From the Neck Down

When the U.S. Food and Drug Administration (FDA) approved Allergan’s Kybella (deoxycholic acid) for adults with moderate-to-severe submental fat in April 2015, dermatologists were hopeful that this indication would be just the tip of the iceberg. Since Kybella became available, some of us have been using it off-label elsewhere on the body, including for pockets of fat around the bra line, thighs and upper arms.

Patient Selection

Unwanted fat in and around the bra line is a significant “trouble spot” for many women, and there are few treatments that specifically address this area. It is difficult to liposuction this area, and it also seems to be immune to diet and exercise. Multiple areas comprise the “bra line,” namely the sides (top and bottom) and below and above the back of the bra. Trends in breast augmentation may increase the popularity of a procedure that addresses the bra line. Today women who undergo breast augmentation with implants are choosing to go smaller than they have in previous years, and many are downsizing or removing existing implants because they are too big. These women may find that they need some additional fine-tuning in the bra-line area as well.

Calling it the “bra line” is feminizing, and we need to think of other description for these areas. Men with gynecomastia may also benefit from Kybella in these regions once other conditions causing male breast enlargement have been ruled out with a full physical/imaging/laboratory work-up by the patient’s primary care physician.

Just as in the submental region, Kybella is not for everyone with bra-line fat. Ideal candidates should be within 15 percent to 20 percent of their ideal body weight. Patients with excessive skin laxity are not considered ideal candidates because Kybella reduces fat pockets, it does not tighten and tone the skin.

Treatment Protocol

When I first began treating this area with Kybella, I used 4mLs of Kybella in the first session, followed by 1mL three months later and then an additional 1mL at nine months. The FDA labeling states that a single treatment consists of up to a maximum of 50 injections, 0.2mL each (up to a total of 10mL). Now that I have more experience in treating the bra-line/chest with Kybella, I would probably use 8cc in the first session, and 2mL in the subsequent treatment sessions to achieve a more noticeable effect.

Watch it Now

More on fat reduction from Dr. Jegasothy

Each treatment session takes about two minutes to perform.

The results have been impressive, and we have seen high patient satisfaction. In general, we see a 50 percent improvement after one treatment, and a 90 percent improvement after three treatments. Once the fat is destroyed, it does not come back. Kybella is safe in dark skin and does not cause hyperpigmentation. Patients experience moderate tenderness for 24 to 48 hours and mild edema for four to five days. Treated areas are visual at anatomic baseline at one week, but may be slightly tender to deep palpation for two to three weeks.

We have had a difficult time establishing standardized clothing for before-and-after photos. Ideally, we prefer if the patient wears the same bra for both visits, but this is not always feasible. Loose-paper surgical “bras” do not adequately demonstrate the clinical issue, so we have not adopted them for photography in these patients.

Going forward, I see Kybella as having an ever-expanding role in our practices as we seek to treat a number of trouble spots that have thus far not been addressed with minimally invasive procedures.

S. Manjula Jegasothy, MD is founder of the Miami Skin Institute and a Clinical Associate Professor of Dermatology at the University of Miami Miller School of Medicine. She originally presented this talk during Cosmetic Surgery Forum 2017 in Las Vegas.