Minimally invasive fat reduction

Kohala Coast, HI

- At the Winter Clinical Dermatology Conference, Mark Nestor, M.D., started his talk about minimally invasive fat reduction by asking attendees to raise their hands if they have specific areas of fat they’d like to alleviate. Many hands in the audience went up. But when he asked who would consider liposuction to achieve their fat-reduction goals, most of those hands went down.

That response is not surprising, Dr. Nestor said, seeing as liposuction is an invasive, painful procedure. Like the dermatologists in the audience, patients continue to seek both cosmetic and clinical improvement that results in minimal or no down-time and little procedural risk.

When it comes to excess adipose tissue, basic areas of aesthetic concern include the face (submental area, mandibular border, malar fat pad), upper body (arms and dorsal region, abdomen, hips, love handles) and lower body (saddle bags, buttocks, pubic region, knees). While tumescent liposuction remains the "gold standard" for achieving fat reduction in these and other areas, physicians should consider newer, less-invasive options for many of their patients, Dr. Nestor said.

One such option, laserlipolysis (SmartLipo, Cynosure), is already FDA approved and essentially "melts" fat cells as it heats the dermis, resulting in a reduction of adipocytes and a tighter dermis.

Using high-peak-power laser pulses, laserlipolysis allows adipocytes to be ruptured without charring tissue. Hemostatis of blood vessels causes less bleeding and bruising than liposuction, and the entire procedure is performed under local tumescent anesthesia. One of the best wavelength options involves combining a 1,064 nm wavelength with a 1,320 nm wavelength, as this allows for more efficient, even and safe energy delivery, Dr. Nestor said.

Although not yet FDA approved, another minimally invasive option is focused ultrasound (LipoSonix, Medicis). This procedure focuses high-intensity ultrasound at precise depths within adipose tissue (approximately 13 mm) without harming skin or underlying tissues and organs. The ultrasound produces tissue damage via two mechanisms: temperature rise secondary to direct absorption of ultrasonic energy, and mechanical processes (streaming and shear forces) generated from high pressure levels with the treated tissue, with their inherent thermal effects. This produces thermal coagulation of adipose tissue within the focal beam.

Damaged adipocytes and released triglycerides are engulfed my macrophages. Lipid-laden macrophages then move to the lymph nodes and are believed to then go into the liver. Damaged tissue in the treated area is resorbed over a period of several months. There is no indication that the process results in any increase in cholesterol or triglyceride levels, Dr. Nestor said.

A third fat-reduction option, Cryolipolysis (Zeltiq Aesthetics), involves the non-invasive cooling of fat cells to induce lipolysis without damage to other tissue types. The process involves cooling fat through the surface of the skin for less than 15 minutes, which results in the crystallization of lipids in fat cells, followed by slow dissolution of the cell and gradual release of lipids. According to studies, the natural inflammatory process results in fat-layer reduction over a two- to six-month period and reductions of more than 1 cm (35 percent of fat layer in animal models). This procedure does not change cholesterol or triglyceride levels either, Dr. Nestor said.

The biologic selectivity of Cryolipolysis allows for controlled energy extraction that cools tissue and targets only fat cells, sparing other tissue and cell types. The energy extraction (cooling) is naturally limited by the underlying, well-perfused muscle layer. As a result, Cryolipolysis penetrates the deepest in thick fat areas, tapering to less effect in leaner areas to allow for natural sculpting, Dr. Nestor said. DT