Zeltiq: a new technology worth watching

Developed at Massachusetts General Hospital, Zeltiq is a novel fat melting device, which uses the application of controlled cooling to melt fat non-surgically. The idea, known as cryolipolysis, takes advantage of the finding that fat cells freeze before skin cells do. Thus, if the temperature of the tissues can be lowered to just the right point, the fat cells will be lysed, but the overlying skin will be OK.

The gadget that does this is known as "Zeltiq". And it does seem to work. Each outpatient treatment takes about an hour, and the results take about 3 months to appear. So far, it seems to work best on the abdomen and flank ("love handle") areas. While the results are not nearly as dramatic as those of liposuction, there are clear improvements seen in the pre and post-procedure treatment photos.

A recent pilot study by Coleman and associates found that Zeltiq treatment gave a reduction of 20.4% at 2 months and 25.5% at 6 months in the thickness of the subcutaneous fat layer, which was measured by ultrasound. Although 9 of 10 patients in this small pilot study complained of temporary numbness in the treated areas, this normalized after 3-4 weeks. Biopsies showed no damage to the nerve fibers, which is an important consideration in any fat reduction treatment, as the insulating membranes around nerve fibers have a high fat content. None of the patients had any skin damage or pigment changes.

While the Zeltiq is not FDA approved as yet for fat reduction, it has received the European "CE" mark.

I give this new technology a "looks promising" rating!

Lower body lifts

Just as a tummy tuck can really help people who have a lot of loose skin on their abdomen, a lower body lift is the corresponding operation for people that have significant amounts of excess skin on their lateral (outside) thighs or buttocks. It tightens the lax skin over the "saddlebag" area and buttock by removing the extra stuff, but it does not typically affect the inside of the thigh. Think of grabbing a fold of fabric on your pants in the saddlebag or upper buttock area, and pulling upwards, getting a nice, smooth result.

Most commonly, a lower body lift is done for people that have:
a) lost a major amount of weight through gastric bypass surgery or diet,
b) have had previous liposuction in the area, but have a deflated, loose result,
c) are just plain unlucky, and have a lot of loose skin in that area.

Yes, there is an incisional scar, which is designed so that it is hidden by a standard bikini or swimsuit. The scar is the trade-off for the major tightening of this procedure. So, in other words, this is not an operation for people that just have a little cellulite, related to minor degrees of skin laxity.

If the patient has already had an abdominoplasty, the lower body lift simply extends the incision around the back, curving over the top of the buttocks with a "heart-shaped" design. Some surgeons use a horizontal "belt" incision, but I feel that the curved design works better for women, as it emphasizes the buttock shape in a more attractive way. Most times, there is so much lifting on the sides of the abdomen that I have to re-do the outer portions of the tummy tuck scar!

If the patient has a little extra fat in these areas, some liposuction can be done at the same time. Generally, major liposuction of these areas is done as a separate procedure. Most experts do liposuction first (given decent skin elasticity), then we complete the reshaping of the outer thigh with the lower body lift.

Not all plastic surgeons do this operation routinely, so look for someone who does lower body lifts on a regular basis as part of their busy "body-work" type of practice.

Dr. Fiala interviewed in "Cosmetic Surgery Times"

In the most recent edition of "Cosmetic Surgery Times", the second of a three part special on the obesity epidemic, metabolic syndrome and their potential treatment with various cosmetic surgery techniques features an short interview with....yours truly. (link)

I mentioned how a striking number of patients who present for liposuction and tummy tuck surgery turn out to have metabolic issues, such as high fasting blood sugars, actual diabetes, elevated cholesterol, and other risk factors for heart disease and stroke. It should be something that all plastic surgeons remember to check for, when examining these patients.

We've talked about this topic previously at PSB, in an earlier post (here).

Apparently, Cosmetic Surgery Times reads "PSB - the Plastic Surgery Blog" too! :)

ASAPS 2009: new technologies in body contouring

At the recent ASAPS meeting, a number of breakthrough new technologies were presented, as potential alternatives / improvements on the standard liposuction technique. Bear in mind that most of these wonder gadgets are still in the developmental phase, and do not yet have FDA approval.

But some of the before & after photos looked pretty exciting! Definitely something to watch for over the next few years!

The techniques presented included:

Focused external ultrasound for fat reduction: "Liposonix", "UltraShape"
Radio-frequency assisted liposuction: "BodyTite"
Water-assisted liposuction: "BodyJet" - which is FDA approved.

The BodyTite before and afters seemed to show some clinically significant skin shrinkage effects. Their built-in skin temperature monitoring system may offer a better degree of protection and higher effectiveness than competiting laser lipo machines. But the UltraShape and Liposonix machines have the advantage of being external, non-surgical treatments with minimal "downtime", even though the results are more subtle than traditional liposuction surgery.

It's too early to tell which horse will win this race....

Problems with laser-liposuction: who's the Smart one now?

Over the last few months, I have seen an alarming increase in the number of patients that come in for a second opinion about poorly-performed liposuction (done elsewhere, I might add.) All of these casse have been performed with new high-tech liposuction machines, either laser-assisted (like the SmartLipo) or ultrasonic (like the VASER).

I've seen major skin laxity, uneven liposuction, and obvious over-resection of fat leaving major divots and dents. Many of these problems are very difficult to fix, even with fat grafting techniques.

Here's a few observations:

1. All of these cases were performed by physicians and surgeons operating way outside of their specialty. They were not done by plastic surgeons or dermatologists, who are trained during residency in this technique.

2. In the majority of these patients, physical examination of the patient revealed crummy skin tone and poorly elasticized skin. In other words, since this skin won't contract like we want it to after liposuction, it's completely predictable that the post-op results will be poor, with floppy, deflated areas, and a worsened appearance. A surgeon with any significant training or experience in liposuction would have recognized this - and would have avoided performing liposuction in these patients. It's the wrong tool for the job!

3. All of these patients were preoperatively told by their physicians, "This new wonder lipo machine will tighten your skin".

4. All of these patients now say, "Skin tightening clearly did not happen...now I look worse."

5. None of these patients have an easy fix for their issues. All will require complex and expensive revisional surgery.

Lessons:

A fancy hammer does not a good carpenter make. Any doctor can buy (or rent) a fancy lipo machine.

There is, as yet, no reliable scientific evidence that laser-assisted liposuction:
a) tightens the skin, or
b) works better than standard liposuction.
Any claims to the contrary are "spin" or marketing hype; consider the source and what they're selling.

That being said, the problems seen here were not caused by the type of liposuction machine - but by the doofus using it! While the concept of liposuction is easy, getting excellent results with liposuction takes significant skill.

Please be careful about whom you choose to perform your liposuction. Even if it's performed in an office setting, with local anesthesia, liposuction surgery is still SURGERY. Training, experience and credentials matter.

When Abdominal Fat can be deadly - "Metabolic Syndrome"

It's well known that America has an obesity epidemic, which affects both adults and children alike. But what's not as well known, even in the medical community, is the rapid rise in an obesity-related problem called "Metabolic Syndrome".

Metabolic Syndrome is diagnosed if you have 3 or more of:
- increased waist size (>40 inches for men, 34.6 inches for women
- elevated blood sugars or known Type II diabetes
- elevated blood pressure (> 130/85) or known hypertension
- decreased good cholesterol (HDL)
- increased triglycerides

Why is Metabolic Syndrome important? Because it causes a huge increase in the risks for heart attack and stroke. According to a 2002 article in the Journal of the American Medical Association ("JAMA"), middle aged men with Metabolic Syndrome are three to four times more likely to die of coronary artery disease, and have double the all-cause mortality rate. It affects women similarly, too.

About 47 million people in the United States are believed to have the syndrome, or about one-fourth of the population. It's common here due to our sedentary lifestyle and overall level of obesity.

It's probably more even common than that at my office, because the patients I see for liposuction and tummy tucks are often self-selected; they are seeing me specifically because they have an increased waist size, which is the most obvious part of the syndrome. I now routinely check these patients for the other parts of the syndrome.... Almost every month, we find men and women who never knew they had untreated diabetes, or cholesterol abnormalities, or the whole package -- Metabolic Syndrome. And let me tell you, are they ever thankful we discovered the problem early, rather than after a heart attack! "Doc, I came in for a tummy tuck, and you saved my life!"

It turns out that the fat inside the abdomen, the so-called "visceral fat" (as opposed to the fat that is immediately underneath the skin - "subcutaneous fat") is the chief culprit, together with insulin resistance. Visceral fat is not the harmless layer of insulation we used to think it was - it is metabolically active, giving off hormonal messenger compounds that affect our body. The thicker the visceral fat is, the more health problems are seen. Unfortunately, this internal fat can not be removed by way of liposuction or tummy tuck, so there's no quick fix.

There is an answer, though, and hope for those with the syndrome. Insulin sensitizing medications such as metformin can be used to help with the insulin resistance. Blood pressure and cholesterol medication can help, too, controlling those parts of the syndrome.

Probably the most important treatment, though, is the one that takes the most determination and effort - diet and excercise, particularly aerobic fitness. Several studies show that aerobically fit people with Metabolic Syndrome improve their odds substantially, reducing their risks by a factor of three. Furthermore, overweight people who are aerobically fit have a lower risk of cardiovascular mortality than those who are lean but unfit.

It's time to turn off the TV's and computers, America, and go get some exercise! (And that includes me, too!) Your heart will thank you for it.

Liposuction - keys for success

In order to get a good quality result with liposuction, there are a couple of key factors. These can be nicely divided into "patient" and "surgeon" factors.

On the patient side:
1) Good skin elasticity. Probably the most important factor, as liposuction relies on the natural elastic recoil of the skin for the "shrinking up" effect that occurs after the procedure. Liposuction will not make loose, floppy skin tighter. People with loose skin are not good candidates for liposuction, and usually need some form of body-lift surgery (tummy tuck, etc.)

2) Liposuction is not: a cure for cellulite, or a weight-loss method.

On the surgeon side:
1) Remove the fat evenly and smoothly. Sounds obvious - but surgeon skill is a big part of getting good liposuction results. Experience counts. Don't over-do the suction in one area, or you'll risk a post-operative "divot". I prefer to maintain a little fat just below the skin, to reduce the risk of irregularities and grooves, avoiding what's known as "superficial liposuction".

2) Don't think that the "latest gadget" replaces the need for surgical skill. There's a great deal of marketing hype about new liposuction technology - and it's important to scientifically evaluate the often-exaggerated claims that a manufacturer makes. We've seen this type of hype recently with the wave of new laser-assisted liposuction machines.

"Scarless" breast reduction

Recently, a number of surgeons have been promoting the concept of "scarless breast reduction". While technically, there is a single small incision, compared to a standard surgical breast reduction, it's nearly scarless.

Here's the secret: liposuction. Liposuction is used to remove fatty tissue from the breasts, which makes them smaller, lighter, and more comfortable for women who suffer from the weight of excessively large and heavy breasts.

There's a catch, though. Liposuction-based breast reduction works for women who have breasts that are mostly fatty, and doesn't work if the breast is mostly composed of dense breast glandular tissue. Sometimes this determination is tricky - as there is no inexpensive, accurate test. There are some patients, usually younger in age, where this technique won't work at all.

If the breast is droopy, liposuction breast reduction doesn't really lift the breast, but it usually doesn't make the droop worse either. This is the key difference between standard breast reduction methods and liposuction breast reduction. Liposuction breast reduction usually gives you a "smaller version of what you have now", but not a breast lift.

Surgical breast reduction offers the advantages of lifting and re-shaping the breast - but with the trade-off of additional incisions.

In summary: liposuction breast reduction is a useful option to know about, particularly for women who are worried about scars, or who tend to make thick, ropey scars - and who would like a breast reduction.

Myth: Liposuction can tighten my skin

For a successful result with liposuction, the key to great results is great skin elasticity. Liposuction - whether it be called tumescent liposuction, power-assisted liposuction, ultrasonic liposuction, VASER, or laser-assisted liposuction - does NOT tighten skin in any scientifically-proven reliable way. Many surgeons have hoped that the latest gizmo will somehow change this statement, but so far, skin tightening after any form of liposuction has been a complete disappointment. (Are you listening, SmartLipo fans?)

If there is obviously loose skin, some form of skin tightening procedure will be required, either at the same time as the liposuction, or as a secondary procedure a few months later. For the neck, this usually involves some form of facelift. For the tummy, loose skin requires some form of tummy-tuck (abdominoplasty).

Suctioning areas that have poor elasticity leads to a deflation effect as the fat is removed- with more laxity, ripples, wrinkles and cellulite showing up once the post-op swelling has resolved. Think of converting a fat neck into a "turkey gobbler" - nobody wants that!

If there are areas on the body that have a moderate, but less-than-optimal degree of elasticity, liposuction usually involves some form of trade-off. You'll look better in your clothes with a slimmer figure, but you won't necessarily look better naked or in a skimpy swimsuit. There may be more loose or sagging skin than you might like, and pre-existing cellulite might look worse. Most patients have to think about that choice pretty carefully!

Liposuction is not a magic wand.