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Table of Contents
REVIEW ARTICLE
Year : 2018  |  Volume : 22  |  Issue : 1  |  Page : 2-11

Noninvasive arm fat reduction


1 Department of Dermatology, University of California, Irvine, CA, USA
2 Department of Dermatology, Case Western Reserve University, Cleveland, OH, USA
3 Manhattan Dermatology, Manhattan Beach, CA, USA

Date of Web Publication31-Jan-2018

Correspondence Address:
Dr. Logan William Thomas
Department of Dermatology, University of California, 118 Medical Surge I, Irvine 92697, CA
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jdds.jdds_8_18

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  Abstract 


The demand for new approaches for noninvasive procedures of the upper arm is increasing. This review will present the most recent literature addressing modalities for arm fat reduction. Thirteen papers met inclusion criteria. The greatest arm circumference reduction (2.75 cm) is accomplished with the combination of cryolipolysis and shock therapy. Limited side effects are noted with each treatment modality. The most painful treatment is cryolipolysis. Physicians should be aware of the most common treatment modalities, new advances in devices, and possible side effects that may occur. There is a need to design and implement a universal patient satisfaction scale, such as the Global Aesthetic Improvement Scale. We recommend a standard approach to fat reduction measurement using three-dimensional imaging and suggest using US at a standardized location such as the midpoint between the olecranon and acromion processes. Although preliminary research suggests that noninvasive contouring of the upper arm is successful with limited adverse events, further research in this field will need to be completed to determine the long-term safety.

Keywords: Arm contouring, cryolipolysis, high intensity focused ultrasound, low-level laser therapy, radiofrequency


How to cite this article:
Thomas LW, Juhasz M, Chapman L, Van Hal M, Conic R, Magovern A, Mesinkovska N. Noninvasive arm fat reduction. J Dermatol Dermatol Surg 2018;22:2-11

How to cite this URL:
Thomas LW, Juhasz M, Chapman L, Van Hal M, Conic R, Magovern A, Mesinkovska N. Noninvasive arm fat reduction. J Dermatol Dermatol Surg [serial online] 2018 [cited 2018 Feb 22];22:2-11. Available from: http://www.jddsjournal.org/text.asp?2018/22/1/2/224397




  Introduction Top


Societal views on the perfect body aesthetic have associated slimness with beauty; arm fat impacts how individuals perceive self-beauty and negatively impacts self-confidence.[1] Traditional approaches to arm fat refractory lifestyle modifications include invasive surgical procedures such as liposuction [Figure 1], carrying risks such as postanesthesia adverse events, hospitalization, and prolonged postoperative recovery;[2] the incidence of minor wound complications is 6.3%, and major morbidity is 6.8% 30 days after liposuction.[3]
Figure 1: Invasive brachioplasty. A 42-year-old female with massive weight loss following bariatric surgery presents with (a) excess skin laxity desiring brachioplasty, and (b) 6 months' postprocedure

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Noninvasive approaches to body contouring have become popular, with the development of novel devices and protocols. In a plastic surgery report from 2015, cosmetic surgical procedures have decreased by 10% since 2000, while minimally invasive procedures have increased by 158%.[4] Minimally invasive approaches have reduced concern for severe side effects and complications such as scarring, decreased procedural discomfort and allowed faster recovery.

Arm contouring is currently in demand with many approaches having been studied, and devices yielding promising results in the reduction of adipose tissue. In this review, we discuss evidence of noninvasive devices for arm contouring, including low level laser therapy (LLLT), high-intensity focused ultrasound (HIFU), radiofrequency (RF), and cryolipolysis.

Arm anatomy

The brachial plexus, brachial artery, cephalic vein, and basilic vein are delicate structures in the arm [Figure 2]. Surgical and invasive interventions may lead to complications such as hematoma, infection, and rarely wound dehiscence. Reports of structural damage to the arm have been rare during noninvasive procedures.[5] However, the median nerve, medial cutaneous nerve, and ulnar nerve may be in danger given their superficial locations. There are reported cases of ulnar and/or median nerve palsy with associated paresthesia during RF and cryolipolysis; fortunately, these symptoms spontaneously resolve shortly after treatment.[6],[7]
Figure 2: Important anatomical structures within the arm. Important structures (nerves, arteries, veins) reside on the medial and lateral sides of the arm. Care must be taken to avoid the cephalic vein on the anterior aspect of the arm. The posterior aspect is the ideal area for treatment. (Faringer P. Modern Brachioplasty. Plastic Surgery Pulse News, Volume 7, Number 1. St. Louis: Quality Medical Publishing, 2015)

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Using the search phrase, “LLLT OR high intensity frequency ultrasound (US) OR RF OR cryolipolysis AND arm” in PubMed allowed for the identification of articles discussing arm contouring using one of four noninvasive methods. Articles were reviewed by title and included if they dealt with human subjects, were published in English, and used one of the identified methods. Additional articles for review were identified from the references of included papers


  Results Top


The primary literature search returned 258 results; 13 articles met inclusion criteria. Study designs included: One double-blinded, controlled, randomized trial; one single-site, single-blinded, split-arm, randomized controlled trial; one prospective open-label clinical trial; one nonrandomized clinical trial; one retrospective, nonrandomized, noncontrolled study; and eight other articles that did not clearly identify their study design.

Low level laser therapy

LLLT applies low-irradiancy laser light (1–5000 mW/cm 2) to achieve therapeutic results without photothermal or photoacoustic effects.[8] Although LLLT's mechanism of action is unclear, proposed mechanisms involve modifying lipid metabolism,[9] or reducing oxidative stress in adipose tissue, increasing adiponectin secretion and decreasing insulin resistance.[8] Other hypothesized mechanisms include laser-induced “pores” in the adipocyte membrane causing disruption and triglyceride (TG) leakage; released TG travel through the lymphatic system to lymph nodes where they are hydrolyzed by lysosomal acid lipase generating nonesterified-free fatty acids (FFA) ready for catabolism.[10],[11] Recent studies have shown that a 635 nm diode laser is capable of releasing 80% of fat with 4 min of exposure, and as much as 99% of fat with 6 min.[12] It is important to note that after treatment, there are no macroscopic changes in tissue structure.[13]

Jackson et al. described LLLT treatment of 632 patients each receiving six, 40-min treatments over a period of 2 weeks at the waist, hips, and thighs. Despite not receiving direct treatment, a 0.813 cm circumference reduction 1-week postprocedure was measured at the arm.[9] Nestor et al. described LLLT treatment of 40 patients each receiving six, 20-min treatments to the arm over a period of 2 weeks with a circumference reduction of 3.7 cm 1-week after the last session [Table 1].[14]
Table 1: Low level laser therapy

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A laser device similar to LLLT is Scultpsure ® (Cyanosure, Inc., Westford, MA, USA). This 1060 nm laser is described as a “hyperthermic laser” because tissue is heated during the treatment (as opposed to LLLT, a “cold laser”). The energy delivered by this laser creates movement of particles within the tissue, causing transformation of mechanical to thermal energy; maintaining a temperature of 42°C–47°C causes loss of adipocyte membrane integrity and cell death.[15] The 1060 nm adequately penetrates the epidermis, spares the dermis, and specifically targets adipocytes;[16] clinical results are apparent at 6 weeks with optimal results at 12 weeks. The 1060 nm laser is only FDA-approved for contouring the abdomen and flanks,[16] but studies have shown significant thigh and back fat reduction.[17] Decorato et al. report a 24% adipose thickness reduction of the flank at 3 months, and 21% fat volume reduction 6 months using this laser; further long-term studies are warranted to determine longevity of fat reduction.[18] Currently, there is no literature using the 1060 nm laser for arm contouring and further studies are needed to determine its utility.

High-intensity frequency ultrasound

HIFU uses ultrasonic waves and negative acoustic pressure to achieve results. Focusing acoustic energy at a singular point causes cell membrane disruption, cavitation bubbles, and acoustic energy is transformed into heat with temperatures >57°C.[19],[20] Maintaining temperatures at a specific tissue depth, leads to adipose cell death and coagulative necrosis.[21] Histopathology demonstrates fat necrosis with multicellular inflammatory infiltrates and foreign body giant cells; 4–5-month posttreatment 95% of adipocytes are destroyed.[19],[20] Fortunately, surrounding tissue is unaffected. After adipocyte death, FFAs, inflammatory markers, and chemotactic factors are released, recruiting macrophages 3–4-day posttreatment; after 14–20 days, macrophages engulf and metabolize remaining cellular components. Inflammation and healing may take up to 90 days, with a clear reduction in subcutaneous fat on histology.[21],[22],[23]

Three papers were identified using HIFU to tighten arm and/or elbow skin [Table 2]. Choi et al. describe the Ultraformer ® III, Shurink (Classys Inc., Seoul, Korea) on six females, Asian patients. Using a Global Aesthetic Improvement Scale (GAIS) (-3–3 with-3 = very much worse and 3 = very much improved) investigators and individuals rated 100% “improvement” and at least an “improved,” respectively, 4 weeks' posttreatment. Pain was ranked 5.17 ± 2.48 out of 10 (with 10 being the worst) immediately postprocedure; no pain was noted at follow-up.[24] Rokhsar et al. demonstrate HIFU tightening skin over the elbow in 20 female patients. Physicians and patients noted a 94% and 81% improvement at follow-up, respectively. The mean pain score was 5.7 out of 10.[25] Alster et al. treat 18 female patients with Ulthera ® (Merz Aesthetics, Mesa, AZ). Masked assessors gave a Global Assessment Score (GAS – 0–4 with 0 = no improvement, 1 = 1%–25% improvement, 2 = 25%–50% improvement, 3 = 51%–75% improvement, and 4= >75% improvement) score of 2.05 for single plane treatment, and 2.25 for double plane treatment. About 81% of patients were highly satisfied with the procedure, reporting mild-to-moderate discomfort.[26]
Table 2: High-intensity frequency ultrasound

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Radiofrequency

RF relies on a controlled electrical field to preferentially target and heat the subdermal layer to 43°C–45°C, resulting in dermal tissue remodeling, disruption of collagen cross-linking bonds, denaturation of old collagen fibers, and fibroblast-initiated neocollagenesis.[16],[27],[28] Neocollagenesis is further aided by increased dermal vascular flow secondary to thermal heating.[29] Targeting the subcutaneous adipose tissue creates adipocyte thermolysis, release of TGs and FFAs, inflammatory cascade initiation, and destruction of adipose tissue.[30]

Five papers using RF were identified for inclusion in this review with a total of 89 patients [Table 3].[31],[32],[33],[34],[35] Arm circumference reduction ranged from 0.17 ± 0.98 cm with Regen™ (Pollogen Ltd, Tel Aviv, Israel)[33] to 1.99 ± 0.94 cm with Tripolar RF.[35] Beasley et al. used three-dimensional US to quantitatively measure a 0.57 cm reduction in posterior arm adipose tissue depth, and an estimated 45 cc reduction in adipose volume.[32] No papers were found using ThermiSmooth ® (Almirall, S. A., Irving, Texas, USA) for the specific purpose of arm contouring.
Table 3: Radiofrequency

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Cryolipolysis

Cryolipolysis exploits the higher freezing point of adipose tissue; by cooling subcutaneous fat to 4°C, cryolipolysis spares skin, nerves, vessels, and muscles.[36] Combining with vacuum suction, reduces blood flow and allows for rapid crystallization of adipose tissue. Cellular edema occurs as intracellular water freezes, causing cell lysis. Numerous theories on the mechanism of adipocyte apoptosis after cryolipolysis exist including a decrease in the sodium-potassium-adenosine triphosphatase (ATPase) pump activity and available ATP, increase in lactic acid, and release of mitochondrial-free radicals. After treatment, immediate postischemic reperfusion injury with production of reactive oxygen species causes increase in intracellular calcium and activation of caspases within the apoptotic pathways.[36],[37],[38]

CoolScultping ® (Zeltiq Aesthetics, Inc., Pleasanton, CA, USA) has been approved for contouring of the submental area, thigh, abdomen, flank, bra, and back, and as of January 2017, was approved by the FDA for treatment of the upper arm. Currently, cryolipolysis is the only treatment approved for fat reduction of the arm.[39] Three papers using cryolipolysis, with a total of 24 patients, were identified for inclusion [Table 4].[6],[40],[41] These studies report arm circumference reduction ranging from 0.72 cm using CoolSculpting ® alone [40] to 2.75 cm using ProShock Ice (PromoItalia Group S. p. A, Naples, Italy).[41] Sang et al. demonstrate a 0.203 cm fat layer reduction by combining CoolSculpting ® with adjuvant US.[6] While this paper was being submitted Carruthers et al. published the safety and efficacy of a prototype CoolCup applicator specifically for the upper arm. Thirty patients were treated for 35 min at -11°C resulting in a mean fat layer reduction of 0.32 cm with a standard deviation of 0.27 cm. Four patients experienced numbness in the treatment area which subsequently resolved.[42]
Table 4: Cryolipolysis

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  Discussion Top


Results for noninvasive arm contouring have been promising with studies reporting a significant decrease in arm circumference. Although most clinicians treat the posterior arm,[14],[15],[24],[26],[31],[32],[33],[34],[41] others treat the lateral arm to avoid nerve damage,[40] or treat both anterior and posterior arms.[35] Considering arm anatomy, the best treatment area is the middle posterior arm because it contains the most subcutaneous adipose tissue without concern for structural damage.

The greatest arm circumference reduction, 2.75 cm, was obtained with combination cryolipolysis and shock therapy.[41],[44] Studies report a 0.813 cm circumference reduction with LLLT,[9] and 1.99 ± 0.94 cm with RF.[35] Patients report noticeable changes in arm appearance and are satisfied with overall esthetic results.[6],[15],[24],[25],[26],[31],[35],[40],[41] Unfortunately, patients with weight gain in the posttreatment period demonstrate no response.[32]

A delicate balance exists between minimal treatment with decreased results and side effects versus maximal treatment associated with greater results, but also increased the risk of severe adverse events. Given variable rating systems in each study, it is difficult to determine which modality was most efficacious and satisfying for patients. A universally applied assessment scale such as GAIS could allow for better comparison between modalities. Although the majority of the studied patient population has been female, with the rise in male cosmetic procedures further studies are needed to thoroughly evaluate arm contouring techniques.

There was no report of side effects with the use of LLLT.[9],[14] HIFU results in mild edema,[24] erythema, bruising, and skin tenderness,[26] all spontaneously resolving within 1 week. Patients rate pain during HIFU as 5.17–5.7 on a 0–10 pain scale.[24],[25] RF treatment results in erythema resolving after 1–3 h; other adverse events such as dermatitis, ecchymosis, blisters, and burns took up to 1 week for resolution.[31],[33],[34],[35] On a 0–10 pain scale, RF was reported at 1.25.[31] Cryolipolysis causes erythema, neuropathy, numbness, and bruising, with resolution occurring in approximately 2 weeks.[6],[40],[41] This technique is the most painful rated as 7 on 0–10 pain scale; one subject withdrew from a study due to the inability to tolerate procedural pain.[40] Further studies are warranted to compare the adverse event profile of the various modalities and determine long-term safety after arm contouring.

Most studies included are small and have not been reproduced on larger scale. Limitations comparing studies include a lack of systematic approach to the measurement of arm circumference, as well as variability among modalities of treatment, treatment course, follow-up, adverse events, and overall patient satisfaction. Although most studies use total reduction of arm circumference as a measure of treatment outcome,[9],[14],[31],[33],[34],[35],[40],[41] results were measured differently for each device. Multiple studies recorded arm circumference using a retractable tape measure [9],[14],[31],[32],[33],[34],[35],[40],[41] and standardized measurements by various means including circumferential measurements at a specific distance from the olecranon,[14],[31],[33],[40] placing a grid over a specified area,[25] or using transparent vinyl superimposed on body landmarks such as nevi or scars.[6] Unfortunately, some studies did not even describe how the initial treatment area was identified or accurately measured.

Studies relying on the three-dimensional US to assess adipose tissue reduction,[6],[32] yielded reliable, quantitative results by directly measuring the subcutaneous layer. The use of three-dimensional imaging is superior when measuring subtle reductions in adipose tissue compared to a measuring tape, thus reducing the number of patients needed to adequately power a study.[44],[45] US allows investigators to focus solely on the treatment area, excluding confounding anatomic features; furthermore, US measures not only adipose tissue depth but also volume.[32] To standardize evaluation of adipose tissue, measurements were taken from the area of the arm with the greatest subcutaneous fat,[9],[34] or at a specified distance from the olecranon.[14],[31],[33],[40]


  Conclusions Top


Noninvasive arm contouring using LLLT, HIFU, RF, and cryolipolysis is successful in reducing arm circumference by decreasing subcutaneous adipose tissue deposits. Studies demonstrate that patients are satisfied with results and adverse events are minimal. This review highlights the need for a universal approach to arm measurement and patient satisfaction scale such as GAIS; standardization of treatment evaluation is needed to enable comparison between different modalities. Currently, the most technologically advanced approach to measuring adipose reduction after noninvasive contouring is the three-dimensional US. We suggest standardizing the location of posttreatment evaluation using the midpoint between the olecranon process and acromion process with the arm fully extended. To validate the promising results of noninvasive methods for arm contouring, further research will need to be completed.[43]

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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