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Looking Ahead in Cosmetic Surgery at ASPS

In 2018, nearly 16 million patients underwent a minimally-invasive cosmetic treatment, demonstrating a 228% increase in the number of non-surgical cosmetic procedures performed since 2000. Among the available non-surgical cosmetic procedures, body contouring treatments continue to gain popularity. As a board-certified plastic surgeon, I often reflect on the dramatic paradigm shift I have seen in my chosen discipline. Though I spend several days per week in the OR, I see more patients requesting less and less invasive treatments with higher and higher expectations of these non- or minimally-invasive cosmetic procedures. It was recognizing the importance of technology in plastic surgery that led to my interest of taking a leadership role with ASPS and being a member, speaker, and panelist on the Hot Topics Committee. Working on the committee affords me the opportunity to have exposure to the newest technologies and treatments and forces me to stay current on emerging treatments in my field. 

Traditionally, surgical and non-surgical body contouring procedures (i.e. liposuction and energy-based devices) have concentrated on reducing subcutaneous adipose tissue. While the reduction of subcutaneous fat is an effective means to transform body shape, this approach does not address the underlying musculature — a major contributing factor to overall body contour and aesthetic appearance. As such, this year I was most intrigued by the discussions around my experience and a few other early adopter’s experiences with high-intensity focused electromagnetic (HIFEM) technology, a non-invasive solution for improving muscle tone, definition, and strength.

HIFEM devices (EMSCULPT®, BTL Industries, Boston, MA; CoolTone, Allergan Inc., Westlake Village, CA) utilize a focused electromagnetic field to induce the depolarization of motor neurons and trigger non-voluntary muscle contractions in the region of application. The rapid delivery of electromagnetic pulses to muscle tissue prevents the muscle fibers from entering a relaxation phase, thereby inducing high-tension muscle contractions known as supramaximal contractions, triggering approximately 20,000 muscle contractions per 30-minute session. Under these high-stress conditions, the muscle tissue is forced to adapt and responds by remodeling its inner structure, resulting in the growth of existing muscle fibers (hypertrophy) and an increase in the number of muscle fibers (hyperplasia).

Consequently, the stimulated muscles demonstrate increased thickness and strength. In addition to its effects on muscle tissue, HIFEM stimulation demonstrates a secondary effect on adipose tissue. Similar to the lipid breakdown observed during intensive resistance training, the induction of supramaximal contractions generates an increase in metabolic activity which, subsequently, leads to the apoptosis of adipocytes in the region of treatment. As a result, the stimulated region shows a reduction in the thickness of subcutaneous adipose tissue. Thus, HIFEM devices deliver a regional effect that is twofold — an increase in muscle mass and a reduction of subcutaneous fat. 

As a cosmetic surgeon involved in clinical trials and research, I rely heavily on scientific data when it comes to assessing new devices and novel treatments. As of present, studies evaluating the efficacy of HIFEM technology focus on treatment to the abdomen and buttocks. Clinical studies analyzing the effects of HIFEM technology on the abdomen found a significant increase in muscle mass as well as a reduction in average waist circumference, subcutaneous adipose tissue, and diastasis recti. Research assessing the efficacy of HIFEM treatment to the buttocks demonstrated a lifting effect, an improvement in gluteal folds, an increase in overall firmness, and a significant improvement in overall aesthetic appearance of the buttocks. Data also indicated high patient-reported satisfaction three months after completing treatment comprised of four 30-minute sessions over the course of two weeks. In regard to safety, no adverse events were indicated in clinical studies; mild muscle fatigue, resolving within 12–48 hours, was the only reported side effect. In contrast to traditional energy-based procedures, HIFEM technology is non-ionizing, non-radiating, and non-thermal. For this reason, HIFEM treatment is not subject to the various cold or heat-related side effects of energy-based devices and, provided proper patient selection, has virtually no risk of adverse events. While further clinical research and larger sample studies are warranted, the current data on body contouring with HIFEM devices is promising — demonstrating treatment to be effective and unaccompanied by adverse effects at early follow-up. That being said, research investigating the long-term sustainability of tissue changes associated with HIFEM therapy and the efficacy of treatment in regions other than the abdomen and buttocks is imperative. 

As patient demand for surgical alternatives continues to increase, non-surgical body contouring procedures are invariably among the most requested treatments. There are several available non-invasive, energy-based procedures that aim to reduce unwanted adipose tissue (e.g. radiofrequency, low level laser therapy, ultrasound, cryolipolysis). These procedures, however, require patients with well-defined bulges for successful treatment and are thus limited in the extent to which they are able to improve body shape. Many patients, particularly those with minimal or mild subcutaneous fat, are interested in body contouring but are not appropriate candidates for targeted fat loss. HIFEM technology is the first and only treatment modality that aims to improve muscle tone and definition by targeting muscle tissue rather than adipose tissue. Though consensus regarding the ideal candidate for HIFEM treatment is lacking, it is suggested that patients with low or medium BMI and less than 2.5 centimeters of subcutaneous fat may show the most favorable outcomes. This makes HIFEM treatment an exciting option for low BMI patients seeking an improvement in overall aesthetic but who are not suitable candidates for customary debulking interventions. Additionally, HIFEM technology may be used as a supplement to surgical or non-surgical body contouring procedures; integrating HIFEM treatment with other interventions has the potential to maximize results and optimize patient outcomes. The unique ability of HIFEM treatment to improve muscle tone, strength, and definition provides an innovative approach to body contouring that satisfies the modern patient inclination toward non-invasive procedures. Accordingly, I anticipate that HIFEM technology will promptly become an integral and transformative tool within the field of aesthetics and, conceivably, a valuable adjunct to surgical intervention. 

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