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Shape shiftersDr Patrick Treacy on devices for dealing with post-pregnancy baby weight

Pregnancy leads to many changes in a woman’s body, mainly through the interaction of steroid hormones, lactogen and cortisol on the underlying tissues and structures. The growing foetus itself causes mechanical change also by stretching

skin, muscle and fascia and demanding an increased calorific supply. The amount of extra weight gained during pregnancy varies among women. The National Health Service recommends that the overall weight gain during the nine-month period for women who start pregnancy with normal weight should be in the region 10 to 12 kilograms (22–26 lbs.) but as many British females are already over weight these figures may be downsized. Physicians are aware, insufficient weight gain can compromise the health of the foetus during pregnancy and excessive weight gain can pose risks to the woman and the baby. For women who have gained weight between pregnancies, even a relatively small gain of 1-2 BMI units can increase the risk of high blood pressure or diabetes during their next pregnancy and may also i n c r e a s e the chance of giving birth to a large baby.1 New advice has just been published by the National Institute for Health and Clinical Excellence (NICE) as part of its public health programme. It states that women who are obese (with a BMI over 30) when they become pregnant face an increased

risk of complications such as diabetes, miscarriage, pre-eclampsia, blood clots and death. Obese women are also more likely to have an induced or longer labour, post-delivery bleeding and slower wound healing after delivery. They also tend to be less mobile, which can result in a need for more pain-relieving drugs during labour. These can be

difficult to administer in obese women, resulting in a greater need for general anaesthesia with

its associated risks.2

PHYSIOLOGICAL TYPES1. The ‘pre-baby’ or ‘mating’

body type with fat distribution seen in more normal areas of distribution. In this body type breasts are again used to ‘attract’ a partner rather than being a functional mammary organ. They

tend to be ‘firmer’ due to fat distribution. Women prefer

this body type as it symbolises health, vitality and beauty. Men

prefer it as it shows a female who is ready to reproduce.

2. The ‘post baby’ body type with fat now distributed subcutaneously especially in the

buttocks and thigh area. There are breast volume changes with sagging, especially if the female has breast fed her infant. Breast volume may increase but usually we get shrinkage. In this physiological state the dermal tissue of the abdomen has been distended and sometimes left with long term ‘stretch marks’.

Pregnancy leads to many changes in a woman’s body,

mainly through the interaction of steroid hormones, lactogen and

cortisol on the underlying tissues and structures. The growing foetus itself

causes mechanical change also by stretching skin, muscle and fascia

and demanding an increased calorific supply

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B O D Y/ D E V I C E S

www.aestheticmed.co.uk

A number of newly designed non-surgical

modalities have become available to the consumer

recently, each employing a different mechanism of action to reduce

the appearance of adipose tissue. These devices use laser energy,

radiofrequency, ultrasound or cold (cryolipolysis) to

reduce fat

We shall now look at the problem encountered by the ‘post baby’ body type and what a patient can do to correct them. In some instances the tissues have been distended and sheared to such an extent that surgical repair is the best if not the only option. We will first look at non –surgical methods for removing excess fat. I do not put dieting and exercise as a primary option because most clients feel it is not effective

LIPOSUCTIONLiposuction also known as lipoplasty (“fat modeling”), liposculpture suction lipectomy (“suction-assisted fat removal”) or simply lipo, is a cosmetic surgery operation that removes fat from many different sites on the human body. Areas affected can range from the abdomen, thighs and buttocks, to the neck, backs of the arms and elsewhere. There are many differing mechanism of liposuction including those below.3

Suction-assisted liposuction (SAL) Ultrasound-assisted liposuction (UAL) Power-assisted liposuction (PAL) Twin-cannula (assisted) liposuction (TCAL or TCL) External ultrasound-assisted liposuction (XUAL or EUAL) Water-assisted liposuction (WAL) Laser Assisted

Liposuction can be combined with other procedures (i.e. radiofrequency) that involve a level of skin retraction. The level of skin retraction following liposuction is affected by the age of the patient, quality of skin, presence of underlying disease or smoking and the presence of previous skin damage such as caused by childbirth and surgery. Surgical lifts are also used post-pregnancy to address massive weight loss when the combination of large amounts of skin and shrunken fat cause significant skin drooping. Large volume Liposuction (SAL) in combination with other surgery is common, but may have higher complication rates. The author prefers VASER ® as this is the modality he is most familiar with.

NON-SURGICAL LIPOSUCTION TECHNIQUESA number of newly designed non-surgical modalities have become available to the consumer recently, each employing a different mechanism of action to reduce the appearance of adipose tissue. These devices use laser energy, radiofrequency, ultrasound or cold (cryolipolysis) to reduce fat. Devices are applied directly to the skin of the treatment area and do not employ injections (as in injection lipolysis) or incisions (as in laser assisted liposuction). Although fat loss is more subtle with non-surgical lipolysis techniques compared to surgical liposuction, non-surgical lipolysis techniques have several advantages including reduced risk, reduced cost, and reduced healing time. Laser, radiofrequency, and ultrasound techniques provide

additional advantages of tissue tightening. Because there is no suction

involved, terms such as laser lipolysis, cryolipolysis or body contouring are preferred

to non-surgical liposuction.

CryolipolysisCryolipolysis is the non-invasive cooling of adipose tissue to induce lipolysis - the breaking down of fat cells - to reduce body fat without damage to other tissues. The principle behind cryolipolysis exploits the premise that adipocytes are more susceptible to cooling than other skin cells. The precise application of cold temperatures triggers apoptosis of the adipocytes, which invokes an inflammatory response and leads to slow digestion by surrounding macrophages. In clinical studies, cryolipolysis was shown to reduce subcutaneous fat at the treatment site by up to 25% after one treatment. Improvements were seen in 86% of treated subjects. At 73%, the patient satisfaction rate is higher than with other technologies used for non-invasive lipolysis. Cryolipolysis has been proven to be a very safe method for body contouring, and is accomplished with only minimal discomfort. Expected side effects are temporary erythema, bruising, and transient numbness that usually resolve within 14 days

after treatment.4 Zeltiq obtained FDA approval in 2010 for

cryolipolysis of the flanks and additional approval in 2012 for cryolipolysis of the abdomen. Strawberry was approved by the

FDA in 2013. The author prefers Zeltig’s Coolsculpt®

as this is the cryolipolysis device he is most familiar with.

Radiofrequency B T L _V a n q u i s h _unit-with-logo_HQRadiof req uen c y devices have traditionally been used for tightening of skin laxity and rhytides, as the thermal damage that ensues results in contraction of collagen and remodeling. A clinical study by Franco et al6 shows that radiofrequency devices can be used to selectively heat subcutaneous adipose tissue and induce lethal thermal damage to adipose tissue while sparing the overlying and underlying tissues. Thermal exposures to 43°C–45°C over several minutes may result in a delayed adipocyte death response. This may have a role in decreasing overall waist circumference and fat removal as well. An average decrease of 4.93cm was calculated using BTL’s Vanquish®. This study demonstrated that selective RF system designed for contactless deep tissue heating is a painless, safe, and effective treatment for non-surgical body contouring and circumferential fat reduction.5 The author prefers BTL’s Vanquish® as this is the radiofrequency device he is most familiar with

UltrasoundFocused thermal ultrasound techniques work by raising the tissue temperature above 56 °C, resulting in coagulative necrosis of adipocytes, with sparing of vessels and nerves. Passive heating of the skin may also induce collagen remodeling. Liposonix from Solta Medical uses thermal focused ultrasound while UltraShape from Syneron Candela uses non-thermal focused ultrasound. Ultrashape is FDA-cleared to treat areas of fat on the stomach, hips, and thighs that have been resistant to diet and exercise. The machine delivers ultrasound technology through a hand-held device placed on the targeted area, which causes fat to burst and be eliminated through the body’s natural metabolic process. The author prefers Ultrashape® as this is the focused non thermal ultrasound device he is most familiar with.

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BABY WEIGHT www.aestheticmed.co.uk

Aesthetic Medicine • May 2016

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>> Dr Patrick Treacy is chairman of the Irish Association of Cosmetic Doctors and Irish Regional Representative of the British Association of Cosmetic Medicine. He is a fellow of the Royal Society of Medicine and the Royal Society of Arts. (London) and chairman of the Ailesbury Humanitarian Foundation. He is on the editorial boards of five international aesthetic and dermatology journals and has pioneered facial endoprosthesis techniques for HIV facial lipodystrophy and radiosurgery thermocoagulation.

Low level light laser Low level laser light reduces the stability of

adipocyte cell membranes, allowing cells to release their stores of fat without

damaging the cell. Because the fat is released into the extracellular space, cardio based exercise is usually promoted after the procedure. In 2010, Zerona became the first non-invasive lipolysis device approved by the FDA following a randomized controlled trial demonstrating circumference reduction of the waist, hip, and thighs. The Verjú Green Laser was 510(k) FDA cleared in January 2014 for non- invasive cellulite reduction as well as for non-invasive fat reduction body contouring for

the waist, hips, and thighs. The Verjú Green Laser was featured on “The Doctors” TV show in May 2014.

DIET AND EXERCISE Healthy eating habits combined with regular exercise also help people lose baby fat. Weight loss via exercise and healthy eating carries little risk compared to liposuction. Walking may not sound like much of a workout, but it is one of the simplest ways to ease into a fitness routine after giving birth. Bringing baby along in a front pack will add extra weight that can increase the benefits. Research shows that starting a regular exercise program soon after giving birth is not only good for your overall health, but may also help reduce the risk of postpartum depression. AM

REFERENCES 1. Changes in maternal physiology during pregnancy CEACCP, Jun 2003; 3:

65 - 68. Bernhard H Heidemann and John H McClure

2. Weight management before, during and after pregnancy http://www.nice.org.uk/guidance/PH27

3. Nordqvist, Christian (8 March 2012). “What Is Liposuction? Liposuction Risks And Benefits”. Medical News Today. Retrieved 15 January 2013.

4. Clin Cosmet Investig Dermatol. 2014; 7: 201–205.Published online 2014 Jun 26. doi: 10.2147/CCID.S44371 PMCID: PMC4079633 Cryolipolysis for non-invasive body contouring: clinical efficacy and patient satisfaction Nils Krueger, Sophia V Mai, Stefanie Luebberding, Neil S Sadick

5. Selective Radiofrequency Therapy as a Non-Invasive Approach for Contactless Body Contouring and Circumferential Reduction. Kateřina Fajkošová MUDr, Alena Machovcová MD PhD MBA,b,c Meltem Onder MD, and Klaus Fritz MDd,e