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Nonsurgical Body Contouring of Fat
Summary and Key Features
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Given the dramatic rise of obesity and the obsession with losing weight and improving appearance, the treatment of fat and cellulite is a common cosmetic issue.
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Excess fat and cellulite are distinct entities. Cellulite is best considered a hormonally based structural phenomenon of adipocytes and fibrous septae, whereas excess fat is an overabundance of normal adipocytes.
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The treatment options for excess fat and cellulite are different—a treatment that improves one may have no discernible impact on the other.
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Noninvasive body contouring is a rapidly expanding cosmetic field, with many new technologies recently developed and promising new technologies expected in the near future.
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Topical agents, such as retinoids and methylxanthines, have theoretical benefits on the appearance of fat and cellulite, although objective clinical improvements are limited.
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Injectable therapies, including collagenase, mesotherapy, and injection lipolysis, are also options.
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Physical massage of the affected areas may improve the appearance of fat and cellulite by modulating blood and lymphatic flow.
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Radiofrequency devices use alternating current to generate ionic flow and localized heat in adipocytes, moderately improving the appearance of fat and cellulite.
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Focused ultrasound also specifically targets adipocytes by using pressure waves to damage the cellular membrane, ultimately improving the appearance and thickness of the fat layer.
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Several laser devices using near-infrared wavelengths in combination with physical manipulation have been developed to improve the appearance of fat and cellulite by stimulating dermal collagen formation.
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An adipocyte targeting laser has been developed which selectively heats the adipocytes, thereby leading to apoptosis and clinical reduction in fat volume.
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Cryolipolysis is a therapy by which controlled cold exposure (heat extraction) is used to selectively damage adipocytes, cause apoptosis, gradually and permanently improving the appearance and thickness of the fat layer over several months following the treatment.
Introduction
Obesity is reaching epidemic proportions in the United States, and weight loss remains a challenging goal for many people. Not only does excess fat present cosmetic challenges to our patients, but it is increasingly obvious that there are also associated significant and dangerous medical effects.
In this chapter, we will focus on noninvasive techniques to improve the appearance of fat and cellulite, the benefits of these technologies, and their limitations. The devices and techniques reviewed herein should be thought of not as ways to achieve weight loss, but rather modest body contouring.
These body-contouring treatments are one of the most rapidly expanding areas in medicine and our general culture. According to the American Society for Dermatologic Surgery (ASDS), approximately 1 million body sculpting procedures were performed in 2019, an increase of 60% from 2018.
Although liposuction remains the true gold standard for treating excess fat, it is an invasive procedure with associated discomfort, bruising, and downtime. The last decade has witnessed the advent of many new technologies that have been developed to treat excess adipose tissue through noninvasive techniques. These noninvasive devices use a multitude of techniques to improve the appearance of excess adipose tissue, including a reduction in the overall volume of fat and improvement in the appearance of cellulite.
Fat Versus Cellulite
Prior to discussing therapeutic options, it is necessary to first differentiate fat and cellulite. Excess fat and obesity are an epidemic, mainly resulting from poor dietary and exercise habits. Fat represents a deposition of excess, but structurally normal, adipose tissue. In contrast, cellulite is best considered a hormonally based structural phenomenon of adipose tissue. It is seen almost ubiquitously in post-pubescent women and rarely in men. As a result of these differences, the techniques and technology that effectively treat excess fat may not have any effect on the appearance of cellulite, and vice versa.
Pearl 1
Excess fat is due to accumulation of normal adipocytes, whereas cellulite is best thought of as a hormonally based structural phenomenon of adipocytes and fat septae. As a result, the evaluation and treatment of these conditions are often divergent.
It is thought that hormones likely play a significant role in the formation of cellulite. Estrogens stimulate lipogenesis and inhibit lipolysis, resulting in adipocyte hypertrophy. Cellulite is typically rare in pre-pubertal women and men of any age but is extremely common in post-pubertal women. In fact, it has been suggested that cellulite is best considered a secondary sexual characteristic of females. It has also been proposed that cellulite develops in at-risk areas, due to less effective lymphatic and vascular circulation. Exactly how these differences ultimately cause the structural abnormalities of adipose tissue that result in the appearance of cellulite has not been fully elucidated.
Ultrasound and magnetic resonance imaging (MRI) studies have demonstrated the significant structural alterations between male adipose tissue and female cellulite structure. In male adipose tissue the fibrous septae of the adipose tissue are arranged in an overlapping crisscross pattern. This theoretically provides greater strength to the overall scaffolding of the adipose tissue and prevents herniation of fat cells. In contrast, cellulite has fibrous septae that are arranged parallel to each other and perpendicular to the skin surface ( Fig. 10.1 ). This structure is weaker and allows for the focal herniation of adipose tissue. It is this focal herniation that is thought to cause the classic undulating, lumpy, “cottage cheese” appearance of cellulite. MRI has demonstrated that women with cellulite do indeed have fibrous septae that are oriented in parallel to each other, although these septae may actually be more similar to pillar-like columns ( Figs. 10.2 and 10.3 ). In addition to this structural difference, MRI, ultrasound, and biopsies have also demonstrated that women with cellulite typically have an undulating, lumpy interface between the adipose tissue and the dermis, known as papillae adipose . This interface also likely contributes to the appearance of cellulite. Notably, MRI images showed no correlation between cellulite severity and the thickness of the adipose layer. Therefore, we believe that excess fatty tissue and cellulite should be considered as two distinct entities and that they should be evaluated and treated as such.
Evaluation of Fatty Tissue and Cellulite
Body mass index (BMI), a person's weight in kilograms divided by the square of their height in meters, remains the classic method for determining obesity. However, this may be an oversimplification because it does not necessarily take into account the patient's mixture of muscle and adipose tissue or their overall body type. Furthermore, many patients presenting for noninvasive body sculpting may be in very good shape overall with only a few small problem areas, such as the thighs or flanks (Case Study 1). Although BMI may be a useful tool for defining obesity in large populations, we do not find it particularly useful in our practice. More commonly, we use such measurements as thigh circumference, waist circumference, skinfold thickness, visual assessment, and photographic comparisons pre- and post-procedure in our practice because these more typically reflect the patient's ultimate clinical presentation and outcome. It is important to note that there can be a great deal of variability in these measurements if not performed properly. For example, if the waist circumference is not measured at precisely the same location or in the exact same manner, measurements will be inconsistent and the treatment effect will be difficult to determine. Lighting of before and after photographs can also greatly impact the appearance of the images, leading to over exaggeration or under appreciation of a treatment effect. It is therefore essential that staff be properly trained to perform these measurements and photographs reliably and consistently.
Case Study 1
A female patient presents to discuss noninvasive fat treatment options. She is 35 years old, weighs 185 pounds (84 kg) and is 5′4″ (1.63 m) tall. She has also developed early-onset type II diabetes. She has previously tried to lose weight with diet and exercise but has been unsuccessful. She was recently evaluated by her PCP, who encouraged her to lose weight to improve her diabetes and overall health. She presents to your office because she would like a procedure to treat her excess adipose tissue.
This patient has a common misconception that noninvasive fat treatment can substitute for large-scale weight loss. This patient's BMI is 31.8, which defines her as obese. Furthermore, she already has a medical comorbidity, diabetes, associated with her obesity. This patient absolutely needs help losing weight and improving her medical health, particularly because she has tried and failed previous weight loss strategies. She should be referred to a bariatric weight loss program to help her to achieve her goals of weight loss.
If she is interested in a procedure to help to improve her chances of successfully losing weight, this patient may be a good candidate for laparoscopic banding, partial gastrectomy, or gastric bypass. After the patient has lost weight and is closer to her ideal weight, if she continues to have focal trouble spots of excess fat, she may benefit from a noninvasive body-sculpting procedure at that time.
Pearl 2
BMI is a simple tool to assess overall body habitus. However, BMI is often not the best method to assess localized areas of fat excess and is not often used in our clinical assessments. Furthermore, obese patients (BMI > 30) are often not good candidates for noninvasive body contouring and may require diet, bariatric, or other surgical interventions.
Cellulite can similarly be assessed with various measurements and scales, each of which comes with specific pros and cons. Typically, direct observation with side lighting is the simplest and most effective assessment. Based upon these observations, a relatively simple scoring system for the appearance of cellulite has been described ( Table 10.1 ).
Table 10.1
Cellulite Classification
| Grade I | No or minimal skin irregularity upon standing, pinch test, or muscle contraction |
| Grade II | No or minimal skin irregularity upon standing. Dimpling becomes apparent by pinching or muscle contraction |
| Grade III | Classic skin dimpling at rest with palpable, small subcutaneous nodularities |
| Grade IV | More severe puckering and nodularity |
More recently, technologies such as ultrasound, MRI, and electrical conductivity have been used to assess adipose tissue and cellulite. These technologies are often used in clinical trials to assess the potential efficacy of a novel therapeutic option. However, they are typically not necessary in the evaluation and management of patients in general practice.
Therapeutic Options
There are many different technologies and techniques for noninvasive body sculpting. Options include topical creams, injectable agents, physical manipulation, lasers and light sources, and cryolipolysis. The best option for your patient is dependent on their clinical presentation, treatment goal, and most importantly, their preferences. It is important to emphasize that none of these treatments provides more than a modest, local contouring benefit in most instances, and that these procedures are not intended for actual decreases in body weight.
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