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Medical Trials and Results

Bibliographic reference for this publication:
Palmieri B, Capone S: Palmieri B, Capone S: Cavitazione rimodellamento corporeo: efficacia e
sicurezza degli ultrasuoni. Hitech dermatology 2010; 1: 37-44.

The following translation of the original Italian text has been reviewed with the Authors

B.Palmieri1, S.Capone1

1Department of General Surgery, Azienda universitaria Policlinico di Modena.

Department of General Surgery, Policlinico of Modena University.

Beniamino Palmieri, Associate Professor of General Surgery, University of Modena and Reggio Emilia, Department of General Surgery.
Email: palmieri@unimore.it. Tel: 059422483.

Stefania Capone, Doctor of Medical Biotechnology, University of Modena and Reggio Emilia, Department of General Surgery.
Email: stefycapone@hotmail.it. Tel: 059422483.

Cavitation and body remodelling: effectiveness and safety of ultrasound instruments

SUMMARY: The authors shortly review the up-date medical literature on ultrasound instruments for non –invasive fat tissue remodelling, safety and effectiveness data of focused and defocused devices are reported, as well as the general physical concepts, and biochemical effects on human tissues of mechanical and ultrasonic cavitation.

Keywords: ultrasound instruments, cavitation.

The use of ultrasound instruments on deep and subcutaneous or prefasacial fat tissue remodelling is not recent.

Our extensive research on this issue pioneered the concept of ultrasonic liposuction, in order to reduce the mechanical trauma of the suction tube and consequently the risk of haemorrhagic or fat emboli related to traditional liposuction (1.2).

It is known that the modulation of ultrasound beam, with adequate variations in frequency and power, can induce elective lipolysis, with no damage on stroma and neuro-vascular support. Later on the ultrasound-assisted liposuction (UAL) has been developed.

Fully accomplishing with classic mini-invasive liposuction, but with preliminary epicutaneous ultrasound administration, with the aim of preliminary adequate volume lipo-emulsion amount delivery to render liposuction procedure more homogeneous, reducing the mechanical trauma.

With the experiences progress it was observed that, using instruments focused on subcutaneous adipose tissue, it was possible to reshape the thickness and profile of some fat aesthetically unappealing deposits through a maillny mechanical-vibrational action mechanism rather than heathing cell-membrane dissolving

MECHANICAL AND ULTRASONIC CAVITATION

The concept of ultrasounds focus delivery and the production of "cold" shock waves is not recent, and it is widely used in extra-corporeal shock wave lithotripsys for urinary stones and gallstones, but also for joints and muscles calcifications, whose impact is somehow traumatic and painful requiring anaesthetic pre-treatment.

Conversely defocused ultrasound, induce in the living tissues a greater thermal effect by means of vasodilatation, due to pulsed relaxation, being mainly used in physiotherapy.

In the cellulitis area, a recent study by Kuhn and coll. (3) assessed the impact of extracorporeal mechanical shock waves on human skin (ESVM) as a new cosmetic procedure.

Shock waves are longitudinal acoustic oscillations that transmit single pulse energy with positive pressure followed by an exponential reduction of transmitted energy and a subsequent rebound due to the tensile strength of the tissues following the pulse. The non-focused extra-corporeal shock waves spread radially with a density of energy flow that decreases the third power based on distance from the transducer.

As in the case of ultrasound, shock waves with high or partial focusing can be obtained by using, for example, elliptical mirrors and, at the maximum acoustic intensity of energy flow at a specific degree of depth, the high focused energies are characterized by a pulse energy 0.2 - 0.4 j/mm2 on the focused point. The low-energy shock waves deliver fluxes less than 0.1 mj/mm2 and those intermediate deliver fluxes at 0.1-0.2 mj/mm2.

The frequency energy is another important parameter and distinguishes high and low frequency devices that create cavitation bubbles of different diameters.

The formation of cavitation bubbles, followed by a dispersion of energy around, are the cause of tissue damage and destruction of capillaries (4) and intra-vascular coagulation (5).

There is also a bounce noise caused by the reflection of rays that accentuates the damage to the target tissue and this phenomenon is emphasized in the treatment of kidney stones.

Shock waves at the level of cellular substructures increase the permeability of membrane (6), the lesions of the cyto-skeleton (7) of the mitochondrial endoplasmic reticulum and of nuclear membrane.

It has also been reported, as a result of irradiation with shock waves, the release of Vascular Endothelial Growth Factor (VEGF), of endothelial nitric oxide synthetase and of proliferating cell nuclear antigen (8,9).

It is also proved that the shock waves can also induce transduction of intra and extra cellular signal and generate nitroxide radicals and Heat-Shock Proteins (HSP) (10).

Besides orthopaedic and rehabilitation treatment the shock waves have been successfully used in chronic ulcerative skin lesions (11) and burns being the repair mechanisms due to active hyperemia.

Even in myocardial ischemia Nishida et al (12) had positive findings; furthermore, the shock waves seem to have antibacterial capacity and, according to Angehrn (13), are specifically effective in the treatment of cellulitis by means of collagen rearrangement.

Most of the equipment of shock waves use water pumps as a basic component, but the mechanism of cavitation is different with reference to ultrasound, since in the areas with cellulite, on the basis of the in vivo experiments, no mechanical destruction of fat tissue can be shown, neither leukocyte infiltration, which is instead observed with ultrasound.

GENERAL INFORMATION ON THE PHYSICS OF ULTRASOUND
For a better investigation of the clinical effects of ultrasonic instruments in human tissue let us analyse the types of interactions induced by this type of energy, with reference to its shape and wavelength.

The mechanical effect almost used in adipose tissue remodelling, in example, is induced already at 0.8 MHz with a power of 2 Watt/cm2 and reaches 2.6 atmospheres.

The thermal effect, with probes of 10 cm, has a range limited to a maximum of 3°C.

The biological ultrastructural effects of ultrasounds on the tissues have been verified by numerous studies that have characterized their mechanism of actions evidencing rupture of the cell membrane, intracellular calcium ion influx and degranulation of mast cells.

It has also been shown that ultrasound can stimulate fibroblasts to produce collagen, when applied to tissues exposed to prolonged irradiation (14) and, as the response of the vascular compartment, there is the stimulation of endothelial cells and formation of new capillaries.

About destructive effect of ultrasound it has been shown that prolonged exposure causes modifications of the erytrocytes arrangement and lysis of their membranes.

Mechanical stress of ultrasound causes liquefaction of "thixotropic" tissues that is those with gelatinous consistency that is lost after shaking.

At the intracellular level, both DNA and mitotic spindles show a thixotropic behaviour and therefore ultrasounds can irreversibly alter them inducing apoptosis or cell necrosis.

About the thermal effect, Lhemann and coll. (15) and Kramer (16) showed experimentally an analgesic effect of ultrasound on the ulnar nerve with increase in nerve conduction velocity with increasing temperature.

Dyson (17) states that, in order to achieve a biological effect, the human tissues must be exposed to rises in temperature between 40-45 C° for at least 5 minutes, using ultrasound.

In order to define the type of increase in intercorporal temperature Draper and coll. (18) injected 1 cc of anesthetic at 1% into the upper limb of 10 people and covered the area for 10 min at 3 MHz and emission of 1 W/cm2, making simultaneous thermometric measurements with a 23-gauge needle connected to a thermistor.

The temperature reaches 40.5C° and decreases to 4-5C°, after 5-10 minutes from the insonation at the chosen depth, taking into account that the higher the frequency, the lower the depth of action. No highly destructive phenomenon is achievable with the tools currently approved for medical use by the European Community.

PARAMETERS OF ULTRASOUND-TISSUE INTERACTION

In the ultrasound-tissue interaction, the following parameters have to be taken into account:

ABSORPTION: reduction of generated wave power as long as the wave is absorbed deepinto the tissues.

PENETRATION, inversely related to the frequency : e.g. a frequency of 1 MHz allows input into the skin-subcutaneous tissue up to 3.7 cm, into the muscle up to 3 cm, into the bone up to 7 mm.

REFRACTION and REFLECTION: optic energy orientation change when addressed to the brderlline of different densities tissues .

On these surfaces the remodelling action of ultrasound is further modulated proving to be more effective for example in areas where the fat spills into the collagen reticular stroma and in dense tissue.

For example Ferrario & coll (19) using 1 MHz frequency and a power of 3 W on adipose tissue documented a very limited damage to the membrane of adipocytes, while the collagen fibres are partially conglomerated, helping to remodel the morphology of lax areolar tissue.

On the other side, using an intensity of 20 MHz with a power of 3W there is a widespread destruction of adipocytes and a evaluable retraction of the stromal tissue.

A study by Solomon and coll. (20) evaluated the effect of high intensity focused ultrasound on muscle tissue of rabbits, creating lesions with a 1.46 MHz transducer capable of developing, on a diameter of 1.544 mm2 and a depth of 1 cm, a peak intensity of 10 kW cm2 producing a maximum output power of 170 W.

During the experiments temperature values reached during irradiation were measured with a thermocouple from baseline of 32.5 C° up to 55.2 and 60.2C°.

AS TO the ultrasound mediated thermal damage morphology it evidenced as a cylindrical lesion initially imperceptible (except for a surrounding hyperaemic response) with minimal cellular inflammation and immediate visibility of cytoplasmic nuclear damage, edema, and inflammatory response characterized by histiocytes, lymphocytes and eosinophils. In case of major muscle damage phagocytosis and giganto cellular responses were also observed.

This model is very interesting, in order to define the thermal damage also related also to lysis of adipose tissue and its subsequent stromal rearrangement since irradiation performed in animals shows different effects, possibly related to individual variations in temperature.

CLINICAL STUDIES

A study of Butterwick and coll. (21) assessed potential synergy between us and lipiosuxtiion in remodelling adipose tissue in 31 women aged between 20 and 65 years.

The protocol consisted in the treatment of mid-abdomen with ultrasound intensity between 0.3 to 75 W, with a power of 1 MHz and a depth of action of 4 cm, in the first post-surgery week (22 cases) and in the second week (15 cases).

In the case of aspiration, the thinning of the subcutaneous fat intake from 4 to 2 cm induced the authors to raise the frequency to 2.5 MHz in order to focus the effect of ultrasound on the dermis surface.

In fact, since ultrasonic energy applied to the skin surface is reduced exponentially on the basis of the distance, and absorption increases with the frequency, it follows that the higher the frequency, the greater the absorption under the skin surface related to the attenuation of energy in deep tissues. The pain threshold was the guideline to the energy power delivered.

The treatment lasted 10 minutes on each side and the sessions were twice per week in number of 8 in 22 patients and 6 in 3 patients.

The results showed a significant difference in the outcome of the treated area, being 100% of patients satisfied, but treatment schedule was not superior to the placebo.

According to the experience of the authors the effectiveness of postoperative ultrasonic treatment may preferably be deserved tp patients with greater hardening and edema and greater amount of fibrous tissue within the treated areas.

Among medical instruments most often used world wide, LipoSonix (made in USA) system highly focused at 2 MHz with a power of 2000 Watt/cm2 . and LIPO-matrix, an Israeli-made instrument. Both action mechanism–related effect and safety were the very first investigated issues.

Teitelbaum (22) used an Israeli-made instrument (UltraShape) on 164 healthy volunteers to evaluate on different areas of the body, thighs, abdomen, the effects of ultrasonic energy.

While 137 patients were assigned to the experimental treatment, being divided in groups of 25 to 30 individuals for each treated site, 27 (5 or 6 individuals or each treated area) were used as controls (1:2 ratio of male to female).

The recruited cases had cutaneous fat layer at least ,5 cm thick and were in good health, all being subjected to preoperative laboratory tests.

Each one was , weighed, and the circumference of each treated area evaluated by caliper for thickness and sized for the volume.

Anaesthesia was only epicutaneous (Emla cream, Astra Zeneca) and the treatment was carried out with real time visual control of the cavitation effect.

The session was unique and not repeated, the controls were untreated and, after treatment, each could move and feed,freely, but underwent protocol check-up visits on days 1, 3, 7, 14, 28, 56, 84.

The following parametes were enclosed in the check-up. were weight, photographs and circumference.

In the case of thighs the contra lateral leg was used as control.

On day 14 and 28 the thickness of the subcutaneous tissue was measured with echography. The patients underwent general laboratory exams, including cholesterol HDL, lipoproteins LDL, triglycerides, liver enzymes and complete urine analysis.

liver echography was performed before and after treatment to 14 to 28 day in order to check any iatrogenic hepatic artery stenosis.

For each treatment a 1,9 cm reduction of the circumference was achieved with a response rate of 0,2%, statistically significant.

In 37% of cases the reduction was observed 2 weeks after treatment.

This reduction in thickness was detected in all treated areas and regardless of sex or age. .As to the treatment safety no increase of lipids or lipoproteins or changes in liver echography were observed and no negative effects, except for feelings of vibration and tinnitus during treatment.

In three cases a medium erythema was induced that disappeared the first day, another case developed a purple skin vanishing 7 days after, two further cases developed small vesicles which however, recovered.

The current technology produces a focused ultrasound beam that reaches a well-defined depth of radiation using a convex probe that is able to focus the beam concentrating the energy below the dermis, in such a way not to create pain or damage to the surface and focusing the cavitation damage to the desired depth.

A reasonable expectation of results can be given to the patient in terms of reduction of 2.3 cm for the abdomen, 1.8 cm to 1.6 cm for the sides and thighs.

With regard to fat redistribution, the authors speculate that, in the absence of documented changes in plasma lipid profile, there is probably a re-uptake of triglyceride content in the damaged area in the direction of the surrounding fatty tissue; so there is no need for a recirculation and a transhepatic conversion of fat released from the cavitation process.

Moreno Moraga (23) conducted a prospective study with "UltraShape" on 30 healthy patients undergoing 3 cycles of treatment at one month intervals from each other, and followed during one month after the end of the study.

The treated areas were abdomen, inner and outer thigh, flanks, inner knees and male breast. All were documented with a video camera, with standing persona and standard rotation angles. The area was marked with a dermographic pen and the thickness of the skin was measured, with a value that should not be less than 2 cm.

In all regions except the abdomen, patients were treated bilaterally in the same session; the system was made re-operative with frequency of 200 + -30 kHz and acoustic intensity of output of 17.5 W cm2. The whole process took place under visual control and at the end of each treatment photo records were repeated being the patient free of moving and eating, without lifestyle modification, but forbidding any hand-made physiotherapy or instrumental fat tissue manipulation.

The effectiveness was evaluated by size measurements statistically processed, while keeping careful records of all the unwanted side effects.

The groups included 22 females and 8 males with a middle age of 36.5 + -11.7 years, divided by order of treatment: abdomen 10 patients, 3 patients outer thigh, hips 3 patients, 2 patients inner thigh, inner knee 2 patients, pseudoginecomastia 3 patients.

The patients who underwent ultrasound application in symmetrical areas were treated bilaterally in the same session.

The thickness of the preoperative panniculus was 4.44 + -0.99 cm, already reduced after the first application of 1.3-3,16 cm + -0.59 cm.

After the second application a further reduction from 0.56 to 2.60 cm was observed, after third treatment from 0.4 to 2.16 cm, with an overall reduction of 2.28 + -0.80 cm at the end of treatments. The best lipolytic effect was observed in the outer thigh, followed by the abdomen, while other areas showed the lowest reduction.

After 3 treatments the average circumference reduction observed was 3.95 + - 1.99 cm.

Fig.1: Data on the reduction in centimeters of the anatomical segments treated, which show different sensitivity in terms of response to treatment. (With the permission of the author) (23). The weight of the patients remained constant during the three months of postoperative follow-up, showing a fat redistribution overlapic aesthetic appearance improvement without structural fat volume chahnges.

Side effects were complained by 2 patients ( transient pain during the procedure), while some small burns were bias due to insufficient gel applied to the skin.

Cholesterol remained unchanged during the Ultrashape treatment and some fluctuations of triglycerides were observed with their increase however in the statistically significant normal range.

  Base (M+-SD) After 3 sessions (M+-SD) P
Fat thickness (cm) 4.44+-0,99 2.16+-0.44 <0.01
Weight (kg) 66.0 +-12.1 65.3+-11.5 0.33
Colesterol tot (mg/dl) 205.1+-46.7 205.8+-46.7 0.09
Triglyceride (mg/dl) 85.1 +-43.6 95.4+-45.3 <0.01

Table 1: From Moreno-Moraga (23): systemic safety of ultrasound-induced lipolysis.

In contrast, liver ultrasound scan one month after treatment showed no structural changes. According to the authors the success of the method is due mainly to an optimal contact between skin and transducer, subcutaneous fat thickness at least 2 cm ,(in order to avoid borderline damage to mesenchymal structures), the focus of ultrasound beam on the adipose tissue,and manual remodelling of the treated surface.

The areas to be treated should be marked on the standing patient, targerting an anatomical segment each session and allowing to the patients postop autonomous movement, keeping regularly absent any collection of exudate or edema.

These Authors, treated at least 400 patients in more than 1,000 sessions before publishing data, and they suggest specifici indication to this procedure localized fat deposits in non-obese patients in single or multiple sequential treatments, which are overall safe as much as effective, fulfilling aesthetical requirements.

Another study remarking the substantial safety of ultrasonic treatment in terms of lipid metabolism and faces the costs of the procedure has been published by Fodor et al (24) using an ultrasonic device (LipoSonix) with high intensity and focus.

Between July 2003 and July 2005, the author has treated 33 patients, 30 of them in a single treatment, 3 in two separate sessions after one month; sonication was followed by standard abdominoplasty at different follow up times to directly view the ultrasound remodelling effect; blood serum sampling was obtained immesiately preop, and 24, 48, and 72 hours later, after one week and 1 to 4.5 months

There was no changes in total free fatty acids levels of VLDL, HDL and LDL or triglycerides, on different time intervals as well as , for other parameters like amylase, lipase, WBC, etc.

CT scan and MRI evaluation confirmed the range of lipolytic action of LipoSonix beneath the skin, with no extension to the skin or deep intra-abdominal organs; histopathologic examination revealed a moderate amount of coagulation necrosis of adipose tissue, while all the surrounding structures. Were unchanged

A similar study was conducted by Murray-Garcia et al (25) between July 2003 and February 2004 on 24 patients; later these patients underwent abdominoplasty surgery at a distance of 4-7 days (7 patients), 4 weeks (4 patients), 56 -59 days (6 patients), 84-86 days (6 patients).

The sample were takend at time 0 at 24, 48, 72 hours, 1 week, 4 weeks, 1-3 months.

There were no significant changes from baseline in any of the 24 patients examined for the following parameters: free fatty acid, total cholesterol, HDL, LDL, VLDL, TG levels and, later in time, no change in metabolism of patients amylase, lipase and heritage blood cell.

The ultrasound thermal damage was also used in order to replace the surgical suspension and reshape at the proper tension relaxed facial tissues ( not invasive facelift ) by a welding and the subcutaneous fat tissue with muscle-aponeurotic layers,by a ternmosealing mechanism This unit, named Ulthera by the manufacturer, focuses ultrasonic energy to produce thermal damage lines of 2.5 cm, separated by spaces of 0.5 mm. The same transducer that delivers energy is then used for diagnostic observation and it's skin retraction effects, has been investigated and confrmed by White (26) on a porcine model and cadaver tissue.

The intensity of radiated energy was 0.5 up to 8 Joule/cm2, and the author performed quantitative analysis on the cells viability in the treated area and surrounding locations, using vital dyes. this instrument is ver original and effective emitting a very compact ultrasound beam, which creates a true linear thermal damage not spreading around with 4.4 MHzradiation power This procedure ideally complies to the face integumensts because the layers of fat cells are cavitated overlappning and retracting altogether with deep layers without c damaging the underlying nervous structures, especially the facial nerve.

A recent study by Brown et al (27) reports a series of experiments aiming to investigate, by means of a real-time diagnostic ultrasound scanner, the cavitation effect of ultrasound in water and synthetic hydrogel, as well as on biopsies of skin and subcutaneous fragments of pig, The lysis rate of adipocytes and the prevention of damage to the stromal, using reference tool UltraShape, while the morphology of cavitation damage was investigated by measuring the activity of lactate dehydrogenase (LDH), which expresses positive cell viability in general. The results demonstrated the possibility to focus damage at the selcted depth, avoiding involvement of the superficial layers of the epidermis and obtaining the selective destruction of adipocytes with the focused ultrasound treatment, without any thermal damage to surrounding structures, stroma and vessels. During in vivo studies, the surface of adipose tissue irradiation by the ultrasonic beam had an extension of 10 x 6 mm, regardless of the degree of compression of the skin operated by the transducer.

DISCUSSION AND CONCLUSIONS
It is known that ultrasounds can interact with biological tissues with thermal, mechanical, or cavitational mechanism. The latter is a complex phenomenon that creates intracellular bubbles to which an oscillation or expansion is imprinted until the outbreak of the containing cell membranes releasing mechanical energy,that is the physical end-point of the biological changes observed. By focusing ultrasonic beam it is therefore possible to obtain a very selective destruction of adipose tissue at a well-defined depth of the integument layer.

While the low energy of the ultrasound beam can be used as sonophoresis, sonoporation, gene therapy and strengthening of the bone framework, the high-intensity focused ultrasound instead, mainly produce mechanical waves, also used in the extracorporeal lithotripsy; these waves, instead of heating the temperature gradually and at moderate levels with beneficial effects of hyperaemia of the microcirculation, aside a mechanical shock, indce an instantaneous thermal shock with cell necrosis and temperatures above 56 ° C.

Applications of focused ultrasound in the clinical environment look very selective, with no damage to the skin, no systemic toxicity from circulating products of lipid metabolism due to acute degradation of adipose tissue (28). Although the indications for use of these tools are primarily in the aesthetic medical field, not least the ability to shape the subcutaneous fat also involves the areas of rehabilitation and functional recovery of the body function.

The proven safety of focused ultrasound on circulation and microcirculation, makes the unit suitable and effective also in hypostatic pathology with adipo-lymphedema of the lower limbs, and treatment of adolescent pseudoginecomastia, with obvious psichological benefits (29) reshaping The pectoralis surface without invasive procedures .

Another successful potential use is the lipomatosis or single lipomas, namely in areas such as neck and supraclavicular spaces, where knife surgery is at high risk of damaging neurovascular bundles. The focused ultrasound operative method is in fact at the very beginning but, they will certainly expand gradually to emerging areas of broad clinical interest.

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