If there’s one thing universal across cultures, it is the never-ending quest for the perfect body. While diet and exercise can help to reduce cellulite and stubborn fat, they oftentimes require following strict rules and they are not always effective. This prompts patients to search for alternatives that are more convenient and effective. A few decades ago, this would mean excisional or surgical body contouring surgeries such as liposuction, brachioplasty, and abdominoplasty (all of which are highly invasive). Today, there are many other safer, less invasive treatment options. These new treatment techniques tend to be more affordable, making them the perfect alternative to the conventional surgical body contouring procedures. They effortlessly get rid of stubborn inches that even the most intense training or the strictest of diets cannot remove. In this article, we will discuss about different non-surgical body contouring treatments, including the newer treatment modalities that are still under clinical trials. We will also discuss about the expected outcomes, patient screening and the possible complications that may occur.
Patients who seek body contouring treatments
Generally, there are two types of patients seeking body contouring treatments—those who are well informed and those who are less informed. The former group of patients is knowledgeable about different types of body contouring techniques and treatments, and these patients often know what treatment outcomes they are looking for. Having previously undergone other body contouring procedures, they tend to have more realistic expectations compared to first-timers. On the other hand, the latter group is less informed about body contouring treatments. As a result, these patients can sometimes have unrealistic treatment expectations for minimally invasive (or non-invasive) body contouring treatments. In general, it can be more difficult to manage this group of patients.
The usual areas of concern include the lower back, thighs, and abdomen. Most patients who seek treatments suffer from stubborn fat pockets, cellulite, or excess fat, which diet and exercise generally have no effects on.
Practitioners are advised to consider the possibility of body dysmorphic disorder (BDD) when performing body contouring treatments. BDD is a type of mental disorder characterized by obsessive thoughts of perceived or real flaws and is particularly prevalent among patients seeking body contouring treatments (this will be discussed in detail later).
Patient selection and assessment
When assessing and screening patients for minimally invasive and non-surgical body contouring treatments, practitioners should perform a thorough medical examination. To ensure optimal treatment outcomes, it is recommended to review the physical activity and dietary history, and address any lifestyle factors that may contribute to body fat. Prior to the treatment, doctors should try to understand patient expectations and their reasons for seeking body contouring treatments. As with all aesthetic procedures, an achievable goal is the key to successful treatment. Before undergoing the procedure, patients must be made aware of the limitations of body contouring treatments. It is important to set up clear, realistic expectations in order to avoid disappointment. As always, it is better to underestimate the results than to have an overly high expectation (which may not be achievable). It should be made clear that most non-surgical body contouring treatments do not deliver immediate results. Also, patients should be reminded of the fact that repeat treatments are often required to achieve full results. At the same time, volume measurement and re-treatment photography should be taken as part of the consultation. This allows patients and doctors to compare the difference before and after treatment.
Prior to body contouring treatments, practitioners should rule out patients who demonstrate symptoms of BDD. Validated screening questionnaires such as the Body Dysmorphia Disorder Questionnaire (BDDQ) are recommended for the detection of this disorder. BDDQ is highly reliable and has an accuracy of up to 94%. In an effort to avoid post-treatment complaints (due to unsatisfactory outcomes), doctors should avoid treating patients with known psychopathology (e.g. BDD), and those who have unrealistic treatment expectations.
Techniques of body contouring
Over the last 20 years, new body contouring techniques are being constantly developed. This section details the newer treatments commonly used in aesthetic clinics. Most of them work on the principle of thermal injury (which induces selective apoptosis in adipocytes). Scientists are now beginning to develop new techniques that selectively target the adipocytes without prolonged cooling or heating of the tissues. If successfully developed, these treatments will have a significantly lower risk of adverse effects.
1. Deoxycholic acid
The idea of treating submental fat using injectables is nothing new; however, it wasn’t until 2012 that deoxycholic acid preparations have obtained CE approval. Functioning as a lytic agent, deoxycholic acid is able to disrupt the integrity of adipocyte membrane, subsequently causing adipocytolisis. Consequently, this causes an inflammatory reaction that enhances the removal and phagocytosis of cellular debris. As a result, there will be a long-term reduction in volume.
Deoxycholic acid is specially formulated to rapidly clear after injection. The injections are not likely to damage the surrounding tissues, as they only act on the lipid-rich tissues. Plus, there is no significant increase in the amount of plasma lipids after treatment. Currently, ATX-101 (a deoxycholic acid preparation) is under phase 3 of a randomized control trial for the treatment of submental fat, and the results have been promising so far. The deoxycholic acid preparation has been shown to reduce volume without increasing the laxity of the skin. Plus, ATX-101 seems to have a good side effect profile and it is associated with minimal adverse reactions (although transient injection site reactions such as edema, erythema and pain have been reported). As with other body contouring treatments, patients need to undergo several treatments to achieve optimal outcomes.
Cryolipolysis (or more commonly referred to as fat freezing) works based on the principle of adipocyte cooling. Fat cells (which are characteristically more susceptible to cooling than other cells) will undergo apoptosis when subjected to low temperatures. As a result, inflammatory reactions occur, leading to the phagocyte-assisted adipocyte removal. When the inflammatory reaction subsides, the volume will be reduced. At the same time, the entire subcutaneous layer will be restructured.
Newer devices on the market usually combine freezing with skin surface protection and vacuum mechanism. While indicated for all skin types, there is a risk of complications such as post-treatment bruising, paraesthesia and erythema (redness). It is common to experience pain after the procedure; however, this will usually resolve with time. Practitioners may prescribe local anesthetic as needed for pain relieve. For the best results, it is recommended to perform more than one cryolipolysis treatments. It may take up to six months to see the results.
3. High intensity focused ultrasound (HIFU)
High intensity focused ultrasound (or simply known as HIFU) is a relatively new technology for fat loss. Conventionally used in aesthetic medicine to lift and tighten the facial SMAS layer, high intensity focused ultrasound treatments are now used for volume reduction. Using focused ultrasound, HIFU acts in the subcutaneous layer to create deep areas of coagulative necrosis. In most patients, the results are seen about 12 weeks after treatment. Similar to other body contouring procedures, more than one HIFU treatment is required to produce optimal outcomes. Having an excellent safety profile, high intensity focused ultrasound can be used on all skin types.
Over the last 75 years, radiofrequency (or simply RF) has been a main method of delivering power to tissues for a wide range of purposes. The operating principle of radiofrequency treatments is based on heating of the deep tissues and skin. By converting the radiofrequency waves to thermal energy, RF treatments trigger vasodilation and a series of inflammatory reactions. This subsequently stimulates the thickening of dermis and deeper connective tissues, eventually leading to reorganization. A temperature of 43 to 45°C is typically used. Radiofrequency treatments are mostly indicated for the induction of selective apoptosis in adipocytes (otherwise known as fat cells and lipocytes). Adipocyte apoptosis can help to reduce volume 3 to 8 weeks after treatment. For best results, patients need to undergo several non-ablative radiofrequency treatments.
The newer RF devices usually come with built-in thermo sensors, which help to avoid overheating of the skin surface. While generally safe, this equipment is largely operator dependent, therefore patients can still potentially get burns or experience other complications. Additionally, older radiofrequency devices tend to cause uneven depths of RF penetration (and ultimately an unevenness of fat breakdown). This may cause abnormalities of the surface contour. Multipolar or bipolar radiofrequency devices are significantly more predictable in terms of penetration depth of radiofrequency waves and have a lower risk of contour abnormalities and unevenness in comparison to monopolar radiofrequency devices. Minor side effects such as redness or erythema are relatively common. However, they are usually short-lived and will eventually resolve themselves.
5. Low level laser therapy
In the August 2018 issue of the Aesthetics Journal, Dr. Sarah Tonks discussed about the application of low level laser therapy (LLLT) in body contouring and other fields of aesthetic medicine. Low level laser therapy works based on the principle of infrared (or near infrared) light exposure. It has been shown to alter body composition in several ways, both indirectly (by modulating the expression of leptin, a hormone that plays a role in appetite) and directly (by triggering changes in the metabolism of adipocytes). The FDA has approved a few LLLT devices utilizing light wavelengths of 532nm to 635nm for body contouring. As with RF treatments, it takes several treatment sessions to achieve full effects. Low level laser therapy is not likely to cause any major adverse effects.
Developing at a rapid pace, body contouring is one of the most exciting fields in aesthetic medicine. Every year, there are new technologies and devices being developed. Perhaps one of the most challenging aspects of non-surgical and non-invasive body contouring treatments is patient selection. Performed over several treatment sessions, non-invasive body contouring treatments are usually time intensive, and require commitment on patients’ part. As with all aesthetic procedures, it is important to manage patient expectations carefully. Keep in mind that the key to happy patients is realistic and achievable treatment expectation. When choosing the most appropriate device, there are a lot of factors that need to be taken into consideration. This includes patient demographics, treatment cost, staffing levels, and space available.