Introduction to non-surgical body contouring treatments
Many people are concerned with their aesthetic appearance and strive to achieve their ideal body. Thanks to technological advancements and in-depth scientific research, there are many aesthetic procedures available that can help people get rid of stubborn fat and achieve their perfect body. In the past, aesthetic procedure to sculpt the body was almost synonymous with surgical procedures like traditional liposuction or excisional body contouring. Though these surgical methods are highly effective, they are invasive and require significant downtime. Currently, there are alternative treatment approaches that can even rival the tried-and-tested surgical methods at a fraction of the time, budget, and, morbidity of these surgical procedures.
Who are the patients seeking body contouring?
Patients with body contour concerns can be classified into two major categories that share some similar features between them. The first group of patients are those who have a general understanding about the various treatment methods available and a clear idea of their ideal body shape. They may have also tried some treatment modalities before and have some realistic expectations from body contouring treatment. On the other hand, the second group of patient are less well-informed and as a result, have impractical expectations of what can be achieved via non-invasive or minimally-invasive procedures. Physicians may find it frustrating to manage the latter group of patients due to their tendency to stop treatment course prematurely.
What are the common areas of concern?
Most patients choose to undergo aesthetic procedure when they fail to achieve their ideal body shape via lifestyle changes. They may also seek cosmetic treatment to rectify the appearance of cellulite, excess fat, or pockets of stubborn fat that cannot be managed with diet and exercise alone. These patients usually visit aesthetic clinics with the thighs, lower back, and/or abdomen as common areas of concern However, some patients with underlying Body Dysmorphic Disorder (BDD) may also seek aesthetic treatment; therefore, patients must be carefully assessed before they are deemed suitable to undergo cosmetic treatments. 
How are the patients assessed prior to undergoing body contouring treatment?
Physicians should regard the minimally-invasive body contouring treatments as a medical procedure and perform all the necessary pre-procedural assessments. A patient’s medical history, which includes their dietary and lifestyle information, must be reviewed. Any lifestyle factors that contribute to their aesthetic issues must be identified and addressed by trained healthcare professionals. The pre-procedural consultation session is also reserved for having a discussion with the patients regarding their reasons for seeking these treatments and the treatment goals themselves. Patients who do have impractical treatment expectations must be made to understand the potential outcomes of non-surgical approaches so that they are not disappointed in the future. Physicians must also clearly state and emphasize the need for repeated treatments so that the desirable aesthetic results are achieved in a timely manner and maintained for a prolonged period of time. As part of the pre-procedural session, physicians should document their patient’s initial body shape via pre-treatment photography and volume measurement. This will enable both physician and patient to determine the success rate of the non-surgical procedure by comparing before and after photographs. This pre-treatment stage is also vital for ruling out patients with BDD. A validated screening questionnaire, such as the Body Dysmorphia Disorder Questionnaire (BDDQ), has an accuracy of 94% at detecting patients with BDD. 
What are the usual methods of body contouring?
The last two decades have seen an immense progression in the types and quality of non-invasive or minimally-invasive body contouring. Though they can be differentiated based on the technology used, many of the treatments make use of thermal injury to selectively induce apoptosis, which is essentially programmed cell death, in adipocytes. That being said, there are also other body contouring methods available that do not cause the same side effects as heating or cooling adipocytes for a prolonged period of time. A detailed list of commonly used non-surgical body contouring treatments include the following:
- Radiofrequency: Over the past 75 years, radiofrequency (RF) has been used extensively to deliver energy to tissues for numerous purposes.  Its mechanism of action is converting radiofrequency waves to heat energy, resulting in skin and deep tissue heating. The heat energy will then lead to vasodilation and inflammation that will be followed by the stimulation of dermal thickening, deeper connective tissue thickening, and the reorganization of cells . Following continuous heating at a temperature of about 43°C to 45°C, the fat cells will undergo selective apoptosis without affecting the neighboring cells. The fat cells will then reduce in volume three to eight weeks after the initial RF treatment. [5 Patients who choose this method need to undergo multiple treatment sessions for the best outcomes. Nowadays, RF treatments are considered to be generally safe, as modern devices are fitted with in-built temperature sensors to prevent overheating of the skin surface. Despite this safety feature, patients may still experience undesirable side effects, such as burns, especially when they are treated using operator-dependent devices. Additionally, older monopolar RF devices may result in uneven depths of RF penetration and subsequent uneven fat breakdown and surface contour abnormalities.  Hence, it is best that physicians use bipolar or multipolar handheld RF devices, as they deliver an even penetration of RF waves that will result in uniform fat breakdown and surface contours that are better than those delivered by monopolar devices . Other post-treatment side effects include transient redness.
- High Intensity Focused Ultrasound: This relatively new method has been used in the field of aesthetic medicine to effectively tighten and lift the superficial muscular aponeurotic system (SMAS) layer of the face. As the name suggests, High Intensity Focused Ultrasound (HIFU) makes use of focused ultrasound to induce coagulative necrosis (tissue death) in the subcutaneous layer. This will then lead to volume reduction and tightening, which will become observable around 12 weeks after the initial treatment session.  This treatment approach requires repeated sessions to deliver ideal results. It can be used to treat all skin types successfully with minimal side effects.
- Low Level Laser Therapy: Infrared light has been known to induce changes in the metabolism of adipocytes and in the expression of leptin, an appetite-regulating hormone. The effects of infrared light on body composition have been used to develop Low Level Laser Therapy (LLLT). A review by Dr. Sarah Tonks explained the use of LLLT in non-surgical body contouring treatment and in other areas of medicine . As of now, the Food and Drug Administration (FDA) had approved the use of some devices with wavelengths of light between 532nm and 635nm for contouring the body. These devices also require multiple treatment sessions for optimal outcomes. Patients get to enjoy effective body sculpting effects with very little, if any, secondary reactions.
- Cryolipolysis: This procedure, known as fat freezing, involves exposing the adipocytes to low temperatures. This treatment method is based on the principle that fat cells are triggered to undergo apoptosis and inflammation via phagocytic action once they are subjected to low temperatures. Once they are removed and the inflammation has abated, there is a volume reduction and the reorganization of the subcutaneous layer.  Nowadays, fat-freezing devices are also integrated with skin surface protecting action as well as a vacuum mechanism. Just like the treatment methods explained above, cryolipolysis requires recurrent treatment sessions for optimal effects, with optimal results only visible four to six months after the first session. [9, 10] This treatment is safe and generally suits patients of all skin types. That being said, patients may still experience pain, which is a common aftereffect of cryolipolysis. This side effect should resolve with time, and pain relievers can be prescribed if necessary. Additionally, patients can also develop rare side effects, like redness, bruising, and paresthesia.
- Deoxycholic acid: Deoxycholic acid is a chemical compound that acts as a lytic agent. It was first approved for removing excessive submental fat (fat below the chin, or a double chin) by the European Commission (CE) in 2012 . Once it is injected into fatty areas, it disrupts the cell membranes of adipocytes, resulting in a mild inflammatory response. Subsequently, the cellular debris is removed by the actions of phagocytes, and unwanted volume is reduced in the injected areas.  In-depth clinical studies found that deoxycholic acid only targets lipid-rich tissues without damaging neighboring tissues. Additionally, the administering of deoxycholic acid does not seem to increase the plasma lipid level.  A phase III randomized control trial done in Europe using a deoxycholic acid preparation (ATX-101) demonstrated effective reduction of submental fat without an increase in skin laxity. Test subjects also experienced minimal localized side effects, such as pain, swelling, and redness.  Deoxycholic acid injections also require multiple treatment sessions that should be spaced weeks apart for optimal outcomes.
Non-surgical body contouring treatments are rapidly evolving, with many new technologies and devices introduced into the aesthetic medicine industry. These treatments, though effective, can be difficult, especially when it comes to choosing the suitable patients to undergo the procedure. This is because many non-invasive treatment modalities require more than one session to deliver the best outcomes to patients. Hence, patients’ expectations must be ascertained prior to the treatment. Physicians who are interested in providing these aesthetic treatments at their clinics must consider a factors like expertise, patient demographic, cost, staffing level, and availability of space before they offer the procedure.
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