Vol. 32. No. 1


Just a few short years ago, a special edition like this would have been considered science fiction. It is worth taking a moment to think about where we have been, how far we have come, and where we might be heading. Those of us old enough to remember the early collagen and laser days can only marvel at the progress. Back then, to paraphrase the old proverb, everything did look like a nail. Once progress started, it came with a vengeance. Radio frequency, intense pulsed light, fractional lasers, cryolipolysis, ultrasound, microwave, millisecond, microsecond, picosecond, and the list goes on. Acne scars, sweat, fat, red lesions, brown lesions, skin cancers etc; this list continues as well, and new challenges await. The field of noninvasive procedural dermatology is relatively old, dating back to early laser work by such pioneers as Leon Goldman, Richard Fitzpatrick, Rox Anderson, and Kenneth Arndt. However, rapid advances are a testament to several factors, including technology, physician aptitude, consumer demand, and available corporate funding for research and development. In this context, the future may bring challenges. Consumer demand is likely to remain high, the number of physicians with the skill and interest in using technology is expanding, and innovation shows no signs of slowing down. Whether companies will be financially stable enough to continue support of scientific exploration, as well as remain viable through Food and Drug Administration approval, remains to be seen. The development process for technology is expensive, and it is one of the cautionary links in the chain. The other challenge that looms is physician training, and with it brings two concerns. First, for noninvasive procedures to blossom, we must provide training both during and after residency for physicians to become skilled. The second concern is not new, but that does not diminish its importance, that is, ethics. Providers with a variety of motives have shown interest in the field, including those with minimal skills and/or without MD/DO degrees. It is incumbent on us to ensure basic ethical and skill standards are met, not only to safeguard our patients, but also to protect the future and integrity of our specialty. In this issue of Seminars in Cutaneous Medicine and Surgery, innovative therapies for body contouring will be discussed, including low-level laser therapy, cryolipolysis, and highintensity focused ultrasound. Although each technique has demonstrated promising results, a full characterization of the risks and benefits will likely be realized in the coming years as they are further adopted into clinical practice. The field continues to grow in other directions as well. Low-level laser light therapy can also be used to treat a multitude of common medical conditions, including wound healing, viral infections, and acne. Hyperhidrosis, a relatively common condition that can have a drastic impact on a patient’s quality of life, has disappointing responses to some current noninvasive therapies. In this issue, the use of microwave technology in hyperhidrosis will be discussed, giving providers a promising therapy in their armamentarium. Finally, laser and light devices are increasingly being sought after as an alternative to surgical techniques for skin rejuvenation and also tightening. In this issue, novel non-invasive approaches to facial tightening will be discussed, including the use of radio frequency and microfocused ultrasound. While procedural dermatology is still evolving, the robust development of new therapies, and novel applications of existing therapies, continues to push the limits of what can be done non-invasively. As experience with each modality becomes more defined, providers will be able to choose therapies more selectively for each patient. It is, indeed, a bright time for the field of procedural dermatology, with increasing capabilities and rising patient demand helping to ensure the future success of the field.

Treatment of Hyperhidrosis With Microwave Technology

Carolyn Jacob, MD

Hyperhidrosis is the production of sweat above and beyond normal physiological needs,
regardless of the ambient temperature, and it affects >4% of the population. In addition, a
poll showed up to 21% of the population is bothered on a daily basis by their amount of
underarm sweating. Despite the large number of patients who suffer from hyperhidrosis,
there are relatively few effective nonsurgical treatment options. A new, nonsurgical, lasting
treatment for axillary hyperhidrosis has now been developed using microwave technology
to eliminate sweat glands.
Semin Cutan Med Surg 32:2-8 © 2013 Frontline Medical Communications


Noninvasive Radio Frequency for Skin Tightening and Body Contouring

Robert A Weiss, MD, FAAD, FACPh

The medical use of radio frequency (RF) is based on an oscillating electrical current forcing collisions between charged molecules and ions, which are then transformed into heat. RF heating occurs irrespective of chromophore or skin type and is not dependent on selective photothermolysis. RF can be delivered using monopolar, bipolar, and unipolar devices, and each method has theoretical limits of depth penetration. A variant of bipolar delivery is fractional RF delivery. In monopolar configurations, RF will penetrate deeply and return via a grounding electrode. Multiple devices are available and are detailed later in the text. RF thermal stimulation is believed to result in a microinflammatory process that promotes new collagen. By manipulating skin cooling, RF can also be used for heating and reduction of fat. Currently, the most common uses of RF-based devices are to noninvasively manage and treat skin tightening of lax skin (including sagging jowls, abdomen, thighs, and arms), as well as wrinkle reduction, cellulite improvement, and body contouring.
Semin Cutan Med Surg 32:9-17 © 2013 Frontline Medical Communications


Microfocused Ultrasound for Skin Tightening

Elizabeth L Tanzi, MD | Jennifer L McGregor, MD

The demand for noninvasive skin tightening procedures is increasing as patients seek safe
and effective alternatives to aesthetic surgical procedures of the face, neck, and body. Over
the past decade, radiofrequency and infrared laser devices have been popularized owing to
their ability to deliver controlled heat to the dermis, stimulate neocollagenesis, and effect
modest tissue tightening with minimal recovery. However, these less invasive approaches
are historically associated with inferior efficacy so that surgery still remains the treatment
of choice to address moderate to severe tissue laxity. Microfocused ultrasound was
recently introduced as a novel energy modality for transcutaneous heat delivery that
reaches the deeper subdermal connective tissue in tightly focused zones at consistent
programmed depths. The goal is to produce a deeper wound healing response at multiple
levels with robust collagen remodeling and a more durable clinical response. The Ulthera
device (Ulthera, Inc, Meza, AZ), with refined microfocused ultrasound technology, has been
adapted specifically for skin tightening and lifting with little recovery or risk of complications
since its introduction in 2009. As clinical parameters are studied and optimized,
enhanced efficacy and consistency of clinical improvement is expected.
Semin Cutan Med Surg 32:18-25 © 2013 Frontline Medical Communications


New Waves for Fat Reduction: High-Intensity Focused Ultrasound

Michael E. Kaminer, MD | Nazanin Saedi, MD

With the rising demand for body contouring, noninvasive devices for fat reduction have
become increasingly popular and have grown dramatically over the past decade. Highintensity
focused ultrasound (HIFU) has been used for nearly half a century for the
noninvasive treatment of tumors of various organs, but has only recently been evaluated as
a method for the selective destruction of adipose tissue. HIFU works by ablating subcutaneous
adipose tissue and causing molecular vibrations that increase the temperature of
local tissue and induce rapid cell necrosis. Several studies reveal the safety and efficacy of
HIFU for fat reduction in the abdomen and the flanks. These studies indicate consistent
reduction in abdominal circumference >2 cm after a single treatment. The adverse events
are limited to transient tenderness, bruising, and edema. Increased utility of HIFU for fat
reduction will likely increase over time.


Cryolipolysis: A Historical Perspective and Current Clinical Practice

H Ray Jalian, MD | Mathew M. Avram, MD, JD

Dermatologists have long used cold-based therapeutic approaches for a variety of applications.
Based on the differences in chemical composition, it is possible to selectively
target certain tissues rich with lipid, while sparing the surrounding tissue predominantly
containing water. With historical observations of cold-induced panniculitis suggesting the
feasibility of this strategy, cryolipolysis has emerged as a new methodology using controlled
cooling to selectively target fat. Both preclinical and clinical studies have established
the safety and efficacy of cryolipolysis for noninvasive body contouring. This review
will focus on the evolution of cryolipolysis from initial case reports of cold-induced panniculitis,
to preclinical and clinical studies, and the current clinical practice.
Semin Cutan Med Surg 32:31-34 © 2013 Frontline Medical Communications