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OBES SURGDOI 10.1007/s11695-010-0126-y CLINICAL RESEARCH Efficacy of Low-Level Laser Therapy for Body Contouringand Spot Fat Reduction Mary K. Caruso-Davis & Thomas S. Guillot & Vinod K. Podichetty & Nazar Mashtalir &Nikhil V. Dhurandhar & Olga Dubuisson & Ying Yu & Frank L. Greenway # Springer Science+Business Media, LLC 2010 Results Data were analyzed for those with body weight Background Low-level laser therapy (LLLT) is commonly fluctuations within 1.5 kg during 4 weeks of the study.
used in medical applications, but scientific studies of its Each treatment gave a 0.4–0.5 cm loss in waist girth.
efficacy and the mechanism by which it causes loss of fat Cumulative girth loss after 4 weeks was −2.15 cm from fat cells for body contouring are lacking. This study (−0.78 ± 2.82 vs. 1.35 ± 2.64 cm for the control group, examined the effectiveness and mechanism by which 635– p < 0.05). A blinded evaluation of standardized pictures 680 nm LLLT acts as a non-invasive body contouring showed statistically significant cosmetic improvement after 4 weeks of laser treatment. In vitro studies suggested that Methods Forty healthy men and women ages 18–65 years laser treatment increases fat loss from adipocytes by release with a BMI <30 kg/m2 were randomized 1:1 to laser or of triglycerides, without inducing lipolysis or cell lysis.
control treatment. Subject's waistlines were treated 30 min Conclusions LLLT achieved safe and significant girth twice a week for 4 weeks. Standardized waist circumfer- loss sustained over repeated treatments and cumulative ence measurements and photographs were taken before and over 4 weeks of eight treatments. The girth loss from the after treatments 1, 3, and 8. Subjects were asked not to waist gave clinically and statistically significant cosmetic change their diet or exercise habits. In vitro assays were conducted to determine cell lysis, glycerol, and triglyceriderelease.
Keywords Cold laser . Fat reduction . Low-level lasertherapy . Non-invasive laser This study was supported by Meridian Medical, Inc., Vancouver, BC,Canada V6K 4L9.
M. K. Caruso-DavisSchool of Human Ecology, Louisiana State University,Baton Rouge, LA 70803, USA Laser-based devices are used in a broad array of medicaland surgical applications and their biological effects have been documented for over 20 years. More recently low- Plastic and Reconstructive Surgery, level laser (LLL) devices have been used to facilitate tissue Baton Rouge, LA 70808, USA repair and healing processes. Although physiological methods responsible for augmented cell proliferation and Research Practice Partners, pain relief are unknown, well-controlled clinical trials have Miramar, FL 33027, USA demonstrated that low-level lasers provide therapeutic relief N. Mashtalir : N. V. Dhurandhar : O. Dubuisson : Y. Yu : of pain. Low-level laser therapy is defined as management F. L. Greenway (*) with a dose rate that causes no immediate demonstrable Pennington Biomedical Research Center, temperature rise of the treated tissue and no macroscopi- Louisiana State University System, cally visible change in tissue structure The dosage is a Baton Rouge, LA 70808, USAe-mail: [email protected] magnitude used to define the laser beam energy applied to a particular area of the body tissue measured in joules per Randomization was created from random number tables square centimeter.
and the treatment codes were stored in sealed envelopes The Meridian LAPEX 2000 LipoLaser System is a semi- during the study. Subjects could not be using light conductor-based, low-level laser therapy device (LLLD).
sensitizing agents, diuretics, or undergoing photodynamic The LAPEX 2000 LipoLaser was originally developed and therapy. Subjects were required to have a stable weight, approved for the treatment of pain due to carpel tunnel gaining or losing no more than 2.5 kg in 6 months prior to syndrome. The LAPEX 2000 LipoLaser has been modified the trial. Subjects could not be on a weight reduction and is now being rigorously evaluated for its effectiveness regimen, and they were asked not to change their diet or in reducing areas of local fat accumulation for cosmetic exercise habits during the trial. This study was performed in purposes. The LAPEX 2000 LipoLaser emits light at 635– accordance with the Declaration of Helsinki and approved 680 nm. It is non-thermal and does not heat the tissues. As by the Argus Institutional Review Board. Written informed such, it is considered to be a non-invasive treatment.
consent was obtained from all participants prior to study Neira et al. [] evaluated the effect of a 635–680 nm, 10- mW diode laser radiation with exclusive energy optics on The laser therapy device consisted of a console housing treated fat cells in biopsy specimens. Fat cells were treated most electronics, the controls for the device, and two in vivo with 1.2–3.6 J/cm2 of energy from the laser for 2 to multiprobes that housed four lasers emitting visible laser 6 min. The cells were then removed by lipectomy, light at a wavelength of 635–680 nm. Each subject had two examined by electron microscopy, and compared to cells treatments per week for a total of eight treatments over removed by lipectomy that were not treated with the laser.
4 weeks. Each treatment session lasted approximately Fat cells that were not exposed to the laser treatment looked 30 min. The two multiprobes were placed over the waist like round grapes. Eighty percent of the fat was released bilaterally in three positions as well as two enhancement from the fat cells after 4 min of laser light exposure and probes that were placed to both sides of the inguinal region 99% was released after 6 min of exposure. After exposure and the laser was activated for 10 min in each of these to the laser light, pores in fat cells were visible by scanning positions to encompass the waist from the back to the front.
electron microscope. It was presumed, but not demonstrat- The control arm of the trial utilized the device, but the ed, that the fat was released from these pores, taken up in multiprobes of the device were inactivated during the the lymphatics and reesterified in other tissues or metabo- treatment session.
lized for energy Two individuals conducted the study. One administered the Several studies have recognized that LLL accelerates treatment, and the other, who was blinded to treatment repair processes, stimulates cell proliferation, and pro- allocation, obtained measurements and photographs. The motes vascularization in injured tissues [–However, individual administering the treatment remained blinded to clinical application to body fat reduction as a minimally photographic and girth measurements. Each subject was invasive option is an evolving field which is not well advised about the rules of blinding, and the individual taking studied. We conducted a blinded clinical trial to describe photographs and measurements could not relay this informa- the application of low-level laser therapy to local fat tion to the subject. The individual administering the treatment reduction for cosmetic purposes. As a secondary objec- did not enter the room where the photographs and measure- tive, we also investigated the mechanism by which the ments were obtained. A case report form was used for each laser causes fat loss from fat cells. The mechanistic study measurement session and these forms were placed in a sealed investigated whether the fat loss induced by the laser is envelope until data was analyzed at the end of the study. Two due to (1) the activation of the complement cascade lysing separate people who were not involved in other aspects of the adipocytes, (2) adipocyte death, or (3) release of intact study did the blinded evaluations of the photographs.
triglycerides from cells vs. the release of glycerol and fatty All subjects had photographs taken at a standardized acids after lipolysis.
distance with a standard background and lighting. Girthmeasurements of the waist were obtained in the mannerrecommended by the United States National Institutes of Health (NIH) guidance at the iliac crest using a tape measurewith standardized tension and oriented parallel to the floor ]. A reference point on the body for the pictures andmeasurements was relocated at each evaluation by measuring Forty healthy men and women between the ages of 18– a distance from the floor that was determined in the first 65 years, inclusive, and body mass index (BMI) no greater measurement at baseline. The specified measured distance than 29.9 kg/m2 were randomized in a 1:1 ratio to an was used to ensure all measurements and photographs were experimental laser treatment or to a control laser treatment.
obtained in the same location. The camera was placed on a

tripod at a fixed distance from the floor but was adjusted to Table 1 Baseline demographic characteristics of study subjects in theLAPEX 2000 LipoLaser study the specific height of each individual participant. Standard-ized waist measurements were taken at baseline, treatment 3, and treatment 8. Standardized photographs were taken beforeand after the initial treatment, treatment 3, and treatment 8.
Weight was measured and BMI was calculated at baseline and at treatment 8 (week 4). Blood pressure was measured at baseline, treatment 3, and treatment 8. All adverse events were recorded in the case report forms.
The waist circumference measurements were compared between the control and laser-treated group using a t test.
The data were analyzed using completers and the more Waist circumference (cm) conservative intent to treat analysis. The blinded observers judged improvement on a 0–3 scale. Zero on this qualitative Body mass index (kg/m2) scale represented no improvement, 1 represented mild improvement, 2 represented moderate improvement, and 3 Systolic blood pressure represented marked improvement. The results of the two observers were averaged and compared by t test.
Diastolic blood pressure75.35 In Vitro Studies Using Human Fat Cells Values are means and standard deviation (SD).
Experiment 1 Does the laser activate the complement using a 10× (Zeiss Achroplan objective) and a 20× (LD plan NeoFluor objective), and a Zeiss Axiocam HRc camera [ Human adipose-derived stem cells obtained from subcu- taneous fat during abdominal surgery were plated and Experiment 3 Does the laser increase triglyceride release or differentiated to form adipocytes as described by Bunnel et lipolysis from adipocytes? al. [Human adipocytes were differentiated in 12-well This experiment used human adipocytes in eight 6-well plates. Three of the wells in the plates were left as a control.
plates. Two wells in each plate were used as a control with Fresh plasma replaced one third of the cell culture media inanother three wells. The next three wells had one third ofthe media replaced with plasma that was heat-inactivated todestroy complement. The final three wells in each plate hadone third of the media replaced by a combination of freshhuman plasma and white blood cells. One experimentalplate was irradiated with the LAPEX 2000 LipoLaser for10 min and the other was left as a non-irradiated control.
The cells were then evaluated for evidence of lysis underthe microscope.
Experiment 2 Does the laser kill adipocytes? To evaluate influence of LAPEX 2000 LipoLaser on adipose cell death and viability, we used LIVE/DEAD® CellViability Assays (Invitrogen). Human adipocytes were differ-entiated in 96-well plates. The experimental plate was Fig. 1 The difference in girth loss between placebo and the LAPEX irradiated with the LAPEX 2000 LipoLaser for 10 min and 2000 LipoLaser at treatments 1, 3, and 8 were all 0.4 to 0.5 cm, and the other was left as a non-irradiated control. The cells were the difference in girth loss at treatment 3 was statistically significant then probed with cell viability assay reagent using the (p < 0.05). The difference in cumulative girth loss compared fromtreatment 1 to 3 was statistically significant by LOCF or completer's manufacturer's protocol. Calcein and propidium iodide analysis (p < 0.05). The difference in cumulative girth loss at emissions were then analyzed using a fluorescent plate treatment 8 was significant in subjects who remained within 1.5 kg reader. Images were acquired on a Zeiss Axiovert 40 CFL of their baseline weights (p < 0.05)

scheduling conflicts. There were no adverse events in eithergroup during the trial. The groups were well balanced atbaseline, and the group characteristics are illustrated inTable . Mean weight and BMI did not change significantlyover the eight treatments and 4 weeks. Blood pressure didnot change significantly from baseline to treatment 3, fromtreatment 3 to treatment 8, or from baseline to treatment 8.
The mean placebo subtracted reductions in waist girth attreatments 1, 3, and 8 with the LAPEX 2000 LipoLaserwere 0.49, 0.41, and 0.40 cm, respectively. This singletreatment difference, 0.41 cm (laser −0.59 ± 0.71 cm vs.
placebo −0.19 ± 0.47 cm) (mean±SD), was significant(p < 0.05) on the third treatment done during week 2 in thecompleters analysis, but was not statistically significant by Fig. 2 Blinded appearance ratings on a 0–3 scale over 4 weeks and the intent to treat analysis. The cumulative girth loss at eight treatments favored the LAPEX 2000 LipoLaser treatment treatment 3 on week 2 was a significant 1.74 cm compared to the placebo treatment (p < 0.001) (laser −1.89 ± 2.97 cm vs. placebo −0.16 ± 2.46 cm, media containing 10% fetal bovine serum (FBS). Two other p < 0.05) on both the completers' analysis and by intent to wells had 25% of the media with 10% FBS replaced with treat analysis. Cumulative girth loss at treatment 8 (4 weeks of human serum with 10% FBS. The last two wells had 25% treatment) was 2.15 cm with 15 subjects in the laser group and of the media with 10% FBS replaced with heat-inactivated 16 subjects in the placebo group (laser −0.78 ± 2.82 cm vs.
human serum with 10% FBS. Four of the plates were placebo 1.35 ± 2.64 cm) in those who maintained their weight irradiated for 10 min with the laser and the other four plates within 1.5 kg of their baseline weight (p < 0.05). Cumulative served as a non-irradiated control. Media from the eight girth loss at treatment 8 (4 weeks of treatment) was 1.33 cm replicates of each of the three conditions in the laser with 19 subjects completing in the placebo group and 20 irradiated plates and the non-irradiated control plates were subjects completing in the laser group (laser −0.87 ± 2.65 cm used for glycerol and triglyceride determination.
vs. placebo 0.47 ± 3.19 cm) regardless of weight change (p=NS). The standardized pictures of the participants showed asignificant 1.21 difference (laser 1.21 ± 0.42 vs. placebo0 ± 0) in appearance on a 0–3 scale favoring the LAPEX 2000 LipoLaser group comparing baseline to week 4 (treatment 8)pictures (p < 0.001). When only those participants that remained within 1.5 kg of their baseline weight (N = 31)were considered, the improvement in appearance increased to Forty subjects participated in the clinical trial. Twenty were 1.25 (laser 1.25 ± 0.45 vs. placebo 0 ± 0) on a 0–3 scale treated with the LAPEX 2000 LipoLaser and 20 were comparing baseline to week 4 (treatment 8) pictures treated with an inactive version of the device. One subject (p < 0.001). The girth difference in the laser group compared in the treatment group did not complete the study due to to the placebo group is illustrated in Fig. The differences in Fig. 3 Woman before and after4 weeks and eight treatmentswith the LAPEX 2000LipoLaser

Fig. 4 Man before and after4 weeks and eight treatmentswith the LAPEX 2000LipoLaser appearance from baseline to week 4 (treatment 8) in the whole Experiment 2 The laser does not kill adipocytes.
group and the subjects who remained within 1.5 kg of their The number of viable cells in the laser-treated or baseline weight are illustrated in Figs. and . Fig. untreated group as determined by the propidium iodide shows a placebo subject at baseline and 4 weeks (treatment 8) assay were similar, but calcein levels were lower in the who remained within 1.5 kg of her baseline weight. Figs. laser-treated cells (Fig. Calcein, a non-fluorescent dye, and show a subject who lost 2.2 kg and 2.7 kg in the laser gets transported through the cell membrane, becomes and placebo treatment groups, respectively.
fluorescent due to cleavage with cellular esterases, and getstrapped intracellularly. Normally functioning cells canextrude the entrapped dye. Considering the equal cell In Vitro Study Using Human Fat Cells viability in the two groups, lower calcein levels in thelaser-treated group suggests either intact metabolic func- Experiment 1 The laser does not activate the complement tioning of cells and/or reduction of cell-trapped calcein, perhaps by leakage.
The fat cells that came into contact with plasma or These findings are also consistent with the studies by plasma with white blood cells were lysed in both the laser- Niera [] in which the laser-treated cells showed micro- treated and the control plate, but cells in the control wells or pores in the membrane, which presumably contributed to in wells with heat-inactivated plasma were not lysed. This the leakage of fat from those cells.
indicates that serum complement does lyse fat cells, but thatthe laser does not activate complement. This is consistent Experiment 3 The laser increases triglyceride release, but with the mechanism shown by Niera [] in which the laser not lipolysis from adipocytes. Baseline triglycerides in the created pores through which the fat leaked from the fat cells control wells were undetectable and were increased, as into the interstitial space.
expected, in the wells with serum. The control wells did not Fig. 5 Woman before and after4 weeks and eight treatmentswith the placebo LAPEX 2000LipoLaser who maintained herweight within 1.5 kg of startingweight

Fig. 6 Woman who lost 2.2 kgbefore and after 4 weeks andeight treatments with theLAPEX 2000 LipoLaser increase triglycerides or glycerol in the media in response media in the presence of heat-inactivated or normal serum to laser irradiation. The laser-irradiated wells containing suggesting that any fat loss from adipocytes in response to serum had significantly greater increases in triglycerides the laser treatment is not due to a stimulation of lipolysis.
than the non-irradiated wells containing serum (69 ± 1.7 vs.
On the other hand, the increase of triglyceride into the 66.7 ± 1.5 mg/dL, p = 0.004). The laser-irradiated wells media in response to laser irradiation in the presence of containing heat-inactivated serum had a significantly normal or heat-inactivated plasma suggests leakage of greater increase in triglycerides than the non-irradiated intact triglycerides from cells, a possible mechanism to wells containing heat-inactivated serum (72.6 ± 1.8 vs.
explain the observations of Niera [], which showed 70.1 ± 1.6 mg/dL, p = 0.008). Baseline glycerol levels were reduction in lipid content and the appearance of micropores not different in the laser-treated or the non-irradiated groups in laser-treated adipocytes. These findings suggest that (0.11 ± 0.01 vs. 011 ± 0.01 mmol/L, p = 0.44). The laser- human serum is necessary for the laser to release irradiated wells with serum had significantly lower glycerol triglycerides from the fat cell and that the action is not levels than the non-irradiated group (0.14 ± 0.01 vs.
0.17 ± 0.03 mmol/L, p = 0.01). The glycerol levels in thelaser-irradiated wells containing heat-inactivated serumwere not different from the non-irradiated wells with heat-inactivated serum (0.14 ± 0.01 vs. 0.15 ± 0.02 mmol/L, p = 0.3). Before and after laser irradiation in the presence ofserum in which triglycerides were released, the cells Low-level laser therapy is a light source treatment that continued to appear intact without evidence of lysis generates light of a single wavelength. Low-level laser (Fig. Laser treatment did not release glycerol into the therapy emits no heat, sound, or vibration. Instead of Fig. 7 Woman who lost 2.7 kgbefore and after 4 weeks andeight treatments with the place-bo LAPEX 2000 LipoLaser

Fig. 8 The number of live anddead cells measured by propi-dium iodide and the cellularmetabolism measured by calceinwith and without laser treatment producing a thermal effect, low-level laser therapy acts via fluctuation was to accommodate the effect of menstruation- nonthermal or photochemical reactions in the cells, also related fluid shifts in women while representing a more referred to as photobiological or biostimulatory ].
conservative value in one man with a weight fluctuation of A single LAPEX 2000 LipoLaser treatment yielded girth loss, and repeated treatments remained effective giving Girth loss over the course of the study was greater than approximately a 0.4 to 0.5 cm girth loss per treatment. This 2 cm and statistically significant. The subjects in this study difference was statistically significant at treatment 3, were not obese and an approximate 1 inch (2.54 cm) demonstrating that the effect of the LAPEX 2000 Lip- reduction in waist girth over the course of 8 treatments and oLaser does not appear to diminish with repeated treat- 4 weeks was clinically significant and cosmetically rele- ments through time. The 1.74 cm girth loss at treatment 3 vant. The blinded ratings of the baseline pictures compared suggests that the LAPEX 2000 LipoLaser treatments twice to treatment 8 (week 4) pictures taken in a standardized a week are cumulative in their effect on girth loss.
way demonstrated an improvement in appearance that was It is likely that weight change over the course of highly statistically significant. As expected, the improve- treatment would change waist circumference and confound ment was greater when limiting the comparison to only the results. The subjects selected for the study were asked those subjects that remained within 1.5 kg of their baseline not to lose or gain weight over the course of the study.
Since some subjects did gain or lose a significant amount of The mechanism by which the laser reduces fat from fat weight over the 4-week study, the cumulative fat loss was cells observed by Neira et al. [] was unclear. Fat cell lysis, analyzed only on those subjects whose weight was within lipolysis, followed by glycerol and fatty acid release, or 1.5 kg of their baseline weight. The 1.5-kg weight leakage of fat from fat cells are some possible explanations.
Fig. 9 Human adipocytes inculture before and after LAPEX2000 LipoLaser irradiation for10 min in the presence of serumin which triglycerides were re-leased—cells remain intactwithout evidence of lysis First, we determined if the laser-induced cell lysis by a mobilize subcutaneous fat for body contouring without complement-mediated process. Gay-Crosier et al. found weight loss, future investigations should involve larger that a pulsed dye laser activated complement in normal skin samples and explore the application of this technique to and confirmed this phenomenon by measuring a rise in other body parts for cosmetic contouring.
membrane attack complex of complement [Our experi-ments revealed that plasma with complement lysed cells This study was supported by a grant from with or without the laser and that heat-inactivated serum Meridian Medical, Inc. Mary Katherine Caruso-Davis received without complement did not. Confirming the findings of support for her assistantship through the Bissoon Mesotherapy Niera [], we found that the cells were not killed by laser Foundation. The mechanistic in vitro studies were partially supportedby a CNRU Center Grant # 1P30 DK072476 entitled "Nutritional treatment, but had increased clearance of the dye, consistent Programming: Environmental and Molecular Interactions", sponsored with pores being present in the membranes of the cells.
by NIDDK with the assistance of Jeffrey Gimble, M.D., Ph.D. and Interestingly, laser treatment of human fat cells without Ying Yu, MS. The authors wish to thank Eleanor Meador for serum present did not result in the release of triglycerides, coordinating the study and performing the LAPEX 2000 LipoLasertreatments, Lindsay Southard and Canaan Heard, undergraduates but in the presence of normal serum or heat-inactivated working on the study, and Mary Beth Burnett who assisted in serum, triglyceride in the media was increased by laser irradiation. Presence of serum along with fat cells simulatesin vivo environment to release triglycerides in the presenceof laser irradiation and further confirms the ability of the laser to influence fat loss. There was no increase of glycerolin the media, confirming that the laser did not stimulate 1. King PR. Low level laser therapy: a review. Lasers Med Sci.
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laser therapy appears to offer a non-surgical option to

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