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Frankfurt mod

  1. 1. Arbeitsgruppe IV Cellulitebehandlung mit der Lipolyse
  2. 2. Dr. Patrick Treacy (IRL) Medical Director of Ailesbury Clinic Plastic Surgery Speaker:
  3. 3. “ An Evaluation of Cellulite” the past, present and future Dr. P. Treacy M.D. Medical Director Ailesbury Clinic Dublin Ireland
  4. 4.
  5. 5. What is Cellulite? <ul><li>Cellulite is a term that is used to describe fat deposits under the skin that outwardly give the skin a dimpled, or orange-peel like appearance. It is estimated that up to 80% of women have a problem with cellulite. </li></ul>
  6. 6. <ul><li>Cellulite is a term originally coined in European salons and spas in the 1970’s to describe deposits of dimpled fat found on the thighs and buttocks of many women </li></ul>The History of the term ‘Cellulite’
  7. 7. <ul><li>Widespread promotion of the concept in the United States followed the 1973 publication of Cellulite: Those Lumps, Bumps and Bulges You Couldn't Lose Before, by Nicole Ronsard, </li></ul><ul><li>Nicole Ronsard was the owner of a New York City beauty salon that specialized in skin and body care </li></ul>The Concept of Cellulite Grows
  8. 8. Fat Layer of Skin <ul><li>The fat layer of skin is located in the subcutaneous layer of tissue called the hypodermis. </li></ul><ul><li>The thickness of the fat layer, which varies greatly from one person to another, depends on the size and number of fat cells </li></ul>
  9. 9. <ul><li>Strands of fibrous tissue connect the skin to deeper tissue layers and also separate compartments that contain fat cells. When fat cells increase in size, these compartments bulge and produce a waffled appearance of the skin . </li></ul>The Physiology of Cellulite
  10. 10. What happens during Cellulite? <ul><li>Cellulite is most often seen in women due to hormonal reasons. The fat is arranged in large chambers of macromolecules separated by columns of collagen fibres. </li></ul><ul><li>In people who are overweight excess fat is stuffed in these fibrotic compartments causing them to bulge out. </li></ul><ul><li>On the surface of the skin the bulging provides the dimply appearance of cellulite, especially in areas such as the hips, buttocks or thighs. </li></ul>
  11. 11. What causes the ‘Dimpling’ of Skin ? <ul><li>The ‘ dimpling ’ is caused by modification of the texture of the subcutaneous tissue due to oedema and fibrosis secondary to impaired circulation and degradation of the tissue in this area. </li></ul><ul><li>Alteration and lack of fluid exchange from poor diet, lack of exercise, genetics and other things, helps promote hypertrophy of the adiposities which in turn further aggravates microcirculatory and vascular problems . </li></ul>
  12. 12. So what exactly is Cellulite? <ul><li>Cellulite is localised fat ‘ caught in a jail’ of interstitial connective tissue </li></ul><ul><li>Cellulite is a combination of adipocytes + fibrotic tissue + exudate from vascular origin </li></ul><ul><li>Cellulite is a lack of drainage of fluid secondary to venous + lymphatic stasis because of genetic, hormonal and even environmental reasons </li></ul>
  13. 13. 1. HEREDITY 2. HORMONAL - premenstrual syndrome, puberty, pregnancy, menopause, hormonal treatment 3. VENOUS and LYMPHATIC stasis 4. NUTRITION insufficient water intake - excess of sugars, fats 5. LACK of EXERCISE - sedentary occupation 6. NERVOUS SYSTEM - stress What are the Causes of Cellulite?
  14. 14. GYNOID HYDROLIPODYSTROPHY <ul><li>Cellulite is most often seen in women due to hormonal reasons. </li></ul><ul><li>GYNOID </li></ul><ul><li>There is segmental odema secondary to venous and lymphatic stasis </li></ul><ul><li>HYDRO </li></ul><ul><li>The fat becomes dystrophic as it is arranged in chambers separated by columns of interstitial connective tissue </li></ul><ul><li>LIPODYSTROPHY </li></ul>
  15. 15. <ul><li>Stage 1 Problem seems to appear whenever you press skin </li></ul><ul><li>Stage 2 Dimpling of skin only appears as the patient stands up </li></ul><ul><li>Stage 3 ‘ Peau de orange’ is present when the patient is lying down </li></ul><ul><li>Stage 4 You can actually feel knots in the tissue when you touch it </li></ul>The Different Grades of Cellulite
  16. 16. The Physiology of Stages 1 & 2 <ul><li>Stage 1 and 2 </li></ul><ul><li>The problem only appears whenever you press skin or the patient stands up. This in effect is caused by localised oedema secondary to vascular and capillary extravasation with dissociation of the adipocytes </li></ul>
  17. 17. The Physiology of Stages 3 & 4 <ul><li>Stage 3 </li></ul><ul><li>‘ Orange skin’ is seen whenever the patient is lying down. This is caused by the formation of micronodules of both normal and larger adipocytes encapsulated by a network of collagen fibres </li></ul><ul><li>Stage 4 </li></ul><ul><li>The problem is present at all times because the micronodules fuse together to form painful subcutaneous macronodules . </li></ul>
  18. 18. <ul><li>In 1996 Neil Solomon, M.D., conducted a double-blind study of 100 people to see whether cellulite differed from ordinary fat. </li></ul><ul><li>Specimens of normal fat and cellulitic fat were obtained by a needle biopsy procedure and given to pathologists for analysis and comparison. </li></ul><ul><li>The pathologists found no difference between the two clinical types of fat </li></ul>The Medical Evaluation of Cellulite begins
  19. 19. <ul><li>In 1998, researchers at the Rockefeller Institute used ultrasonography, microscopic examinations, and some fat-metabolism studies to see whether “cellulitic&quot; skin and normal skin differed in seven healthy adult subjects (five women, two men; four affected, three unaffected </li></ul>The Medical Investigation of Cellulite <ul><li>Rosenbaum M and others. ‘An exploratory investigation into the morphology and biochemistry of cellulite’. Plastic and Reconstructive Surgery 101:1934-1939, 1998 </li></ul>
  20. 20. <ul><li>The researchers concluded </li></ul><ul><li>(a) certain characteristics of skin make women more prone than men to develop cellulite </li></ul><ul><li>(b) the process is diffuse rather than localized; and </li></ul><ul><li>(c) there were no significant differences in the appearance or function of the fatty tissue or the regional blood flow between affected and unaffected sites within individuals </li></ul>The Medical Concept of Cellulite
  21. 21. <ul><li>“ A nticellulite &quot; products sold through retail outlets, by mail, through the Internet include &quot;loofah&quot; sponges; cactus fibres; special washcloths; horsehair mitts; creams and gels to &quot;dissolve&quot; cellulite; supplements containing vitamins; minerals and/or herbs bath liquids; massagers rubberised pants; exercise books; brushes; rollers; body wraps; and toning lotions . </li></ul>The World Market for Cellulite products
  22. 22. <ul><li>“ Anticellulite&quot; products sold through retail outlets, by mail, through the Internet also include tablets that work while you are awake and others that reduce cellulite….. while you sleep! </li></ul>The Growing Market for Cellulite Products 135 million Europeans are overweight 50 million Europeans suffer from obesity This is an increase of 25% in ten years
  23. 23. Body Wrapping <ul><li>The wrapping causes temporary water loss by compression and by perspiration. The water is quickly replaced within 24 hours and the concept that toxins can be removed by this method is absurd. . </li></ul><ul><li>Body wrap advocates claims this technique works because ‘cellulite’ is really water logged fatty tissue. ‘Suddenly Slender’ markets clinics in the U.S. and Canada. Heavily marketed as clients are dressed up like mummies and it makes good television. </li></ul>
  24. 24. <ul><li>Herbal Product developed by Italian chemist called Gianfranco Merizzi. Ingredients include compounds clover extract, evening primrose oil, fucus vesiculosis, bioflavanoids, soya lecithin, ginko biloba, iron oxide and fish oil. </li></ul>Cellasene ® March, 1999, on CNBC-TV, Rexall's CEO claimed 3 clinical trials demonstrated a 90% success rate Results would not be submitted to scientific journals because they did not want to reveal the amounts of each ingredient in its formula. Under pressure tests showed no controls or validity Lis-Balchin M. Parallel placebo-controlled clinical study of a mixture of herbs sold as a remedy for cellulite . Phytotherapy Research 13:627-629, 1999. showed no effect with Cellasene
  25. 25. <ul><li>The FDA considers promotion of muscle stimulators or Iontophoresis devices for any type of body shaping or contouring to be fraudulent </li></ul>Relax-A-Cizor, claimed to reduce girth by delivering electric shocks to the muscles. 410,000 units were sold for $200 to $400 before FDA obtained an injunction in 1970 to prohibit sales because of its potentially harmful effects which included abnormal heart rhythms, miscarriages , and worsening of hernias, ulcers, and epilepsy. FDA. Electrical Muscle Stimulators and Iontophoresis Devices. Import Alert #89-01, revised 3/17/97. Electrical Stimulation Devices and Iontophoresis
  26. 26. <ul><li>1998, FDA approved a French technique Endomologie, which onsisted of a treatment head with 2 motorised rollers and a suction device that compressed affected tissue between the rollers. </li></ul>The introduction of Endermologie ® The manufacturer got approval for &quot;temporarily improving the appearance of cellulite”
  27. 27. <ul><li>Endermologie ® , was a subdermal approach to treating cellulite. It was pioneered by LPG Systems in France a decade before.  It was given extensive coverage on TV networks and magazines </li></ul>Endermologie ® <ul><li>It started life as a deep tissue massage for injured horses. It claimed to increase circulation by 200% and expel toxins and water build up as the underlying connective fibres were stretched . </li></ul>
  28. 28. <ul><li>The Endermologie ® procedure usually takes 10 to 20 treatments to get any results, and one or two maintenance treatments per month are required to maintain these effects. The patient then has to complete a maintenance programme or the benefits are lost. </li></ul><ul><li>The typical cost to a patient is 50 Euro/ session and the patient usually pays in the region of 1,000 Euro for an effect to be seen. This effect must be continually maintained </li></ul>Endermologie ®
  29. 29. <ul><li>A 1998 study of 85 women between ages 21 to 61 found that 46 patients who completed seven sessions showed a mean index reduction in body circumference of 1.34 cm </li></ul><ul><li>Another 39 patients who completed 14 sessions of treatments showed a mean index reduction in body circumference of 1.83 cm </li></ul><ul><li>Chang P and others. Non invasive mechanical body contouring (Endomologie) A one-year study and clinical outcome. Aesthetic and Plastic Surgery 22:145-153, 1998 . </li></ul>The clinical evidence for Endermologie ® ?
  30. 30. <ul><li>However in 1999 another controlled trial, involving 52 women, found no objective difference in thigh girth (at two points) or thigh fat depth measured by ultrasound) ) </li></ul><ul><li>Collis N and others. Cellulite treatment: a myth or reality: a prospective randomised, controlled trial of two therapies. Endomologie and aminophylline cream. Plastic and Reconstructive Surgery 104:1110-1114, 1999 . </li></ul>Medical evidence for Endermologie®
  31. 31. <ul><li>VelaSmooth™ is a medical device for the treatment of cellulite. Using the combined energy technology — Bi-Polar Radio Frequency and Infrared Light — plus tissue mobilization and suction to safely and effectively re-contour the skin surface, the Vela is a clinically proven, effective solution for cellulite </li></ul>Shaper or Velasmooth ® <ul><li>RF increases oxygen intracellular diffusion by heating adipose tissue to a depth up to 10 mm </li></ul><ul><li>Infrared Light increases elasticity of skin and heats subcutaneous fat to a depth of up to 3 mm, while safeguarding the skin from damage </li></ul><ul><li>Suction manipulates and smoothes out the skin </li></ul>
  32. 32. <ul><li>Recommendations </li></ul><ul><li>Give 3 syringes or 15mls per side </li></ul><ul><li>Expect a lot of bleeding </li></ul><ul><li>Procedure is somewhat painful </li></ul><ul><li>Can be used in combination therapy </li></ul><ul><li>Started with Shaper but recalled for EC </li></ul><ul><li>Give earlier then monthly if required </li></ul>Lipodissolve ®
  33. 33. <ul><li>Low material costs </li></ul><ul><li>Fast process 15-20mins </li></ul><ul><li>Simple techniques </li></ul><ul><li>No machine involved </li></ul><ul><li>Good patient tolerance </li></ul><ul><li>Minimal collateral risks </li></ul><ul><li>Multiple mechanisms of action </li></ul><ul><li>Long term therapeutic effect </li></ul><ul><li>The typical cost to a patient is is Euro 300 per session and the patient may pay in the region of Euro 1.000 </li></ul>Advantages of Lipodissolve ®
  34. 34. <ul><li>Safe option to liposuction </li></ul><ul><li>Results seen in 3-10 sessions </li></ul><ul><li>Insignificant side effects </li></ul><ul><li>Smoothens 'orange peel ' </li></ul><ul><li>Reported well-being and vitality from treatment </li></ul><ul><li>Reduces cholesterol levels </li></ul><ul><li>Improves liver and cellular functions </li></ul>Advantages of Lipodissolve ®
  35. 35. Lipodissolve ® versus Liposuction 1 . More even pleasing contour is achieved 2 . Final adjustments can be made at the end 3 . No general anaesthetic required . 4 . Minimal bleeding and bruising 5 . Effective control of pain during/after the procedure 6 . Short recovery time following the procedure . 7 . Rapid return to work and normal activities . 8 . Tiny puncture points. No stitches . 9 . No hospital stay required 10 . Substantially lower cost
  36. 36. <ul><li>Recommendations </li></ul><ul><li>Avoid NS Aspirin / NSAID for 2-3 days </li></ul><ul><li>Local Amethocaine (Anestop) Gel </li></ul><ul><li>Postpone if inflammatory or infective lesions </li></ul><ul><li>Drink fluid post procedure to combat swelling and odema as well as aid diuresis of PPC </li></ul>Post Lipodissolve ® Procedure
  37. 37. The Bottom Line The amount of fat in the body is determined by an individuals eating and exercise habits The distribution of fat in the body is determined by heredity Endermology can temporarily help dimpling but it does not remove fat Only Liposuction and PPC can permanently remove fat
  38. 38. <ul><li>During 1990’s treatments for cellulite remained largely unsuccessful because they targeted the skin appearance. It soon became apparent that dimpling on the surface of the skin would require a deeply acting treatment such as.. . </li></ul>The Treatment of Cellulite Liposuction Endomologie Lymphatic Drainage Ultrasound Diet
  39. 39. ELOS technology <ul><li>The technology is based on combined tissue heating using optical energy and RF current. </li></ul><ul><li>ELOS technology may be combined with vacuum pulses for treatment of subcutaneous tissue. </li></ul>
  40. 40. The Vela Idea <ul><li>Re-contouring of skin surface by increase of controlled metabolism in adipose tissue by increasing rate of metabolic reaction and substance diffusion. </li></ul>
  41. 41. VelaSmooth <ul><li>Infrared light tight the skin </li></ul><ul><li>RF creates hyperthermia of fat </li></ul><ul><li>Vacuum and mechanical action stretch connective tissue and improves blood circulation </li></ul>
  42. 42. Cellulite Treatment Fat clusters growing in chambers of connective tissue (septae) create cellulite phenomena Vela treatment destroys the fat by acceleration of metabolic process Improved skin appearance after 5-10 sessions
  43. 43. Vacuum pinches the skin and attaches it to the rotating electrodes
  44. 44. Mechanism of Increasing Blood Supply <ul><li>90% of blood vessels are closed at normal atmospheric pressure. </li></ul><ul><li>Decreasing the atmospheric pressure vessel cause dilatation and increases blood flow. </li></ul>
  45. 45. Heating Scheme for Deep Hyperthermia <ul><li>Infrared light heats the tissue up to 5mm depth </li></ul><ul><li>RF heats tissue from 5 to 15mm depth </li></ul>IR Lamp Parabolic reflector Infrared filter RF electrodes
  46. 46. Hyperthermia Effect on Metabolism <ul><li>Increases substance exchange between fat cells and blood vessels </li></ul><ul><li>Increase rate of fat metabolic reaction </li></ul>
  47. 47. Oxygen Transport Coefficients in Water Hyperthermia increases diffusivity of oxygen and decreases skin viscosity delivering more oxygen from capillaries to mitochondrion 4.88x10 -5 0.467 60 3.99x10 -5 0.547 50 3.24x10 -5 0.653 40 1.97x10 -5 1.002 20 Diffusivity of O 2 [cm 2 /s] Viscosity of H 2 O [centipoises] Temperature O C
  48. 48. Hyperthermia Effect on Rate of Metabolism <ul><li>Arrhenius law for yield of chemical reaction </li></ul><ul><li>Y=At e BT </li></ul><ul><li>Where A and B as constant, t is time and T is temperature </li></ul><ul><li>Rate of metabolic reaction is exponential function of tissue temperature. </li></ul>
  49. 49. Treatment Philosophy <ul><li>Make the body better looking </li></ul><ul><li>Redistributing the water and triglyceride by activating the metabolism of adipose tissue </li></ul>
  50. 50. Treatment Schedule <ul><li>Number of treatments – 8-10 </li></ul><ul><li>Treatments frequency - twice a week </li></ul><ul><li>Supporting treatment - Once in 1 to 3 months </li></ul><ul><li>Treatment duration 30-40min </li></ul>
  51. 51. Typical improvement curve (based on C. Lee M.D. data) Strong effect Saturating effect Moderate effect
  52. 52. Treatment Indication <ul><li>Cellulite </li></ul><ul><li>Non proportional fat distribution </li></ul><ul><li>Post liposuction non-uniformity of adipose tissue </li></ul>
  53. 53. Cellulite Treatment <ul><li>Number of passes and levels of energy should be adjusted to obtain stable erythema over the treated area </li></ul><ul><li>Slow replacement of applicator or staying on one place not longer then 5 pulses </li></ul>
  54. 54. Dr. M. Kulick, USA Cellulite treatment
  55. 55. G.Boey M.D.,Canada Cellulite treatment
  56. 56. Dr. Shah, Vela
  57. 57. Dr. Shah, Vela
  58. 58. Dr. Christopher Ho, Vela
  59. 59. Dr. Shah, Vela
  60. 60. Dr. Shah, Vela
  61. 61. Dr. Shah, Vela
  62. 62. Tina Alster, Vela (focused)
  63. 63. Dr. Shah, Vela
  64. 64. Non-proportional Fat Distribution <ul><li>Some parts of the body accumulate more fat and have to be treated more aggressively to improve body contour </li></ul><ul><li>Improvement of body contour is more spectacular than uniform fat reduction </li></ul>
  65. 65. Anchor Zones <ul><li>Even small reduction of fat in anchor zones improves significantly the body contouring </li></ul>
  66. 66. Treatment of Anchor Zones <ul><li>The anchor zones should be treated at maximal settings </li></ul><ul><li>Average number of passes applied to the anchor zones should be higher that for rest of the body at least by 2 passes </li></ul>
  67. 67. Before After Body Contouring H. Akai, M.D. Tokyo, Japan
  68. 68. Treatment of Post Liposuction Patients <ul><li>Improves the results </li></ul><ul><ul><li>Allows homogenization of adipose tissue </li></ul></ul><ul><ul><li>Improve healing process </li></ul></ul><ul><ul><li>Reduce loose skin </li></ul></ul><ul><li>Treatment technique </li></ul><ul><ul><li>Two passes with slow replacement of applicator or with staying on one place during 4-6 pulses </li></ul></ul><ul><ul><li>Two passes with fast moving the applicator with stronger pressing the skin </li></ul></ul>
  69. 69. Dr. A. Del Giglio, Italy , Post Liposuction Treatment