Minor Invasions

Minor Invasions 618 372 IEEE Pulse

Above: Alexis Hazen, Associate Professor of Plastic Surgery at New York University, conducts a hair transplant.
In a quickly produced YouTube video shot at the Z Center for Cosmetic Health outside Los Angeles, baby-faced plastic surgeon, Dr. Michael Zedah, stands over the nearly perfect body of an unidentified female patient. She lays on her belly, her buttocks bare. On the upper edges of her thighs, ovals drawn with a Sharpie marker indicate her “problem” areas. Carefully, Zedah and his assistant place a gooey, protective sheet of gel over the ovals, massaging out the air bubbles between the gel and the skin, before aligning a toaster-sized machine on top the marked area.
The unidentified woman is undergoing a procedure called Coolsculpting®, a cosmetic procedure that destroys fat cells through temporary exposure to freezing temperatures. Over the course of an hour, the machine suctions fatty tissue into a small compartment that freezes the area, killing the fat cells underlying the skin. The technique, which was developed by scientists at the Massachusetts General Hospital, is today FDA-approved, and widely accepted for small amounts of fat removal. It is one among many so-called non-invasive procedures that have emerged on the scene in recent years.
Videos like these, of white-toothed plastic surgeons touting their latest and greatest cosmetic technologies, pepper the Internet these days. And people are paying attention. Despite the low production value, this short video managed to get more than 13,000 hits in a year. Another video, set in the notoriously upscale neighborhood of Beverly Hills, California, has been viewed nearly half a million times.
Such procedures are symptomatic of the plastic surgery field’s own facelift. Over the past 18 years, this business of becoming beautiful, while viewed skeptically by some, has seen tremendous technological advances in less invasive surgery. Biotech companies are riding the wave, touting a smorgasbord of skin-tightening, fat melting, hair-replacing technologies capable of producing a new you over your lunch break.
“Patients are excited they can get significant results without having to go to the operating room,” said Dr. Elizabeth Lee, a San Francisco-based plastic surgeon. This, in turn, has emboldened an increasing number of patients to come through her doors. And Lee isn’t alone. Last year, the American Society for Aesthetic Plastic Surgery (ASPS) reported more than 10 million cosmetic procedures, both surgical and otherwise, were performed in the United States—a 274% increase since 1997. For these procedures, Americans spent a whopping $12 billion dollars.


As the demand for leave-no-trace procedures is on the rise, a rising number of new technologies have emerged that have increasingly enabled Americans to bypass the knife altogether. Rox Anderson, a dermatologist, researcher, and perpetually curious scientist from the Massachusetts General Hospital, has played a role in the advance of non-invasive cosmetic technologies. His research resulted in a suite of technologies, like Coolsculpting©, that utilize cold to kill fat—a procedure called cryolipolysis. Anderson was first inspired to freeze away fat back in 2007, by a rare syndrome called Popsicle Panniculitis, in which infants exposed to very cold temperatures at birth experience inflammation of fat, and the subsequent loss of it. This happens because lipids, which crystalize at higher temperatures than water, freeze while water does not, irritating and eventually killing the fat cells they inhabit. Over the course of several weeks, the dead cells are processed by the body, and disposed of through the urine.
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From photothermolysis to cryoliploysis, this researcher and physician has helped shape new techniques in cosmetic surgery

Rox Anderson performs his Coolsculpting technique.
Rox Anderson performs his Coolsculpting technique.

The first time Edward Ross met Rox Anderson, he was stunned. It was 1994, and Ross, who was 34, and just beginning his medical fellowship in dermatology at the Massachusetts General Hospital, expected to meet an older man with gray hair and a beard—someone well worn by his years in the laboratory, perhaps with an attitude to match. But when he walked into Anderson’s office, he was greeted by a man just 10 years his senior, clean cut, energetic, and friendly. “He was sort of a regular guy,” said Ross, “with all the papers he has, I thought he’d be in his 70s.” Anderson, a researcher and physician at the Massachusetts General Hospital (MGH), is a dermatologist by trade, but a voracious scientist by nature. Perpetually driven by a suite of simultaneous interests, his body of work and prolificity is staggering. In his 38 years as a researcher, he has co-authored over 250 scientific books and papers, and has been awarded more than 60 national and international patents. His work has spanned the fields of biology, physics, chemistry, engineering, and medicine, and he has made significant contributions to all of them.  

Rox Anderson.
Rox Anderson.

Anderson is largely known for his work with lasers. That started while working as a physicist in the photomedicine laboratories at MGH in the late 1970s, but persisted through his medical training at Harvard Medical School and MGH. As a dermatologist, he was particularly struck by children with debilitating facial birthmarks caused by a high concentration of blood vessels. Known descriptively as “port wine stains,” they resemble splashes of dark red wine on the skin. At this time in the early 1980s, lasers were beginning to be used for laproscopic surgeries, and the technology was gradually improving. Anderson knew it was possible to restrict bloodflow to the vessels that caused the birthmarks by damaging them with a laser. The trouble was, it couldn’t be done without also damaging the skin.
“If you want to remodel your house, you don’t come at it with a wrecking ball,” he said. Likewise, in cosmetic surgery, “you come in with little damages the skin can remodel. You do little fix-up jobs.” A new kind of laser was needed for this kind of work—one that damaged the vessels, but bypassed the skin. Thus, Anderson and his colleague, John Parrish, conceived of selective photothermolysis, a theory that particular wavelengths of light could target specific tissues, like blood vessels. This led to the development of pulsing lasers, which by emitting short bursts of light, did just that. It was a major milestone in cutaneous laser treatment, one that has become the foundation of the development of multiple new technologies and treatments in dermatology and beyond.
Anderson himself has adapted the idea to treat microvascular and pigmented lesions, remove tattoos, as well hair removal, which is today one of the most popular uses of lasers in medicine. “Most people are very strong clinically, or they’re very strong in the basic sciences, and the translational part is lost,” said Ross, who is now a dermatologist at the Scripps Research Institute in San Diego, California. “Rox is equally as adept in a clinic and in a lab—it’s his mastery of science that allows him to really look at a situation and take all those pieces of the puzzle and put them together, usually in ten seconds,” he said.
Anderson’s development of cryoliploysis, the non-invasive technique utilized in Coolsculpting technology (see the article “Minor Invasions” for more information), involved a somewhat unintentional detour from lasers. The problem was cosmetic fat removal, and Anderson was troubled that there was no alternative to liposuction, which can sometimes result in complications from anesthesia or a misplaced cannula. He thought there might be a non-invasive solution using laser surgery, provided he could get his hands on the right laser for the job—one that could target fat while bypassing the dermal layer. After seven painstaking years of persistent research at MGH using a non-medical laser designed by the Navy, he finally got it to work, but it was, “frightfully expensive, exceedingly painful,” he said, and only managed to remove a small amount of fat. It didn’t really solve the problem.
That’s when he remembered Popsicle Panniculitis, the rare occurrence where a newborn is exposed to extreme cold, and experiences inflammation of and subsequent fat loss. “Pay attention to mother nature—she’s done most of the good experiments,” he said. Anderson hypothesized that exposing targeted areas of the body to these temperatures in a controlled manner might result in fat loss. When he tested his theory, he turned out to be right. This was the foundational work that later became Coolsculpting.
“Rox has accomplished a great deal,” said Stuart Nelson, a colleague of Anderson’s and Professor of Surgery and Biomedical Engineering at the University of California, Irvine. “He has a strong desire to achieve, but it is tempered with a curiosity that frequently leads him to new insights that others never would have explored,” he said.
Today, Anderson continues his pioneering work. He recently found a way to treat acne by shooting a gold-coated glass nanoparticle bead into a patient’s oil gland, which he destroys by blasting the particle with a laser. This eliminates the gland, as well as the potential for an acne breakout. He believes this could have numerous applications beyond acne. Switch out the gold-coated nanoparticle for laser-activated medication, genes, or even whole cells like stem cells, and there is “an entrée of things that could be done with a whole set of microsurgeries and lasers and so on,” he said, “a whole world there to be explored.”
These are the kinds of visions that make him so valuable to his field. According to Nelson, Anderson, “represents a prototype of the successful researcher of the 21st century in that he combines a multitude of skills and collaborations to solve meaningful problems.” His style of connecting the dots creatively, and deep understanding of science, said Ross, is something that needs to be passed on to future generations of scientists—and Anderson knows it. “He’s helped a lot of people like me try to be like him in small ways,” said Ross, “he’s done that for the whole field of dermatology.”
“Ten years ago if you had told me that we could remove half a liter of fat in a single treatment that lasted an hour and was painless, and had no drugs, radiation, or surgery, I would have told you that you were nuts!” he said, but it works. In fact, it’s quite effective. Around 85% of all people show visible results after one treatment. Hitting the market about five years ago, what became Coolsculpting© technology was one of the very first completely non-invasive procedures to hit the market, and has since become one of the most popular of its kind.
Utilizing an assortment of devices ranging from lasers to ultrasound transducers, clinicians and engineers are continuously creating and improving what’s available. Like cryolipolysis, the treatments tend to be relatively painless, and aside from tolerating a little redness, and perhaps some soreness, there is virtually no recovery time. Alexis Hazen, Associate Professor of Plastic Surgery at New York University, doesn’t think Coolsculpting©, which can only be used on smaller areas at one time, is quite effective enough, so she prefers a newer non-invasive technology called Vanquish, which targets fat cells using radiofrequencies emitted by a large panel that fits over the entire abdomen.
“Coolsculpting® works,” she said, “but if the idea is that you want to pay for something that gets results within your lunch hour, Vanquish is the way to go.” Unlike cryolipolsus, fat cells are killed by heat, but then similarly processed by the body, and excreted through the urine. “As is the case with liposuction,” said Hazen, “when you remove the fat, it’s gone, so if you gain weight, you’re not going to gain weight in those spots again.” Her patients also seem to prefer the treatment to Coolsculpting®, which some think can be uncomfortable. Vanquish, she said, is warm and soothing.
Non-invasive procedures are great not only for the kind of patient that has little time to spare, but also those that are not candidates for surgery because they are too old or unhealthy to safely go under anesthesia, or simply don’t want to have surgery.
And that goes for all sorts of procedures, not just fat reduction. Broadband light treatment, another of Anderson’s major research interests, utilizes pulsing light to treat a variety of skin conditions, including acne, scarring, and sun damage. The pulsing light stimulates collagen production, which renews and firms the skin, without causing the oozing and burning a chemical peel does. It is also commonly used for permanent hair removal, and actually takes less time than electrolysis, and requires fewer treatments.

Ashish Bhatia, dermatologist and Associate Professor of Dermatology at the Northwestern Feinberg School of Medicine.
Ashish Bhatia, dermatologist and Associate Professor of Dermatology at the Northwestern Feinberg School of Medicine.

Ashish Bhatia, a dermatologist and Associate Professor of Dermatology at the Northwestern Feinberg School of Medicine, attributes the rise in the numbers and quality of these procedures to the rise in biomedical engineers, and the meaningful collaborations between them and clinicians like himself. Bhatia has been heavily involved in the development of an assortment of new biomedical technologies, and recognizes that bringing engineers into the picture has made technology less of a limiting factor in turning good medical treatment ideas into reality. “There’s a lot of ground-level innovation,” he said of smaller tech companies, who are building simpler, cheaper devices. These are making new advances available and affordable not only to a larger patient market, but a larger market of smaller-time physicians who previously couldn’t afford new large, expensive technologies in their offices. This, he believes, is going to tremendously expand the market for aesthetic technology. “It’s an incredibly exciting time to be in this field,” he said.

Small Invasions

The major technology for these non-invasive procedures, however, is still largely out of reach for many physicians. Thus, surgical and minimally invasive procedures are still the major players, but they too have undergone their own evolution. In the early 1990s, “We would make incisions for a brow lift that went over the forehead from ear to ear, then we would peel down the forehead and lift everything up,” said Dr. Elizabeth Lee, a San Francisco-based plastic surgeon, recalling her residency. But today, with new endoscopic methods, these kinds of large-scale invasions are no longer necessary. Tiny incisions not only minimize scarring, they leave the patient less vulnerable to infection, and more surgical precision leaves the body with a smaller area to heal. Whereas older techniques might put the patient out of commission for one to two months or more, today they can now return to work in one to two weeks.
Most patients, however, still prefer the alternative, which foregoes the knife entirely. “The last 10-15 years were really dominated by two things,” said Bhatia, “fillers and (botulinum) toxins.” The ASPS reported injections of botulinum toxin, like Botox®, to be the #1 non-surgical technique since 2000. Revance Therapeutics is currently in Phase 2 clinical trials for a topical botulinum toxin that’s expected to hit the market in the latter half of this year.
Dermal fillers, however, which are used to plump up tissues and tighten skin, are where the real innovations are happening. Fillers vary in chemistry, longevity, and softness. One procedure that is becoming increasingly common repurposes fat removed by liposuction or breast reduction into more desirable areas. “The nice thing about fat is that it’s your own, and it lasts forever,” said Hazen. “Most of the other substances dissolve over time,” she said. The trouble is, the results can be a little less predictable and more expensive than synthetic treatments. Most synthetic fillers only last a year, but there have been recent improvements. A relatively new arrival to the scene, which was FDA-approved in October of 2013, Juvéderm Voluma®, is a filler used primarily for plumping up the cheeks, and lasts a maximum of two years.
Most recently, injectables are taking on a new character—rather than plump up, one new product takes away. Kybella, which was FDA-approved at the end of April 2015, is a synthetic drug that mimics deoxycholic acid, the substance in our bile that breaks down fat. When injected in fatty areas, it does much the same, breaking down fat cells, which are then processed out of the body. Currently, it’s being used to reduce double chins, and usually takes about two to three treatments before patients see substantial results. Prior to its release, only liposuction and platysmaplasty, a procedure that either removes or tightens neck muscles, were the available treatments. “It’s a brilliant idea,” said Bhatia, “and this is also something we can now offer people that are not surgical candidates.” Of course, there are downsides. The drug can cause nerve damage, which might make for an uneven smile, or worse, difficulty swallowing, but the risks are still fewer than surgery.

Minimal Results

Despite the enthusiasm for minimally and non-invasive treatment options, most, if not all, are either temporary or themselves minimal. “There is a lot of technology out there, not all of it is as useful as we would like it to be,” said Lee. Managing the patients’ expectations is imperative with these technologies, she said. In fact, some physicians avoid these techniques altogether, including Jason Roostaeian, a plastic surgeon and Assistant Clinical Professor at the University of California in Los Angeles, isn’t convinced the non-invasive procedures are worth the effort.
“I’m in an academic setting, and for a lot of these technologies, there’s an element of marketing and a lot of them are revenue generators,” he said. “People love these mini-facelifts, but you get a mini result. Any minimally invasive procedure gets a minimum result.” The minimally invasive procedures that he does condone, he views as a mere stopgap to buy patients time before a larger procedure, like a facelift or liposuction. Even cryolipolysis, which many physicians, like Taylor, are beginning to embrace, only works well for a certain kind of patient—one with youthful, elastic skin, and small problem areas. “This is mainly for people who are in shape and have stubborn areas,” said Taylor, and, according to Roostaeian, “that’s pretty rare in our practice, to be honest.”

Jason Roostaeian, a plastic surgeon and Assistant Clinical Professor at the University of California in Los Angeles, isn’t convinced the non-invasive procedures are worth the effort.
Jason Roostaeian, a plastic surgeon and Assistant Clinical Professor at the University of California in Los Angeles, isn’t convinced the non-invasive procedures are worth the effort.

Furthermore, multiple treatments are required for the patient to see desirable results, and while they’re often less expensive than surgery—averaging $1,208 for Coolsculpting® as opposed to $3,099 for liposuction—the results are more subtle. If, however, you add in the amount of time off work, argues Lee, “then having surgery is always more expensive because something like Coolsculpting® has much less downtime.” After a non-invasive treatment, she said, you can basically go about your normal day after treatment, which certainly isn’t the case for any invasive procedure.
Ultimately, minimally and non-invasive procedures are not yet replacements for surgery, at least for the moment, but they can add finishing touches. “There was a time when we didn’t have any of this, and all you did was surgery—all we did was pull on the skin, and that’s as good as it gets,” said Taylor. “Now we have these treatments complementary to each other, and each part is a separate piece of the puzzle. It all comes together to make a better picture.” After the swelling goes down following liposuction, for instance, there might be some remaining fatty areas. Coolsculpting® can be used to smooth out those areas, said Taylor. After a facelift or necklift, a Venus treatment might be used for those final skin-smoothing finishing touches. “It’s a nice way to continue moving patients towards their goal,” said Taylor, “towards the best they can be.”
And it’s just getting better. “What I love about being in research is I get to see what will be out in five years,” said Bhatia, “because of technological advances and engineering, there are going to be so many more procedures available to people with much less risk.”

For Additional Information

  1. 2014 Cosmetic Surgery National Data Bank STATISTICS. Rep. New York: American Society for Aesthetic Plastic Surgery, 2014. Print.
  2. “Injectable Dermal Fillers Guide | American Board of Cosmetic Surgery.”Injectable Fillers Guide. The American Board of Cosmetic Surgery, 2015. Web. 26 June 2015.
  3. “THE SCIENCE BEHIND THE COOLSCULPTING PROCEDURE.” How Does the CoolSculpting Procedure (Cryolipolysis®) Work?ZELTIQ Aesthetics, Inc., 2015. Web. 26 June 2015.