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Surgery and Cosmetics

New Devices in Cellulite Treatment and Body Sculpture

Neil Sadick, Tsippora Shainhouse

Tuesday, December 04, 2007

Cellulite refers to the "cottage cheese-type," mottled, dimpled skin seen commonly on the hips, thighs, and buttocks of women. Between 85% and 98% of women over the age of 20 demonstrate some degree of cellulite, and treatment has become one of the most requested cosmetic surgical procedures. Cellulite is caused by the retention of subcutaneous fat between increasingly inelastic, supporting vertical fibrous bands that normally anchor the dermis to the deep fascia, and the projection of this fat into the upper dermis, creating a mattress-like, puckered appearance. While the etiology of cellulite is unknown, various hypotheses have been suggested to explain the development of this non-pathologic condition, including: differential architecture of female (non-androgenic) skin, stretched and weakened connective tissue septae, altered dermal vasculature, and chronic inflammation of dermal fibrous septae.1 Many studies have reported normal histological finding in cellulite biopsies, with no inflammation of fibrous septae.

The amount of overall body fat does not correlate with degree of cellulite. However, women do have a significantly greater baseline deposition of subcutaneous fat than men, perhaps explained by both estrogen-induced lipogenesis1 and estrogen-associated lowering of the basal metabolic rate (estrogen yields a third of the metabolic activity of testosterone). Furthermore, classic female cellulite distribution (thighs, buttocks, lower abdomen, hips, and upper arms) may be attributed to increased estrogen-receptor density and receptor sensitivity at these sites. As adipocytes grow, they exert pressure on surrounding tissues, which damages dermal vasculature, causing inflammation and hypoxia, as well as interfering with lymphatic drainage. Increased vascular permeability due to raised capillary pressures has been hypothesized to cause fluid retention in the dermis, inter-adipocyte, and intra-lobular septae. Impedance of lymphatic circulation may also lead to fluid accumulation in the fibrous septae and increased lipogenesis. Finally, fibrous dermal bands in cellulite-prone areas contain inflammatory cells, which, too, may account for some localized edema. This swelling further compresses vessels, yielding more tissue hypoxia and acidosis which, together with proteoglycan deposition in dermal collagen, triggers interstitial fibrosis, sclerosis, collagenesis, and ectatic neovascularization. Enlarging adipocytes become tethered between these edematous, thickened, sclerotic fibrous bands creating the 'sewn-down' padded-appearing cellulite.

Various modalities have been attempted to reduce the appearance of cellulite:

  • It has been suggested that topical preparations may temporarily dehydrate the skin, increase collagen formation to thicken the overlying skin, prevent lipocyte maturation, or cause localized lipolysis
  • Physical methods employ external suction or massage to manipulate fibrous bands or encourage lymphatic drainage and improve circulation
  • Surgical methods, including traditional liposuction, present a more permanent reduction of localized fat cells but can be associated with significant morbidity and patient down-time
  • Light and sound energy are now being harnessed both to destroy adipocytes and to direct neocollagenesis through selective dermal heating, in order to improve skin surface texture for a permanent, localized treatment with negligible patient down-time


Endermologie

Endermologie ES1 (LPG Systems, Valence, France), developed in France in the 1970s, is a non-invasive, machine-assisted skin kneading process that is meant to reduce the appearance of cellulite by mobilizing and redistributing subcutaneous fat by stretching the tethering, vertical fibrous septal bands, as well as stimulating lymphatic drainage. Stocking-covered folds of skin are sucked in and kneaded through the rollers of an electrically powered, handheld device. Twice-weekly visits are safe, and sessions last 10-45 minutes. There is no associated lipocyte destruction, hence results are not permanent. However, there is little objective evidence to support its efficacy.2

VelaSmooth

VelaSmooth (Syneron Medical, Richmond Hill, Ontario, Canada) is a device that involves the simultaneous application of infrared (IR) light, continuous-wave bipolar radiofrequency (RF) and mechanical suction-based massage of the skin and fat. Theoretically, the IR and RF heat the skin, increasing local blood supply and oxygen availability to adipose tissue, thus increasing fat metabolism. As IR itself only penetrates 1-3 mm, not reaching adipocytes, these energies may have effect at the dermal-fat junction by initiating collagen remodeling through controlled tissue inflammation and collagen contraction.3,4 The mechanical, pulsed-vacuum massage component stretches the fibrous dermal septae to redistribute adipocyte clusters and promotes microcirculation and lymphatic drainage of fat decay products. Studies recommend a total of eight 30-minute sessions, held biweekly, followed by monthly maintenance treatments. Many studies have been published using this system, with the above treatment regimen. A mild to good improvement is noted in 90-100% of patients in most studies. An approximately 50% improvement in cellulite appearance (based on photographic images) and objective reduction in thigh circumference in one study seem to be consistent (40-65% improvement) with other similar trials. The device has 3 power levels, employing up to 20 watts of power, a light spectrum of 700-2000 nm, and a treatment area of 4 x 4 cm (see Figure 1a and b).

Figure 1a. Female patient with cellulite on the buttocks and upper thighs before treatment

Figure 1b. Female patient after 12 treatment sessions performed over a 6-week period (settings: Optical: 3, RF: 3, and Vacuum: 3)

TriActive

The TriActive Cellulite Workstation (Cynosure Inc., Chelmsford, MA, USA) is a system approved by the U.S. Food and Drug Administration (FDA) for the temporary reduction of cellulite. It combines 6 diode lasers (wavelength 810 nm) with contact cooling and mechanical aspiration-massage. The rhythmic massage distends the skin and fibrous septal bands to enhance microcirculation, which may increase skin elasticity and promote lymphatic drainage. The diode lasers stimulate dermal fibroblasts to produce collagen, creating a smoother skin appearance. Treatment includes 16 sessions, each lasting 30-45 minutes; 3 sessions a week for 2 weeks, then biweekly for 5 weeks. Monthly maintenance treatments are recommended.

A recently reported, prospective, randomized study compared the clinical efficacy of Velasmooth versus TriActive in the treatment of cellulite.5 Both systems have been individually demonstrated to reduce the appearance of collagen through the combination of either low-energy laser or heat/ radiofrequency and mechanical manipulation.6 Twenty women, age 24-55, with clinically apparent cellulite, were used as controls, with the randomization of TriActive to one thigh and VelaSmooth to the other. Results were measured by objective thigh circumference reduction and photographic image changes, and subjective patient perception. After twice-weekly, 15-minute treatment sessions for 6 weeks, efficacy was noted to be statistically the same for the two systems, across all three measures. A 28-30% improvement in thigh circumference was measured, and 25-50% of images demonstrated improvement. Of note, there was significantly more bruising associated with the VelaSmooth system.

SmoothShapes

SmoothShapes (SmoothShapes Inc., Merrimack, NH, USA) combines a dual-band wavelength diode and IR laser (650 nm, 900 nm) with roller-vacuum massage to improve the appearance of cellulite and reduce adipose volume. The protocol involves 12, bi-weekly, 50-minute sessions over 6 weeks, with the recommendation of annual maintenance treatment. Treatment area is 7 x 4 cm.

FDA testing involved a multi-site, multi-Independent Review Board-approved, controlled, blinded clinical study, involving a total of 86 patients, 74 of whom completed the entire protocol, including pre- and post-treatment elective MRI to evaluate adipose volume. For each patient, one thigh was treated with the SmoothShapes laser and massage and the other thigh was treated with massage only. Adipose volume was measured by MRI pre-treatment, and at the end of study. Eighty-one percent (81%) of patients demonstrated significant, objective, volumetric reduction in subcutaneous fat of the treated leg, on MRI, as well as subjective improvement in skin contour. A subset of patients (17/86) had pre- and post-study serum lipids measured; no statistically significant increase or decrease was associated with volumetric reduction of fatty tissue. Five patients elected to have a follow-up MRI at 13 months post-study, and 4 of them (80%) maintained their results.

Alma - Accent

The Accent system by Alma (NexGen Lasers Inc/ Alma Lasers Ltd., Ft Lauderdale, FL, USA) is the only device that employs both bipolar (superficial, 60-100 watts) and unipolar (deep, 100-200 watts) RF to provide volumetric thermotherapy for the reduction of cellulite. The unipolar RF has three mechanisms of action:

  1. thermal vascular damage, which initiates inflammation cascade, fibroblast proliferation, neocollagenesis/remodeling, and, ultimately, dermal fibrous septal tightening
  2. increase in local blood flow by vasodilation and hyperemia, and promotion of lymphatic drainage of trapped fatty debris
  3. heat-induced lipocyte destruction and fatty acid dissolution

The bipolar RF promotes local dermal heating and collagen contraction near the dermal-fat junction, tightening the skin and reducing dimpling.7 Skin is heated to a temperature of 40-44 degrees Celsius and maintained for 1-2 minutes, before moving to next 5 x 6 cm treatment area. Treatment requires 3-6, bimonthly, 45-minute sessions with possible maintenance. A recent study involved 26 healthy females, age 18-50, with clinical cellulite of the thighs and/or buttocks who received 2 bimonthly treatments.8 Thickness of subcutaneous fat, as well as dermal collagen changes were evaluated with real-time scanning image ultrasound before each treatment and 15 days after the second treatment. Sixty-eight percent (68%) of patients demonstrated a 20% volume contraction, when measured from the stratum corneum to the underlying muscle. Structural collagen changes included thickening and realignment of septae.

UltraShape

UltraShape (UltraShape Ltd., Tel Aviv, Israel) utilizes the mechanical vibration effect of ultrasound waves to selectively lyse adipocyte cell membranes for permanent fat cell destruction. Not yet available in the United States, this non-invasive (no epidermal wounding involved), painless procedure has been shown to yield an average of 2cm reduction in body circumference with a single treatment session and the triglycerides from lysed adipocyes are cleared via the lymphatic and venous circulations, without increasing serum lipid concentrations.9 In a 2000 study performed in the UK, 27 patients (16 women, 11 men), age 18-57, were used as controls, with the randomization of UltraShape treatment to one side (flank, outer thigh, abdomen).9 A single, 1-2 hour treatment was performed, directed by a built-in video tracking and guidance system. Patients were pre-treated with EMLA topical anesthetic cream. Circumference measurements and photographic imaging were performed on treated and control sides on post-treatment days 0 (pre-treatment), 1, 3, 7, 14, 21, and 28. Ultrasound of fat thickness was measured on both sides, pre-treatment and post-treatment days 14 and 28. Serology (BMP, LFTs, lipid panel, and coagulation panel) and urinalysis were performed at days 0 and 28 as well as monthly for an additional 2 months. Liver ultrasound was performed on day 0 and 28. Statistically significant reduction of fat was noted on all treated body sites at day 28 (1.8 cm-2.3 cm). Blood and urine tests were normal in all patients, as was liver ultrasound, suggesting that all lipolysis debris is cleared in normal fat metabolism pathways, without adverse sequelae. One patient had a 5mm blister at the end of his treatment, but no other adverse events were noted. Other European studies have demonstrated similar, if not better, results.

Liposonix

Liposonix (LipoSonix Inc., Bothell, WA, USA) utilizes the thermocoagulation effect of precise, high intensity focused ultrasound (HIFU) waves to destroy adipocytes for permanent fat reduction. HIFU damages tissue initially, by directly raising cell temperature via absorption of ultrasound energy, and then, by mechanical destruction (cavitation, streaming, shearing) from the thermally-induced high pressures. Surrounding tissues are not affected, minimal inflammation is elicited, and the released triglycerides and fatty debris are cleared via the lymphatic and venous circulations, without increasing serum lipid concentrations.10  To evaluate the histological impact or HIFU, a study11 involving 33 patients receiving HIFU treatment to the abdomen, followed by abdominoplasty at various assigned post-treatment intervals was performed. In vivo evaluation by MRI and CT revealed reduction in fat volume. Histologically, adipocyte damage is noted by 1 week post-treatment, with significant adipocyte destruction at 1 month. By 4-5 months post-treatment, pathology demonstrated complete, normal wound healing with minimal fibrosis and no damage to the skin.

Traditional Liposuction

The only way to effect long-term body contouring is by the permanent destruction of fat cells. Traditional manual, invasive liposuction involves the introduction of a metal cannula into the subdermis, manual loosening of adipocyte clusters and a fibrous septae, followed by mechanical suction of the dissected tissue. Pre-operative tumescent anesthesia not only reduces pain, but creates a suprafascial hydrodissection along the fibrous septa, and facilitates homogenization of adipose tissue,12 minimizing cannula-induced trauma and bleeding. Destroyed adipocytes do not regenerate in a treated area, and in fact, clinical, local reduction in adipose tissue and cellulite can be objectively demonstrated. However, this method may not be best for aesthetic liposculpture, as some patients may be left with loose overlying skin, while others report increased dimpling due to non-uniform fat removal and secondary scarring. Further, the traumatic loosening can cause significant bleeding, vascular and nerve damage, and fat emboli.

SmartLipo

SmartLipo (Cynosure Inc, Westford, MA) is a laser-assisted method of destroying and permanently eliminating adipocytes, that is equally effective, but less traumatizing to surrounding structures than traditional liposuction, has faster recovery times, less operator effort and provides associated skin tightening.13 Dubbed "interstitial laser lipolysis," after infusing tumescent anesthesia, a 300 μm optical fiber, run through a 1 mm metal micro-cannula, is used to convey laser light from a pulsed Nd:YAG system (1064 nm, 40 Hz, 150 mJ, 100 microsec pulses). The disposable tip of the laser fibers extends beyond the cannula, directly thermodamaging adipose tissue by altering intracellular Na-K concentrations and inducing permanent cell lysis. Direct thermocoagulation of small vessels reduces intra and post-operative bleeding, induces collagen degeneration and rupture of fibrous dermal bands, which liberates tethered skin, creates inflammation and neovascularization, which, in turn, promotes collagen neogenesis, and produces clinically tightened, smoother skin.14 A 2-3 mm cannula is inserted to mechanically suction the tumescent fluid and some of the melted fat. Aggressive avulsion of subcutaneous tissue is not needed, as seen in traditional liposuction. The residual fat debris is cleared via the lymphatic and venous circulations; transient increased circulating lipid levels have been noted in studies.15

Because of the gentler, controlled nature of this system, it is recommended for specific situations,16 including:

  • small areas
  • areas of current or potential for moderate flaccidity
  • multiple or highly vascular areas
  • repeat procedures in areas of fibrosis
  • traditionally "forbidden areas," including the inner upper thigh and peri-umbilical areas (see Figure 2a and b)

Figure 2a: Female patient with fat contour in "forbidden" peri-umbilical area before treatment

Figure 2b: Female patient 1 week after treatment (settings for the abdomen: Probe: 3 mm, Energy:4105 J/cm2, Watts: 6 W, Amplitude: 40 Hz; settings for the flanks: Probe: 4 mm, Energy:1500 J/cm2, Watts: 6 W, Amplitude: 40 Hz)


Laser-assisted liposuction (LipoSmart) would seem to be a significant improvement and advancement in the art of liposuction. A prospective, randomized-controlled, double-blinded clinical trial comparing traditional liposuction methods with laser-liposuction was recently published.15 Twenty-five (25) healthy females, age 27-47, were used as controls, with the randomization of traditional liposuction to one side, and laser-liposuction to the contralateral comparable body part. Multiple body areas could be treated in the same patient, each randomized separately, for a total of 220 treatment sites. All patients were followed for the complete follow-up course (6 visits, up to 11 months post-treatment). Photographic evaluations were performed, and analyzed by 2 outside physicians unfamiliar with the cases. Clinical improvement in cellulite appearance was observed and proved statistically comparable between the 2 treatment modalities. Laser-liposuction was associated with statistically significant less pain, lower blood concentrations in the removed fat, and greater histologic adipocyte damage than traditional liposuction. Laser-liposuction takes longer to perform, and the fat cannot be re-used for other procedures, including fat transfer, since it becomes emulsified. But, moreover, it must be cautioned that laser-liposuction was also associated with significantly higher concentrations of triglycerides and free fatty acids in the blood, alerting to the potential for hepatic and/ or renal toxicity.

Subcision

Subcision is an invasive technique that improves the appearance of non-facial cellulite, by disrupting the anatomic structure that binds the subcutaneous fat. After anesthetizing the treatment area, an 18-gauge cutting needle or blade is introduced into the deep subcutaneous fat (1-2cm deep), parallel to the skin surface, and used to undermine in that horizontal plane, with the intention of severing some of the fatty lobular septae that bind the underlying muscle to the overlying dermis. Bruising is meant to occur, to stimulate inflammation and fibrosis. Subcision has 3 mechanisms of action:

  1. Severing of fibrous septae releases skin and unbinds fat
  2. Resultant hematomas stimulate autologous filling of cellulite depressions with new connective tissue
  3. Redistribution of both fat and tension forces between fat lobules

A 3-year study17 involving 232 female patients, age 18-52, with clinically apparent (skin changes) cellulite demonstrated favorable results with this procedure. Seventy-nine percent (79%) of patients were satisfied after a single treatment, 20% felt the treatment was partially successful, and only 0.8% of patients were dissatisfied. Side effects include post-operative pain and post-bruising hyperpigmentation, which resolve with time. This procedure may be a helpful adjuvant to traditional liposuction, which aims to remove fat, but does not sever the fibrous septae that promote fat retention and herniation. Subcision can correct clinical surface alterations as a primary treatment modality, or an adjunctive therapy to reduce residual contour abnormalities post-liposuction.

Mesotherapy

Mesotherapy is the use of intra- or subcutaneous injections of various substances to ameliorate medical and cosmetic conditions. Traditional cellulite-reducing cocktails include: pentoxiphyllline, hyalurinidase or collagenase, carnitine, calcium pyruvate, aminophylline or caffeine, coumarin, artichoke, melilotus or ginko biloba.18 Although anecdotal and limited experimental data suggest that traditional mesotherapy ingredients may theoretically reduce fat, side effects include fat necrosis, infections, and cutaneous eruptions. Further, the beneficial effects have not been supported by peer-reviewed studies. A similar procedure involves the subcutaneous injection of phosphatidylcholine together with the emulsifier deoxycholate. This recipe has been demonstrated in peer-reviewed trials, to induce lipolysis in small pockets of adipose tissue, secondary to cell membrane lysis by the deoxycholate component. Animal studies have demonstrated adverse effects, including cholestatic hepatitis and antibody formation, so it is best to demonstrate caution with this treatment modality.

Conclusion

Cellulite is a very common skin contour irregularity in women, which involves the tethering of subcutaneous fat. Multiple treatment modalities are available that attempt to shrink the appearance of fat cells and improve microcirculation to decrease edema. Above are some of the latest devices that attempt to improve circulation, break down fat clusters, and even permanently destroy fat cells. While these procedures are new and evolving, preliminary data does suggest promise for clinical, aesthetic improvement.

References

  1. Avram MM. Cellulite: a review of its physiology and treatment. J Cosmet Laser Ther. 2004;6:181-5.
  2. Collis N, Elliot LE, Sharpe C, et al. Cellulite treatment: a myth or reality: a prospective randomized controlled trial of two therapies, Endermologie and aminophylline cream. Plast Reconstr Surg. 1999;104:1110-7.
  3. Sadick NS, Mulholland RS. A prospective clinical study to evaluate the efficacy and safety of cellulite treatment using the combination of optical and RF energies for subcutaneous tissue heating. J Cosmet Laser Ther. 2004;6:187-90.
  4. Alster TS, Tanzi EL. Cellulite treatment using a novel combination radiofrequency, infrared light and mechanical tissue manipulation device. J Cosmet Laser Ther. 2005;7:81-5.
  5. Nootheti PK, Magpantay A, Yosowitz G, Calderon S, Goldman MP. A Single Center Randomized, Comparative, Prospective Clinical Study to Determine the Efficacy of the VelaSmooth System versus the TriActive System for the Treatment of Cellulite. Lasers Surg Med. 2006;38:908-912.
  6. Alster TS, Tehrani M. Treatment of Cellulite with Optical Devices: An Overview with Practical Considerations. Lasers Surg Med. 2006;38:727-30.
  7. Brown A, de Almeida GO. Novel Radiofrequency (RF) Device for Cellulite and Body Reshaping Therapy. Alma Lasers - White pages. http://www.almalasers.com/
  8. del Pino E, Rosado RH, Azuela A, et al. Effect of controlled volumetric tissue heating with radiofrequency on cellulite and the subcutaneous tissue of the buttocks and thighs. J Drugs Dermatol. 2006;5:714-22.
  9. Otto, J. Non-Invasive Body Contouring via Selective Mechanical Ultrasound Lipolysis. Congress: IMCAS, Paris, France, January 2006 (abstract)
  10. Fodor PB, Smoller BR, Stecco KA, et al. Biochemical Changes in Adipocytes and Lipid Metabolism Secondary to the Use of High-Intensity Focused Ultrasound for Non-Invasive Body Sculpting. ASAPS Chicago, Illinois, USA, September 2006 (poster)
  11. Smoller BR, Garcia-Murray E, Ricas A, et al. The Histopatholocal Changes from the Use of High-Frequency Ultrasound (HIFU) in Adipose Tissue. Amer Acad Dermatol Annual Meeting, San Francisco, California, USA, March 2006 (poster)
  12. Sattler G. Advances in liposuction and fat transfer. Dermatol Nurs. 2005;17:133-9.
  13. Kim KH, Geronemus RG. Laser lipolysis using a novel 1,064 nm Nd:YAG Laser. Dermatol Surg. 2006;32:241-8.
  14. Badin AZD, Gondek LBE, Garcia MJ, et al. Analysis of laser lipolysis effects on human tissue samples obtained from liposuction. Aesthetic Plast Surg. 2005;29:281-6.
  15. Prado A, Andrades P, Danilla S, et al. A prospective, randomized, double-blind controlled clinical trial comparing laser-assisted lipoplasty with suction-assisted lipoplasty. Plast Reconstr Surg. 2006;118:1032-45.
  16. Badin AZD, Moraes LM, Gondek L, et al. Laser lipolysis: flaccidity under control. Aesthetic Plast Surg. 2002;26:335-9.
  17. Hexzel DM, Mazzuco R. Subcision: a treatment for cellulite. Int J Dermatol. 2000;39:539-544.
  18. Rotunda AM, Kolodney, MS. Mesotherapy and Phosphotidylcholine Injections: historical clarification and review. Dermatol Surg. 2006;32:465-80.
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