Abstract
Selective noninvasive radiofrequency fat destruction for body contouring using the BTL Vanquish ME (maximum energy) produces some permanent destruction of subcutaneous fat cells. Four to six 45-minute treatment sessions by a non-contact application for each body part area (abdomen, love handles, thighs) are usually advised. Some improvement of the results with radiofrequency fat destruction will continue to become more obvious by 3–4 months. While the results are moderate when compared to liposuction, patients like the non-surgical treatment with no down time.
6 Noninvasive Radiofrequency Fat Destruction for Body Contouring
BTL Vanquish ME has quickly risen to the top of the “non-surgical device” chain by providing circumferential reduction of the abdomen with no anesthesia, pain, or down time. BTL Vanquish ME is a selective radiofrequency device that targets subcutaneous adipose tissue, permanently reducing the number of fat cells in the area treated. During treatment, the unit’s non-contact device (or applicator) is positioned over the area to be treated and delivers RF-based energy, initiating induced apoptosis in the fat layers. 1 The treatment protocol recommends four weekly sessions of 45 minute duration to achieve results. It takes approximately 21 days for the absorption and excretion of the destroyed adipose cells to occur, so one can expect to see full results 3 to 4 weeks after their final treatment. We have found that six treatments improve results significantly and offer up to twice weekly sessions if hydration levels are maintained—a crucial component to a successful Vanquish ME series.
Long before radiofrequency devices were used in the aesthetic arena they were used in other areas of medicine such as pain management. BTL, a leading manufacturer of both medical and aesthetic devices, was founded in 1993 in Prague, Czech Republic. The company’s early years were devoted to the development and advancement of devices which used targeted radiofrequency therapy to treat pain. The discovery that such technology might also destroy fat cells led to the research and development of the aesthetic devices we use today. A 2013 study using Vietnamese pigs led to the following conclusion, “A new model of fat reduction using high-frequency RF has been successfully achieved in a porcine model. This has very positive implications in the development of an operator independent, contact free device for reduction of fat in clinical practice.” 2 In 2013, BTL introduced Vanquish, a non-surgical fat reduction device unlike any others on the market due to its non-contact, large spot size applicator and painless treatments. Using a patented Energy Flow Control (EFC) system, this device automatically tunes the tissue-applicator-generator circuitry to selectively deliver the energy to the adipose tissue layer while minimizing the risk of overheating of the skin, muscles, or internal organs. 3 The original Vanquish has since been upgraded to the Vanquish ME system we currently use today. The new system provides the patient with more targeted heat and does so more efficiently than the original device. BTL Vanquish ME offers improved tuning performance, more concentrated thermal energy and less scatter to non-fatty tissue. 4 We have found the results with the upgraded system to be superior and the treatments still tolerable, but hotter than what was felt with the original device.
A common question asked during fat reduction consultations is how BTL Vanquish ME can heat the subcutaneous fat to a degree that initiates induced apoptosis without causing thermal injury to the skin, muscle, and deeper structures. Skin and muscle tissue contain a significant amount of water while fat does not. Radiofrequency waves travel easily through water and therefore penetrate the skin quickly, but are unable to get past the subcutaneous fat layer. Only when impeded in the subcutaneous fat layer does the energy heat to apoptotic temperature levels. The energy is essentially trapped in the fat layer leaving minimal risk to the muscle and deeper structures (▶Fig. 6.1). Patients feel what has been described as “a comfortable warmth” and often times find the treatment pleasurable. The combination of the skin temperature remaining at a lower degree than the adipose tissue and the device’s multiple skin cooling features contribute to patient comfort during treatment.
It is an absolute necessity for patients to be well-hydrated during treatments with BTL Vanquish ME. Well-hydrated skin allows more energy to penetrate the skin and impede the fat layer inducing greater apoptosis. Patients should increase their water consumption beginning the day before a treatment, and continue hydrating the day of, and day following a Vanquish ME session. The following hydration recommendation was made in The Supplement to Modern Aesthetic Journal, “Patients who are well-hydrated rapidly reach 200 watts of energy, while those who are not well-hydrated may not reach this desired energy peak. To encourage rapid and high-energy attainment, instruct patients to drink half their body weight in ounces the day of, the day before, and the day after Vanquish ME treatment.” 5
Vanquish ME is most effective in treating diet and exercise resistant areas of fat in individuals otherwise at a healthy weight. The initial consultation will determine if a patient is a good candidate for Vanquish ME. Although Vanquish ME is not designed to be a weight loss procedure, it is a good tool to “jump start” a patient’s weight loss effort. Patients are motivated by results and seeing a positive change from Vanquish ME inspires people to make the lifestyle changes associated with long term weight loss. The amount of change is variable, however anyone with excess subcutaneous fat treated with Vanquish ME will see a result (▶Fig. 6.2). According to Dr. Jerry L. Cooper, “Treatment is appropriate for any patient with external fat-fat that can be pinched between the thumb and index finger.” 5 It is often times offered as a non-surgical alternative for people who would benefit from liposuction but do not want to have a surgical procedure, or in whom surgery is contraindicated. Unlike many non-surgical devices, Vanquish ME can treat all skin types and has zero downtime. Patients can go right back to work after treatment and are encouraged to exercise in the days following. The most common areas treated are the abdomen (upper and lower), love handles, and “bra fat”. The large, non-contact applicator has side panels which allow for additional contouring to the waist when treating the abdomen or back. The abdomen can often times be treated as a single area, however if the area of excess fat is both superior and inferior to the umbilicus in a patient with a long torso it is necessary to treat it as two areas.
There are different ways to approach a patient who has multiple areas of concern. In most patients each area is treated individually with a series of six treatments, completing one series before beginning the next. We have found that this allows patients to assess their results before investing more time and money into additional areas. We know they are going to get a result, however, a patient’s true expectation of a result can only be determined after the fact and we ultimately want people to feel like their return on financial investment was worth it. In addition to giving people the opportunity to weigh the cost/benefit ratio it can be difficult for patients to lie still for the hour and a half it takes to treat two areas consecutively. There is additional time needed to reposition the patient from supine to prone (or vice versa) and set up the device a second time. On occasion if a patient is most concerned with their abdomen, but has minor bulging of the love handles, a hybrid treatment of forty-five minutes to the abdomen, and fifteen minutes to the love handles will be done to optimize the circumferential reduction. It is well worth adding the additional time at no additional cost to enhance the result and have a happy patient in the end. Patients are typically treated with Vanquish ME once a week for 6 weeks, however patients that are able to stay well-hydrated and are looking for expedited results can do twice-weekly sessions. There are exceptions with people feeling and seeing changes sooner, but most patients can expect to see their full result about a month after their last treatment. It should be noted that BTL Vanquish ME is contraindicated in people with metal implants and any active implanted medical device.
BTL Vanquish ME is as close to a “one size fits” all device you can come by for fat reduction. It can be used on all skin types, treats the smallest area of excess fat to bulk reduction, and is very popular among both men and women. More and more men are embracing cosmetic procedures to improve their appearance and this trend will continue to rise. The growing number of non-surgical options is a contributing factor to the increase in male patients. This is beneficial for BTL Vanquish ME since so many men have excess fat in their abdomen, love handles, and flanks. Even more so than women, men like to be discreet about having cosmetic procedures and are turned off by the idea of pain and/or downtime from a procedure. Since bringing the original Vanquish into the practice we have seen an influx of men who otherwise might not have come through the front door. Some of these men have been determined to be better liposuction candidates and have gone on to have surgery. Others opted for non-surgical radiofrequency treatments to either avoid surgery or because their excess fat was minimal. Having more options for patients has proven to be appealing to patients and financially beneficial to the practice. Most men and women find Vanquish ME to be a comfortable experience, feeling heat but not overheated, with the “rare hot” spot easily alleviated by moving the device or lowering the wattage.
During a treatment the patient lies underneath the device’s large spot, non-contact applicator which attaches to an “arm” that is designed to optimally position the applicator (▶Fig. 6.3). The official recommendation is for the applicator to be positioned 10mm away from the skin on all three sides. In our practice we aim to get the applicator as close to the skin without touching as possible (▶Fig. 6.4). It is imperative that the physician or physician extender take as much time as needed to get the applicator in close proximity to the skin. The “arm” of the device has three components that can be adjusted independently to customize the applicator positioning to the patient’s frame. The side panels are flap-like structures that can be moved up and down to further fine tune the set up. Once the set up is complete the operator can begin the treatment.
Vanquish ME offers a maximum of 200 watts of radiofrequency energy and the wattage is titrated to the highest amount possible while maintaining a tuning of greater than 90% (preferably >95%). If the tuning drops below 90%, the wattage should be decreased until it returns to a minimum of 90%, ideally 95% or greater (▶Fig. 6.5). A common misconception is that the higher the wattage, the greater the amount of induced apoptosis that will occur, however this is not the case. Vanquish ME is most effective when operating at a wattage that provides the greatest efficiency. The output and absorption are measured and these numbers should be as close together as possible (▶Fig. 6.6). A wide discrepancy between these two calculations indicate inefficiency, and therefore less efficacy. There are multiple reasons why the optimal wattage varies from patient to patient, and treatment to treatment in the same individual. Patients with larger amounts of subcutaneous fat will absorb more radiofrequency energy than patients with smaller treatment areas. Typically the wattage for optimal absorption decreases as patients have more treatments and the fat layer gets smaller. This may not be the case with larger patients who can sustain the highest wattage for the entire Vanquish ME series. Device operators should keep in mind that if a patient has a substantial layer of fat but is unable to maintain a high wattage throughout treatment, the applicator might be too far away from the skin. If this is the case the device can be paused to allow for repositioning of the applicator. The side panels can often be adjusted without treatment interruption. If a patient is not well-hydrated, the radiofrequency energy is unable to penetrate the skin effectively and there will be less energy available to the fat layer for absorption.
Patients and practitioners alike love the BTL Vanquish ME safety profile. Although it is technically possible for a patient to sustain a thermal injury, it is extremely unlikely when Vanquish ME treatments are set up and monitored appropriately. The Vanquish ME device is operator independent in the sense that once the device is set up there is no other manual operating required. This does not however make it a “set and forget” device. It is crucial for the safety and efficacy of the treatment for the operator to be monitoring the patient throughout the entire duration of a Vanquish ME session. The closer the device applicator is to the skin, the easier it is for the radiofrequency energy to reach the subcutaneous fat layer. This will cause more apoptosis but will also make the skin feel hotter. It is the operator’s responsibility to interact with the patient to determine when the heat becomes intolerable. For most patients this will be never, but it is not uncommon to have to lift the side flap of the applicator, or turn down the wattage to give patients relief. “Hot spots” usually resolve quickly without pause in the treatment. Occasionally patients will experience a self-limiting panniculitis after Vanquish ME which feels like a firm nodule and can be tender. Reassurance should be given that this inflammatory response surrounding a destructed fat cell will resolve once the fat cell is absorbed by the body. The metabolic process can take 2–3 weeks and it is not necessary to cease treatments during this time. Over the counter anti-inflammatory medications can be taken as needed for pain relief. Possible side effects of non-contact, selective radiofrequency treatments include mild redness and swelling for one hour or so, temporary increased skin sensitivity to heat, and occasionally, excessive sweating at the end of the treatment. 3
Patients who are good candidates, are well-hydrated, and treated by trained practitioners can expect to see results after a series of BTL Vanquish ME (▶Fig. 6.7). As with any surgical or non-surgical procedure results vary from person to person. A good consultation with an emphasis on realistic expectations will heavily influence a patient’s perception of treatment success. A Vanquish ME series always begins with a pre-procedure set of photographs using the BTL floor mat to ensure identical foot positioning in the before and after photos. In our practice, the protocol for mid-section photographs has patients lift their arms straight out in front of them so that they are perpendicular to the body. Arms should never be lifted above shoulder height as this position stretches out the torso, distorting the baseline anatomy. In addition to photographs, it is common for providers to measure the treatment area before treatment and one month after the last treatment to quantify centimeters lost. The positioning and tension of the tape measure must be identical in the before and after measurements in order for this to be an accurate tool to assess results. The lack of reliability in circumferential measurements has led many providers to rely on photographs alone to document change. Patients see and feel the difference in their clothes and that is the ultimate gauge of success. The other methods of measuring fat reduction are caliper measurements, bioimpedance-based scale measurements, ultrasound, and most recently magnetic resonance imaging (MRI). 6
The use of MRI is proving to be an accurate and reliable method to quantify the fat thickness reduction following Vanquish ME. A recent study published in the Journal of Drugs in Dermatology showed statistically significant results in a case study that used MRI scanning to measure the difference in fat layer thickness before and after treatment. Five of the six patients enrolled in the study completed it with one patient dropping out for reasons unrelated to the study. The subjects had baseline MRI measurements of fat thickness and were measured a second time four weeks following their last Vanquish ME treatment. The abdominal area was scanned in several equidistant slices. The MRI scans were mostly obtained in dual-echo regime and exported in DICOM format for further analyses. 6 The patients completed four, 45-minute treatments, once a week for 4 weeks. The average reduction in fat layer thickness among the patients in the study was 5.36 mm. There was no significant change in patient’s weight suggesting the results were in fact due to Vanquish ME rather than diet and exercise. MRI scanning is not a realistic method to measure patient results on a routine basis due to the cost of imaging, however it serves a great purpose in determining the efficacy of the technology.
BTL Vanquish ME alone will give patients circumferential fat reduction but in certain cases it is used in conjunction with other devices for synergistic effect, or as a secondary treatment. For people who have excess fat and skin laxity, a combination treatment of radiofrequency fat reduction and a skin tightening device will give patients a better result than either treatment alone. For patients who have a contour abnormality either from liposuction or cryolipolysis, Vanquish ME can often times smooth out the area of irregularity. In our experience, Vanquish ME has become a popular “gateway” procedure leading patients to other non-surgical and surgical procedures after a positive experience. We also have patients who initially opt for Vanquish ME over liposuction for the non-surgical benefits, but later go on to have liposuction to achieve even greater results. It is human nature to always want more of a good thing and once patients see a positive change in their body we find they no longer fear surgery the way they once did. For the patient who had unrealistic expectations going into a radiofrequency fat reduction series, or the rare patient who does not get a good result (less likely now that Vanquish has been upgraded to Vanquish ME), surgery might become a consideration since the non-surgical option was attempted and unsuccessful. It often times goes back to the initial consultation if a liposuction upgrade is stated as an option. A patient who feels like they were promised more than they received from radiofrequency fat reduction may look for a new practice to have surgery with. On the other hand, if a patient feels that they were well educated on the results they could expect from Vanquish ME, they are more inclined to stay “in-house” for additional procedures. We are very forthcoming with our patients regarding what they are likely to achieve with non-surgical radiofrequency fat reduction versus traditional liposuction and give a thorough consultation to all patients.
When incorporating a new non-surgical device into a practice there are many factors to consider. In addition to the device being efficacious, it has to offer a new procedure or enhance an existing one, and must make financial sense for the practice. A downside to many non-surgical devices is the cost of associated consumables. Consumable costs can be substantial and either increase procedure fees or lower the practice profit. BTL Vanquish ME does not have a consumable making it a cost-seffective device to incorporate into practice. It keeps the overhead of the device down and allows for complementary treatments if a patient would benefit from an additional session or two once a series is complete. Patients are usually appreciative of the gratis treatments and this can often times determine the overall level of satisfaction from the Vanquish ME experience.
With the success of non-contact, selective radiofrequency therapy for circumferential fat reduction came the BTL Flex applicator which is now FDA cleared to reduce fat around the thighs and saddlebags. The legs have long been a difficult area to treat non-surgically and many patients complain of unwanted fat in this area. The Flex applicator has a unique design allowing the inner and outer thigh to be treated simultaneously. The device placement can be further customized to target the upper or lower thigh depending on the patient’s concerns. Treatment with the BTL Flex applicator follows the same protocol of 4–6 weekly treatments with each leg treated for 30 minutes. We have found that it takes longer than the mid-section for leg results to occur and this is likely due to the amount of fibrous connective tissue in the legs. Patients are getting results and The Aesthetic Guide reported clinical study results of 40 patients that showed an average of 1 inch reduction over four treatments of 30 minutes per leg. 7
In the few years that we have been using selective radiofrequency for non-surgical fat reduction there have already been significant advancements in the technology. We are seeing better results with the upgraded Vanquish ME system and the Flex applicator has opened the door to treat areas outside the mid-section. Treating the legs with Vanquish ME is gaining in popularity and will only continue to do so with the new FDA clearance. Patients like the fact that they can get results without pain, anesthesia, or downtime. It will be exciting to watch the further evolution of selective radiofrequency for fat reduction. There are currently protocols being put in place to treat the upper extremities and this is likely just the beginning for this technology.
References
[1] Frentzen Jeffrey, Executive Editor, Physicians Prefer BTL Vanquish ME as Stand Alone or Adjunctive Tx, The Aesthetic Guide, 2–5, July/August 2015[2] Weiss R, Weiss M, Beasley K, Vrba J, Bernardy J. Operator Independent Focused High Frequency ISM Band for Fat Reduction: Porcine Model Lasers Surg Med 2013; 45:235–239[3] Fajkošová K, Machovcová A, Onder M, Fritz K. Selective radiofrequency therapy as a noninvasive approach for contactless body contouring and circumferential reduction. J Drugs Dermatol 2014; 13(3):291–296[4] Frentzen Jeffrey, Executive Editor, Physicians Report BTL Vanquish ME Attracts Male Patients, The Aesthetic Guide, 1–4, January/February 2016[5] Cooper JL, Salazar M. Safe, Effective Fat Reduction for Diverse Patient Populations, Supplement to Modern Aesthetics, 9–10, July/August 2015[6] Downie J, Kaspar M. Contactless Abdominal Fat Reduction with Selective RFTM Evaluated by Magnetic Resonance Imaging (MRI): Case Study. J Drugs Dermatol 2016; 15(4):491–495[7] Frentzen Jeffrey, Executive Editor, New BTL Flex Applicator Eases Noninvasive Thigh Treatments, The Aesthetic Guide, 2–3, January/February 2015Related posts:
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