New is necessary for a long time.
RSL sculpting is a necessary and justified stage in the cellulite correction procedure.
Abstract. Microcirculation recovery and high-quality lymphatic drainage of soft tissues is the basis for effective correction of any cellulite stage. Such cellulite correction capabilities are typical for the hardware RSL sculpting method. The evidence-based changes obtained by us in the course of functional and instrumental studies are described in detail in this article.

At present, cellulite is one of the most common problems that women would like to resolve in the aesthetic medicine clinics. Moreover, more than 85-98% of patients suffer from the manifestations of peripheral lipodystrophy (it is an official designation of cellulite). According to various sources, the incidence of peripheral lipodystrophy varies from 80% in women aged 20-35 years and up to 95% or more in women over 35 years old that is becoming a serious medical and social issue [11, 12, 13].

Cellulite (French “cellulite”) is a cosmetic problem of the skin appearance, worsening of which is caused by the structural changes in the subcutaneous fat. This skin condition is not a disease and is not included in the international classification of diseases. However, it leads to the serious psychological problems in 48-50% of women, and therefore requires timely correction.

Currently, a significant number of domestic and foreign publications are devoted exclusively to the specification issues of the disease pathogenesis and selection of adequate therapy [10]. At the same time, the boundaries between the aesthetic and medical aspects of this problem are blurred. Cellulite is not specified as a disease, since it is not included in ICD 10. Although, according to this classification, peripheral lipodystrophy can be classified as the code E 88.1 (lipodystrophy, not elsewhere classified). All the methods used to eliminate PLD are aimed at restoring the balance of the internal environment, and this is already a treatment.

Cellulite has a complex etiology resulting from a combination of various factors. The reasons for its occurrence include the hormonal factors, genetic factors [3], [4], changes in metabolism, physiology, dietary regime, dimorphic skin structure depending on gender, changes in the connective tissue structure [2]. The weakened connective tissues, enlarged fat cells and decreased microcirculation in the subcutaneous layer play a key role in the cellulite pathophysiology [1].

Most authors specify the microcirculation loss as the root cause of this pathology [6, 7]. Other researchers consider the problem as a secondary phenomenon arising dye to the vascular compression by hypertrophied adipocytes. In any case, the fat deposition intensity in adipocytes depends on the blood circulation rate that should be normalized. At the initial stage, the capillaries are changed in the affected areas, leading to an increase in the capillary pressure and higher capillary permeability, extravasation and subsequent interstitial edema. In the case of poor venous and lymphatic outflow or changed capillary permeability, water is retained in the adipose tissue, while exacerbating metabolic disorders. The high-molecular proteins also enter the interstitial tissue together with water, while stimulating fibroblasts to increase the production of collagen fibers [8]. In addition, as the metabolic dysfunctions strengthen, hypoxia and acidosis lead to the fibrotic changes in the connective tissue structures that aggravates congestion [9]. Under conditions of stasis, the adipocytes accumulate not only fat, but also toxins that enhances metabolic imbalance and impaired microcirculation [6, 7]. This is a vicious pathogenetic circle.

In the search for new effective ways to eliminate cellulite, it is important to rely on an understanding of the disease etiology and pathogenesis and apply individual comprehensive treatment based on the correct identification of the problem stage.

Among a significant number of cellulite correction methods, the following are used: external therapy, physical, surgical and pharmaceutical methods that are successfully combined by us. Moreover, the hardware methods significantly prevail due to their high efficiency and possible simultaneous combination of impact mechanisms.

When selecting therapy for the patients of our clinic, we do not proceed from the aggressive advertising of newfangled methods. However, we rely on the knowledge of physical properties of the equipment used to achieve the maximum effect of the comprehensive therapy.
Regardless of the disease stage and severity, it is compulsory to include methods that improve blood microcirculation and soft tissue lymphatic drainage [14].

The research papers suggest that the use of therapy aimed at correcting microcirculation is an important approach for the cellulite elimination in female patients.

For this purpose, we have verified capabilities of the RSL sculpting method by using the BeautyLizer devive.
In order to obtain reliable data and possible changes during the RSL sculpting application, we have used the instrumental diagnostic methods, such as plikometry that is measurement of the fat fold thickness and thermography.
Due to the availability of highly professional equipment in the clinic, all patients underwent color duplex ultrasonography screening of veins and arteries of the lower extremities prior to treatment, after the 3rd and 6th RSL sculpting procedures that was innovative in the study of this method.

All patients received monotherapy with the BeautyLizer device that prevented the influence of other possible methods on the obtained result.
RSL sculpting provides the combined effect of vibration compression by rotating silicone spheres and high brightness red light (LED).

During the procedures, the recommended standardized vibration compression technique was used. Due to the rotating silicone spheres, the skin and underlying soft tissues were subjected to the short-term compression (squeezing) and lifting. RSL sculpting activates the maximum number of skin mechanoreceptors, treats all skin layers, hypodermis and even muscles that enhances the expected lymphatic drainage effect. Vibration compression has tissue stimulating and vasodilating effects [15]. Even a small local difference in atmospheric pressure changes the gradients of hydrostatic and osmotic pressures and the relevant fluid filtration direction through the blood capillary wall. The local pneumatotherapy amends the fluid filtration direction from the blood into the interstitial tissue. As a result, the fluid filtration rate from the interstitial tissue into the bloodstream and lymphatic vessels is increased, drainage of intercellular spaces is deepened [15, 90]. This procedure for routing the venous and lymphatic outflow, with previously improved compression in the area of important strategic lymph nodes, contributed to a significant improvement of microcirculation. The device spheres rotate at an adjustable frequency that allows to obtain maximum comfort during the procedure. The hardware physiotherapy (luminotherapy) plays an important role among the various methods for microcirculation and lymphatic drainage normalization. The combination of vibration compression and built-in LED red light (luminotherapy) in one procedure, enhances microcirculation and production of collagen and elastin [15, 26, 30, 74, 85, 90, 155]. LED radiation is a type of radiant energy that causes heat generation, when absorbed by the tissues. Vascular distention is accompanied by an increase in blood flow rate, and lymph circulation enhancement. The pronounced thermal effect increases the metabolic processes, improves tissue trophism, and stimulates the ATP synthesis [30]. Due to the effect of LED radiation, the body chromophores (water, proteins - melanin and hemoglobin) transform the absorbed energy with the subsequent formation of primary biologically active substances, such as serotonin, histamine, etc. This cannot but have positive therapeutic effects aimed at restoring the connective tissue, microcirculation and neuroendocrine system, providing anti-inflammatory, lipolytic, and regenerative effects [57].

The procedure was performed in a standard way in 3 stages: warming up, impact on the problem areas, and relaxation.
Areas of impact: lower leg, front, back thighs, buttocks, waist area. The procedure duration was 60 minutes. The course of therapy for all patients consisted of 6 procedures, the procedures were performed 2 times a week.

To compare the correction results for features that have various variation ranges, the rate of change of the studied parameters was calculated at all stages of observation.

When comparing the results of cellulite correction in all patients with no exception, it is possible to indicate the multidirectional changes in indicators before and after correction. The changes were more pronounced in the patients with edematous cellulite with a past medical history of the initial stages of venous circulatory disorders of the lower extremities. In this group of patients (7 persons) a significant decrease in the leg circumference by an average of 1-2 cm and the lower thighs by 2-3 cm was found already after the 3rd procedure that indicated an effective decrease in edema. During the examination, it was possible to notice a change in the skin color, represented by the disappearance of grayish-cyanotic hue, the skin has a light pink physiological color (Figures 1, 2, 3, 4).

Figures 1, 2, 3, 4 – Patient, 52 years old. Grade 2 peripheral lipodystrophy: a - before treatment; b - after 3 procedures; c-after 6 procedures.

Post-RSL sculpting clinical changes included a body capacity decrease, a decrease in the tissue edema, improvement in the body pattern, improvement in the skin color, and increasing its tone.
Figures №1
Figures №2
Figures №3
As a result of 6 correction procedures, all patients demonstrate a decrease in the circumference of waist, buttocks, upper thighs, shins, the weight loss is shown. The particularly significant positive dynamics was observed in the case of edematous cellulite. There were significant changes in all measured circumferences (buttocks, upper and lower thighs, waist area).

All patients noted a tendency to weight loss, however, due to the variability of indicators, they cannot be considered reliably significant.

Comparative analysis of anthropometric indicators is given in Figure 4.4.3.
The changes in thermography data were also not reliable. Maybe, it was due to the lack of a clear division of patients into the groups, depending on the cellulite stage or an insufficient number of procedures performed (the course recommended by the developers is 10 or more procedures). The changes were recorded only in the group of patients with a past medical history of vascular diseases of the lower extremities.

The obtained data of duplex ultrasonography screening of veins and arteries of the lower extremities seems to be interesting. The inferior vena cava (IVC), common iliac vein (CIV) and external iliac vein (EIV), common femoral vein (CFV), deep femoral vein (DFV), superficial femoral vein (SFV), popliteal vein (PV), posterior tibial vein (PTV), peroneal vein (PV), sural vein (SV), great saphenous vein (GSV) and small saphenous vein (SSV) were studied.

The majority of patients demonstrated no obvious vascular abnormalities prior to the commencement of study. Failure of the perforating veins and a reduced blood flow rate in the superficial veins were found in 7 patients only. After the third procedure, they noted a decrease in edema that was confirmed by objective measurements and subjective sensations. After the 6th procedure, all patients demonstrated changes in the form of a significant blood flow acceleration, mainly in the superficial vessels. An increase in venous tone improving microcirculatory perfusion was noted.

The more detailed analysis of data obtained requires a larger group and a comparison of groups with various initial starting indices of venous and arterial blood flow.

Having analyzed the results obtained, it can be argued that the RSL-sculpting method has a positive effect on skin and subcutaneous fat, significantly reducing swelling and soft tissue volume.

Figures 6 and 7
Figures №4
Figures №5
A decrease in the circumference of the lower legs, even in the case of a small number of procedures performed, also indicates a pronounced anti-edema effect of the combined therapy of vibration compression and LED therapy.

The evidence-based changes in the blood flow of the superficial vessels of lower extremities is important that provides grounds to recommend the RSL sculpting as a therapeutic method for abnormal vessels of the lower extremities not complicated by the risk of thrombogenesis. One of the main advantages of RSL sculpting is that the treatment does not injure the leg vessels confirming that the varicose veins are not a contraindication. This is especially important, since most of the hardware cellulite correction methods have a number of contraindications, including the vascular diseases of the lower extremities.
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