Acoustic wave therapy for cellulite, body shaping and fat reduction

A Clinical Guide to the Treatment of Cellulite and Comprehensive Review of the Etiology, Pathophysiology, and Utility of Intervention

INTRODUCTION

Cellulite is a common esthetic concern affecting most women. Despite its prevalence, there is no consensus on the optimal treatment approach for cellulite, partly due to the complex and multifactorial nature of its pathophysiology. Understanding the underlying biological processes along with available treatment options is important to be able to effectively counsel patients on effective management of this condition. This review aims to focus on high-quality evidence behind pathophysiology of cellulite, severity and grading, and its available treatment options.

METHODS

A comprehensive review of the literature was performed using PubMed and Embase databases. Manuscripts that provided objective data with respect to pathophysiology, grading scales, and applications of treatment options were utilized.

RESULTS

Using the existing CSS classification, an evidence-based algorithm is proposed for treatment of cellulite. Mild cellulite is best served with lifestyle modifications such as healthy diet, hydration, and exercise. Use of topicals in mild cellulite patients as adjuncts to lifestyle modifications have the highest efficacy, although there are inconsistent data on topical treatments. Moderate cellulite is best targeted with noninvasive treatment options including laser therapy, radiofrequency, and ultrasound. Radiofrequency demonstrates the strongest efficacy in the current peer-reviewed literature. Severe cellulite is recommended to be treated with minimally invasive approaches such as subcision and injectables.

CONCLUSION

Cellulite is a challenging cosmetic problem to treat, and thus multimodal treatment options should be considered in an attempt to achieve optimal outcomes and patient satisfaction. As the pathophysiology of cellulite is further elucidated, more targeted treatments may be developed in the future.

LEVEL OF EVIDENCE V

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 the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Non-invasive Body Contouring Technologies: An Updated Narrative Review

INTRODUCTION

Nowadays, a lot of body contouring devices and methods are introduced all over the world. The object of the present narrative review was to update and classify existing evidence on these methods and devices.

METHODS

We searched databases including PubMed, Cochrane, and Google Scholar for 11 essential keywords, including cryolipolysis, high-intensity focused ultrasound (HIFU), shock wave, low-level laser therapy (LLLT), radiofrequency (RF), capacitive resistive electrical transfer (TECAR), high-intensity focused electromagnetic (HIFEM), electromyostimulation (EMS), carboxytherapy, mesotherapy, and acupuncture and their abbreviations, in addition to obesity, overweight, cellulite, subcutaneous fat, and body contouring.

RESULTS

Totally 193 references were used in 11 main topics.

CONCLUSION

In order to help physicians with finding the best evidence in different methods, the data were summarised in 11 topics. Furthermore, FDA-approved devices, side effects and common protocols were described in each section.

LEVEL OF EVIDENCE I

This journal requires that authors 39 assign a level of evidence to each article. For a full 40 description of these Evidence-Based Medicine ratings, 41 please refer to the Table of Contents or the online 42 Instructions to Authors www.springer.com/00266 .

Cellulite: Current Understanding and Treatment

Cellulite is an aesthetically distressing skin condition that manifests as dimples and depressions, producing an uneven surface to the skin. Occurring in 80% to 90% of females, mostly on the thighs, buttocks, and hips, it is associated with profound negative psychosocial and quality of life issues. Its ethiopathogenesis and pathophysiology are likely to be multifactorial and complex and not fully understood. There is no effective treatment for cellulite, although a number of different treatment modalities are available, from noninvasive to minimally invasive. The efficacy of most treatments is unpredictable and improvements in cellulite appearance are short lived, although significant progress has been made with newer treatments. This review provides an update on the current state of knowledge about cellulite, with an emphasis on patient assessment and an individualized treatment approach for optimal results.

Level of Evidence 5

Cellulite: Current Treatments, New Technology, and Clinical Management

BACKGROUND

Cellulite is a well-known concern for many women; however, treatment can prove challenging because of the complexities of cellulite etiology, the various factors contributing to its appearance, and the multitude of therapies and procedures available.

OBJECTIVE

To discuss current cellulite treatment options and effective clinical management.

METHODS

A roundtable meeting was convened to discuss and share views on current cellulite treatment options, new technologies, and clinical management. The participants' views helped guide a narrative review on this topic.

RESULTS

Advanced interventions for cellulite treatment-such as physical and acoustic subcision, radiofrequency, and injectable biostimulators-are gradually being established, with accumulating evidence showing efficacy, patient satisfaction, and potentially long-lasting outcomes. Cellulite severity rating scales are necessary for assessing treatment outcomes, but these can be complex to use in clinical practice, and the majority do not include patient or clinician perspectives.

CONCLUSION

With the advent of new treatments and technologies, cosmetic surgeons and dermatologists will need to tailor their approach to each patient's needs and manage patient expectations because multimodal methods are likely to be required to address the various factors underlying cellulite appearance.

Shock Wave Therapy in Plastic Surgery: A Review of the Current Indications

BACKGROUND

Extracorporeal shock wave therapy (ESWT) represents a promising, non-invasive management strategy supporting the treatment of a variety of conditions related to plastic surgery.

OBJECTIVES

This literature review aimed to give a systematic overview of current applications, its mechanism of action, and its potential to provide tangible therapies in plastic surgery.

METHODS

The databases PubMed (National Institute of Health, Bethesda, MD), Embase (via Ovid [Elsevier, Amsterdam, the Netherlands]), and the Cochrane Library (Cochrane, London, UK) were searched for articles published up to June 1, 2021. Clinical studies of any design including ESWT in the context of plastic surgery were included. Two reviewers extracted data, and 46 articles were analyzed after application of the inclusion and exclusion criteria.

RESULTS

Forty-six included studies (n = 1496) were categorized into the following broad themes: cellulite/body contouring/skin rejuvenation, burns/scar treatment, diabetic foot ulcers/chronic wound, and future perspectives of ESWT. Overall, applications of ESWT were heterogenous, and the majority of studies reported effectiveness of ESWT as an alternative treatment technique. Flawed methodology and differences in technical standards limit the outcome and conclusion of this review.

CONCLUSIONS

There is yet insufficient evidence to support the effectiveness of any specific intervention included in this review; however, all included studies reported improvements in key outcomes. Where reported, ESWT displayed a good safety profile with no serious adverse events. Further research is needed to provide more evidence to delineate the indications of ESWT in plastic surgery.

Improvement of body contour in young women using a high-power radiofrequency device

Localized fat and excess body fat: this is one of the main causes of dissatisfaction with body contour and decreased self-esteem. The objective of this report is to present the results of treatment using Capenergy C 200 in a group of young volunteers who received treatment only in the right half of the body. We will review the science and literature of the effect of TECAR and its role in body contouring. The average decrease in the arm is 2.9 cm p = .026. The nipple rise was 2.1 cm, p = .002. The decrease in abdominal diameter was 3.3 cm, p = .027 at the end of the treatment. For the thigh, the difference in diameter was 3.9 p = .026, this difference being statistically significant. TECAR radiofrequency treatment therapies, for body contouring in the breast, arms, abdomen and thighs, are effective and can show positive results after 6 treatment sessions, resulting in body satisfaction at the end of the treatment.

Gluteal Subcutaneous Adipose Tissue in Women of Different Ages and Body Mass Index observed by Magnetic Resonance Imaging

BACKGROUND

Magnetic resonance Imaging (MRI) is a recognized method to assess the morphological characteristics of subcutaneous adipose tissue (SAT). This study aimed to assess objectively different characteristics of SAT of women with different ages and body mass index (BMI) using MRI.

MATERIALS AND METHODS

Retrospective, observational study. Pelvic-MRI exams of 133 women aged between 15 and 80 years, with BMI 16 to 30 kg/m² were assessed.

RESULTS

There was a moderate positive correlation between the total fat thickness and the BMI (r = 0.64; p<0.0001) considering the entire sample. Within the different age groups, strong positive correlation was observed for age groups 15 to 30 years (r=0.76; p<0.0001) and 46 to 60 years (r=0.75; p<0.0001), and moderate positive correlation in the others (r=0.61; p<0.0001 [31-45 years] and r=0.53; p<0.0001 [>61 years-old]). There was no correlation between age and fat layer thickness. Correlation between deep fat layer thickness and BMI showed similar pattern to that of the total fat layer. Within the different BMI groups, SAT thickness tends to decrease with aging in patients with low BMI.

CONCLUSION

Inside each age group, the average thickness of the total fat layer increases according to BMI. The results suggest that BMI influences the thickness of SAT throughout life and how SAT changes with age in patients with different BMI. In patients with moderate BMI, the thickness of SAT remains stable.

Microwave Therapy for Cellulite: An Effective Non-Invasive Treatment

Background: Cellulite represents a common cosmetic problem that affects nearly all women. This study aimed to evaluate microwave therapy’s effectiveness for cellulite treatment. Methods: In this study, 26 women showing severe or moderate cellulite underwent four sessions of microwave therapy on the buttocks and posterior thighs. The following assessments were performed at baseline and the three-month follow-up after the last treatment: the Cellulite Severity Scale (CSS), Nürnberger–Müller classification scale, photographic evaluation, and buttocks/posterior thighs circumference measurements. A Likert scale questionnaire was used to assess patient satisfaction at the 3-month follow-up. Results: The treatment positively affected the cellulite severity as confirmed by the Cellulite Severity Scale (CSS) and Nürnberger–Müller classification scale results. CSS showed a significant amelioration in cellulite severity between the initial assessment and the 3-month follow-up for the buttocks and posterior thighs, with total average scores that ranged from 10.7 ± 3.1 to 4.5 ± 1.8 (p < 0.01). The treatment also resulted in a remarkable improvement in comfort/satisfaction and a buttocks and posterior thighs circumference reduction. No serious adverse events were observed. Conclusions: Microwave therapy has proven to be a safe treatment for improving cellulite appearance and reducing body circumferences.

Comparison of Extracorporeal Shock Wave Therapy versus Manual Lymphatic Drainage on Cellulite after Liposuction: A Randomized Clinical Trial

Introduction

Cellulite is associated with variations in the skin appearance with cottage cheese, mattress-like, or orange peel. The most common areas for these lesions are the posterior or upper thighs and buttocks and mainly affect females after puberty. The objective of the study was to determine whether extracorporeal shock wave therapy (ESWT) or manual lymphatic drainage (MLD) is more effective for the reduction of the grade of cellulite after liposuction.

Methods

This study is a single-blinded randomized controlled clinical trial. Thirty females with grade 3 cellulite were randomly distributed into two groups equal in number (n = 15), group A was equipped to ESWT and group B was equipped to MLD. The cellulite grading scale was used to assess cellulite grade, and the skinfold caliper was used to assess the thickness of subcutaneous fat. The assessment was carried out before and four weeks after starting the treatment. Both groups received topical retinol twice daily for four weeks; in addition, group A received ESWT, while group B received MLD, two times/week for 4 weeks.

Results

The mean values of the skinfold caliper in group A decreased by 24.4% and in group B by 15.38% with a significant difference between the two groups (p < 0.001). Also, the mean values of the cellulite grading scale decreased significantly after treatment in group A compared with the mean values of group B (p < 0.001).

Conclusions

There was more reduction in the grade of cellulite and thickness of subcutaneous fat in the ESWT group than the MLD group after liposuction.

Comparison of Cellulite Severity Scales and Imaging Methods

Cellulite is characterized by dimpled contour alterations of the skin and is present in approximately 85% to 90% of postpubertal females. Although the pathophysiology of cellulite remains to be fully elucidated, experimental evidence indicates a multifactorial process involving the number and types of fibrous septae, microvascular dysfunction, subcutaneous inflammation, decreased dermal thickness with age, and fat deposition. Cellulite is a major cosmetic concern for many women, and a number of both noninvasive (eg, massage, cosmeceuticals, laser therapy) and minimally invasive techniques (eg, subcision, collagenase injection) have been evaluated to improve the appearance of the affected skin. However, evidence for many of these treatments is limited, largely due to the lack of a validated, convenient tool for the standardized evaluation of cellulite severity. Various imaging modalities have been employed to characterize cellulite severity and the impact of treatment, but only 2-dimensional and 3-dimensional digital photography have been adequately validated. However, in many cases, imaging findings do not correlate with subjective measures of cellulite severity. A number of cellulite rating scales have been developed; some provide only a qualitative measure, whereas others do not fully capture all clinically relevant aspects of cellulite, including the perspective of the patient. There remains an unmet need for global adoption of a validated scale that can be utilized easily by clinicians and patients in clinical and research settings. We propose features that should be included in an ideal rating scale for assessment of cellulite severity.

The BODY-Q Cellulite Scale: A Development and Validation Study

BACKGROUND

Cellulite is a localized metabolic disorder of the subcutaneous tissue. To measure the impact of cellulite and its treatment(s) on patients' health-related quality of life, a psychometrically sound patient-reported outcome measure is needed.

OBJECTIVES

The authors sought to develop and field test a new BODY-Q cellulite scale to measure the appearance of cellulite.

METHODS

Appearance-related codes from the original BODY-Q qualitative interviews were reexamined, and a set of cellulite-specific items was developed and refined through cognitive patient interviews (n = 10) and expert input (n = 17). This scale was field-tested in adults with cellulite through 2 crowdworking platforms. Rasch Measurement Theory analysis was employed to refine the scale and examine its psychometric properties.

RESULTS

The field-test sample included 2129 participants. The 15-item scale was reduced in length to 11 items. Data from the sample fit the Rasch model (X2 [99] = 21.32, P = 0.06). All items had ordered thresholds and mapped out a targeted clinical hierarchy. The reliability statistics for the person separation index was 0.94 and for Cronbach's alpha was 0.97. In terms of validity, worse scores on the cellulite scale were associated with being more bothered by how the cellulite looked overall, having more severe cellulite on the Patient-Reported Photo-numeric Cellulite Severity Scale, and having more self-reported cellulite and more areas of the body with cellulite.

CONCLUSIONS

The BODY-Q cellulite scale can be utilized to measure appearance of cellulite and provides a solid basis for future studies evaluating the impact of cellulite and its treatment.

Insights Into the Pathophysiology of Cellulite: A Review

BACKGROUND

The etiology of cellulite is unclear. Treatment of cellulite has targeted adipose tissue, dermis, and fibrous septae with varying degrees of success and durability of response.

OBJECTIVE

Results from clinical trials that target different anatomical aspects of cellulite can provide insights into the underlying pathophysiology of cellulite.

MATERIALS AND METHODS

A search of the PubMed database and ClinicalTrials.gov website was conducted to identify clinical trials that have investigated treatments for cellulite.

RESULTS

A lack of trial protocol standardization, objective means for quantification of improvement and reported cellulite severity, and short-term follow-up, as well as variation in assessment methods have made comparisons among efficacy studies challenging. However, the lack of durable efficacy and inconsistency seen in clinical results suggest that dermal or adipose tissue changes are not the primary etiologies of cellulite. Clinical studies targeting the collagen-rich fibrous septae in cellulite dimples through mechanical, surgical, or enzymatic approaches suggest that targeting fibrous septae is the strategy most likely to provide durable improvement of skin topography and the appearance of cellulite.

CONCLUSION

The etiology of cellulite has not been completely elucidated. However, there is compelling clinical evidence that fibrous septae play a central role in the pathophysiology of cellulite.

Facial Tightening Effects, Following Focused and Radial Acoustic Wave Therapy Assessment, Using a Three-Dimensional Digital Imaging

Background and Objectives

Acoustic wave therapy is a novel facial tightening technique that involves nonthermal penetration of the skin and subcutaneous tissue, affecting cells and their metabolism, and resulting in an increased release of unwanted fat and activation of blood and lymphatic flow in tissues. The objective of this study was to investigate the effectiveness of acoustic wave therapy.

Study Design/Materials and Methods

A total of 333 patients underwent multiple facial tightening treatment sessions using focused and radial acoustic waves. Each patient received 2,000–3,000 pulses of focused acoustic waves at a power of 0.45–0.88 mJ/mm² with a pulse frequency of 3–5 Hz and 4,000 pulses of radial acoustic waves at 4‐bar power at a frequency of 21 Hz. These sessions were performed more than three times, and treatments were repeated at 1‐month intervals. Digital photographs superimposed three‐dimensional volumetric assessments, and three‐dimensional skin surface displacement calculations using vectors were used to evaluate the results 12 months after the last treatment. Patients also evaluated the results using a 5‐point Likert scale.

Results

Improvements in skin texture, clarity, and laxity were observed in digital photographs. Superimposed three‐dimensional color images showed marked volumetric reduction and/or formative modification for even contour toward the lower mid‐face. Most vectors showed three‐dimensional skin surface displacement at the lateral sides of the temples, cheeks, and chin, in an upward direction. These results were obtained and sustained for up to 12 months without edematous reactions. Almost all patients reported improvement, with 79% reporting “good” or “excellent” improvement. Complications were minor and transitory. Persistent side effects were not observed.

Conclusion

Acoustic wave therapy could be used as a standard facial tightening treatment, with skin rejuvenation effects shown on digital photographs and three‐dimensional quantification assessments. This noninvasive acoustic wave approach was found to be a safe, long‐lasting, and effective method for facial tightening. Lasers Surg. Med. 00:00–00, 2020. © 2020 Wiley Periodicals LLC

Effect of shock wave therapy associated with aerobic exercise on cellulite: A randomized controlled trial

BACKGROUND

Cellulite is a multifactor and controversial condition. Several methods have been explored to reduce it, not always with favorable results. Shock Wave Therapy has been shown to be effective, but the results of its association with an Aerobic Exercise Program are unknown.

AIMS

To verify whether Shock Wave Therapy in association with an Aerobic Exercise Program reduces the degree of severity of Cellulite in the gluteal region and in the ⅓ of the proximal posterior of the thigh.

METHODS

Forty-five healthy women, aged from 18 to 32, randomly assigned, considering the severity degree in the Cellulite Severity Scale and the level of physical activity, in three groups: two experimental and one control group. The control group performed the evaluations. The experimental group 1 performed an Aerobic Exercise Program, and the experimental group 2 associated this program with a Radial Shock Wave Therapy protocol. The experimental groups completed six interventions within 3 weeks. In addition, the degree of severity in the Cellulite Severity Scale, height, body composition, skin temperature, and subcutaneous adipose tissue thickness were assessed. One-way ANOVA test and Kruskal-Wallis were used to obtain the results, with level of significance of 0.05.

RESULTS

Forty-two women completed the study. There was a significant reduction in the severity of Cellulite between experimental group 2 and group 1 (P = 0.032), and from group 2 to the control group (P = 0.042).

CONCLUSION

The association of Shock Wave Therapy and Aerobic Exercise was shown to be effective in reducing the severity of cellulite.

Effectiveness of the Electromagnetic Shock Wave Therapy in the Treatment of Cellulite

In the past centuries, the human body was undervalued; nowadays, however, it is overvalued, and thus the manifestation of the dissatisfactions regarding the body has been increasing. Most of the time, these dissatisfactions are related to cellulite, which is most common in women. Its treatment is one of the challenges which encourage the development of new therapeutic modalities, among them the shockwave therapy. Objective. To evaluate the efficacy of ESWT in the treatment of cellulite in gluteus and posterior of thigh. Method. This is a prospective and comparative study, in which volunteer women who attended the criteria of inclusion were selected and who were subjected to 10 sessions of ESWT. The following were performed as an evaluation method: anthropometry, perimetry, skin viscoelasticity with the Cutometer®, thickness of hypodermis with diagnostic ultrasound, analysis of the scale of severity of cellulite (CSS), and quality of life by the Celluqol® questionnaire. The evaluations occurred before the first session (baseline), after 6 and 10 sessions, and during a follow-up of 3 months after the last session. The statistical test applied was the ANOVA one-way with post hoc of Tukey (P-value < 0.05). Results. There was significant improvement (P<0.05) for CSS, for the variable referring to gross elasticity and skin deformation ability evaluated in the Cutometer® and improvement of quality of life represented by Celluqol®. The result was maintained particularly in the follow-up of 3 months after the end of the treatment. Conclusion. The results presented demonstrated the effectiveness and safety of ESWT in the treatment of cellulite and in the decrease of the degrees, improvement of the aspect of the skin, and reestablishment of quality of life. This trial is registered with ClinicalTrials: NCT03275259.

Clinical evaluation of simultaneously applied monopolar radiofrequency and targeted pressure energy as a new method for noninvasive treatment of cellulite in postpubertal women

INTRODUCTION

This study investigates noninvasive cellulite treatments based on simultaneous application of monopolar radiofrequency (RF) and targeted pressure energy to evaluate efficacy and safety and to see whether simultaneous application has any benefits in noninvasive cellulite treatments.

METHODS

Thirty women with cellulite (fibrous/adipose/aqueous types) received 4 gluteofemoral treatments (~24 minutes; ~1000 cm² ) using a simultaneous application of RF and targeted pressure energy. Clinical improvement was assessed using a pentile grading scale and satisfaction questionnaires. Hip/thigh circumference was measured. Ultrasonography and thermography observed changes in dermal/subcutaneous tissue composition and in gluteofemoral thermal profile. Evaluation at 3 months posttreatment was compared against the baseline.

RESULTS

The clinical improvement averaged 2.17 ± 0.95 (54% improvement). Cellulite was reduced in 93% of cases, while 73% of patients showed good/very good/excellent improvement, with most significant improvement seen in patients with moderately severe cellulite. Hips and thigh circumference decreased on average by 2.31 cm and 2.13 cm, respectively (P < .001). Patient satisfaction was very high, averaging 4.47 ± 0.57 points (1-5 scale). Ultrasonography revealed smoothing and thickening (+0.28 ± 0.15 mm) of the dermis and an average reduction of 1.96 ± 1.60 mm in fat thickness (P < .05). Subjects with significant cellulite reduction had a more homogenous thermal profile at follow-up as a result of therapy-induced diminution of topographic skin defects. No adverse events were recorded.

CONCLUSION

The application is effective and safe for treating cellulite. The level of clinical improvement after 4 sessions is comparable to results reported after 6-20 sessions in studies on stand-alone RF/laser/targeted pressure energy devices. The technology is promising and deserves further attention and research.