The Future of Body Contouring Minimally Invasive Procedures Mark Steven Nestor, M.D., Ph.D. Director Center for Cosmetic Enhancement, Center for Clinical and Cosmetic Research, Aventura FL Voluntary Associate Professor Department of Dermatology and Cutaneous Surgery Department of Surgery, Division Of Plastic Surgery University of Miami Miller School of Medicine Activis: Research Grants Allergan: Research Grants, Almirall: Consultant, Annacor: Research Grants Bayer Healthcare: Consultant, Brickell Biotech: Research Grants Castle: Cosmederm Biosciences: Research Grants Croma: Consultant, Research Grants DUSA Pharmaceuticals: Research Grants Erchonia: Consultant, Research Grants Evolus: Research Grants Ferndale: Consultant, Research Grants, Galderma: Consultant, Research Grants, Disclosures IFC: Research Grants LaLumiere, LLC: Research Grants, Consultant, LEO Pharma:, Research Grants MELA Sciences: Consultant, Myoscience: Consultant, Speaker Neothetics: Research Grants, Consultant, Sensus: Consultant, Sinclair: Research Grants, Consultant, Smith & Nephew : Strathspey Crown: Shareholder Suneva: Thermi: Consultant,, Speaker Ulthera: Consultant, Research Grants Valeant: Research Grants, Consultant, The Aging Face and Body Introduction I Population is aging and in addition to accumulated significant UV exposure is becoming overweight (obese) and at the same time losing aesthetic fat Aesthetically, the aging face reflects fat and bone loss and redistribution as well as photoaging causing lines and wrinkles Skin throughout the body also reflects the changes, especially photoaging BMI also increases as we age and has aesthetic implications especially because the Toned body is also the new fashion statement and a reflection of youth. The Aging Body Introduction II Patients are looking to become heathier, treat age associated conditions and to improve their appearance as well as other physical needs Liposuction has been the gold standard but ultimately, our patients desire safe, effective, minimally invasive procedures to Turn back the Clock, remove unwanted fat, tone and tighten skin and improve their overall health Face Submental area Mandibular Malar fat pad Skin Laxity Upper Body Arms, Gynecomastia Abdomen, Hips, Flanks, Love handles Skin Laxity Lower Body Saddle bags Thighs Buttocks, Knees Skin Laxity Adipose Concerns Excess Adipose Tissue and Lax Skin Effective Safe Easy to master Experts vs. everyone Low initial investment? Device vs. injectable Dermatologist friendly! Fat reduction and tightening Ideal Treatment? Fat and Body Sculpting 1
Overview of Minimally Invasive Lipolysis Methods Overview of Minimally Invasive Skin Tightening Methods Lypolysis* Mechanism Cold Laser & Mechanical Induced Heat Chemical Modulation Drug & LLLT Induced Heat* Tightening Mechanism Heat Heat Heat Heat Heat* Method Cryolipolysis FCT 1060 Ultrasound (HIFU) Deoxycholate salmeterol xinafoate Photo- Modulation Topical RF Method IPL Ultrasound (HIFU) Ablative or Fractional Laser Laser (Cutaneous or Fiber) Topical RF Examples CoolSculpting Iovera SculptSure LipoSonix Kybella LIPO-202 Verju ThermiTight Thermi 250 Examples Titan Ulthera Fraxel Erbuim 1064 ThermiTight Thermi 250 Injectable and Topical Radio Frequency Minimally Invasive Total Patient Care for fat reduction and skin tightening High Powered Temperature Controlled RF for skin tightening and bulk fat reduction Temperature controlled radio frequency Timed and regulated RF energy emission improved safety more reliable clinical outcomes Multiple applications facial nerve ablation sub-dermal skin tightening and sculpting ablation of axillary sweat glands skin tightening and smoothing (non-invasive)* vaginal rejuvenation (non-invasive) Temperature (celcius) 80 60 50 40 Energy emission is user controlled to regulate maximum temperature during a timed dosage Nerve Deep fat Sub-dermis Skin 30 0 30 60 90 120 Time (seconds) 2
Cont. RF, 65C, 60sec Target Tissue Temperature 50C Isotherm Liver Collagen Remodeling, Tightening Lipolysis, Sculpting Nerve 40-42 o c 45-50 o c 45-70 o c Epidermis Dermis Subcutaneous layer (fat) 5mm 85 o c The Thermal and Electrical Effects on Tissue in CRFL Applications It is generally agreed that raising tissue temperature above the lethal temperature range of T 45 50C for 20 seconds or more will destroy cell structures and bio-molecules. Thus, it is useful to know in the CRFL case the expected dimensions of the 45 50C isotherm volume Cosman, Electric and Thermal Field Effects in Tissue Around Radiofrequency Electrodes Pain Medicine Vol. 6, No. 6, 2005 * Absolute safety endpoint is external skin temperature of 42 o c. If use 47C subcutaneous will not exceed 42C in the skin. Tissue Tightening Study 48 Tissue Samples 4cm x 4cm grid Each treated 1 pass @ 51C internal, 41C external Avg. Surface Reduction of 23% from 4cm 2 to 3.08cm 2 2 nd pass only yielded 2-3% additional reduction (n=27) Dermal Collagen Thickening John Ferguson, MD Honolulu, Hawaii /after 30 days 25db Ultrasound /after 30 days 30db Ultrasound After 4 Weeks After 4 Weeks 3
After After 4 Weeks After 6 Weeks Brock Ridenour, MD External RF for Skin Tightening & Fat Destruction Temperature Power and Frequency 250 watts at 470 Khz has deepest potential penetration compared to other devices at higher frequencies Temperature Control enables clinician to use temperature as endpoint; no focal pain; reduced risk of arcing; slow movement Temperature and Impedance Monitoring results in constant computerized power output adjustments to deliver accurate and gentle temperature endpoints Monopolar and Bipolar dual modes highest level of versatility Wide Array of Electrodes (7 monopolar, 1 bipolar) - in sizes from 20mm to 100mm; choose appropriate electrode for anatomical area and targeted tissue Precision Depth Control user selected depths (by electrode) from 3 mm (bipolar), 6mm 30mm (mono-polar) 4
470 Khz frequency has deepest penetration due to low tissue resistance 40 Mhz 4 Mhz 1 Mhz 470 Khz Frequency Temperature Control Temperature Control enables clinician to use temperature as clinical endpoint no focal pain reduced risk of arcing Slow operator movement Temperature and Impedance Monitoring constant computerized power output adjustments to deliver accurate and gentle temperature endpoints Dual modes enables highest level of operator versatility Monopolar deep projected energy delivery Bipolar shallow surface energy delivery Monopolar / Bipolar Controlled Radio Frequency 42-45 o C 45-50 o C Smoothing Wrinkles Advantage: power + frequency + temperature control + size 30mm bipolar 20mm 30mm 40mm Skin Subcutaneous fat Wrinkles and Skin Laxity Heating of the skin promotes 3 different kinds of effect: Immediate contraction of collagen Immediate collagen remodeling and increased elasticity Stimulate fibroblasts for long term stimulation of new collagen production Body Slimming Cellulite Skin Subcutaneous fat Muscle Submuscular fat 60mm 70mm 80mm 100mm 5
Selective Adipose Apoptosis (Body Slimming) Adipose cell viability dropped while protecting epidermal and dermal layers when subjected to hyperthermic conditions In vitro (9 hours) 45C @ 3 minutes = 60% cell death 50C @ 1 minute = 80% cell death In vivo (9-24 days) 43-45C @15 minutes = significant cell death Cellulite Orange peel skin; swollen fat Smooth skin; better blood flow supply Adipose Connective Deep Fat Muscles Hyperthermic Injury to Adipocyte Cells by Selective Heating of Subcutaneous Fat with a Novel Radiofrequency Device: Feasibility Studies, Franco, et al, Lasers in Surgery and Medicine, 42:361-370 (2010) Controlled Radio Frequency 2 days after 1 treatment 45C, upper and lower abdomen @ 10 min/area Richard Gregory, MD Roxanne Sylora, MD Progressive Improvement Over Time 45C, 4 Tx: Baseline, 2, 5 and 10months Douglas Key, MD Ed Zimmerman, MD Douglas Key, MD 6
4 Weeks after 4 Treatments J.D. McCoy, NMD The Future of Body Contouring Summary and Conclusions Aging face and body is a factor of genetics and environment form UV to our diet; clinical and aesthetic consequences Patients looking for minimally invasive methods to reduce fat and tighten skin New advances in Injectable and High Powered Temperature Controlled RF for fat reduction, skin tightening and other applications 7