Content uploaded by Débora Aparecida Oliveira Modena
Author content
All content in this area was uploaded by Débora Aparecida Oliveira Modena on Dec 09, 2017
Content may be subject to copyright.
For Peer Review Only
E
xtracorporeal shockwave: mechanisms of action and
physiological aspects for cellulite, body shaping and
localized fat – systematic review.
Journal:
Journal of Cosmetic and Laser Therapy
Manuscript ID
Draft
Manuscript Categories:
Reviews of Treatment Studies
Date Submitted by the Author:
n/a
Complete List of Authors:
Modena, Débora; Universidade Estadual de Campinas, Surgery
Department; Ibramed Research Institute, Study Group in Technology
Applied to Health, Brazil
Silva, Caroline; Universidade Estadual Paulista Julio de Mesquita Filho -
Campus de Marilia, Human Development and Technologies; Ibramed
Research Institute, Study Group in Technology Applied to Health, Brazil
Grecco, Clovis; Ibramed Research Institute, Research Development and
Innovation
Guidi, Renata; Universidade Estadual de Campinas, Biomedical Engineering
Department; Ibramed Research Institute, Study Group in Technology
Applied to Health, Brazil.
Moreira, Renata; Ibramed Research Institute, Study Group in Technology
Applied to Health, Brazil
Coelho, Andresa; Ibramed Research Institute, Study Group in Technology
Applied to Health, Brazil
Sant'Ana, Estela; Ibramed Research Institute, Study Group in Technology
Applied to Health, Brazil.
Souza, José; Ibramed Research Institute, Study Group in Technology
Applied to Health, Brazil.
Keyword:
Cellulite, acoustic wave therapy, extracorporeal shockwaves, shockwaves
cellulite
E-mail: drwilkerson@skinandlasers.com URL: http://mc.manuscriptcentral.com/mclt
Journal of Cosmetic and Laser Therapy
For Peer Review Only
Title Page
Extracorporeal shockwave: mechanisms of action and physiological aspects for
cellulite, body shaping and localized fat – systematic review.
Physiology extracorporeal shock waves
MSc. Débora A Oliveira Modena
a,c
, PT. Caroline Nogueira da Silva
b,c
, PhD. Clovis
Grecco
c
, PT. Renata Michelini Guidi
c,d,e
, PT. Renata Gomes Moreira
c
, Andresa A
Coelho
c
, PhD. Estela Sant’Ana
c
, José Ricardo de Souza
c,e
.
a
Of Surgery Department, Faculty of Medical Sciences, University of Campinas
(Unicamp), Brazil.
b
Human Development and Technologies, Universidade Estadual Paulista (UNESP),
Brazil.
c
Ibramed Research Institute: Study Group in Technology Applied to Health, Brazil.
d
Biomedical Engineering Department, Faculty of Electrical Engineering and
Computing, University of Campinas (Unicamp), Brazil.
e
Centro de Estudos e Formação Avançada Ibramed (CEFAI), Brazil.
Corresponding Author: MSc. Débora A Oliveira Modena
de.modena@ibramed.com.br
Av. Dr. Carlos Burgos, 2800 - Jardim Itália, Amparo - SP, 13901-080
Page 1 of 23
E-mail: drwilkerson@skinandlasers.com URL: http://mc.manuscriptcentral.com/mclt
Journal of Cosmetic and Laser Therapy
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
For Peer Review Only
Contributions of all authors
MSc. Débora A Oliveira Modena
a,c
, search for articles in the database, articles analysis,
manuscript writing.
PT. Caroline Nogueira da Silva
b,c
, search of articles in the database, articles analysis,
manuscript revision, contributions in writing the manuscript.
PhD. Clovis Grecco
c
, manuscript revision, contributions in writing the manuscript.
PT. Renata Michelini Guidi
c,d,e
manuscript revision, contributions in writing the
manuscript.
PT. Renata Gomes Moreira
c
, manuscript revision, contributions in writing the
manuscript.
Andresa A Coelho
c
, manuscript revision, contributions in writing the manuscript.
PhD. Estela Sant’Ana
c
, manuscript revision, contributions in writing the manuscript.
José Ricardo de Souza
c,e
.
manuscript revision, contributions in writing the manuscript.
Page 2 of 23
E-mail: drwilkerson@skinandlasers.com URL: http://mc.manuscriptcentral.com/mclt
Journal of Cosmetic and Laser Therapy
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
For Peer Review Only
1
Extracorporeal shockwave: mechanisms of action and physiological aspects for
cellulite, body shaping and localized fat – systematic review.
Abstract: Extracorporeal Shockwave Therapy – ESWT has had a wide use in
rehabilitation, and has presented positive effects in the treatment of unaesthetic
affections. The objective of the present study was to search, in the literature, the
mechanisms of action and the physiological aspects of shockwaves acting on the
biological tissue to improve the condition of cellulite and localized fat. A systematic
review of the literature was carried out in the period from September 2016 to February
2017 based on the bibliographic databases Lilacs, MedLine, PubMed and Scielo.
Fifteen articles were identified in that systematic review, three of which were excluded
because they did not make the complete access to the article available or the theme
investigated did not encompass the objective of the study. The revision demonstrated
that extracorporeal shockwaves present relevant effects on the biological tissue, which
leads to the restructuring of skin properties and subcutaneous tissue, clinically
improving the aspects of cellulite and localized fat.
Keywords: cellulite, acoustic wave therapy, extracorporeal shockwaves, shockwaves
cellulite, shockwaves subcutaneous fat.
Page 3 of 23
E-mail: drwilkerson@skinandlasers.com URL: http://mc.manuscriptcentral.com/mclt
Journal of Cosmetic and Laser Therapy
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
For Peer Review Only
2
Introduction
Growing technological advances in technology have promoted the
development of new electromedical devices that can stimulate new therapeutic
modalities. The Extracorporeal Shock Wave Therapy - ESWT is an example of
technological evolution that opens the possibility for a non-invasive therapeutic
modality, validated for use in the healthcare sector, indicated for the treatment of
musculoskeletal disorders and which has recently been explored in the scope of
aesthetic affections. Even with the growing use of this technology, its mechanisms of
action have not yet been clearly established (1,2).
The use of ESWT had its beginnings in the early 70s in Extracorporeal
Lithotripsy, then becoming a golden standard for the treatment of gallstone, renal
calculi, ureteral calculi and vesical calculi [3,4]. During Lithotripsy treatment for lower
ureteral calculi, physicians observed that some patients presented increase in bone
density in the pelvic region. Based on this observation, they began to use equipment
designed for Lithotripsy for the treatment of orthopedic dysfunctions, originating a new
technology that allowed the grading of depth and intensity with which shockwaves
penetrate biological tissues (4,5).
In 1997 in Vienna, Austria, the European Society for Musculoskeletal
Shockwave (ESMST) was founded, with the objective of promoting the research and
development of therapy in Europe. In Brazil, the use of shockwaves as an orthopedic
therapy started in 1998. In 2001, ESWT was approved by the Federal Drug
Administration (FDA), for the treatment of chronic plantar fasciitis in the United States
(EUA) (5,6).
The possibility of the use of ESWT in aesthetic treatments emerged from
the observations of surgical results, when women suffering from muscle disorders, after
Page 4 of 23
E-mail: drwilkerson@skinandlasers.com URL: http://mc.manuscriptcentral.com/mclt
Journal of Cosmetic and Laser Therapy
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
For Peer Review Only
3
receiving hip prosthesis, reported an enhancement in mobility and pain, an improvement
in the aspect of the skin and body contour, suggesting that there was a decrease in the
body circumference in the treated area (4,7,8).
The ESWT technology appeared during World War II when submarines
were attacked by bombs and remained intact, and the sailors on board presented serious
trauma with visceral and pulmonary lesions without external lesions. These lesions were
attributed to the shockwaves, which went through the submarine walls and propagated
amongst the sailors. In everyday life, shockwaves can be perceived when there is
thunder, which occurs due to the intense heating and the rapid expansion of the air
surrounding the lightning (4,9).
ESWT is characterized by a high pressure pulse (80 MPa) in a time interval
of extremely short duration (in the order of nanoseconds), which produces mechanical
pressure waves that promote cavitation in liquid medium (gas bubbles in fluid medium)
and increase in local temperature. These shockwaves propagate in the target tissue,
generating essential mechanisms of action such as the mechanical impact in the tissues
and formation of microbubbles, which favors the achievement of the therapeutic
objective (4).
For therapeutic purposes, there are four types of shockwave generators: The
electro-hydraulic system, the piezoelectric system, the electromagnetic system and the
pneumatic system, the latter two being the most frequently used in rehabilitation and
aesthetics (6,10). The electromagnetic generator presents two coils inside that generate a
magnetic field when run through by electricity – the action of the field causes the
projectile, situated inside the applicator, to move quickly and collide with the tip of the
applicator. In the collision of the bullet, there is the transfer of energy from the
projectile to the tip of the applicator, which then transfers the energy received in the
Page 5 of 23
E-mail: drwilkerson@skinandlasers.com URL: http://mc.manuscriptcentral.com/mclt
Journal of Cosmetic and Laser Therapy
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
For Peer Review Only
4
form of mechanical waves to the treatment area. In the pneumatic generator, differently,
the projectile is displaced towards the tip by the pressure exerted by the compressed air
(5,6,10) (Figure 1).
ESWT equipment can be built in such a manner that it emits two types of
waves, classified as focal waves (more intense and profound), directed at the target
tissue, or radial waves (less intense and more superficial) diverge over the treatment
area (5,11). There is equipment which offer the two types of wave and other that use
only one which is adequate to the therapeutic objective. The ESWT energy can also be
classified as low, medium and high, and that favors the field of action because each
energy reaches structures like muscles, tendon and bones in different depths and forms
(7,8,12).
Considering that this technology is relatively new in the aesthetic area, there
are few studies that discuss the interaction between ESWT and the biological tissues for
this purpose, which makes decision-making about the use of this technology difficult
based on evidence. Therefore, the objective of this study was to present a revision of the
literature about the technical aspects, mechanisms of action and physiological effects
that involve the use of extracorporeal shockwave therapy in aesthetic alterations.
Material and Methods
This is a revision of the literature carried out from September 2016 to February based
on bibliographic databases Lilacs, MedLine, PubMed and Scielo. As the theme is
relatively recent, there is difference in the indexing processes in the bibliographic
databases; therefore, the search for free themes, without the use of the controlled
vocabulary (descriptors) was the option chosen. Using this strategy, there was an upturn
of a greater number of references, guaranteeing the detection of most of the published
Page 6 of 23
E-mail: drwilkerson@skinandlasers.com URL: http://mc.manuscriptcentral.com/mclt
Journal of Cosmetic and Laser Therapy
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
For Peer Review Only
5
studies within pre-established criteria. Terms such as cellulite, acoustic wave therapy,
extracorporeal shockwaves, shockwaves cellulite, shockwaves subcutaneous fat were
combined. The selected studies included the extracorporeal shockwave theme and the
discussion of the mechanisms of action and physiological effects in the treatment of
aesthetic alterations.
All of the original articles indexed about the action of ESWT on cellulite
and localized fat written in English published between 2005 and 2017 with
experimental (clinical trials, randomized or not) or observational (case studies, case-
control, cross-sectional studies and before-and-after treatment studies) approaches
carried out in humans were included. Experimental studies were excluded.
After checking titles, authors and abstracts, with the objective of avoiding
the repetition of publications, the availability of complete access and the theme were
investigated, and an evaluation of articles by peers, specialists in the investigated area,
was carried out.
After the inclusion of the articles, an analytical reading of each study was
performed, as well as a record of concept, method used for evaluation, classification of
ESWT use in the pre-established area, in the mechanisms of action, the physiological
effects and last but not least, a comparative analysis between the findings and the
theoretical discussion.
Results
In the systematic review, 15 papers were identified, three of them were excluded
because not providing complete access availability, or they were animal studies or the
theme investigated did not encompass the objective of the study. The selected papers
are presented according to Table 1.
Page 7 of 23
E-mail: drwilkerson@skinandlasers.com URL: http://mc.manuscriptcentral.com/mclt
Journal of Cosmetic and Laser Therapy
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
For Peer Review Only
6
Table 1. Published studies about the action of ESWT on cellulite and localized fat.
ESWT: Extracorporeal Shockwave Therapy
Discussion
The objective of the present study was to search for literary evidence about
the physiological effects of ESWT in biological tissues in aesthetic disorders. ESWT
has continuously been indicated for the treatment of cellulite, also known as Gynoid
Lipodystrophy (12-14). Cellulite is an aesthetic alteration which attacks the thighs,
gluteus, abdomen and upper region of the arms. It is a multifactor disorder with increase
of adipose tissue that causes cellular dystrophy, dysfunctions of the hydraulic
metabolism with blood congestion, tissue fibrosis and proliferation of fibroblasts around
the adipose cells (1,12,14). Cellulite is more common in women, because they present
about 21 to 22 billion adipose cells, whereas men present about 17 to 18 million. This
difference in the quantity of adipocytes causes men to have a smaller ability to store fat
in relation to the female sex. Besides, the subcutaneous conjunctive tissue of women
presents some particularities such as the fine fibrous septum, directed vertically in the
cutaneous surface, causing the adipose cells to present a regular form and the projection
of these structures become superficial reaching the dermis, giving the skin the “orange
peel” appearance (9,15-17).
Several treatments for cellulite have been developed in the last decades,
with the objective of promoting the improvement of blood and lymphatic circulation
using physical treatments, pharmacotherapy and treatments in association with
electromedical equipment. However, there is not any one treatment that is completely
effective (16–20).
Page 8 of 23
E-mail: drwilkerson@skinandlasers.com URL: http://mc.manuscriptcentral.com/mclt
Journal of Cosmetic and Laser Therapy
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
For Peer Review Only
7
The first ESWT study for the treatment of cellulite was carried out in 2005,
in a clinical study with 26 women with average age of 45 years, which compared the
independent application of ESWT and in combination with decongestive therapy for
two weeks. Six sessions of ESWT were performed with 1.000 shots in only one thigh
and the decongestive therapy was performed in both thighs. The authors concluded that
one single application of ESWT can significantly decrease the levels of Plasma
Malondialdehyde (MDA), a biomarker of the level of oxidative stress, which would
cause improvement of the biomechanical properties of the skin (19). Oxidative stress is
generated when there is imbalance in the production and tamponade of free radicals,
biochemical physiological alterations during metabolic processes or due to external
factors such as poor nutrition, exhausting exercise, psychological stress, and tobacco
use, among others. As we suffer the influence of these factors, the cell walls and their
molecules are attacked, causing a continuous and aggressive imbalance, which
unleashes a cascade of events that induce the cellular aging. When the oxidative stress
reaches high levels in the body it causes inflammation and cytotoxicity and it plays an
important part in fibrotic degeneration, which can contribute to the formation of
cellulite (7,19-21).
According to Wang (2003), the use of ESWT promotes a cascade of
physiological events, which have not yet been entirely elucidated. What is known is that
after the application there is improvement in the metabolism with subsequent stimulus
of microcirculation by the liberation of nitrous acid and improvement in cell
permeability, which favors the exchange of substances and the reorganization of the
cellular matrix. This leads to the rebalance of the production and tamponade of free
radicals. This data was reaffirmed by the findings of Siems et al. (2005), where there
was improvement of the aspect of the skin after six sessions of ESWT (9,19,21–23).
Page 9 of 23
E-mail: drwilkerson@skinandlasers.com URL: http://mc.manuscriptcentral.com/mclt
Journal of Cosmetic and Laser Therapy
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
For Peer Review Only
8
Angehrn et al. (2007) evaluated the effects of ESWT in the treatment of
cellulite in 21 women aged between 20 and 60 years. 40 thousand shots were applied in
the lateral area of the thigh, twice a week, during six weeks of treatment. The authors
used diagnostic ultrasound as evaluation method (Collagenoson®), which evaluated the
distribution of the epidermis, dermis and subcutaneous tissue. The results showed that
ESWT was effective for the treatment of cellulite, because it promoted the remodeling
of the collagen by realigning the dermal fibers and the improvement in the aspect of the
skin, which remained latent after six months (8).
Corroborating the findings of Angehrn et al. (2007), in 2008 two studies
evaluated the effects of ESWT in cellulite and body contour. First Kuhn et al. (2008)
presented a case study with a 60-year-old woman with cellulite degree three in the
gluteus and thighs, where four sessions of ESWT were applied only in the left thigh;
after the end of the application the patient underwent orthopedic surgery in the region of
the hip in which a sample of tissue of the treated and of the non-treated regions were
removed. The authors concluded that there was histological improvement of the dermis
with increase of the thickness of the extracellular matrix of the dermis, by means of
induction of neocollagen and neo-elastin (8,24).
The second study was developed by Christ et al. (2008), who evaluated 59
women with cellulite, subdivided in two groups in which: the first received six sessions
of ESWT for three weeks and the seconds eight sessions in four weeks of treatment.
The results presented were considered excellent, because there was an increase in the
elasticity and firmness of the skin in both groups after three and six months of therapy
of 95 to 105%, respectively (15).
Page 10 of 23
E-mail: drwilkerson@skinandlasers.com URL: http://mc.manuscriptcentral.com/mclt
Journal of Cosmetic and Laser Therapy
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
For Peer Review Only
9
Angehrn et al. (2007); Kuhn et al. and Christ et al. (2008) found in their
studies similar results which involve induction of formation of collagen, neo-elastin,
improvement of the aspect and elasticity of skin and remodeling of collagen (8,15,24).
Collagen is a protein synthesized by the fibroblast, fundamental in the
constitution of the extracellular matrix and of the conjunctive tissue, and its main
objective is to structure and protect the properties of the skin. In cellulite, there are
structural alterations in the intracellular and extracellular matrix, degradation of
collagen and of fibroblasts. One of the objectives to be achieved is to stimulate the
fibroblasts to induce the synthesis of new collagen fibers (neocollagen) and elastin (neo-
elastin) with subsequent restructuring of the properties of the tissue, which we call
collagen remodeling (14-16,25,26). The cells in our body recognize mechanical stimuli,
due to this the fibroblasts are activated and start a cascade of formation of neocollagen
and neo-elastin and the restructuring of the tissue. This mechanism is called
mechanotransduction of signal, when the cell responds to a mechanical stimulus with
biochemical reactions in cascade and act on the cellular level transmitting the energy to
the extracellular matrix (27).
The first stimulus of ESWT is mechanical, characterized by the peak of
pressure, short duration, with high density of energy and low frequency; when in
contact with the treatment area this mechanical energy leads to the activation of
mechanotransduction of signal and the extracellular matrix mobilizes the cells. These
cells, respond to the indirect effect of shock wave cavitation, bringing forth alterations
beneficial for the treatment of cellulite such as the increase of local circulation and
stimulus to the production of collagen, leading to the restructuring of the dermis and
epidermis, thus restoring the elasticity of the conjunctive tissue and improving skin
texture (2,28).
Page 11 of 23
E-mail: drwilkerson@skinandlasers.com URL: http://mc.manuscriptcentral.com/mclt
Journal of Cosmetic and Laser Therapy
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
For Peer Review Only
10
Adatto et al. (2010) and Adatto et al. (2011) evaluated the effects of ESWT
in cellulite and the improvement of body contour, and in their last study the objective
was to evaluate ESWT in localized fat (29,30).
For the treatment of cellulite, 25 women who received 3000 shots in an area
of 10x15cm² in the lateral region of the thigh were evaluated and six sessions twice a
week were performed. The results demonstrated reduction of the appearance of cellulitis
after three months of the last treatment. The authors concluded that the shockwave
therapy can stimulate lymphatic drainage and microcirculation. In the study about
improvement of the body contour, 14 women were evaluated after eight sessions in the
lateral region of the thigh, with the application of 4500 shots. There was temporary
improvement in the texture and elasticity of skin, and a reduction? of the adipose tissue
(29,30).
Besides the mechanical effects, ESWT has the effects of unstable cavitation,
which is the formation of gas microbubbles in the biological liquids, which implode
causing physiological effects (3-6). According to Steinbach et al. (1993) and Kuhn et al.
(2008), the effects caused by cavitation are related with the dose of energy used to
achieve the therapeutic objective. When high doses of energy are used, the damages are
the increase of cellular diffusion with improvement in the permeability of the cellular
membrane, lesions in the endoplasmic reticulum in the cytoskeleton that gives form to
the cell and in the cellular junctions. All these factors may lead to apoptosis. There is
still the liberation of endothelial growth factor, synthesis of eNOS enzyme, which
induces the production of endothelial nitric oxide (NO) (24,31). For smaller doses of
energy, the principle of action of ESWT is the stimulus to the self-regeneration of the
tissue; therefore, smaller doses are indicated for the treatment of different types of
Page 12 of 23
E-mail: drwilkerson@skinandlasers.com URL: http://mc.manuscriptcentral.com/mclt
Journal of Cosmetic and Laser Therapy
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
For Peer Review Only
11
musculoskeletal diseases. However, both doses stimulate the local blood circulation and
the metabolism (31).
During the bibliographic revision carried out in the present study, out of the
12 articles evaluated, most of them used high doses between 3 and 4 bar for devices
with pneumatic shockwave energy generators. Therefore, we can suggest that, by the
findings in this study, that high energy is efficient in the treatment of localized fat,
because the effects of ESWT can lead to cellular apoptosis (28,32,33).
Another Ferraro et al. (2012) study, also demonstrated decrease in thickness
of the layer of localized fat and of the circumference of the treated area and
improvement in the aspect of the skin after 12 months of the end of treatment. However,
the study protocol evaluated the combination of ESWT with cryolipolysis sliding mode,
using the device that presents both these therapies, but it was not possible to evaluate if
the results could be attributed solely to the use of ESWT, because cryolipolysis also
presents significant results for the reduction of localized fat. It is worth mentioning that
the technique of cryolipolysis sliding mode differs from conventional cryolipolysis
usually mentioned in literature [33].
Knobloch et al. (2013) compared two groups, application of ESWT
(0,25mJ/mm²) in gluteus and thighs, followed by thigh strengthening training and the
second control group with application of ESWT (0,01mJ/mm²) in gluteus and thigh,
followed by thigh and gluteus strengthening training. In both groups, six sessions were
applied for two weeks. The objective was to evaluate if the muscle strength training
would lead to additional effects to the ESWT therapy in the improvement of cellulite.
The results obtained demonstrated that the combination of therapies presented superior
results in relation to the control group, with significant alterations of 24% in the
improvement of the aspect of cellulite. The authors suggest that this improvement
Page 13 of 23
E-mail: drwilkerson@skinandlasers.com URL: http://mc.manuscriptcentral.com/mclt
Journal of Cosmetic and Laser Therapy
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
For Peer Review Only
12
occurred through the mechanical energy of ESWT, which acts on the fibrous septum
and induces their reorganization, making the skin smoother (34).
Proving the previous results, Russe-Wilflingseder et al. (2013) evaluated, in
their double blind randomized clinical trial, the effects of ESWT in the treatment of
cellulite. A placebo group was evaluated, where the transfer of energy was blocked and
for a second group that effectively received intervention were performed weekly
sessions for seven weeks. The treated group presented improvement in the aspect of
skin, in the appearance of cellulitis with decrease of undulations and depth and
reduction in the circumference of thighs after three months of treatment; however, the
researchers suggested that these results can be temporary (28).
The findings corroborate the effects of ESWT in the remodeling of collagen,
formation of neocollagen and neo-elastin, acting in the improvement of tissue firmness
and preventing that the irregularities present in the subcutaneous tissue project onto the
dermis, decreasing the aspect of “orange peel” skin (8,15,30,35).
In 2014, Schlaudraff and collaborators evaluated the individual clinical
result of the treatment of cellulitis with ESWT in 14 women who received 7500 shots in
unilateral thigh and gluteus in two sessions per week in four weeks, totalizing eight
treatments. The authors concluded that there was improvement and decrease in the
degrees of cellulite, but that this result cannot be correlated with individual variables
such as body mass index (BMI), weight, height or age (28).
Nassar et al. (2015) evaluated the efficacy of lipolysis induced by ESWT, in
15 individuals; eight sessions during four weeks were carried out, and 4000 shots were
applied. The authors concluded that ESWT was efficient in the improvement of body
contour, with reduction of the circumference and the fat layer and improvement of the
appearance of cellulite after three months of the end of the treatment (36).
Page 14 of 23
E-mail: drwilkerson@skinandlasers.com URL: http://mc.manuscriptcentral.com/mclt
Journal of Cosmetic and Laser Therapy
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
For Peer Review Only
13
The most recent study published, Hexsel et al. (2016), is in accordance with
the previous findings. This study evaluated the efficiency of ESWT in the treatment of
cellulite and body contour with 5000 shots in the region of gluteus and posterior region
of thigh for 12 sessions. The authors concluded that there was decrease in the
circumference of the treated area, measured in the magnetic resonance exam, with
improvement of the severity of the degrees of cellulite (37).
The systematic review carried out in the present study shows that the use of
ESWT in the treatment of cellulite and localized fat seems to be a tool with efficient
results, provided that the parameters used are observed. The main effects reported in
these studies are related with the activation of the mechanisms of action and the
physiological effects as a result of the stimulus by mechanical shockwaves and effects
of cavitation promoted by the shockwave therapy.
The main effects observed in the biological tissue are: damage to the
extracellular matrix which promotes a cascade of physiological reactions that favor the
reorganization of the extracellular medium, increase of blood and lymphatic circulation,
alterations in the permeability of the cellular membrane, liberation of nitric oxide,
balance of free radicals, drainage of molecular proteins, stimulus for fibroblast
activation by mechanotransduction, formation of neocollagen, neo-elastin and
remodeling of collagen. Other results of the action of ESWT in the biological tissues
were described by Kuhn et al., (2008) and Nassar et al., (2015), the authors suggest that
ESWT can induce lipolysis and/or apoptosis of the adipose cell (8,24,36).
The few studies about ESWT in aesthetic affections show that the
mechanisms of action and physiological effects of this technique are beneficial and
promising for the treatment of cellulite, body contour and localized fat, particularly
because they represent a safe and non-invasive therapeutic mode. There are no reports
Page 15 of 23
E-mail: drwilkerson@skinandlasers.com URL: http://mc.manuscriptcentral.com/mclt
Journal of Cosmetic and Laser Therapy
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
For Peer Review Only
14
of adverse reactions of ESWT in the treatment; only the discomfort reported by the
therapist due to the noise emitted by the shock of the projectile colliding with the tip of
the applicator; to minimize this discomfort, the use of an auricular protector is
suggested.
Conclusion
The results presented in this study show the efficacy of the ESWT technique
as a safe and non-invasive method. Its mode of action in the biological tissue benefits
the treatment of cellulite, body contour and localized fat. Because it is a relatively new
therapy in the aesthetic area, ESWT is a promising field for studies and application, but
it still requires investigation as to the mechanisms of action and their interaction with
the adipose tissue, which demands further experimental studies with ESWT in aesthetic
affections.
Conflicts of Interest
The authors declare that there are no conflicts of interest regarding the
publication of this paper.
References
1. Quatresooz P, Xhauflaire-Uhoda E, Piérard-Franchimont, Piérard GE. Cellulite
histopathology and related mechanobiology. Int. J. Cosmet. Sci 2000; 28 (3): 207–
210, 2006.
2. Thiel M, Nieswand M, Dörffel M. Review: The use of shock waves in medicine a tool
of the modern OR: An overview of basic physical principles, history and research.
Minim. Invasive Ther. Allied Technol 2000; 9(3):247-253.
Page 16 of 23
E-mail: drwilkerson@skinandlasers.com URL: http://mc.manuscriptcentral.com/mclt
Journal of Cosmetic and Laser Therapy
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
For Peer Review Only
15
3. Notarnicola A, Moretti B. The biological effects of extracorporeal shock wave therapy
(eswt) on tendon tissue. Muscles. Ligaments Tendons J 2012;2(1):33-37, 2012.
4. Ogden JA, Tóth-Kischkat A, Schultheiss R. Principles of shock wave therapy. Clin.
Orthop. Relat. Rel 2001; 387:8–17.
5. Kertzman P, Lenza M, Pedrinelli A, Ejnisman B. Tratamento por ondas de choque
nas doenças musculoesqueléticas e consolidação óssea – Análise qualitativa da
literature. Rev. Bras. Ortop 2010;50 (1): 3–8.
6. Wang C.Extracorporeal shockwave therapy in musculoskeletal disorders. J. Orthop.
Surg. Res 2012;7(1):7-11.
7. Knobloch K, Kraemer R. Extracorporeal shock wave therapy (ESWT) for the
treatment of cellulite-A current metaanalysis. Int. J. Surg 2015; 24:1-8.
8. Angehrn F, Kuhn C, Voss A. Can cellulite be treated with low-energy extracorporeal
shock wave therapy?. Clin. Interv. Aging 2007; 2(4): 623- 630.
9. Wang C. An overview of shock wave therapy in musculoskeletal disorders. Chang
Gung Med. J 2003; 26(4):220-232.
10. Malliaropoulos N, Crate G, Meke M, Korakakis V, Nauck T, Lohrer H, et al.
Success and Recurrence Rate after Radial Extracorporeal Shock Wave Therapy for
Plantar Fasciopathy: A Retrospective Study. Biomed Res Int 2016; 1-8.
11. Chen TW, Lin CW, Lee CL, Chen CH, Chen YJ, Lin TY, et al. The efficacy of
shock wave therapy in patients with knee osteoarthritis and popliteal cyamella.
Kaohsiung J. Med. Sci 2014;30(7): 362-370.
12. Rossi AB, Vergnanini AL. Cellulite: a review. J. Eur. Acad. Dermatol. Venereol
2000;14(4):251-262.
13. Avram MM. Cellulite: a review of its physiology and treatment. J. Cosmet. Laser
Ther 2004; 6(4):181-185.
Page 17 of 23
E-mail: drwilkerson@skinandlasers.com URL: http://mc.manuscriptcentral.com/mclt
Journal of Cosmetic and Laser Therapy
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
For Peer Review Only
16
14. Afonso MJPJ, Tucunduva MCT, Pinheiro BVM, Bagatin E. Cellulite: a review. Surg
Cosmet Dermatol 2010;2(3): 214-219.
15. Christ C, Brenke R, Sattler G, Siems W, Novak P, Daser A. Improvement in Skin
Elasticity in the Treatment of Cellulite and Connective Tissue Weakness by Means of
Extracorporeal Pulse Activation Therapy. Aesthetic Surg. J 2008; 28(5): 538- 544.
16. Rawlings AV. Cellulite and its treatment. International Journal of Cosmetic Science
2006;28(3):175-190.
17. Writers AM. Cellulite: No clear evidence that any type of treatment is effective.
Drugs Ther Perspect 2015;31(12): 437-440.
18. Zerini I, Sisti A, Cuomo R, Ciappi S, Russo F, Brandi C, et al. Cellulite treatment: a
comprehensive literature review. Journal of Cosmetic Dermatology 2015;14(3):224-
240.
19. Siems W, Grune T, Voss P, Brenke R. Anti-fibrosclerotic effects of shock wave
therapy in lipedema and cellulite. Biofactors 2005; 24(1): 275-282.
20. Kandola K, Bowman A. Oxidative stress – a key emerging impact factor in health,
ageing, lifestyle and aesthetics. International Journal of Cosmetic Science 2015; 37:1-
8.
21. Koshiyama K, Kodama T, Yano T, Fujikawa S. Structural Change in Lipid Bilayers
and Water Penetration Induced by Shock Waves: Molecular Dynamics Simulations.
Biophysical Journal 2006; 91(6): 2198- 2205.
22. Moosavi-nejad SJ, Satoh M, Takayama K, Island G. Shock wave induced
cytoskeletal and morphological deformations in a human renal carcinoma cell line.
Cancer Science 2006; 97(4): 296-304.
23. Frairia R, Berta L. Biological Effects of Extracorporeal Shock Waves on
Fibroblasts. A Review. Muscles Ligaments Tendons 2011; 1(4): 138-147.
Page 18 of 23
E-mail: drwilkerson@skinandlasers.com URL: http://mc.manuscriptcentral.com/mclt
Journal of Cosmetic and Laser Therapy
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
For Peer Review Only
17
24. Kuhn C. Impact of extracorporeal shock waves on the human skin with cellulite: A
case study of an unique instance. Clinical Interventions in Aging 2008; 3(1): 201-210.
25. Baxter SC, Morales EMO, Goldsmith EC. Adaptive Changes in Cardiac Fibroblast
Morphology and Collagen Organization as a Result of Mechanical Environment. Cell
Biochemistry and Biophysics 2008; 51(1): 33–44.
26. Khan MH, Victor F, Rao B, Sadick NS. Treatment of cellulite. J. Am. Dermatology
2010; 62(3): 361-370.
27. Humphrey JD, Dufresne ER, Schwartz MA. Mechanotransduction and extracellular
matrix homeostasis. Nat Rev Mol Cell Biol 2014;15(12): 802-812.
28. Schlaudraff KU, Kiessling MC, Császár NBM, Schmitz C. Predictability of the
individual clinical outcome of extracorporeal shock wave therapy for cellulite. Clin.
Cosmet. Investig. Dermatol 2014; 7: 171-182.
29. Adatto M, Adatto NR, Servant J, Vester J, Novak P, Krotz A. Controlled,
randomized study evaluating the effects of treating cellulite with AWT ® / EPAT ®.
Journal of Cosmetic and Laser Therapy 2010; 12: 176-182.
30. Adatto MA, Adatto NR, Novak P, Krotz A, Haller G. Body shaping with acoustic
wave therapy AWT (®) /EPAT (®): randomized, controlled study on 14 subjects. J.
Cosmet. Laser Ther 2011; 13: 291-296.
31. Steinbach P, Hofstaedter F, Nicolai H, Roessler W, Wieland W. Determination of the
energy-dependent extent of vascular damage caused by high-energy shock waves in an
umbilical cord model. Urological Research 1993; 21: 279-282.
32. Butterworth PA, Walsh TP, Pennisi YD, Chesne AD, Schmitz C, Nancarrow SA.
The effectiveness of extracorporeal shock wave therapy for the treatment of lower
limb ulceration: a systematic review. Journal of Foot and Ankle Research 2015; 8:1-9.
Page 19 of 23
E-mail: drwilkerson@skinandlasers.com URL: http://mc.manuscriptcentral.com/mclt
Journal of Cosmetic and Laser Therapy
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
For Peer Review Only
18
33. Ferraro GA, De Francesco F, Cataldo C, Rossano F,Nicoletti G, D’Andrea.
Synergistic effects of cryolipolysis and shock waves for noninvasive body contouring.
Aesthetic Plast. Surg 2012; 36 (3):666-679.
34. Knobloch K, Joest B, Krämer R,Vogt PM. Cellulite and focused extracorporeal
shockwave therapy for non-invasive body contouring: A randomized trial. Dermatol.
Ther 2013;3(2): 143-155.
35. Nishida C. Appropriate body-mass index for Asian populations and its implications
for policy and intervention strategies. Lancet 2004; 363(9403): 157-163.
36. Nassar AH, Dorizas AS, Shafai A, Sadick NS. A randomized, controlled clinical
study to investigate the safety and efficacy of acoustic wave therapy in body
contouring. Dermatol. Surg 2015; 41: 366-370.
37. Hexsel D, Camozzato FO, Silva AF, Siega C, Camozzato FO. Acoustic wave
therapy for cellulite, body shaping and fat reduction and fat reduction. Journal of
Cosmetic and Laser Therapy 2017; 4172:1-9.
Page 20 of 23
E-mail: drwilkerson@skinandlasers.com URL: http://mc.manuscriptcentral.com/mclt
Journal of Cosmetic and Laser Therapy
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
For Peer Review Only
19
Page 21 of 23
E-mail: drwilkerson@skinandlasers.com URL: http://mc.manuscriptcentral.com/mclt
Journal of Cosmetic and Laser Therapy
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
For Peer Review Only
Figure 1. Electromagnetic System (a): (A) coils, (B) projectile, (C) tip of the applicator.
Pneumatic System (b): (B) projectile; (C) tip of the applicator, (D) compressed air inlet.
Page 22 of 23
E-mail: drwilkerson@skinandlasers.com URL: http://mc.manuscriptcentral.com/mclt
Journal of Cosmetic and Laser Therapy
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
For Peer Review Only
Table 1. Published studies about the action of ESWT on cellulite, body contour and
localized fat.
Author Year Protocol
Treatment
Area Conclusion
Siems et al. 2005
ESWT +
Decongestive
therapy Thigh
Decrease of oxidative stress and
improvement of skin properties.
Angehrn et
al. 2007
ESWT
Lateral
region of
thigh
Remodeling of collagen and
improvement of the aspect of
skin.
Kuhn et al. 2008
ESWT
Thigh and
gluteus
Histological improvement of
epidermis and of the extracellular
matrix of the dermis.
Christ et al. 2008
ESWT
Thigh and
gluteus
Improvement of elasticity and
tightness of skin.
Adatto et al.
2010
ESWT Lateral
region of
the thigh
Improvement in skin texture and
elasticity, number of depression
and decrease of thickness of the
subcutaneous tissue. 2011
Ferraro et al. 2012
ESWT+
Cryolipolysis
Abdomen,
arms,
gluteus and
thigh.
Decrease of the thickness of the
adipose tissue, circumference of
the treated area and improvement
of the aspect of the skin.
Knoblock et
al. 2013
ESWT+
Muscle
strengthening.
Thigh and
gluteus
Improvement of the aspect of
cellulite.
Russe
-
wilflingseder
et al. 2013
ESWT Thigh
Temporary improvement of the
aspect of the skin and reduction in
the circumference of the thigh.
Schlaudraff
et al. 2014
ESWT
Thigh and
gluteus
Decrease in the degree of
cellulitis.
Nassar et al. 2015
ESWT Thigh
Reduction of the circumference of
the treated area, thickness of the
fat layer and appearance of
cellulite.
Hexsel et al. 2016
ESWT
Thigh and
gluteus
Decrease of the circumference of
the treated area and severity of
the degrees of cellulite.
Page 23 of 23
E-mail: drwilkerson@skinandlasers.com URL: http://mc.manuscriptcentral.com/mclt
Journal of Cosmetic and Laser Therapy
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
