**4. Discussion**

Although the technologies mentioned above are new and still evolving, the clinical evidence combined with our personal experience highlights that using HIFEM, RF, and TPE may target multiple types of patients with skin, fat, or muscle concerns. It needs to be considered that every patient is different and has specific requirements based on the physical constitution and personal preferences when it comes to visual appearance and body contour. Liposuction has always been perceived as a problem-solving procedure regarding the improvement of esthetic appearance. However, due to its invasive nature and discomfort, which limits patient's post-treatment, many would prefer a more convenient way of achieving desirable improvement. The interest in non-invasive body contouring procedures is therefore on the rise in recent years.

Considering the patient comfort and safety, the non-invasive alternatives to SAL were searched intensively in the past. In 2009, Zelickson et al. [41] established a concept of controlled and selective destruction of fat cells by inducing temperatures in the subcutaneous fat layer close to or below the freezing point, termed cryolipolysis. Using the Yucatan pig animal model, they found the reduced thickness of the fat layer associated with local inflammatory response, inferring that such treatments in humans may lead to subsequent changes in body contour. The further studies conducted by several authors evidenced the proposed effectiveness for fat reduction in human subjects. It was found that, in general, cryolipolysis causes a 22% reduction of subcutaneous fat thickness when used on the abdomen or flanks, i.e., the most frequent body parts treated by traditional SAL [42–49]. However, although these body parts' efficacy is relatively high, cryolipolysis solely focuses on the reduction of fat tissue, limiting its application and versatility. Also, although the majority of animal or human studies found no significant risks associated with cryolipolysis, still it has been evidenced that on rare occasions, treated subjects may develop adverse reactions referred to as paradoxical adipose hyperplasia (PAH) [50, 51], leading to sudden fat bulging and need of corrective surgical treatment.

Similar to cryolipolysis, focused high-intensity ultrasound (HIFU) was also introduced in the past decade as a possible substitute for invasive procedures in body contouring. HIFU technology primarily relies on disruptive mechanical effects on adipocytes with minimal damage to neighboring structures such as vessels,

nerves, and connective tissue [52, 53]. According to various sources [5, 53–56], the therapy may result in substantial contour improvement with fat reduction above 20% after multiple treatment sessions. Nonetheless, Shek et al. [52] concluded that HIFU treatments showed insignificant changes among the Southern Asians, suggesting design modifications for this particular group of patients.

Most recently, modalities such as HIFEM, RF, and TPE have emerged in esthetic practices. Due to its effectiveness, great safety profile, convenient use, and multifactorial treatment effect, it may pose a promising and complex alternative to SAL, with treatment outcomes not limited to fat reduction only. HIFEM is a patented technology and the first of its kind to be used in the esthetic field to enhance the overall appearance of individuals and, most importantly, target the muscle tissue, which has been neglected for a long time. Before this technology was introduced in 2018 with the launch of the Emsculpt device, intensive magnetic fields for esthetic treatments were barely understood. Since then, physicians are getting more and more familiar with the technology, discovering all its possible applications. Emsculpt pioneered the use of non-invasive body shaping through enhancing muscle strength. Nonetheless, the patient demand for outstanding results and the strong emphasis on reliable fat reduction are still pushing the technological progress forward. Therefore, the Emsculpt Neo device launched in 2020 took the concept of Emsculpt further by combining HIFEM with radiofrequency. Due to the simultaneous application and synergistic effect of both electromagnetic fields, physicians have now available the efficient tool to deliver two types of treatment in a single procedure. Recent clinical studies documented the more pronounced results stemming from the HIFEM+RF combination, showing the significant changes at the level of muscle and fat tissues (−30% in fat thickness, +25% in muscle thickness, and 19% reduction in abdominal separation). In response to the treatments, patients demonstrated measurable changes in body contour and muscle definition [26, 30, 31].

Certain concerns cannot be resolved with the customary liposuction as it only focuses on fat reduction. For instance, skin pendulosity and laxity cannot be addressed and even worsened after SAL, as the skin naturally contracts due to fat removal. While liposuction reduces the fat efficiently, in some cases, it leads to deformities accompanied by sagging skin. Fortunately, all of these concerns can be addressed non-invasively utilizing RF and TPE energy to ensure complete esthetic enhancement after the fat reduction. Emtone is one of the first and sole device that delivers both mechanical and thermal energy simultaneously, removing the major causes of loose skin and cellulite non-invasively and effectively. The combination of mechanical and thermal energy is designed to treat the major factors of cellulite and skin laxity on top of that. It may help eliminate any irregularities due to skin aging as well as correct visible sagging post liposuction treatments.

These innovative technologies are an excellent alternative to liposuction, or they can be used in some specific cases as a complementary solution to profound the results. They can help in strengthening muscles, improving core muscles, enhancing the overall esthetics of the patients by skin improvements in addition to fat reduction. HIFEM, RF, and TPE have proven effective in a standalone regime or when used as combination treatments. Particularly, the combination treatments usually show to be highly effective for many individuals. Generally, the pre-treatment assessment often determines that the cosmetic concerns are of multifactorial origin. Therefore, combining multiple modalities that targets multiple tissues or causes can provide the best possible results. While HIFEM alone focuses on the deep tissues, inducing predominantly changes in the muscles, monopolar RF and TPE focuses on improving the condition of superficial layers, including dermal microcirculation, improved quality, tone of the skin, and laxity reduction. This

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

type of therapy is ideal for addressing the concerns of the patients regarding body contouring. When combined, it is recommended to use Emsculpt first to restore the musculature and body contour before using Emtone to address skin concerns. However, in cases where extensive fat tissue changes are required, the subjects may benefit more from simultaneous HIFEM+RF therapy, which eliminates excessive fat tissue alongside muscle toning.

There are definitely some specifics that come with non-invasive treatments. As mentioned above, physicians should carefully choose the most suitable procedure (for instance, see presented cases in Section 3). The subject's lifestyle may also help determine appropriate treatment and dosage since individuals with betterdeveloped musculature and active lifestyles tend to achieve high HIFEM intensities sooner. Typically, the treatments are done over the course of two to four weeks in four sessions, requiring 30-minutes per application. In general, achieved results may vary from subject to subject. Nonetheless, the improvement should be best recognizable from 1 to 3 months after the last treatment, maintaining the enhancement level at a minimum for 6 to 12 months depending on the subject's dietary and sport habits [23]. Based on the reported results from multiple investigations, we recommend to follow-up your patients 12 to 24 months after their last treatment, and in case that any significant decline in results occurs, identify the cause and consider the importance of the maintenance procedures.
