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© 2018 Journal of Cutaneous and Aesthetic Surgery | Published by Wolters Kluwer - Medknow 67
Review Article
Fat Busters: Lipolysis for Face and Neck
Abhay Talathi, Prajakta Talathi
SkinSpace Clinic, Mumbai
Abstract
Persistence and hypertrophy of fat pads particularly of the face and neck region disturb beauty proportions, thus demand treatments.
Phosphatidylcholine and deoxycholic acid are the most commonly used solutions for injection lipolysis. As we stand today, sodium
deoxycholate preparation is approved by the US Food and Drug Administration for the same. This article describes the correct use of
solution to achieve fat reduction and ensure safety. Complete details of patient selection, assessment, dosing, and injection techniques
are described in this article. Abrief note on posttreatment care and complications is also provided.
Keywords: Fat busters, injection lipolysis, sodium deoxycholate, submental fat
IntroductIon
The demand for fat reduction injections in aesthetic
therapies has always been on the rise. Persistence and
hypertrophy of fat pads particularly of the face and
neck region disturb beauty proportions, thus demand
treatments. An effective reduction of this fat shall help
individuals achieve better appearance and the desired
contoured face and neck.
The history of use of fat-reducing injections goes way
back in 1960s when phosphatidylcholine was first isolated
in Ukraine[1] and subsequently used for dissolving
fat. Initially, a formulation consisting mainly of lipid
phosphatidylcholine dissolved in the bile salt deoxycholate
was used as an intravenous medication to prevent or treat
fat embolism.
HIstory In AestHetIc use[1]
In Italy, at the end of the 1980s, Dr. Sergio Maggiori
began to use phosphatidylcholine in the infiltration of
xanthelasma with satisfactory results. He presented this
method at the Fifth International Mesotherapy Congress
in Paris in 1988. In 1995, the Brazilian dermatologist,
Dr. Patricia Rittes, treated her own lower eye pads by
injecting phosphatidylcholine under her eyes. In 2003,
“Network Lipolysis” was founded in Germany by Ulrich
Bunzek and Dirk Brandl, and with this started the
European investigation of the scientific background of
this new aesthetic therapy. As we stand today, sodium
deoxycholate preparation is approved by the US Food
and Drug Administration (USFDA) for the reduction of
persistent submental fat.
VArIous FAt-dIssolVIng substAnces
Phosphatidylcholine
Phosphatidylcholine[1,2] is the most important and
essential phospholipid in the human body. It facilitates
the emulsification of fat into the tiniest particles
within the nanosphere, enabling the absorption and
transportation of fat. After subcutaneous injections
of phosphatidylcholine into fat tissue, the adipocytes
burst and phosphatidylcholine increases the secretion of
triaglycerol-rich lipoproteins.
Deoxycholic acid
Deoxycholic acid is a component of human bile acid, which
plays a vital role in emulsification and digestion of fat in
the intestine. Rotunda and colleagues[2] demonstrated that
externally developed deoxycholic acid physically disrupts
the cell membrane of adipocytes causing cell death and
Address for correspondence: Dr. Abhay Talathi,
19 Alankar, 2nd Floor, Goregaon West,
Mumbai-400104.
Ph: 9769585491.
E-mail: skinspaceclinic@gmail.com
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For reprints contact: reprints@medknow.com
How to cite this article:Talathi A, Talathi P.Fat busters:Lipolysis for
face and neck. J Cutan Aesthet Surg 2018;11:67-72.
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Talathi and Talathi: Fat busters
68 68 Journal of Cutaneous and Aesthetic Surgery ¦ Volume 11 ¦ Issue 2 ¦ April-June 2018
that relatively protein-poor tissue such as fat is more
sensitive to the cytolytic effects of deoxycholic acid than
relatively protein-rich tissues such as skin and muscle.
Clinical efficacy and safety of deoxycholic acid have been
established by multiple studies.
Deoxycholic acid injection[3] (Kybella in the United States)
was approved in 2015 as a first-in-class injectable drug for
improving the appearance of double chin associated with
submental fat.
concentrAtIon oF substAnces
On reviewing literature, one realizes that multiple
variable combinations of both deoxycholic acid and
phosphatidylcholine have been tried. Some standard
combinations are as follows.
Lipostabil[4] contains phosphatidylcholine (50 mg/mL)
together with deoxycholic acid, sodium hydroxide,
sodium chloride, α-tocopherol, benzyl alcohol, and
ethanol.
Kybella contains deoxycholic acid (10 mg/mL).[3]
GeoLysis contains deoxycholic acid (10 mg/mL).
MecHAnIsM oF ActIon[5]
Following injection of lipolytic solution, the adipocyte cell
wall is destroyed, resulting in the cascade of inflammatory
necrosis of cell and reduction in the size of adipocytes.
Inflammatory cascade also results in fibroblast migration
and stimulation, resulting in buildup of more collagen
[Figure1].
IndIcAtIons
Persistent submental fat:Clinically manifests as moderate-
to-severe convexity or fullness inferior to jawline, also
termed as a double chin appearance. Till date, the use of
injection lipolysis is approved by the USFDA only in the
reduction of persistent submental fat [Figure2].
Other face and neck fat pads: Facial fats like cheek, chin
and jaw fat pads are injected by few physicians as off-label
indications. The results of these indications are variable
and techniques are not standardized as that of submental
fat injection.
A few cases of injection of fat busters in lipoma and male
breasts are also reported.
Figure 1: Mechanism of action of deoxycholic acid (Image adopted from Ref. 5)
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Talathi and Talathi: Fat busters
Journal of Cutaneous and Aesthetic Surgery ¦ Volume 11 ¦ Issue 2 ¦ April-June 2018 69
As the most published data exist on double chin fat
reduction, we have explained the detailed technique for it
in the following sections.
Contraindications: No Absolute Contraindications exist
for procedure. It can be avoided if there is infection at the
site of injection entry. It should not be done in patients
not willing to accept the downtime of the procedure and
having unrealistic expectations.
PAtIent AssessMent
Patient assessment[6] is carried out by observing for
submental fullness in frontal and profile view of
face with Frankfort plane being parallel to the floor.
Convexities are observed and graded as follows so as
to decide dosing schedule for the patients and setting
expectations right.
Double Chin Rating Scale (Adopted from Ref. [3])
PrePArAtIon And MArkIngs
Double chin fat is located anterior to platysma muscle.
Thus, before marking the injection site, the patient is
asked to contract platysma muscle so that fat is palpated
(platysma muscle is used when the patient moves jaw
inferiorly while loudly saying “Eee”).
Submental fat compartment for deoxycholic acid
treatment is delineated by marking the submental crease
anteriorly, the hyoid bone posteriorly, and the lateral
boundaries are judged on palpation usually corresponding
with continuation of labiomental crease.
After marking the submental fat, multiple injection points
are marked at a distance of 1 cm away from each other in
a gridlike manner [Figure3].
Other important anatomic landmark is the inferior
mandibular border with the antegonial notch (a bony
landmark at the anterior masseter that approximates the
location of the marginal mandibular nerve). Marginal
mandibular nerve is located within 1 to 4 cm away from the
inferior border of mandible and is in close proximity of
antegonial notch. This area has to be cautiously injected.
InjectIon tecHnIque
Deoxycholic acid is injected into the submental fat with
the help of a 1-mL tuberculin syringe and thin needle
(usually 30 G and 13 mm)[6].
The following steps are carried out:
1. After consent and accurate photography, the injection
area is marked as explained previously.
2. Complete aseptic precautions are followed while
injecting. In our opinion, topical anesthesia does not
play any role in reducing the discomfort of injection
as fat is placed deep; however, for sensitive patients, it
may be used.
3. Typically 3–5 mL of deoxycholic acid is injected
per session divided in multiple pricks, and dose per
injection prick is close to 0.2–0.3 mL. This leads to
delivery of 30–50 mg of deoxycholic acid per session.
4. It is wise to pinch the submental fat with a nondominant
hand so as to ensure the correct plane of injection. The
depth of the prick has to be between 6 and 10 mm as
the fat is deep seated.
Figure 2: Frankfort plane (Image adopted from Ref. 3.)
Figure 3: Grid pattern of injection (Image adopted from Ref. 3)
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Talathi and Talathi: Fat busters
70 70 Journal of Cutaneous and Aesthetic Surgery ¦ Volume 11 ¦ Issue 2 ¦ April-June 2018
5. Typically three to five sessions are required with an interval
of 4 weeks between two sessions. In our experience, the
duration between two sessions can be increased to 8
weeks so as to reduce the number of sessions.
6. Topical antibiotics are applied after injections.
7. Patients shall experience some discomfort and pain
after injection, lasting from 2days to 2 weeks followed
by reduction of fat.
PosttreAtMent cAre
Patients can experience mild swelling, discomfort, and
pain as an indicator of inflammation for the duration
varying from 2days to 2 weeks postinjection.
Patients can be aligned for the same. Cold compresses
can be effectively used to alleviate discomfort. Oral
anti-inflammatory medicines are rarely used.
Patients are instructed not to massage the treated area for
the next 48 h.
Usually, the patients can be followed up after 4 weeks to
assess the results and also to plan further sessions as per
their requirement.
clInIcAl results
1. Most of the patients treated with injection lipolysis for
the reduction of double chin are extremely satisfied
with the outcome as per our experience.
2. Reports published about the treatment results of other
body sites have claimed to achieve reduction in upper
belly by 3.7 cm, lower belly by 3.9 cm, thighs by 1.9 cm,
and upper arms by 1.6 cm.
3. For safety reasons, lower eye pads have been eliminated
from the list of lipolysis indications by the Network
Lipolysis, and the treatment should only be performed
by physicians who are able to make a releasing cut in
case of retro-orbital bleeding [Figure4].
coMPlIcAtIons[1,7]
1. Discomfort, pain, and swelling: These are most
common and shall subside with time. Swelling and
pain after only deoxycholic acid injection may last
up to 10–14 days, whereas the discomfort after
injection of the combination of deoxycholic acid and
phosphatidylcholine usually lasts for up to less than
a week.
2. Bruise/ecchymosis: These are due to injury to local
blood vessels, are very localized, and disappear in a
few days.
3. Marginal mandibular nerve injury: This is due to
injecting a lot of deoxycholic acid close to the nerve.
Clinically, it may result in asymmetrical smile. It can
be avoided with correct injection technique in most of
the individuals.
4. Skin ulceration: Superficial injection may result in
ulceration, hence should be avoided.
5. Rarely dysphagia can occur.
suMMAry
Deoxycholic acid is a first-in-class injectable drug for the
reduction of submental fat and represents a minimally
invasive, customizable alternative to liposuction and
surgery for the patients with moderate-to-severe submental
fullness.
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Talathi and Talathi: Fat busters
Journal of Cutaneous and Aesthetic Surgery ¦ Volume 11 ¦ Issue 2 ¦ April-June 2018 71
Phosphatidylcholine combination probably helps in
the transportation of free fatty acids after breakdown.
Injection lipolysis is extremely effective and safe in the
treatment of submental fat, and usually without the need
for adjunctive treatments to address skin laxity.
Declaration of patient consent
The authors certify that they have obtained all appropriate
patient consent forms. In the form the patient(s) has/have
given his/her/their consent for his/her/their images and
other clinical information to be reported in the journal.
The patients understand that their names and initials will
not be published and due efforts will be made to conceal
their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
reFerences
1. Hasengschwandtner F. Phosphatidylcholine treatment to induce
lipolysis. J Cosmet Dermatol 2005;4:308-13.
2. Rotunda A, Suzuki H, Moy RL, Kolodney MS. Detergent effects
of sodium deoxycholate are a major feature of an injectable
phosphatidylcholine formulation used for localized fat dissolution.
Dermatol Surg 2004;30:1001-8.
3. Dayan SH, Humphrey S, Jones DH, Lizzul PF, Gross TM, Stauffer
K, et al. Overview of ATX-101 (deoxycholic acid injection): a
nonsurgical approach for reduction of submental fat. Dermatol
Surg 2016;42:S263-70.
4. Klein SM, Schreml S, Nerlich M, Prantl L. In vitro studies
investigating the effect of subcutaneous phosphatidylcholine
injections in the 3T3-L1 adipocyte model: lipolysis or lipid
dissolution? Plast Reconstr Surg 2009;124:419-27.
5. Salti G, Ghersetich I, Tantussi F, Bovani B, Lotti T. Phosphatidylcholine
and sodium deoxycholate in the treatment of localized fat: a
double-blind, randomized study. Dermatol Surg 2008;34:60-6.
Figure 4: Results of double chin reduction
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Talathi and Talathi: Fat busters
72 72 Journal of Cutaneous and Aesthetic Surgery ¦ Volume 11 ¦ Issue 2 ¦ April-June 2018
6. Jones DH, Kenkel JM, Fagien S, Glaser DA, Monheit GD,
Stauffer K, etal. Proper technique for administration of ATX-101
(deoxycholic acid injection): insights from an injection practicum
and roundtable discussion. Dermatol Surg 2016;42:S275-81.
7. Fagien S, McChesney P, Subramanian M, Jones DH. Prevention
and management of injection-related adverse effects in facial
aesthetics:considerations for ATX-101 (deoxycholic acid injection)
treatment. Dermatol Surg 2016;42:S300-4.
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