these are better candidates for bariatric surgery and abdominoplasty.”


Drs. Moore, Jeneby, Engleman, Larrabbee and Rivkin report no relevant disclosures. Dr. Schlessinger has performed clinical trials for Liposonix, Ultrashape and Kybella. Dr. Fromowitz is a speaker for Cutera. Dr. Kilmer has received research support from and has been a medical advisory board member with Cutera (stock options too), Cytrellis (stock options) Alastin, Allergan, Dominion, Pulse Biosciences, Lumenis Lutronic, Merz, Sciton, Sienna Labs, Solta/Valeant (advisory board only) and Syneron/Candela. She has received research support in the past year from Galderma, BTL, R2 Derm and Revance. She has stock in Avava and HintMD.

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