Freezing Fat? An Alternative to Liposuction Announced

Lots of pills and gadgets promise to help you "burn" fat. And they almost always disappoint. Maybe it's all a matter of degrees. Instead of burning fat, should you be trying to freeze it instead?  Check out the latest....

Two new products take a cold approach to fat loss. In September, the Food and Drug Administration approved Zeltiq's CoolSculpting system for fat removal. Offered at doctors' offices across the country — including almost 30 in California, according to the company's website — the procedure supposedly kills fat cells through extreme cold.

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Liposuction Patient Selection

Selecting Liposuction Patients

Cosmetic practices spend large amounts of time planning their clinic, what services they are going to offer, and advertising to get patients interested enough to come in and purchase services. Unfortunately, practices do not spend enough time identifying good liposuction candidates after they walk in the door. As a consequence, patient safety, outcomes, and patient satisfaction can greatly be affected. To be a successful surgery center or medical spa, and eliminate possible liability, you must be able to identify which type of patients you want signing up for surgical procedures.  

Cosmetic patients are for the most part kind, caring and wonderful people. When you are conducting services and they feel comfortable with you, they will tell you all about their marriage, divorce, kids, job, etc. There are simply a plethora of good patients. Unfortunately, there are a few cosmetic patients who may be at the wrong point in their lives for undergoing cosmetic surgery. When patients come in for services such as Liposuction, you are entering a relationship with these patients that will extend through the surgery and through follow ups and aftercare. The ideal relationship you want to create is one of harmony, happiness, peace, instead of dysfunction and high-stress.  So how do you identify what patents might be best for liposuction?  

It all starts even before the consult. If a patient comes in to your office and is rude to the receptionist or other staff, be cautious and understand that this is a person your office will have to interact with many times over the course of their treatment(s).  If they are not happy with minor everyday events, they probably will be very unhappy recovering from surgery and in a binder for one month. During the consult, a patient can sometimes be harboring some unrealistic expectations due to media, false advertising, and their own ideas. This is where the patient care coordinator or Surgeon needs to educate the patient on what he/she can expect as an outcome.  Sometimes it’s a joke when a patient says, “I want to look like J. Lo in the butt and Dolly Parton in the breasts.”  Other times a patient is serious and you need to explain what is and is not possible with their body type.  Showing your before and after pictures during this time of previous cosmetic patients who have the same body shape is important so patients can form their own picture of what they can expect with their results.  

Another red flag is if the patient has had multiple plastic surgeries and is still not happy with their body or the patient believes their abdominal fat is sticking out over their jeans t and you cannot visually see that for yourself. Such a patient may be suffering from body dismorphic disorder (BDD).  BDD is observed in as many as 10% of all cosmetic patients. Signs and symptoms of BDD include a strong belief that a patient has an abnormality or defect in their appearance that makes them ugly, feeling extremely self-conscious, avoiding social situations, refusing to appear in pictures. Patients with body dismorphic disorder may focus on a body feature they want to change and then focus on another part in the future (picture Heidi Pratt). Please realize you can never make possible BDD types of patients happy and refer suspected BDD patients to a mental health provider for treatment. If you are in doubt, it might be a good idea to refer your patient to a mental health professional for clearance before moving forward with cosmetic surgery.

Sometimes patients come in with an urgency to get surgery performed “right away.” The sense of hurry needs to be explored as this could be related to a divorce or other catastrophic event that may not be in the patient’s best interest nor lend the patient’s full dedication to a surgical procedure. It’s always a good idea to wait until a patient is in a “good place” in their lives.  Further, patients, who are excessively obese, have psychological or emotional problems, history of drug abuse and unrealistic treatment goals are also not good candidates. It is mandatory to perform a comprehensive preoperative consultation including a screening questionnaire to identify patients who are appropriate candidates. A liposuction consultation should cover the risks, goals, anticipated results, and expected postoperative care. All patients’ questions should be answered and an assessment should be made as to whether or not the patient is the right candidate for surgery.

The ideal patient for cosmetic procedures is content, with a pleasant disposition and not dealing with any life changing problems when they come into your office. They are realistic about their expectations and basically feel good about themselves but have an area or two that is troublesome. Patients need to be made aware that liposuction is strictly a body-contouring procedure and should never be viewed as a method of weight loss or an alternative to diet and exercise. Patients should be selected with localized adipose deposits that will not go away despite diet and exercise. As in all cosmetic procedures, proper patient selection is vitally important in ensuring satisfactory results after liposuction.

Wendy Hovorka B.S.  M.L.A.  Valley Laser Surgical Solutions Vein Center,  McAllen, Texas

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Zeltiq vs. Zerona

Zerona and Zeltliq booth promise to freeze fat and shed pounds well enough that it would be a slam dunk to add these treatments to your medical spa or laser clinic. But do they work?

Here's some commentary from the NY Times Story

Doctors and patients alike are excited by the prospect of having new technologies that can attack fat without surgery. It is too early, however, for consumers to know how effectively either device works. That hasn’t stopped men and women unhappy with back fat and muffin tops from paying thousands for treatment in recent months...

...Zeltiq Aesthetics, based in Pleasanton, Calif., is a cautious wallflower that aims to get the data behind its device approved by the F.D.A. before it makes too rowdy an entrance to the party. Its slogan is “More Science. Less Fat.”

Meanwhile, Erchonia Medical, based in McKinney, Tex., has aggressively marketed its Zerona laser as “the first non-invasive body contouring procedure to effectively remove excess fat” even though it has yet to receive F.D.A. clearance to promote this use. (In general, the F.D.A. must sanction a medical device for a specific use before a company can market that use. But doctors are free to use devices off label. )

Nonetheless, a brochure for Zerona states patients can collectively “lose up to 9 inches without the pain or down time of surgery.” Nationwide, medical spas, chiropractors, cosmetic surgeons, plastic surgeons and dermatologists now offer Zerona for $1,700 to $3,800 for six sessions. Part of the reason the device has made inroads during these strapped times is that doctors don’t buy it outright, but pay per use.

So how is Zerona supposed to work? The low-level laser causes “fat to seep out of a cell, almost like a balloon being struck by a needle,” said Ryan Maloney, medical director for Erchonia Medical. The fat enters the lymphatic system, and is eventually used as energy, Dr. Maloney said.

Zeltiq uses controlled cooling to target and eliminate fat cells, a process called selective cryolipolysis. Skin isn’t damaged, but subcutaneous fat, which is more sensitive to targeted cold, begins a two-month death march soon after exposure to Zeltiq.

Doctors on the advisory board for Zeltiq Aesthetics have put the word out about it on television news segments. But at this stage, the company itself has been careful not to promote its device directly to consumers since its F.D.A. clearances for, say, pain reduction during dermatologic treatments don’t encompass fat reduction. Gordie Nye, the chief executive, sent an e-mail message declining to be interviewed for this article.

The company has clinical data that has been submitted to the F.D.A. for approval, according to a few doctors who were principal investigators. Data relayed at a meeting of the American Society of Dermatologic Surgery showed a 22 percent reduction of the fat layer as measured by ultrasound.

Erchonia Medical has published the results of its clinical trial in Lasers in Surgery and Medicine. Thirty-five patients in the treatment group lost an average of 3.5 inches total in hips, thighs and their midsection according to the company’s clinical trial. The company has promoted Zerona as “a new body-sculpting procedure designed to remove fat and contour the body without invasive surgery.” But the F.D.A. has not sanctioned marketing this use. It has cleared the Zerona laser for pain reduction 24 hours after breast augmentation or as a way to decrease the pain associated with recovering from liposuction.

In general, Karen Riley, a spokeswoman for the F.D.A., said “it is considered off-label promotion if you are marketing to the public a use that has not been cleared.” Steven Shanks, the president of Erchonia Medical, said, “Since we use the exact same power for liposuction and breast augmentation, we self-certified the device.” He said that in January 2009, the company had applied for a 510K clearance — which is based on the notion that an older device is substantially equivalent to a new one — and had yet to receive it. (Such a delay is atypical, Ms. Riley said, adding, “most 510Ks are cleared within six months.”)

Last month, Dr. Robert B. Seltzer, a dermatologist in Pasadena, Calif., ran an advertisement in The Los Angeles Times for an informational seminar that called Zerona “the holy grail.” In a phone interview, however, he said, “I’m not 100 percent convinced” and planned to return his Zerona if he didn’t continue seeing results in his patients. (So far 5 out of 6 have been pleased.)

After reviewing Erchonia Medical’s clinical study, Dr. Brian M. Kinney, a plastic surgeon in Los Angeles, said, “I can’t prove that it works.” His concerns are that the tape measure method of gauging circumferential changes “isn’t consistently reliable.” What’s more, study participants and the placebo group were assessed only two weeks after their last treatment, not long enough to measure adequately whether results last.

Dr. Kinney doesn’t have a Zerona or a Zeltiq cooling device, though in the case of the latter, he said, “it is well documented that freezing fat tissue aggressively enough can lead to fat necrosis,” or, fat dying, over a few months.

Patient selection for any body contouring procedure is crucial, said Dr. Jeffrey M. Kenkel, vice chairman of plastic surgery at the University of Texas Southwestern Medical Center in Dallas. Dr. Kenkel, who recently replicated results of Zerona’s clinical trial in 12 of his patients, doesn’t offer Zerona to obese patients, or to ones who have had surgery in the area they want treated. “It’s critical to be evaluated by a doctor,” he said.

Success is also dependent on diet and exercise, he said. If you’re sedentary and not eating healthy food, he said, then once fat is leaked after Zerona treatments, “your body will just store it again.”

How the body rids itself of fat, and how quickly, after any noninvasive body slimming procedure is unclear, said Dr. Lawrence S. Bass, a plastic surgeon in Manhattan who started using a Zeltiq device last July. That includes, he said, forthcoming devices like UltraShape and LipoSonix, which employ ultrasound waves to single out fat. It’s a “sticking point with the F.D.A. with all these things,” he said. Dr. Bass was not a clinical investigator for Zeltiq, but he said, “I’m convinced both on the science and clinical experience, it’s able to eliminate fat noninvasively.”

Nadine Tosk, a publicist for Zeltiq, explained that the rollout of the device was “very limited right now.” Dr. Jeffrey Dover, a dermatologist in Chestnut Hill, Mass., who advises Zeltiq and participated in its clinical trial, said a few board-certified plastic surgeons and dermatologists were “handpicked” because “we know they do good work.” Restraint is key, he said, because a doctor could apply Zeltiq to “the same spot” in the same day, which isn’t how it’s meant to be used. Hourlong treatments are best spaced out by two months, said Dr. Dover, who charges $700 per spot.

That said, a doctor with a Zeltiq device isn’t hard for patients to find. More than five dozen “Zeltiq specialists” can be found by ZIP code at body-contouring.com, which is a patient guide not sponsored by manufacturers of body-slimming devices. Dr. Jason N. Pozner, a plastic surgeon in Boca Raton, Fla., appears topless in a YouTube.com video that shows his left flank being suctioned and cooled as he reads his Kindle. (His partner, Dr. David J. Goldberg, was an investigator for Zeltiq.)

Ms. Bonvouloir hasn’t given up on Zerona. Recently, she paid $2,100 for six treatments at Parker Day Spa in Parker, Colo. This time, each session is followed by a massage that supposedly speeds the release of fat. “I still have three more sessions,” Ms. Bonvouloir wrote in an e-mail message. “Again, they are convinced I will lose some inches. I’d like to know when!!!”

Not exactly a raging endorsement but that shouldn't come as a surprise. Is anyone we know having success with Zerona treatments? Is Zeltiq or Zerona going to cause trouble for Thermage?

Tumescent Liposuction vs. Laser Liposuction

Liposuction: is tumescent or laser lipo better?

Plastic Surgeons today are using various types of liposuction. I prefer tumescent liposuction with thin cannulas instead of laser lipo. This is a manual method of liposuction that I believe yields the best liposuction result because the surgeon has the most amount of control.

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Liposuction Technique: Thin Cannulas

Liposuction Training Video: Why thin liposuction cannulas give the best result.

Dr. Ricardo Rodriguez is a Yale trained, board certified plastic surgeon specializing in multiple procedure makeovers. He performs unique procedures such as the body lift, brazilian butt lift, stem cell facelift, endoscopic brow lift, and lip lift. He is Medical Director of his own AAAASF accredited surgery center in Baltimore, Maryland.

Link to this video on Vimeo.

The Hidden Dangers of Beauty

Normally, I barely listen to the radio when driving in my car, but today on the John Tesh Radio Show (Sunday) my ears perked up when he started to discuss the hidden "dangers" of young girls using makeup too early. Dangers in makeup? Really?

The broadcast was entitled "The Ugly Truth About Young Girls Wearing Makeup". The line that grabbed my attention was "the sooner your daughter starts wearing makeup, the sooner it might kill her!" This was a quote coming from Stacy Malkan, a cosmetic expert who wrote the book Not Just A Pretty Face: The Ugly Side of the Beauty Industry. According to the John Tesh website, Malkan states "by the time most North American girls become teenagers, many have a daily make-up ritual that includes lipstick, mascara, eyeliner, nail polish and perfume, not to mention skin lotion, shampoo, conditioner, and hair color treatments." She goes on to say "in fact, experts estimate that a typical young girl now walks around with at least a dozen layers of beauty products on her body! As the makeup layers add up, so does her exposure to dangerous chemicals, and that’s very bad news for a young girl’s health."

Apparently the culprits are chronic exposure to parabens and phthalates which have been found to disrupt hormone levels during adolescent years which may result in early puberty. Malkin continues to state "one study found that HALF [sic] of all North American girls now begin to show signs of breast development by the age of 10 – which is more than two years sooner than females from our grandmother’s generation. Other studies link those unusual hormone levels to a higher depression rate among young girls, and a higher risk for breast cancer! That’s why experts recommend women of all ages find out exactly what chemicals go into their makeup."

There is a website suggested for reference to verify the ingredients in certain beauty products and cosmetics and it is called the Skin Deep Cosmetic Safety Database. I was instantly intrigued and raced to my Mac when I got home to give it a try! Here's how my products scored:

(Scale: 0-2=Low hazard; 3-6 Moderate Hazard; 7-10 High Hazard).

• Cleanser: 3 (moderate hazard) 
• Toner: 7 (high hazard) 
• Moisturizer: 5 (moderate hazard) 
• Eye Cream: 6 (moderate hazard) 
• Lip Cream: 7 (high hazard) 
• SPF 30: 7 (high hazard) 
• Concealer: 4 (moderate hazard) 
• Foundation Primer: 5 (moderate hazard) 
• Foundation: 9 (high hazard) 
• Loose Powder: 5 (moderate hazard) 
• Blush: 7 (high hazard) 
• Bronzing Powder: 8 (high hazard) 
• Eyeshadow: 7 (high hazard) 
• Mascara: 8 (high hazard) 
• Lipstick 6: (moderate hazard) 

My gosh, I'm a walking carcinogen!!! Like most women, I use an array of products, from medical grade like Obagi, spa grade like SkinCeuticals, high end department stores like Merle Norman, Estee' Lauder and Laura Mercier, right down to drug store brands like Maybelline. It seems no company's products were completely safe. And, makeup is just the beginning for young girls!

More and more young girls are taking their skin care regimens to the next level by having microdermabrasion treatments and chemical peels, with some escalating to laser and injectable therapies. Putting aside the various protocols for acneic adolescents, there has actually been a rise in the U.S. of young girls undergoing laser hair removal, photo facials, dermal filler procedures, even laser lipolysis. Where do we draw the line as clinicians? 21? 18? 16 with parental consent? I know in our medical spa we have been approached by parents inquiring as to what our policy is for treating adolescents for non-medical related conditions. The number one request is laser hair removal for ethic skin types predominately for excess facial hair. Many clinicians feel it is a low-risk procedure which can lift a child's self-esteem. Some clinicians disagree and feel a child is much too young to be exposed to laser therapies.

I'm not a laser expert and am uncertain as to if many aesthetic equipment manufacturers have performed clinical trials on adolescents for laser procedures (other than port wine stains). I'm more apt to believe the answer to this questions will become clearer as the years go on and by remembering the first rule is to "do no harm".

That, and to throw away your teenager's makeup!

Author: Paula D. Young RN runs internal operations and training at Young Medical Spa and is the author of the Medical Spa Aesthetics Course, Study Guide, and Advanced IPL & Laser Training course for medical estheticians and laser technicians.

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Plastic Surgery Statistics: What's in a Number?

The American Society for Plastic Surgery released their 2008 statistics on cosmetic procedures performed in the U.S. and stated there is a 12% decline in the number of surgical and non-surgical procedures.

The ASAPS reports the top five non-surgical cosmetic procedures are: 

1. Botox Cosmetic - 2.46 million procedures, down 11%
2. Laser Hair Removal - 1.28 million procedures, down 9%
3. Hyaluronic Acid Fillers (including Restylane, Perlane, Juvederm, Hylaform) - 1.26 million procedures, down 13% (is Radiesse and other fillers included in this research as well?)
4. Chemical Peels - 591,808 procedures, up 3%
5. Laser Skin Resurfacing - 570,880 procedures, up 12% 

According to the ASAPS, breast augmentation has now taken the number 1 spot over liposuction. Here’s the top 5 surgical rankings for 2008 as compared to 2007: 

1. Breast Augmentation - 355,671 procedures, down 11%
2. Liposuction - 341,144 procedures, down 25%
3. Eyelid Surgery - 195,104 procedures, down 19%
4. Rhinoplasty - 152,434 procedures, not much change
5. Abdominoplasty - 147,392 procedures, down 20%

It’s no surprise this decline is directly related to our economical status, but to what extent? Is the economy actually discouraging people from having procedures performed, or, are they simply making more financially sound choices? There have been major technological advancements in the arena that is aesthetic medicine and I found it interesting that the research did not mention these newer procedures performed by plastic surgeons, as well as non-core physicians.

While liposuction numbers are down; it appears as though the number of body shaping and sculpting procedures in the U.S. is on the rise as evidenced by all of the new devices at ASLMS and THE Aesthetic Show, our own data in our practice, and the new laser lipo centers popping up all over the place.

As patients become more educated about the newer procedures available, they now have the advantage of making an educated choice to forego general anesthesia, the lengthy time off of work for recovery, and the high price tag that comes with liposuction and tummy tucks, and are choosing to have minimally invasive procedures instead.

Maybe these newer procedures are so far down on the list that they weren't worth mentioning? Or, maybe the ASAPS’s data is not truly reflective of the current practices of aesthetic medicine in the U.S. as performed by all aesthetic physicians? I’d like to see the ASAPS, along with their “independent research firm”, realize that other physicians besides plastic surgeons perform a variety of aesthetic services that are continually evolving into more cost-effective, efficacious and safe procedures for today’s savvy consumers.

Author: Paula D. Young RN runs internal operations and training at Young Medical Spa and is the author of the Medical Spa Aesthetics Course, Study Guide, and Advanced IPL & Laser Training course for medical estheticians and laser technicians.

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Laser Lipo ~ One Lump, or Two?

I like to regularly read through various self-help forums to understand the patient’s point of view on the types of procedures we perform. (Laser Lipo, SmartLipo) I believe in doing so, it can help fine tune our procedures, prepare us better for responses to patients with similar experiences, and help us perform overall better customer service.

One of the common complaints I have continually come across was lumps and bumps patients have experienced post laser lipolysis. Many seem somewhat traumatized by the bumps, others state their physicians have given them no explanation or even treatment for the lumps.

Let me first preface that this is in no way comparable to the lumps and tracts after traditional liposuction for reasons we’re all well aware of. In fact, many of our patients are coming in to have those lumps and tracts removed with laser lipo. Patients need to be well educated about the healing process of the lymphatic system, underlying tissue layers, the remaining layer of fat post laser lipolysis, and that lumps can be part of that process for some. How many lumps remain visible after the healing process has been completed (6 months or more) is dependent upon how much fat was left underneath the skin from the procedure, how aggressive the procedure was (amount of fat removed and severity of manipulation), and how the area was treated during the healing process. These lumps can be pockets of just fat, or consolidation of scar tissue and body fluid, even seromas that require regular draining until gone.

It doesn’t matter if the device used was a lipo lysing laser or the ultrasound Vaser, lumps can occur and tend to be more operator dependent than anything. No surprise to any of us, I noticed with many physicians I talked with experienced more lumps at the beginning of their training and had to bring many patients back for touch-ups. These physicians tell me that as their experience level increased they began to see fewer lumps and attributed the reduction to technique enhancements from training with more experienced physicians, choices of suction devices and cannulas, aggressiveness of suction post lysing, and post treatment regimens.

Because you can’t rush a physician’s level of experience, what you can do is offer your patients methods to help keep the lumpy bumpies away. These treatments can be started as early as 2 weeks post-procedure or as early as tolerated by your patient.

Here are some of the laser lipo remedies that we currently use or have been suggested to me by others.

• Proper garment fitting
• Placement of large foam surgical pad across abdomen under garment to disperse pressure evenly
• Lymphatic massage, or deep tissue massage, by an experienced massage therapist
• Use of a roller ball. We like the Omni roller ball suggested to us by our dear friend Dr. Richard Goldfarb (thanks Rich!)
• Ultrasound therapy
• VelaShape, or comparable device. We give our patients 2 free sessions with every laser lipo procedure. We like the blending of the infrared, radio frequency, roller motion and suction to help our patients smooth out and tighten the skin.
• Endermologie
• Use of a small cannula to excise the areas of fat (plastic surgeon suggested)

More theories and suggestions are welcome!

Author: Paula D. Young RN runs internal operations and training at Young Medical Spa and is the author of the Medical Spa Aesthetics Course, Study Guide, and Advanced IPL & Laser Training course for medical estheticians and laser technicians.

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