A wide variety of devices are presently being evaluated to help improve the appearance of cellulite. As of this writing, two devices are cleared by the United States FDA for the treatment of cellulite-The Triactive fCynosure, Bedford, MA) and the Velasmooth (Syneron, Israel). These units, as well as many more under development, add to the
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Laser Treatment of Cellulite
benefits of deep tissue suction massage produced by the LPG Endermologie machine by incorporating lasers, light sources, and/or radiofrequency into their mechanism of action. Unfortunately, there have not been any reported clinical evaluations to determine which if any of these additional treatment modalities increase the efficacy and by what extent. At times, it appears that each company incorporates something new and patentable into their device more for sales and marketing than for scientific advancement. This section will review the possible bene- fits from these advances and the cument peer-reviewed literature comparing the Triactive and Velasmooth systems.
Low-energy lasers have been demonstrated to have beneficial effects on wound healing and biochemical effects on endothelial cells, erythrocytes, and collagen.
We have evaluated a device with a low-fluence laser and suction massage that was developed to reduce the appear- ance of cellulite. This device combines massage with a dynamic suction action, a low-energy diode laser, and contact cooling. The proposed mechanism of action con- sists of increased tissue perfusion and mobilization of lym- phatic drainage due to the combination of dynamic suction massage with lowlevel laser irradiation, and reduction in tissue edema due to contact cooling. This study was designed to evaluate the combination of active and passive mechanisms in the treatment of cellulite.
A11 subjects Q000/o) exhibited observable improvement in cellulite following l0 treatments. Blinded evaluation of pre (T0) and post (Tl0) -treatment photos yielded an average improvement of 1.67 on a 4-point scale, or mod- erate improvement (Fig.6.rr). We also observed a measur- able improvement in thigh and hip circumference. Average hip circumference measured 100.62 cm at T0, 100.56 cm at T5, and 99.35 cm at Tl0, with an average hip reduction of I .21 cm. Average thigh circumference measured 50.80 cm at T0, 50.53 cm at T5 and 49.97 cm at Tl0, with an average thigh reduction of 0.83 cm. All subjects found the treatment to be pleasant. Often, patients fell asleep during the treatment sessions. There were no adverse effects reported throughout the study.
In short, we found that the Triactive device decreased hip and thigh circumference. In addition, blinded evalua- tors found improvement in appearance of cellulite in all subjects. Treatment was progressive, with an improve- ment in cellulite over the course of the procedures.
Improvements included reduction in the appearance of skin dimpling, improvement in the overall contour of the limb, and improvement in overall skin texture Patients enjoyed the procedure and found it to be relaxing, with no side effects.
There was no significant change in either BMI or percent body fat. This suggests that observed improve- ment were attributed to the Triactive, and suggests that the Triactive device provides localized treatment/ without an apparent systemic effect on the body.
Our next study evaluated Syneron's VelaSmooth. This technology is based on a combination of two different
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Fig. 6.11 Cellulite treatment with Triactive Subject betore (A) and following 10 treatments (B) (Reproduced with permission from: Boyce S, Pabby A, Chuchaltkaren P, Brazzini B, Gotdman MP 2OO5 Clinical evaluation of a device for the treatment of cellulite: Triactive. Am J Cosm Surg 22:233-237\
ranges of electromagnetic energy, which produce heat (infrared light, and radiofrequency) combined with mechanical manipulation of the skin and also has been demonstrated to improve the appearance of cellulite The proposed mechanism of action of the Velasmooth is that heating subcutaneous tissue and fat leads to increased localized blood flow and lipolysis.
Our study compared the Velasmooth with the Triac- tive on the same patient. Patients were treated twice a week for 6 weeks with the randomization of TriActive on one side and VelaSmooth on the other side. There were a total of l2 treatments per leg.
We calculated a 280/o improvement with Velasmooth versus a 300/o improvement with Triactive in the upper thigh circumference measurements, while a 560/o versus 370lo improvement was observed, respectively, in lower thigh circumference measurements. These differences in treatment efficacy, using the thigh circumference mea- surements were nonsignificant (P > 0.05).
Based on pre- and post-treatment photographs that were blindly evaluated, we found that 250/o [5 out of 19) of the subjects showed improvement in cellulite appear- ance for both TriActive and VelaSmooth. The averaqe percent lmprovement based on random photography grading from a scale of 1-5 (l representing no improve- ment and 5 representing most improvement) for the VelaSmooth versus TriActive are 7ok and 25010, respec- tively. This difference was also nonsignificant [P =
0 . 0 9 1 ) .
Perceived grade change was also calculated based on random side by side comparisons ofbefore and after pho- tographs. Seventy-five percent (15 out of 19) subjects showed improvement in the VelaSmooth leg, while 55%
(ll out of 19) subjects showed improvement in the Tri- Active leg. The average mean percent improvement was roughly the same for both treatments (22o/o and 200/0, respectively) and showed no statistically significant differ- ence (P > 0.05) (FiS.6.tz). Some patients did have an increased benefit from one machine compared with the other, but overall, both systems were not statistically different.
The only real difference between these two treatment modalities was adverse effects. Bruising incidence and intensity was 30% higher in the VelaSmooth leg than in the TriActive leg. Seven of 20 subjects reported bruising with VelaSmooth, whereas I subject reported bruising with TriActive, and 3 patients reported bruising with both VelaSmooth and TriActive. Extent of bruising ranged from minor purpura to larger and diffused bruises, which lasted for an average of a week with no intervention ( F i g . 5 . 1 3 ) .
A recent new study suggests that, as would be expected, more diffuse deep radiofrequency, may have an even greater result on skin tightening of cellulitic skin. Gold- berg's group treated 30 female subjects with upper thigh cellulite using a unipolar radiofrequency device (Accent, Alma Lasers). Al1 subjects were treated 6 times over the course of l2 weeks. The mean decrease in thish
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Fig. 6.12 Before (A) and after (B) photographs of the subject seen in F i g 6 1 1 ( R e p r o d u c e d w i t h p e r m i s s i o n f r o m : N o o t h e t i P K , M a g p a n t a y A , Y o s o w i t z G , C a l d e r o n S , G o l d m a n l V l P : A s i n g l e c e n t e r , r a n d o m - ized, comparative, prospeclive clinical study to determine the ef{icacy of the Velasmooth system versus the Triactive system tor the t r e a t m e n t o f c e l l u l i t e L a s e r s S u r o M e d 2 0 0 6 : 3 8 : 9 0 8 - 9 1 2 )
Laser Treatment of Cellulite
Fig. 6.13 Purpura after treatment with the (A) Triactive and (B) Velasmooth (Reproduced with permission from: Nootheti PK, M a g p a n t a y A , Y o s o w i t z G , C a l d e r o n S , G o l d m a n M P : A s i n g l e c e n t e r , randomized, comparative, prospective clinical study to determine the efficacy of the Velasmooth system versus the Triactive system for the treatment ol cellulite Lasers Surg Med 2006;38:908-912)
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circumference was 2 45 cm. Of note there were no changes noted with MRI evaluations and blood lipid analysis His- tologic analysis did show fibrosis in the deep dermrs, con- sistent with the clinical findings of skin tightening.
Finally, new focused ultrasound emulsification tech- niques are being developed that may also impact on the 'fat'
of cellu1ite. Further studies will determine the effi- cacy of this approach as a primary treatment modality or in combination with other approaches.
SUMMARY
Although 850/o of post-pubertal women have various degrees of cellulite, nearly all women think they do.
Although cellulite is not a medically debilitating physical defect, it does impact the psychological well-being of many patients. Apparently, 'Madison
Avenue' is trans- forming this normal female characteristic into a malor public health problem and 'herd
mentality' provides a profit for industry It is expected that our role as physi- cians is not to dictate public policy or public opinions, rather, to it is to provide sound scientific reasoning. Our hope is that this chapter provides a brief introduction into the scientific pathophysiology of cellulite and an evalua- tion of safe and effective treatments to temporarily improve its appearance. Treatments are being developed;
long-lasting results are required.
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Complications in Laser and Light Surgery
Tina S. Alster, Ehzabeth L. Tanzi
INTRODUCTION
Complications of cutaneous laser surgery can be under- stood by reviewing the evolution of laser technology over the past four decades. Lasers initially were designed to operate in a continuous-wav" (C\M) mode, which produced a continuous beam of radiation that subsequentiy was absorbed by a tissue chromophore. Although particular skin structures could be destroyed using these early lasers, their use was limited because the energy emitted not only altered the target, but also conducted heat into adjacent nonirradi- ated tissue. The nonselective thermal injury produced in adjacent tissue resulted in significant side effects and com- plications, namely, hypopigmentation and scarring
The safety and efficacy expected from modern laser systems can be attributed to the ground-breaking work of Anderson and Parrish in the 1980s Their theory of selec- tive photothermolysis outlined the mechanism for specific tissue destruction through manipulation of the type of laser energy produced and the manner in which it was delivered Thus, a specific chromophore or target can be selectively destroyed with minimal thermal tissue damage when the laser wavelength matches that absorbed by the chromophore and when the target is exposed to the laser energy for an interval shorter than its thermal reiaxation time (the time required for the target to cool to half its peak temperature after laser irradiation)
Lasers designed based on the theory of selective photothermolysis are more specific and have a lower risk profile in terms of scarring; however, they have their own unique side effect profiles. Depending upon the wave- length and puise durations delivered, dyspigmentation, epidermal cell injury, textural changes, as well as crustrng and tissue splatter potentially can occur. It is important to remember that even the safest of lasers can cause injury if used inappropriately Application of stacked pulses, use of excessive energy or power settings, and improper patient selection potentially can result in a high rate of morbidity with any laser system.
PATIENT SELECTION
Because of the varied side effects and complications pos- sible after cutaneous laser surgery, it is essential that each
patient receive consultation and counseling before treat- ment to assess his or her specific risk of adverse sequelae.
Laser surgeons must spend time educating patients on the realities of laser treatment and the potential side effects that may occur. During the consultation, clinical photographs and written material can enhance the patient's understanding of the procedure, expected clinical outcome, and potentiai complications. It is also important that patients understand the importance of good wound care after a laser procedure Preoperative laser evalua- tion should include a basic medical history, including documentation of medications and allergies. A history of smoking, abnormal scarring, excessive sun exposure, allergic or inflammatory conditions, herpes simplex virus (HSV] outbreaks, immune disorders, or previous cosmetic procedures within the involved area should also be ascer- tained Proper pretreatment education and close physician follow-up helps to reduce morbidity and al1ows fbr early recognltion and management of potential problems.