10 Blending Nonsurgical Treatments with Surgery for Skin Lifting on the Body Summary The aesthetic treatment of body areas poses unique challenges. Surgical lifting procedures such as thigh lifts, buttock lifts, abdominoplasty, brachioplasty, and body contouring after massive weight loss continue to be popular treatments. However, significant downtimes and incidences of complications and unfavorable results make nonsurgical options and minimally invasive options the wave of the future, and nonsurgical corrective options must be blended with surgical corrective options. Keywords: broadband light (BBL), cellulite, cryolipolysis, intense pulsed light (IPL), microfocused ultrasound, nonablative fractional resurfacing, radiofrequency-assisted liposuction (RFAL), skin excision procedures, skin laxity, striae Key Points • Nonsurgical skin lifting and smoothing has unique biological and commercial challenges compared to comparable facial treatments. • Currently, nonsurgical treatments principally address skin surface smoothness, whereas surgical approaches address major skin laxity along with cellulite. • Nonsurgical approaches are useful to reduce small amounts of fat or to make small revisions in surgical results. • Skin smoothing requires multiple treatments, creating small incremental changes. • Pharmacologic and biological approaches hold promise for the future either alone or in combination with energy-based treatments. Aesthetic treatment of body areas poses unique challenges to the surgeon. After addressing body shape and size with surgical and nonsurgical options for contouring, the skin itself must be addressed. Skin laxity and a variety of issues of skin smoothness need to be treated. Surgical lifting procedures have historically been the only useful options. Thigh lift, buttock lift, abdominoplasty, and brachioplasty have been able to tailor out skin redundancy to a productive degree. While this continues in growing numbers, particularly in body contouring after massive weight loss, the significant downtime associated with the procedures, the significant incidence of complications, and the occasional unsatisfactory aesthetic tradeoffs such as widened scars, put momentum behind the search for alternative approaches. Separate from laxity per se are various issues of skin smoothness such as cellulite, striae, and skin crepiness. They represent specific changes resulting from aging, skin injury, and photodamage, respectively, that represent unique morphologic/anatomic manifestations and pathophysiology. These differences color the specific treatment approaches needed for each of them. Skin tailoring surgery has not addressed these issues well, nor has classical liposuction. Non-surgical options and minimally invasive options are the mainstay of treatment currently and for the foreseeable future and must be blended with surgical corrective options. Significant progress has been made in the past few years developing treatment modalities that consistently and durably create improvement in these unwanted features. Nonetheless, at this writing, the ability to create the degree or completeness of improvement that most patients desire has remained an elusive challenge. The active modern lifestyle places patients in more revealing clothing more often than ever before. This shift has made body skin smoothing much more central to the modern scope of aesthetic medicine. There are many issues relating to the development of “loose skin” in body areas. The skin itself is undergoing all of the aging changes that have been described for facial areas. The amount, density, integrity, and organization of structural proteins has degraded along with the amount of glycosaminoglycans in the skin. This is due, in part, to the slowing of metabolism and the reduction in vascularity associated with a more aged appearance to the skin, which is more pronounced in body areas than in the face due to the lower baseline turnover/metabolic rate and vascularization. Such changes are exacerbated by controllable factors such as ultraviolet light exposure and smoking. Skin in the body is exposed to gravitational forces across much larger areas than the face. A complex network of connective tissue fibers supports the skin in place so that it does not sag to the bottom of the trunk or appendage in the direction of the current gravitational pull. Such support undergoes changes in the organizational pattern of the fiber direction, and in vascularity, and it is distorted by the weight- and surfacedistorting effects of fat from weight gain and/or loss. The amount of weight in the skin flap and the amount of laxity that can develop is much greater in magnitude than that associated with most aging faces. Medical treatments that produce modest improvements in skin density or support, which can be clinically useful in the face when cumulated over the area of the face and neck, can be less productive when attempting to treat the body because of the larger magnitude of the changes present and the greater degree of correction needed to achieve desirable aesthetic outcomes. Adding more energy to most treatments simply does not further amplify the biological response obtained, but it does increase the risk and recovery time. Whereas the treatment for skin smoothing was originally designed for the face and requires the use of a disposable with an additional cost for the provider, there has been an additional economic challenge. The cost of treatment is adapted for coverage of the face and neck areas. Treating larger body areas with the same technology becomes cost prohibitive. Some manufacturers have overcome this by creating a handpiece or disposable that is adapted for body use, but it must be configured in a way that prevents use on the face to avoid cannibalizing the more lucrative facial revenue stream. These kinds of economic challenges have limited the use of some technologies on the body. Other technologies are equally suited to use in a wide variety of anatomic sites or are developed specifically for body site treatment. The size of the applicators used in facial rejuvenation are often so small that treatment times on body sites are lengthy, further adding to the cost and tedium of cross-purposing the device for body treatments (see Video 2.11). Energy-based treatments take several approaches, from heating to create a biological expression of various cytokines or some other mechanism of upregulating synthetic or metabolic activity in cells, to cell shock yielding apoptosis, to frank coagulation at one or more defined depths in the skin or subcutaneous tissues.1 During the healing response that ensues with the latter approach, new collagen is deposited that may change the thickness, biomechanical properties, or relationship of the skin relative to its associated tissues, thereby improving its appearance. This sort of tissue remodeling has some inherent limitations. Most treatments deliver an empirically determined set of energy parameters in the hope of producing a desired tissue temperature/time/spatial distribution profile. To the extent that any individual patient differs from the average in the study group used to validate the technology, the endpoint achieved in practice may vary significantly. This may be further exacerbated by technique differences from provider to provider, and further modulated by patient discomfort tolerance issues. Some of the more advanced options currently available offer feedback to help ensure that the proper endpoint is attained. Even ensuring that the target tissue effect is perfectly achieved does not guarantee a particular outcome. These techniques, unlike invasive surgery, do not make a major anatomical or mechanical change in patient tissue, but they push the tissue by creating a controlled injury and then rely on the healing response to provide the clinical improvement. The problem is that the tissue response varies widely from individual to individual even among patients who appear to be ideal candidates for treatment. There will always be a proportion of patients that will generate a subclinical response (nonresponders). Efforts to accurately predict which patients will behave in this fashion have so far been unsuccessful, necessitating careful patient counseling and a realistic perspective on the part of providers about the current state of the art and its associated limitations. Treatments whose endpoint stops short of coagulation seem to produce somewhat less of a response than the more aggressive treatments. However, the mean result and range of results of these two approaches have not been studied in a comparative manner. The degree of improvement may be only modestly different in most patients. A baseline level of energy exposure is necessary to reach the onset of a clinical response. Increasing the exposure beyond this seems to provide only modest improvements in results. Bulk heating or any treatment that produces bulk tissue necrosis is clearly associated with significant recovery time and adverse events, including tissue tethering, distortion of contour, nodules, and induration, which can take months to resolve or leave permanent sequelae. There is a certain sweet spot where improvement is optimized with few if any adverse events. “Dialing up the energy” adds little clinical improvement but greatly increases the incidence of adverse events. A variety of medications have been used topically to stimulate skin synthetic activity. Due to the difficulty of getting biologically active molecules into the skin topically, changes to deep skin and subcutaneous structures have not been well addressed in this fashion. Office-based treatments have been attempted to drive medications or serums into the skin using ultrasound, microdermabrasion, fractional resurfacing, and iontophoresis, among others. The observation that fillers stimulate collagen replacement has prompted some investigators to attempt broad-based placement of small amounts of diluted filler under the affected skin. Using active dermal matrix fillers, which stimulate a controlled inflammatory response, this may result in enough collagen deposition to restore some of the support and texture of youthful skin.2 This is analogous to the energy-based devices that produce tissue coagulation and an inflammatory healing response to produce new collagen and aesthetic improvement. Other investigators have attempted to control the direction of skin smoothing or redraping with linear injection of filler oriented along the intended vector (s) of redraping.3 Massiveweight-loss patients have a greater diversity and severity of aesthetic issues that need correction and are beyond the scope of this chapter. During surgical planning, an analysis must be performed of the effect of each procedure on the various anatomic layers of the surgical site, such as skin, fat, muscle, and fascia.4 Surgery may not address a layer at all, or surgery may improve one aspect of the aesthetic problems in a tissue layer but not others. For example, skin laxity may be reduced but the surface texture and biological functioning of the skin and its intrinsic elasticity remain unchanged. If skin is pulled tighter, there is no change in the aging composition of the skin itself. Energy-based devices stimulate the production of collagen and elastin, resulting in skin that more closely resembles youthful skin in histology, composition, and metabolism. In the adipose layer, minor postsurgical irregularities are common. A “touch-up” can be performed using liposuction, but noninvasive body-contouring devices produce just as good an improvement in a more efficient fashion. Surgical body-contouring procedures make shape and size changes but have little or no impact on the overall appearance of the skin surface. Liposuction alone can reduce fat with little or no change in skin laxity and a frequent loss of smoothness. Energy-based devices can achieve a more meaningful combination of reduced fat and tightened skin. These devices may be used at the time of surgery in conjunction with liposuction (
10.1 Introduction
10.2 Why Is Body Smoothing a Hard and Unsolved Biological Issue?
10.2.1 Economic Issues
10.2.2 Basic Approach of Energy
10.2.3 Basic Approach of Pharmacology
10.3 Selecting Surgical and Nonsurgical Options Based on Patient Findings
Fig. 10.1 and 
Fig. 10.2). Alternatively, there are energy-based modalities that can be used after a surgical or nonsurgical contouring procedure (
Fig. 10.3). These principles form the basis for planning combinations of surgical and non-surgical approaches to achieve more complete aesthetic improvement.
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