As discussed in my previous post, liposuction, or surgical fat reduction, remains one of the top five cosmetic surgical procedures performed in the U.S. This is in part due to a rapidly increasing demand for body contouring procedures and the popularity of more powerful, safer and more effective noninvasive devices demonstrating success in fat reduction, skin tightening and cellulite improvement.
The “gold standard” for reducing and/or shaping localized or widespread areas of fat is liposuction, but “lipo-like” results can be seen with selective noninvasive technologies in the right patients and with the right combination therapies. Therefore, it isn’t surprising that many companies are working to develop technologies that require little to no downtime and result in no long-term complications.
While solo treatment with FDA-approved devices for fat reduction have the ability to provide substantial improvement, as seen in clinical trials, we’ve also seen anecdotal evidence with combination treatments. This leads to a recent question posed by an individual on RealSelf on whether or not soaking in a hot tub prior to a CoolSculpting procedure could improve clinical results. Here is why, theoretically, this concept has validity.
Noninvasive Technologies for Fat Reduction
Noninvasive Technologies for Fat Reduction
The majority of the noninvasive fat reduction technologies work through a mechanism of controlled thermal injury to excessive adipocytes inducing an inflammatory cascade. The thermal damage, whether it be cold (e.g., CoolSculpting) or hot (e.g., Liposonix), causes permanent destruction of adipocytes leaving behind a localized or circumferential reduction to the problem areas. In some instances, the inflammation, once cleared, can improve the texture (laxity, crepiness) of the skin through tightening due to new collagen stimulation. This is not proven in trials, but is reported anecdotally. The results from these procedures can take up to three months (or more) to be evident and can have significant consequences such as bruising, swelling and/or neuropraxia requiring treatment with anti-inflammatory (NSAIDS) or neurological medications (gabapentin, pregabalin).
Recent approval of a focused ultrasound technology (Ultrashape) gives improvement without inflammation since there is no thermal damage. Rather, there is mechanical or acoustic disruption of adipocytes without damage to surrounding structures such as nerves, vessels, lymphatics or connective tissue. Localized improvements are seen much more quickly since there is minimal inflammation, but may require a series of treatments for a more substantial results. Similarly, the results are permanent with continued proper diet and exercise, as the adipocyte number is forever reduced, rather than just shrunken.
Candidates for noninvasive fat reducing procedures have localized areas of excess fat, without significant laxity and good muscle tone. If you can “pinch an inch” or grab a palm size or greater of excessive fat, the patient may be a suitable candidate. Patients who are overweight, with significant laxity, poor muscle tone and a lot of cellulite, are not the best candidates and should be referred for lifestyle modification and improved fitness through exercise, diet and nutritional supplementation.
Are Combinations Synergistic?
Other technologies using radiofrequency, massage/tissue manipulation, infrared and/or pulsed magnetic fields (e.g., Velashape or Venus Legacy) solo or in combination, have been documented in the literature for improving skin laxity and cellulite and reducing localized fat. In the past, these technologies did not have the power to sustain results, and all that could be hoped for was improvement, not permanent remedy. As the science has improved, long-term results can be obtained if the appropriate series of treatments are performed and the technique is mastered. The technique relies on sustained tissue heating for an appropriate time to influence adipocyte cell death and/or damage (often 15 to 20 minutes at 40∘C to 42∘C) and to stimulate dermal heating for augmented collagenesis. Protocols are individualized based on the treatment area and condition being treated.
What I have seen in my clinical body contouring practice is improved and sustained results from combining therapies. There is anecdotal literature supporting combination treatments for improved and more sustained results, although there are very few large blinded studies. The theory is that pre- and/or post-heating of adipocytes may compromise cell health or even cause cell death and significantly improve the results of the primary treatment for fat reduction. There are no proposed protocols for combination treatments, as no studies have evaluated the commonly used fat reduction procedures with the commonly used skin tightening or dermal heating devices.
Decorative terms such as “fire and ice,” “wind and fire,” or “wind and ice,” have emerged in the body contouring space, which refer to using treatments at the same time to improve results. I have performed these combinations with enhanced improvements and without increased complications as compared to either alone, suggesting the synergy of such combination therapies.
Additionally, I recommend radiofrequency and massage/tissue manipulation treatments (e.g., Velashape or Venus Legacy) for my liposuction patients starting three weeks post-treatment to improve the metabolism of the tissue through vessel dilation and improved oxygen delivery; tighten the skin to the new body contour; decrease post-operative swelling; and influence a greater improvement in fat reduction while also decreasing the risk of irregularities/ripples, lumps and/or seromas. These patients report enhanced improvements with quicker recovery anecdotally. (see Figure 1)
Figure 1. Patient shown before (left) and six weeks after (right) high-definition body contouring/abdominal etching lipocontouring procedure, with very little post-treatment swelling or irregularity seen. Radiofrequency treatments (Velashape) were initiated two weeks after the lipocontouring procedure to promote enhanced results and decrease post-procedural swelling.
The future for noninvasive fat reduction
The future for noninvasive fat reduction
In the past, the only way to truly “sculpt” or “shape” a person’s body was lipocontouring with fat transfer — and this is still the “gold standard” treatment for a large majority of patients. Candidates for this treatment are those with significant body size or multiple body areas for treatment, or those who desire definition or enhancement of certain body parts like the chest or buttocks. (see figures 2 and 3)
Figure 2. Patient shown before (left) and one day after (right) fat transfer to the breasts after water-assisted fat harvesting and lipocontouring of the back, arms and anterior thighs.
For patients with small problem areas who hope for improvement, “lipo-like” results can be obtained with the currently available noninvasive devices and appropriate lifestyle modifications. The future will define what the best combinations of these technologies may be (if any) and what protocols should be followed to get enhanced results without the need for surgery. Clinical trials comparing technologies and commonly used combinations are needed.
Figure 3. Patient shown before (left) and two weeks after (right) fat transfer to the buttocks following water-assisted fat harvesting and lipocontouring from the abdomen, flanks, back, arms and medial thighs.
What can we learn from this post?
The most important take-home message for this realself.com post is that there is currently little evidence to suggest that pre-heating the body or body fat through a sauna, hot yoga or hot tub prior to CoolSculpting will give enhanced improvements. However, the theory of pre- or post-damaging or compromising the fatty areas areas for an enhanced result is supported with anecdotal evidence and through my personal clinical practice. More commonly, physicians are using massage and/or radial shockwaves treatment post-CoolSculpting for enhanced results by quicker resorption of fat and recovery from procedural inflammation, further suggesting that combinations can be synergistic. This patient’s question generates a significant number of questions that will likely be answered in the near future as more physicians are beginning to use multiple modalities to improve results.
Jason Emer, M.D., is a board-certified and fellowship-trained general, cosmetic and procedural dermatologist who is passionate about advancing safe and effective treatments in the field of cosmetic dermatology and laser surgery. Dr. Emer’s expertise and interests include the full range of general dermatological conditions, novel therapeutics, cosmetic face and body treatments, including aging skin, veins, body sculpting, fat harvesting and fat transfer.
