Vol. 28. No. 4


Can you believe that fat can be removed, predictably, without surgery? This fantastic development is the basis for this issue of Seminars in Cutaneous Medicine and Surgery. In today’s body-conscious society, it is difficult to find a person who would not desire to change their body shape in some manner. Patients often seek a physician’s opinion regarding fat removal options. It is important that all physicians, both those who perform fat removal and those who do not, be well versed in the body contouring options available so that they can properly counsel inquiring patients. Today, liposuction is the most common surgical cosmetic procedure performed in the United States.1 Liposuction has been performed regularly since the late 1970s,2 although over time, liposuction techniques have been refined. The advent of the “tumescent” technique in 1987 eliminated the need for general anesthesia, making liposuction easier and safer to perform.3 Despite the safety and efficacy of conventional liposuction, many patients seek a less invasive method for body contouring. A variety of devices have been developed in an attempt to reduce fat nonsurgically. Radiofrequency, ultrasound, lasers, and cryolipolysis are some of the new modalities employed to remove fat without liposuction. The mechanism of action, efficacy, and safety of each of these new devices will be presented in this issue of Seminars in Cutaneous Medicine and Surgery. Although all these new devices are exciting and offer great possibilities, it is important for the physician to also recognize their limitations so that the patient can be appropriately counseled. Some of the devices may not be a replacement to conventional suction liposuction, but rather an adjunct to liposuction. With this recent explosion of new body-contouring devices, it is hoped that the practice of body shaping can be further perfected. It is our hope that this journal edition will spark interest in people with regard to these devices, and further entice physicians and industry to perform additional clinical trials investigating these technologies.

Cryolipolysis for Reduction of Excess Adipose Tissue

Andrew A. Nelson, MD | Daniel Wasserman, MD | Mathew M. Avram, MD, JD

Controlled cold exposure has long been reported to be a cause of panniculitis in cases such
as popsicle panniculitis. Cryolipolysis is a new technology that uses cold exposure, or
energy extraction, to result in localized panniculitis and modulation of fat. Presently, the
Zeltiq cryolipolysis device is FDA cleared for skin cooling, as well as various other
indications, but not for lipolysis. There is, however, a pending premarket notification for
noninvasive fat layer reduction. Initial animal and human studies have demonstrated
significant reductions in the superficial fat layer thickness, ranging from 20% to 80%,
following a single cryolipolysis treatment. The decrease in fat thickness occurs gradually
over the first 3 months following treatment, and is most pronounced in patients with limited,
discrete fat bulges. Erythema of the skin, bruising, and temporary numbness at the
treatment site are commonly observed following treatment with the device, though these
effects largely resolve in approximately 1 week. To date, there have been no reports of
scarring, ulceration, or alterations in blood lipid or liver function profiles. Cryolipolysis is a
new, noninvasive treatment option that may be of benefit in the treatment of excess adipose
Semin Cutan Med Surg 28:244-249 © 2009 Elsevier Inc. All rights reserved.


Overview of Ultrasound-Assisted Liposuction, and Body Contouring With Cellulite Reduction

Neil S. Sadick, MD, FAAD, FAACS, FACP, FACPh

Body contouring is a rapidly growing sector of esthetic procedures and dermatologic
surgery. Currently, liposuction is one of the most popular cosmetic procedures with
considerable research being conducted into devices that would facilitate fat emulsification.
The advent of ultrasound-assisted liposuction presented physicians with a great tool in
approaching more superficial as well as fibrous adipose irregularities. Additionally, our
increasing understanding of laser, light, and radiofrequency interaction with adipose tissue
is allowing for these energy sources to be used noninvasively to improve body contours.
This article will provide an overview of the vibration amplification of sound energy at
resonance third-generation ultrasound device for liposuction as well as the VelaShape
platform for noninvasive adipose and cellulite reduction. As body contouring technology
and coinciding experience grow, so will the ability to achieve the aims of more efficient,
safer, and cosmetically pleasing body sculpting.
Semin Cutan Med Surg 28:250-256 © 2009 Elsevier Inc. All rights reserved


High-Intensity Focused Ultrasound Effectively Reduces Adipose Tissue

Afschin Fatemi, MD

Liposonix is considered to be a nonsurgical treatment for body contouring that uses
high-intensity focused ultrasound (HIFU) to disrupt adipocytes percutaneously. We wanted
to find out about its efficacy, effectiveness, and so forth. The technique delivers energy
across the skin surface at a relatively low intensity, but brings this energy to a sharp focus
in the subcutaneous fat. At the skin surface, the intensity of the ultrasound energy is low
enough so that no damage occurs. The focusing of the ultrasound beam at specific depths
beneath the epidermis, combined with proprietary application techniques, results in adipose
tissue disruption. Once adipocytes have been disrupted, chemotactic signals activate
the body’s inflammatory response mechanisms. Macrophage cells are attracted to the area
to engulf and transport the lipids and cell debris. This results in an overall reduction in local
adipose tissue volume. Our clinical and histologic studies will show exactly what happens
under the skin. We did a series of studies on gross pathology and histology, and we tried
to correlate these with the clinical results. The histologies show clearly that adipocytes are
disrupted by HIFU. The pathologies show the lesions, but they are always at a safe distance
from dermis or the epidermis. The correlation between focal depth, energy levels, and
clinical results is evident. The average circumference reduction after treatment of the
abdomen and waist is 4-5 cm. Liposonix turns out to be a safe and effective technique for
nonsurgical body sculpting by reduction of fat deposits.
Semin Cutan Med Surg 28:257-262 © 2009 Elsevier Inc. All rights reserved.


Non-Invasive, External Ultrasonic Lipolysis

Arie Benchetrit, MD, FRCS(C) | Kyle M. Coleman, MD | William P. Coleman, III, MD

Numerous nonsurgical techniques and devices have sought to reproduce the effectiveness
of liposuction. Unfortunately, the vast majority of these has fallen short of adequate results
or has been plagued with complications. UltraShape (UltraShape; Yoqneam, Israel) is a
device that is able to accomplish the reduction of the subcutaneous fat with a procedure
that is both comfortable and leads to good patient satisfaction. Its design of a nonthermal
ultrasonic energy is able to produce cavitation leading to fat cell lysis while sparing
adjacent blood vessels and nerves. Although the results are not equivalent to surgical
results, this device will offer a safe and effective alternative for patients who are apprehensive
about undergoing liposuction.
Semin Cutan Med Surg 28:263-267 © 2009 Elsevier Inc. All rights reserved.