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     Brief Experience in the Use of Combined Technologies
             in the Treatment of Body Imperfections
                                     Dr. Patrizia Giardino 1, Andrea Pelosi 2

1) Specialist in Reconstructive Plastic Surgery, European Dermatological Institute, Milan - Italy
2) Physiotherapist, Milan - Italy

Introduction                                                  Districtual or localised fat deposits, with
                                                              their typical “trochanter cushion” or
Over the last decade in the medical and                       “saddle bag” appearance, consist of
aesthetics sector there has been a gradual                    an increased accumulation of fat in the
increase in the demand by patients for                        regions where adipose depots are normally
non-invasive methods for treating skin                        present. In females these deposits,
imperfections in general, and in particular,                  prevalently found on the sides of the hips,
for treating “cellulite” or “F.E.P.”, areas of                buttocks, thighs and medial face of the
localised fat and skin flabbiness.                            knee, can be considered as a secondary
                                                              sexual characteristic since influenced by
F.E.P.   or    Fibrosclerotic  Edematous                      the female sex hormones. The adipocytes
Panniculopathy is the term used to identify                   in these areas are in fact very rich in
modifications in the subcutaneous adipose                     oestrogen receptors, hormones which
panniculum mainly of an aesthetic nature,                     exert an action favouring the accumulation
found prevalently, although not exclusively                   of fat inside these cells. This “hormone-
in females and located electively in the                      dependency” may therefore explain the
trochanter and superolateral areas of                         scarce effectiveness that nutritional diets
the thighs, inner parts of the knees and                      have in these areas.
                                                              Skin flabbiness is caused by the relaxation
It is evidence of a condition of suffering                    of the dermal-epidermal tissues and
in the fat cells due to haematic stasis                       subcutaneous layer that may derive from
followed by oedema, degeneration of                           two main factors:
the fundamental interstitial substances                       a) hypotrophy of the underlying muscular
and collagen fibres, fragmentation of the                     mass, meaning that the surface tissues
elastic fibres, an increase in the number                     lack their normal support;
(hyperplasia) and thickness (hypertrophy)                     b) a reduction in the elastic-collagen
of the reticular fibres, finally resulting in                 component of the derma or the supporting
sclerosis. In broad terms we are faced                        fatty tissue.
with a chronic degenerative process of the                    In the latter case, which may involve all body
derma-hyperdermic structures.                                 areas including the face, with multifactorial
                                                              etiopathogenesis (aging, photoaging, and

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dietary imbalances),                             helping to restore the skin’s normal
the correct therapeutic proposal requires        collagen-elastic tension.
surgical dermolipectomy /lifting in the more
severe cases, while in milder or moderate        The two TriActive+ radiofrequency
cases, a mini-invasive or non-invasive           handpieces exploit a multipolar technology
treatment is recommended in order to             to treat imperfections caused by cellulite
stimulate the production of neocollagen          and skin flabbiness (body and face), that
and extracellular matrix.                        implements a special electrical current
                                                 (extremely safe for the body) to induce a
                                                 molecular oscillation on the dermal and fat
Materials                                        cells with a localised rise in temperature.
                                                 The radiofrequency therefore gives rise
Over a 6 month period we experimented            to contraction of the collagen fibres (by
with the use of a new medical device,            breaking the weak bonds inside the
the TriActive+, for the treatment of the         molecules themselves) with subsequent
conditions described above.                      stimulation of the fibroblasts and
The TriActive+ is a platform that exploits       neocollagenogenesis and reactivation of
six different handpieces (with Laser,            the microcirculation.
Ultrasound and Radiofrequency), designed
to treat widespread lipodystrophy, localised     Ultrasounds are mechanical sound waves
fat deposits and skin flabbiness.                produced by special handpieces which,
                                                 on passing through the skin cause the
The synergic action of the six handpieces        adipocytes to vibrate and exert a mechanical
allows for treating body imperfections in        massage.
order to achieve:                                The special sound waves generated by
                                                 the platform act selectively on the cellulite
• toned, elastic skin;                           via specific mobilisation of the tissues
• harmonious remodelling of the body             that partially ruptures the        adipocyte
contours;                                        membranes, releasing their triglyceridic
• a reduction in the oedema and painful          content (eliminated via natural physiological
symptoms caused by venous-lymphatic              pathways), and reducing compression
insufficiency of the lower limbs.                on the blood vessels with subsequent
                                                 drainage of the oedema.
The laser handpiece, which combines three        The ultrasounds produce a more effective
different synergic actions (laser stimulation,   action on reducing the “mattress”
localised cooling and dermal massage),           appearance, especially in more advanced
is characterised by an instrumental and          stages of cellulite.
methodical approach to cellulite aimed at
restoring the skin’s normal homeostatic
conditions.                                      Methods
The deep laser stimulation reactivates
the arterial, venous and lymphatic micro-        A total of 22 patients were recruited for
circulations; the localised cooling reduces      this trial with an average age of 45 years,
the effect and reabsorption of the oedema;       suffering from:
the dermal massage mobilises the tissues,

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      •   Cellulite                                  trophism.
      •   Districtual adiposity (D.A.)               The circumference of the area to be treated
      •   Moderately overweight                      was measured and the skin-fold technique
      •   Venous-lymphatic stasis                    applied.
      •   Fluid retention
      •   Flabby Skin                                Based on the assessment made, the
      •   Post-op oedema after laser lipolysis or    indications were established for proceeding
          liposuction surgery in a combination       with the Triactive+ treatment and the type
          of 2 or more of the indications listed     of methods and protocols to be followed
          above.                                     were decided.

    An accurate anamnesis was obtained               Patients with skin pathologies, infectious
    for identifying any previous or current          diseases,         phleblitis-thrombophlebitis-
    pathologies, pharmacological therapies,          phleobthrombosis,         neoplasias,   heart
    risk factors, causes and concomitant             and vascular failure, diabetes, renal
    causes (hormonal imbalances, metabolic           and hepatic impairment or dysfunction
    alterations, pregnancies, diet, use and abuse    were excluded, as well as patients with
    of alcohol, smoking etc.) in the subject’s       pacemakers and/or metal prostheses,
    history that could be responsible for the        transplants, osteoporosis, pregnant and
    onset of blood and lymphatic circulation         nursing mothers, patients under the age of
    deficiencies, cellulite, fluid retention,        18 and those with anticoagulant therapies
    obesity, etc. During this phase, detailed        in progress (possibility of persistent
    information was also collected in relation       erythema).
    to the symptomatology, motivations and           In     slightly-to-moderately      overweight
    goals that induced the subject to contact a      patients, the treatments were associated
    medical or aesthetics centre.                    with a sensible diet and moderate physical
    A careful examination was also carried
    out of the subject’s general physical            Cycles consisting of a minimum of 3 to a
    conditions: morphotype (gynoid or android),      maximum of 8 sessions were carried out, each
    overweight or obesity conditions, signs of       lasting from 30 to 60 minutes (depending of the
    venous insufficiency in the lower limbs,         size of the area to be treated) with a frequency
    identification of any asymmetries between        of 1 session a week.
    the body segments, and alterations in            At the end of the cycle, 6 of the patients
    posture, with photographic documentation         treated continued the maintenance
    of the body segments to be treated.              sessions with a frequency of 1 session
                                                     every 15 days.
    Information was also obtained regarding          Two patients who began the cycle of
    the texture and moisture content of the          sessions for treating facial skin flabbiness
    skin (presence or absence of oedema and          had to discontinue for personal reasons
    its characteristics), pain on palpation in the   which were in no way related to the
    areas most typically affected by cellulite       treatment itself.
    (inner thigh, front and external thigh areas),   Four patients underwent a cycle of sessions
    in order to provide a “staging” of it, and       with Triactive+ (Laser + RF) within the
    also in relation to skin and muscle tone and     context of post-op treatment after laser

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  lipolysis, and as an aid to improving skin                                   Face
  tightening. It was possible to commence
  the session one week after treatment
  with the laser component for the first 3/4                            Arms
  sessions (thanks to the significant draining
                                                                                                      Lower Limbs
  component of the laser and its gentleness
  in treating the tissues), followed by two or
  more Laser+ RF sessions.                                               Abdomen
  After liposuction of the abdomen,
  one patient who still showed signs of                           Graph 3: Body areas treated
  oedema and persistent “induratio” of the
  abdominal tissues after 2 months, had a
  rapid resolution of the problem after only 3                    Results
  sessions of Laser + RF.
                                                                  The patients underwent reassessment
  Following are graphs illustrating the details                   of the treatment after 3-4 sessions,
  of the treatment methods in the patients.                       during which it was decided if and how
                  Overweight   Post-op Edema                      many sessions were still necessary for
                                       Heavy-Leg Syndrome         completing the treatment. Finally, the last
                                                                  assessment was carried out at the end
                                           Venous-Leg Syndrome    of the scheduled sessions, during which
  Flabby Skin                                                     control photographs and centimetric
                                                                  measurements were taken, the skin-
                                               Distrectual        fold technique applied, and the texture,
                                               Adiposity (D.A.)   aesthetic aspect and painfulness of the
                                                                  tissues reassessed. Moreover, patients
             Cellulite 1-3                                        were invited to express their overall opinion
                                                                  of the treatment according to a scale from
  Graph 1: Pathologies treated
                                                                  0 to 4 (results: 0-none, 1-poor, 2-average,
                                                                  3-good, 4-excellent).
            US + Laser
                                                                  In photographic terms, an improvement
                                                                  in the skin tissue quality, including a
                                                                  reduction in cellulite imperfections and
US + Laser + RF                                   Laser + RF
                                                                  skin revitalisation (rosier skin colour due to
                                                                  enhanced microcirculation) and remodelling
                                                                  of the body contours, as observed in 90%
                                                                  of cases.

  Graph 2: Combined use of the sources

                                                                  Figure 1: Thermographs before and
                                                                  after treatment.

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    The centimetric measurements of the                                                                 there was an overall revitalisation of the
    circumference of the lower limbs taken at                                                           tissues which enhanced the microcirculation
    the level of the root of the thighs and knee                                                        (80%) and a slight improvement in skin
    show a 0.5-cm to 3-cm reduction.                                                                    flabbiness (20%). However there were
                                                                                                        no follow-up assessments of the patients
    In the treatment of the lower limbs it was                                                          treated capable of revealing the initial
    possible to visually observe a significant                                                          effects of shrinkage of the collagen fibres
    improvement in fluid retention, restoration                                                         by the RF or of the fibroblast stimulation
    of tone and elasticity to the tissues treated,                                                      for neocollagen storage, a process that
    a remodelling of the body contours, a                                                               usually takes about 6 months to be carried
    reduction in the orange-peel aspect where                                                           out correctly.
    present, and an overall revitalisation
    of the tissues which enhanced the                                                                   In patients who underwent laser lipolysis
    microcirculation.                                                                                   or liposuction surgery, in whom treatments
                                                                                                        with Triactive+ were applied for the
    80%                                                                                                 purpose of reducing post-op recovery times
                                                                                                        (regression of the oedema, “sponginess”
                                                                                                        and hardening of the tissues on palpation,
                                                                                                        improvement of the ecchymosis), a more
                                                                                                        rapid stabilising of the results of the surgery
    50%                                                                                                 was observed in approximately 50% more
                                                                                                        cases than patients who not receiving
                                                                                                        these treatments after surgery.

                                                                                                        From an analysis of the questionnaire filled
                                                                                                        out by the patients, it is evident that 77%
    10%                                                                                                 of patients judged the results as good while
                                                                                                        the remaining 22% judged the results as
                                                                                                        excellent, as confirmed in the following graph.


                                     Orange Peel
                                 Aspect Reduction

                                                    Toning & Elasticity
                                                            of the skin

                                                                          Superficial Microcirculaion



    Graph 4: Improvement observed                                                                        60%

    100% of patients who complained of pain
    and heaviness of the lower limbs at the end                                                          40%

    of the day (heavy-leg syndrome) before
    receiving treatment, showed an 80 to 90%                                                             30%

    improvement in the symptoms.                                                                         20%

    In the treatment of abdomen and thighs,                                                              10%

    an improvement in tone and elasticity of the
                                                                                                                Excellent   Good   Medium     Poor      None
    treated tissues (75%) was observed as well as
    good remodelling of the body contours (70%).                                                        Graph 5: Assessment of patients depending
    In the treatment of upper arms and face,                                                            on the result

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Tolerance of the treatment was excellent
and no patients were forced to interrupt or
discontinue the sessions due to the onset
of pain or side effects.

The only side effect observed was the
appearance of mild ecchymosis after
use of the ultrasounds that cleared up
spontaneously within 5-6 days. There
were no reports of persistent erythema or
burning of the treated tissues.

                                                   Figure 2: Distrectual adiposity

In our opinion it was interesting to observe
that in some cases the expected results
were obtained after only 3-4 sessions,
while in more difficult cases an additional
3-4 sessions were sufficient for completing
the treatment with both operator and
patient satisfaction. Therefore, with cycles
of only 1 session a week for a maximum
of 8 sessions, it is possible to observe
considerable visual and symptomatological
improvements in the problems treated,
with hardly any side effects.
Moreover, the possibility of combining
                                                   Figure 3: 3rd stage cellulite
different methods and different protocols
in the same session depending on the
elective requirements and problems in the
individual patient is the most significant
factor of the Triactive+ that makes it
possible to obtain good and rapid results
in the treatment of skin imperfections that
are usually hard to resolve.
Patient compliance is also excellent since
Triactive+ is well tolerated and the initial
benefits in terms of visible results can already
be appreciated after the first 2 to 3 sessions.
                                                   Figure 4: Districtual adiposity

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