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Int J Endocrinol Metab. Inpress(Inpress):e36727.
Published online 2016 July 3.
doi: 10.5812/ijem.36727.
Review Article
Review of the Mechanisms and Effects of Noninvasive Body
Contouring Devices on Cellulite and Subcutaneous Fat
Zahra Alizadeh,1,2 Farzin Halabchi,1,2 Reza Mazaheri,1,2 Maryam Abolhasani,1,* and Mastaneh Tabesh1
1Sports Medicine Research Center, Neuroscience Institute, Tehran university of Medical Sciences, Tehran, IR Iran
2Department of Sports and Exercise Medicine, Tehran University of Medical Sciences, Tehran, IR Iran
*Corresponding author: Maryam Abolhasani, No. 7, Ale-ahmad HWY, P. O. Box: 14395578, Tehran,IR Iran. Tel: +98-21886302278, Fax: +98-2188003539, E-mail:
dr_m_abolhasani@yahoo.com
Received 2016 January 30; Revised 2016 June 08; Accepted 2016 June 26.
Abstract
Context: Today, different kinds of non-invasive body contouring modalities, including cryolipolysis, radiofrequency (RF), low-level
laser therapy (LLLT), and high-intensity focused ultrasound (HIFU) are available for reducing the volume of subcutaneous adipose
tissue or cellulite. Each procedure has distinct mechanisms for stimulating apoptosis or necrosis adipose tissue. In addition to
the mentioned techniques, some investigations are underway for analyzing the efficacy of other techniques such as whole body
vibration (WBV) and extracorporeal shockwave therapy (ESWT). In the present review the mechanisms, effects and side effects of the
mentioned methods have been discussed. The effect of these devices on cellulite or subcutaneous fat reduction has been assessed.
Evidence Acquisition: We searched pubmed, google scholar and the cochrane databases for systemic reviews, review articles, meta-
analysis and randomized clinical trials up to February 2015. The keywords were subcutaneous fat, cellulite, obesity, noninvasive body
contouring, cryolipolysis, RF, LLLT, HIFU, ESWT and WBV with full names and abbreviations.
Results: We included seven reviews and 66 original articles in the present narrative review. Most of them were applied on normal
weight or overweight participants (body mass index (BMI) < 30 kg/m2) in both genders with broad range of ages (18 to 50 years on
average). In the original articles, the numbers of included methods were: 10 HIFU, 13 RF, 22 cryolipolysis, 11 LLLT, 5 ESWT and 4 WBV
therapies. Six of the articles evaluated combination therapies and seven compared the effects of different devices.
Conclusions: Some of the noninvasive body contouring devices in animal and human studies such as cryolipolysis, RF, LLLT and
HIFU showed statistical significant effects on body contouring, removing unwanted fat and cellulite in some body areas. However,
the clinical effects are mild to moderate, for example 2 - 4 cm circumference reduction as a sign of subcutaneous fat reduction
during total treatment sessions. Overall, there is no definitive noninvasive treatment method for cellulite. Additionally, due to the
methodological differences in the existing evidence, comparing the techniques is difficult.
Keywords: Body Contouring, Subcutaneous Fat, Cellulite
1. Context
In the recent years, noninvasive body contouring tech-
niques have become one of the most widespread proce-
dures and are growing fast in areas of esthetic medicine
(1,2). The vast majority of surgical body contouring meth-
ods has inherent risks and complications such as pain,
swelling, prolonged recovery, scarring, hematoma or in-
fection, which make noninvasive procedures increasingly
popular (3-5). According to reported data by the Ameri-
can society for aesthetic plastic surgery in 2013, the signifi-
cant risk of invasive body contouring procedures has led
to 521% growth of noninvasive techniques since 1997 (6).
In addition, it has been estimated that noninvasive body-
contouring procedures are growing 21% annualy (7). Even
for shortening postoperative recovery, decreasing bruis-
ing and more skin tightening, surgical lipectomy tech-
niques are combined with noninvasive methods (7).
1.1. Cellulite and Subcutaneous Fat
Cellulite is a skin discomfort developed by multiple fac-
tors (8) but the main etiology is not completely understood
(9). The appearance of skin changes and it becomes like an
“orange peel”. Cellulite is commonly found on the thighs
and buttocks (8,10,11). Cellulite is more common in adult
females than males. Up to 98% of females are concerned
about their skin changes due to cellulite and the changes
decrease their self-esteem (12).
The Nurnberger and Muller scale is the most com-
monly used classification for cellulite (9,13). Accord-
ing to this scale, three grades were defined: I- visible
changes with skin clamping or muscle contraction; II- visi-
ble changes without manipulation; and III- visible changes
associated with nodules. In addition to Nurnberger and
Muller grading-score, recent classification includes four
additional variables: (i) the number of evident depres-
Copyright © 2016, Research Institute For Endocrine Sciences and Iran Endocrine Society. This is an open-access article distributed under the terms of the Creative Commons
Attribution-NonCommercial 4.0 International License (http://creativecommons.org/licenses/by-nc/4.0/) which permits copy and redistribute the material just in
noncommercial usages, provided the original work is properly cited.
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Alizadeh Z et al.
sions; (ii) the depth of visible depressions; (iii) appearance
alterations of skin surface and (iv) laxity grade. Accord-
ing to these items, cellulite is classified with three degrees:
mild, moderate and severe (9). Estimating accurate results
of anti-cellulite therapies is not easy but there are some
practical methods for measuring the outcomes such as
real-time scanning ultrasound image, three-dimensional
optical skin surface measurement, clinical photograph-
ing, histological findings, personal questionnaires, etc. (14-
18).
Subcutaneous fat is different from cellulite. As men-
tioned before, cellulite is defined by focused and topo-
graphic skin changes with an orange-peel look, yet subcu-
taneous fat is an indicator of peripheral fat mass, which
could be evaluated by circumference and skin fold mea-
surements and variation in these parameters could be con-
sidered as an indicator of cellulite changes. However, other
cellulite indices such as skin elasticity and dermal thick-
ness should be considered besides these measurements
(11).
In the past, different methods of body contouring were
assessed in order to specify their safety and influence on
subcutaneous fat reduction and the treatment of cellulite.
Patient satisfaction in the short-term and medium-term,
durability of the results and time to obtain maximum
outcomes, common complication and recovery time were
considered in these studies. The objectives of this paper
were to review and evaluate prominent methods on nonin-
vasive subcutaneous fat removal and improvement of cel-
lulite and comparing their clinical results. Since, there is
physiological and biochemical diversity between subcuta-
neous fat tissue and cellulite, both were included in the re-
view.
2. Evidence Acquisition
We used pubmed, google scholar and the cochrane re-
view database websites to find relevant articles in the En-
glish language (abstract and/or full-text). Systematic re-
views, review articles, meta-analyses and randomized clini-
cal trials (published up to February-2015) were considered.
The keywords used for our research were as the following:
noninvasive body contouring, subcutaneous fat, obesity,
cellulite, cryolipolysis, radiofrequency (RF), low-level laser
therapy (LLLT), infrared light and high-intensity focused ul-
trasound (HIFU), extracorpeal shockwave therapy (ESWT)
and vibration exercise. To increase the inclusiveness of our
search strategy, authors also studied the texts to find other
relevant cited manuscripts that were not retrieved in the
initial search. Given the narrative nature of the review, no
formal quality assessment was done.
3. Results
In the primary search, we found 2024 articles with the
keywords. Non-English papers, and articles that did not
mention clinical efficacy measures or used invasive meth-
ods were excluded. Further, articles, which focused on the
effects of various methods on weight loss or percentage
body fat, were omitted. We included seven reviews and 66
original articles in the present narrative review. Most of
them were applied on normal weight or overweight partic-
ipants (body mass index (BMI) < 30 kg/m2) of both genders
with broad range of ages (18 to 50 years on average). Six
of the articles evaluated combination therapies and seven
compared the effects of different devices. The summary of
the results is mentioned in Figure 1.
Below, we discuss the common noninvasive body con-
touring methods:
3.1. High Intensity Focused Ultrasound
The concept of applying HIFU for therapeutic aims was
introduced in 1942 and for more than 50 years HIFU has
been used for treating organ tumors, kidney stones and
uterine fibroids to decrease the need for aggressive proce-
dures (19-21). Recently, attention was drawn to HIFU devices
for reducing adipose tissue and body contouring (7).
By using an external transducer, HIFU energy cuts off
targeted adipose tissue. However, it has no effects on sur-
rounding tissues. Due to high convergence of ultrasound
energy at high frequencies, tissue damage is limited to a
small focal point. ultrasound energy makes molecular vi-
brations at the zone, that leads to increasing temperature
at targeted tissue above 56°C and coagulative necrosis of
fat cells (20,22,23).
There are various types of HIFU devices in the mar-
ket such as LipoSonix (Medicis Technologies Corporation,
Bothell, Washington), which are approved by the food and
drug administration (FDA), yet there are also other ultra-
sound devices developed for noninvasive body contouring
not yet approved by the FDA such as Proslimelt (medical
care consulting, Murten, Switzerland), Medcontour (gen-
eral project, Florence, Italy), Ultracontour (Medixsysteme,
Nimes, France), Novashape (UltraMed,Milton,ON, Canada),
Accent Ultra (Alma, Buffalo Grove, IL, USA and Vaser-Shape
(sound surgical technologies, Louisville, CO, USA) (7,22).
In 2011, a preclinical animal research on 26 pigs was
performed. Treatment was applied by HIFU in one session
for each site (25 ×25 mm for each site) and energy levels
varying from 85.3 to 270 J/cm2. The study showed success-
ful decrease of subcutaneous fat. In addition, no adverse
effects were seen on the skin, fascia, or other surrounding
tissues. No systemic abnormalities in blood chemistry pa-
rameters or fat emboli were reported during necropsy (22).
2Int J Endocrinol Metab. Inpress(Inpress):e36727.
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Alizadeh Z et al.
Identified Articles Through Database Searching
(n = 2024)
Screened Article
(n = 73)
Excluded Articles
(n = 1951)
Review Articles
(n = 7)
Original Articles
(n = 66)
HIFU
(n = 10)
RF
(n = 13)
LLLT
(n = 11)
Cryolipolysis
(n = 22)
ESWT
(n = 5)
WBV
(n = 4)
Figure 1. The Flowchart of the Search Strategy
In a randomized, single-blind, sham-controlled study
in 2012, 180 males and females (18 - 65 years) participated
with Body Mass Index (BMI) of ≤30 kg/m2and Subcuta-
neous adipose tissue (SAT) thickness of ≥2.5 cm in the
treatment region (anterior abdomen and flanks). During
the study, participants continued their usual diet and phys-
ical activity. Patients were divided to three groups and re-
ceived HIFU treatment at one of the three total doses of en-
ergy: 177 J/cm2(three passes at 59 J/cm2), 141 J/cm2(three
passes at 47 J/cm2), or 0 J/cm2(three passes at 0 J/cm2;
sham group) for nearly one minute for each targeted zone
and 15 minutes for the total treatment session. No abnor-
malities in blood lipids or inflammatory markers were re-
ported. The most adverse effects of treatment were pain,
ecchymosis and swelling. Post-treatment follow-up at 12
and 24 weeks revealed no significant changes in choles-
terol, triglycerides, free fatty acids, markers of inflamma-
tion and liver or renal function (24). Moreover Jewell et al.
confirmed HIFU as a useful method for reducing waist cir-
cumference. After 12 weeks, significant reduction in waist
circumference in the two study groups was reported. The
mean decrease in waist circumference was more than 2 cm.
However, no changes in weight or BMI were reported (25).
Likewise, a retrospective study in 2010 with 85 par-
ticipants (57 females and 28 males with a mean age of
43.8 years), showed similar findings at ≤16-week fallow-
up. Mean energy level of the HIFU device was 134.8 J/cm2
and treatment session duration varied from 60 to 90 min-
utes. The most common adverse effects of this study were
edema, tenderness, ecchymosis, and hard lumps, and only
one participant experienced major pain. No significant
change on blood lipids was reported. The average decrease
in waist circumference was 4.6 cm, 12 weeks after treat-
ment (26).
Shek al. published a single center prospective study
on 12 Chinese participants (nine females and three males,
with a mean age of 39.5 years), who underwent single treat-
ment on their anterior abdominal wall. Subjects with BMI
Int J Endocrinol Metab. Inpress(Inpress):e36727. 3
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Alizadeh Z et al.
≤30 kg/m2and subcutaneous adipose tissue ≥2.5 cm in
the targeted zone were recruited in the study. The mini-
mum energy level for the treatment session was 150 J/cm2
and the energy was increased up to patient’s tolerance
level (mean 161 J/cm2). Initial measures included weight,
BMI, and waist circumference. Statistically, a significant
decrease in waist circumference at four, eight and twelve-
week fallow-up was reported. The average decrease of waist
circumference was 1 cm at the 12th week follow-up. How-
ever, there was no significant change in weight or BMI (20).
In a clinical trial in Paris, HIFU technique was applied
on 25 Caucasian subjects (females with a mean age of 38.9
years) and this treatment was shown to be a safe procedure
for body contouring, which had a significant effect on ab-
dominal circumference. Mean BMI of patients was 24.5 and
mean baseline abdominal fat thickness was 3.24 cm. Each
patient received three treatment sessions at 14-day inter-
vals. According to the reported data, mean changes in cir-
cumference from baseline were -2.47 ±0.44, -3.52 ±0.46
and -3.51 ±0.56 cm on days 14, 28 and 56, respectively (27).
Tosum up, it seems that HIFU is a safe and efficient tech-
nology for reducing subcutaneous adipose tissue without
any significant effect on blood lipid or inflammatory mark-
ers and with no local adverse effects such as burns or scar-
ring. Studies based on the use of HIFU for body contour-
ing showed that self-reported patient’s satisfaction is ap-
proximately 47% to 86%. These treatment effects are not de-
pendent on diets or daily physical activity. In addition to
the above-mentioned benefits of HIFU, the recovery time
of the procedure is minimal, which can be considered as
an important advantage. However, according to available
evidences no considerable influence was reported on BMI
or body weight (20,22,25,26,28).
3.2. Radiofrequency
Radiofrequency is an electromagnetic wave that was
initially used for treating periorbital wrinkles, rhytids and
skin laxity (29,30). Today, RF is extensively used for body
contouring, skin tightening and cellulite reduction (31).
Radiofrequency is commonly used for increasing
deeper skin temperature without any epidermal or der-
mal ablation. It is not only used as an efficient method
for contracting or inducing skin tightening but also as
an effective method for reducing fat in repetition (31,32).
However, there is no standard protocol for treatment
time with RF, and the range of therapeutic sessions were
widespread between 1 and 24 weeks (30). However, higher
temperature at shorter time could be lethal for adipose
tissue but it is not necessarily comfortable for patients;
longer time, for example eight to ten minutes, with lower
temperature, leads to intended adipose cells damage (32).
Former researchers insisted that different parameters in
addition to time are related to the success of RF, such as
power and the frequency of treatment sessions, yet the
exact protocols in this area are unavailable (30).
Radiofrequency generates heat in different tissues by
transforming energy through three basic mechanisms
from electromagnetic field (32). These mechanisms in-
clude (i) orientation of electric dipoles that already exists
in the atoms and molecules in the tissue; (ii) polarization
of atoms and molecules to produce dipole moments; and
(iii) displacement of conduction electrons and ions in the
tissue. The frequency of an RF device ranges between 3 kHz
and 24 GHz, and the monopolar and the bipolar configura-
tion are used commonly in medicine (31).
Vela Smooth was the first RF device, which was used
widely for body contouring. Now, there are various types
of RF devices in the market such as Thermage (SoltaMedi-
cal, Hayward, CA, USA), Accent (Alma Lasers), TriPollar (Pol-
logen, TelAviv, Israel), Freeze (Venus Concepts, Karmiel, Is-
rael) and most recently TiteFX (Invasix).
A variety of studies demonstrate smoothening of the
cellulite exposure using RF and reduction of subcutaneous
tissue, which leads to circumference reduction (16,17,33-
36). Manuskiatti and colleagues evaluated the effects of a
TriPollar RF technology on abdomen and thigh circumfer-
ences and cellulite appearance in 39 female subjects with
cellulite grade ≥2 (Nurnberger-Muller scale). The subjects
received eight treatment sessions, seven days apart, with-
out any change in their physical activity and diet. Four
weeks after the last treatment session, the study showed
significant circumference reduction of the abdomen and
thigh regions. Nevertheless, there was no significant re-
duction in buttocks and arms. In addition, the study
showed that TriPollar RF improved the appearance of cel-
lulite (16). For assessing treatment procedure’s outcomes,
circumference measurements of treated region were done
along with taking real-time scanning images and measur-
ing skin elasticity. The cellulites condition was evaluated
in each patient according to the Nurnberger-Muller scale
(16).
Del Pino et al. assessed the effects of applying unipo-
lar RF [the Accent RF System (Alma Lasers Inc)] on subcu-
taneous fat of the buttocks and thighs of 26 female sub-
jects (ages 18 to 50 years) with visible cellulite (grade 1 to
3). Two treatment sessions, two weeks apart, were con-
sidered. They used real-time scanning image ultrasound
for measuring the distance between the dermis and the
camper’s fascia, and their findings showed that controlled
tissue heating with RF could reduce the thickness between
the dermis and fascia. The average reduction in thigh and
buttocks were 2.64 and 1.8 mm, respectively. Understand-
ing the effect of treatment sessions from changes on skin
texture and clothing leads to patient’s satisfaction with the
4Int J Endocrinol Metab. Inpress(Inpress):e36727.
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Alizadeh Z et al.
procedure and was assessed by the studying group (14).
Another study in Spain revealed that RF could improve
upper thigh cellulite in females aged 24 - 58 years, and the
positive effects remained at least for six months after treat-
ment. Van Der Lugt et al. applied a unipolar, volumetric
RF device (frequency between 0.6 and 2.4 MHz) for 12 ses-
sions, one week apart. All of the fifty female subjects (with
homogenous cellulite depositions) showed considerable
amelioration in buttock skin conditions, which was com-
pletely noticeable by real-time scanning ultrasound image
and comparing the distance between stratum corneum
and Camper’s fascia and from the stratum corneum to the
muscle, before and two weeks after treatment sessions.
Most of the patients were satisfied with the treatment.
However, two months after the last session, slight return
was seen in the favorable treatment results (17).
Another study in New Jersey revealed that utilization
of unipolar RF (Alma Lasers, Buffalo Grove, IL) improved
upper thigh cellulite in females. All the subjects were over
the age of 30 years with upper thigh cellulite (grade 3 to 4,
according to the Nurnberger-Muller scale). Their thigh cir-
cumference decreased 2.45 cm on average after six sessions
of treatment, one week apart. However, there were no sig-
nificant changes in body weight and blood lipids after the
treatment (34).
Sadick and Mulholland (35) reported their experience
on the use of RF energies in order to treat cellulite in 35 fe-
male subjects. Each patient received 8 to 16 treatment ses-
sions one week apart and target zones were thighs and/or
buttocks. Subjects were instructed to continue their nor-
mal lifestyle (including diet and fluid consumption). After
eight treatment sessions, the mean reduction in circumfer-
ence was 2.03 cm.
By reviewing related articles on RF therapeutic effects
on skin laxity, Araujo et al. confirmed that up to 96% of
former studies obtained positive outcomes with RF. These
data were collected by before and after exposure pictures,
patient’s questionnaires, biopsy, etc. (30). Satisfaction for
subcutaneous fat reduction with RF was approximately 71
- 97%, according to patients’ self-reported data (4). How-
ever, significant statistical outcomes about the effects of RF
on skin laxity and cellulite treatment were low and limited
(30,37).
In summary, it seems that RF is a safe and relatively
effective method for improving skin appearance and de-
creasing subcutaneous fat, especially in the abdomen and
thighs. In addition, safety and relatively lower time for ap-
plying the modality are important advantages.
3.3. Cryolipolysis
Cryolipolysis is one of the newest procedures for non-
invasive fat reduction, which was introduced as a body con-
touring technique in 2007 (19,38). It has a major difference
from other modalities such as ultrasound, radiofrequency,
etc. (11). The principle of cryolipolysis is based on higher
sensitivity of adipocytes to cold in comparison with other
water-rich cells (39).
In 2010, cryolipolysis received FDA clearance for love
handles (Zeltiq). In 2012 and 2014, FDA clearance was ob-
tained for fat removal by cryolipolysis at abdomen and
thighs, respectively (7,19,40).
The efficiency of the method on reducing fat layer
thickness without any physical damage to circumambient
tissue has been proven clinically. Assessing the efficacy of
cryolipolysis and its potential side effects in different sub-
jects showed that not only the procedure was effective in
reducing adipose tissue, but also patient satisfaction was
high after the treatment session (4,5,38-48).
Jalian reported fat cells sensitivity to cold injury in 1902
(19). In 1941, the term “adiponecrosis e frigore” was used
by Haxthausen for sores, which occurred due to exposure
to exceeding cold (49). During the period between 1940
and 1970, case reports showed gradual fat reduction in the
lower cheeks of children who suck on a popsicle and the
effect was known as “popsicle panniculitis” (5,50). Such
findings led to the advancement of cryolipolysis as a body
contouring method (5,19).
A preclinical animal research to assess effects of con-
trolled cooling on subcutaneous fat was performed in
2008. In this study, black Yucatan pigs were placed under
general anesthesia and their target zones (10 sites for each
pig) were exposed to exceeding cold temperature within
10 minutes (20, -1, -3, -5, and -7 degrees C). The four pigs
were controlled on days 1, 2, 7, 14 and 28 after the treatment
session and the fallow-up continued up to 3.5 months for
one pig. The assessment showed approximately 40% de-
crease in fat layer thickness without any scarring or dam-
age to surrounding tissues (51). In addition, it seems that
the best results in fat damaging were obtained at lower de-
grees (5,51). However, studies have demonstrated that un-
der temperature conditions as high as 1°C, adipocytes are
damaged and possibly their chances of survival decreases.
Scientific evidence on the effects of temperatures below -
7°C on dermis and epidermis is not available, owing to the
fact that the majority of research has been carried out un-
der conditions with temperatures over -7°C. (43,52). Sim-
ilar to Manstein, Zelickson et al. reported their porcine
experiment that underwent cryolipolysis for one session.
Their findings showed that the thickness of the superficial
fat layer decreased by 33% without any side effects (52).
In human studies, the protocol of cooling has been
done by cup-shaped applicators with two cooling panels.
A vacuum pulls the tissue and draws the target zone be-
tween cooling panels. The constriction of blood vessels ac-
Int J Endocrinol Metab. Inpress(Inpress):e36727. 5
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Alizadeh Z et al.
celerates the cooling process. The treatment session usu-
ally takes one hour (5,7). Despite the fact that there are
not any considerable changes in body fat instantly after
the treatment session, different studies proved the efficacy
of the procedure on reducing subcutaneous adipose tissue
over time (11). In a prospective human clinical study, Dover
et al. revealed a decrease in lateral flank and back fat fol-
lowing cryolipolysis. In this study, 32 subjects underwent
a 60-minute treatment session. At a four-month post treat-
ment fallow-up, 84% of subjects showed some degree of fat
thickness reduction by photographic assessment. In addi-
tion, significant reduction in fat layer (22%) was reported
in ultrasound evaluation in ten participants. Furthermore,
more than 90% of participants were satisfied with the pro-
cess and no significant complication was reported (53).
In another study, ten subjects (older than 18 years old)
underwent cryolipolysis for 30 to 60 minutes on their love
handles. Two and six months after the treatment, fat layer
thickness decreased by nearly 20% and 25.5%, respectively.
In addition, weekly neurologic assessment showed that
cryolipolysis could make mild reversible changes in a short
period, but the changes returned within two months after
the treatment (43).
Shek et al. reported their experience on Chinese sub-
jects with visible central fat bulge (on the abdomen and/or
love handles). Subjects (males and females, above 18 years
old) were divided to two groups. Group A received one
treatment session on the abdominal fat bulges and group
B received two treatment sessions on two sites (abdomen
and flank), 60 days apart on average. After two months,
14% abdominal adipose tissue reduction in group A, and 14
and 13.4% fat reduction in abdomen and flank region, re-
spectively in group B, was shown by caliper measurement.
Moreover, it was reported that increasing the number of
treatment sessions to two, improved the positive results.
In this study, the fat layer reduction in the abdomen region
rose by 7.2%, two months after the last treatment, and 4.3%
improvement was found in the flank. This was statistically
significant for abdominal fat (48).
Zelickson et al. demonstrated that using cryolipoly-
sis for treating inner thigh fat bulges could be safe and
effective for male and female subjects. They assessed 45
patients (mean age 48.1 years and mean body mass index
24.6 kg/m2), who underwent one treatment session with a
flat cup applicator. At two- and four-month fallow up ses-
sions, photographic evaluation, circumferential measure-
ments and ultrasound imaging was performed. The re-
sults showed a 0.9-cm reduction in inner thigh fat bulges
at a 16-week fallow up, and 93% of the participants were
satisfied (39). In a similar study on subjects with BMI of
up to 40kg/m2, a single treatment session on inner thighs
was performed. Comparing photographs and ultrasound
imaging at a four-month fallow-up showed a 20% fat reduc-
tion (3.3 mm) on average (41).
The shape of the applicator has recently been changed
to a new generation of sharply-contoured device. A clinical
study, in 2014, assessed the effectiveness of this new appli-
cator on flanks. In this study, 10 female subjects (mean age
42.2 years and mean body mass index 24.3kg/m2) received
two treatments for each flank with 50% overlap. Photo-
graphic evaluation showed 43% improvement in reducing
fat bulges on average in a follow-up after three months
without significant side effects (40).
In a multicenter study, 518 males and females received
the treatment in different target zones, including ab-
domen, back, buttocks, inner thighs and knees. At the 12-
week fallow up, treated sites were evaluated by skin fold
thickness. Overall, 94% of subjects experienced fat reduc-
tion in comparison with the controlled side. In addition,
a 23% decrease in adipose tissue at the treated sites was re-
ported. Blind investigation with photographs revealed fat
layer thickness reduction in 73% of the patients. In addi-
tion, the results suggested the greatest reduction on ab-
domen and flank and the least changes on thighs, knees,
and buttocks (44).
A comprehensive review in Canada showed the efficacy
and safety of cryolipolysis in reducing thigh, abdomen,
arm, and back fat bulges. In this study, investigators as-
sessed the treatment process at 464 sites, during three
years. The major treatment zones were abdomen and flank
but some treatments were performed on other zones. Skin
texture, laxity and cellulite were improved after the treat-
ment (42).
The long-term effect was not clear. In two case re-
ports, it was mentioned that two males, who underwent
cryolipolysis treatment sessions were successful in keep-
ing the fat reducing results, two and five years after the pro-
cedure (54).
In summary, using cryolipolysis for body contouring is
effective for patients with separate fat bulges. However, it
seems that the procedure is not pronounced for obese pa-
tients with considerable skin flaccidity (55). cryolipolysis
is not dependent on the operator and this should be con-
sidered as an advantage for the technique, yet long treat-
ment sessions are an important disadvantage (7). Kennedy
et al. also reported that in most studies, assessing effects
of cryolipolysis were done by patient questionnaires, an-
thropometric measurements, clinical photographing, etc.
Self-reported satisfaction on reducing subcutaneous fat in
patients was more than 70% (4).
3.4. Low-Level Laser Therapy
Low-level laser therapy is another noninvasive method
for reducing adipose tissue and received FDA clearance in
6Int J Endocrinol Metab. Inpress(Inpress):e36727.
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Alizadeh Z et al.
2010. Before that, LLLT was widely used for treating other
problems such as neurologic, ophthalmic, dental and der-
matologic diseases (56-58).
Although there are some evidences, which show the
effects of LLLT on reducing fat in combination with lipo-
suction, the evidences for the effects of this method as a
stand-alone procedure, are not sufficient (56). Applying
LLLT for fat removal has no observable consequence on
surrounding tissues and does not increase tissue temper-
ature. Moreover, it takes time to show its own effect on the
treated zone. The laser beam energy is defined by the ray
dosage that is emitted to the body (7).
The type of device available in the market, works at a
wave-length of 635 nm and has four adjustable arms. One
treatment session with LLLT lasts up to half an hour and
six to eight sessions is required in order to obtain opti-
mum results. In addition, manufacturers encourage con-
sumers to use some supplements such as vitamin B5 and
L-carnitine, Ginkgo biloba or green tea to reinforce circula-
tory and lymphatic systems (56).
Using LLLT for fat reduction and body contouring is
based on experiences, which showed that applying 635-nm
laser leads to deflation of temporary tiny openings within
membrane of adipose cells and releasing fats into the in-
terstitial space. The result of these changes is reduction
of unwanted fat. However, the openings have no destruc-
tive effect on body cells but let lipids enter the interstitial
space and excrete from the body. It seems that the above-
mentioned mechanism is the consequence of photoexci-
tation process of cytochrome c oxidase in mitochondria’s
respiratory chain (56,59,60). The first experiments of us-
ing LLLT with the possible mentioned mechanism, demon-
strated that applying 635 nm, 10 mw intensity for six min-
utes caused approximately 99% fat reduction (60), though
later studies such as the experience of Brown et al. did not
support the these findings (61).
In 2009 Jackson et al. reported that applying LLLT to
reducing body fat could be effective on overall circumfer-
ence. They assessed 67 overweight participants (BMI 25
to 30 kg/m2), which underwent LLLT (635-nm light with
2.5 mW power) for two weeks (three treatment sessions
in each week). After treatment by LLLT (Zerona lipolaser
was the first device that received FDA clearance), a total of
891-mm fat reduction was observed across waist, hips, and
thighs. Maximum fat reduction was reported across the
waist (2.66 cm). However, two weeks after the last treat-
ment session, a 7.8-mm increase in circumferences was
seen in three treated zones (62). In another clinical study,
Jackson et al. reported that treating 689 subjects with LLLT
(12 treatment sessions within 14 days) leads to 13.13-cm cir-
cumferential reduction in waist, hips, thighs, arms, knees,
neck and chest (63).
Caruso-Davis et al. used 635 - 680 nm LLLT (Merid-
ian LAPEX 2000 lipolaser system, Meridian medical Inc.
Anyang, Korea) for reducing adipose tissue. Forty subjects
with BMI of < 30 kg/m2participated in their experiment
and received eight treatment sessions (half an hour for
each session) within one month. Average fat reduction on
waist circumference after the last treatment session was
equal to 2.15 cm (64). There were two studies, which mea-
sured patient’s satisfaction after the treatment procedure.
In the study of Nestor et al., satisfaction was reported up
to 80% but in the research of Lach et al. reduction of sub-
cutaneous fat in normal weight women was nearly 32% (1,
65).
In conclusion, while some studies introduced LLLT as
an effective method for body contouring and fat removal,
more studies are needed to prove efficacy and safety of this
method.
3.5. Extracorporeal Shockwave Therapy
Extracorporeal shockwave therapy has been a method
for treating kidney stones since 1980 (45). In addition, the
procedure has been used for curing lesions and wounds.
Nowadays, the device is being used for body contouring
and treating cellulite (66,67).
Although the full mechanism of ESWT is not clear yet,
it seems that it is based on converting electrical energy to
mechanical energy (68). The energ y created in this process
is limited to target zones by affecting acoustical interfaces
and no significant changes in surrounding tissue are ob-
served (66).
The power and effectiveness of the device is affected by
shockwave energy, the frequency of the generated waves,
the number of pulses, and the number and interval of re-
treatments (69).
The commonly used form of ESWT in treating soft tis-
sue is defocused, low-energy shockwaves, which comes in
contrast with focused, high-energy ESWT and is commonly
applied for delay-union or non-union fractures (69).
It seems that applying extracorporeal shockwave could
be an effective method for treating cellulite due to skin col-
lagen remodeling (66). Angehrn et al. assessed the shock-
wave effects on cellulite of 21 women. The participants re-
ceived 12 sessions of low-energy defocused ESWT (96000
shots for each person) during six weeks in the lateral thigh.
After the last session, high-resolution ultrasound measure-
ments and personal questionnaire showed some degrees
of improvement on their skin elasticity (66).
Another randomized-controlled trial in 2013 was per-
formed to investigate the effects of ESWT along with exer-
cise on cellulite. The intervention group received six ses-
sions of focused ESWT on gluteal and thigh areas (2000
Int J Endocrinol Metab. Inpress(Inpress):e36727. 7
Uncorrected Proof
Alizadeh Z et al.
impulses, 0.35 mJ/mm2) every one to two weeks. Six ses-
sions of SHAM-ESWT was performed on the control group.
Daily gluteal strength trainings were prescribed for both
groups. The results showed significant improvement in
skin appearance and cellulite severity scale, but no effect
on thigh circumference was reported (67).
It seems that ESWT could be considered as an effective
method for body contouring and cellulite treatment, yet
further studies are required to determine the effect of this
technique on circumference reduction.
3.6. Vibration Exercise and Weight Reduction
Current ACSM guidelines for weight reduction suggest
moderate-intensity aerobic exercise in addition to a mod-
erate caloric restriction, which further improves weight
loss. Other exercise modalities such as resistance training
have received a lot of attention for weight loss. An exercise
mode that needs little time and physical exertion but pro-
vides advantages to increase muscle function and possible
weight loss would be of interest to most people. One such
exercise mode is vibration exercise (70).
Vibration exercise kicks off a fast and repetitious
eccentric-concentric activity that induces muscular work
and increases metabolic rate (70). This is done by stand-
ing on a machine with an oscillating platform or some
other devices such as vibrating slimming belt or hand-
held devices. Low frequency vibration (5 - 45 Hz) increases
muscle activity via stimulating the muscle spindle, involv-
ing the spinal reflex apparatus, which may increase en-
ergy expenditure and might be favorable for weight reduc-
tion (70). In fact, the vibration transferred to the muscle-
tendon complex results in a stretch-shortening action,
which stimulates muscle spindles and evokes subsequent
muscle contractions via monosynaptic and poly-synaptic
reflexes. These reflexive muscle contractions increase local
metabolic rate (71).
Vibration exercise is a very popular exercise mode and
there are different types of vibration machines in fitness
centers and gyms. There are many reports in the literature
suggesting that vibration exercise is an efficient method
for reducing workout time while improving muscular per-
formance to increase energy expenditure and decrease
body fat. It has been reported that a 10-minute vibration ex-
ercise is equal to a one-hour of conventional exercise (70).
It has been suggested that increased fat oxidation both
during and after exercise and catecholamine release may
cause weight loss in lean people who engage in vibration
exercise but the underlying mechanisms remain unequiv-
ocal (70).
Recently, the ability of vibration exercise to increase
skeletal muscle perfusion in the lower limb has been re-
ported in the literature. The amount of increase in mus-
cle blood flow seems to be related to the vibratory load and
is due to reflexive muscular contractions during vibration
exercise (71). In some reports, there is a positive linear cor-
relation between vibratory load and muscle perfusion (71).
A systematic review by Fuller et al. in 2013 indicated that
vibration exercise increases muscle perfusion, particularly
in the lower extremities, with the amount of increase in
perfusion being positively related to the vibratory load (71).
The effect of whole body vibration exercise on body
composition has been evaluated in different studies. Mi-
lanese et al. explored the short-term effect of whole
body vibration (WBV) exercise on anthropometric mea-
surements. Fifty obese women were randomly allocated
to a ten-week WBV training group or a non-exercise con-
trol group. Whole body vibration exercise consisted of 14
minutes of vibration training on the WBV device (Bioplate
RF, BIOS, Milano, Italy) with amplitude of 2 - 5 mm and
frequency of 40 - 60 Hz, twice a week. Before and after
the ten-week experimental period, anthropometric assess-
ments and dual-energy x-ray absorptiometry (DXA) were
carried out. The results showed that compared to the con-
trol group, subjects submitted to WBV exercise had signif-
icantly lower BMI, total body and trunk fat, sum of skin-
folds and body circumstances. These results suggested
that WBV exercise improved body composition and might
be a useful addition to lifestyle recommendations (72).
Another study in Belgium by Roelants et al. investi-
gated the effects of 24 weeks of WBV training on body com-
position compared with fitness training on forty-eight un-
trained females. Vibration platform (35 - 40 Hz, 2.5 - 5.0
mm; Power Plate®) was used for WBV training. The fitness
group performed a standard cardiovascular (15 - 40 min-
utes) and resistance training (leg press and leg extension
exercises 20/8 RM). Body composition was determined by
the underwater weighing method and 12-points skinfold
thickness assessment. After 24 weeks, there were no sig-
nificant changes in weight, percentage of body fat or skin-
fold thickness in any of the groups. A significant strength
gain was observed in both groups. The results of the study
showed that although WBV training didn’t reduce weight
and subcutaneous fat, it could increase muscle strength
comparable to the strength gain following a standard fit-
ness training program (73).
To sum up, the results of studies on vibration exercise
are contradictory and it is difficult to draw any conclusion
about its effects on body composition, especially on local
fatness. Although vibration exercise has gained popularity
for weight loss and body contouring, it does not have the
capability to substitute aerobic exercise in terms of energy
costs. However, it seems that like resistance training, vibra-
tion exercise does have a positive effect on blood flow (70,
71), which could increase metabolic rate in relevant areas
8Int J Endocrinol Metab. Inpress(Inpress):e36727.
Uncorrected Proof
Alizadeh Z et al.
and can improve fat free mass and muscle strength with-
out any significant effect on skinfold measurements (73).
3.7. Combination Therapy
For increasing positive results of body contouring
methods, in some studies, combination treatment regi-
mens were used such as combination of cryolipolysis and
shockwave, RF and suction, etc. Moreover, in some cases,
especially in the cellulite therapeutic approach, manual
massage is considered (4,18,37). It seems that the results
can improve by combining several techniques. For exam-
ple, in one study the best abdomen circumference reduc-
tion was observed by using cryolipolysis in combination
with ESWT, yet in another study, the best results in buttocks
fat removal were gained by using 635-nm LLLT in combina-
tion with vibration therapy (45,57). In another research,
when the HIFU technique was combined with RF therapy,
positive outcomes were nearly 72%, which was assessed by
a satisfaction survey (74). However, the existing evidences
in this field are very limited.
4. Conclusions
According to the existing evidences in animal and hu-
man studies, some of the noninvasive techniques such
as cryolipolysis, RF, LLLT and HIFU have shown statisti-
cally significant effects on body contouring, removing un-
wanted fat and cellulite. However, the reported effects of
such devices were mild to moderate and the mentioned
methods have little or no effect on body weight reduc-
tion and total percentage of body fat. On average, circum-
ference reduction after noninvasive methods was 2 - cm.
Moreover, there were major differences in the investiga-
tion methods especially target zones, number and time of
fallow-up sessions and type of measurements or outcomes.
Therefore, comparing the effectiveness of these methods
was too hard. The follow-up sessions in most studies were
planned 6, 12 or 24 weeks after treatment sessions and ev-
idence on long-term outcomes or recurrence of subcuta-
neous fat after 24 weeks is inadequate. One of the most
important aspects of body countering methods is patient
satisfaction following treatment, which is not noticeable
in most cases because most of the participants expect sim-
ilar outcomes to surgical procedures. Focusing on the role
of noninvasive body contouring methods on cellulite or
subcutaneous fat as a sole defining method is too chal-
lenging. As a former experiment showed, some method-
ological faults in studies, such as lack of an end-point for
cellulite severity or absence of clinical statistical analysis,
make it very difficult to obtain confirmed results and it
seems there is no definitive treatment method for cellulite
and subcutaneous fat.
Acknowledgments
The authors acknowledge the Tehran University of
Medical Sciences for facilitating the data collection.
Footnote
Authors’ Contribution: Study concept and design: Zahra
Alizadeh and Reza Mazaheri. Drafting of the manuscript:
Zahra Alizadeh, Mastaneh Tabesh and Farzin Halabchi.
Critical revision of the manuscript for important intellec-
tual content: Zahra Alizadeh. Study supervision: Zahra Al-
izadeh and Maryam Abolhasani.
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