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대한비만학회 2014년 제28회 춘계 연수강좌 ࠜ֜׆ଲ ण ౿߹ 심 경 원 이화여자대학교 의과대학 가정의학과 Clinical Measurement of adiposity MEMO Direct methods - BIA (Bioelectrical impedance analysis ) - DXA (Dual energy x-ray absorptiometry ) - Multi-slice CT - MRI Indirect methods - Anthropometry ; W.C. , W-H ratio (m/c) - Skinfold thickness - BMI (Body mass index) 131 개원가의 비만 시술 고찰 MEMO Diagnosis of Cellulite Cellulite score by Nurnberger-Muller scale Stage 3: Padded appearance standing up and lying down Stage 2: Padded appearance standing up that disappears lying down Stage 1: Padded appearance only with the pinch test Stage 0: No cellulite even with the pinch test Stage of cellulite 정상 상태 1단계 2단계 ¾ Adipocyte edema ¾ Interstitial congestion ¾ Adipocyte ¾ Adipocyte ¾ Collagen fibers’ agglomerate Dissociation 3단계 swelling 4단계 ¾ Micrpnodes` agglomeration ¾ Micronodes 형성 ¾ vasoconstriction Production of cellulite Alteration of extracellular martix concentration protidique ↑ Alteration of pre-capillary sphincter Interstitial pressure ↑ Capillary pressure ↑ Viscosity ↑ Edema Hypoxia 132 Stasis Capillary permeability ↑ 심경원: 기구를 이용한 비만 치료 MEMO Strategy of local adiposity Tx. Cellulite treatment - cellulite reduction - collagen rejuvenation Body-sculpting Therapy - targeting for local fat reduction Drug injection method : HPL, Carboxytherapy, Laser lipolysis Device method : Endermologie – LPG, Radiofrequency, Ender plus(+RF) Ultrashape , Cavitation ESWT Endermologie the first FDA approved nonsurgical treatment for cellulite reduction and body contouring. Developed in the late 1970s in France Consisted of two moving rollers with negative pressure btw the rollers 133 개원가의 비만 시술 고찰 MEMO Applications of depressotherapy Cellulite Fibrosis, scar Edema For lymphatic drainage For skin toning , firming Pre. or Post. Complementary therapy for liposuction indurations ↓, residual fat ↓, edema ↓ Combined therapy with other lipolytic device MICRO CIRCULATORY EFFECTS OF THE LPG TECHNIQUE Investigation centre Methodology Results ALBERGATI – BACCI LATTARULO - CURRI Centre of molecular biology Milan, 1998 Evaluation by Doppler flow & VCSO (n = 8 women) Reactivation of fibroblasts metabolism Reactivation of lipolyse Stimulation of vasomotion Reactivation of metabolic activities of the extra cellular matrix Laser Doppler Flow Echo Doppler Cutaneous blood flow multiplied by 4 to 5 ASAPS meeting Blood flow of greater saphenous vein IPRAS meeting multiplied by 2 to 3 ASPRS Meeting Lymphatic flow multiplied by 3 FODOR – WATSON Plastic Surgery Faculty UCLA,1999 Lymphoscintigraphy Communication XX congress of the Italian society of aesthetic medicine Rome (1999) ILLOUZ, 1998 Clinical Data post operative Prevention of pre & post operative complications of lipoaspiration (œdema, pain, ecchymoses) Medico- surgical Encyclopaedia Surgical techniques LATRENTA Cornell University college New York, 1999 Endermologie® vs.. Lipoaspiration (n=36 women) Endermologie® is the indispensable complement of lipoaspiration (pre & post) ASAPS meeting Aesthetic Surgery Journal 134 심경원: 기구를 이용한 비만 치료 MEMO CUTANEOUS EFFECT OF THE LPG TECHNIQUE Investigation centre Methodology Results Communication SHACK, ADCOCK Vanderbilt University Nashville, Tennessee, 1998 Histology of tissues treated Yucatan Pigs (n=12) Increase of the production of collagen by 27% to 130% in longitudinal, dense and deep collagen layers Aesthetic Surgery journal (1998) 12th congress conference of aesth. plastic and reconstructive surgery 1999. Congress of Aesth. surgery, 1998, LA TITLE, ENGLISH Dallas, 1997 Body circumference measured in centimetres (n=24 women) Mean body circumference loss linked to the number of Endermologie® sessions, regardless of weight change (average reduction of 4,22 % ) Clinic Effects of Endermologie® in cellulite and non invasive body contouring DAVER Hôtel Dieu de Marseilles France, 1991 Evaluation of the effects of the LPG’s technique by photogrammetry Average reduction of 3,5 cm of thigh circumference (20 sessions) (n=20 women) Médecine féminin LAMN, DONOVAN New York University 1997 Evaluation of the effects of Endermologie® by magnetic resonance imaging (n=7 women) Reduction of subcutaneous adipose masses Lipo-electrostimulation Mechanism of electrolipolysis Mechanical action ( 8 Hz ) - provoke rhythmical contraction Thermal action ( 8Hz ) - vasodilation, activation of circulation Neuro-hormonal action ( 15 Hz ) - stimulation of β receptor Toning action (40 Hz ) - activation of lymphatic circulation - nutrient transfer 135 개원가의 비만 시술 고찰 MEMO Effects Skin elasticity improve Microcirculation improve Skin lifting Lipolytic activity improve Collagen activity improve Tissue oxygenation increase Side effects Burn Ultrasonolysis Ultrasonolysis Mechanism of ultrasonolysis - Vibration → micronize fat - Hypermeabilisation of the cellular memb. Of adipocyte → fatty acid evacuated by the lymphatic and venous circuit - dilation of the micro lymphatic & venous channels - defibrosis Power - esthetic part ; maximum 2 watt - burn risk ↑ ; over 3 watt 136 심경원: 기구를 이용한 비만 치료 MEMO Effects - Thermic Effects Circulation Tissue Metabolism Fibrolysis - Nonthermic Effects - Cavitation Medium movement (pressure difference) S/E - Bruise (m/c), Hematoma, allergic reaction - pain, swelling Contraindications of ultrasono Cutaneous skin lesions of all kinds Ischemia and arthritis Cancer ( risk of diffusion ) Osteoporosis Pregnancy Pacemaker Recent transplantation Bone prosthesis Phlebitis * intrauterine device (IUD) - DUB risk ! Extracorporeal Shock Wave Therapy VEGF, eNOS, PCNA are reported (Wang et al 2006) Shock waves local blood circulation and metabolism ↑ 137 개원가의 비만 시술 고찰 Velashape Vacuum + IR + RF Velasmooth & Triactive Triactive system 808nm diode laser assisted endomology single center study (n = 20) Triactive vs velasmooth upper thigh 28% vs 30% improvement lower thigh 56% vs 37% improvement difference nonsignificant (P > .05). Bruising 60% (VelaSmooth > Triactive) 138 MEMO 심경원: 기구를 이용한 비만 치료 MEMO Efficacy of tx at cellulite stage stage1 stage2 stage3 stage4 Electro-stimulation ++++ +++ +++ ++ ultrasono +++ ++++ +++++ +++++ Presso-Therapy +++++ ++++ ++ + Depresso-therapy +++++ ++++ ++ + Cold Ablation HPL (Hypotonic pharmacologic lipodissolution) Mechanism Osmotic effect lipolytic effects of drugs ± Ultrasound or RF or low level 139 개원가의 비만 시술 고찰 MEMO The Result of HPL is influenced by many factors 1. Osmolality of solution 2. Volume of solution 3. Added procedure No severe pain Need for other procedure (RF, carboxy, meso…) Little benefit for skin elasticity Long time therapy Step lipolysis 1단계: 이완 지방분해 전단계 Defibrosis Vascularization 2단계:지방분해 TG의 분해 Lipolysis 3단계:순환 분해된 지방을 혈관계로 배출 Lymphatic – Drainage Circulation LPG,massage Carboxy 4단계:연소, 산화 FFA의 연소 Combustion Aerobic Exerc Ise & Water drinking RF, Cavitation HPL,Laser LPG, U.S, Carboxy 5단계:피부재생 피부 탄력 향상 Toning Firming RF, Carboxy,laser 피부재생 연소산화 순환 지방분해 이완 Conclusion Most procedure are safe, but cannot be replace the liposuction. However, When the patients keep their regular treatment schedule, keep healthy life style as well as healthy diet Need for weight reduction through diet and Exercise Less evidence-based datas Consideration for cost-effectiveness 140