According to Erika Sheyn, senior director of aesthetics at Guidepoint Qsight (New York, N.Y.), after an initial surge in 2023, the body shaping market has experienced a mild downturn. “Q1 2024 is down on monthly patient spend per 
practice in the nonsurgical body contouring segment compared to Q1 2023 and Q1 2022, so current procedure revenue data appears to be following that trend,” she reported. “Total U.S. sales for nonsurgical body contouring procedures was $106.6 million in Q1 2024, down from $139.9 million in Q1 2023.”
One potential offset of this slight downturn is the continuing trend of younger and younger patients stepping into the world of aesthetic medicine. “Qsight reported that Generation X (born 1965 – 1980) made up the largest share of nonsurgical body contouring spending in Q1 2024, followed by Millennials,” Ms. Sheyn added.
However, the brightest hope comes from a new sensation. Not since the emergence and development of liposuction has body shaping been at a turning point like it is now. Injectable glucagon-like peptide-1 receptor agonists (GLP-1) such as semaglutide have become all the rage because they are scientifi cally proven to control appetite and hunger in a way that truly facilitates weight loss.
Between the diabetes and obesity usage categories, J.P. Morgan Research estimates the GLP-1 market will exceed $100 billion by 2030.1 Also, according to Qsight, the recent surge in Semaglutide has largely driven total U.S. spending on the Weight Loss & Dietary Lifestyle segment in aesthetics. At $422.4 million in Q1 2024, it more than doubled from what was seen in Q1 2023 ($195.1 million).
Edward Zimmerman, MD, founder and director of Aesthetic Revolution Las Vegas (Las Vegas, Nev.) feels weight loss drugs could be fairly classifi ed as a body contouring modality because they address unwanted fat,” he said “They are changing lives, but they also represent an opportunity for both existing and emergent body contouring modalities."
Weight reduction leads to loss of more than just fat. Science shows that muscle mass is also lost. A 2021 randomized, head-to-head, placebo- controlled trial2 treated obese adults (n=195) in four groups with the 
following: liraglutide (a GLP-1 receptor agonist) with normal activity, liraglutide plus exercise, exercise alone with placebo, and placebo plus normal activity. While the liraglutide-only group lost the most weight and kept it off, the liraglutide-plus-exercise group was alone in experiencing improvement in the various health markers measured, such as insulin sensitivity and body fat percentage.
This is a perfect storm for therapies like the muscle building Emsculpt from BTL Aesthetics (Boston, Mass.). “Emsculpt was the best performing device in the nonsurgical body contouring category in 2023 measured by the three-point market share growth to finish the year with 27% market share,” said Duey Xu, data scientist at Qsight (Auckland, New Zealand). “There is no way to tell yet how weight loss drugs are affecting that segment of the market, but intuitively, it stands to reason that there will be signifi cant impact, given what we have already seen.”
Electric muscle stimulation (EMS) in one form or another has been in medicine for decades, but only recently has been successfully applied to aesthetic medicine in a profound way. Pure Impact from Sofwave Medical Ltd. (Yoqneam, Israel) is the newest arrival. “When undergoing treatment, the contractions the device induces are much more natural feeling than other devices, in my experience,” Dr. Zimmerman reported. “Instead of feeling achy and fatigued later, I feel energized, like I had a thorough workout and endorphin release.”
Precisely placed electrodes allow the treatment to emulate plyometric exercise (similar to martial arts). “You can tailor results with strategic placement of the PlyoPods,” Dr. Zimmerman added. “If I am working on someone’s buttocks and they want elevation and projection, I place the electrodes to affect muscles contracting on the lateral and superior poles, versus the lower, lateral gluteal muscles. Similarly, I can isolate the lateral abdominal oblique muscles and snatch the waist without causing more rectus projection, so we work towards a swimmer’s body rather than a body builder’s physique.”
Pure Impact is a module for the Sofwave platform, which uses ultrasound for more comfortable, non-invasive dermal coagulation. “We pair the high energy, ultrasound skin smoothing/ lifting abilities of the Sofwave with Pure Impact’s precise muscle stimulation to achieve better overall body results,” Dr. Zimmerman noted. In addition, Sofwave was recently FDA cleared for treatment of upper arm laxity.
For plastic and reconstructive surgeon Adam Rubinstein, MD (Miami, Fla.), the major advance on the surgery front is that there are techniques and devices that allow surgeons to take results to the next level. “With the patients of GLP-
1 receptor agonists we are going to see greater demand. While surgery is the still the gold standard for many aesthetic indications, for skin retraction, Renuvion (Apyx Medical) is my go-to,” Dr. Rubinstein expressed. “It allows us to be more aggressive with the liposuction,” he explained. “If we know we can get better contraction of skin, we can take more fat and get a better result that is also smoother and tighter.
Energy-based devices – especially used in combinations – paved the way for greater success in improving overall health via fat loss because they provide key elements that diet cannot, according to aesthetic and anti-aging physician, Ana Becerril, MD from Mexico City, Mexico. “Combination therapies give you better overall results,” she said. “With the variety available from the current armamentarium – between surgical, energy-based nonsurgical and injectable modalities – we can sculpt, reduce stubborn localized unwanted fat, reduce laxity, and build and maintain muscle mass. Combining muscle stimulation with lasers or RF for improving skin retraction is very effective. We have also combined energy-based therapies with injection lipolysis.”
Body Shaping with Injectables
According to plastic surgeon Sachin Shridharani, MD, founder of LUXSURGERY in Manhattan, N.Y., the only FDA-approved injection adipocytolysis therapy in the U.S. right now is deoxycholic acid. “Reducing submental fat was the gateway, now we are doing it all over
the body. In most cases, two to three treatment cycles are best to achieve patient satisfaction.” Patient selection, with respect to thickness of the targeted fat pad, as well as the skin quality overlying the anatomic location, is the top treatment pearl.
“Deoxycholic acid is an excellent tool for spot shaping stubborn pockets of fat that may persist even after weight loss,” Dr. Shridharani began, “but it is important to determine if deoxycholic acid is appropriate, if you can resolve (or the patient can accept) some resultant laxity, or if what the patient wants is best achieved in some other way.” Dr. Shridharani prefers needle injection over cannula for deoxycholic acid. “The cannula is great for many things, but needles give me the precise depth and location for deposition.”
Combining injection lipolysis with energybased modalities is not diffcult, according to Dr. Becerril, but one must pay attention to the order of treatment and do things in different sessions. “You reduce fat with injection lipolysis first. You tighten the skin with energy-based therapies such as lasers or RF in a later series of sessions, and later apply the muscle stimulation technologies,” she expanded. “You want to make sure the patient has healed from the injection before you try other therapies because there will be some swelling or bruising from the injection lipolysis.”
The novel use of neurotoxins for body contouring, provides a twist on the usual paradigm, according to Audrey Rose, ARNP, founder of the Audrey Rose Institute of Medical Aesthetics (Woburn, Mass.). “We have harnessed this well-understood, widely used minimally invasive modality to sculpt muscularity in key areas,” she explained. A good example is the gastrocnemius.
“In our culture we do not see it this way, but slim calves are an ideal in many Asian cultures. By injecting neurotoxin into key areas of the muscles, we can subtly but noticeably alter their shape withou
t undercutting their function. The calves help with mobility and balance, but also boost circulation of blood back to the heart. So, a patient with stage four pitting edema in the legs, for example, would not be a good candidate for neurotoxin injections in the gastrocnemius.”
Patients’ buttocks are another prime target. “We perform a nonsurgical butt lift using hyperdilute biostimulatory fillers,” Ms. Rose added. “If a patient has a gluteal crease we give them just the signature lift. To support and complement that we give them minor projection by injecting the inferior portion of that gluteal muscle causing the superior portion to hyper contract, thus lifting the butt and further improving that crease.”
She added that these techniques are often ideal for patients undergoing gender transition as well. “There are cultures and people groups that have different aesthetic standards, whether or not we fully understand them. It is about reducing cultural biases and being inclusive in a way that still promotes safe, effective, relevant aesthetic intervention.”
Awareness On the Cusp of Revolution
The explosion of weight loss injectables and its effect on the market may be unprecedented, but the immediate aftereffects are not. “Anytime something like this happens, the hype and the potential for a cash grab motivates people,” said Nick Tvrdik, founder and wellness director of Aria Integrative Health in Denver, Colo. His holistic healthcare center provides comprehensive, individualized plans that include weight loss injectables and the spectrum of body shaping modalities – with patients under watchful care from the get-go. This starts with body scanner scales that can accurately measure body fat and muscle mass but includes evaluations and monitoring of patient health (including blood tests).
“There are serious consequences when physicians are not doing their jobs, and it only takes a few bad apples," Mr. Tvrdik emphasized. “There are side effects to weight loss drugs beyond ‘Ozempic face and butt’ that are noteworthy, and we are not talking about them. For example, some people experience fecal incontinence. The importance of maintaining muscle during weight loss is just one factor. Proper medical supervision means more than medical professionals simply buying product and hanging out a shingle.”
Dr. Zimmerman agreed. “We tried adopting weight loss injectables on a provisional basis, but it just was not for us,” he said. “This is something one should not undertake lightly. It is more important to use our armamentarium to the benefit of the patient, and we have a chance to play a unique role in what we all hope is a health revolution. We need to work to make the most of it, and that means doing things right, complete with testing, monitoring and education.”
Innovation Spotlight
The new EON+ Advanced update from Dominion Aesthetic Technologies, Inc. (San Antonio, Texas) introduces artificial intelligence (AI), fl exible setup, intelligent energy management and automated QuickCool cycles enhancing precision
, comfort and effectiveness. EON+ Advanced swiftly transitions from a small segment to a larger, customized segment in seconds. It creates tailored curves to effectively target challenging areas like the flanks and inner thighs. In just 20 minutes, EON achieves an impressive 6.3 mm fat loss. No less than 40 safety sensors ensure optimal safety and precision, providing crucial data for system improvements.
Z Wave by Zimmer MedizinSystems (New-Ulm, Germany) is making waves in the aesthetic industry with non-invasive applications spanning from cellulite reduction to post-procedure recovery enhancement. The Class 1 device is renowned for the temporary reduction of cellulite appearance; it also increases local blood circulation and relieves minor aches and 
pains. Its powerful sound waves radiate deep into the tissue, stimulating circulation and enhancing lymphatic drainage. This action integrates seamlessly with surgical liposuction, but augments energy-based body sculpting results as well, reducing recovery time and minimizing side effects. Z Wave is FDA cleared for enhancement of local blood circulation and may improve, and even resolve, capsular contracture post-breast enhancement surgery.
References:
1. The increase in appetite for obesity drugs. J.P. Morgan online. https://www.jpmorgan. com/insights/global-research/ current-events/obesity-drugs accessed April 22, 2024.
2. Lundgren JR, Janus C, Jensen S, et al. Healthy weight loss maintenance with exercise, liraglutide, or both combined. N Engl J Med 2021;384:1719-30.
