Nonsurgical Body Contouring 2020: More Customizable Treatments and Natural-Looking Results

By Kevin A. Wilson, Contributing Editor

Few areas of aesthetic medicine have enjoyed the kind of rapid advancement seen in nonsurgical body contouring. The market has been there, waiting, but until fairly recently the technology was inconsistent and disappointing. The gulf between surgical and modalities that were non- or minimally invasive was extremely wide.

24 The Aesthetic Guide | September/October 2020 | www.theaestheticguide.com The Aesthetic Guide | September/October 2020 | www.theaestheticguide.com 25 “Body contouring is an essential part “Fat reducing devices involve thermal of any aesthetic practice,” said board modulation, by heating or cooling, certified plastic surgeon Sachin M. to destroy fat cells,” Dr. Shridharani Shridharani, MD, medical director of expressed. “The body processes the LUXURGERY (New York City, N.Y.), “and crystallized or lysed fat cells and cellular as a plastic surgeon I see many patients debris, leaving a slimmer appearance in seeking to improve their body appear- the treated area. However, the treatments ance. Surgery is often the gold standard are limited in how deep into the fat one but many patients who come in these can go without causing damage to sur- days are looking for non- or minimally face tissue.” invasive options, as well. These nonsur- Non-invasive stimulation of musculature, gical options are becoming more cus- the latest technology to take the market tomizable and provide natural-looking by storm, attacks the problem from a results.” completely different angle. “By inducing supramaximal contraction of target Radiofrequency (RF) technology set the muscle groups, patients can achieve stage, but initial offerings suffered from muscle hypertrophy, improved tone and lackluster results and/or significant pain increased strength from a few sessions associated with treatment. Eventually RF that would take hours in the gym and still Sachin M. Shridharani, MD, modalities, alone or in combination with not adequately target some muscles,” FACS other modalities in a single platform, Dr. Shridharani said. “For a lot of patients Plastic Surgeon began to emerge that provided physi- Medical Director this makes a huge difference, and it LUXURGERY cians the ability to recontour localized makes sense to firm up the underlying New York City, NY areas of unwanted fat using nonsurgical musculature to support an overall body methods. Good results were available for contouring result.” the fitter subgroup of patients, but many soon used RF as an adjunct Dr. Shridharani added that this is not a to various liposuction techniques to substitute for going to the gym, but rather enhance outcomes. a nice supplement to a workout regimen. One major advantage of this modality is Deanne Mraz Robinson, MD And though they can have a visible effect its medical application – notable thera- Modern of Connecticut on fat deposits, most RF devices – then peutic effects seen with the improvement Westport, CT and now – best contribute by inducing of difficult-to-train core musculature, contraction of overlying skin. When including better posture and relief from paired with microneedling, RF is still a various forms of urinary and rectal popular method of handling skin laxity for incontinence. body contouring. In fact, most therapies in the nonsurgical class are used to provide Experts agree that the ideal body con- liposuction patients with an ideal result touring patient is already in relatively good physical condition and lives a Steven Bengelsdorf, MD that surgery alone could not provide. Cosmetic Surgeon healthy lifestyle, but has areas that are Nashville, TN With the rise of cryolipolysis, the quest for difficult to manage for one reason or a more aesthetically-pleasing silhouette another. “These are the patients that will became much more attainable and realistic, get the best results,” said cosmetic sur- according to Deanne Mraz Robinson, MD, geon Steven Bengelsdorf, MD (Nashville, Tenn.). “For many years I had to perform of Modern Dermatology of Connecticut tummy tucks, liposuction and other inva- (Westport, Conn.). “Cryolipolysis was what sive procedures,” he said, “but I don’t really woke up the industry and the public Adrian Gaspar, MD anymore because of the exceptional OB/GYN Specialist because treatment is easy, safe, relatively results we can obtain with minimally Owner and Director hassle-free and gives people results that Espacio Gaspar Clinic of invasive body contouring.” He added Gynecology, Anti-Aging and they like,” she said. “It definitely touched that physicians rarely rely on a single Bioregenerative Medicine off the avalanche.” technology to address a patient’s body Mendoza, Argentina contouring needs, so it is a multimodality While initially costly, the advent of legiti- treatment. “The best results are obtained mate competition in non-invasive laser by removing fat, toning the underlying lipolysis and contactless selective RF muscle and tightening the overlying skin.” improved accessibility to some degree. With the power to safely and effectively Dr. Mraz Robinson agreed. “We offer debulk fat deposits in even larger BMI several technologies including cryoli- Fernando Gagliardi patients, contactless selective RF took Manager polysis and non-invasive laser lipolysis BodyContour the field to another level without erasing for fat, various skin tightening therapies Luxembourg the utility of other methods. and electromagnetic muscle stimulation.

26 The Aesthetic Guide | September/October 2020 | www.theaestheticguide.com Before and after the TightSculpting procedure by Fotona Jonathan M. Sykes, MD Photos courtesy of Adrian Gaspar, MD Director of Roxbury Institute Beverly Hills I think many physicians offering body con- subcutaneous fat to cause apoptosis of Beverly Hills, CA touring in the market offer these types of adipocytes and tighten the fibrous septae. therapies alone, and often in combination. Together they provide an excellent global It depends on the patient; some will do result for our body contouring patients well with one therapy, but some will ben- with no downtime or disposables,” said efit greatly when other options are used to Adrian Gaspar, MD, owner and director of enhance the overall result.” the Espacio Gaspar Clinic of Gynecology, Anti-Aging and Bioregenerative Medicine Michael H. Gold, MD Dermatologist Among Dr. Mraz Robinson’s favorites are (Mendoza, Argentina). “This is not for larger dilute biostimulatory fillers combined Director patients, but those requiring a visible, yet Tennessee Clinical Research with RF or microfocused ultrasound for subtle revision of the silhouette by treating Center skin tightening as well as non-invasive fat Gold Skin Care Center specific areas of unwanted fat.” reduction and electromagnetic muscle Nashville, TN stimulation. Science has shown that outcomes with “Partnering muscle stimulation with lipo- non-invasive body contouring treatments suction helps provide a more cohesive, such as cryolipolysis, non-invasive laser harmonious outcome,” Dr. Shridharani indi- lipolysis or contactless selective RF are cated. “We now have the unique opportu- improved significantly with an adjunctive nity in the industry to combine the proven, massage component. FDA cleared for the traditional fat reducing surgical and nonsur- temporary reduction of the appearance of gical treatments with emerging technology cellulite, the temporary increase in local for the best possible outcomes.” blood circulation and to relieve minor muscle aches and pains, the Z WaveQ Beyond these, which have been covered system from Zimmer MedizinSystems significantly in the media over the last (Irvine, Calif.) is ideal for the task, according decade, there are many more options to Dr. Bengelsdorf. “Manual massage to available. Some are repurposed existing facilitate fracturing of the frozen adipocytes technologies, such as use of dilute bios- was difficult and incredibly inconsistent. timulatory fillers or skin tightening tech- Z Wave has been a game changer. It is nologies, and others are completely novel. simple, safe, reliable and easy to delegate to trained staff,” he shared. Its projectile has Some technologies, by nature, are ideal a five times greater mass than pneumatic for concurrently treating fat and tightening systems for a softer pulse and maximum skin. TightSculpting™ from Fotona (based in the U.S. and Europe) is a unique non- patient comfort to the patient. An innova- invasive laser treatment that combines tive water-cooled generator ensures high two procedures in one for sculpting and efficiency and durability. skin tightening on all body areas. This plat- It is also indicated for cellulite, a condi- form tightens the skin by generating new tion that almost all women endure. “It is a collagen, resulting in an overall improve- complicated condition and some cannot ment of contour laxity and elasticity in the treated areas. And, the exclusive be treated successfully, but mostly we are delivery modes are used in concert for dealing with a combination of fat hyper- hyperthermic adipocyte destruction and trophy in conjunction with fibrous septae collagen remodeling. tethering the skin to tissue underneath,” Dr. Bengelsdorf pointed out. By improving local microcirculation and reducing the fat, Before and after treatment “TightSculpting combines the 2940 nm with the Z WaveQ system from Er:YAG laser to tighten skin over the the appearance of cellulite is improved. Zimmer MedizinSystems treatment area, with the 1064 nm laser in “Patients we treat with the Z Wave tend to Photos courtesy of Zimmer ultra-long pulse mode to penetrate to the be very satisfied with their results.” MedizinSystems

28 The Aesthetic Guide | September/October 2020 | www.theaestheticguide.com Ultracontour NG from MedixSysteme AG (Ruggell, Liechtenstein) has eight key benefits in one machine from a hands- free protocol to multiple applicators, and painless non-invasive treatment with thermal, mechanical and vibrating effects safe for all skin types. Ultracontour NG offers up to 20 piloted and custom-pro- grammed emitters which can be placed at various body locations simultaneously to treat subcutaneous fat in the arms, belly, legs, buttocks and love handles. Furthermore, specific programs are avail- able for men and women.

The emitters deliver highly focalized frac- tionated ultrasound (termed sonodynamic therapy) for point-by-point targeting at the precise depth of local adiposity from between 0.8 cm and 1.3 cm, but with the unique UMD (ultrasonic mechanical drainage) effect automatically delivering intense pulses to the fat in larger areas automatically. The operator can choose up to five levels of UMD power based on area treated and fat thickness. And, there are six UMD belts offering the flexibility to adapt to each patient’s individual body areas.

According to Fernando Gagliardi, manager Before and after treatment with Ultracontour NG from MedixSysteme of BodyContour (Luxembourg), the improve- Photos courtesy of Fernando Gagliardi ment of lymphatic drainage is especially beneficial to women during menopause or after childbirth. “Ultracontour NG provides a mechanical and thermal effect that is long- lasting for unwanted fat and cellulite. It is safe, easy to use, provides visible results over time, and can treat the full body within 20 minutes. It appeals to both men and women.”

Thread lifting has legitimate body appli- cations, according to Jonathan M. Sykes, MD, director of plastic surgery at the Roxbury Institute Beverly Hills (Beverly Hills, Calif.). “Threads create improve- ment without incisions or much down- time. Lifting and volumizing with threads involves both the volume of multiple implanted threads, and the generation of new collagen on this thread scaffold,” he explained. “They work especially well in Before and after a knee lift using Mono PDO threads areas with fine, crepey skin.” from Les Encres Photos courtesy of Linda Gordon, ACBP Les Encres Threads (Nashville, Tenn.) feature the largest thread selection in the market, with more than 60 offerings such as Mono, Screw, COG and Pressure Molded threads from PCL, PLLA and PDO compounds. Specialty threads are also offered for use around the infraorbital area, region and the rest of the body. “Threads are well-suited for

30 The Aesthetic Guide | September/October 2020 | www.theaestheticguide.com lifting the breast, buttocks, over the knee, is possible and routinely performed in my the upper arm and more. They work by clinic but can be prohibitively expensive repositioning as well as volumizing, which for some.” provides an additional repositioning effect,” Dr. Sykes noted. “Threads are Endo Aesthetics, headquartered in particularly good for creating a look cus- Malvern, Pa. has made recent strides in tomized to the patient’s individual needs. the development of an injectable cellulite Similar use of fillers is often prohibitively therapy that is generating buzz. Qwo™ expensive due to the amount needed.” (collagenase clostridium histolyticum- Les Encres threads are packaged in a aaes), is the first injectable cellulite custom designed, heat- and moisture- product FDA approved for the treatment resistant thread pouch to maintain of moderate to severe cellulite in the but- product stability and viability. tocks of adult women. According to Dr. Mraz Robinson, the enzyme components While injectable body contouring thera- of Qwo specifically target collagen types pies aren’t exactly new, the quality of 1 and 3 to release the fibrous septae for offerings has improved considerably, a smoother appearance in areas riddled according to dermatologist Michael H. with cellulite. “It makes a lot of sense to Before and eight months after Renuva Gold, MD, director of the Tennessee provide a meaningful non-invasive solu- procedure by MTF Biologics Clinical Research Center and Gold Skin tion that specifically targets this crucial Photos courtesy of MTF Biologics Care Center (Nashville, Tenn.). “This aspect of cellulite,” she said. “We can field has changed dramatically over the then address other aspects of cellulite past several years to include not only using existing technologies, if needed, improvement in skin tightening and cir- such as fat reduction, skin tightening or cumferential reduction, but fat reduction biostimulatory fillers.” and muscle tightening/stimulation as well. There are now truly viable injectable Dr. Shridharani was involved with clinical alternatives with good science behind trials for Qwo. “I have seen marked ben- them, and more are coming.” efit for patients in the clinical trial followed out to one year in my practice. The future One clear example is Renuva adipose is bright for Qwo.” allograft matrix from MTF Biologics (Edison, N.J.), an off-the-shelf injectable Expectations management is still a key alternative to autologous fat transfer. component of the therapeutic continuum, but that has also changed, according to Renuva restores volume in the face, Dr. Mraz Robinson. “With the Internet and hands and body in a short, in-office social media, patients tend to spend time procedure. “It contains the same growth researching beyond the hype and have factors, collagen and proteins present access to information and images that in autologous fat,” Dr. Gold said. “This regular patients like themselves have adipose-derived matrix treatment can shared, but we still need to guide patient be used virtually anywhere on the body expectations carefully because Instagram in need of volumizing. Over time, the adi- and other media may not provide a real- pose matrix is replaced by your own fat istic vision for that individual.” which, for those with remodeling needs, can be a major benefit.” The product is “The take-home message is that we have processed to preserve the extracellular a wide variety of truly great options for matrix containing collagens, proteins non- and minimally invasive body con- and growth factors found in adipose touring,” said Dr. Mraz Robinson. “Surgery tissue. The resulting matrix serves as a is still the gold standard, but the distance framework to support the cellular repopu- between surgical and nonsurgical has lation and vascularization at the site of been reduced considerably, and in injection. Renuva is to be used where fat many cases the two are complementary. naturally exists. “This is a perfect addition Typically, patients who are candidates to the field.” for nonsurgical options are more than willing to accept whatever trade-off exists Injection adipocytolysis has gained prom- between the results of surgery and the inence, according to Dr. Shridharani. “This associated risk, recovery and downtime. treatment achieves very localized yet And for many patients, given the nonsur- highly customizable results. ATX-101, or gical options we now have, surgery just Kybella from Allergan (Irvine, Calif.), was isn’t the ideal choice anymore.” FDA approved for the submentum, but is commonly used off-label on the body for specific areas such as the pubis, around the knees or bra fat. Use on larger areas

32 The Aesthetic Guide | September/October 2020 | www.theaestheticguide.com