CLINICAL

BODY OF EVIDENCE

Dr Paul Charlson asks, is injectable lipolysis revolutionising non-surgical body contouring?

Non-surgical solutions for fat reduction and skin rejuvenation continue to dominate patient demand. Among the most talked-about innovations are Aqualyx and PB Serum – two injectable treatments designed to sculpt, refine and rejuvenate the body without the need for invasive surgery.

Several adipocytolytic injectable products are available in the UK market and are modifications of deoxycholate (DC). These include: Aqualyx, Desoface and Desobody. PB Serum is a cocktail of recombinant enzymes and hyaluronic acid.

AQUALYX

Aqualyx is a fat-dissolving injectable treatment developed to target localised fat deposits that resist diet and exercise. It is not a weight-loss solution but rather a body contouring tool.

Aqualyx is an injectable treatment of 12alfa-dihydroxy-5beta-24oico cholanic acid sodium salts, which is a modified compound of cholanic acid (DC).

It was developed by Professor Pasquale Motolese, president of the Italian Society of Aesthetics and Medicine, and was first introduced in 2009. It is sometimes referred to as “Motolese’s Solution” and is classed as a medical device (European CE mark, approved in December 2012). The CE registration for Aqualyx is granted for use of the solution in a two-step treatment with an external ultrasound device, so most practitioners use it as a standalone off-license product.

Technique

The product is suitable for any area of fat, although care on the face is particularly important.

The technique involves using a long needle passed into the area of fat to be dissolved, although I sometimes use a long cannula. Long strands of product are deposited retrogradely.

The area required may need passes in different directions and depths in a homogeneous fashion. Care is required to ensure it is in the fat (best to pinch the fat) and no large boluses of the product are left.

The treatment is generally repeated every four weeks and can take between two and eight sessions. This is dependent on the site and the amount of fat. I prefer it for smaller areas of fat and often combine it with HIFU.

How does it work?

Aqualyx destroys the fat cell membrane. Thuangtong R, Bentow JJ, Knopp K, et al (2010)1 noted that the product differentially destroys adipose cells; cells such as muscle cells with higher protein content are protected.

Does it work?

Amore et al (2016)2 found a 76% success rate on average across a number of sites. This was a large trial over many countries and using various injection sites and numbers of treatments.

There are several studies that confirm the effectiveness of DC as a lipo-destructive agent.3-4

Histological examination suggests that cytolysis using DC can continue for several weeks and therefore it is better to space the treatments at least four weeks apart.

Real Self rated it worth it in 40% of 13 patients. My experience is better than this, with around an 80% satisfaction rate. My feeling is that setting realistic expectations and patient selection are vital components.

Side effects

Generally, DC is safe, with the main side effects being swelling and reddening up to 14 days after treatment. There are potentially more serious side effects. I had one patient who had transient demyelination of the marginal mandibular nerve following treatment of submental fat. This resolved after a few weeks. This has been noted with a similar product, Kybella . (Kythera Biopharmaceuticals, Inc.)5 Other case reports with nodule formation, skin necrosis and infection have been noted but are very rare.

DESO FACE AND BODY

Another product used in the UK is Deso, which is very similar to Aqualyx, and some practitioners prefer this, claiming it is more effective. I cannot find any studies to compare the two products, so which is better appears to be a matter of personal choice.

PB SERUM

PB Serum contains a blend of enzymes and active ingredients: Collagenase breaks down damaged collagen and promotes regeneration; lipase dissolves fat cells in targeted areas; lyase reduces fluid retention and puffiness and hyaluronic acid enhances skin hydration and elasticity. This is a relatively new set of products in the UK and is potentially interesting. Fierro-Arias et al (2017)6 considered its use in lipolysis and scar improvement and found it useful in some cases. I personally use this product in clinic and, in particular, on the face in the jowl fat, where it is less likely to create side effects compared with DC. It has been reasonably effective.

There have been a few studies, such as Jabbour et al (2024)7 , which found PB serum effective in submental fat in 10 patients and found good efficacy with 92 % improved skin firmness, 84% fat reduction, and excellent safety.

PB Serum is interesting and there is definitely some potential for treating jowl and submental fat safely.

Technique

The technique for injecting PB Serum consists of depositing a bolus of product in the deep face and then retrograde injection into the more superficial tissue.

One drawback of PB Serum is that it has to be used at the time of reconstitution or soon after, and cannot be stored, making it more expensive than DC.

LEMON BOTTLE

No article on injection lipolysis could be complete without mentioning Lemon Bottle. Lemon Bottle, which is manufactured by South Korean cosmetics company SID Medicos, is marketed as a “natural” injectable product that “targets fat deposits”. The product reportedly contains bromelain, riboflavin and lecithin. The GPhC warned the sector that unlicensed medicinal products are not required to meet standards for safety and efficacy, may not disclose the full list of ingredients and come with “limited or no clinical safety data”. In March 2024, Swiss medicines regulator Swissmedic warned the public against using Lemon Bottle, stating that the product had “no medicinal effect”.

Whilst some practitioners and patients say that it is effective, I was unable to source any studies proving its efficacy or safety.

CONCLUSIONS

DC has the longest track record and is effective at destroying fat. It is largely safe but has to be used with care as there are risks that may be underplayed by its exponents. I have treated many patients and, in general, without issue and with a high degree of patient satisfaction. DC is better for smaller areas of fat, causes significant swelling and takes several treatments. The cost of the product is relatively low.

For scar remodelling, jowl and chin fat PB Serum is a promising alternative as the side effect profile is good with less swelling, and it appears effective. Again, it requires multiple treatments, but it does help to tighten sagging skin. The main drawback is its cost. Currently, the preparation kit can treat at least two patients, but if it is not used within a few hours, it needs to be discarded, so planning is essential. Other potential areas of interest for injection lipolysis are small lipomas and cellulite.

DR PAUL CHARLSON

Dr Paul Charlson FRCGP FBCAM DPD DOccMed DRCOG has clinics in London and Yorkshire. He has used injection lipolysis since 2011 and treated many patients in his clinics with Aqualyx and PB Serum. Paul is past president of BCAM and Co-Chair of Clinical Advisory Board Of JCCP.