220

Review
http://dx.doi.org/10.17784/mtprehabjournal.2014.12.194

Physical therapy in the treatment of body

aesthetics dysfunctions - literature review.
Fisioterapia no tratamento das disfunções estéticas corporais – revisão de literatura.
Jane Guiname Mota Silva(1), Eduardo Filoni(2), Fátima Faní Fitz(3).
Universidade de Mogi das Cruzes (UMC), São Paulo (SP), Brazil.

Abstract
Introduction: The aesthetic disorders, such as skin laxity, localized fat and cellulite, are common complaints among
the population in general. The physiotherapy provides techniques for treatment of these dysfunctions noninvasively.
Objective: To review the physical therapy techniques used to treat the body dysfunction aesthetic through a litera-
ture review. Method: It was performed a literature review of studies published between September/1997 and Octo-
ber/2013, in Portuguese or English, in the Scielo, PEDro, Pubmed, Lilacs e Medline database. Results: A total of 1.165
articles were found. Of these, 37 were potentially eligible after reading the title and summary, and a total of 11 stu-
dies were included. The studies addressed some techniques like radiofrequency, combination of bipolar radiofrequency,
infrared, vacuum and mechanical massage (Velashape), ultrasound of high intensity focused, cellulite cream, mecha-
nical massage, lymphatic drainage and tissue manipulation, ultrasound of low intensity, and cryolipolysis. Conclu-
sion: We conclude that the physical therapy techniques are effectives, safe and well tolerated by patients in the tre-
atment of localized fat. They help to sculpt the body and to reduce cellulite. However, it is necessary to perform ran-
domized controlled trials, with larger sample size, since the majority of the included studies are prospective and re-
trospective clinical trials.
Keywords: Localized Fat. Skin Laxity. Body Contouring. Cellulite. Physical Therapy.

Resumo
Introdução: As disfunções estéticas, como a frouxidão tecidual, a gordura localizada e o Fibro Edema Gelóide (FEG),
são queixas comuns entre a população de forma geral. A fisioterapia disponibiliza técnicas para tratamento destas dis-
funções de maneira não invasiva. Objetivo: Revisar as técnicas fisioterapêuticas utilizadas para o tratamento das dis-
funções estéticas corporais por meio de uma revisão de literatura. Método: Foi realizada uma revisão bibliográfica de
estudos publicados entre setembro/1997 e outubro/2013, em português ou inglês, nas bases de dados Scielo, PEDro,
Pubmed, Lilacs e Medline. Resultados: Um total de 1.165 artigos foram encontrados. Destes, 37 foram potencialmen-
te elegíveis após a leitura do título e resumo, e um total de 11 estudos foram incluídos. Os estudos abordavam as téc-
nicas de radiofrequência, a combinação de radiofrequência bipolar, infravermelho, vácuo e massagem mecânica (Ve-
lashape), ultrassom de alta intensidade focalizado, creme anticelulite, massagem mecânica, drenagem linfática e ma-
nipulação de tecidos, ultrassom de baixa intensidade e criolipolise. Conclusão: Conclui-se que as técnicas fisiotera-
pêuticas abordadas nos estudos incluídos são eficazes, seguras e bem toleradas pelos pacientes para o tratamento da
gordura localizada, auxiliando a esculpir o corpo, além de ajudar na redução do FEG. Entretanto, existe a necessidade
da realização de ensaios clínicos randomizados e controlados e com tamanho amostral maior, visto que a maioria dos
estudos incluídos são ensaios clínicos prospectivos não controlados e estudos retrospectivos.
Palavras-chave: Gordura Localizada. Flacidez de Pele. Contorno Corporal. Celulite. Fisioterapia.

Received: 6 June 2014. Accepted: 8 September 2014. Published: 16 September 2014.

1. Physical Therapy Student at Universidade de Mogi das Cruzes (UMC), São Paulo (SP), Brazil.
2. Coodinator and professor of Physical Therapy School, Universidade de Mogi das Cruzes (UMC), São Paulo (SP), Brazil.
3. Professor of Physical Therapy School, Universidade de Mogi das Cruzes (UMC), São Paulo (SP), Brazil.

Corresponding Author
Fátima Faní Fitz - Universidade de Mogi das Cruzes, Centro de Ciências Biomédicas - Avenida Imperatriz Leopoldina, 550 - Vila Leop-
oldina - Zip Code: 05305-000 - São Paulo, SP – Brazil - Phone: (11) 3648-5050 - E-mail: [email protected]

MTP&RehabJournal 2014, 12:220-230

Jane Guiname Mota Silva, Eduardo Filoni, Fátima Faní Fitz. 221

Introduction Discussion
The tissue laxity, the subcutaneous fat deposit lo- Physiotherapy Dermato-Functional acts in the pre-
cated on the body and “cellulite” are the most common vention and recovery of the integumentary system,
complaints among patients treated by Dermato-Functio- treating metabolic, circulatory and endocrine dermato-
nal physiotherapy. Among the causes of these disorders logical disorders, aiming body aesthetic and functional
are the chronological aging, photo aging, changes in body recovery. Radiofrequency techniques were used in this
size experienced during pregnancy and weight loss.(1) study, the combination of bipolar radiofrequency, in-
The “cellulite” has a prevalence between 85% and frared, vacuum and mechanical massage (Velashape),
98% in all ethnic groups. Among the risk factors that high-intensity focused ultrasound, cream called “cellu-
contribute to its emergence are excess body fat, hor- lite”, mechanical massage, lymphatic drainage and tis-
monal factors, inadequate diets, genetic predisposition, sue manipulation, ultrasound low intensity and cryoli-
smoking, postural and orthopedic disorders, inactivity polysis. The following will be presented and discussed
and also external compression of body tissues caused each of the techniques discussed in the included studies.
by wearing tight clothes.(2) Although the main complaint
is related to aesthetics, sagging skin, excess body fat Radiofrequency and aesthetic body dysfunctions
and “cellulite” cause functional and emotional proble- The radiofrequency has been applied to reduce
ms and may lead to decreased self-esteem and creating “cellulite”. Induction diathermy has a favorable effect on
problems in interpersonal relationships.(3,4) Thus, these microcirculation and tissue oxygenation, and can also
disorders are considered a health problem, by presen- lead to the renewal of collagen, such as stimulation of fi-
ting major impact on quality of life of women.(5) broblasts increases the production of collagen and elas-
Dermato-Functional physiotherapy has worked to tin (the latter responsible for improving elasticity and
correct these dysfunctions, using resources that operate firmness skin). As reported in the literature, the use of
noninvasively, improving the quality of life of these pa- radio frequency leads to a noticeable improvement in
tients.(6) Given the great demand for non-invasive pro- the appearance of skin affected by “cellulite” areas.(45-47)
cedures, as well as the motivation of researchers to de- Proper technique can be low or high frequency mo-
velop new techniques to replace surgical treatments to nopolar, bipolar or tripolar application. In the applica-
improve body contour,(7,8) this study aims to review the tion of monopolar device, an electrode is located in the
physical therapy techniques used to treat bodily dys- target area and the other return electrode is placed at
functions aesthetic through a literature review. a certain distance, so that the electric current passes
through the tissue between the electrodes. Bipolar im-
Methods plementation, both electrodes are embedded in a single
The work refers to a literature review of published tool.(48) Can be also used to tripolar application, which is
scientific articles in Portuguese and English, published based on three or more electrodes. In this, as in others,
between September to October 1997/2013. The Medli-
ne, Pubmed, PEdro, SciELO and LILACS databases were
used to conduct the research. The following descriptors
according to the Medical Subject Headings (MESH) were
used: skin laxity, fat, physical therapy modalities, ae-
robic exercise, galvanic current, exercise, muscle stre-
tching, exercise, pilates, radiofrequency and ultrasound.
Articles reporting the role of physiotherapy in the treat-
ment of bodily aesthetic disorders were included. Consi-
dered aesthetic bodily dysfunctions localized fat, cellu-
lite and laxity skin. No studies of narrative and editorial
review were included, because they did not fit the crite-
ria proposed by the study.

Results
A total of 1,165 studies were found after removing
duplicates. Of these, 37 were considered potentially eli-
gible after reading the title and abstract. A total of 11
studies were included after reading in full. Details of in-
clusion and exclusion studies are shown in Figure 1. The
details of the studies included were tabulated and are
shown in Table 1. Figure 1. Flowchart of the inclusion and exclusion criteria.

MTP&RehabJournal 2014, 12:220-230

 222 Fisioterapia e disfunções estéticas corporais.

Table 1. Details of the included studies.

Author/ Characteristics of participants, sam- Study Design and Inter- Measures of Outcome, Results and
Year ple size (N), duration of symptoms ventions Conclusion.
Measures of Outcome = Evaluate the
safety and tolerability of cryolipolysis.
Effectiveness of treatment according to
patient satisfaction (scale of 4 points -very
satisfied, satisfied, neutral, dissatisfied).
Results = No significant side effects
N= 518
or adverse events were reported.
Inclusion Criteria: Different ages, men
Type of Study= Multicenter T h e p r o c e d u r e w a s w e l l t o l e r a t -
Dierickx et and women, with a medical history and
retrospective study. ed, with 89% of respondents report-
al, 2013 (35) different type of skin and presence of
Protocol= cryolipolysis. ing positive perception of treatment.
localized fat.
73% of patients were satisfied. In assessing
Exclusion Criteria = Not reported
body fat observed a 23% reduction in the
thickness of the fat layer.
Conclusion= The cryolipolysis is a safe,
well-tolerated and effective treatment is a
good and non-surgical method for reducing
subcutaneous fat.
Type of study= Prospective
clinical study.
Protocol = We used simul-
taneous two transducers: a
probe for freezing fatty tissue
(cryolipolysis) and low-inten- Measure of outcomes = Patients were
sity ultrasound to cellulite. examined by two surgeons not involved in
The cryolipolysis was carried the treatment. Weight and height of each
out for 30 minutes with sliding individual was recorded. The follow-up period
area with slow movements was 12 months, and the method of evalu-
and a temperature range ation of post-treatment was standardized.
Age = Between 21 and 62 years.
between 0 and -5 °. Subjective assessment of skin density and
N= 50
The low intensity ultrasound volumetric fat reduction was made. The as-
Inclusion Criteria= 37 women and 13
has been used with a conduc- sessment of patients was obtained through
men with the presence of localized fat
tive gel for 10 to 15 minutes. a questionnaire with a scale 0-5 pertaining
and cellulite.
For edematous cellulite, the to comfort and satisfaction.
Exclusion Criteria = Men and women
Ferraro et probe was used to freeze for Results = Reduction in the thickness of body
with osteoporosis, phlebitis, thrombophle-
al, 2012 (4) 5 minutes and then used the fat after treatment was 3.02 cm and the
bitis, patients with metal fragments, joint
shock probe for 5 minutes. body circumference was 4.45 cm. The weight
prostheses and intrauterine, pregnant
The cryolipolysis and low- remained unchanged during the treatment,
women, patients with reduced nervous
intensity ultrasound was re- and no adverse effects were observed and a
sensibility, neurological disorders, pa-
peated four times (20 min- reduction in fat thickness was accompanied
tients affected by arteriopathies, signifi-
utes each side) for localized by a significant improvement in microcircula-
cant inflammation or neoplastic diseases.
fat, and for fibrous cellulitis tion and cellulite.
were used 10 minutes of low Conclusion= The Results shows that the
intensity ultrasound and 10 action of cryolipolysis and low-intensity ul-
minutes of cryolipolysis. trasound is safe, well-tolerated and effective
The duration of treatment was ways as non-invasive procedure for body
defined as the size of the area contouring treatment.
being treated, minimum of 20
minutes and a maximum of
60 minutes.
1 session every 15 days for 8
consecutive weeks.
Measures of outcomes = Measurements
were performed in a traditional way, by pal-
Type of study= Prospective
pation performed before and 4 weeks after
clinical study.
completion of therapy. The stage of cellulite
Protocol = Treatment group:
was evaluated according to the scale of
28 women treated with ra-
Numberger-Müller, and thigh circumference
diofrequency. The treatment
and body mass index was calculated to be
began with the lower energy
measured.
dose recommended by the
Age= 24-58 years. Results = The cellulite was reduced in 89.2%
manufacturer (110 J/cm 2 )
N= 45 of women who underwent treatment with
Mlosek et which was increased by about
Inclusion Criteria= Women with cellulite radiofrequency. After treatment, the follow-
al, 2012 (36) 10-20 J/cm2).
stage I to III. ing observations were made: there was a
Placebo group: 17 women
Exclusion Criteria= Not reported. reduction in the thickness of the dermis and
who underwent treatment
subcutaneous tissue, increased echogenicity
without increasing the trans-
in reflection on the increased number of colla-
mitter.
gen, decreased subcutaneous tissue growing
Placebo group: 17 women
in bands fibers in the dermis, and the reduc-
who underwent treatment
tion edema. In the placebo group, there were
without increase increasing
no statistically significant changes.
the transmitter.
Conclusion = The radio frequency enables
a reduction in cellulite.

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Jane Guiname Mota Silva, Eduardo Filoni, Fátima Faní Fitz. 223

Measures of outcomes = In classic ul-

trasonic examinations were evaluated: the
thickness of the hypodermic layer and the
total thickness of the dermis and subcuta-
neous tissue. In ultrasound imaging at high
Type of study= Prospective frequency was evaluated: the thickness of
controlled clinical study. the epidermis, the dermis thickness, echo-
Age= 22-61 years Protocol = Group treatment: genicity, and the presence or absence of
N= 61 cellulite cream used for 30 edema of the dermis.
Mlosek et
Inclusion Criteria = Women diagnosed days. The cream was used in Results = A statistically significant differ-
al, 2011 (37)
with cellulitis based on palpation exam. the cellulite affected area by ence was observed in the thickness of the
Exclusion Criteria = Not reported. 2X/day. Control group: They subcutaneous tissue in echogenicity in the
ingested placebo medication surface area and length of the subcutaneous
in tablet form for 30 days. tissue as well as the presence of edema in the
treatment group. Discussed the changes were
not observed in the placebo group.
Conclusion = Ultrasound classic and high
frequency are useful for monitoring “anti-
cellulite” therapy methods.
Measures of outcomes = The first method
was effective shift in height of the circumfer-
ence of the iliac at 12 weeks after initiation
of treatment.
Age= 18-65 years
The second method of efficacy included
N= 180
change in waist circumference into 4 and 8
Inclusion Criteria = Men and women
weeks. At 12 weeks the patients completed
with BMI ≤ 30 kg/m2 and thickness of
a satisfaction survey which gave a score 1-5
subcutaneous adipose tissue in the abdo-
to questions such as: perception of improve-
men and flanks ≥ 2.5cm.
ment in abdominal structure, intention to
purchase additional treatment, and overall
Exclusion Criteria= Coagulation disor-
satisfaction with the results.
ders or use of medications, dietary sup- Type of study= Multicenter,
Within 7 days following treatment, patients
plements limiting coagulation or platelet randomized double-blind con-
rated the level of discomfort and pain that
aggregation, diabetes or cardiovascular trolled.
felt like medications being taken.
disease; any previous cosmetic proce- Protocol = Subjects were
Researchers assessed the degree of aes-
dure, surgical scar or laparoscopy in the randomized into three groups
thetic improvement in 4th, 8th and 12th week
treatment area; skin disease, abnormali- to receive High Intensity Fo-
Jewell et based on photos.
ties of skin or soft tissues of the abdominal cused Ultrasound (HIFU) with
al, 2011 (38) Side effects and blood samples were analyzed
wall, sensory loss, dysesthesia, or metal different doses in regions of
before and after treatment.
implants for weight loss; Surgical proce- the anterior abdomen and
Results = In assessing the extent of the
dures for weight reduction, use of current flanks. The groups were: 47
circumference at the level of the iliac crest,
treatment with steroids or immunosup- J/cm2 (141 J/cm2 total); 59
there was significant improvement for the
pressive chronically; implantable fixture, J/cm2 (177 J/cm2 total); or 0
59 J/cm2 group compared with the control
history of cancer; use of illicit drugs or J/cm2 (control group).
group, however, this was not observed in the
alcohol (ie, four or more drinks per day
result group 47 J/cm2. In the investigation
and pregnant and lactating women also
of subjective measures of overall aesthetic
patients who did not agree to change your
improvement and patient satisfaction were
diet, participate in any program of weight
favorable in the treatment groups compared
loss were excluded; using any substance
to control. Adverse events, such as discom-
for promoting weight loss, or to undergo
fort, bruising and swelling were rated mild
any cosmetic procedure (including sur-
to moderate.
gery) of the trunk, back, or abdomen.
Conclusion = Treatment with high-intensity
focused ultrasound reduces waist circumfer-
ence is well tolerated to sculpt the body
non-invasively.
Measures of outcomes = Evaluation of
waist circumference was performed before
Age= 22-69 years
treatment and after 8 to 12 weeks. During
N= 85
a post-treatment with 4 months of follow-up
Inclusion Criteria = healthy adults
visits. Fifty patients were randomly selected
who expressed a desire to undergo body
for a brief survey to assess their overall
sculpting with High Intensity Focused
Type of study= Clinical ret- satisfaction with the procedure and conduct
Ultrasound (HIFU), have at least 1 cm
rospective study. of their aims to reduce waist circumference.
of adipose tissue beyond the focal depth
Fatemi et Protocol = One session of Results = Waist circumference decreased
planned to be used, and no contra indica-
al, 2010 (39) High Intensity Focused Ultra- by an average of 4.6 cm after 3 months. Of
tions exist for the use of HIFU.
sound (HIFU) lasting 60-90 the 85 treated patients, 10 (11.8%) reported
Exclusion Criteria= Body mass index
minutes. adverse events, including prolonged sensitiv-
less than 30 kg/m2, pregnancy, implanted
ity (n=3), ecchymoses (n=3), pits (n=2), or
electrical devices, clotting or current
swelling and pain (n=1).
anticoagulant therapy, cancer, hernia,
Conclusion = The authors conclude from
sensory loss in the area being treated, or
their experience that HIFU is a safe and ef-
suspected systemic or chronic disease.
fective means of treatment to sculpt the body
non-invasively.

MTP&RehabJournal 2014, 12:220-230

 224 Fisioterapia e disfunções estéticas corporais.

Measures of outcome = Biopsy of the

Type of study = Prospective subcutaneous layer of the cellulite area (but-
study. tocks) immediately after the first treatment
Protocol = Patients received session performed.
1 session of bipolar pulsed Results = Following treatment with radiofre-
radiofrequency. Treatment quency epidermis had a thin layer of keratin
sessions were conducted with which would have been related to the fre-
a 22cm transducer. Gel to quent passage of the tool. In all histological
improve contact between the samples collected after treatment of the kera-
transducer and the skin was tin layer was thinner than in samples taken
used and was placed in notice- before treatment, but the keratin layer was
Age= 24-47 years
able pressure transducer at thinner not comparable to that produced by
N= 30
the time of treatment, while, a chemical peeling agent. The dermis showed
Inclusion Criteria= Women with photo
Trelles et if the traced figure of eight collagen fibers realigned and slightly apart,
skin types II to V, with grades (grade 3)
al, 2010 (40) movement with the skin tissue with edema and lymphocytic infiltrate around
similar cellulite on the buttocks.
in an upward direction. Termi- the dilated vessels. In all samples, adipocytes
Exclusion Criteria = Previous treatment
nation of treatment was pro- had lost their round shape and rectangular
for cellulite.
longed when a temperature of polyhedral presenting. Furthermore, some
the skin surface of about 42°C adipocytes appeared necrotic and without
was observed, or when pain or any fat content.
burning sensation was felt, or Conclusion = The radiofrequency treat-
presence of intense erythema. ment produces a decrease in cellulite in lipid
The duration of the treatment content as well as changes in adipocyte cell
session was 45 minutes. At membrane, leading to disruption and cell
the end of the session was death and lipid content of extruded out of the
applied Aloe Vera gel serving cell. More studies are needed to characterize
as a moisturizer. the nature of the material showed that ex-
tracellular lipid with oil red stain in biopsies.
Meansure of outcomes = The participants
were evaluated using standardized photo-
graphs, analysis of body composition, body
weight, body mass index, % fat, fat mass, fat
free mass, total body water, measurement of
Type of study= Prospective thigh circumference, waist-hip ratio, meas-
Age= Over than 30 years. Protocol = First group urements of fat thickness of the abdomen,
N= 60 (n=20) compared mechani- flanks and thigh regions with folded skin.
Inclusion Criteria= Women with degree cal massage. Three sessions/ Result = All groups had decreased subcu-
of cellulite ≥2 according to the scale of week for 5 weeks. taneous fat after treatment (p <0.05). The
Nürnberger Score. Second group (n=20) us- thigh circumference decreased by an average
Bayrakci et
Exclusion Criteria = Heart disease, liver ing the technique of manual of 0.5 cm in all groups. The thickness of thigh
al, 2010 (41)
disease, hypothyroidism, pregnancy, he- lymph drainage. Four ses- fat decreased 1.66 mm in Group 1; 2.21 mm
matologic diseases, therapy with amino- sions/week for 5 weeks. in Group 2 and 3.03 in Group 3 mm.
phylline and theophylline, varicose veins, Third group (n=20) using the Region of the abdomen and flanks decreased
diet or recent weight loss, liposuction or technique of connective tissue 2.4 and 2.58 mm of fat thickness in Group
other surgery for the thighs and buttocks. manipulation. Four sessions/ 1, 1.78 and 2 mm in Group 2 and 1.23 and
week for 5 weeks. 0.64 mm in Group 3, respectively. The aver-
age difference in waist-hip ratio was 0.1 cm
in all groups.
Conclusion= All treatment techniques are
effective to reduce fat located in patients
with cellulite.
Age= 28-70 years.
N= 29 Measures of outcome = Measured of cir-
Inclusion Criteria = Age ≥ 21 years and cumference, photographs and body weight
at least nine months postpartum, signifi- measurements were performed before
cant sagging skin and subcutaneous fat Type of study= Non rand- treatment and at 1 and 3 months follow-up.
deposits, as determined by the investiga- omized clinical trial. Assessment of treatment satisfaction (not
tor, postmenopausal women, tubal ligation Protocol = Treatment of the satisfied, somewhat satisfied, satisfied, very
or filling out a form of birth control. upper extremities: 19 patients satisfied, very satisfied) to each follow-up
Exclusion Criteria = Known photosensi- underwent five weekly ses- visits.
tive disease, use of substances that cause sions with Velashape. Result = Change in arm circumference at
photo sensitivity, keloids, isotretinoin Treatment of the abdomen the fifth session of treatment was statistically
Brightman within 6 months of treatment, use of and flanks: 10 subjects under- significant with an average loss of 0.62 cm.
et al, 2009 nonsteroidal anti-inflammatory drugs two went 4 weekly sessions with At 1 and 3 months follow-up, the average
(42)
weeks before or two weeks after treat- Velashape. loss was 0.71 and 0.59 cm, respectively.
ment, pregnancy or breastfeeding, history Velashape - combinação de Reduction in abdominal circumference in the
of cancer in the area treated, treatment radiação infravermelho (In- third session of treatment was statistically
with a laser or other device areas of study frared) (20W/700-1,500 nm), significant with a reduction of 1.25 cm. At 1
within 6 months of study treatment or in com radiofrequência bipolar and 3 months follow-up, the average loss was
the treatment zones intended for treat- (50W), vácuo (200mbar - 1.43 and 1.82 cm, respectively.
ment within 9 months during the study or pressão negativa 750 mmHg) Conclusion = This study demonstrates
treatment, having undergone any surgery e massagem mecânica. statistically significant, sustainable circum-
in the treated areas within 9 months dur- ference reduction and improvement in the
ing the study or treatment, or suffering appearance of the arms and abdomen treat-
from hormonal imbalance that may affect ment with Velashape.
the weight or cellulite.

MTP&RehabJournal 2014, 12:220-230

Jane Guiname Mota Silva, Eduardo Filoni, Fátima Faní Fitz. 225

Type of study = Controlled Measures of outcome = The changes in

trial the connective tissue were evaluated using
Protocol = Group A: 15 pa- the Super System DermaScan-C. Measure-
tients underwent treatment ments of skin elasticity were performed
Age= 21-63 years. of plane acoustic waves with using the system DermaLab. Photos of the
N= 59 six sessions of therapy for 3 treated areas were taken at each therapy
Inclusion Criteria = Age> 20 years, weeks. and at follow-up.
stage 2 or 3 of cellulite according to Nürn- Group B: 44 patients un- Result = Skin elasticity improved gradually
berger Score scale, and ability to read and derwent treatment of plane during the course of therapy in 73% of pa-
understand the informed consent form. acoustic waves with eight tients and increased at the end of therapy.
Exclusion Criteria = gravidez e ama- therapy sessions over 4 At 3 and 6 months follow-up, skin elasticity
Christ et al,
mentação, flebite ou trombose venosa weeks. had improved by up to 95%. The side effects
2008 (43)
profunda em MMII, inflamação na região The treatment was performed include pain for three patients during therapy
da terapia, lipoaspiração ou endermologia with a portable device plan. and slight reddening of the skin.
na região da terapia menos de 6 me- This includes a source of Conclusion = This study confirmed the ef-
ses antes do estudo, graves problemas acoustic wave and connector fects of acoustic waves in biological tissue
cardiovasculares, marcapasso, áreas de membranes that are placed on therapy, including pacing, improvement of
dor difusa, e o uso de antagonistas da the skin equipment. Applies microcirculation and cell permeability. Ultra-
vitamina K. ultrasound gel on the skin sonography showed increased density and
before, to avoid energy losses firmness of the collagen / elastic fibers in the
due to air layer between the dermis and subcutaneous tissue network. The
connector membranes and treatment was most effective in older patients
skin. with a long history of cellulite.
Measure of outcome = Efficacy was as-
sessed by changes in thickness of the fat
measured by ultrasound and by measuring
Type of study= Prospective the circumference. Weight change was moni-
Age= Not reported
Protocol = 8 men and 22 tored for evaluating if the reduction in thick-
N= 30
women underwent three ses- ness of fat or circumference was dependent
Inclusion Criteria = Fat located at
sions of High Intensity Fo- or independent of weight loss. Photographs
least 2 cm in thickness measured with
cused Ultrasound (HIFU), with were taken before and after each treatment
Moreno- a compass, and physical examinations
1-month interval, and were session.
-Moraga et and blood.
followed for one month after Result = All patients showed a significant
al, 2007 (44) Exclusion Criteria= Patients with ac-
the last session. The treated reduction in the thickness of subcutaneous
tive malignant disease other terminal or
areas are the abdomen, in- fat in the treated area. The weight remained
severe liver disease, or severe hyperlipi-
ner and outer thighs, flanks, unchanged during treatment and follow-up.
demia, large tattoos or scars in the area
inner knees, and in men with No adverse effects were observed.
of ​​disease treatment.
pseudo-gynecomastia. Conclusion = This study demonstrates the
efficacy and safety of HIFU is a non-invasive
transdermal method to reduce the fat deposit
in the body.

power is generated when current passes between the (Velashape), in the region of the arms, abdomen and
electrodes.(49) flanks, with the goal of treating localized fat and sagging
In this review, three studies addressed the ra- skin postpartum.(42) Velashape is the first medical device
diofrequency. Mlosek et al. (36)
used technique in ra- to receive certification from the Food and drug Adminis-
diofrequency pole eight sessions of treatment of tration (the agency that regulates the sale of food and
“cellulite.” The authors observed a decrease in the medicine in the United States), considered the best re-
thickness of the dermis and subcutaneous tissue, in- source for the reduction of fat and circumference layer,
crease in the number of collagen fibers, reduction in acting effectively in reducing “cellulite “. The use of si-
subcutaneous tissue growth bands in the dermis, and multaneous movements of suction (negative pressure),
a reduction of the edema. The technique was effec- infrared, bipolar radiofrequency and mechanical massa-
tive for reducing cellulite and safe for not expressing ge promotes increased metabolism of fat cells, decrea-
side effects.(36) sing its size and stimulating the production of collagen,
In another study, which does not focus on the tre- thereby improving skin texture. The combination of dual
atment of “cellulite”, but discusses the reaction of adi- energy allows synergistic effects preheating the target
pocytes, the authors analysed the histological findings tissue with infrared, mitigating the impedance and thus
of biopsies on the localized cellulite on the buttocks. And allowing greater attraction radio frequency.(48,50) Bright-
found that they showed changes in shape, size and con- man et al.(42) have observed that application of Velasha-
tent of lipids, as well as cytoplasmic and nuclear mor- pe arm promoted a significant change from the fifth tre-
phology. After treatment, there was a decrease in the atment session with an average loss of about 0.6 cm. In
lipid content in cells, and changes in the membrane of the abdomen, the significant loss gave up after the third
adipocytes, leading to breakage and cell death and lipid treatment session, with an average loss of 1.2 cm. It is
content of extruded out of the cell.(40) shown, therefore, an effective treatment in reducing cir-
Another study used a combination of bipolar radio- cumference and improves the appearance of the abdo-
frequency, infrared, vacuum and mechanical massage men and upper arm.(42)

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 226 Fisioterapia e disfunções estéticas corporais.

High-Intensity Focused Ultrasound and body each session. At the end of treatment was observed that
dysfunctions aesthetic the reduction of fat thickness correlated positively with
Ultrasound can be used in medicine as a diagnostic the initial measurement (rs=0.88, P<0.01). Also obser-
method, when used in imaging or as a therapeutic mo- ved average circumference reduction of 3.95±1.99 cm.
dality which emits focused ultrasound waves to deliver The change in circumference was significant compared
energy concentrated in a focal volume at a precise depth to baseline (P<0.01). Another fact was found that there
in the subcutaneous tissue. This system was designed to was no significant variation in weight of the patients,
use the mechanical energy (not heat) to break down fat showing that reduction of fat thickness and circumfe-
cells without damaging nearby structures (skin, blood rence occurred due to treatment and not due to weight
and lymph vessels, muscles and peripheral nerves).(44) loss, confirming its efficacy. Among the adverse events
In the treatment of localized adiposity, a stable cavita- observed in one case the presence of bubbles, howe-
tion occurs and unstable transitional openings perfor- ver the procedure was considered safe. As in the study
ming cell membranes, termed ultra-cavitation, produ- by Fatemi et al., Completing examinations of fatty acids
cing the opening of the interstitial liquid triglycerides. were performed and no significant difference was obser-
The damage occurring to adipocytes results in an in- ved. Also, we carried out the ultrasound examination of
flammatory response, composed primarily of macropha- post-treatment liver to verify the presence of steatosis,
ges, neutrophils, and plasma cells attracted to engulf which was not observed, suggesting that the high-inten-
and transport the damaged cells lymphocytes.(39) sity focused ultrasound is a safe technique with no ad-
Fatemi et al.(39) conducted a retrospective study of verse physiological effects.(44)
a series of cases with the use of high intensity focused
ultrasound with only one session. A waist circumferen- “Anti-cellulite” body lotion and body dysfunctions
ce of 85 patients was measured before application of ul- aesthetic
trasound and three months after treatment. For the au- Hydrolysis of body fat is carried out by the enzy-
thors, this time was necessary because the damaged fat me cyclic adenosine monophosphate (cAMP), which is
tissue is reabsorbed within eight weeks after the appli- released in the mitochondria adipocyte cell. The accu-
cation of high frequency ultrasound. The authors obser- mulation of fat in the cells is related to the insufficient
ved a reduction of waist circumference of about 4.6 ± amount of cAMP produced for burning fat. However, the
2.4 cm after about 3 months of treatment with the use procedures for the treatment of localized fat deposits
of average energy intensity of 147 J/cm2. About 70% of and “cellulite” is oriented to increase production of this
the 50 patients selected for assessment of treatment sa- enzyme by the action of mitochondria. Increased blood
tisfaction showed themselves satisfied with the results. and lymphatic circulations are generating internal heat,
The authors also evaluated the side effects of HIFU and which leads to mitochondria to increase cAMP produc-
observed that about 11.8% of the patients had any ad- tion. The Cosmetology uses active ingredients with vehi-
verse effects. Among the effects are the presence of cular ways that promote increased blood and lymphatic
altered sensitivity, bruising, presence of hard lumps, circulation, and dissociation of fibrosis fat. (51)

swelling and pain. Investigations of cholesterol and tri- The use of cosmetics called “anti-cellulite” was
glycerides were performed to confirm the safety of the addressed in only one study, which aimed to verify how
treatment, not observing changes. Therefore, this tech- the ultrasound technique can be used to assess the cha-
nique proved to be effective for body sculpting without racteristics of the skin after aesthetic treatment of dys-
being invasive.(39) functions. In this study two groups were evaluated:
Jewell et al.(38) used high-intensity focused ultra- the first used a cosmetic “anti-cellulite” and the second
sound in different doses. Patients were randomized into placebo pills for 30 days. In the treatment group was
groups using 47 J/cm2 (141 J/cm2 overall), 59 J/cm2 noted to decrease the thickness of subcutaneous tis-
(177 J/cm2 total) and a control group that received 0 J/ sue, probably by improving local circulation, which re-
cm2. Satisfactory in the study groups (47 J/cm and 59 J/ sults from the fact that the cream was used in the thi-
cm²) results were observed after twelve weeks of treat- ghs twice daily. The way of using the cream should lead
ment. Among the observed side effects are edema and to mechanical peeling epidermis. The active ingredients
hematoma, and few patients reported pain during treat- used to obtain the results were the protein of Cucurbi-
ment and no reported severe pain after its completion. ta pepo (pumpkin), which aims to protect collagen fi-
However, due technique is considered safe and effica- bers and prevent their degradation; mulberry extract,
cious in the reduction of localized fat according to the which is rich in polyphenols that improve the microcir-
protocol used.(38) culation and have oxidizing action; the orange extract,
The writer Moreno-Moraga and his collaborators, in which provides flaking of dead epidermal cells and sti-
2007, used the high intensity focused ultrasound in three mulates microcirculation; and a unique amino acid T
sessions separated by an interval of one month between containing the functional group of L-carnitine which ser-

MTP&RehabJournal 2014, 12:220-230

Jane Guiname Mota Silva, Eduardo Filoni, Fátima Faní Fitz. 227

ves as a guide for the fatty acids through the mitochon- are the reduction of body fat with reduced complica-
drial membrane.(37) tions and risks related to invasive plastic surgery pro-
cedures.(59)
Mechanical massage and manual lymphatic Three articles were included in this review. Used
drainage in body dysfunctions aesthetic two low-intensity ultrasound, and one of these combined
The authors Bayrakci et al.(41) used a mechanical with cryolipolysis, and the third used the cryolipolysis in
massage, manual lymphatic drainage techniques and isolation.
manipulation of the connective tissue into three distinct In the article the authors Ferraro et al.(4) used the
groups. The main finding of this study was that the use combination of low-intensity ultrasound and cryolipoly-
of different treatment techniques promote a decrease sis. The procedure was intended to reduce the fat cells
in the thickness of the regions with accumulation of fat, and effectively make treatment of the EGF through re-
such as the abdomen, flanks and thighs, when asses- modeling of the collagen. There was a mean reduction in
sed by caliper. However, no change was detected in the circumference of fat at the end of treatment to the abdo-
percentage of total fat and fat mass, obtained with an men 6.86 cm, 5.78 cm for the thighs, 2.75 cm for arms,
instrument measuring bioelectrical impedance. In short, 5 cm to the gluteal region, and 2.25 cm for the ankles (p
the mechanical massage, manual lymphatic drainage <0.05). The final reduction of fat thickness was signifi-
and techniques of manipulation of tissue are presented cant compared with baseline (z=-5.38, p <0.0001). The
as safe and effective methods for the reduction of locali- largest reductions in the thighs and abdomen, regions
zed fat. For the authors of this study, none of these tech- with higher fat percentage were observed, while the an-
niques discussed could replace conventional liposuction kles showed the smallest reduction.(4)
surgery, although they may be suitable alternatives for The treatment, in addition to improving the sta-
those patients who do not wish to undergo surgery.(41) bility of connective tissue and skin structure and cause
Already Collis et al.(52) authors conducted a study a reduction in adipose tissue, also stimulated the met-
with three groups. The first was treated with anti-celluli- abolic activity in subcutaneous adipose tissue, a factor
te cream with active ingredient aminophylline which is a that optimizes the flow of oxygen and nutrients, signifi-
phosphodiesterase inhibitor, the enzyme responsible for cantly increasing lymphatic drainage. One important as-
the breakdown of cyclic adenosine monophosphate. The pect that distinguishes this treatment liposuction, for
second to endermology, which is a mechanical massa- example, is the smallest number of discomfort during
ge. The third combined the two methods, namely, “an- treatment, which in some cases becomes zero. Moreo-
ti-cellulite” cream and endermology. The results found ver, procedures have been relatively rapid, non-invasive
by these authors were poor, which led them to conclu- without causing pain, or physical limitations after treat-
de that the few benefits that must be met more by die- ment drawbacks. The conclusion is that the treatment
tary modification, increased water intake and exercise has proved to be effective and safe.(4)
than by the application of techniques endermology and Dierickx et al. (35)
aimed to evaluate the safety, tol-
cellulite cream.(52) erability and patient satisfaction with treatment cryo-
lipolysis. The researchers treated 518 patients. There
Low intensity ultrasound and cryolipolysis in were no reported significant side effects or adverse
body dysfunctions aesthetic events. The procedure was well tolerated, with 89% of
The purpose of using low-intensity ultrasound is the respondents reporting a positive perception of the dura-
stimulation of microcirculation in the subcutaneous tis- tion of treatment and 96% reporting minimal discomfort
sue to improve the structural and metabolic changes, tolerable. The survey results showed that 73% were sat-
reducing the visible signs of “cellulite”.(53) The biological isfied and 82% of patients would recommend the pro-
effects are caused by the release of mediators such as a cedure to a friend cryolipolysis. In the measurement, a
vascular endothelial growth factor,(54) which significant- reduction of 23% in the thickness of the fat layer in 3
ly increases angiogenesis and local blood circulation.(55) months after treatment was observed. In regions of the
The cryolipolysis is a technique that has been con- abdomen, back and flanks treatment was more effec-
sidered “non-invasive liposuction”, whereby the reduc- tive, noting that in 86% of subjects, there was improve-
tion of the fat layer by the selective destruction of fat ment in the evaluation conducted by the researchers.
cells occurs.(56) This technique involves exposure to cold According to the authors, with a suitable selection of pa-
reduction to obtain a controlled gradually the subcuta- tients cryolipolysis becomes a well-tolerated and effec-
neous fat layer without damage to other tissues.(57) Ad- tive for the reduction of subcutaneous fat safe method
ipose tissue is placed in contact with the plates frozen of treatment.(35)
using a pressure applicator that thermally destroys fat The authors Christ et al.(43) used ultrasound with
without damaging the skin. The dead cells are then met- intensity and low pulses, in order to stimulate the me-
abolically eliminated.(58) The advantages of cryolipolysis tabolic activity in subcutaneous adipose tissue in order

MTP&RehabJournal 2014, 12:220-230

 228 Fisioterapia e disfunções estéticas corporais.

to evaluate the effectiveness of this technique in incre- the improvement in skin properties, obtained with the
asing the strength of the connective tissue and impro- use of chemical products (creams or lotions), usually be-
ving the structure and skin texture. There was an incre- tween 12% and 25%, reaching more than 30% in indi-
ase in cell permeability in the short term, which stimu- vidual cases. This study confirmed the effects of acous-
lated the exchange of substances of fat cells and the ac- tic waves in biological tissue therapy, including stimula-
tivation of enzymes that break down fat. The protecti- tion of microcirculation, improvement of cell permeabili-
ve and therapeutic effects of acoustic waves are com- ty. The ultrasound examination showed increased densi-
plex and include stimulation of lipolysis, the release of ty and firmness of the collagen/elastic fibers in the der-
toxic aldehyde products of lipid oxidation, reduction of mis and subcutaneous tissue network. (43)

oxidative stress, reinforcement of antioxidants, a better

synthesis of collagen and measurable and visible impro- Conclusion
vement skin condition. This improves the skin condition We conclude with this review that physiotherapy
was clearly observed by the final evaluation. In Group A through their techniques contributes to the treatment
(six sessions held over three weeks), the elasticity in- of localized fat, helping to sculpt the body and reduce
creased from 45% to 75% in three months; and Group cellulite, less invasive and well tolerated by patients sa-
B (conducted 8 sessions over 4 weeks) increased from fely. However, it is noteworthy that there is a need to
73% to 95% in the third month and 105% at six mon- conduct randomized controlled trials, with larger sam-
ths, indicating that improvement in skin elasticity in the ple size, since most of the included studies it is prospec-
long term can be observed. The authors also state that tive clinical trial uncontrolled and retrospective studies.

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