Your body’s shape is influenced by two different types of fat: superficial fat (the fat found in the deeper layers of our skin) and visceral fat (fat that surrounds our internal body organs). Most us think of our fat as being superficial, just under the skin surface. Visceral fat is a deeper fat. An example is a beer belly, where the fat has accumulated deep within the abdominal cavity. There is a large belly, but there is little to no fat to pinch.
What is fat and where does it come from?
Fat is a form of lipid (chemicals that are insoluble in water) that our body uses to store energy. When we take in more energy (measured in calories) than we use (metabolize), our body stores this excess energy in the form of fat. The fat is then taken up by fat cells (adipocytes) that are found throughout the body. As fat cells take up fat they get bigger and bigger, much like balloons that are being inflated.
Fat cells are found throughout the body but we have genetic predispositions to where the fat is found and how much fat is taken up. In addition, as we age our metabolic rates change and with it comes a change in how much fat is stored. Typically, as we get older our lifestyles become less active, and if our intake of food doesn’t change, we begin to store excess calories as fat. At the same time, genetics and metabolism help to explain why there are many who still have disproportionate fat deposits (saddlebags, belly fat, etc) even with dieting and exercise. No two persons are identical and each of us responds in our own way.
Basic Approach to Fat Removal and Body Shaping
There are four basic approaches for dealing with excess fat: making less fat, mechanically removing fat cells, destroying (killing) the fat cells, and removing the fat molecules from within the fat cells. Let’s discuss each method.
Making less fat.
This is the diet and lifestyle approach. The idea is to reduce the amount of energy you take in (as calories) and increase the amount of energy you use. This is the starting place to any successful program for fat removal and body shaping. There are hundreds of diet programs and thousands of books written on the subject. We are constantly bombarded with diet and exercise messages. Yet, dieting is easier said than done. How does one decide what works and what does not? Unfortunately, it isn’t easy and there is plenty of hype and hucksterism. There is always someone selling another diet program.
The truth is that almost all diet programs will work if followed. How easy they are to follow and how well they work is where they differ. In addition, most diets require a commitment to making a change, which is often not easy. What is ultimately needed is not just a diet, but a change in how we eat and live. The best diet programs are only a bridge to making that change. Without understanding how to eat better and live better, no diet program can truly be successful.
Even good eating and exercise habits may not be enough. Genetically programmed areas of fat deposition, such as a saddelbag may not improve with diet and lifestyle efforts. It may be necessary to do other things, and this is where the other methods can be important. Getting a jumpstart on a positive change in habits is helpful with the other methods.
Removing fat cells.
Removing fat cells can be done by liposuction. A cannula is placed into the fat space and the fat is suctioned out. Over the years liposuction has been refined but the basic principle remains the same. Today we have laser liposuction, vibration-assisted liposuction, ultrasonic liposuction, and water-assisted liposuction. These are all variations of the basic principle. In some cases they actually provide a benefit to the patient, in other cases they make it easier for the surgeon to remove the fat.
Liposuction, when done under local anesthesia in a completely awake patient, is incredibly safe. There are serious complications that can occur, but they almost always relate to the use of general anesthesia, or the skill and expertise of the surgeon.
With liposuction, once the fat cells are removed they are gone forever. Liposuction can very effectively remove fat cells from a given area. In fact, in the hands of a less-than-skilled surgeon, too much fat can be removed. Proper liposuction requires leaving enough fat to provide the right amount to cushion the skin. Having no fat under the skin is a not a pleasing appearance.
In addition, the desired fat can all be removed in one session from a given area. It is surgery, and there will be a short recovery period, but for most people, the recovery period is quick and easy and the results are almost immediate. A disadvantage to liposuction is that because it requires the active participation of an experienced surgeon, the cost is more than other forms of fat removal. But for many, it is the best option. Whether it is right for you is something that can only be determined after consultation with an experienced physician who can evaluate your unique situation.
Destroying fat cells.
Fat cells can be destroyed (killed) in three ways, by heat, by cold, and by chemicals. If we increase the temperature of the fat layer to a high enough temperature for a long enough period of time, we start destroying the fat cells. Of course, we have to do this without hurting the skin, collagen, or adjacent tissue.
There have been a number of technologies that have been proposed to do just this. Lasers, of course, have been tried but it turns out that lasers need a target and there isnʼt a great target for lasers in fat. What is needed is bulk heating and what has been found to work the best is radio frequency (RF) energy. There are now a number of devices on the market that provide RF energy. Types of technology include monopolar, bipolar, unipolar, and tripolar. Thermage, Exilis, Apollo, and Accent are some of the names of various RF devices. All of these are just variations on how to deliver the RF energy and whether any of them is better than another is still unclear. Each of these RF technologies requires contact with the skin and skill on the part of the technician.
A newer RF technology has been developed which does not require contact with the skin or technical skill to properly deliver. It is called Vanquish and it works by setting up an RF field around the body. This creates energy flow through the fat layers and can create enough heat to kill fat cells. The device works by properly placing it around your body and then just turning it on. The RF field does the rest. Vanquish is a much more efficient and effective RF technology for destroying fat cells.
What is clear is that as long as we can provide enough energy to heat the fat cells for long enough period of time, we can kill the fat cells. If we do it properly, the skin is protected.
The advantage of RF energy is that it can be relatively painless. There may be some discomfort, but it can easily be managed. It also does not require the active participation of a physician, so it should be less expensive than liposuction. But there are also disadvantages. First, it will require multiple treatments, so the cost can add up over time. Second, it will take weeks to months for the final results to be apparent so it does not provide an instant gratification. Finally, there is a limit to the amount of fat that can be removed. Even in the best of situations, only between 20% to 40% of the fat can be removed. But for many that amount of fat removal can provide a pleasing improvement in their body shape.
In addition to killing cells by heating them, fat cells can be killed by freezing. This is the idea behind Coolsculpting by Zeltiq. It does work, but a session of Coolsculpting reduces the fat layer about the same as RF, for an average of between 20% to 25% reduction over time. Coolsculpting has some interesting limitations that may not make it the right choice for most people. Next weekʼs newsletter will look at Coolsculpting and the marketing behind it in much more detail.
A final way to destroy fat cells is by injecting the fat space with chemicals that will destroy the cells and reduce the fat. This is the idea behind such treatments as lipodissolve which was actively marketed for many years. It lost favor because it turns out to be difficult to accurately dissolve just the fat cells while sparing normal tissue. For some people, it didnʼt work at all and for others it worked much too well causing serious tissue damage.
Recently a new approach to chemical fat cell destruction was approved by the FDA. It is called Kybella. Rather than try to remove fat from large areas of the body using a chemical approach, the makers of Kybella realized that small focal areas of fat could be effectively targeted using this approach. Where Kybella really works is to target that small collection of fat cells that form just under the chin (submental area). When used properly by an experienced physician, Kybella can be an excellent solution.
Emptying fat from fat cells
Over the last ten years, it has become apparent that there are a number of chemical pathways in our body that are triggered by light. These reactions often respond to a particular wavelength of light energy at levels that are much lower than used in laser treatments. They have been given the name of low level light therapy (LLLT) or cold laser. There is one chemical pathway that is important for fat reduction. The right wavelength of light can open a pore in the fat cell. When the pore is opened, it allows the fat within the fat cell to leak out and like a balloon, the fat cell deflates. This happens not just for one cell but for many, many cells and with it comes a reduction in size and an improvement in shape.
Initially, there was a lot of resistance to the idea that fat would respond to this low energy light treatment. It seemed to be magic, but those who were researching this were able to show actual scientific proof of the effect. Plus the first practical device on the market, Zerona, showed that it does work. Today there are several devices on the market.
LLLT for fat removal does work and has some advantages. There are no risks. The level of light energy used is completely safe and completely painless. The effect does not require heat, or cold, and so there is no risk for any kind of injury. In addition, it does not require a physician, nor is it labor intensive, so it is generally much less expensive than other options. Finally, it seems to have an effect over the entire body, not just in the areas where the light has been shined. But there are some significant disadvantages. First, the pore requires time to open and remains open for only a short period. What this means is that you must undergo the procedure for almost an hour at a time and you must repeat it within 48 hours to have an effect. Second, it requires an extended amount of time for the fat cell to lose fat, therefore it takes many treatments (6 to 12). Even with low-cost treatments, the price can add up and the cost in time and effort can be substantial. Finally, the fat cells are not removed, damaged, or killed. This means that they will fill back up with fat. How quickly that occurs depends on your diet and lifestyle. In fact, if you are not careful with your diet during the treatments you may not see any benefit at the end of the program.
Summary (see table)
Fat removal and body shaping begins with diet and lifestyle choices. Unfortunately, there are no magic pills. But with a commitment to good habits, there are multiple options available to help with improving the way one looks. These technologies can actually make a real difference. Which one is right for you depends on your physical makeup, what you want to accomplish, and the choices you need to make. It is impossible to decide which is the right approach without a consultation. Beware of any marketing hype that touts one technology as the right answer. The most important decision you can make is to discuss these choices with someone who understands the advantages and disadvantages of each of them and will put your best interest first.