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Body Contouring for Fat and Muscle in Aesthetics: Review and

Debate

Robert D Murgia DO, MA , Claire Noell MD , Margaret Weiss MD ,

Robert Weiss MD

PII: S0738-081X(21)00165-6
DOI: https://doi.org/10.1016/j.clindermatol.2021.08.009
Reference: CID 7658

To appear in: Clinics in Dermatology

Please cite this article as: Robert D Murgia DO, MA , Claire Noell MD , Margaret Weiss MD ,
Robert Weiss MD , Body Contouring for Fat and Muscle in Aesthetics: Review and Debate, Clinics
in Dermatology (2021), doi: https://doi.org/10.1016/j.clindermatol.2021.08.009

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Body Contouring for Fat and Muscle in Aesthetics: Review and Debate
Robert D Murgia, DO, MA1; Claire Noell, MD1; Margaret Weiss, MD1; Robert Weiss, MD1
1
Maryland Dermatology Laser, Skin, & Vein Institute, Hunt Valley, MD

Correspondence
Dr. Robert D Murgia, DO, MA, Maryland Dermatology Laser, Skin, & Vein Institute, 54 Scott
Adam Road, #301, Hunt Valley, MD 21030. Email: drmurgia@gmail.com

Abstract
The recent demand for non-invasive fat reduction and muscle toning has generated the need for a
variety of non-invasive body contouring devices: Cryolipolysis, radiofrequency, focused
ultrasound, laser energy, and high-intensity focused electromagnetic energy. Many of the recent
technologies are still relatively new, and clinical trials are limited. There is also a lack of
comparison between modalities, which makes it difficult for practitioners to select the best
treatment option for patients. We review the currently available treatment modalities and offer
relevant insights.
Introduction
In recent years, there has been a rising dissatisfaction with the appearance of one’s own
body. Over 60% of men and 70% of women were dissatisfied, which is likely associated with
sedentary lifestyles and unbalanced diets.1 This has likely contributed to an increased demand for
body contouring procedures. Until recently, the only reliable procedures for fat reduction were
abdominoplasty and liposuction. Although liposuction remains the standard treatment, it is
associated with many significant risks and the need for considerable post-surgical downtime,
which has led to a patient preference for less invasive methods of body contouring.2-4 Newer
modalities include non-invasive lipolysis and muscle stimulation. Current technologies use
cryolipolysis, radiofrequency (RF), focused ultrasound, laser energy, and high intensity focused
electromagnetic (HIFEM) technology. We review the currently available modalities and offer
additional insights.

Cryolipolysis
Cryolipolysis uses selective cooling for the non-invasive destruction of fat. This novel
approach for fat removal was approved by the United States Food and Drug Administration
(FDA) in 2010. It has been used in the treatment of localized fat on the flanks, abdomen, upper
portion of the arms, breast, flanks, buttocks, submental area, and thighs. This modality revolves
around the concept that lipid-rich adipocytes are more susceptible to freezing temperatures than
surrounding water-rich cells, which can allow for selective apoptosis and preservation of
adjacent structures.5-7
Early preliminary studies designed to examine the selective destruction of fat using local,
non-invasive, controlled cooling demonstrated a visible indentation for all body sites tested and
an up to 80% reduction of the superficial fat layer.8 This study supported that a significant
reduction in fat could be achieved without damage to local structures. Histologic analysis
showed the presence of an inflammatory infiltrate and lobular panniculitis, which peaked at 30
days post-treatment. Macrophages continued to ingest and clear the apoptotic fat cells, which
caused a gradual reduction of fat up to 90 days after the treatment.7,8 This induction of adipocyte
apoptosis had no significant effect on serum triglyceride or cholesterol levels and liver function
tests.9 As the inflammatory process declined over 2-3 months, the volume of fat decreased.10
With the CoolSculpting device (ZELTIQ Aesthetics, Allergan, Pleasanton, CA), a cup-
shaped applicator with cooling panels is used, which contains vacuum-suction to ensure tight
contact and optimal positioning of the skin. The area to be treated is located between the cooling
panels. Immediately following treatment, the skin becomes clay-like or stiff and should be
thoroughly massaged for at least 2 minutes in order to improve clinical outcomes (Figure 1).11
Post-procedural massage aids in the mobilization of lipid crystals and increases tissue
reperfusion after cooling.
Cryolipolysis seems to be well-tolerated and effective for fat reduction. Erythema is the
most common side effect, and any pain is typically minimal. Other mild side effects include
bruising, transient changes in sensation, and infiltration at the treatment site.11 Cryolipolysis is
safe for all skin types, and changes in pigmentation have not been reported even after repeated
use.12 Skin phenotype makes no difference in treatment outcomes. As with any aesthetic
treatment, rare adverse events can occur with cryolipolysis, which includes paradoxical
adipocyte hyperplasia (PAH). The published incidence rate is 0.025%, or 1 in 4,000 treatment
cycles. This clinically presents as a painless, firm, well-demarcated growth of previously treated
tissue at approximately 3-9 months post-treatment, and the treatment is liposuction. Since the
majority of cases are associated with large applicators, we recommend using smaller applicators,
particularly in patients who may be predisposed (males of Hispanic or Latino descent).
Consultation with body contouring experts, such as dermatologic surgeons, are highly
encouraged, and all patients should be fully informed of potential adverse events.13
During consultation, the physician should inform the patient to expect a 20-30%
improvement from a single treatment and that multiple treatments may be required to achieve
desired results. Successive treatments can be performed as early as 4-8 weeks following the
initial session. It may be best for patients to wait 4-5 months to observe the maximal result. The
best candidates are those within their ideal weight range who exercise regularly, eat a healthy
diet, but still have noticeable fat bulges. Patients should be aware that a healthy and active
lifestyle are vital to maintaining results.14

Radiofrequency
In addition to fat reduction, RF devices can also tighten the overlying skin.15 The novel
combination of RF with epidermal cooling allows for skin tightening without epidermal ablation
and prolonged downtime.16 In 2002, the first RF device was cleared by the FDA for the
improvement of periorbital rhytides, which was subsequently followed by approvals for full-face
wrinkles and appearance of cellulite when vibration was added to the delivery system.17
RF technology is based on an oscillating electrical current that forces collisions between
charged molecules and ions, which generates heat. Depending on the targeted depth, frequency,
and cooling, RF-generated tissue heating has different biologic and clinical effects. RF allows for
the non-invasive and selective heating of large volumes of subcutaneous adipose tissue with
minimal risk of damage to surrounding epidermis, dermis, and muscle. By selecting the
appropriate electric field, practitioners can control the heating.18 In-vivo studies have
demonstrated that 15 minutes of thermal exposure to 43-45 degrees Celsius results in delayed
adipocyte death.19 RF heating can cause a micro-inflammatory stimulation of fibroblasts, which
can additionally induce neocollagenesis and neoelastogenesis.20
RF can be delivered using monopolar, bipolar, or unipolar devices. With monopolar
devices, a delivery electrode is placed over the target area and a grounding pad is applied at a
distant site. The current then passes through the target tissue to induce deeper thermal damage.
Monopolar devices can be static, where a short cycle is given while the handpiece is held in
place, or dynamic, where the handpiece is continuously moved. With a bipolar device, the energy
travels between positive and negative poles, which are typically built into the handpiece. The
distance between the electrodes determines the depth of penetration, which is typically confined
to within 1-4mm of the skin surface. Unipolar RF devices utilize just one electrode form which a
large energy field is emitted. Newer RF devices can be labeled as tripolar or multipolar;
however, these are just variations of the basic delivery methods.18
The Exilis device (BTL, Marlborough, MA) combines focused monopolar RF delivery
with several safety features, including Peltier cooling and 2 different hand applicators designed
for the face (Figure 2) or body. Dynamic monopolar RF is effective for fat reduction of the
posterior upper arm as measured by high resolution Duplex ultrasound in 20 patients who had 4
treatments scheduled 2 weeks apart.21 The Vanquish ME (BTL, Marlborough, MA) was designed
for a contactless deep-tissue application that emits RF over a large field--termed focus field RF
or multipolar. This high-frequency system focuses energy specifically into the adipose tissue,
and the large delivery head allows for treatment of obese patients. Early animal models have
demonstrated 70% fat reduction (Figure 3).22
 RF technology is commonly used for body contouring and is generally well-tolerated.
The most common side effects are transient erythema and edema at treatment sites. Unlike with
lasers, RF energy relies on the heating of water rather than selective photothermolysis, which
makes it safe for all skin types. In rare cases, erythematous papules, papular urticaria, first-
degree burns, blisters, and bruising have all been reported with direct contact devices; however,
these adverse events, which are generally mild and self-limited, are more likely to be associated
with operator error, such as excessively slow movement of the handpiece.23

Non-Thermal Focused Ultrasound

Non-thermal focused ultrasound (NTFU) devices deliver concentrated energy to a precise
depth in order to generate cavitation. The UltraShape (Syneron Candela, Wayland, MA) applies
non-invasive, therapeutic, focused ultrasound to treatment sites to reduce the contour of localized
fat deposits. This device produces non-thermal, pulsed, ultrasonic waves at a controlled depth.24
Early studies have demonstrated the destruction of fat cells without injury to surrounding local
structures, such as nerves, skin, and vessels.25 This technique exploits the differential
susceptibility of fat cells to the mechanical stress induced by ultrasound waves.
The UltraShape device includes an external visual guidance system used to direct a
focused beam of ultrasound energy. Low frequency ultrasound waves are delivered in pulses to
the targeted tissue to cause cavitation, which subsequently leads to cell death and apoptosis due
to mechanical cellular disruption.7 One of the initial studies to determine the efficacy of NTFU
was conducted in Spain on 30 healthy patients who had 3 treatment sessions at 1-month
intervals.26 All patients showed a significant reduction in subcutaneous fat thickness within the
treated areas. Weight remained unchanged, and there were no increases in cholesterol levels;
however, triglyceride levels were mildly elevated but still within normal limits. Hepatic
ultrasounds showed no evidence of increased fat deposition in the liver. Adverse events are
typically limited to transient pain during the treatment as well as occasional erythema and
ecchymosis post-treatment.

Laser Energy
In 2015, the application of a 1060nm diode laser for fat reduction became the first and
only FDA-cleared hyperthermic laser for non-invasive body contouring.27 The SculpSure device
(Cynosure, Westford, MA) causes injury to adipocytes from direct heating of tissue. The device
consists of 4 flat, non-suction, contact cooling applicators that can preserve the dermis from
overheating and can be placed in a variety of configurations (Figure 4).28 Energy from the laser
creates movement within molecules of the exposed tissue to generate heat, and a temperature of
42-47 degrees Celsius must be maintained within the adipocytes. At this temperature, the cell
membranes of adipocytes begin to lose their structural integrity, which then leads to delayed cell
death.19
The selection of the 1060nm wavelength is vital to the success and safety of this device
due to its particular affinity for adipocytes. This wavelength has the ability to penetrate to an
appropriate depth in order to adequately target adipocytes and has little absorption within the
dermis, which can leave the overlying skin and adnexal structures unharmed. Similar to its
cryolipolysis counterpart, the damaged adipocytes and other cellular debris are removed using
the body’s natural mechanisms. This process begins with the induction of inflammation that
stimulates macrophage mobilization. Results of this process are appreciable at 6 weeks and are
considered to be optimal at 12 weeks post-treatment.19,27,29
 In multicenter studies, there was a 13% reduction in fat thickness of the flanks and a 16%
reduction of the abdomen at 12 weeks after a single treatment.30,31 Additional studies have found
significant fat reduction of the back and thighs.32 Although not statistically significant, treatment
of the flanks with 1060nm laser demonstrated a 24% reduction in fat volume, while cryolipolysis
produced a 22% reduction.33 Several different clinical endpoints have been established, including
thermal sensations during treatment, observed ultrasound signal change 1 week post-treatment,
and post-treatment tenderness lasting up to 3 weeks.34 Patients may undergo multiple treatments
spaced at least 4 weeks apart.35 As with other modalities, a satisfactory reduction in fat volume
did not always correlate with a reduction in weight.
The 1060nm diode laser lipolysis procedure is well-tolerated, and patient satisfaction
rates have been at least 90%.30-32 The most commonly reported side effects are minimal
discomfort during the procedure and mild-to-moderate post-procedural tenderness that typically
lasts 1-3 weeks.35 Early clinical studies have also demonstrated no significant changes in serum
lipid profiles or liver chemistries following treatment.36 Since melanin is minimally targeted with
this wavelength, it is safe to use in all skin types.37 Ideal candidates are non-obese and wish to
improve stubborn areas of adiposity that are resistant to diet and exercise.27

High-Intensity Focused Electromagnetic Energy

HIFEM technology has more recently been introduced to the field of aesthetics as a tool
for muscle toning and strengthening beyond the capability of normal exercise.38,39 The
EMSCULPT (BTL, Marlborough, MA) utilizes HIFEM technology to induce tonic muscle
contractions to the abdominal area.40 Electromagnetic induction is unique, since it produces a
deeper penetration than electrical stimulation without affecting the skin. This allows for the
selective stimulation of motor neurons without pain because nociceptors are not activated.
HIFEM technology delivers rapidly alternating magnetic fields with intensities up to 2.5T and
frequencies of 3kHz to induce electric currents in the underlying tissue. Motor neurons are
subsequently stimulated due to their sensitivity to propagating electric currents, which causes
muscle contraction. The combination of various pulse parameters can lead to supramaximal,
involuntary muscle contractions at thousands per minute. Although originally intended for the
treatment of muscle, HIFEM has also been found to affect the surrounding fat. Clinical effects
are based on the principle of a supraphysiologic response of muscle with subsequent rapid boost
of fat metabolism;39,41,42 however, the exact mechanisms behind fat reduction have been
controversial. Additional research should focus on this phenomenon.
Initial studies on HIFEM abdominal application have demonstrated a significant
reduction of waist circumference (Figure 5). A clinical study of 22 patients with an average BMI
of 23.8 underwent a standard 4-treatment series of 30-minute HIFEM treatments spaced 2-3 days
apart.40 A mean 4.4cm reduction in waist circumference was measured at 3 months, and fat
reduction occurred with increased muscle definition. Comparing 1-year follow-up measurements
to baseline, MRI and CT studies demonstrated a mean 14.63% reduction in fat, 19.05%
thickening of muscle, and 10.46% reduction of diastasis recti.41
EMSCULPT produces nearly 20,000 pulses per treatment session. Standard abdominal
treatments are applied in supine position with the applicator positioned over the umbilicus in
order to target the rectus abdominis and external and internal obliques. The applicator may be
adjusted to ensure homogenously distributed contractions. Initial stimulation intensity is set
according to the patient’s tolerance threshold and is challenged throughout the treatment. Data
suggests that ideal candidates have less than 1in of pinchable subcutaneous fat.40,41
 Currently, HIFEM represents the newest category of technology in non-invasive body
contouring. It can also be used safely in conjunction with other treatment modalities in order to
enhance results. If initial fat reduction strategies reveal lax musculature, HIFEM can then be
used to induce muscle contouring. In addition to the standard abdominal treatment, HIFEM is
also being used for non-invasive butt lifts and bulking and strengthening of the biceps, triceps,
and calves.

Conclusions
The growing demand for non-invasive body contouring is fueled by a general desire to
avoid traditional surgical procedures, such as abdominoplasty and liposuction. Available
treatments allow for the safe and effective targeting of fat, and some also provide tissue
tightening or muscle toning. Since some technologies are still relatively new, more studies are
needed to offer additional insights. Studies comparing treatment modalities are lacking, and
debates persist on which devices are most effective. When choosing the ideal treatment, patients
and physicians should discuss individual goals in order to set realistic expectations and maintain
patient satisfaction. Patients should know that these treatments are not substitutes for healthy
lifestyles and weight loss.
Figures

Figure 1. Patient immediately post-treatment with cryolipolysis.

Figure 2. Patient undergoing radiofrequency (RF) treatment using the facial handpiece with
Exilis (BTL, Marlborough, MA).
Figure 3. Fat reduction in treated (right) versus untreated (left) area in porcine model using a
multipolar non-contact device, Vanquish ME (BTL, Marlborough, MA). Arrows display a
decrease in the width of the fat layer between the treated and non-treated areas.

Figure 4. Contact cooling applicator with SculpSure (Cynosure, Westford, MA).

Figure 5. Patient at 30 days following 4 treatments of EMSCULPT (BTL, Marlborough, MA)
standard treatment regimen.
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