ATLANTA – Noninvasive body contouring is the "new frontier" in dermatologic surgery, according to Dr. Michael S. Kaminer.

Last year in the United States, noninvasive contouring was performed more often than liposuction, and while the competition between devices is getting fierce, not all are created equal, said Dr. Kaminer, a dermatologist in private practice in Chestnut Hill, Mass.

In fact, only four devices are approved by the Food and Drug Administration for noninvasive fat removal. Of those, Dr. Kaminer discussed three for which the data – and his own experience – are most compelling: CoolSculpting, which destroys fat through cryolipolysis; Liposonix, which destroys fat using high-intensity focused ultrasound; and the Zerona laser, which destroys fat using LED light.

The CoolSculpting device from Zeltiq made its debut about 7 years ago and was approved in 2012 for fat reduction. Cryolipolysis induces apoptosis in the adipocyte, and then the body clears the dead fat cells.

Case reports suggest that CoolSculpting reduces fat by about 21%, on average, with a single procedure, Dr. Kaminer said at the annual meeting of the American Society for Dermatologic Surgery.

In some cases, 50% fat reduction can be achieved within 90 days. The effects, which include skin tightening, seem to be durable based on 4-year follow-up studies, he said.

In a small pilot study in his practice, Dr. Kaminer found that 80% of patients were happy (rating their improvement as at least a 7 on a scale of 1-10) after a single procedure. The remaining 20% reached that level of satisfaction after a second treatment.

CoolSculpting is particularly useful for treating fat at the bra line and at the waist, with these areas typically requiring two or three treatments in his office, he said.

The CoolCurve+, a new applicator developed by Zeltiq to expand the capabilities of the CoolSculpting device, allows for treatment in more areas.

Liposonix from Solta Medical destroys unwanted subcutaneous adipose tissue and fat using high-intensity focused ultrasound. This device "made a big splash" when it was approved specifically for noninvasive waist circumference reduction in 2011, Dr. Kaminer said.

Most of the end effects are based on heat, although there is some mechanical or acoustical component that disrupts and "basically kills" the fat cells. Some evidence also suggests that this device promotes contraction and thickening of collagen, thereby tightening the skin.

"I think the jury may still be out on that one ... I don’t know if it is a skin-tightening device, but I haven’t seen any proof that would say that it definitely is," he said.

One particular benefit of this device is its customizability. The transducer can be used more heavily in areas where there is more fat and lighter in areas where there is less fat, and it can be worked around the umbilicus in those with an umbilical hernia, so it can be used more as a sculpting device than a "bulk fat remover," he said.

Patient comfort can be an issue with this device. "This hurts, so what we’ve started to do is use a low fluence, multiple-pass protocol," he said. When low fluencies are used, no pain medicine is needed. The exception is treatment of the sensitive inner thighs.

The Zerona laser from Erchonia Medical is approved for general body contouring and basically uses low-level laser therapy to deliver light to the skin. "The key effect of Zerona – and this is sort of the concept that I think we are all going to have to start to think about and decide if we buy it – is the concept of a transitory pore, which is basically a hole that’s poked into a fat cell by exposing it to 635-nm red light," he said. The fat leaks out of the adipocytes, causing long-lasting and perhaps permanent change.

Dr. Kaminer said that he uses CoolSculpting as his "go-to device" for love handles, bra line, and abdomen treatments. The workflow is easy: A nurse can put the applicator on and the patient can read a book for an hour or watch television. This treatment – like any treatment that uses suction – can be problematic in patients with an umbilical hernia, however, he added.

The Liposonix device also can do a nice job on the abdomen and love handles, and perhaps the bra line, and it is really the only device that can be used on the arms and the outer and inner thighs, which "respond really nicely to Liposonix," he said. Treatment can be painful, however, and this can be limiting in some practices.

Dr. Kaminer has been a consultant to Thermage, Sciton, and Zeltiq and has stock ownership or options in Cabochon, Miramar Labs, and Thermage.

Experience builds with noninvasive body contouring