Editorial Board Forum: Does Non-Invasive Fat Reduction Fit Your Practice?

If you offer device-based fat reduction, what prompted the decision? If you do not offer device-based reduction, why not?

Joel Schlessinger, MD: I have done trials on several competing fat treatments, so it was an area of interest to me. We went with the Zeltiq/CoolSculpting due to the ease of use and the fact that it was less painful than other options. It was also a no-brainer, as I offer liposuction and laser-assisted liposuction, so the patient population was already there.

Haideh Hirmand, MD: Demand for noninvasive reduction and the particular technology efficacy prompted my decision to offer it. When there is real demand from patients and real supply from doctors, i.e., the technology works, it is a win/win. I have CoolSculpting and love it. I tried Liposonix and didn't love it! I will keep trying new technologies.

Jeanine Downie, MD: have offered the Exilis Elite since January 2011 and the Vanquish since June 2013. The Exilis is terrific for melting fat all over— upper arms, back fat, stomachs, love handles, buttocks, thighs, above the knees and around the ankles. The Vanquish I pair with the Exilis to melt larger areas of fat. The Vanquish has the largest spot size and can treat the back fat and sides or the abdominal fat and love handles. Additionally, it treats the buttocks.

I researched the fat melting devices for a talk at the World Congress of Dermatology I gave in Seoul, Korea in 2011. The BTL technology was superior to everything I investigated and I am very happy with their products. I also have the Protégé, which I use for melting fat on the face and neck, as well as for tightening the eyelids.

Dina Anderson, MD: The cosmetic portion of my practice is highly specialized to facial injectables and adjuvant laser/peel/ topical therapies. I believe to do something well, you need to do it often to perfect your individual technique and “think outside the box” as well as to learn from your mistakes (which is part of what makes you an expert and thought leader). I am happy to refer my patients to my surgical colleagues that specialize in body contouring and perform a lot of liposuction, tummy tucks and other body specific surgical procedures.

Greg Buford, MD: I do not currently offer non-invasive fat reduction for several reasons. But the main reason is that I am concerned about long-term efficacy as well as patient expectations. I have found that the marketing behind many of these devices is often grossly exaggerated and that claims are being made that are simply not attainable. As such, these patients become enamored with the possibility of a no downtime procedure that will accomplish equivalent results to a surgical procedure. And in most cases, that is simply not the case.

WHAT HAVE BEEN SOME OF THE BIGGEST MISUNDERSTANDINGS YOU'VE ENCOUNTERED FROM PATIENTS?

Dr. Schlessinger: The biggest misconception is the same one we have with liposuction: that this is a substitute for diet and exercise. This sometimes sets up a sad and/or challenging interaction with the patient at the time of the consultation. Additionally, we often have parents who are bringing in children and expect us to tell them we can help, which is another potentially challenging interaction.

Dr. Downie: The biggest misunderstanding is that patients think the devices will help them lose weight. It makes inches go down, but they do not lose weight!! They must drink a lot of water and really hydrate to flush the fat cells out.

Dr. Schlessinger: I can't tell you how many folks we have sent for bariatric surgery consultations after they ended up in our office for a CoolSculpting consultation. We often find that there are difficult family/husband/wife situations that we have to sort through in these consultations, and this can make for a tough interaction as well. Many of the most egregious issues happen when a husband (or wife) brings in their partner and expresses displeasure with their physique. Most of the time, we avoid these cases like the plague as both of the individuals end up unhappy. Sadly, many individuals do this to save a marriage or relationship and that usually doesn't work out, either.

Dr. Hirmand: It is always that “the fat goes somewhere else right”? Patients have the fear of developing a lump of fat somewhere else.

Dr. Anderson: I have a practice where the majority of my patients are thin and many of them that inquire do not have the necessary fat to qualify for the procedure. I “tested” both Thermage and Liposonix in my office a few years ago. Although I am thin, I was reassured that I had enough body fat to be eligible for a treatment on my abdomen. Having given birth to my daughter less than a year prior, I was eager to have a therapy to target that last inch or two that was a reminder of my previous pregnancies.

A few months after a RF session, I started to have pain on the right side of my abdomen when I would do certain leg lifts and crunches. I also palpated a mass in the area that would “come and go,” especially after meals and when lying down. I didn't think much of it until it had persisted for nine to 12 months. I then panicked and had an abdominal ultrasound, colonoscopy and abdominal CT. Luckily, all were negative and while the discomfort has resolved, the lump still flares on and off…I believe that the RF formed an adhesion in deeper tissue because there wasn›t enough fat in the targeted area.

WHAT ARE THE BIGGEST FACTORS THAT INFLUENCE RESULTS AND HOW DO YOU MANAGE THESE?

Dr. Hirmand: With non-invasive fat reduction, keeping the metabolic rate the same or increasing it preferably and certainly not decreasing it, while maintaining or preferably lowering caloric intake, are essential. We manage these by just going over it with the patients.

Dr. Schlessinger: I look for a trend in the right direction for weight and some improvement over time, rather than a “top-ever” weight or close to the top weight. Additionally, I don't want to have someone who has just lost hundreds of pounds or a significant amount of weight on an unrealistic diet or fad. We want folks who have maintained a new, close to goal weight and are realistic in their expectations. When it comes to Zeltiq, we let our patients know that they will have to do more than one procedure in order to achieve what they want.

Dr. Buford: I medically direct a facility that does perform non-invasive fat reduction and they have been very pleased with the results. But they also combine nutritional counseling and personal training to achieve the results they achieve. I think this is a great step in the right direction because even some of the surgical results we achieve simply cannot persist unless there is a change in lifestyle habits.

The Experts Say

“With the advent of obesity gone wild in America, it seems there will be a never-ending supply of overweight individuals to court.”

—Joel Schlessinger, MD

“I am comfortable referring to other dermatologists that utilize these machines for fat reduction. In NYC, I think it's safe to say that 100 percent of these procedures are performed by ancillary staff (PA's, MA's, RN's and aestheticians). However, the patient should feel that they are in a setting where this is part of a practice where body procedures are common and frequent for the practice.”

—Dina Anderson, MD

“I make patients drink 12 or more glasses of water a day and if they want to exercise and eat better I assure them that they will have an even better cosmetic result.”

—Jeanine Downie, MD

What are your secrets for setting and managing patient expectations? Can you share any specific examples of challenges in this regard and how you managed dissatisfaction?

Dr. Downie: I manage their expectations by having a clear discussion with each patient that this is not liposuction. They look and feel better in their clothes.

Dr. Schlessinger: I write down my expectations and share that with the patients. If I think they need to have liposuction instead of CoolSculpting, I tell them that and usually they listen. My rate of declining procedures has gone up steadily over the years and now I only accept about 30-50 percent of my liposuction/ CoolSculpting patients. It is better to avoid a bad outcome than to have one, and this is especially important in this area. CoolSculpting isn't for everyone, but it seems the company is encouraging this. In our experience, the results aren't that great if you are more than 15 percent over goal weight.

Dr. Hirmand: Under promise; Over deliver. I had one patient who didn't get results from CoolSculpting, but her weight had gone up 7 lbs. since treatment. I had to explain the situation to her.