Body contouring procedures have two components: adjustment of tissue volume and the fitting of overlying skin to that adjusted volume. Liposuction allows us to control tissue volume and thus anatomic shape with minimal scar burden.
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Body contouring procedures have two components: adjustment of tissue volume and the fitting of overlying skin to that adjusted volume. Liposuction allows us to control tissue volume and thus anatomic shape with minimal scar burden.
In patients with reduced skin elasticity from age, pregnancy or other factors, the most dramatic volume change might be completely obscured by loose skin. In these cases, skin excision becomes necessary to achieve desirable results. The great trade-off in these cases; however, has always been removal of skin excess in exchange for scars.
Energy-based devices have revolutionized this conversation by causing skin and soft tissue contraction with energy in the form of heat. In addition, energy-based devices have extended our body contouring capabilities by allowing for the noninvasive destruction of fat as well as induction of muscle growth. The advent of energy-based devices is particularly relevant to male body contouring, as plastic for men is subject to a relatively greater taboo. The ability to achieve excellent results with minimal or no scars and downtime is making these procedures more approachable for males.
Energy Modalities
The wide range of available energy-based devices can be separated into minimally invasive modalities (which tend to have more significant effects) and noninvasive modalities (whose results tend to be less profound).
Minimally invasive devices are the basis of energy-based surgery. Minimally invasive energy-based body contouring devices are passed through the same ports used for liposuction, so no additional scarring is necessary. We use two forms of minimally invasive energy-based devices in our practice.
Minimally Invasive
The first minimally invasive modality is a bipolar radiofrequency energy device, BodyTite, which targets superficial connective tissues and dermis. This treatment is designed to “shrink wrap” the skin envelope to achieve a contour similar to liposuction.
The second device, VASER, uses ultrasound energy to tighten deeper tissues, potentiating the volumetric changes achieved with liposuction. VASER offers some skin tightening benefits as well.
Bipolar RF. Minimally invasive energy-based devices like BodyTite allow us to achieve skin contraction in patients that either cannot or do not want to undergo skin excision procedures. Radiofrequency energy generates heat, and that energy causes soft tissue.
Radiofrequency energy can be delivered for the purpose of soft tissue tightening in several forms (monopolar, bipolar and multipolar). Of the various radiofrequency devices available, we have seen the best balance of high-quality results and an excellent safety profile with bipolar radiofrequency energy (BodyTite). BodyTite has one pole that is inserted into the subdermal tissue and another pole that follows along outside the skin, effectively “sandwiching” the target tissue between the two poles. Each of the poles senses temperature in real time, allowing for very precise control of tissue temperature.
Ultrasound. Vibration amplification of sound energy at resonance (VASER) uses a thin titanium rod to transmit ultrasound energy to the treatment area. We find the ultrasound energy emitted from the VASER probe is clinically useful for two primary reasons. First, the rapid vibration of the device essentially knocks fat cells free from surrounding connective tissue, allowing for more effective treatment of dense fat pockets frequently found in males. This has the added benefit of making the following fat suction step less traumatic with less bleeding and bruising. Second, the ultrasound energy of VASER heats deeper connective tissue, causing tissue construction and soft tissue tightening.
Noninvasive Modalities
Noninvasive body contouring has been wildly popular since its introduction. The promise of improved body shape and muscle definition without surgery or downtime is alluring. While many noninvasive body contouring devices our available, we have seen the most success with Emsculpt Neo, which combines high intensity focused electromagnetic energy (HIFEM) to force involuntary muscle contractions with radiofrequency energy to reduce fatty volume and tighten skin. Interestingly, HIFEM can actually decrease visceral fat volume, a feat never before possible with any invasive or noninvasive modality.
Emsculpt Neo is FDA cleared for use on multiple body areas. The abdomen and buttocks are the most common treatment sites. Of note, the treatment program for the buttocks is designed for muscle growth with minimized fat loss, as the intention in this area is to achieve a lift and volume increase.
We use Emsculpt Neo both as a standalone treatment and in combination with minimally invasive body contouring procedures. When used alone, we find the device will offer pleasing results to properly selected patients that are educated to have reasonable expectations. It must be made very clear to patients that this treatment is not a substitute for liposuction or other surgery, but real improvements can be expected. We describe predicted results as getting patients “to the next level” of body contour. For example, someone with significant abdominal adiposity can expect to see a reduction, but they certainly will not have a flat abdomen with muscle definition. Alternatively, someone with minimal abdominal adiposity but without muscle definition can expect to have some definition after treatment. Finally, someone with early muscle definition will likely see that definition significantly increased after treatment.
Emsculpt Neo can also be used to enhance the results of minimally invasive body contouring procedures. In these instances, we like to wait at least two weeks after the initial procedure to begin treatment with Emsculpt Neo to allow for initial healing and to permit the return of some protective sensation to the region. One rare risk of Emsculpt Neo is thermal injury, and reduced sensation can increase this risk.
Countouring Areas For Men
With this view of available energy-based treatments in mind, we can explore applications in male body contouring by anatomic area.
Torso. The abdomen and waist are the two areas men are most interested in contouring in our practice. While some may be interested in contouring one of these areas and not the other, it is almost always beneficial to treat both areas together to achieve ideal proportions. In contouring the male torso, we are aiming to highlight naturally existing landmarks from the front (e.g. semilunar lines) and a V-shape is achieved from the posterior perspective. We find that VASER is very useful in achieving deep tissue contraction in men with significant superficial abdominal adiposity. It also facilitates suction assisted lipectomy in the fibrous tissue of the back and posterior waist. VASER can be used more superficially in the context of high-definition liposuction (e.g. abdominal edging). Ultrasound energy has also been used to enhance abdominoplasty results by allowing for less traumatic abdominoplasty flap liposuction.
BodyTite is useful for superficial soft tissue tightening in the abdomen of men who may be on the verge of requiring an abdominoplasty to achieve an aesthetically pleasing result. Especially when combined with VASER, sufficient soft tissue and skin tightening can often, in our experience, be achieved in these borderline cases to achieve satisfactory cosmesis without the scars of formal abdominoplasty. It is critical in these cases to discuss expectations with the patient to educate him that he will not achieve abdominoplasty-like results with this procedure, but dramatic improvement may be possible. It is advisable to also walk these patients through the abdominoplasty process and assess their willingness to consider it as a lifeboat option should a disagreeable amount of skin excess remain after their procedure.
Chest. In considering an appropriate treatment plan for chest contouring and gynecomastia, one must first decide whether enough glandular tissue is present in addition to excess fat to warrant direct excision along with a suction-based strategy. We will almost never perform skin excision as part of the primary operation as all but the most severe cases will eventually demonstrate sufficient skin contraction to avoid the stigmata of excision. BodyTite can be incorporated into our primary procedure in cases for which skin excess is a significant concern. We generally employ VASER in all gynecomastia cases for three reasons. First, the adipose tissue of the male breast is quite fibrous, and the incorporation of VASER can consistently enhance the efficacy and decrease the trauma of suction assisted lipectomy in this context. Second, the ultrasound energy contributes to enhanced contraction of the soft tissue envelope and therefore overall cosmetic result. Third, while we do not find that VASER can be relied upon to sufficiently fragment glandular tissue to a degree that precludes the need for resection, it is possible that in cases on the border of requiring glandular excision, VASER disrupts the stromal tissue sufficiently to obviate this step. In cases with significant glandular tissue, this can be excised per the surgeon’s preferred protocol after adipose reduction with VASER-assisted liposuction.
Arm. VASER and BodyTite are both useful in minimally invasive arm contouring. We find that VASER is beneficial in virtually all male arm liposuction cases, as it helps us effectively address firm male fat with reduced trauma, bleeding and bruising. In cases of mild to moderate skin laxity, BodyTite is a useful adjunct to address cutaneous excess. In more severe cases, particularly those presenting with skin laxity after massive weight loss, successful treatment may require formal Brachioplasty. Liposuction is a well-recognized adjunct to Brachioplasty as it can enhance aesthetic outcomes and reduce the need for undermining and subsequent wound healing problems. VASER can potentiate these effects by tightening skin and soft tissue while reducing the trauma with which the liposuction is performed.
The role of energy-based devices in thigh contouring is analogous to that in arm procedures. VASER is helpful in addressing stubborn fatty deposits in nearly all men, and BodyTite can be added to address mild to moderate skin laxity. More severe loose skin requires an invasive approach, which can be enhanced with VASER. In cases of borderline severity, the combined use of VASER for deep tissue laxity and BodyTite for sagging skin may obviate the need for thigh lift altogether.
Post-Contouring
We strongly encourage all minimally invasive body contouring patients to undergo a series of Emsculpt Neo treatments after their surgery. We find that in addition to the benefits described earlier, the process accelerates the resolution of edema and the manifestation of contour improvement.
An Exploding Market
The popularity of male body contouring procedures is exploding. Noninvasive options offer the possibility of improved contour to those who may never have considered even a minimally invasive operation. The thoughtful application of energy-based devices can enhance the results and extend the indications of classic minimally invasive procedures. In addition, these devices may obviate the need for more invasive approaches by contracting skin and deeper soft tissues. Male body contouring can be taken to the next level with energy-based modalities in properly selected patients.
Darren Smith, M.D., FACS is a board certified plastic surgeon practicing in New York City. He is a known expert in aesthetic surgery and cosmetic injectable treatments.
