The document provides information about Velasmooth® treatment for cellulite. It defines cellulite and discusses its causes. It then describes the Velasmooth® treatment which uses radio frequency and infrared light to heat the skin and fat tissues. This promotes fat metabolism and lymphatic drainage to reduce the appearance of cellulite. The treatment schedule and parameters are outlined along with expected improvements seen after 6-10 sessions.

1. “ An introduction to Velasmooth® in the treatment of Cellulite” Dr. P. Treacy Ailesbury Clinic Dublin Ireland

2. MEDICAL DISCLOSURE: Dr. Patrick J. Treacy is a Cosmetic Doctor registered in UK and Ireland I have previously been registered in United States, Australia, New Zealand and South Africa. I purchased my own Velasmooth ® equipment. I have no financial interest or stock in Syneron I receive no additional remuneration for equipment bought by you after attendance at this lecture .

4. What is Cellulite? Cellulite is a term that is used to describe fat deposits under the skin that give the skin a dimpled like appearance. It is estimated that up to 80% of women have a problem with cellulite.

5. 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 The History of the term ‘Cellulite’

6. P romotion of the concept in U.S. after publication of Cellulite: Those Lumps, Bumps and Bulges You Couldn't Lose by Nicole Ronsard, the owner of a New York City beauty salon that specialized in skin and body care The Concept of Cellulite Grows

7. Fat Layer of Skin The fat layer of the skin is located in the subcutaneous layer of tissue known as the hypodermis.

8. 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 dimpled appearance of the skin . The Physiology of Cellulite

9. What happens during Cellulite? 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. In people who are overweight excess fat is stuffed in these fibrotic compartments causing them to bulge out.

10. What causes the ‘Dimpling’ of Skin ? 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.

11. So what exactly is Cellulite? Cellulite is localised fat ‘ caught in a jail’ of interstitial connective tissue Cellulite is a lack of drainage of fluid secondary to venous + lymphatic stasis because of genetic, hormonal and even environmental reasons

12. 1. HEREDITY 2. HORMONAL - premenstrual syndrome, 3. VENOUS and LYMPHATIC stasis 4. NUTRITION insufficient water intake - excess of sugars, fats What are the Causes of Cellulite?

13. Stage 1 Problem seems to appear whenever you press skin Stage 2 Dimpling of skin only appears as the patient stands up The Different Grades of Cellulite

14. Stage 3 ‘ Peau de orange’ is present when the patient is lying down Stage 4 You can actually feel knots in the tissue when you touch it The Different Grades of Cellulite

15. The Physiology of Stages 1 & 2 Stage 1 and 2 The problem only appears whenever you press skin or the patient stands up. This is caused by localised oedema secondary to vascular and capillary extravasation with dissociation of the adipocytes

16. The Physiology of Stages 3 & 4 Stage 3 ‘ 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 Stage 4 The problem is present at all times because the micronodules fuse together to form painful subcutaneous macronodules .

17. 1996 Dr. Neil Solomon, conducted a double-blind study of 100 people to see whether cellulite differed from ordinary fat. The pathologists found no difference between the two clinical types of fat The Medical Evaluation of Cellulite begins

18. 1998 , researchers at the Rockefeller Institute used ultrasound, microscopic examinations, and some fat-metabolism studies to see whether “cellulitic" skin and normal skin differed The Medical Investigation of Cellulite

19. The researchers concluded (a) certain characteristics of skin make women more prone than men to develop cellulite (b) there were no differences in the appearance or function of the fatty tissue or the regional blood flow The Medical Concept of Cellulite

20. Products include special washcloths; creams and gels, supplements herbs bath liquids; massagers rubberised pants; brushes; rollers; body wraps; and toning lotions . The Market for Cellulite products

21. “ Anticellulite" products include tablets that work while you are awake and others that reduce cellulite….. while you sleep! 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

22. Body Wrapping The wrapping causes temporary water loss by compression and by perspiration. The water is quickly replaced within 24 hours . Body wrap claims this technique works because ‘cellulite’ is really water logged fatty tissue..

23. 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. Cellasene ®

24. 1998, FDA approved a French technique called Endomologie, for temporarily improving the appearance of cellulite Endermologie ®

25. Endermologie ® usually takes 10-20 treatments. Monthly maintenance is required to maintain these effects. Endermologie ®

26. Procedure is unable to break down dimpling effect although it can be used in combination therapy Lipodissolve ®

27. During 1990’s treatments for cellulite remained largely unsuccessful because they targeted skin appearance. It soon was apparent that dimpling on the surface of the skin would require a deeply acting treatment . The Treatment of Cellulite

28. 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 Velasmooth ®

29. Velasmooth ® RF increases oxygen intracellular diffusion by heating adipose tissue to a depth up to 10 mm Infrared Light increases elasticity of skin and heats subcutaneous fat to a depth of up to 3 mm, while safeguarding the skin from damage Suction manipulates and smoothes out the skin

30. Vela Smooth Design Ergonomic applicator Intuitive, simple interface Sophisticated software controlling treatment parameters

31. Vela Technical Specifications Infrared (IR) range 700-2000nm RF power 30 W IR power 30 W Treated area 40x40 mm (for thighs, buttocks, and abdomen ) 25x30 mm (for arms, calf, under-chin, and face )

32. Large Applicator 4 mechanisms : IR, RF, Rollers, Skin Curving (Suction) 3 intensity levels

33. Small Applicator No rollers

34. Clinical Indications Temporary reduction in circumferences Temporary reduction in the appearance of cellulite Improvement in the local blood circulation Improvement of skin texture Relief of minor muscle aches and pain

35. Contraindications Current or history of cancer Pregnancy and nursing Scarring , infection, or fragile skin at the tx. area History of keloid scarring Patients with a pacemaker or internal defibrillator

36. Contraindications Known photosensitivity to near infrared light Use of medications known to induce photosensitivity, including Accutane, and anticuagulants Diabetes (Type I or II), unless under control Varicose veins in the treated area

37. Anatomy of Cellulite Fat cells swell and push upwards as septa are rigid Blood and lymph vessels are compresses Accumulation of intracellular fluids and toxins

38. Cellulite Treatment Fat deposits caught in chambers of connective tissue (septae) create phenomenon of cellulite Velasmooth ® treatment destroys the fat by acceleration of metabolic process

39. Cellulite Treatment This leads to an improved skin appearance after about 6-10 sessions

40. Velasmooth ® Vacuum pinches the skin and attaches it to the rotating electrodes

41. Mechanism of Increasing Blood Supply 90% of blood vessels are closed at normal atmospheric pressure. Decreasing the atmospheric pressure vessel cause dilatation and increases blood flow.

42. Mechanism of Deep Hyperthermia Infrared light heats the tissue up to 5mm depth RF heats tissue from 5 to 15mm depth IR Lamp Parabolic reflector Infrared filter RF electrodes

43. Deep Hyperthermia by IR + RF Infrared (IR) light heats the tissue down to the deep dermis RF heats tissue down to the subcutis Lamp Parabolic reflector Infrared filter RF electrodes

44. Rollers- Mechanical effect Rollers and Vacuum Suction (150 mbar or 750 mm of Hg) Massaging effect facilitates drainage of trapped intercellular fluid to lymphatics

45. Rollers- Mechanical effect Breaking connective tissue bonds also helps to reduce volume of fat chambers in hypo-dermis

46. Suction Helps Hyperthermia Suction brings the target closer to the IR and RF source Target is the blood vessels in the deep dermis and in the subcutaneous fat layer and the tissue around

47. Suction Mechanism for Increased Blood Supply 90% of blood vessels are closed at normal atmospheric pressure Decreasing the atmospheric pressure increases vessel dilation and blood flow Thinning the cell membrane also helps in increased substance exchange between fat cells and vessels

48. Vela Smooth Idea Re-contouring of skin surface by: Increasing metabolic rate in adipose tissue due to: Increased blood supply Increased oxygen diffusivity and exchange Between blood vessels and fat cells Reduced fat chambers size due to: Reduced size of fat cells Mechanical breakage of connective tissue bonds Intercellular fluid drainage

49. Hyperthermia Effect on Metabolism Increases substance exchange between fat cells and blood vessels Increase rate of fat metabolic reaction

50. 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

51. Hyperthermia Effect on Rate of Metabolism Arrhenius law for yield of chemical reaction Y=At e BT Where A and B as constant, t is time and T is temperature Rate of metabolic reaction is exponential function of tissue temperature.

52. Treatment Schedule Number of treatments – 8-10 Treatments frequency - twice a week Supporting treatment - Once in 1 to 3 months Treatment duration 30-40min

53. Typical improvement curve (based on C. Lee M.D. data) Strong effect Saturating effect Moderate effect

54. Treatment Indication Cellulite Non proportional fat distribution Post liposuction non-uniformity of adipose tissue

55. Cellulite Treatment Number of passes and levels of energy should be adjusted to obtain stable erythema over the treated area Slow replacement of applicator or staying on one place not longer then 5 pulses

56. Velasmooth ® Cellulite treatment

57. G.Boey M.D.,Canada

58. Velasmooth ® Cellulite

59. Dr. Christopher Ho, Vela

60. Dr. Shah, Vela

61. Dr. Shah, Vela

63. Dr. Shah, Vela

64. Tina Alster M.D. , Vela

65. Dr. Shah, Vela

66. Non-proportional Fat Distribution Some parts of the body accumulate more fat and have to be treated more aggressively to improve body contour

67. Anchor Zones Even small reduction of fat in anchor zones significantly improves the body contouring

68. Treatment of Anchor Zones The anchor zones should be treated at maximal settings Average number of passes applied to the anchor zones should be higher that for rest of the body at least by 2 passes

69. Before After Body Contouring H. Akai, M.D. Tokyo, Japan

70. Treatment of Post Liposuction Patients Improves the results Allows homogenization of adipose tissue Improve healing process Reduce loose skin Treatment technique Two passes with slow replacement of applicator or with staying on one place during 4-6 pulses Two passes with fast moving the applicator with stronger pressing the skin

71. Dr. A. Del Giglio, Italy , Post Liposuction Treatment

72. Hyperthermia Effect on Metabolism Heat produced by IR increases oxygen dissociation from oxy-hemoglobin in heated dermal blood vessels Heat produced by RF increases rate of oxygen intracellular diffusion by deep hypodermal heating Fat metabolic reaction in adipocytes mitochondria is increased Use of stored energy from fat cells (lipolysis) results in shrinkage of cells themselves

73. Treatment Protocol Treat thighs, buttock and abdomen with large applicator, and arms, calf, under-chin, and face with small applicator ~ 10 Treatments performed twice a week ( Patients with lymphatic drainage problems need more sessions) Maintenance treatments done monthly, then bi-monthly Average treatment time 30-45 min ~10 mins per area (thigh, buttock, abdomen, arms, chin) No more than 5 sec dwell on one site

74. Treatment Parameters Best results with maximal (3 rd ) level Reduce IR for dark skin or over dark tattoo Reduce RF on curved areas with bad coupling Reduce suction on sensitive areas (abdomen, inner-thigh) and on loose skin

75. Treatment Parameters Use lower levels for muscle aches, poor circulation and skin texture Increase levels in subsequent sessions Repeat passes until persistent endpoints are apparent Endpoints are general erythema, edema and warmth

76. Treatment Tips Pretreatment - exfoliation and trimming of long hair Avoid anticoagulants (if medically permitted), as they increase the chance of bruising Use conductive water spray – not gel! Replenish spray only when movement of roller is affected – not when the spray appears dry

77. Treatment Tips Treating without spray – keep skin very clean Work in general direction of the lymphatics – ONE WAY Change direction to achieve best contact . Keep ONE WAY

78. Facilitate Lymphatic Drainage

79. Before and After 8 Cellulite Treatments Before After

80. Before and After 8 Cellulite Treatments

81. Fat Anchor Zones Evidence of body contouring by fluids redistribution in anchor zones Result = reduction in circumference

82. THANK YOU!

83. QUESTIONS?