Is This the Shape of Things to Come?

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Skin Deep

Body-contouring procedures — nonsurgical treatments that promise to freeze fat or build muscle while you lie there — are soaring in popularity. Are they for real?

By Courtney Rubin

To Laura Salter, a fashion and lifestyle blogger, it seemed that no amount of diet and exercise would shrink her love handles or inner thighs. She thought that what she called the "obvious bulges" in her clothing were affecting her self-confidence and thus her work, but liposuction wasn't an option. She has three children and no time for recovery.

So in February 2018, Ms. Salter, 42, decided to have her fat frozen off, paying $2,400 — yes, a blogger who paid — for a roughly two-hour cryolipolysis, or fat freezing, session. (Fat cells freeze faster than skin cells, so a roll of it can be clamped by a machine and literally frozen to death.)

Agony level: five minutes of "Ooh, this is awful," she said, until each part went numb, followed by 20 minutes of "sharp, stabbing" post-treatment pain as the nerves thawed.

She was back in spin class two days later, feeling a little bruised. CoolSculpting, the brand name for the treatment, had promised results in two to three months, and sure enough, at the two-month mark Ms. Salter suddenly noticed the fat was gone — by her own measurement, one and a half inches off each thigh and half an inch off each love handle.

"I definitely didn't eat anything to celebrate," said Ms. Salter, who lives in Estes Park, Colo. "I just had the satisfaction of wearing my skinny jeans and my little turtleneck and not having any fat spilling over."

[Related: What is CoolSculpting?]

So-called body-contouring procedures like the one Ms. Salter had are increasing in popularity, rising 43 percent from 2017 and quadrupling since 2012, according to a 2019 report from the American Society for Dermatologic Surgery. (And those figures include only a fraction of the hundreds of thousands of fat-erasing treatments done at medical spas.)

For every one liposuction, there are more than 10 noninvasive body-sculpting treatments, according to the A.S.D.S. The genre includes fat-melting treatments via laser (brand names like SculpSure), radio-frequency (truSculpt, Vanquish) and ultrasound (Liposonix).

CoolSculpting from Allergan is by far the most popular, with multiple doctors describing it as a game changer — the first to give consistent, reasonably effective results without surgery — and it has come to define the market.

Not surprisingly, the category is rapidly expanding, most recently with muscle-building treatments that sound like something out of a late-night infomercial, in that they promise toning with zero exercise. First came Emsculpt, which debuted last year, using electromagnetic waves to cause a way-above-physiological-norm of 20,000 muscle contractions in 30 minutes, building muscle fibers by 16 percent — or so says BTL Aesthetics, the device's owner.

In June the F.D.A. cleared two more treatments for those who want a little muscle without the, er, heavy lifting. One is truSculpt Flex, which pumps up muscle via electrical current, which is similar in principle to the ab belts of those late-night infomercials except it has electrodes that can work on eight areas simultaneously.

The other is CoolTone, an Allergan offering coming later this month, which uses the same principles as Emsculpt but claims to be 50 percent stronger. (Brent Hauser, the vice president for sales and marketing at Allergan, said in an email that tests haven't yet concluded how much added muscle mass that amounts to.)

Of course there is a giant asterisk next to these devices, which is that they’re designed for regular gymgoers with minimal extra weight — very, very minimal, as in "a B.M.I. of 25 or less," Brad Hauser, the vice president for research and development at Allergan, wrote in an email. (Brad Hauser and Brent Hauser are identical twins.) They can be used alone, if you have minimal body fat, but they’re designed so they can be paired, one treatment after another in the same visit, with the fat busters.

How well this entire category of noninvasive devices works is relative.

"Liposuction is definitely the gold standard — there's no question it works better," said Dr. Mathew Avram, the faculty director for dermatology laser and cosmetic training at Harvard Medical School, as well as a CoolSculpting adviser. "But we’ve seen that patients are willing to pay a premium for modest results with no downtime."

In 2018, the average cost of liposuction was $3,518, according to the American Society of Plastic Surgeons. The average CoolSculpting treatment is $2,000 to $4,000, according to company figures, and fat-liquefying lasers like truSculpt ID are $2,150.

The muscle devices offer only temporary results (unlike the fat ones, which are permanent), though again with an asterisk: One's weight remains the same. Clients feel the muscle firmness (and soreness) immediately, but, as with the fat zappers, results can take some two months to show up.

The muscle-building devices are also time-consuming. They require at least four treatments (roughly $750 to $1,000 apiece) in quick succession (as in, days apart), plus top-ups every three months. Compare that with CoolSculpting, where some clients, including Ms. Salter, are finished after one session.

S. Tyler Hollmig, the director of laser and cosmetic dermatology at Dell Medical School at the University of Texas, is skeptical. There are no randomized trials showing efficacy of the muscle machines, and none offer other known benefits of exercise, such as improved cardiac health. All that, along with a steep price tag.

"I don't think these will disrupt the workout industry," Dr. Hollmig said. "It might be cheaper to have Tracy Anderson as one's personal trainer than to consistently afford these devices." (Ms. Anderson trains Gwyneth Paltrow, among others.)

But truSculpt Flex appealed to Katie Rosenthal, 28, a geologist in Denver, specifically because it doesn't involve the gym.

"The only thing I do for my abs is skip workouts," Ms. Rosenthal said, joking.

In September, she finished six 90-minute sessions in two weeks, at a total cost of $4,900. (Results won't peak for another eight to 12 weeks, but she said she is starting to notice.)

What to consider if you’re thinking about any of these treatments? First, keep in mind that none of them work on visceral fat, like a hard beer belly. That's a diet and lifestyle issue, said Whitney Bowe, a dermatologist in Manhattan.

Somewhat paradoxically, the muscle machines, whose effects are the most temporary, can be more painful than the fat ones. Michael Kelly, a clinical professor of plastic surgery at the Florida International University medical school, has had CoolSculpting ("no big deal" on the pain-ometer) and offers it in his practice; he found his trial of Emsculpt "more uncomfortable." His staff, Dr. Kelly said, couldn't tolerate the higher settings.

Dr. Bowe, who just ordered a CoolTone for her practice, thinks muscle machines may be an option for clients who aren't good fat-removal candidates because their skin lacks elasticity.

"If we get rid of the fat there, you’ll just have hanging skin," she said. "But if you have more muscle for the skin to rest on, it's like a redraping, and it might look firmer or tighter."

The fat-melting treatments claim to do some simultaneous "skin tightening" by contracting collagen in fibrous tissues surrounding the fat, a result that Lindsay Fisher, 38, of Denver, said she got from a $4,300 truSculpt treatment on her belly and love handles (and was why she chose it over CoolSculpting).

CoolSculpting is best used on squeezy, pinchable fat. Potential problems: If the applicators that grab the fat are incorrectly placed or the device is used on an area that doesn't actually bulge from the surrounding tissue, the results can be unsightly. When this happens, Brad Hauser said via email, "we typically recommend two treatment sessions so practices can address any unevenness."

More common is neuropathic pain — a stabbing, shooting kind not improved by over-the-counter drugs — that can persist for weeks or months. (It can be treated with prescription drugs.)

For Ms. Salter, the blogger, the results were worth the risk.

"It really takes a toll on you when you have those problem areas," she said.

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