Impact of extracorporeal shock waves on the human skin with cellulite: A case study of an unique instance

Abstract

In this case study of an unique instance, effects of medium-energy, high-focused extracorporeal generated shock waves (ESW) onto the skin and the underlying fat tissue of a cellulite afflicted, 50-year-old woman were investigated. The treatment consisted of four ESW applications within 21 days. Diagnostic high-resolution ultrasound (Collagenoson) was performed before and after treatment. Directly after the last ESW application, skin samples were taken for histopathological analysis from the treated and from the contra-lateral untreated area of skin with cellulite. No damage to the treated skin tissue, in particular no mechanical destruction to the subcutaneous fat, could be demonstrated by histopathological analysis. However an astounding induction of neocollageno- and neoelastino-genesis within the scaffolding fabric of the dermis and subcutis was observed. The dermis increased in thickness as well as the scaffolding within the subcutaneous fat-tissue. Optimization of critical application parameters may turn ESW into a noninvasive cellulite therapy.

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Clinical Interventions in Aging 2008:3(1) 201–210 201
CASE REPORT
Impact of extracorporeal shock waves
on the human skin with cellulite: A case study
of an unique instance
Christoph Kuhn1
Fiorenzo Angehrn1
Ortrud Sonnabend2
Axel Voss3
1Klinik Piano, Biel, Switzerland;
2Pathodiagnostics, Herisau,
Switzerland; 3SwiTech Medical AG,
Kreuzlingen, Switzerland
Correspondence: Fiorenzo Angehrn
Klinik Piano, Gottstattstrasse 24,
CH-2504 Biel, Switzerland
Tel +41 32 344 4040
Fax +41 32 344 4042
Email angehrn@klinikpiano.ch
Abstract: In this case study of an unique instance, effects of medium-energy, high-focused
extracorporeal generated shock waves (ESW) onto the skin and the underlying fat tissue of a
cellulite affl icted, 50-year-old woman were investigated. The treatment consisted of four ESW
applications within 21 days. Diagnostic high-resolution ultrasound (Collagenoson) was per-
formed before and after treatment. Directly after the last ESW application, skin samples were
taken for histopathological analysis from the treated and from the contra-lateral untreated area
of skin with cellulite. No damage to the treated skin tissue, in particular no mechanical destruc-
tion to the subcutaneous fat, could be demonstrated by histopathological analysis. However an
astounding induction of neocollageno- and neoelastino-genesis within the scaffolding fabric
of the dermis and subcutis was observed. The dermis increased in thickness as well as the
scaffolding within the subcutaneous fat-tissue. Optimization of critical application parameters
may turn ESW into a noninvasive cellulite therapy.
Keywords: cellulite, extracellular matrix, fat tissue, high-resolution ultrasound of skin,
extracorporeal shock wave, histopathology, scaffolding of subcutaneous connective tissue
Introduction
Affecting most post-adolescent women of all races, cellulite (gynoid lipodystrophy) – the
dimpling of skin primarily on thighs and buttocks – can be considered as a normal
macroscopic expression of the female skin (Müller and Nürnberger 1972; Pavicic et al
2006). It is uncommon in men. The majority of affected men also suffer androgen-
defi ciency disorders (such as Klinefelter-syndrome, hypo-gonadism or cirrhosis; Baker
et al 1976). While cellulite was the ideal type of women at the times of impressionism,
today this “orange peel” aspect of the skin is severely unacceptable, such that it may induce
embarrassment and psychosocial inhibition in those suffering its consequences. In itself
cellulite is not potentially hazardous to health (Smith 2002). A few treatments ensured
by some evidence-based support are available today (such as the mechanical therapy of
folding-unfolding and suction called endermology, topically applied caffeine and retinol,
and the recommendation of exercise and weight loss; Pavicic et al 2006). Medium-energy,
high focused extracorporeal shock waves (ESW) applied locally to the skin with cellulite
may be a potential noninvasive therapy approach. Recently low-energy defocused ESW
treatment showed some evidence of remodeling of the collagen within the dermis (Angehrn
et al 2007). Shock wave treatments are to be distinguished from high intensity ultrasound
used in liposculpturing (Adamo et al 1997; Rohrich et al 2000).
Physics of extracorporeal shock wave (ESW)
Shock waves such as lightning strikes with their subsequent thunder are acoustical
longitudinal waves that transmit energy through a medium from the place of their

Clinical Interventions in Aging 2008:3(1)
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Kuhn et al
generation to distant areas. Shock waves (Figure 1a) are
presented by a single, positive pressure pulse followed by
an exponential descent and a comparatively small tensile
amplitude below surrounding’s pressure (Gerdersmeyer
et al 2002; Wilbert 2002; Wess 2006). Due to the high com-
pressibility of gases, small pressure variations induce large
changes in the density and temperature of the medium. In
less compressible media such as liquids and solids, a shock
wave with 10 MPa is still considered weak (Gerdersmeyer
et al 2002).
Unfocused extracorporeal shock waves (ESW) radially
spread with an energy fl ow density which decreases by the
third power with distance from the applicator. High-focused,
focused, or partially focused ESW (by using elliptic acoustic
mirrors) have their maximum of energy fl ow density at a
specifi c penetration depth. High-energy ESW have an energy
fl ow density per pulse of 0.2–0.4 mJ/mm2 at the focus,
whereas low-energy ESW have energy fl ow density per pulse
smaller than 0.1 mJ/mm2 (Rompe et al 1997; Urhahne 2005)
with a medium-energy focus between 0.1 mJ/mm2 and 0.2
mJ/mm2. The damage by high-energy ESW outside of the
treatment zone is almost completely avoided by focusing.
The ESW application frequency is another important physi-
cal parameter.
pressure
time
generation
of shock-wave
negative
pressure peak
slow
decrease
positive
pressure peak
pressure of
surrounding
high-energy
shock waves
low-energy
shock waves
cavitation bubbles
from previous
shock wave
stress & tensile
effects
of shock wave on
cavitation bubbles
microjets from
implosion of
cavitation bubbles
fast
increase
regeneration
(hidden)
destruction
(evident)
tissue
shock wave
b)
c)
d)
a)
impedance
interface:
reflection
tissue
tissue 1
tissue 2
pressure
inhomogenity:
shrink
stretch
Figure 1 Shock-wave: its physics and main biological effects. a) A shock wave is a single, positive pressure pulse rising from surrounding’s pressure followed by an exponential
descent and a tensile amplitude below surrounding’s pressure. The rising occurs within nanoseconds to large amplitude up to 10–100 MPa, whereas the tensile amplitude is
of long duration of 2000 nsec with a comparatively small negative pressure peak between 10% to 20% of positive pressure peak. b) and c) In overcoming the cohesive forces
of fl uid cavitation bubbles are generated or enlarged by the shock-wave’s tensile wave component (even in the case of a negative pressure peak of less than 1 MPa). The
bubbles may grow to achieve radii of more than 30 µm. These cavitation bubbles collapse after the shock-wave propagated further and surrounding’s pressure is re-established.
Subsequent jet-streams can arise with velocities as large as 800 m/sec. d) The energy loss at acoustic impedance interfaces between tissues (Table 1) and even at sub-cellular
structures (Bereiter-Hahn and Blase 2003; Lemor et al 2004) by refraction and diffraction contribute to the biological effect of ESW (Table 2).

Clinical Interventions in Aging 2008:3(1) 203
Impact of ESW on cellulite
Biological effects of ESW
In overcoming the cohesive forces of fl uid by the shock-
wave’s tensile wave component (Figure 1a) cavitation bubbles
(Figure 1b and 1c) (Haeussler and Kiefer 1971; Sapozhnikov
et al 2002; Wolfrum et al 2003; Wolfrum 2004; Wess 2006)
are generated (low frequency range of ESW application)
or enlarged (high frequency range). The implosion of large
cavitation bubbles and the subsequent strong jet-streams
(Figure 1c) are the primary cause of adverse effects such as
tissue damage, destruction of blood vessels (loosening of
endothelial cells; Steinbach 1993) and formation of blood
clots in vessels (Brodmann 1998). Energy losses at acoustic
impedance interfaces (Table 1) on the back side relating
shock-wave infl ux (caused by refl ections) as well as the
shrink and stretch from pressure inhomogeneity within the
shock-wave (Rompe et al 1997; Gerdersmeyer et al 2002)
contribute to the biological effects (Figure 1d). High-energy
extracorporeal shock wave therapy (ESWT) is worldwide the
golden standard to treat urolithiasis through fragmentation
of the kidney stone (Müller et al 2004).
On the subcellular level, the damages are the increase
of permeability of the cell-membrane (Koshiyama 2006),
lesions of the cytoskeleton (Moosavi-Nejad 2006), changes
of mitochondria, endoplasmatic reticulum, and nuclear
membrane of the cell that may lead to apoptosis (Kato
2007). Biological reactions of liberation of different agents
(measured by immuno-histo-chemistry) such as vascular
endothelial growth factor (VEGF), endothelial nitric oxide
synthase (eNOS), and proliferating cell nuclear antigen
(PCNA) are reported (Siems et al 2005; Wang et al 2006).
ESW-application may induce intra- and extracellular
signal-transduction and may generate NO-radicals and
heat-shock proteins (HSP) (Neuland et al 2005).
The stimulating effect of low-energy (partially-focused
as well as focused) extracorporeal generated shock waves
on biological processes within the tissues reached has
increasingly become the centre of interest in the last few
years. The principle of action, that ESW induces self-
regenerating processes within the healthy tissue surrounding
the focus of affl iction, appears to be universal. A multitude
of very different indications like musculoskeletal diseases
(calcaneal spur, tennis-elbow, golf-arm, lime-shoulder;
Wang et al 2006), orthopedics (pseudarthrosis; Siebert
and Buch 1997), chronic skin lesions (ulcus cruris) and
burnings (Sparsa et al 2005; Schaden et al 2006) respond
positively to shock wave therapy. Shock waves are also
effective as a means to increase local blood circulation and
metabolism. These mechanisms are considered responsible
for fi nal healing (Delius et al 1995). Thus ESW is already
used to treat myocardial ischemia (Nishida et al 2004).
Additionally ESW seems to have a high antibacterial
effect (Gerdesmeyer et al 2005). Low-energy defocused
ESW treatment may be effective in treating cellulite by
remodeling collagen within the skin (Angehrn et al 2007).
Because of these diverse effects, we investigated the
impact of medium-energy, high-focused ESW treatment
on cellulite, examining skin and subcutaneous fat by
histology.
The pathophysiology of cellulite
Based upon anatomy and histology of the skin, Nürnberger
and Müller (1972, 1978) formulated a scheme for
development of cellulite (Figure 2). Up to the 7th or 8th
Table 1 Acoustical impedance values related to human skin.
Aqueous gel: optimal contact between ESW application device
and skin
Substance tissue Impedance [103 kg/s m2]
(lower and upper limits)
Air 429
Water 1480
Fat 138
Skin 1530–1680
Blood 1620
Muscle 1650–1740
Bone 3200–7400
Ta b l e 2 Estimates of the energy involved in metabolism
(nutritional basic turnover) and of the physical energy of a shock
wave (value higher by factor of 4*106). Note that the physical focus
of a shock wave (6 dB = 50% isobar) is much smaller than the
tissue volume within which the shock wave (after many refl ections
and diffractions) is fi nally absorbed
Metabolism (nutrition, caloric assessment):
Basal metabolic rate (energy per day) 6480 kJ/86400s = 75 W
Total number of cells 5.0∗ 1013
Metabolic rate per cell 1.5∗ 10−12 W
Metabolic energy per cell in 1µs1.5∗ 10−18 J
Shock wave (single, duration of 1µs):
SW-energy in focus volume in 1µs 3.1∗ 10−3 J
Focus-volume (6 dB = 50% isobar, elipsoid
length 21 mm and ∅ 7.2 mm)
5.7∗ 10−7 m3
Total body volume (cellular fraction: 75%) 7.5∗ 10−2 m3
Mean cell volume 1.1∗ 10−15 m3
Number of cells in focus-volume 5.2∗ 108
SW-energy per cell in 1µs6.0∗ 10−12 J

Clinical Interventions in Aging 2008:3(1)
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Kuhn et al
fetal month in both sexes, the upper part of the subcutaneous
tissue just below the corium consists of standing fat-cell
chambers and septa running radially similar to those of the
adult woman. At birth, sex-typical differences are clearly
manifest: in male newborns, small, polygonal fat-cell cham-
bers and septa of netted, angled and parallel to the surface,
crisscrossing connective tissue are distinctly those of adult
males in addition to the corium being thicker and coarser
in fi brous structure. These sex-typical structural differences
probably are called forth by the proliferative effect of andro-
gens on the mesenchyme (fi broblast activity) during the last
third of fetal life.
Incipient cellulite recognized by an “orange peel” appear-
ance represents focally enlarged fi bro-sclerotic strands par-
titioning the hypodermis and limiting the out pouching of
fat lobules (Quatresooz et al 2006). In contrast, full-blown
cellulite recognized by a dimpled skin surface represents
subjugation of the hypertrophic response of the hypodermal
connective tissue strands when the resistance is overcome
by progressive fat accumulation (in subjects with high body
mass indexes) forming papillae adiposae that protrude into
the lower reticular dermis (Quatresooz et al 2006). A simple
grading-score of cellulite by inspection is given (Nürnberger
and Müller 1978) (Table 3).
Prospective design study: Methods,
materials and human resources
Human resource
A woman aged 50 with colored skin and cellulite grade 3 at
her thighs and buttocks had to have surgery on both hips. After
giving her informed consent, she agreed to have the skin at her
left thigh treated with ESW several times (Table 4) before the
operation. The hip-surgery was carried out under lumbar anes-
thesia and on this occasion two representative full-thickness
skin samples were taken at the same time, one at the site of
the ESW application and one at the contra-lateral, symmetric
untreated side to be examined by means of histopathology.
The following regime was carried out:
Figure 2 Inner structure of the female skin and the underlying subcutaneous tissue. Partitioned border zone between corium and subcutis. The plane of the subcutis with
papillae adiposae rising into dells (valley-like) and pits (hole-like) on the undersurface of the corium. Modifi ed from Nürnberger and Müller 1978.
Table 3 Cellulite grading (Nürnberger and Müller 1978)
Grade Defi nition
0 • Smooth surface of skin while lying down and standing.
• Wrinkles upon pinch-test.
1 • Smooth surface of skin while lying down and standing.
• Mattress-phenomenon upon pinch-test.
2 • Smooth surface of skin while lying down.
• Mattress-phenomenon spontaneously while standing.
3• Mattress-phenomenon spontaneously while standing and
lying down.

Clinical Interventions in Aging 2008:3(1) 205
Impact of ESW on cellulite
ESW-Device
The shock waves are produced by electro-hydraulic means
with the device ActiVitor-Derma®, the probe ActiVitor Probe
D0 and along with the following adjustments (Table 5).
Collagenoson®
The high-resolution ultrasound of the skin (Tikjob et al 1984)
represents an imaging-producing and noninvasive diagnostic
tool, which is able to give an exact representation of the skin
and its adnexa. The ultrasound system used in this study
included a probe of 22 MHz (yielding a high-resolution axial
of 50 µm, lateral of 200 µm, and a depth of 6 mm) that was
placed upon wet skin. It measured the microstructure of the
mesenchymal connective tissue and the collagen structures
within the extracellular matrix of the dermis (collagenometry),
showing both the epidermis and the boundary between dermis
and subcutis. With this device, the structure and the quality
of the collagen and thus the result of cellulite therapy can be
exactly evaluated (Mole et al 2004).
LCCT-device
Liquid crystal contact thermography (LCCT) measures minor
differences in skin temperature (Hoffmann et al 1989). Here
we use LCCT to detect a change in micro-perfusion of the
surrounding tissue treated by ESW.
Results and discussion
Hyperemia was clearly visible by LCCT at the site of ESW
treatment, starting from immediately thereafter and lasting
days (Figure 3). Comparing high frequency, high resolution
ultrasound measurements of medium-energy, high-focused
ESW-treated and untreated skin areas, we could see some
improvement in the epidermis and the extracellular matrix
of the dermis (Figure 4).
Impact of ESW on extracellular matrix
of skin with cellulite
In a recent study (Angehrn et al 2007) the hypothesis was
stated that low-energy defocused ESW treatment (12 therapy
sessions) is effective in treating cellulite through the remodeling
of skin’s collagen. This effect can be corroborated by the
subjective comments of the subjects (where improvement from
treatment may have a latent period of from 2 to 6 months) as
well as by measuring the microstructure of the skin using high
frequency ultrasound (Collagenoson®). The present prospective
design study (medium-energy, high-focused ESWT, 4 therapy
sessions) supports this hypothesis by a histopathologic sample.
On this sample no signs of tissue repair are visible. However an
amazing induction of neocollageno- and neoelastino-genesis
is observed within the scaffolding fabric of dermis resulting
in increased in thickness of the dermis (Figure 5).
Impact of ESW on subcutaneous fat
tissue
Besides tightening the skin and improving its quality, an ideal
therapy of cellulite should assure a reduction of subcutaneous
fat. In our case of ESW treatment and the follow-on by histo-
logical analysis, we could not ascertain any direct or indirect
signs of mechanical destruction or liquefying of fat tissue on
any one of the histological slices. Signs of necrosis as well as
the infi ltration of leucocytes and macrophages were absent.
In the course of our limited facility of histological methods,
we could not entirely role out fat reduction by apoptosis.
On the other hand, we could detect a substantial increase in
the scaffolding of the subcutaneous fat tissue and we thus
Table 4 ESW application and therapy documentation scheme
Left Right
Day 0 LCCT • •
Collagenoson • •
1. ESWT application •
Day 7 2. ESWT application •
Day 14 3. ESWT application •
LCCT • •
Day 21 LCCT • •
4. ESWT application •
Collagenoson • •
Surgery: skin samples • •
Table 5 ESW application adjustments
Focus High-focused
6 dB (= 50%) isobar
Length (z) 21 mm
Diameter ∅ (x,y) 7.2 mm
Penetration depth 5.0 mm
Pressure rising-time 10–15 nsec
Shock-wave duration 1–2 µsec
Positive pressure peak 40 MPa
Negative pressure peak 1–2 MPa
Energy fl ow density 0.115 mJ/mm2
Frequency 4 Hz
Number of pulses 200/cm2
Treated area 2 x 2 cm2
Total duration 3 min + 20 sec

Clinical Interventions in Aging 2008:3(1)
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Kuhn et al
Figure 3 LCCT (Liquid crystal contact thermography, RW27ST with colors corresponding to temperature steps of 0.70 Celsius) of left, proximal, lateral thigh: before 1st ESW-
application (control, left), immediately after 3rd ESW-application (middle) and before 4th ESW-application (right). Note the hyperemia at the site of ESW-treatment.
Figure 4 High-frequency high-resolution ultrasound measurement of skin (Collagenoson®) of left thigh before treatment (control) and after treatment (same site). Treatment:
medium-energy, high focused ESW. Notice: increased collagen contentment after treatment.
Immediately
after third
ESW
application
Before
fourth
ESW
application
Before
first
ESW
application

Clinical Interventions in Aging 2008:3(1) 207
Impact of ESW on cellulite

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Kuhn et al
Figure 5 Histopathology of skin and of subcutaneous fat tissue. a) Hematoxylin Eosin stain (HE, nuclei: blue; cytoplasma and connective tissue: red-pink), b) Elastin Van
Gieson stain with Resorcin-Fuchsin (EVG, elastic fi bers: black, collagen: red, muscle tissue: yellow). One characteristic and representative slide taken from the central (ESW-
treated) part of the skin-sample (surface: 75 mm*28 mm, depth: 40 mm, evenly spaced slides) and a corresponding slide (control) of the not treated skin-sample (surface:
70 mm*25 mm, depth 40 mm). Photographs focusing (i) epidermis/dermis/subcutis (4×-objective), (ii) epidermis/dermis (10×-objective), (iii) subcutis (10×-objective).
Note: Magnifi cation of each image indicated by bar. No signs of tissue repair are visible – such signs of a response to an injury would be tissue-necrosis, extravasation of eryth-
rocytes, the infi ltration of neutrophils lymphocytes and macrophages and the subsequent scar-formation. However an increase of the skin’s connective tissue, the extracellular
matrix, particularly collagen and possibly elastin is observed resulting in increased thickness of the dermis and of the scaffolding within the subcutaneous fat tissue.

Clinical Interventions in Aging 2008:3(1) 209
Impact of ESW on cellulite
conjecture a stupendous induction of neocollageno- and
neoelastino-genesis within the subcutaneous tissue by ESW.
Conclusion
The application of external and internal forces are consid-
ered to be able to regulate gene expression and cell behavior.
In particular, cell stretch is considered to be a stimulus
supporting cell proliferation (skin expanders). The signaling
pathways linking mechanical stretch to cell proliferation and
survival (eg, activation of anti-apoptotic kinase PKB/Act) are
still not well described (Kippenberger et al 2005).
These encouraging results put forward that optimization
of critical application parameters may turn ESW into a nonin-
vasive cellulite therapy, not by reduction of subcutaneous fat,
but by strengthening the skin’s scaffolding fabric, particularly
of the dermis and the subcutaneous fat tissue.
Further studies should show whether parameters such
as the patient’s age (adolescent, adult or elderly females),
body-composition (obesity), and the stage of cellulite have
an infl uence on the outcome of ESW treatment. In our case,
a histological analysis was possible by a planned operation
symmetrical and at the same sites. In implementing a study
with many participants, a noninvasive method of analysis
must be applied such as high-resolution ultrasound.
Acknowledgments
Sarah Baccolini, Clinic Piano, Biel, Switzerland (measure-
ments and organisation); SwiTech Medical AG, Kreuzlingen,
Switzerland (providing device for medium-energy, high-
focused ESW treatment, ActiVitor Ortho/Derma); Pathodiag-
nostics, Herisau, Switzerland (providing histology laboratory
material). The authors have no confl icts of interest to report.
References
Adamo C, Mazzocchi M, Rossi A, et al. 1997. Ultrasonic liposculpturing:
extrapolations from the analysis of in vivo sonicated adipose tissue.
Plast Reconstr Surg, 100:220–6.
Angehrn F, Kuhn C, Voss A. 2007. Can cellulite be treated with low-energy
extracorporeal shock wave therapy? Clin Interv Aging, 2:623–30.
Baker HW, Burger HG, de Kretser DM, et al. 1976. A study of the endocrine
manifestations of hepatic cirrhosis. Q J Med, 45:145–78.
Bereiter-Hahn J, Blasé C. 2003. Ultrasonic characterisation of biological
cells. In: Kundu T ed. Ultrasonic Nondestructive Evaluation: Enge-
neering and Biological Material Characterisation. Boca Raton: CRC
Pr, pp 725–59.
Brodmann M, Ramschak H, Schreiber F, et al. 1998. Venous thrombosis after
extracorporeal shock-wave lithotripsy in a patient with heterozygous
APC-resistance. Thromb Haemost, 80:861.
Delius M, Draenert K, Al Diek Y, et al. 1995. Biological effect of shock
waves: In vivo effect of high energy pulses on rabbit bone. Ultrasound
Med Biol, 21:1219–25.
Gerdersmeyer L, Maier M, Haake M, et al. 2002. Physikalisch-technische
Grundlagen der extrakorporalen Stoßwellentherapie (ESWT). Der
Orthopäde, 31:610–17.
Gerdesmeyer L, von Eiff C, Horn C, et al. 2005. Antibacterial effects of
extracorporeal shock waves. Ultrasound in Med and Biol, 31:115–19.
Haeussler E, Kiefer W. 1971. Anregung von Stoßwellen in Flüssigkeiten
durch Hochgeschwindigkeits-Wassertropfen. Verhandlungen Dtsch
Phys Gesellschaft (VI), 6:786–9
Hoffmann R, Brutsch H-P, Largiader F, et al. 1989. Liquid-crystal-contact
thermography – a new diagnostic method for determination of skin
circulation. Helv Chir Acta, 56:263–6.
Kato K, Fujimura M, Nakagawa A, et al. 2007. Pressure-dependent effect of
shock waves on rat brain : induction of neuronal apoptosis mediated by
a caspase-dependent pathway. J Neurosurg, 106:667–76.
Kippenberger S, Loitsch S, Guschel M, et al. 2005. Mechanical stretch
stimulates PKB/Akt phosphorylation in epidermal cells via angiotensin
II type 1 receptor and epidermal growth factor receptor. J Biol Chem,
280:3060–7.
Koshiyama K, Kodama T, Yano T, et al. 2006. Structural change in lipid
bilayers and water penetration induced by shock waves: Molecular
dynamics simulations. Biophys J, 91:2198–205.
Lemor RM, Weiss EC, Pilarczyk G, et al. 2004. Mechanical properties of
single cells: Measurement possibilities using time-resolved scanning
acoustic microscopy. Ultrasonic Symposium, IEEE 1:622–9.
Mole B, Blanchemaison P, Elia D, et al. 2004. High frequency ultraso-
nography and celluscore: an improvement in the objective evaluation
of cellulite phenomenon. Annales de chirurgie plastique esthétique,
49:387–95.
Moosavi-Nejad SF, Hosseini SHR, Satoh M, et al. 2006. Shock wave
induced cytoskeletal and morphological deformations in a human renal
carcinoma cell line. Cancer Sci, 97:296–304.
Müller G, Nürnberger F. 1972. Anatomical principles of the so-called
“cellulite”. Arch Dematol Forsch, 244:171–2.
Müller SC, Hofmann R, Köhrmann KU, et al. 2004. Epidemiologie, instru-
mentelle Therapie und Metaphylaxe des Harnsteinleidens. Deutsches
Ärzteblatt, 101:A-1331/B-1101/C-1065.
Neuland H, Kesselman-Evans Z, Duchstein H-J, et al. 2004. Outline of the
Molecularbiological Effects of the Extracorporal Shockwaves (ESW)
on the Human Organism. Orthopädische Praxis, 9:488–92.
Nishida T, Shimokawa H, Oi K, et al. 2004. Extracorporeal cardiac shock
wave therapy markedly ameliorates ischemia-induced myocardial
dysfunction in pigs in vivo. Circulation, 110:3055–61.
Nürnberger F, Müller G. 1978. So-called cellulite: an invented disease.
J Dermatol Surg Oncol, 4:221–9.
Pavicic T, Borelli C, Korting HC. 2006. Cellulite – the greatest skin problem
in healthy people? An approach. JDDG, 10:861–70.
Quatresooz P, Xhaufl aire-Uhoda E, Piérard-Franchimont C, et al. 2006.
Cellulite histopathology and related mechanobiology. Int J Cosmetic
Sci, 28:207–10.
Rohrich RJ, Morales DE, Krueger JE, et al. 2000. Comparative lipoplasty analy-
sis of in vivo-treated adipose tissue. Plast Reconstr Surg, 105:2152–8.
Rompe JD, Küllmer D, Vogel J, et al. 1997. Extrakorporale Stoßwellentherapie-
Experimentelle Grundlagen, klinischer Einsatz. Orthopäde 26:215–28.
Sapozhnikov OA, Khokhlova VA, Baileya MR, et al. 2002. Effect of over-
pressure and pulse repetition frequency on cavitation in shock wave
lithotripsy. J Acoust Soc Am, 112:1183–95.
Schaden W, Thiele R, Kölpl C, et al. 2006. Extracorporeal shock wave
therapy (ESWT) in skin lesions. 9th International Congress of the Inter-
national Society for Musculoskeletal Shockwave Therapy (ISMST).
News Letter ISMST, 2:13–14
Siebert W, Buch M. 1997. Extracorporeal shockwaves in orthopedics.
Berlin: Springer.
Siems W, Grune T, Voss P, et al. 2005. Anti-fi brosclerotic effects of shock
wave therapy in lipedema and cellulite. BioFactors, 24:275–82.
Sparsa A, Lesaux N, Kessler E, et al. 2005. Treatmernt of cutaneus calcinosis
in CREAST syndrome by extracorporal shock wave lithotripsy. J Am
Acad Dermatol, 53:263–5.
Steinbach P, Hofstaedter F, Nicolai H, et al. 1993. Determination of the
energy-dependent extent of vascular damage caused by high-energy
shockwaves in an umbilical cord model. Urol Res, 21:279–82.

Clinical Interventions in Aging 2008:3(1)
210
Kuhn et al
Tikjob G, Kassis V, Sondergaard J. 1984. Ultrasonic B-scanning of the
human skin. An introduction of a new ultrasonic skin scanner. Acta
Derm Venereol, 64:67–70.
Urhahne P. 2005. Klinische Studie zur Behandlung häufiger Erkrankun-
gen des Bewegungsapparates des Pferdes mittels fokussierter
extrakorporaler Stoßwellentherapie (ESWT) [Dissertation]
München Uni.
Wang C-J, Wang F-S, Yang KD. 2006. Biological mechanism of musculo-
skeletal shockwaves. 9th International Congress of the International
Society for Musculoskeletal Shockwave Therapy (ISMST). News
Letter ISMST, 1:5–11.
Wess O. 2006. Physics and technology of shock wave and pressure wave
therapy. 9th International Congress of the International Society for
Musculoskeletal Shockwave Therapy (ISMST). News Letter ISMST,
2:2–12.
Wilbert DM. 2002. A comparative review of extracorporeal shock wave
generation. BJU Int, 90:507–11.
Wolfrum B, Ohl C-D, Mettin R, et al. 2003. Die Bedeutung von Kavitations-
blasen für transiente Membranpermeabilisierung und Zellschädigung.
Fortschritte der Akustik – DAGA 2003, Aachen, 826–827. M. Vorländer,
Deutsche Gesellschaft für Akustik e.V. (DEGA) Oldenburg.
Wolfrum B. 2004. Cavitation and shock wave effects on biological systems
[Dissertation]. Göttingen Uni.