Cellulite: What can lasers do?

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Cellulite: What can lasers do?
8/1/2007
Joely Kaufman , Henry Chan, M.D.
Dermatology Times

Up to 98 percent of women have cellulite, and virtually no one wants it, but is there an effective treatment? That question remains unanswered, but we have options, and even more are in the pipeline.

History, histology

Contrary to popular belief, the appearance of cellulite has little to do with overall weight, and can appear in thin as well as obese women.

The difficulty in finding a valid and reproducibly reliable treatment stems from the lack of agreement on the exact etiology of cellulite.

The histology of the adipose tissue from an area of cellulite does not demonstrate any abnormalities when compared with normal fat tissue areas; hence, the problem does not lie within the adipocyte itself, yet in its position in the skin. Many researchers have suggested that it stems from a herniation of adipose tissue into the dermis.

Others imply a hormonal etiology, as men with cellulite typically have associated hormone abnormalities, or are on supplementation.

Still others attribute the cause to altered microcirculation and accumulation of water and lymph leading to edema.

Available therapies focus on these three proposed etiologies as they target cellulite.

Light, massage

The first in-office treatment targeting cellulite was a computer-driven, hand-held device termed LPG (Louis Paul Guitay) Û also called Endermologie. The science behind this device is not well-defined, but the goal of LPG is to use suction and deep massage to increase the circulation to the areas of cellulite. The device is approved by the Food and Drug Administration for the temporary treatment of the appearance of cellulite. One single-blinded trial found no significant improvement with the use of this device (Plastic Recons Surg. 1999).

Other controlled studies are essentially lacking. Our clinical experience is that after 10 to 20 treatments, a few patients may notice a mild improvement in cellulite appearance, but no loss in size or total fat content. Results are typically temporary, and return to baseline a couple of months after discontinuing therapy.

Despite the inconsistent results seen with LPG, two of the newer devices employ the suction and massage technique with the addition of light and/or radiofrequency. Tri-Active Laser Dermology (Cynosure) uses three different methods to target cellulite, and hence the name. Massage, suction and deep laser stimulation are combined in one treatment. The use of the massage and suction is aimed at increasing vascular and lymphatic circulation, and the 810 nm diode laser with epidermal cooling is for deep tissue heating. Deep tissue heating is to promote collagen formation, which can lead to textural changes. Improvement in the clinical appearance of cellulite was demonstrated in a published trial after 12 treatments using the Tri-Active system (Boyce et al. Am J of Cosmet Surg.).

Another device, which also uses laser light and massage, is the VelaSmooth (Syneron Medical). The VelaSmooth, however, also adds bipolar radiofrequency (RF) to its device. The laser used in the VelaSmooth system emits wavelengths between 700 nm and 1,500 nm. The addition of RF is for tissue tightening.

Two published studies with the VelaSmooth have demonstrated a thigh circumference reduction of 1 cm to 2 cm with eight treatments. (Alster J. Cosmet Laser Ther. 2005. Saddick NS. J Cosmetic LaserTher. 2004). As with the Tri-Active and LPG systems, a series of eight to 16 treatments is required. Side effects include transient erythema and edema and bruising. There are no published reports of scarring or dyspigmentation with either of these systems. One side-by-side comparison shows improvement of cellulite with both systems, and no significant differences between the two systems with respect to clinical results (Nootheti et al. Lasers Surg Med. 2006).

Unipolar radiofrequency (RF) devices are the newest in the fight against cellulite. Patients treated twice with the Accent device (Alma Lasers) (combination bipolar and unipolar RF) showed fat volume contraction of 20 percent in 68 percent of treated sites (J Drugs in Dermatol. 2006). Unipolar radiofrequency is also used in the ThermaCoolÙ system (Thermage?), which is FDA-cleared for noninvasive treatment of wrinkles.

One downside to unipolar RF is that it tends to be more painful than bipolar RF. The battle between unipolar RF and bipolar RF still continues in this realm, as well as the world of wrinkles. Physiologically, unipolar RF heats tissue much deeper and does have the possibility of melting fat. This has been seen in a few case reports as a complication when treating wrinkles at higher settings. In contrast, bipolar RF heats more superficially and may be better for tissue tightening than for treatment of fat. Time will tell how well these devices will perform in the office setting.

Ultrasound

New ultrasound devices should also hit the FDA soon, including Contour I (Ultrashape) and Sonosculpt (LipoSonix).

The focused ultrasound is capable of breaking adipocytes via vibration and not heat. The ruptured fat cells are reabsorbed via the normal systemic pathways.

Treatments are placed one month apart to allow time for lipid metabolism. In a clinical trial, an average circumference reduction of 3.95 cm after three treatments was reported with the Ultrashape device, with an ultrasound measured mean fat reduction of 2.28 cm. Patients must have at least 2 cm of measurable fat in order to be eligible for treatment. Circulating lipids levels were unchanged in studies from both companies. These devices are currently available in Europe and South America, but are not approved by the FDA at this time.

A study in the Asian population (H. Chan et al) produced less favorable results. Only 42 percent of patients had some degree of improvement after three treatments with contour I. One patient developed a blister and scar.

The main possibility for the differences in results, as compared with others, may be related to the usually smaller body size of Asians. As a result, the large transducer prevents the firing of enough shoots and the rib cage and pelvis simply obstruct the procedure.

Liposuction is still able to remove more fat than any of these devices. A newly introduced laser-assisted liposuction device may make this procedure easier to perform. This year, Cynosure released its SmartLipo laser lipolysis device. Nd:Yag laser pulses of 1,064 nm are delivered directly to the subcutaneous fat via a small cannula. The laser then melts the fat, and the dissolved fat can either be extracted with a traditional liposuction cannula or left in place for natural reabsorption by the body.

The infrared laser may also lead to collagen production in the area treated, resulting in tightening of the overlying skin. The idea is that this procedure is less traumatic than liposuction, as the cannula is much smaller and, in many cases, there is no need for suction at all. There is evidence that laser-assisted liposuction is less painful than traditional liposuction, but does have the side effect of higher postoperative free-fatty acid levels (Prado et al. Plastic and Reconstr Surg. 2006). It is best for small areas of fat deposition and is not a replacement for traditional liposuction. It is important to remember that removing fat in many cases does not improve the appearance of cellulite, as cellulite is not related to overall fat content.

LED, IPL

Several LED devices are also being examined for treatment of cellulite in combination with topicals (Photoactiv).

These devices are also pending FDA approval for this indication. There is also some evidence that IPL may improve the appearance of cellulite.

Despite the lack of randomized, controlled trials with most laser and light devices for cellulite, growth in this area is expected over the next couple of years.

It seems that the future of light- assisted cellulite treatment may lie with radiofrequency and focused ultrasound devices. Some of the new devices may prove to be an alternative, as opposed to a replacement, for traditional liposuction.