**1. Introduction**

Areas of exercise-resistant or diet-resistant fat, skin issues, and muscle concerns are many reasons the patients turn to cosmetic surgeries. Whether these concerns come from fatty areas at the abdomen, back, or thighs that would not budge, loose skin after dramatic weight loss, or pregnancy, many people try to find the best ways to eliminate these problems.

While skin excision is needed in some cases, liposuction is often the most preferred treatment for patients to contour or shape their bodies and eliminate the extra fat for different areas. Liposuction, also referred to as lipo, lipectomy, liposculpture suction, or lipoplasty, is a popular cosmetic surgery that breaks and sucks away the fat from the body. A cannula, a hollow instrument, is used to remove the fat during the procedure. The instrument is inserted into the skin, and a highpressure, powerful vacuum is applied to the cannula to evacuate the fat. Due to its invasive nature, the whole procedure often requires anesthesia to combat patient

discomfort associated with the insertion of a cannula. It is commonly used on the abdomen, flanks, upper back, neck, buttocks, thighs, and volar arms and calves.

The procedure is highly popular around the world and is one of the topperforming cosmetic procedures [1]. This treatment helps permanently remove the fat cells and enhance the shape of the body. Nevertheless, the remaining fat cells could grow bigger if the patient does not follow a healthy lifestyle after the surgery. Also, liposuction does not resolve skin irregularities as stretch marks, dimples, or cellulite. It does not affect muscle tissue by any means since it primarily focuses on enhancing or changing the body's adipose contour. Additionally, only a limited amount of fat can be eliminated, and there are certain risks and downtime associated with the treatment.

While most patients are happy with the outcome of their traditional body contouring procedures, a fair number of them are left with unresolved problems. Moreover, many are still reluctant to undergo surgery to reduce fat and prefer a procedure without any down time or scars. Fortunately, in recent years, numerous minimally invasive and non-invasive alternatives to liposuction have been introduced. These procedures for fat reduction and body contouring do not require any anesthesia or incision and have no downtime. The introduction of non-invasive treatments allows physicians to offer such patients with non-invasive fat reduction and body contouring treatments as an alternative to surgery-assisted liposuction (SAL).

While the numerous body-contouring treatments aim to target adipose tissue by utilizing light energy [2, 3], ultrasound [4, 5] or cold temperatures [6, 7], the new revolutionary non-invasive HIFEM technology [8–12] has brought attention to the underlying muscle tissue as well. In addition, the combination of High-intensity Focused Electromagnetic field (HIFEM) with synchronized [13] or externally applied radiofrequency (RF) and targeted pressure energy (TPE) [14] can provide a new solution for body contouring dilemmas, such as striae, skin contour irregularities, cellulite, residual subcutaneous fat, and diastasis recti without the need for any surgery.

This chapter aims to introduce non-invasive HIFEM, RF, and TPE technologies as a viable alternative to the conventional SAL procedure when used in a standalone regime or as a combination treatment. As always, patient selection and preferences are the key factors when prescribing the procedure that should fit his/her needs regarding the specific body area and imperfection that is going to be treated. Given the technological advancements in the non-invasive field of esthetics in recent years, we believe the technologies mentioned above may achieve competitive and perhaps advantageous results in some specific cases.

#### **2. Technology and mechanism of action**

Since patients who attend your practice are unique with varying goals and needs, it is essential to understand the importance of providing various solutions to help them accomplish their desired results. Over time, you might have encountered many patients who wanted to achieve a contoured body, tight muscles, and smooth skin appearance without the necessity of the invasive surgical procedure.

While this might have been impossible a decade ago, the non-invasive solution evolved greatly in the past few years. Today, with appropriate patient selection and treatment planning, it may offer an outstanding alternative to liposuction (see Section 3. Non-invasive technologies as an alternative to SAL). Not only these noninvasive solutions may provide an alternative to SAL, but they also have capabilities to enhance the results post-SAL. Physicians can combine these procedures to

#### *Non-invasive Alternatives for Liposuction DOI: http://dx.doi.org/10.5772/intechopen.101396*

further enhance patient results post-liposuction based on the patient's expectations and goals. To understand the abovementioned procedures in detail, it is integral to learn about their mechanism of action (MOA).

A systematic electronic search by using the terms "HIFEM" and "targeted pressure energy (TPE)" was carried out to identify the relevant literature published since January 2018. Articles investigating the effect of the HIFEM procedure as a standalone tool or in combination with synchronized RF, and monopolar radiofrequency combined with TPE were further evaluated based on the Author's knowledge. In addition, the reference lists of analyzed articles were inspected to identify the additional valid source of information. Research that quantitatively documents changes in fat, muscle and skin tissue in response to the treatments was summarized with special attention given to histological studies, evidencing the induced changes at the molecular/tissue level. Besides, the outcomes, including but not limited to improvement of patient appearance, comfort, and satisfaction, have been reviewed as well.

## **2.1 HIFEM**

The first-ever HIFEM based procedure was shown in 2018 when the Emsculpt device (BTL Industries Inc., Boston, MA) was introduced to the market and gained considerable popularity among patients and physicians. Emsculpt is FDA-approved for toning and strengthening the abdominal muscles, arms, calves and lifting and toning the buttocks. This technology treats muscle laxity in numerous parts of the body, including calves, thighs, biceps, triceps, abdominal areas, and buttocks. Its function is based on the law of electromagnetic induction. Hence it utilizes electromagnetic coil build-in the device's applicator, which generates a strong and varying magnetic field, penetrating the treated area and targeting neuromuscular tissue. Since medical usage did not require such an intensive magnetic field, broad spot size, and stimuli with a high repetition rate before introducing the Emsculpt device, HIFEM technology must be specifically engineered to meet the criteria necessary for esthetics.

Four treatment sessions are recommended to induce visible changes in the treated area. Nonetheless, some subjects may benefit from a few additional treatments to maximize their goals [10]. Each session typically lasts for around 30 minutes, including the pre-treatment preparations, and depending on the patient's availability. They can be scheduled 1–2 times a week. The device allows using two applicators simultaneously, enabling the concurrent application of HIFEM, especially over the buttocks, arms, calves, and abdomen in higher BMI subjects. It is necessary to take the subcutaneous fat thickness into account. Ideal candidates for HIFEM treatments are men and women with fat thickness up to 3 cm [15].

Overall, the treatment is safe without any side effects, and besides slight muscle soreness the day after the therapy due to the fatigue and muscle regeneration, it causes no discomfort. Emsculpt has shown considerable improvements in body image a few months following the final treatment [8–12, 16, 17], comparable to the progress one achieves after an intensive workout. Many patients claim that noticeable changes may be seen just after a few days of treatment.

#### *2.1.1 Supramaximal contractions*

HIFEM utilizes a rapidly changing magnetic field with intensities up to 1.8 T and penetration depth of roughly 7 cm, generated by the circular coil embedded in the device applicators. Based on the law of electromagnetic induction, this alternating field induces electrical currents in the targeted tissue. In general, the current passes across a nerve membrane into its axon. It results in depolarization, which is required to trigger the opening of voltage-gated sodium and potassium ion channels. Then, the action potential is initiated, and it is further propagated by the physiological mechanisms of nerve conduction, evoking a contraction of muscle fibers. The excitation is selective to muscle tissue due to the tailored parameters of the HIFEM field. The alpha motor neurons (a component of peripheral nerves) directly responsible for initiating muscle contractions are activated first [18, 19].

In normal conditions, the highest tension that can be physiologically held and developed is Maximal Voluntary Contraction (MVC), lasting for barely a second. The contractions with higher tension are referred to as supramaximal. The HIFEM technology can create supramaximal contractions and sustain them for multiple seconds to drastically enhance the physiologic stress required for muscles to adapt. On the contrary, in the voluntary means of muscle contractions, the muscles' fibers relax between every stimulus because of the inability of the central nervous system to signal the other impulse when it is still in action [18]. However, this non-invasive technology generates the impulses with such frequency that it offers no relaxation phase, thus generating the continuous contraction of high intensity. During one therapy, muscles are forced to contract several thousand times. When the muscle tissue is exposed to such overload, it adapts to these supramaximal contractions by remodeling its inner structure, leading to the growth of myofibrils (hypertrophy) and possibly generating new muscle fibers (hyperplasia) [20]. Consequently, this increase in muscle volume and density results in improved muscle definition and tone.

#### *2.1.2 Breakdown of fat*

Muscles require a sufficient amount of energy during any physical activity to generate contractions. This energy is primarily derived from Adenosine Triphosphate (ATP) and then from glycogen and creatine phosphate. However, if those compounds are insufficient, the body's catabolic processes occur through lipolysis, which refers to the breakdown of the lipid in glycerol and free fatty acids (FFA). FFA molecules are then utilized as the energy source required for body metabolism and muscle activity.

Supramaximal contractions demand a high amount of energy; thus, adipocytes – the basic unit of fat tissue – close to contracting muscles are depleted by lipolysis to compensate for the considerable increase in energy consumption. It has been evidenced that when FFA's are in a surplus, the fat cells get quickly overwhelmed and may enter apoptosis, otherwise known as a programmed adipocytes deletion, resulting in metabolically induced fat reduction [21].

#### *2.1.3 Clinical evidence*

So far, the abdominal and buttock body areas have received the greatest attention from researchers. Therefore, most clinical studies performed with HIFEM investigate the changes in fat and muscle tissue on the abdomen and buttocks. Although results may vary based on patient group and evaluation technique, the evidence is sufficient to extrapolate the expected results after the HIFEM procedure.

At first, various objective methods were used to assess changes in the treated abdominal tissues, including computed tomography (CT) [10], magnetic resonance (MRI) [8, 9], diagnostic ultrasound (USN) [11], and circumference measurements [17]. The results were consistent across the studies, with maximum improvement in fat and muscle observed 3 months after the last treatment. In the North American population sample, the average fat reduction was 18.9%, coinciding with a 15.6%

#### *Non-invasive Alternatives for Liposuction DOI: http://dx.doi.org/10.5772/intechopen.101396*

increase in muscle thickness, a 10.6% decrease in rectus abdominis separation, and a 4.1 cm decrease in waist circumference, on average. In specific patient samples, the results may have been offset even towards higher levels, as experienced in limited groups of post-partum subjects [8] or European patients [22]. Regarding the longevity of achieved results, Kinney and Kent [23], in their follow-up study, evidenced that results are maintained at 12 months post treatments in subjects who follow a healthy and active lifestyle. They also suggested an application of maintenance treatment after 1 year, which may be used as prevention against individual results decline. Also, the same authors recently unveil that HIFEM technology has a positive effect on visceral adipose tissue by using retrospective analysis of CT and MRI scans from the previous studies [24]. HIFEM was found to decrease visceral fat by 14.3% on average in reviewed patients, offering an interesting option to combat abdominal obesity non-invasively.

Correspondingly to the abdomen, reduction in fat and increase in muscle tissue was also observed when investigating HIFEM's effect on upper arms and calves. MRI examination revealed increment in cross-sectional area of musculus biceps brachii (+17.1%), triceps brachii (+10.2%), and gastrocnemius (+14.6%) while fat thickness on upper arms (−12.8%) and calves (−9.9%) was significantly reduced [16].

Finally, Busso, Denkova, and Jacob et al. have documented improvement of body image and lifting effect after HIFEM treatments on buttocks. In these questionnaire-based studies, the patients reported high satisfaction levels (up to 85%) and noticeable changes in buttock contour, visible on digital photographs. The buttock lifting effect was further explained by Palm's12 MRI study, which found that a significant volumetric increase of gluteal muscles (+13.2% on average) occurs, while more prominent growth of musculus gluteus maximus, medius, and minimus was found in the upper buttock region. Interestingly, no significant changes in fat thickness were found, which was attributed to the different metabolic activity of adipose tissue on buttocks that shows considerably lower lipolytic rate [25].
