Everyone has seen those medical news segments on television about the problem of obesity in America, and physicians recognize the potentially far-reaching effects of obesity on a patient's health. Typically, close-up shots of potbellies and flabby bottoms flash by on-screen, accompanied by a reporter's voice detailing the rising rates of obesity.

Perhaps in response to increased pressure from public health advocates or simply from a desire to look better, the number of Americans seeking to trim their body fat seems to also be rising. From fad diet plans and gimmicky exercise plans to prescription and herbal fat-blockers and burners, the public is looking for quick and easy ways to cut the flab. And trends in the cosmetic market confirm that more Americans are interested in maintaining a youthful, healthy body image.

While a "cure" for fat eludes us, addressing fatty deposits cosmetically has gradually become an accepted practice, and the available procedures have grown in popularity and design. Liposuction has been the gold standard of fat removal for years, but the development of new technologies in cosmetic dermatology may change the way physicians and consumers view the treatment of fat.

A subject of recent conjecture, light therapies for the treatment of fat are on the horizon and may present physicians and patients with a variety of new options—but also potentially a number of challenges. These therapies are not going to be magic, melting fat so that rotund patients become svelte after just a few treatment sessions. But for the patient who needs to "sculpt" problem areas or achieve tightening and smoothing after weight loss (whether "traditional" or via liposuction), soon-to-be-released technologies will offer benefit. It is important for dermatologists to gain familiarity with new interventions and understand where they fit within the larger market of fat-treating procedures. Ahead we will look at what's in store for body contouring light therapies, and how they may figure into the practice of cosmetic dermatology.

Light-Out the Fat
Body contouring is a major component on the frontier of new aesthetic developments, and after years of anticipation and speculation it appears ready to surge to prominence in cosmetic dermatology. While this is cause for enthusiasm, there still remain a number of educational and practical hurdles about the technology and its use for treating fat. According to Mathew M. Avram, MD, Director of the MGH Laser and Cosmetics Center in Boston, there are already a number of therapies showing the potential for body contouring, most of which were developed for other indications but have been found to treat fat. However, lasers specifically designed for fat treatment are still on the cusp of release. "At this point, there is no commercially available laser that selectively targets fat," he observes. "Rather, there are a group of devices that purport to provide body contouring as well as improvement in the appearance of cellulite." Lasers that selectively target fat are still in the investigational stage, but Dr. Avram notes this will change over the next months and years.

Unlike other fat treatments that go beneath the skin to target fat, emerging laser therapies would essentially start with the skin and work down. Like all cosmetic laser therapies, light-based treatment for fat will work via the theory of selective photothermolysis. "There are particular wavelengths of light that will selectively target lipids," he says. These are the parameters on which fat-treating lasers are based. But it is too early to predict how effective any laser that selectively targets fat will be. While the technology exists to treat fat with lasers, questions about safety as well as specific details on the treatment itself still need to be answered. These are some of the variety of challenges in producing feasible fat treatments, he explains.

Laser-based fat-removal procedures currently exist, and there are data to show safety and efficacy. In one retrospective analysis of contouring procedures, researchers determined that removal of small volumes of fat via sub-dermal 980nm diode laser tissue contraction can be performed safely and effectively with high levels of patient satisfaction.1 Almost immediately after treatment, contour correction and skin retraction were evident in most patients. There was no scarring, infection, burns, hypopigmentation, bruising, swelling, or edema. While ecchymoses were observed in almost all patients, they resolved in less than one week for the majority of patients. The authors report, "Ultrasound imaging confirmed that the thermal effect generated by the laser results in melting and rupture of the collagenous and subdermal bands."

Another study2 reviewed laser-assisted lipolysis with a medium-pulsed 1064nm Nd:YAG system, finding it particularly useful in treating lower abdomen and submental areas where skin laxity may occur after removal of adipose tissue.

Lipolysis is one of many potential applications for light-based technologies targeting fat, and it continues to gain attention for its efficacy, safety, and ease of administration. These "light and lipo" procedures represent a crossover of liposuction and laser technology. But the development of lasers that selectively treat fat represents potentially the most exciting technological development as Dr. Avram indicates; when they are available, they should markedly impact the aesthetic market.

Key Differences
Compared to liposuction or other alternatives, light therapies will likely provide a more subtle kind of treatment, according to Dr. Avram. Thus, there are several built-in advantages for the patient. "Light technologies offer a non-invasive means of reducing fat. They obviate the need for tumescent or general anesthesia, and there is also far less bleeding," he notes. These are important advances in the realm of treating fat, and they are consistent with the many other aesthetic procedures inching closer to truly non-invasive procedures.

Dr. Avram feels that the next challenge is providing significant improvement, which to this point is not feasible outside liposuction. However, he doesn't view this as a drawback of body contouring, but as a condition of a new way of approaching the treatment fat. Therefore, body contouring perhaps should not be framed as a competitor to liposuction, but as a different procedure altogether, offering different outcomes. "Liposuction provides dramatic improvement of large areas with one treatment. It will remain the gold standard for fat removal in the near future," says Dr. Avram. These therapies will more likely have complementary functions, he explains.

There also remain questions as to the involvement of dermatologists in the development and use of new light-based devices/procedures. As several physicians and researchers have noted, non-physicians and physicians from different specialties—e.g. plastic surgery—are performing aesthetic procedures. Since fat is often perceived to be "within" the skin, potential clients may not immediately think of dermatologists when considering the procedure. The sometimes-frenetic nature of the aesthetic market may also cause concern among dermatologists looking to capitalize on this technology and incorporate it into practice. But dermatologists can rest assured that body contouring procedures will always demand the expertise of dermatologists, Dr. Avram maintains.

Dermatologists will be the first and best practitioners to harness the technology and will be at the forefront of its use, he suggests. "The most significant new technologies have developed within the field of dermatology, and fat is an integral part of dermatology," he explains. "Given the dermatologist's deep understanding of the skin (i.e., the epidermis, dermis and subcutaneous fat), these lasers will play a major role in our field, and will offer outpatient procedures suited for dermatology practices."

Dr. Avram adds that when these procedures are available, they will provide a huge boost to aesthetic practices and to the specialty of cosmetic dermatology as a whole. When that will be is more difficult to pinpoint. Dr. Avram warns that the learning curve will be steep due to the intricate nature of body contouring.

It may take patients longer to fully understand the benefit of body contouring, as many of them will likely compare it to liposuction. Unlike liposuction, however, laser-based fat therapies will provide nuanced treatment to cellulite and other areas of the skin and body that a patient wishes to subtly "sculpt," Dr. Avram emphasizes.

A Developing Field
Aesthetic procedures are becoming as nuanced as patient demand, which is reflected in the growth of laser companies and devices in the cosmetic market and the rapid introduction of new technologies at dermatology conferences and events. These trends are part of a larger shift and growth in prominence of aesthetics in the US.

With more Americans interested in these procedures, body contouring and other aesthetic procedures will likely continue growing, providing lucrative opportunities for physicians.

Although Dr. Avram and other laser specialists are enthusiastic about laser fat treatments moving in the right direction, it's still perhaps too early to make predictions about their future in dermatology. Several companies will likely be unveiling their devices soon, but there's no guarantee for the future of body contouring therapies in dermatology. "The current commercially available devices provide mild, temporary improvement in fat contouring and/or cellulite," he observes.

In the near future, Dr. Avram expects to see more effective devices with a variety of treatment modalities. "These devices may be based upon radiofrequency, laser, cooling, ultrasound and other technologies, some of which have shown great efficacy," he explains.

Some of these are already in use in other countries, further indicating that they will likely soon arrive in the US. For example, Dr. Avram points out ultrasound treatments for fat are available outside the US, but have not yet received FDA approval. Says Dr. Avram: "There is an exciting future in this field. Given this nation's great interest in body contouring, these technologies will provide an important new avenue of non-invasive treatments into our practices."