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from baseline at all posttreatment times until 90 min after   tissue, further study in this field is warranted.
         completion of the treatments.
                                                             Financial support and sponsorship
         Elevation of blood NEFA levels suggests  that nonfocused   Nil.
         ultrasound metabolized  TG within  fat cells to glycerol
         and NEFA, followed  by release of NEFA into the blood   Conflicts of interest
         stream through the lymphatic system  While lymphatic   There are no conflicts of interest.
         drainage manipulation might  shift  NEFA in  the  lymphatic
         system to adipose tissue via blood circulation, blood NEFA   REFERENCES
         levels increased before application of lymphatic drainage
         procedures. Given the half-life of NEFA of 1.7-3.0 min, such   1.   Mulholland RS, Paul MD, Chalfoun C. Noninvasive body contouring with
         shifts of NEFA from lymphatics to the blood circulation is   radiofrequency, ultrasound, cryolipolysis, and low-level laser therapy. Clin
                                                                 Plastc Surg 2011;38:503-20.
         unlikely to maintain the high levels of NEFA until 90 min   2.   Honda T, Suzuki T, Tanaka I, Goto H, Kure K, Hishiyama J, Isago T. Clinical
         after drainage. It might be possible for the TG in the blood   analysis of noninvasive body contouring by nonfocused ultrasound device.
         vessels within the adipose tissue being a source; however,   J JSAPS 2014;3:10-20. (in Japanese)
         blood vessels in adipose tissues are sparse. It is more likely   3.   Teitelbaum SA, Burns JL, Kubota J, Matsuda H, Otto MJ, Shirakabe Y, Suzuki
                                                                 Y, Brown SA. Noninvasive body contouring by focused ultrasound: safety
         that the NEFA originated  from the  abundant TG in the   and efficacy of the Contour 1 device in a multicenter, controlled, clinical
         adipocytes within the adipose tissue.                   study. Plast Reconstr Surg 2007;120:779-89.
                                                             4.   Jewell ML, Solish NJ, Desilets CS. Noninvasive body sculpting technologies
         There is no definitive  evidence that TG can be  released   with an emphasis  on high-intensity focused ultrasound.  Aesth Plast Surg
         into inter-cellular spaces due to increased permeability of   5.   2011;35:901-12.
                                                                 Garcia O, Schafer M. The effects of nonfocused external ultrasound on
         adipocyte membranes,  and then degraded to NEFA and     tissue temperature and adipocyte morphology. Aesthetic Surg J 2013;33:117-
         glycerol-3-phosphate in  transit  to  the  blood stream.  An   27.
         alternative involves lipolysis activation within adipocytes   6.   Bani D, Quattrini A, Freschi G, Russo GL. Histological and ultrastructural
         resulting in elevation of blood NEFA. TG may be metabolized   effects of ultrasound-induced cavitation on human skin adipose tissue. Plast
                                                                 Reconstr Surg Glob Open 2013;1:e41.
         within adipocytes by ultrasonic stimulations,  mimicking  a   7.   Haar GT, Coussios C. High intensity focused ultrasound: physical principle
         photochemical mechanism. The body contouring mechanism   and devices. Int J Hyperthermia 2007;23:89-104.
         of low-level laser treatment may involve activation of   8.   Gadsden E, Aguilar MT, Smoller BR, Jewell ML. Evaluation of a novel high-
         cyclic adenosine monophosphate in mitochondria within   intensity focused ultrasound device for ablating subcutaneous adipose
                                                                 tissue for noninvasive body contouring: safety studies in human volunteers.
         adipocytes, and subsequent activation of hormone-sensitive   Aesthetic Surg J 2011;31:401-10.
         lipases resulting in metabolism of TG in adipocytes. [12,13]  9.   Fatemi A. High-intensity focused ultrasound effectively reduced adipose
                                                                 tissue. Semin Cutan Med Surg 2009;28:257-62.
         The current study suggests nonfocused ultrasound    10.  Jewell ML, Baxter RA, Cox SE, Donofrio LM, Dover JS, Glogau RG, Kane
                                                                 MA, Weiss RA, Martin P, Schlessinger J. Randmized sham-controlled trial to
         metabolizes  TGs immediately  after  treatment,  but  it   evaluate the safety and effectiveness of a high-intensity focused ultrasound
         is  unclear whether  this  involves  intra-  or extra-cellular   device for noninvasive body sculpting. Plast Reconstr Surg 2011;128:253-62.
         spaces of  adipocytes.  Since  there  was  no  control group   11.  Brown SA, Greenbaum L, Shtukmaster S, Zadok Y, Ben-Ezra S, Kushkuley
         in the current study, but given the short half-life of NEFA,   L. Characterization of nonthermal focused ultrasound for noninvasive
                                                                 selective fat cell disruption (lysis): technical and preclinical assessment.
         the significant elevation of blood  NEFA must be due to   Plast Reconstr Surg 2009;124:92-101.
         the effects of activated lipolysis within the adipose tissue   12.  Avci P, Nyame TT, Gupta GK, Sadasivam M, Hamblin MR. Low-level laser
         induced by ultrasound-induced cavitation.               therapy for fat layer reduction: a comprehensive review. Lasers Surg Med
                                                                 2013;45:349-57.
                                                             13.  McRae E, Boris J. Independent evaluation of low-level laser therapy at 635
         Given  the  paucity  of clinical or biochemical  evidence  for   nm for non-invasive body contouring of the waist, hips, thighs. Lasers Surg
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         110                                                                     Plast Aesthet Res || Volume 3 || April 25, 2016
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