Visceral fat, which is concentrated mainly in between the visceral organs inside the abdomen, can be decreased through ‘proper’ diet and ‘correct’ exercise (Figure 1). This is because some diets can lead to gaining more fat, while some exercises can result in gaining more weight. On the other hand, the deep reserve fat layers of the subcutaneous is typically removed by liposuction. Liposuction is not carried out on the more superficial fat layer, because there is the possibility of hitting the dermis, which in turn will cause unnecessary induration. The skin may appear smooth after liposuction surgery, but there is production of palpable scar tissue underneath. On top of that is the superficial fat layer of the subcutaneous. They are specifically removed by energy-based machine treatments like ultrasound, red Light, infrared light, and cryotherapy, and at the surface is dermal fat, which produces cellulite. Some readers may be thinking that there is no fat in the dermis. However, as will be explained later, this is where fat protrudes, even up to the epidermis, to produce cellulite. Now, this where radiofrequency, infrared and skin curving machine treatments come into play.
Figure 1. Fat distribution: visceral fat, subcutaneous fat and cellulites
Next are some examples of treatments that can be used for dermal and hypodermal tissues. We have High Intense Focused Ultrasound to literally explode fat cells. Cryolipolysis is used to freeze fat cells, so that they go into apoptosis, then radiofrequency combined with trans-epidermal nerve stimulation contracts collagen and tones abdominal muscles. Infrared light with low level laser therapy drains fat via lymphatics, while pulsed electromagnetic field promotes neovascularisation. Lastly, red light directly destroys the fat cell wall. Miniature scissors can even be used to ‘snip out’ cellulite, and thermocoagulation collapses spider veins and telangiectasias. Please take note that all of these are US FDA-approved and with CE Clearance from Europe.
It is necessary to remember that fat cells are part of the body's connective tissues (Figure 2). Now, all connective tissues come from fibroblasts. So, if one always stretches, elastin develops. If one needs firming up, then collagen is developed. If someone has excess energy, fat deposition is enhanced. Now, if looking at the fat cell, the nucleus is not at the centre anymore. The reason is because it does not control the function of the cell anymore, unlike in most cells where the nucleus is the one that dictates what the cell will be doing. In fat cells, it is already controlled hormonally by circulating metabolic enzymes.
Figure 2. Loose connective tissue, fibroblast and adipocyte
Fat distribution
When someone overeats and is inactive, this raises the question of where fat will be deposited, as well as where fat will be burned when dieting and exercising. This is the typical fat distribution that differs from person to person, and differs between men and women (Figure 3). If, at birth, 80% of someone's fat predilection is at the tummy, then if they gain 10 lbs of fat, 8 lbs will be deposited in the tummy. Even in adult life, fat predilection will still be 80% at the tummy. So, if by whatever means 10 lbs of fat is lost, then 8 lbs of it will be lost in the tummy. Therefore, it is irrelevant which body area is exercised, the excess fat will be burned wherever it is.
Figure 3. Fat distribution in men and women
Cellulite
Next, the development of cellulite will be detailed. On the left of Figure 4, ‘normal’ skin can be seen, with the smooth epidermis, small fat cells and ‘‘good’’ venous drainage. On the right of Figure 4, cellulite has developed, with venous drainage blocked and engorged fat cells, which push the dermis against vertical connective tissues and produce the orange peel appearance at the epidermis. No amount of vigorous exercise will remove cellulite, and it can develop even in those with a very strict diet.
Figure 4. Cellulite development
How cellulite develops
At the left of Figure 4, there is a healthy subcutaneous tissue with different fat layers. When focusing on where the reserve fat layer is, the fat cells are wide apart with ‘good’ lymphatic spaces in between. The venous drainage is also patent and dilated. When someone overeats and does not do any physical exercise, fat will deposit here initially. Then, the fat cells will grow and impinge on each other. So, fatty tissue in this layer increases by hypertrophy and they will also constrict the venous drainage. If someone continues to deposit fat, it will then be deposited in the superficial fat layer.
When looking at the hypodermis in the middle (Figure 4). As can be seen, the fat cells are organised into groups. There are lymphatic spaces in between cells and lymphatic spaces in between each group of fat cells. If fat continues to be developed, this will increase in number (not in size), so the number of fat cells here will increase per group. Therefore, in this layer, fatty tissue increases by hyperplasia. Most of the lymphatic spaces are now gone, along with the venous drainage. The difference of fat hypertrophy versus fat hyperplasia is important because, as will be discussed later, one produces ‘bad’ fat hormones, while the other produces ‘good’ fat hormones. If fat continues to be deposited, it will protrude into the dermis.
When looking at the surface where the dermis and epidermis is, there are vertical connective tissues that adhere the epidermis to the dermis (Figure 4). Furthermore, there are also spaces in between that have no vertical connective tissues. This is where cellulite will develop. If fat continues to be deposited, these spaces will become ‘hills’ and in between are ‘valleys’. This produces the characteristic ‘orange peel’ appearance of the skin with cellulite. So, at the right of Figure 5, this is not a healthy subcutaneous tissue anymore, but rather a cellulite formation already.
Figure 5. Cellulite in women (left) versus men (right)
Cellulite in women versus men
Now, let's compare cellulite in women and why men do not get cellulite. The left of Figure 5 shows the typical skin of women, while on the right is the typical skin of men. In women, the dermis is thin; that is why excessive hypodermal fat can easily protrude out from it. In men, the dermis is thick, which is why any excess fat does not easily protrude out from it. In women, the hypodermis is thick, explaining why fat can easily accumulate in it, while in men, the hypodermis is thin, which is why it is harder to deposit fat under the skin of men. In women, the vertical septa are vertical and few. So, any excess fat easily goes upward. In men, the vertical septa are diagonal and plenty, which makes it hard for any fat to go upward to the epidermis. This raises the question of why men are treated with anti-cellulite machines. The answer is simple: just because men do not have cellulite does not mean they cannot have excess hypodermal fat.
Beneficial adipokines in subcutaneous fat versus detrimental adipokines in visceral fat
Fat hormones can be ‘good’ or ‘bad’. The more common ones are listed in the table with the beneficial hormones on the left, while the detrimental hormones are on the right. Based on the anatomic locations of fat, subcutaneous fat releases ‘good’ hormones, while visceral fat releases ‘bad’ hormones. Similarly, the lower body fat releases ‘good’ hormones, while the upper body fat releases ‘bad’ hormones. Furthermore, superficial subcutaneous fat releases ‘good’ hormones, while deep reserve fat releases ‘bad’ hormones. So, the difference is if the fat cells grow by hyperplasia or by hypertrophy if they will be beneficial or detrimental.
General approach to body shaping and systemic fat removal
The idea is that, if a patient comes into a clinic shaped like a ‘log of wood’ that is straight, bulky and rough, the practitioner's job is to make them curvaceous, slim and smooth. So, initially, general weight loss can be promoted through diet and exercise. Then, ‘problem’ areas can be treated for specific inch loss, and the final touches are skin tightening, tissue firming, and anti-cellulite for smoothing.
Combination of treatments
The best results can be gained through a combination of treatments due to synergy of their individual strengths, but they have to be carried out in the proper sequence. If the patient begins with having excess fat, then initially the practitioner increases metabolism and drains fat via lymphatics coupled with diet and exercise. This should be followed by machines with body shaping and toning capabilities, like those with trans-epidermal nerve stimulation and electromagnetic fields. Then, if cellulite is present, it can be treated with synergy of bipolar radiofrequency with infrared. Later on, loose skin will develop when fat volume is lost, so it can be tightened with deep or superficial radiofrequency. Finally, for bulges and fatty protuberances that are left behind after all of this, these are the ideal targets for fat cell wall destruction.
Spectrum of electromagnetic field in non-invasive aesthetics
Electromagnetic waves will now be introduced, which are being used by energy-based devices in aesthetic practice. They consist of radiofrequency with the extra high frequency being microwaves (ultrasound), including visible light of red, orange, yellow, green, blue, indigo, violet and invisible infrared light, as well as ultraviolet. The last are X-rays (that include gamma rays). Ultraviolet (from unprotected sunlight) and X-rays (diagnostic and therapeutic) are harmful in large amounts, which is why they are in ‘red’ in Figure 6, which means stop, since they are dangerous for the patient.
Figure 6. Electromagnetic spectrum of lasers and energy-based devices
In a diagrammatic representation of an electromagnetic wave (Figure 6), the point from the start of the horizontal letter ‘S’ to the point at the end of the letter S, is considered one cycle. Now, if two waves are connected, the point from the peak of the wave to the point of the peak of the next wave, is considered one cycle. So, the wavelength is inversely proportional to the number of cycles. With a long wavelength, the cycles are less frequent, and with a medium wavelength, the cycles are medium in frequency. If one has a short wavelength, the cycles are more frequent. Therefore, the longer the wavelength, the less cycles one will have. Consequently, the lower frequency of cycles, the less radiation will be exposed.
If looking at ‘the electromagnetic spectrum’ in Figure 6, as the wavelength is shortened, like to the ‘negative’ power of 10–15, there are more waves created within the same distance, therefore more frequencies, so it is to the ‘positive’ power of 18–23. There is more radiation and is, therefore, more harmful, like X-rays and ultraviolet light. As the wavelength becomes long, it is already at positive power (from the previous negative power), the frequency decreases, like where it is at positive power of 3–7 (from the previous 18–32) and therefore less radiation, ergo less harmful. That is why radiofrequency, ultrasound waves, and infrared light are safe and labelled green in Figure 6. Visible light is somewhere in between, so it has been marked yellow for practitioners to exercise caution. So, among all the electromagnetic waves, to the left is the safest (green means safe), to the right is the most harmful (red means stop) and the middle is yellow, which means to exercise caution.
NOTE: UV light from the sun initially causes tanning only. If you get too much, Sun Burning occurs. Eventually Skin Cancer can develop if exposure is repeatedly done. Now with LASERs, not all of them can be done by Aesthetic Nurses. You can only do Class IIIA or Cold LASERs. And not even a regular M.D. or Dermatologist can do LASER Treatments. Class IIIB or Hot LASERs should be done by a LASER-trained dermatologist.
Lasers for body contouring
Most aesthetic practitioners are familiar with lasers. It is a light source that gives out photon energy, and the photons are amplified by a certain substance, like CO2 or erbium, so that the emitted radiation is higher. For example, in Nd-YAG lasers, there is a neodymium crystal with yttrium, Aluminium, and Gallium. However, for body contouring for removal of subcutaneous fat, low level laser therapy or cold lasers are used. Usually, the light spectrum of red light and infrared light is used, and the reason is simple: the penetration of red light and infrared light reaches the subcutaneous fat. This is in relation to non-ablative photo biostimulation using cold lasers and not ablation using hot lasers. For ultraviolet light, it is concentrated on the epidermis so that most of the sun's harmful radiation is absorbed there, causing skin cancer. However, with red light and infrared light, it is concentrated at the hypodermis where subcutaneous fat is located.
Differentiating radiofrequencies
In radiofrequency, there are different variations (for example, monopolar versus unipolar, bipolar versus tripolar and multipolar versus thermomagnetic pulse). In regard to radiofrequency, there is a power source and a target tissue that will absorb the energy. Imagine that the power source is a battery, while the light bulb is the target. In this simple circuit, there is a positive and a negative charge that dictates the flow of electrons. It should be remembered that all radiofrequencies are considered diodes (‘di’ meaning ‘two’ and ‘ode’ meaning ‘pole’). So, they have two poles, namely: a positive pole (anode) and a negative pole (cathode). Therefore, all of them—whether unipolar, monopolar, bipolar, tripolar or multipolar—are basically ‘bipolar’ in the purest sense of the word. In monopolar radiofrequency, the applicator head is the anode, while a ground connected at the back of the body is the cathode. In bipolar radiofrequency, there are two poles in the applicator head; one is the anode, while the other is the cathode. In tripolar radiofrequency, initially one is an anode, while the other two are cathodes. Similar to all multipolar radiofrequencies, they alternate in being positive or negative, which is why they use alternating current from the wall outlet to which the machine is plugged in. Take note that, in unipolar RF, the applicator head is the anode, while the entire body is the cathode. The purpose of all radiofrequencies is subdermal heating, whether ablative or non-ablative. In non-ablative radiofrequencies, decreased viscosity of collagen and increased metabolism should be promoted, as well as collagen contraction and neovascularisation. However, to avoid pain sensation, the skin surface should not exceed 44°C. In ablative radiofrequencies, re-organisation of the dermis by neocollagenesis is being promoted. If using monopolar radiofrequency with low amplitude but high power, ablation in the dermis can be caused, but if using unipolar radiofrequency with high amplitude but low power, stimulation in the hypodermis can be caused. It is the tripolar radiofrequency models that became multipolar radiofrequency machines throughout the years. Now, the latest is MP2 technology, a magnetic pulse with multi-polars (eight poles outside and four poles inside, plus vacuum and cooling) was added. So, every millisecond, bursts of radiofrequency are produced homogenously so that there are no heat spikes or pain. As there are different distances between various pairs of electrodes, there are various penetration depths, creating a 3D hemisphere. However, there is one more dimension added with a magnetic pulse to make it 4D. When treating the surface, an area, with a length and a width, is being treated—that is 2D. Now, when you add depth, that is not 2D anymore, but already 3D, involving a volume. Then, when adding concentration of energy within the 3D space, another dimension is added—4D. It will look like the magnetic pulse pushes energy in and out; so, radiofrequency waves are created. Magnets push it in and out. Suction increases the volume and promotes lymphatic drainage, while air cooling makes the treatment more tolerable.
Multiple technologies and energies in one single machine
In the 1990s, before the advent of electro-optical synergy (which was the first device that combined radiofrequency with light energy), most machines employed only one form of technology. So, it was either radiofrequency, light energy or suction only. The idea of mixing different energies was taboo and unheard of since it was thought to be too dangerous. The risk was not suited for the sake of aesthetic purposes only. Therefore, patients who wanted to undergo treatments with these technologies had to stagger their treatments, since doing it on the same day was not allowed, and even if they did (by not following the safety recommendations), they had to do it for 2–3 hours, since each treatment takes 45 minutes to 1 hour. At the turn of the century, this mis-notion was debunked with the ‘avant garde’, and futuristic ELOS where radiofrequency and light energies were combined. Furthermore, to add volume to the target area, skin fold was produced using suction, while manual techniques were developed to simulate lymphatic drainage.
Different machines
Regarding the choice of machines and choice of parameters with each, the author uses three machines, namely: Endermologie, Vela Shape and Maximus TriLipo. All of these have body shaping, anti-cellulite and firming capabilities.
Even in the same machine among the three mentioned, parameters can be adjusted to suit the problem area.
Key points
- Body contouring is mostly removal of local subcutaneous fat after intra-abdominal visceral fat is initially reduced
- Knowledge on how fat is deposited and how it is genetically distributed is important. Systematic fat removal should be done in a proper sequence from inside going out or from deep to superficial
- The type of technology and parameters should be suited depending on the target tissue when using energy-based devices for non-invasive aesthetic treatments.
CPD reflective questions
- Is body fat distribution the same for everybody?
- Which subcutaneous fat should be treated first: deep reserve or superficial or dermal?
- Can cellulite be removed by diet and exercise? Can it develop even with the undernourished?
- What is the purpose of subdermal heating in all radiofrequency aesthetic treatments?
- What does ‘ELOS’ mean in reference to the first combined energy aesthetic treatment?