Aesthetic Surgery Journal http://aes.sagepub.com/
Does Cryolipolysis Lead to Skin Tightening?: A First Report of Cryodermadstringo W. Grant Stevens Aesthetic Surgery Journal published online 12 June 2014 DOI: 10.1177/1090820X14539699 The online version of this article can be found at: http://aes.sagepub.com/content/early/2014/06/09/1090820X14539699 A more recent version of this article was published on - Aug 1, 2014
Published by: http://www.sagepublications.com
On behalf of:
American Society for Aesthetic Plastic Surgery
Additional services and information for Aesthetic Surgery Journal can be found at: Email Alerts: http://aes.sagepub.com/cgi/alerts Subscriptions: http://aes.sagepub.com/subscriptions Reprints: http://www.sagepub.com/journalsReprints.nav Permissions: http://www.sagepub.com/journalsPermissions.nav
Version of Record - Aug 1, 2014 >> OnlineFirst Version of Record - Jun 12, 2014 What is This?
Downloaded from aes.sagepub.com at Dicle Ãœniversitesi on November 7, 2014
539699 research-article2014
AESXXX10.1177/1090820X14539699Aesthetic Surgery JournalStevens
Aesthetic Surgery Journal OnlineFirst, published on June 12, 2014 as doi:10.1177/1090820X14539699
Letter to the Editor
Does Cryolipolysis Lead to Skin Tightening? A First Report of Cryodermadstringo
Aesthetic Surgery Journal 1 –3 © 2014 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: http://www.sagepub.com/ journalsPermissions.nav DOI: 10.1177/1090820X14539699 www.aestheticsurgeryjournal.com
W. Grant Stevens, MD, FACS Skin laxity occurs over time as collagen and elastin fibers break down. The breakdown is exacerbated by environmental factors, such as ultraviolet radiation, pollution, and stress. The rate of collagen and elastin degradation accelerates with time, while the rate of new collagen and elastin formation slows. For facial and neck laxity, several treatment methods exist, such as surgical lifts, minimally-invasive filler injections, and nonsurgical devices employing radiofrequency, laser, infrared, and ultrasound energy.1-4 To treat skin laxity on the body, the same treatment methods are available, although they are not as commonly used. Cryolipolysis (CoolSculpting System; Zeltiq Aesthetics, Pleasanton, CA) is a noninvasive method for selective fat reduction on the body. This nonsurgical procedure uses controlled cooling to reduce subcutaneous fat without inducing damage to surrounding tissues. Cleared by the Food and Drug Administration for fat reduction in 2010, cryolipolysis is an established procedure to safely and effectively reduce fat. A retrospective study on cryolipolysis discussed its clinical safety and efficacy, as well as its potential for business growth, in a plastic surgery practice.5 As shown in the aforementioned article, significant fat reduction can be achieved nonsurgically by cryolipolysis. Patients in flank and buttocks examples in the article also showed evidence of significant skin tightening.5 While cryolipolysis is well established as a nonsurgical method for fat reduction, it has not been documented as a skin-tightening procedure until now. To illustrate the skin-tightening phenomenon often observed in cryolipolysis patients at this practice, 2 patients are presented. In addition to the expected reduction in fat layer thickness, the patients were observed to attain visible skin tightening in the treatment areas. Cryolipolysis treatments were delivered to targeted areas for fat reduction per standard treatment cycles for 60 minutes’ duration. A vacuum applicator pulled the targeted tissue into an applicator cup with parallel, temperature-controlled cooling plates. In addition to the anticipated fat reduction following treatment, skin tightening in the cryolipolysis treatment area was observed. As shown in the female abdomen treatment in
Figure 1, cryolipolysis produced significant volume reduction and skin tightening after 4 months. For the female abdomen and flanks patient in Figure 2, the large fat volume loss did not result in skin laxity; instead, 4 months after treatment, the tightened skin adhered well to her new body contours. Pronounced skin folds evident in pretreatment photos were no longer visible posttreatment. While only 2 sample patients are shown in this article, the improvement in skin appearance following cryolipolysis has been anecdotally reported in many patients, estimated to be 25% at our practice. We have delivered more than 8000 treatment cycles to date, and skin laxity has never been noted to increase following treatment, even after significant fat volume reduction; we estimate that a quarter of our cryolipolysis patients show visible improvement. These are subjective observations from our patients and clinicians, but we wanted to publish these observations to raise awareness of an unexpected effect of cryolipolysis that merits discussion and further exploration. The resultant skin tightening has been observed in patients with skin laxity, regardless of age, and does not appear to be treatment site specific. At this point, it is unknown how predictable the skin-tightening results are and how other factors—such as patient age, skin condition, number of cryolipolysis cycles, and duration after treatment—may affect the resultant skin tightening. A follow-up study is planned that will objectively quantify both fat reduction and skin tightening following cryolipolysis in a larger patient population. While treatments for facial and neck skin laxity are popular aesthetic procedures, the options for treatment of skin Dr Stevens is a Clinical Professor in the Department of Surgery, the Director of the Aesthetics Division of the University of Southern California (USC) Division of Plastic and Reconstructive Surgery, and the Director of the Marina del Rey–USC Aesthetic Surgery Fellowship, Los Angeles, California. Corresponding Author: Dr W. Grant Stevens, 4644 Lincoln Boulevard, Suite 552, Marina del Rey, CA 90292, USA. E-mail: [email protected]
Downloaded from aes.sagepub.com at Dicle Ãœniversitesi on November 7, 2014
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Aesthetic Surgery Journal
Figure 1. This 38-year-old woman sought treatment for excess fat and received 2 cycles to the lower abdomen and 2 cycles to the upper abdomen: pretreatment (A, B) and 4 months posttreatment (C, D). Cryolipolysis nonsurgically reduced undesirable fat deposits, and the patient attained skin tightening. Weight change since baseline, –4 lb. Procedure by Dr Grant Stevens.
laxity on the body are limited. Most patients do not wish to undergo surgery to tighten thin, crepey, sagging skin in areas such as arms, abdomens, flanks, thighs, and buttocks. While dermal fillers can successfully replace lost volume in the face and produce a more youthful appearance, injectable fillers are not feasible for treatment of extensive skin laxity on the body. The most common treatment methods to tighten skin on the body induce tissue heating via radiofrequency, laser, infrared, or ultrasound energy. As shown in this case report, cryolipolysis may be a viable nonsurgical procedure for skin tightening. In addition to fat layer reduction, cryolipolysis can noticeably reduce skin laxity. The mechanism by which cryolipolysis induces skin tightening is not known. The improved appearance in the skin may not actually be skin tightening but perhaps dermal thickening, resulting in an improved appearance to thin, crepey skin. The change in skin firmness may be the result of stimulated collagen production, new elastin formation, fibrosis, or tissue compaction. Histology analysis from previous studies
has shown that the epidermis, dermis, and underlying muscle tissue were not affected in the cryolipolysis treatment sites.6,7 In addition, histologic analysis demonstrated that with the selective removal of adipocytes, the thickness of interlobular septa increased at 90 days posttreatment.7 Additional histology analysis from clinical studies is needed to further investigate the changes to the skin and fat layers following cryolipolysis. This letter to the editor presents the first report on cryodermadstringo—skin tightening from cryolipolysis—and is intended to raise awareness of a phenomenon observed in practice but not yet published in the scientific literature. Cryolipolysis is an established, safe, and effective procedure for nonsurgical fat reduction. Moreover, it can achieve clinically significant skin-tightening results. A clinical research study is currently underway to explore cryolipolysis-induced skin-tightening hypotheses, to obtain quantitative objective measurements of skin tightening, and to establish the mechanism of action.
Downloaded from aes.sagepub.com at Dicle Ãœniversitesi on November 7, 2014
Stevens 3
Figure 2. This 58-year-old woman was dissatisfied with subcutaneous fat in her abdomen and back: pretreatment (A, B) and 4 months after first treatment (C, D). Following 2 treatment visits spaced 2 months apart (each consisting of 4 cryolipolysis cycles to the abdomen and 2 cycles to the bra fat area), the fat was visibly reduced and the skin noticeably tightened. Despite the appreciable fat volume loss, the skin draped well across the new body contours, rather than sagging. Weight change since baseline, –5 lb.
Disclosures Dr Stevens is an investigator for Sientra (formerly Silimed; Santa Barbara, CA), Cohera Medical (Pittsburgh, PA), and Mentor CPG (Santa Barbara, CA); medical luminary for BTL (Framingham, MA), Cutera (Brisbane, CA), Merz (Greensboro, NC), and Syneron-Candela (Greensboro, NC); speaker for Allergan Academy (Irvine, CA) and Cynosure (Westford, MA); consultant for TauTona (Menlo Park, CA); medical luminary and speaker for Cutera (Brisbane, CA) and Solta (Hayward, CA); and medical luminary, investigator, and speaker for Zeltiq (Pleasanton, CA).
References 1. Dobke MK, Hitchcock T, Misell L, Sasaki GH. Tissue restructuring by energy-based surgical tools. Clin Plast Surg. 2012;39:399-408.
2. Bogle MA, Dover JS. Tissue tightening technologies. Dermatol Clin. 2009;27:491-499. 3. Sadick N. Tissue tightening technologies: fact or fiction. Aesthet Surg J. 2008;28:180-188. 4. Dierickx CC. The role of deep heating for noninvasive skin rejuvenation. Lasers Surg Med. 2006;38:799-807. 5. Stevens WG, Pietrzak LK, Spring MA. Broad overview of a clinical and commercial experience with CoolSculpting. Aesthet Surg J. 2013;33:835-846. 6. Manstein D, Laubach H, Watanabe K, Farinelli W, Zurakowski D, Anderson RR. Selective cryolysis: a novel method of noninvasive fat removal. Lasers Surg Med. 2008;40:595-604. 7. Zelickson B, Egbert BM, Preciado J, Allison J, Springer K, Rhoades RW, Manstein D. Cryolipolysis for noninvasive fat cell destruction: initial results from a pig model. Dermatol Surg. 2009;35:1462-1470.
Downloaded from aes.sagepub.com at Dicle Ãœniversitesi on November 7, 2014
Does Cryolipolysis Lead to Skin Tightening?: A First Report of Cryodermadstringo W. Grant Stevens Aesthetic Surgery Journal published online 12 June 2014 DOI: 10.1177/1090820X14539699 The online version of this article can be found at: http://aes.sagepub.com/content/early/2014/06/09/1090820X14539699 A more recent version of this article was published on - Aug 1, 2014
Published by: http://www.sagepublications.com
On behalf of:
American Society for Aesthetic Plastic Surgery
Additional services and information for Aesthetic Surgery Journal can be found at: Email Alerts: http://aes.sagepub.com/cgi/alerts Subscriptions: http://aes.sagepub.com/subscriptions Reprints: http://www.sagepub.com/journalsReprints.nav Permissions: http://www.sagepub.com/journalsPermissions.nav
Version of Record - Aug 1, 2014 >> OnlineFirst Version of Record - Jun 12, 2014 What is This?
Downloaded from aes.sagepub.com at Dicle Ãœniversitesi on November 7, 2014
539699 research-article2014
AESXXX10.1177/1090820X14539699Aesthetic Surgery JournalStevens
Aesthetic Surgery Journal OnlineFirst, published on June 12, 2014 as doi:10.1177/1090820X14539699
Letter to the Editor
Does Cryolipolysis Lead to Skin Tightening? A First Report of Cryodermadstringo
Aesthetic Surgery Journal 1 –3 © 2014 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: http://www.sagepub.com/ journalsPermissions.nav DOI: 10.1177/1090820X14539699 www.aestheticsurgeryjournal.com
W. Grant Stevens, MD, FACS Skin laxity occurs over time as collagen and elastin fibers break down. The breakdown is exacerbated by environmental factors, such as ultraviolet radiation, pollution, and stress. The rate of collagen and elastin degradation accelerates with time, while the rate of new collagen and elastin formation slows. For facial and neck laxity, several treatment methods exist, such as surgical lifts, minimally-invasive filler injections, and nonsurgical devices employing radiofrequency, laser, infrared, and ultrasound energy.1-4 To treat skin laxity on the body, the same treatment methods are available, although they are not as commonly used. Cryolipolysis (CoolSculpting System; Zeltiq Aesthetics, Pleasanton, CA) is a noninvasive method for selective fat reduction on the body. This nonsurgical procedure uses controlled cooling to reduce subcutaneous fat without inducing damage to surrounding tissues. Cleared by the Food and Drug Administration for fat reduction in 2010, cryolipolysis is an established procedure to safely and effectively reduce fat. A retrospective study on cryolipolysis discussed its clinical safety and efficacy, as well as its potential for business growth, in a plastic surgery practice.5 As shown in the aforementioned article, significant fat reduction can be achieved nonsurgically by cryolipolysis. Patients in flank and buttocks examples in the article also showed evidence of significant skin tightening.5 While cryolipolysis is well established as a nonsurgical method for fat reduction, it has not been documented as a skin-tightening procedure until now. To illustrate the skin-tightening phenomenon often observed in cryolipolysis patients at this practice, 2 patients are presented. In addition to the expected reduction in fat layer thickness, the patients were observed to attain visible skin tightening in the treatment areas. Cryolipolysis treatments were delivered to targeted areas for fat reduction per standard treatment cycles for 60 minutes’ duration. A vacuum applicator pulled the targeted tissue into an applicator cup with parallel, temperature-controlled cooling plates. In addition to the anticipated fat reduction following treatment, skin tightening in the cryolipolysis treatment area was observed. As shown in the female abdomen treatment in
Figure 1, cryolipolysis produced significant volume reduction and skin tightening after 4 months. For the female abdomen and flanks patient in Figure 2, the large fat volume loss did not result in skin laxity; instead, 4 months after treatment, the tightened skin adhered well to her new body contours. Pronounced skin folds evident in pretreatment photos were no longer visible posttreatment. While only 2 sample patients are shown in this article, the improvement in skin appearance following cryolipolysis has been anecdotally reported in many patients, estimated to be 25% at our practice. We have delivered more than 8000 treatment cycles to date, and skin laxity has never been noted to increase following treatment, even after significant fat volume reduction; we estimate that a quarter of our cryolipolysis patients show visible improvement. These are subjective observations from our patients and clinicians, but we wanted to publish these observations to raise awareness of an unexpected effect of cryolipolysis that merits discussion and further exploration. The resultant skin tightening has been observed in patients with skin laxity, regardless of age, and does not appear to be treatment site specific. At this point, it is unknown how predictable the skin-tightening results are and how other factors—such as patient age, skin condition, number of cryolipolysis cycles, and duration after treatment—may affect the resultant skin tightening. A follow-up study is planned that will objectively quantify both fat reduction and skin tightening following cryolipolysis in a larger patient population. While treatments for facial and neck skin laxity are popular aesthetic procedures, the options for treatment of skin Dr Stevens is a Clinical Professor in the Department of Surgery, the Director of the Aesthetics Division of the University of Southern California (USC) Division of Plastic and Reconstructive Surgery, and the Director of the Marina del Rey–USC Aesthetic Surgery Fellowship, Los Angeles, California. Corresponding Author: Dr W. Grant Stevens, 4644 Lincoln Boulevard, Suite 552, Marina del Rey, CA 90292, USA. E-mail: [email protected]
Downloaded from aes.sagepub.com at Dicle Ãœniversitesi on November 7, 2014
2
Aesthetic Surgery Journal
Figure 1. This 38-year-old woman sought treatment for excess fat and received 2 cycles to the lower abdomen and 2 cycles to the upper abdomen: pretreatment (A, B) and 4 months posttreatment (C, D). Cryolipolysis nonsurgically reduced undesirable fat deposits, and the patient attained skin tightening. Weight change since baseline, –4 lb. Procedure by Dr Grant Stevens.
laxity on the body are limited. Most patients do not wish to undergo surgery to tighten thin, crepey, sagging skin in areas such as arms, abdomens, flanks, thighs, and buttocks. While dermal fillers can successfully replace lost volume in the face and produce a more youthful appearance, injectable fillers are not feasible for treatment of extensive skin laxity on the body. The most common treatment methods to tighten skin on the body induce tissue heating via radiofrequency, laser, infrared, or ultrasound energy. As shown in this case report, cryolipolysis may be a viable nonsurgical procedure for skin tightening. In addition to fat layer reduction, cryolipolysis can noticeably reduce skin laxity. The mechanism by which cryolipolysis induces skin tightening is not known. The improved appearance in the skin may not actually be skin tightening but perhaps dermal thickening, resulting in an improved appearance to thin, crepey skin. The change in skin firmness may be the result of stimulated collagen production, new elastin formation, fibrosis, or tissue compaction. Histology analysis from previous studies
has shown that the epidermis, dermis, and underlying muscle tissue were not affected in the cryolipolysis treatment sites.6,7 In addition, histologic analysis demonstrated that with the selective removal of adipocytes, the thickness of interlobular septa increased at 90 days posttreatment.7 Additional histology analysis from clinical studies is needed to further investigate the changes to the skin and fat layers following cryolipolysis. This letter to the editor presents the first report on cryodermadstringo—skin tightening from cryolipolysis—and is intended to raise awareness of a phenomenon observed in practice but not yet published in the scientific literature. Cryolipolysis is an established, safe, and effective procedure for nonsurgical fat reduction. Moreover, it can achieve clinically significant skin-tightening results. A clinical research study is currently underway to explore cryolipolysis-induced skin-tightening hypotheses, to obtain quantitative objective measurements of skin tightening, and to establish the mechanism of action.
Downloaded from aes.sagepub.com at Dicle Ãœniversitesi on November 7, 2014
Stevens 3
Figure 2. This 58-year-old woman was dissatisfied with subcutaneous fat in her abdomen and back: pretreatment (A, B) and 4 months after first treatment (C, D). Following 2 treatment visits spaced 2 months apart (each consisting of 4 cryolipolysis cycles to the abdomen and 2 cycles to the bra fat area), the fat was visibly reduced and the skin noticeably tightened. Despite the appreciable fat volume loss, the skin draped well across the new body contours, rather than sagging. Weight change since baseline, –5 lb.
Disclosures Dr Stevens is an investigator for Sientra (formerly Silimed; Santa Barbara, CA), Cohera Medical (Pittsburgh, PA), and Mentor CPG (Santa Barbara, CA); medical luminary for BTL (Framingham, MA), Cutera (Brisbane, CA), Merz (Greensboro, NC), and Syneron-Candela (Greensboro, NC); speaker for Allergan Academy (Irvine, CA) and Cynosure (Westford, MA); consultant for TauTona (Menlo Park, CA); medical luminary and speaker for Cutera (Brisbane, CA) and Solta (Hayward, CA); and medical luminary, investigator, and speaker for Zeltiq (Pleasanton, CA).
References 1. Dobke MK, Hitchcock T, Misell L, Sasaki GH. Tissue restructuring by energy-based surgical tools. Clin Plast Surg. 2012;39:399-408.
2. Bogle MA, Dover JS. Tissue tightening technologies. Dermatol Clin. 2009;27:491-499. 3. Sadick N. Tissue tightening technologies: fact or fiction. Aesthet Surg J. 2008;28:180-188. 4. Dierickx CC. The role of deep heating for noninvasive skin rejuvenation. Lasers Surg Med. 2006;38:799-807. 5. Stevens WG, Pietrzak LK, Spring MA. Broad overview of a clinical and commercial experience with CoolSculpting. Aesthet Surg J. 2013;33:835-846. 6. Manstein D, Laubach H, Watanabe K, Farinelli W, Zurakowski D, Anderson RR. Selective cryolysis: a novel method of noninvasive fat removal. Lasers Surg Med. 2008;40:595-604. 7. Zelickson B, Egbert BM, Preciado J, Allison J, Springer K, Rhoades RW, Manstein D. Cryolipolysis for noninvasive fat cell destruction: initial results from a pig model. Dermatol Surg. 2009;35:1462-1470.
Downloaded from aes.sagepub.com at Dicle Ãœniversitesi on November 7, 2014
