By: Darren Smith, MD, FACS
Body contouring consists of two components: adjustment of tissue volume and fitting the overlying skin to that adjusted volume. Tissue volume is controlled with liposuction at the cost of minimal scar burden. But the most dramatic volume change might be completely obscured by loose skin.
Historically, loose skin was treated exclusively by excision. The great trade-off in these cases, however, has always been the creation of 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 ability to achieve excellent results with minimal or no scars and downtime is making these procedures more approachable for males. And the advent of energy-based devices is particularly relevant to male body contouring, as plastic surgery for men is subject to a relatively greater taboo.
Moreover, 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 Body-Contouring Methods
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. The first is BodyTite, a bipolar radiofrequency device designed to “shrink wrap” the skin envelope to the contour achieved with liposuction. The second device, VASER, uses ultrasound energy to tighten deeper tissues. VASER offers some skin-tightening benefits as well.
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 contraction. Of the various radiofrequency devices available (monopolar, bipolar, and multipolar), 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, “sandwiching” the target tissue. Precise temperature control is afforded by real-time temperature monitoring at each pole.
VASER, which stands for “vibration amplification of sound energy at resonance,” transmits ultrasound energy via a thin titanium rod. VASER’s ultrasound energy is useful for two reasons. First, the rapid vibration of the device employs cavitation to free fat cells from connective tissue, allowing for more effective treatment of the dense fat pockets that are frequently found in males. This has the added benefit of making the following fat suction step less traumatic. Second, VASER heats and thus tightens deeper connective tissue.
Noninvasive Body Contouring
In terms of noninvasive body contouring, of the many devices available, we have seen the most success with Emsculpt Neo. This device combines high-intensity focused electromagnetic energy, or HIFEM, to force muscle contractions with radiofrequency energy to reduce fat volume and tighten skin. HIFEM can also decrease visceral fat volume—a feat never before possible with any invasive or noninvasive treatment modality.
At my practice, we use Emsculpt Neo as a standalone treatment and in combination with minimally invasive body-contouring procedures. When used alone, the device will offer pleasing results to properly selected patients.
Patients must be educated that this treatment is not a substitute for liposuction or other surgeries, but real improvements can be expected. Someone with significant abdominal adiposity, for example, can expect fat reduction, but they will not have a flat abdomen with muscle definition. Someone with minimal abdominal adiposity can expect to have some definition after treatment, however.
Emsculpt Neo is also useful in enhancing results of minimally invasive body-contouring procedures. We like to wait at least one week 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. Thermal injury is a rare risk of Emsculpt Neo, and reduced sensation can increase this risk.
Best Practices
The two areas men are most interested in contouring? The abdomen and waist. In contouring the male torso, we aim to highlight naturally existing landmarks from the front (e.g., semilunar lines) and achieve a “V-shape” from the posterior perspective. VASER is very useful in achieving deep-tissue contraction in men with significant superficial abdominal adiposity. It also frees fat from the fibrous tissue of the back and posterior waist. VASER is used more superficially in high-definition liposuction (e.g., abdominal edging).
BodyTite is useful for superficial soft-tissue tightening in the abdomen of men who may be on the verge of requiring an abdominoplasty. Especially when combined with VASER, sufficient soft-tissue and skin-tightening can often be achieved with BodyTite in these borderline cases without the scars of an abdominoplasty. It’s critical to discuss expectations with the patient and educate him that he will not achieve abdominoplasty-like results with this procedure, but dramatic improvement may be possible with a much less invasive approach.
Regarding 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 seldom perform skin excision as part of the primary operation since all but the most severe cases will eventually demonstrate sufficient skin contraction. We will often incorporate BodyTite into our primary procedure in cases for which skin excess is a concern.
We try to employ VASER in all gynecomastia cases for the following three reasons.
- VASER can consistently enhance the efficacy and decrease the trauma of suction-assisted lipectomy in the fibrous adipose tissue of the male breast.
- The ultrasound enhances soft-tissue contraction and, therefore, the overall cosmetic result.
- While VASER cannot be relied upon to sufficiently fragment glandular tissue to a degree that precludes the need for resection, in cases on the border of requiring glandular excision, VASER may disrupt the stromal tissue sufficiently to obviate this step. If indicated, glandular tissue can be excised per the surgeon’s preferred protocol after adipose reduction with VASER-assisted liposuction.
BodyTite and VASER are both useful in minimally invasive arm contouring. VASER is beneficial in virtually all male arm liposuction cases, as it addresses fibrous male fat with reduced trauma, bleeding, and bruising. BodyTite is a useful adjunct to address cutaneous excess in mild to moderate cases. In more severe cases, successful treatment usually requires formal brachioplasty. VASER can also be used to enhance liposuction’s well-recognized role as an adjunct to brachioplasty. Note: The role of energy-based devices in thigh contouring is equivalent to that in arm procedures.
We encourage all patients having a minimally invasive body contouring procedure to undergo a series of Emsculpt Neo treatments after their surgery. In addition to the benefits described earlier, this process accelerates the resolution of edema and the manifestation of contour improvement.
With the burgeoning popularity of male body contouring, noninvasive options offer the possibility of improved contour to those who may never have considered even a minimally invasive operation. We find that the thoughtful application of energy-based devices can enhance the results and extend the indications of classic minimally invasive procedures in male body contouring.
Additionally, in borderline cases, these devices may obviate the need for more invasive approaches by contracting skin and deeper soft tissues. To sum it up, energy-based treatments can take male body contouring treatments to the next level in properly selected patients.
Darren Smith, MD, FACS, is a New York City-based plastic surgeon providing cosmetic enhancements such as breast augmentation, liposuction, and tummy tucks. Follow him on Instagram at @NYCPlasticsDoc.
