ATX-101 for reduction of submental fat: A phase III randomized controlled trial

Management of Serious Adverse Events Following Deoxycholic Acid Injection for Submental and Jowl Fat Reduction: A Systematic Review and Management Recommendations

Pivotal Phase 3 randomized control trials have demonstrated a favorable safety profile for ATX-101 in submental fat (SMF) reduction; however, in real-world settings, several serious adverse events (SAEs) have been reported, most of which are procedure related and avoidable. Current understanding of the management of uncommon AEs and SAEs is based on the aesthetic surgeon's discretion, and overzealous protocols for sclerosis agents are being applied for ATX-101-induced arterial injury. This review focuses on showcasing the management of SAEs reported previously and updating it with personal clinical experiences with ATX-101 for SMF and jowl fat reduction. Along with adherence to the standard procedures for ATX-101 administration, the authors recommend investigating other potential causes of SMF accumulation and jowling mechanism, appropriate demarcation of the surface area to determine the number of vials, and assessment of the fat pad thickness to determine the number of required treatment cycles for optimal therapeutic outcomes. Surgery is preferable for jowling caused by compartment displacement (ptosis), whereas fat-reducing treatments such as ATX-101 are contraindicated for jowling caused by subcutaneous tissue atrophy. Some proactive measures that can be employed to prevent AEs include avoiding intradermal injections to prevent skin ulceration/necrosis, injecting lidocaine to check for smile asymmetry as an indication of marginal mandibular nerve proximity, administering 1 to 2 mm deeper injections in males to prevent alopecia, employing good aseptic techniques to prevent abscess formation, injecting 1 product at a time using correctly labeled syringes, and confirming the diagnosis of pyoderma gangrenosum before treating it as an infection.

Level of Evidence 3

Lipolytic agents for submental fat reduction: Review

RESULT

The review delves into the realm of reducing submental fat, presenting a comprehensive analysis of various lipolytic agents used in plastic surgery and dermatology. The introduction establishes the context by defining the key indicators of a youthful neck and emphasizing the significant influence of fat in the aging process, particularly in the submental area. The usage of aminophylline involves subcutaneous injections, facilitating fat breakdown by increasing cyclic adenosine monophosphate and inhibiting adenosine receptors. Hypotonic pharmacologic lipo-dissolution induces fat dissolution via injected compounds under pressure, while lipolytic lymphatic drainage employs hyaluronidase to reduce tissue viscosity, aiding fat circulation. Glycerophosphorylcholine containing choline alfoscerate claims to activate fat metabolism, whereas the utilization of phosphatidylcholine combined with deoxycholate lacks cosmetic approval due to safety concerns. Deoxycholic acid has FDA approval for submental fat reduction, yet its mechanisms remain incompletely understood. Understanding the complex anatomy and mechanisms of lipolytic agents is essential for safe and effective submental fat reduction, despite evolving practices and off-label utilization. Clinical guidelines and references support this discussion, offering insights for safer applications.

Efficacy, safety, and potential industry bias in using deoxycholic acid for submental fat reduction ‒ A systematic review and meta-analysis of randomized clinical trials

Lipolytic substance injections to reduce localized fat have been extensively used because it is a low-invasive method. This review aimed to evaluate the efficacy and safety of deoxycholic acid in submental fat reduction compared to a placebo and investigate the potential industry sponsorship bias in the results of randomized clinical trials on this topic. Ten electronic databases were extensively searched for randomized clinical trials without restriction on language and year of publication. Two reviewers extracted the data and assessed the individual risk of bias in the studies with the RoB 2.0 tool. The industry sponsorship bias was evaluated according to citations in the articles regarding industry funding/sponsorship throughout the texts. Fixed and random effects meta-analyses were performed, and the results were reported in Risk Ratio (RR) at a 95% Confidence Interval (95% CI). The initial search provided 5756 results, of which only five were included. Only two studies had a low risk of bias. All studies showed a potential industry bias. The meta-analysis showed that patients treated with deoxycholic acid had significant positive results for all efficacy outcomes and a higher risk of fibrosis, pain, erythema, numbness, swelling, edema, pruritus, nodules, headache, and paresthesia. The low to moderate certainty of evidence found allows concluding that deoxycholic acid is effective in submental fat reduction, causing well-tolerated adverse effects. However, all eligible studies showed a potential industry bias.

Rose S, Battucci S, Simonyi S. CONTOUR Australia: Condition of Submental Fullness and Treatment Outcomes with Belkyra Registry

Submental fat (SMF) contributes to an aged or overweight appearance that may negatively impact an individual's psychological well-being. Deoxycholic acid (ATX-101) is an injectable formulation of deoxycholic acid approved to treat SMF. The Condition of Submental Fullness and Treatment Outcomes Registry (CONTOUR) Australia study was designed to understand treatment patterns and outcomes with ATX-101 in Australia.

Methods

CONTOUR Australia was a phase 4, prospective, observational, multicenter registry that enrolled adults considering treatment for SMF reduction.

Results

The registry enrolled 86 patients from six sites. Significant changes from baseline through the end of treatment indicated improvement in mild to moderate fullness associated with SMF on the Clinician-Reported SMF Rating Scale and the Patient-Reported SMF Rating Scale, improvement in SMF-associated psychological impact after treatment on the Patient-Reported SMF Impact Scale, no overall worsening in skin laxity based on Submental Skin Laxity Grade, and increased patient satisfaction with the face/chin on the Subject Self-Rating Scale after receiving treatment. Adverse events were all mild and mostly related to the injection site (ie, bruising and swelling).

Conclusion

CONTOUR Australia observed clinically meaningful and significant outcomes and further supports ATX-101 as a well-tolerated and effective treatment for SMF reduction.

Evidence-Based Medicine for Nonsurgical Facial Rejuvenation

Options for nonsurgical facial rejuvenation treatment have increased significantly in both availability and popularity over the past two decades. However, there remains a paucity of clinical practice guidelines and evidence-based recommendations for these procedures. The purpose of this article is to assess the presence of current high-level research for various methods of nonsurgical facial rejuvenation using the Oxford Centre for Evidence-Based Medicine. Botulinum toxin injections remain the best-studied method, with several randomized controlled trials guiding recommendations for safety and efficacy. Several studies on injectable fillers document complications and recommendations to avoid these, but sample sizes are small and many are noncomparative. Deoxycholic acid has been well examined and Food and Drug Administration approved to address submental fat but has not been studied in other areas of the face. Although chemical peels, laser skin resurfacing, energy-based facial rejuvenation, microneedling, and platelet-rich plasma have a variety of facial rejuvenation applications with minimal side effect profiles, there is significant variability with treatment protocols, outcomes measures, and randomized controlled trials with extended follow-up to develop clinical practice guidelines.

An Assessment of the Reduction of Submental Fullness With ATX-101 (Deoxycholic Acid Injection) in the Expanded Safe Zone

Background and objective Facial aesthetics have a huge impact on how individuals view themselves and are viewed by society. The aesthetics of the face are tremendously influenced by the shape of the chin and neck. In this study, we aimed to observe the outcomes in individuals after the use of ATX-101 (deoxycholic acid injection) in an expanded safe zone for submental fullness. To ensure optimal outcomes and reduce the risk of adverse events, appropriate patient selection is the key. ATX-101 treatment may be administered in combination with hyaluronic acid fillers, botulinum toxins, cryolipolysis, and radiofrequency treatment. This is the first study of its kind to be carried out at the national level in Pakistan. Materials and methods This was a quasi-experimental study conducted at the Rawalian Burn and Reconstructive Surgery Unit, Holy Family Hospital, Rawalpindi, Pakistan for a period of nine months, from 10-1-2021 to 11-10-2021. A total of 62 patients who fulfilled the inclusion criteria were enrolled. We recorded if any complications had occurred or not. Moreover, the total number of treatment sessions, the volume of injectables used, and the interval between sessions were also documented. ATX-101 package was injected into the treatment area. Due care was taken to avoid the region of the marginal mandibular nerve. After the procedure, outcomes and complications were observed. Results In this study, patient satisfaction was reported in 59 (95.2%) patients. After the fourth session, final improvement was observed in 59 (95.16%) patients. Tenderness was found in seven (11.3%) patients, bruising was noted in four (6.5%), edema was found in seven (11.3%), numbness was noted in one (1.6%), whereas paresis and alopecia were not found in any of the patients. Conclusion Our study concluded that ATX-101 is a very useful modality with fewer complication rates and is associated with significant improvement in the expanded safe zone for submental fullness.

The Study of a Validated Assessment Scale for a Localized Submental Fat Volume

BACKGROUND

This aim of this study was to develop an objective tool for rating submental fat applied to Koreans.

METHODS

The study was conducted between April 2019 and October 2019. A total of 92 subjects were enrolled in the study. Clinical photos of the subjects were categorized using validated CR-SMFRS by three plastic surgeons and one dermatologist. The categorized photos were then shown to six different plastic surgeons for evaluation.

RESULTS

The Cohen's kappa value for the six raters were 0.830, 0.742, 0.703, 0.907, 0.862, and 0.793 with statistical significance (p < 0.001). ICC value was between 0.860 and 0.966 (p < 0.001). Since the Cohen's value and ICC were above 0.6 for all raters, the ratings performed by all six raters were used in the analysis. The ICC values between raters were between 0.899 and 0.902.

CONCLUSIONS

We came up with a set of reference photos that can be used for submental fat rating scale applicable to Korean subjects.

LEVEL OF EVIDENCE

II.

Hepatic Acat2 overexpression promotes systemic cholesterol metabolism and adipose lipid metabolism in mice

AIMS/HYPOTHESIS

Acetyl coenzyme A acetyltransferase (ACAT), also known as acetoacetyl-CoA thiolase, catalyses the formation of acetoacetyl-CoA from acetyl-CoA and forms part of the isoprenoid biosynthesis pathway. Thus, ACAT plays a central role in cholesterol metabolism in a variety of cells. Here, we aimed to assess the effect of hepatic Acat2 overexpression on cholesterol metabolism and systemic energy metabolism.

METHODS

We generated liver-targeted adeno-associated virus 9 (AAV9) to achieve hepatic Acat2 overexpression in mice. Mice were injected with AAV9 through the tail vein and subjected to morphological, physiological (body composition, indirect calorimetry, treadmill, GTT, blood biochemistry, cardiac ultrasonography and ECG), histochemical, gene expression and metabolomic analysis under normal diet or feeding with high-fat diet to investigate the role of ACAT2 in the liver.

RESULTS

Hepatic Acat2 overexpression reduced body weight and total fat mass, elevated the metabolic rate, improved glucose tolerance and lowered the serum cholesterol level of mice. In addition, the overexpression of Acat2 inhibited fatty acid, glucose and ketone metabolic pathways but promoted cholesterol metabolism and changed the bile acid pool and composition of the liver. Hepatic Acat2 overexpression also decreased the size of white adipocytes and promoted lipid metabolism in white adipose tissue. Furthermore, hepatic Acat2 overexpression protected mice from high-fat-diet-induced weight gain and metabolic defects CONCLUSIONS/INTERPRETATION: Our study identifies an essential role for ACAT2 in cholesterol metabolism and systemic energy expenditure and provides key insights into the metabolic benefits of hepatic Acat2 overexpression. Thus, adenoviral Acat2 overexpression in the liver may be a potential therapeutic tool in the treatment of obesity and hypercholesterolaemia.

Non-invasive system delivering microwaves energy for unwanted fat reduction and submental skin tightening: Clinical evidence

BACKGROUND

Cervicomental contour represents an important aesthetic problem.

AIMS

This research evaluates the safety and the efficacy of a new non-invasive system delivering microwave energy for the treatment of submental skin laxity and fat.

METHODS

Forty-eight subjects underwent submental treatment with the device at hand at Poliambulatorio San Michele, Reggio Emilia, Italy. The treatment was performed on the submental area starting from 1.5 cm below the lower border of the mandible up to the hyoid bone. Treatment consisted of 6 sessions of 10 min, with a 2-week interval between each session. At the baseline and upon follow-up 12 weeks from the last treatment, the following evaluations were performed: Photographic evaluation, Clinician-Reported Submental Fat Rating Scale (CR-SMFRS), Submental Skin Laxity Grade (SMSLG), Five-Point Likert Scale Questionnaire (LSQ) for Skin Laxity, Patient-Reported Submental Fat Rating Scale (PR-SMFRS) and Numeric Rating Scale (NRS) for pain evaluation.

RESULTS

Mean submental fat and laxity scores evaluation significantly decrease respectively from 3.4 ± 0.5 and 3.7 ± 0.5 at baseline to 1.7 ± 0.6 and 2.4 ± 0.6 (p < 0.01) at 12-week follow-up after the last treatment. The treatment was well-tolerated according to the NRS results. Out of the 47 participants (70.2%), 33 were very satisfied or satisfied. Most patients denied experiencing any discomfort during and after the treatment with the non-invasive device delivering microwaves. The submental subcutaneous fat reduction, the improvement of submental skin tightening, and aesthetic results are confirmed also by photographic evaluation. No side effects were observed.

CONCLUSIONS

Our results showed the potential microwaves role in the treatment of localized submental subcutaneous adiposities and skin laxity.

Efficacy of a Novel Injection Lipolysis to Induce Targeted Adipocyte Apoptosis: A Randomized, Phase IIa Study of CBL-514 Injection on Abdominal Subcutaneous Fat Reduction

BACKGROUND

CBL-514 is a novel injectable drug that may be safe and efficacious for localized abdominal subcutaneous fat reduction.

OBJECTIVES

The aim of this study was to assess the safety and efficacy of CBL-514 in reducing abdominal subcutaneous fat volume and thickness.

METHODS

This Phase IIa, open-label, random allocation study consisted of a 6-week treatment period and follow-up at 4 and 8 weeks following the last treatment. Participants were randomly allocated to receive 1.2 mg/cm2 (180 mg), 1.6 mg/cm2 (240 mg), or 2.0 mg/cm2 (300 mg) of CBL-514 with up to 4 treatments, each comprising 60 injections into the abdominal adipose layer. Changes in abdominal subcutaneous fat were assessed by ultrasound at follow-up visits. Treatment-emergent adverse events were recorded.

RESULTS

Higher doses of CBL-514 (unit dose, 2.0 and 1.6 mg/cm2) significantly improved the absolute and percentage reduction in abdominal fat volume (P < 0.00001) and thickness (P < 0.0001) compared with baseline. Although the COVID-19 pandemic halted some participant recruitment and follow-ups, analysis was unaffected, even after sample size limitations.

CONCLUSIONS

CBL-514 injection at multiple doses up to 300 mg with a unit dose of 2.0 mg/cm2 is safe, well-tolerated, and reduced abdominal fat volume and thickness by inducing adipocyte apoptosis. Although other procedures exist to treat abdominal fat, they have limitations and may cause complications. At a dose of 2.0 mg/cm2, CBL-514 safely and significantly reduced abdominal fat volume by 24.96%, making it a promising new treatment for routine, nonsurgical abdominal fat reduction in dermatologic clinics.

LEVEL OF EVIDENCE: 4

Chronic Infection and Nodule Formation following Deoxycholate Injection

Aqualyx (Marllor International Ltd, Rimini, Italy) was originally developed in Italy by Professor Pasquale Motolese and has been commercially available since 2009. It is a deoxycholate, aqueous gelatinous solution mixed with saline and buffering compounds. It is the only drug approved by the European Union for the reduction in localized fat. Aqualyx is sold exclusively to doctors and nurses trained in intralipotherapy. In the case of our patient, the product administered was advertised as Aqualyx, but was not administered by a trained health professional and was administered too superficially. The patient developed severe pain following the injection and was unable to sit for several weeks. There was localized skin necrosis, and palpable collections where the injection was administered. Our initial suspicion was development of an abscess or hematoma. To characterize further, we arranged an ultrasound scan that showed a “superficial hypoechoic lesion” but no deeper infection or spread. The numerous painful nodules ruptured onto the skin surface, resulting in purulent and bleeding lesions. This case demonstrates the importance of appropriate training and competence in performing cosmetic procedures including injections and fat dissolving treatments.

Submental Fat Reduction Using Sequential Treatment Approach with Cryolipolysis and ATX‐101

Background

Submental fat (SMF) detracts from facial aesthetics and negatively impacts self‐image.

Aims

To evaluate safety, effectiveness, and satisfaction of cryolipolysis and ATX‐101 used sequentially to reduce SMF.

Methods

A prospective, open‐label, interventional, single‐site study enrolling 22‐ to 65‐year‐old participants rated as Grade 4 (extreme) on the Clinician‐Rated SMF Rating Scale (CR‐SMFRS). Co‐primary effectiveness endpoints were proportions of participants with ≥1‐grade and ≥2‐grade improvement on CR‐SMFRS at 12 weeks post final treatment. Additional assessments included ultrasound measurement of fat thickness and Subject Self‐Rating Scale (SSRS) scores at 12 weeks post final treatment. Safety was assessed throughout the study.

Results

Of 16 enrolled participants, 62.5% were female, mean age of 43, and mean body mass index of 31.8 kg/m². 100% of participants achieved ≥1‐grade improvement, and 71.4% achieved ≥2‐grade CR‐SMFRS improvement. Mean (SD) reduction in SMF thickness was 0.2 mm (1.3), and SSRS scores ≥4 (slightly to extremely satisfied) were reported by 71.4% of participants. Adverse events (AEs) were mild and resolved by study end. No unanticipated adverse device effects or serious or unexpected AEs occurred.

Conclusion

Sequential treatment with cryolipolysis and ATX‐101 was found safe and effective for reducing extreme SMF, resulting in approximately a 2‐grade improvement.

The effectiveness and side effects of bipolar radiofrequency to treat submental laxity

BACKGROUND

Submental skin laxity becomes a common cosmetic problem with age. Bipolar radiofrequency is a new, non-invasive procedure. Unlike the LASER, the radiofrequency (RF) device has no specific chromophore absorption. Thus, the device can be used on any skin type.

OBJECTIVE

To evaluate the effectiveness and adverse effects of the bipolar RF for treatment of submental laxity and skin tightening.

MATERIAL AND METHODS

Twenty-two patients with submental laxity were treated with Forma^TM on both sides of the submental area. The patients underwent four sessions every two weeks for one and half months. Two blinded dermatologists evaluated the pre-treatment and post-treatment photographs every visit. The three-dimensional photographs were recorded by Vectra^® camera and determined the association.

RESULTS

All 22 patients completed all the treatment sessions. The degree of improvement was statically significant after the third session based on the physical assessment scale and after the second session in terms of the submental laxity score. The fat volume reduction was statically significant from one week to six months from baseline. Almost all subjects developed transient erythema immediately after the treatment. No serious side effects were noted.

CONCLUSIONS

The bipolar RF device is another potential choice for skin tightening due to its efficacy and safety profile. It can be used with any skin type and has few side effects.

A Randomized, Double-Blind, Multi-Center, Placebo-controlled, Phase 2 Clinical Trial to Evaluate the Efficacy and Safety of DWJ211 in the Treatment of Moderate to Severe Submental Fat

Excessive accumulation of submental fat (SMF) causes a lower face cosmetic problem. A lipolytic injectable has recently been developed as a solution. To investigate the effects and safety of DWJ211 (a newly developed lipolytic injectable) in the reduction of SMF and to identify the optimum dose. In this multi-center, double-blind, placebo-controlled study, subjects with moderate to severe SMF were randomized to injections of DWJ211 0.5%, DWJ211 1%, DWJ211 2% or placebo in the submental area, every 4 weeks, up to week 12. Efficacy was determined by improvements in physician-assisted SMF rating scales (PA-SMFRS) and subject-assisted SMF rating scales (SA-SMFRS) 4 weeks after the last treatment (week 16). Safety was assessed by inquiries, subject diary entries of adverse events, laboratory tests, and vital sign checks. Of 140 enrolled subjects, 136 were included in the analysis. The proportions of subjects who achieved ≥1-grade improvement on the PA-SMFRS were 41.7%, 65.7%, 84.4%, and 72.7%, and the proportions of subjects who achieved ≥1-grade improvement on the SA-SMFRS were 50.0%, 71.4%, 93.8%, and 81.8% for the placebo, DWJ211 0.5%, DWJ211 1%, and DWJ211 2% group, respectively. Adverse drug reactions (ADRs) were more common in each of the treatment groups compared with placebo, with the most common ADR being injection site pain. No subjects experienced any serious adverse events. The 1% DWJ211 dose was beneficial for SMF reduction and had a tolerable safety profile. Thus, we selected 1% as the dose to be tested in a Phase 3 clinical trial. This article is protected by copyright. All rights reserved.

Adverse effects of deoxycholic acid in submandibular glands, submental, inguinal and subplantar regions: a study in rats

OBJECTIVE

We aimed to evaluate the effects of the deoxycholic acid (DCA) in the submental and subplantar regions of rats, and to histologically analyze the changes caused in the submandibular glands, soft tissues of the paw, and inguinal adipose tissue.

MATERIAL AND METHODS

Sixty male Wistar rats were divided into DCA and control (CG) groups. DCA was injected in the submental, inguinal, and subplantar regions, and saline was injected in the CG. The animals were euthanized after 24 h and at 7 and 21 days.

RESULTS

The DCA group showed edema in the submental region in 24 h and in the paw in all experimental times. In the paw there were also erythema and ulceration in 7 days, and alopecia after 21 days. At 21 days, a few animals also showed erythema and ulceration in paw; however, there was no significant difference from CG. Histological analysis of the paw showed an intense inflammatory process, with a predominance of neutrophils, lymphocytes, and plasma cells in 24 h and 7 days. In the adipose tissue, we observed loss of architecture and inflammatory infiltrate, followed with a lower number of adipose cells, and at 21 days, fibroplasia. In the submandibular glands we observed inflammatory infiltration, loss of tissue architecture, and fibrosis.

CONCLUSIONS

DCA produces a significant inflammatory process in the structures. It can cause skin ulcerations and, in salivary glands, it causes loss of tissue architecture and fibrosis.

CLINICAL RELEVANCE

There has been growing increase in the use of DCA for aesthetic purposes by health care providers. Due to the presence of important anatomical structures in the submental region, constant vigilance is required to report new adverse effects.

Tightening and Reduction of Unwanted Submental Fat Using Triple-Layer High-Intensity Focused Ultrasound: Clinical and 3-Dimensional Imaging Analysis

BACKGROUND

Unwanted submental fat (SMF) is aesthetically unappealing, but methods of reduction are either invasive or lack evidence of their use.

OBJECTIVE

The authors sought to evaluate the safety and efficacy of a novel triple-layer high-intensity focused ultrasound (HIFU) regimen for SMF reduction.

METHODS

Forty Korean subjects with moderate/severe SMF were evaluated after receiving a session of triple-layer HIFU treatments (using 3.0-, 4.5-, and 6.0-mm focusing transducers). The objective evaluation based on the 5-point Clinician-Reported Submental Fat Rating Scale (CR-SMFRS) and patients' satisfaction based on the 7-point Subject Self-Rating Scale (SSRS) were determined 8 weeks after treatment. Three-dimensional image analysis was also performed.

RESULTS

At the follow-up visit, the proportion of treatment responders defined as subjects with ≥1-point improvement in CR-SMFRS was 62.5%, and the proportion of patients satisfied with appearance of their face and chin (score ≥4 on the SSRS) was 67.5% of the total patients. The results of 3-dimensional analysis were consistent with clinical observations. Only mild and transient side effects were observed for some patients with no serious adverse effects.

CONCLUSION

The triple-layer HIFU regimen including the novel 6.0-mm transducer has benefits for tightening and rejuvenation of the area with unwanted SMF, showing reasonable safety profiles.

Alternative Cosmetic and Medical Applications of Injectable Deoxycholic Acid: A Systematic Review

BACKGROUND

Beyond submental fat reduction, injectable deoxycholic acid (DCA) has gained popularity in recent years for various minimally invasive lipolysis applications.

OBJECTIVE

To summarize and evaluate the evidence of off-label uses of injectable DCA.

METHODS

MEDLINE, Embase, CINAHL, Web of Science, and CENTRAL were searched. The outcomes measured included applications of DCA, treatment regimen, and its efficacy. An overall success rate for each condition was calculated based on the improvement defined in the included studies.

RESULTS

Eleven studies evaluated the cosmetic use of DCA for excess adipose tissue on various anatomical locations. The outcomes were evaluated at time points ranging from 1 to 21 months post-treatment, with overall success rates over 85%. Eight case reports and series reported the success of using DCA treating lipomas, xanthelasmas, paradoxical adipose hyperplasia, fibrofatty residue of infantile hemangioma, piezogenic pedal papules, and HIV-associated lipohypertrophy. Although the preliminary efficacies were high, the overall recommendations for off-label uses are weak because of the lack of high-level studies.

CONCLUSION

The review emphasizes the diversity of injectable DCA as a minimally invasive technique for lipolysis. Further high-level studies demonstrating consistent treatment regimens and methods of evaluation are warranted to make more definitive recommendations regarding off-label DCA use.

Improvements in Submental Contour up to 3 Years After ATX-101: Efficacy and Safety Follow-Up of the Phase 3 REFINE Trials

BACKGROUND

ATX-101 (deoxycholic acid) significantly reduced submental fat (SMF) severity in two 24-week Phase 3 studies (REFINE-1 and REFINE-2).

OBJECTIVES

The aim of this study was to evaluate the durability of effect and long-term safety of ATX-101.

METHODS

REFINE study patients who maintained ≥1-grade improvement on the Clinician-Reported SMF Rating Scale (CR-1 responders) 12 weeks after their last REFINE treatment were eligible for enrollment in this multicenter, double-blind, nontreatment, long-term, follow-up study (NCT02163902). The primary endpoint was CR-1 response at Years 1, 2, and 3. Patient-reported satisfaction, psychological impact, and adverse events were monitored.

RESULTS

In total, 224 patients (ATX-101, n = 113; placebo, n = 111) were enrolled. Maintenance of CR-1 response was significantly better in the ATX-101 group than in the placebo group at Year 1 (86.4% vs 56.8%; P < 0.001), Year 2 (90.6% vs 73.8%; P = 0.014), and Year 3 (82.4% vs 65.0%; P = 0.03). Most (74%) ATX-101‒treated patients satisfied at 12 weeks remained satisfied at Year 3. Significant reductions from baseline in psychological impact scores were sustained through Year 3 (P < 0.001). No new treatment-related adverse events were reported.

CONCLUSIONS

Improvements in submental contour achieved with ATX-101 are maintained for 3 years in most patients. No new safety signals emerged.

LEVEL OF EVIDENCE: 2

Safety, Tolerability, Pharmacokinetics, and Pharmacodynamics of Cholic Acid (MT921) after a Subcutaneous Injection in the Submental Area to Humans

This study aimed to explore pharmacokinetics, pharmacodynamics, and safety/tolerability of MT921, an injectable cholic acid, after a single subcutaneous administration to healthy volunteers. A randomized, double-blinded, placebo-controlled, single dose-ascending phase 1 study enrolled 24 subjects who were assigned to three groups (60 mg, 120 mg, and 150 mg) of MT921. Blood samples were obtained for a 24-h period before and after injecting MT921 to the submental fat area. Plasma concentrations of cholic acid and deoxycholic acid were determined for pharmacokinetic analysis. Levels of free fatty acid, triglyceride, and total cholesterol were measured for pharmacodynamic analysis. Safety and tolerability were assessed until 21 days post-dose. While systemic exposure to cholic acid tended to increase as the MT921 dose increased, pharmacokinetic profiles of deoxycholic acid were similar among dose groups without showing significant changes. Pharmacodynamic profiles were comparable when measured at baseline and post-dose. The most frequent adverse events were injection site pain and edema. All adverse drug reactions resolved without treatment. MT921 appeared to be well-tolerated after an injection to the submental area at a dose up to 150 mg. Systemic exposure to cholic acid increased as the dose increased. Blood lipid profiles and deoxycholic acid levels were not affected by MT921 treatment.

Safety and Efficacy of Deoxycholic Acid Injection for Hypogastric Fat Reduction: A Pilot Study

BACKGROUND

Although deoxycholic acid (DCA) has been proposed for use in other areas, it is used primarily for treating moderate-to-severe fat in the submental area.

OBJECTIVE

To evaluate the safety and efficacy of DCA for fat reduction in the hypogastric region.

MATERIALS AND METHODS

A prospective, longitudinal, nonrandomized, open-label, interventional pilot study was performed. Deoxycholic acid was transcutaneously injected in upper right, upper left, lower right, and lower left hypogastric zones. Fat thickness was assessed using calipers, ultrasound, and 3-dimensional scanning. The primary end point safety was evaluated by laboratory tests and the incidence of adverse events.

RESULTS

Fourteen patients (54 treatment sessions) were included. The mean total volume administered was 26.6 mL. The main local adverse events were edema (94.4%), bruising (90.7%), and erythema (79.6%), all being self-limited (the mean duration 9.6, 7, and 2 days, respectively). A DCA dose was significantly associated with erythema duration (p = .0421) but not with edema duration (p = .1611) or bruising incidence (p = .1013). Measurement using calipers, ultrasound, and 3-dimensional scanning revealed significant fat thickness reduction. Patient-reported outcome measure scores revealed a significant improvement in patient satisfaction.

CONCLUSION

Deoxycholic acid may be a safe and effective option for reducing fat thickness in the hypogastric region, although given the cost/benefit ratio probably should be reserved for small deposits.

Randomized, Placebo-Controlled Phase 1/2 Study to Determine the Appropriate ATX-101 Concentration for Reduction of Submental Fat

BACKGROUND

ATX-101 is indicated for submental fat treatment.

OBJECTIVE

Evaluate ATX-101 versus placebo for reducing submental fat.

MATERIALS AND METHODS

Adults with unwanted submental fat across 6 global sites were randomized to ATX-101 (0.5%, 1.0%, or 2.0%) or placebo for ≤4 treatments every 28 days. Outcomes included safety (adverse events and pain visual analog scale) throughout the study and efficacy (submental fat rating, patient satisfaction, and submental fat improvements) at Week 16.

RESULTS

Eighty-four of 85 enrolled patients received ≥1 ATX-101 treatment (0.5% [n = 20], 1.0% [n = 20], 2.0% [n = 22] or placebo [n = 22]). Most patients (n = 82) experienced adverse events, which were mostly mild/moderate, seemed to be dose-related, and led to no study discontinuations. The mean pain scores were highest in the ATX-101 1.0% and 2.0% groups. Week-16 change from baseline in the submental fat rating scale was significantly greater for ATX-101 0.5% and 1.0% versus placebo (p ≤ .05). At Week 16, 71%, 74%, 53%, and 40% of patients in the ATX-101 0.5%, 1.0%, 2.0%, and placebo groups, respectively, achieved a ≥1-grade reduction in submental fat from baseline. Satisfaction with appearance and patient-assessed global improvement ratings increased in all ATX-101 treatment groups versus placebo.

CONCLUSION

All ATX-101 concentrations were safe and efficacious for moderate/severe submental fat reduction.

Best Clinical Practices with ATX-101 for Submental Fat Reduction: Patient-related Factors and Physician Considerations

Background:

Submental fat can be reduced with ATX-101 (deoxycholic acid injection), a customizable and minimally invasive alternative to liposuction. In the years since its approval, the treatment patterns of ATX-101 have evolved.

Methods:

A panel of experienced physicians from the United States gathered to generate best practices for the use of ATX-101 in submental contouring.

Results:

The expert panel provided their insights on appropriate patient selection, managing patient expectations of ATX-101 treatment outcomes, and adverse events, and guidance on ATX-101 administration for optimal outcomes are presented here.

Conclusion:

These best clinical practices on the use of ATX-101 for the reduction of submental fat should enable physicians to enhance the patient treatment experience and outcomes.

Development and Validation of the Patient-Reported Submental Fat Rating Scale and the Patient-Reported Submental Fat Impact Scale

BACKGROUND

No validated assessment tools are available to evaluate patient-reported outcomes specifically related to submental fat (SMF).

OBJECTIVE

To develop and validate scales measuring the severity (Patient-Reported SMF Rating Scale [PR-SMFRS]) and psychological impact (Patient-Reported SMF Impact Scale [PR-SMFIS]) of SMF.

MATERIALS AND METHODS

A literature review, content validation interviews (concept elicitation [n = 29] and cognitive debriefing [n = 15]) in adults with SMF, and expert interviews (n = 3) were conducted to develop the PR-SMFRS and PR-SMFIS. Psychometric validity (acceptability, reliability, and validity) for the PR-SMFRS and PR-SMFIS was assessed using data from 1 phase 2 and 5 phase 3 ATX-101 studies in patients with excess SMF.

RESULTS

The PR-SMFRS was constructed as a single-item, 5-point rating of the SMF amount/size. The PR-SMFIS was constructed as a 6-item scale, with an 11-point numeric rating for each item. Both scales demonstrated acceptable psychometric properties (test-retest reliability and internal consistency). The anchor-based minimally important difference analysis suggests a 1-point improvement on the PR-SMFRS (scale of 0‒4) and a 3-point improvement on the PR-SMFIS (scale of 0‒10) represent clinically meaningful change.

CONCLUSION

The PR-SMFRS and PR-SMFIS are reliable, valid instruments for assessing the severity and psychosocial impact, respectively, of SMF and detecting clinically meaningful change with intervention.

Tissue Modification in Nonsurgical Facelift Options

Nonsurgical facelifts are a term for a heterogeneous group of procedures used by physicians to improve facial rejuvenation without the use of operative techniques. Patients demand these services due to the reduced recovery time and generally lower risk. However, nonsurgical techniques, to be effective, must induce conformational change in the cells and tissues of the face. Therefore, these techniques are significant procedures that have associated risks. Understanding the tissue modifications and mechanisms of action of these techniques is vital to their safe and effective use. The purpose of this article is to provide a background of tissue modification in nonsurgical facelift options.

ATX-101 (Deoxycholic Acid Injection) Leads to Clinically Meaningful Improvement in Submental Fat: Final Data From CONTOUR

BACKGROUND

Submental fat (SMF) can negatively affect perceptions of health and attractiveness. The Condition of Submental Fullness and Treatment Outcomes Registry (CONTOUR) was designed to understand SMF treatment in clinical practice.

OBJECTIVE

To report efficacy, treatment characteristics, and safety associated with real-world use of ATX-101 (deoxycholic acid injection).

METHODS

CONTOUR enrolled adults considering treatment for SMF reduction. ATX-101-treated patients who completed the end-of-treatment questionnaire were divided into those who ended treatment because they met their treatment goals (n = 197) and those who did not (n = 196).

RESULTS

Patients who met their goals (a more defined jawline, looking younger, and looking thinner) were more likely to have less SMF at baseline and to receive ≥2 ATX-101 treatments. More patients who met their goals achieved clinically meaningful reduction in SMF and reported increased satisfaction with their appearance (90% vs 57%). Moderate and severe patients' ATX-101 volume was similar for both those who met goals and those who did not, but extreme patients who met their goals required 10 mL more than those patients who did not.

CONCLUSION

Careful patient selection, adequate volume administration, and an appropriate number of treatments (dependent on baseline SMF severity) contribute to successful outcomes with ATX-101.

Deoxycholic acid in the submental fat reduction: A review of properties, adverse effects, and complications

BACKGROUND

Deoxycholic acid (DCA) was developed by the pharmaceutical industry for aesthetical use in submental fat reduction. It represents the first lipolytic substance approved by the Food and Drug Administration (FDA) for fat reduction in that area.

AIMS

This study presents an update of properties and the use of DCA, as well as adverse events and possible complications.

METHODS

A search in MEDLINE/PubMed, Cochrane, and Bireme/LILACS databases was performed using the terms: "deoxycholic acid" OR "ATX-101" AND "injection" NOT "amphotericin" NOT "biliary" NOT "bile." Experimental studies developed in animals, clinical trials, literature reviews, case reports, and letters to the editor that included the DCA mechanism of action, dose, manner of use, adverse effects, and complications were selected.

RESULTS

The most frequent adverse events are edema, local pain, bruise, and numbness, which usually spontaneously regress. However, complications, including, skin necrosis, nerve injury, alopecia, and vascular events, can occur, demanding complex management without specific protocols.

CONCLUSION

Although DCA is beneficial for lysis of adipose tissue, clinicians should be aware about the adverse effects and risks involved with the use of this substance. The knowledge of local anatomy, properties, and adverse effects are fundamental to treatment with DCA.

Uncommon Adverse Effects of Deoxycholic Acid Injection for Submental Fullness: Beyond the Clinical Trials

Deoxycholic acid (BELKYRA^TM, Allergan, Markham, ON, Canada) is a minimally invasive injectable treatment approved by Health Canada for the nonsurgical reduction of submental fullness. Multiple phase III clinical trials have proven the efficacy and safety of deoxycholic acid. In the clinical trials, the most common adverse events (AEs) reported, such as injection site pain, numbness, swelling, bruising and induration, were transient and mild-to-moderate in severity. Additional postmarketing AEs have been reported in the literature. In this study, we reviewed the uncommon reported events and aimed to increase clinician awareness of the potential adverse effects for patient counselling of risks and benefits, identify AEs of procedures that may be performed outside of the medical environment, and identify factors that increase the risk of an adverse event. Beyond the clinical trials, real-world case reports and case series have been reported for the AEs of alopecia, transient neuropraxia, vascular occlusive events/vascular injury, and skin necrosis. Dermatologists need to be aware of these risks, for the treatment and management of their own patients and for those patients who may be treated outside the medical clinic environment that present for medical management of these AEs.

Histological Analysis of the Effect of ATX-101 (Deoxycholic Acid Injection) on Subcutaneous Fat: Results From a Phase 1 Open-Label Study

BACKGROUND

ATX-101 is approved for submental fat reduction.

OBJECTIVE

To characterize the histological effect of ATX-101 injection into subcutaneous fat.

METHODS

This Phase 1 open-label study enrolled 14 adults to receive injections of ATX-101 into abdominal fat at varying concentrations (0.5%, 1.0%, 2.0%, or 4.0%), volumes (0.2 or 0.4 mL), spacing (0.7, 1.0, or 1.5 cm), and time points before scheduled abdominoplasty (1, 3, 7, or 28 days). During abdominoplasty, tissue was excised and preserved for histology.

RESULTS

All injection paradigms resulted in histological changes confined to the subcutaneous layer, which were more prominent at higher concentrations and independent of volume and spacing. Key features at Day 1 after injection were adipocytolysis, blood vessel injury, neutrophilic inflammation, and lysis of locally present neutrophils. At Day 3, inflammation was reduced versus Day 1, and hemorrhage and lipid lake formation (at higher concentrations) were observed. Day 7 samples exhibited prominent adipocytolysis, mild inflammation, lipid-laden macrophages in the septae, and repair of vascular injury. At Day 28, inflammation was largely resolved and prominent features were septal thickening, neovascularization, and atrophy of fat lobules.

CONCLUSION

Subcutaneous injection of ATX-101 induces adipocytolysis and local inflammation with septal thickening and resolution of inflammation by 28 days after injection.

Jowl Reduction With Deoxycholic Acid

BACKGROUND

The study proposes a novel protocol for targeting the jowls using deoxycholic acid (DCA) injections, with emphasis on safety and feasibility of the procedure.

METHODS

This prospective study was conducted at a cosmetic practice between June 2016 and May 2017. Twelve consecutive patients seeking reduction/improvement in mild/moderate jowl fat were injected with DCA subcutaneously in a predefined circular area 1.0 cm above the mandibular border. Treatment response was assessed using physician-evaluated Global Aesthetic Improvement Scale (GAIS) and Subject GAIS.

RESULTS

Twelve patients (11 women and 1 man) with mild (n = 8) or moderate (n = 4) jowls were treated. After the first treatment, GAIS responses for 24 jowls showed 5 jowls with vast improvement, 15 with moderate improvement, and 4 with no change. After the second session for 5 jowls in 3 patients, GAIS responses showed vast improvement in 4 jowls and moderate improvement in 1. Adverse events included induration (n = 4), bruising (n = 6), numbness (n = 2), pain (n = 5), redness (n = 3), edema (n = 9), and dysphagia (n = 1).

CONCLUSION

Results of this early experience showed that DCA injections were safe and effective for nonsurgical jowl reduction.

Real-World Experience With 100 Consecutive Patients Undergoing Neck Contouring With ATX-101 (Deoxycholic Acid): An Updated Report With A 2-Year Analysis

Deoxycholic acid (DCA; ATX-101) injection was approved for the treatment of mild-to-moderate convexity associated with submental fat in 2015.

Bile acids in glucose metabolism and insulin signalling - mechanisms and research needs

Of all the novel glucoregulatory molecules discovered in the past 20 years, bile acids (BAs) are notable for the fact that they were hiding in plain sight. BAs were well known for their requirement in dietary lipid absorption and biliary cholesterol secretion, due to their micelle-forming properties. However, it was not until 1999 that BAs were discovered to be endogenous ligands for the nuclear receptor FXR. Since that time, BAs have been shown to act through multiple receptors (PXR, VDR, TGR5 and S1PR2), as well as to have receptor-independent mechanisms (membrane dynamics, allosteric modulation of N-acyl phosphatidylethanolamine phospholipase D). We now also have an appreciation of the range of physiological, pathophysiological and therapeutic conditions in which endogenous BAs are altered, raising the possibility that BAs contribute to the effects of these conditions on glycaemia. In this Review, we highlight the mechanisms by which BAs regulate glucose homeostasis and the settings in which endogenous BAs are altered, and provide suggestions for future research.

Effect of a Formulation Containing Low-Dose Sodium Deoxycholate on Local Fat Reduction

BACKGROUND

Synthetic deoxycholic acid (DCA) has been approved as an injectable drug for the nonsurgical reduction of submental fat.

OBJECTIVE

In this study, we evaluated the fat-reducing effects of a new formula containing a low dose of DCA and fat dissolution by topical application of DCA.

METHODS

Sodium deoxycholate (99.1% pure) and the new formulation containing 10% DCA were injected or topically applied to the dorsa of obese mice (induced by a high-fat diet). The rate of change in body weight was evaluated, together with comparisons of micro-computed tomography images, body composition measurements, and histology findings.

RESULTS

The results showed that the new formula containing low-dose DCA was as effective as the older high-dose formulation with respect to the rate of change in body weight and reductions in subcutaneous fat pad area, body fat weight, and the thickness of the subcutaneous fat layer. Furthermore, topical application of the high-dose, but not the low-dose, formulation yielded promising effects.

CONCLUSIONS

The development of a better protocol for the high-dose preparation, including dose optimization and application methods that minimize the adverse effects of DCA, merits further study.

NO LEVEL ASSIGNED

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine Ratings, please refer to Table of Contents or online Instructions to Authors - www.springer.com/00266 .

Novel Expanded Safe Zone for Reduction of Submental Fullness with ATX-101 Injection

ATX-101 (deoxycholic acid injection; Kybella) provides an approved nonsurgical treatment option for reduction of submental fullness caused by submental fat. Current one-size-fits-all recommendations for the use of ATX-101 limit treatment to a central area, which may not provide complete resolution of submental fat for some patients. An expanded safe zone is described, allowing for individualized, comprehensive treatment of submental fat with ATX-101 according to each patient’s anatomy and desired outcomes.

Injection of an Adipocytolytic Agent for Reduction of Excess Periaxillary Fat

BACKGROUND

The principal current treatment options for reduction of excess anterior periaxillary fat (APAF) are invasive procedures such as excision and liposuction.

OBJECTIVES

The aim of this study was to evaluate the efficacy and safety of ATX-101 (deoxycholic acid injection) as a treatment to reduce APAF.

METHODS

In this retrospective study, 12 women with periaxillary fullness underwent ATX-101 treatment. Patients were examined to confirm that fullness was due to excess APAF and sufficient subcutaneous fat was present to warrant treatment. Before treatment, the lateral and medial borders of the treatment area were identified and marked. A 1-cm grid was placed to guide the placement of the ATX-101 injections. Reduction in APAF was based on visual assessment and palpation by the clinician, and assessment of before/after patient photographs by the patient and 2 blinded plastic surgeons; all had to agree that APAF reduction had occurred. Patient satisfaction was also assessed. Safety was evaluated in terms of adverse events (AEs).

RESULTS

Patients underwent a mean of 1.8 ATX-101 treatments; 5 patients received 1 treatment, whereas 7 received multiple treatments. Ten patients achieved a reduction in APAF and were satisfied with treatment. One patient was satisfied after 1 treatment but did not return for posttreatment photographs. One patient did not show any noticeable reduction in APAF after 1 treatment; however, this patient was satisfied and additional treatments are planned. Common AEs included injection-site numbness, edema, and tenderness that lasted for a mean of 18.6, 6.0, and 4.5 days, respectively.

CONCLUSIONS

ATX-101 effectively reduced APAF and was generally well tolerated in this small cohort. Larger prospective studies are needed to confirm these findings.

LEVEL OF EVIDENCE: 4

Novel Surface Anatomic Landmarks of the Jowl to Guide Treatment with ATX-101

Supplemental Digital Content is available in the text.

Facial appearance is critical to physical attractiveness, and maintaining a youthful face and neck is a major motivation for individuals seeking facial cosmetic procedures. A strong mandibular border without prominent jowls is one sign of a youthful face as jowling occurs with age, contributing to squaring of the face and loss of jawline definition. Excess jowl fat has traditionally been reduced with surgical liposuction when jowling is caused by fat flow across the mandible. The approval of ATX-101 (deoxycholic acid injection) for submental fat reduction provides a minimally invasive technique that may also be suitable for jowl fat reduction. The author has developed novel facial markings that consistently isolate the jowl fat area of concern at the mandible for treatment with ATX-101. The current work refreshes physicians on important jowl anatomical structures, defines the facial markings that consistently isolate the jowl, and describes an injection technique to safely treat excess jowl fat with ATX-101.

Current Trends in Management of Submental Liposis: A Pooled Analysis and Survey

Importance

Since its approval by the US Food and Drug Administration for treatment of moderate to severe submental liposis in April 2015, deoxycholic acid (Kybella) has received significant media attention as a novel aesthetic treatment. Four phase 3 clinical trials have published data demonstrating the safety and efficacy of the drug compared with placebo; however, no study has juxtaposed the product with submental liposuction.

Objective

To evaluate the efficacy of injectable deoxycholic acid in the treatment of isolated submental liposis.

Evidence Review

A pooled analysis of the data from the 2 European and 2 North American phase 3 clinical trials was performed by grouping the study participants by treatment arm to analyze efficacy, adverse effects, and treatment variables. Members of the American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS) were also surveyed regarding their clinical use of deoxycholic acid, fees, and adverse events.

Findings

The pooled analysis included 1738 unique patients (348 men [20.0%] and 1390 women [80.0%]; mean [SD] age, 47.7 [1.6] years) and revealed that all studies demonstrated efficacy compared with placebo. However, a significant number of patients experienced pain, edema, and numbness after injection. The clinical trial population was injected with a mean (SD) of 186.0 (106.6) mg of drug per patient during the course of treatment. A total of 102 members responded to the survey, representing 4% of AAFPRS membership. Based on the results of the survey, clinicians reported charging a mean (SD) of $691.04 ($168.68) per 20-mg vial of deoxycholic acid, resulting in a cost of $6426.35 per study participant. The survey revealed a mean (SD) total cost to the patient for submental liposuction to be $2976.56 ($1041.62).

Conclusions and Relevance

Although the clinical trials demonstrated functional drug efficacy, the large volume of drug used precluded cost-effectiveness. The survey found clinical practice to differ from the protocols used in the trials. Deoxycholic acid may be only fiscally efficacious for patients with mild to moderate submental liposis who require only 20 to 30 mg of drug per treatment for 3 treatment sessions.

Level of Evidence

1.

Facial Nerve Injury and Repair: A Practical Review for Cutaneous Surgery

BACKGROUND

The facial nerve and its branches are at risk of injury during dermatologic surgery. Few publications in the dermatologic literature discuss facial nerve injury and management.

OBJECTIVE

To review facial nerve injury and management, including static and dynamic repair techniques, and to review outcomes in facial nerve reconstruction.

METHODS

Two detailed literature reviews were performed using PubMed. First, articles reporting facial nerve injury and/or management in the dermatologic literature were identified. In addition, articles pertaining to outcomes in facial nerve reconstruction with a minimum of 20 patients were included.

RESULTS

Fifty-three articles reporting outcomes in facial nerve reconstruction were identified and consist of retrospective reviews and case series. Most patients achieve improvement in facial symmetry and movement with nerve repair.

CONCLUSION

Timing of facial nerve repair is an important consideration in management of facial nerve injury, with earlier repairs achieving better outcomes. Facial nerve repair does not result in normal facial movement, and improvements may require a year or more to be realized. Many options exist for facial nerve reconstruction, and patients with long-standing facial nerve injuries may still benefit from treatment.

Personal (Self) Perceptions of Submental Fat Among Adults in the United States

Supplemental Digital Content is Available in the Text.

BACKGROUND

Satisfaction with discrete facial areas influences self-perceptions of attractiveness, self-esteem, and quality of life. Currently, there is a lack of understanding of how the submental area impacts feelings and behaviors.

OBJECTIVE

To characterize the effects of submental fat (SMF) on feelings/emotions and actions/behavior among adults in the United States.

METHODS

Online health-based surveys recruited approximately 400 adults (18–65 years) in each of 5 categories based on the respondent's assessment of their SMF. Respondents either agreed or disagreed with 17 statements regarding their feelings/emotions and actions/behaviors related to the area underneath their chin.

RESULTS

Overall, 1996 respondents were included (equal distribution of males/females; mean age, 41.9 years). Even a slight amount of chin fat was associated with negative feelings and behaviors. As SMF increased, so did the number of respondents reporting negative self-perceptions such as being embarrassed by the area under their chin. In general, a greater percentage of female compared with male respondents reported negative feelings and behavioral changes due to their submental area.

CONCLUSION

Excess SMF can have a substantial negative effect on a person's feelings of attractiveness and behaviors. Reduction of SMF may not only improve one's appearance, but also may enhance one's self-esteem.