Going hot and cold

01 Dec 2013

We examine the bene ts of heating and freezing technologies in fat reduction and body shaping

One of the biggest growth areas in aesthetic medicine in recent years has been the global body shaping market. Predicted to reach $2billion by 2017, the market growth is being largely driven by minimally invasive non-surgical devices, which o er more cost effective, lower downtime treatments. All of this makes body contouring potentially one of the most lucrative areas of cosmetic medicine and one that aesthetic clinics cannot afford to ignore.

Advances and developments in technologies have significantly enhanced the treatment outcomes of non-surgical devices. While procedures such as VASER and laser lipolysis have carved their own niche, bridging the gap between non-invasive treatments and surgery, it is the more minimally invasive sector of the market that is seeing the most growth: there has been a significant boom in the number of devices available on the market in recent years. Two technologies that approach body contouring from opposite ends of the spectrum are radio frequency and cryolipolysis, one using heat energy and the other using cold. Cryolipolysis has undoubtedly been one of the most talked about treatments of 2013 using freezing rather than heating technology to destroy fat cells. But does the advent of this new generation of body shaping treatments mean RF has had its day or do the two o er their own distinct advantages and disadvantages?

THE HEAT IS ON: RADIO FREQUENCY

Offering the additional advantage of skin tightening and cellulite reduction, radio frequency has become one of the most commonly utilised technologies in aesthetic body contouring devices. Facing tough competition from ultrasound assisted treatments such as VASER and UltraShape and the boom in cryolipo devices, which are often more effective in targeting fat, the radio frequency body market has not rested on its laurels. We have seen new and improved versions of existing technologies coming to market, such as the VelaShape III from Syneron Candela and Accent Ultra (ABC Lasers), as well as new technologies incorporating RF such as Venus Freeze (Ellipse), Vanquish and Exilis (BTL Aesthetics), i-Lipoxcell (Chromogenex), 3D-Lipo (3D-Lipo Ltd) and Viora Reaction (AZTEC Services).

RF energy works for body contouring because it is able to penetrate deep into the dermis and sub-dermal layers of the skin, without damaging the epidermis. It also increases blood circulation, allowing the fatty deposits to be drained through the lymphatic system, which is why it also works to reduce the appearance of cellulite. The first RF body contouring devices that came to market were predominantly RF only and offered limited results in fat reduction, which were highly dependent on patient selection, what system you were using and operator technique. As such, many practitioners only found it useful for body contouring when combined with other treatments.

Dr Ravi Jain from the Riverbanks Clinic in Harpenden comments, “RF provided temporary changes in appearance of skin laxity and cellulite but the volume changes were absolutely minimal at best. I found it often worked in combination with other technologies such as VASER Liposuction as a post-operative care method to help massage the treated areas and encourage skin tightening as well as help minimise fibrosis. One of the biggest problems with RF is that it is extremely operator dependent and even then results were modest and temporary. We discovered a high proportion of unhappy patients.”

Dr Kim Singh has been using Accent as a stand-alone treatment since 2005 as well as to enhance his treatment outcomes from VASER. He says, “Since 2007 when we started doing VASER we have been adding Accent into our post-treatment care protocol. It smoothes out the end result and it helps with skin tightening if there is any lax skin. After VASER you can often get a few small ripples and Accent can really finish that off nicely.”

The industry has recently seen an in flux of next generation RF devices, which incorporate new technologies to allow for more optimal and consistent results in fat reduction as well as cellulite and skin tightening. BTL Aesthetics has launched two RF devices onto the market, which are showing positive results. The first was the Exilis, a device that claims to be ‘redefining’ radio frequency (RF) technology. The treatment harnesses its energy through its Energy Flow Control (EFC) system. The installed EFC module controls the energy flow and automatically eliminates energy peaks. This process is known as Square (‘Flat Top’) Spectrum Energy Profiling and is a unique feature of Exilis therapy. EFC automatically monitors the energy distribution on the body through multiple sensors.

“Exilis is unique in delivering monopolar RF with a grounding pad, so we know it is penetrating to the appropriate, therapeutic skin level - from the epidermis down to the subcutaneous layer - and the results have been outstanding,” says Robert Weiss, MD, associate professor of dermatology, Johns Hopkins School of Medicine. “The built-in temperature sensor permits delivery of enough energy to improve skin without pain. In fact, our patients liken the heat sensation to a warm massage. Using Exilis is like driving a Ferrari with the best brakes. It is high performance yet very safe, and you always feel you are in total control of its power.”

The latest system the company has brought to the market is the Vanquish. The non- contact device uses selective RF energy that heats the adipose tissue to the point of apoptosis. The Vanquish is able to selectively heat the fat cells to a temperature of 44-45°C while the surrounding tissue remains unaffected at 40-41°C. The system was trialled at San Diego Cosmetic Surgery Practice Moradi MD for three months, to reduce fat in the abdomen and flanks of selected patients. One patient who has seen improvements says, “After only three treatments, my abdomen is firmer and tighter. Where my clothes were tight before, they now feel loose. Vanquish is truly a remarkable treatment for anyone who wants to tighten and firm unwanted midsection fat on their body.”

As the body shaping market has advanced we are also seeing the launch of more combination devices, which combine RF with other modalities in one device.

VelaShape (Syneron Candela) for example combines RF with infrared as well as tissue mobilisation and suction. This has been proven to enhance results for fat reduction as well as cellulite reduction. The latest VelaShape III device, launched this month, takes this further by incorporating increased RF power. The higher energy density gives improved heating in the tissue. This means that the end point temperature is achieved much faster, and the treatment time and number of sessions required to achieve an optimal result are reduced.

Another combination device launched onto the market this year was the i-Lipoxcell (Chromogenex). It incorporates four technologies for intelligent body fat analysis and measurement, laser diode fat reduction, IR Vacuum massage and radio frequency skin tightening. The system incorporates both visible red and infrared laser for bio-stimulation of metabolic pathways resulting in the release of fatty acids and glycerol, shrinking fat cells. Results are seen immediately.

Another company that quickly realised the bene ts of combining RF with other technologies was Alma Lasers who launched the Accent UltraTM as an update to the original Accent system. It uses combined hot and cold selective resonance ultrasound with high frequency RF. Split into two modules, the UltraTM module provides ultrasound energy for treating cellulite and reducing fat whilst the UniFormTM module provides radio frequency energy and lymphatic drainage for body reshaping and skin tightening. 

THE BIG FREEZE: CRYOLIPOLYSIS

Cryolipolysis is undoubtedly one of the biggest recent trends in body contouring. Ideal for removing pockets of body fat, particularly in the stomach area, flanks, thighs and back, it is proving popular with patients and practitioners alike because of its low downtime, minimal discomfort and impressive results in destroying fat.

Devices utilising cryolipolysis include CoolSculpting, CoolTech, Lipoglaze and 3D-Lipo. Like RF, cryolipo is not a weight loss treatment and is not indicated for obese patients. Results can be expected to be visible within four to six weeks in most cases. Although multiple treatments may be required there is also no need for post-procedure massage or exercise to enhance results. However, it does not have the additional benefits of skin tightening, which you get with RF. Cryolipolysis effectively cools the subcutaneous fat cells in order to induce apoptosis and lipolysis, without damaging any of the surrounding tissues or the skin. These lipids are then transported by the lymphatic drainage system to be processed and eliminated through the body in the same way that fat from your food is eliminated. This process is very gradual, meaning that there is no danger of your lymphatic system being overloaded.

Dermatologist Dr Penelope Tympanidis says, “Interestingly, the exposure to cooling is set so that it causes cell death of subcutaneous fat tissue without apparent damage to the overlying skin. The fat cells in the treated area are gradually eliminated through the body’s normal metabolic processes. With a single treatment subjects have a 20% reduction after two months and 25% reduction at six months in the fat layer as assessed by ultrasound. The lipolytic effect of treatment takes place within about two to four months. It appears primarily applicable for limited, discrete fat bulges. As long as the patient maintains his or her weight with diet and exercise, long-term results should remain stable.”


Rajiv Dash, managing director of Aesthetics of London, has noticed some positive results. He says, “Cryogenic lipolysis is much more suitable for pockets of fat. There are primarily two reasons for this: the first is cost. It is a more expensive treatment for the area covered and if a client needed to repeat treatments or cover multiple areas the cost can quickly mount up. The biggest advantage of this treatment is that post- treatment the fat cells undergo apoptosis and die o , so it is a more permanent solution. Cryogenic lipolysis is very effective on clients who are otherwise within their desired weight range but have small pockets of fat to lose, the added advantage being that any fat loss would be permanent.”

The first cryolipolysis device on the market was CoolSculpting® by Zeltiq, which
set the gold standard for the use of this technology in body shaping. Over 400,000 CoolSculpting® by Zeltiq treatments have been performed worldwide. The CoolSculpting® device is positioned on the area of the body to be targeted and using a suction action, draws the fat bulge into the CoolSculpting® treatment applicator where two cooling plates are situated. The list of areas of the body that the system can now treat is more comprehensive with the launch of CoolCurve+, a specially designed and developed applicator for flanks, and for really slim people who have stubborn, exercise-resistant areas of fat. The anatomically shaped curvature of CoolCurve+ allows for an e ective t to the body and ultimately improved tissue draw, making it easier to treat more areas and a multitude of body shapes. Final results can be seen in 60-90 days when the frozen fat cells are gone for good.

Another treatment that has been making headlines is the Lipoglaze from LoveLite Ice. The Lipoglaze machine works by first gently heating and then rapidly cooling the target area. This causes the fat cells to crystallise and permanently destroys up to a third of fatty deposits per session. The body then naturally eliminates this waste tissue over the next few weeks. Debra Robson from LoveLite says, “Our preliminary clinical studies, due for full publication by the beginning of 2014, have proven that the treatment works, is safe and results have shown from 11% up to a huge 59% reduction in subcutaneous fat. The difference in results seems to be based on the thickness in the layer of subcutaneous fat..”

Dr Ravi Jain uses the CoolTech system. He says, “I evaluated three systems before choosing CoolTech. At first I wasn’t sure if this would work, with claims of results in just one session. I started to see a few lipo patients come to me because they’d had a freezing treatment which had left a large indentation in their stomachs. To me this meant that the technology actually did kill o fat cells in one session, and so the only improvement needed was to learn how to feather it better. Also, some of the business models for other technologies did not suit my practice profile with very high installation and running costs. I wanted a technology that would have low ongoing costs but be highly effective with pleasing results.

So I invested in CoolTech and we waited anxiously for the results to come through. At one month, after a single session, we saw changes better than an eight-week course of RF or USS. At three months some of the results were akin to liposuction. I was staggered and my patients were thrilled. 

Dr Tympanidis believes further studies are needed but is encouraged by the outcomes of cryolipolysis for fat reduction. She says, “Although the mechanism of action for cryolipolysis is not yet completely understood, the e cacy and safety of this non-invasive procedure for fat layer reduction has been demonstrated in the studies available to date. Further studies will assist in identifying the mechanism and elucidate the full potential of this technology to perform safe, non-invasive fat reduction for areas of local fat accumulation.”

If you still can’t decide whether hot or cold treatments provide the best results then one system that o ers both is the 3D-Lipo. The system has applications for both cavitation and cryolipolysis to physically destroy the fat cells. Added to this, with the combination of radio frequency and 3D-Dermology (vacuum skin rolling for targeted cellulite reduction), you are able to combine an effective skin tightening application for both face and body, and also target cellulite.

Dr Martyn King, medical director of Cosmedic Skin Clinic in Tamworth believes it is 3D-Lipo’s multi-faceted approach that o ers a key advantage. He says, “It appealed to us that 3D-Lipo offered a combination of technologies. We tried it out and the cavitation and RF seemed to be a lot better than some other devices we had seen and tried on the market. At the same time cryolipolysis was something we were interested in. There are stand-alone machines for this but they work out a lot more expensive and the consumables are a lot more so having it all in one machine was the best option for us.” 



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