Phototherapy and Radiofrecuency for Cellulite

1. INTRODUCTION Cellulite affects about 85 to 98% of women of all races after the onset of puberty, suggesting a hormonal component in its pathogenesis. It is a condition that consists of an edematous infiltration of the connective tissue, followed by polymerization of the fundamental substance which, infiltrating into the fabrics, produces a consecutive fibrotic reaction. Then, cellulite occurs as a consequence of connective tissue edema and ground substance hyperpolymerization. Thus, it manifests itself in the form of nodules or plaques of varied extension and location, and may even present pain in the affected areas. The occurrence of multiple factors in its etiology makes it difficult to choose only one type of therapy for its treatment. Thus, aiming at greater therapeutic efficiency, the association of therapies is studied. One of the methods that can be chosen is radiofrequency, whose main mechanisms of action are dermal heating and vasodilation. The thermal action triggers an inflammatory cascade and stimulates neocollagenesis, causing the dermis to thicken. Vasodilation, on the other hand, leads to hyperemia and lymphatic drainage in the fat tissue. The association of these mechanisms improves the appearance of the skin, bringing good results to aesthetic problems. Another technology that can be applied in the treatment of cellulite is the use of phototherapy. Light Emitting Diodes (LEDs) are devices made up of solid semiconductors linked together and that generate light. They provide a reliable, high-power light source in narrow bands that evenly illuminate a surface. LED does not use ablative or thermal mechanism, but there is a photochemical effect, in which light is absorbed and exerts a chemical change, showing the ability to induce photobiological processes in cells. In addition, LEDs have the ability to combine wavelengths with an array of various sizes, thus stimulating a wider range of tissue types. In addition to these technologies, manual lymphatic drainage is a standard therapeutic tool that has been extensively studied over the years, which uses massage with gentle compressions to stimulate the removal of excess lymph that may be present in cellulite. Linked to its application, the therapist can also choose to use compression of the treated region, playing an important role in additional reduction, increasing the continuous pumping mechanism. Several studies prove the effectiveness of the therapies mentioned above in the treatment of EGF. However, its cause is multifactorial and it is not possible to isolate each of these factors, which together, contribute to the onset of the disorder, requiring the combination of different treatments to achieve maximum results. Thus, the purpose of this study will be to evaluate the Sanae Method for the treatment of cellulite, using a combination of therapies.
2. OBJECTIVES Main objective: ● Evaluate the Sanae method for the treatment of Cellulite. Specific objectives:

• Investigate whether there is an improvement in the appearance of the region affected by cellulite through photographic and term photographic images;
• Analyze whether there are clinical changes through PAFEG after using the Sanae method (combination of therapies);
• Check for possible changes in skin architecture through ultrasound and magnetic resonance imaging after using the Sanae method (combination of therapies);
• Check changes in the quality of life of patients with cellulite.
• Check the degree of "satisfaction of the treated individual" with the results of treatment with the Sanae method.

1. JUSTIFICATION The scientific production has the objective of appropriating reality to better analyze it and, later, producing transformations regarding the discussion on the use of protocols with combined therapies to maximize the therapeutic effect in the treatment of cellulite. In addition to being a very relevant practical aspect, it is of importance for the academic environment, taking into account the changes caused by the pathophysiology of cellulite, in addition to its great impact on society. Cellulitis is a pathology that preferentially affects women, with a multifactorial etiology, thus, carrying out a more detailed study of the combination of therapies can be beneficial for the development of a more efficient treatment protocol, ensuring more satisfactory aesthetic results.
2. MATERIALS AND METHODS The participants, after selection, will be guided about the procedures to be performed and will sign the Free and Informed Consent Term (TCLE). They were then submitted to assessment using the PAFEG, validated by Meyer et al. (2005), which is a data collection instrument that allows evaluating the degree of cellulite and the levels of sensory alterations resulting from this condition, and later, the CELLUQOL summary questionnaire, validated by Hexsel et al. (2011), to assess the quality of life of volunteers. The registration of photos will be carried out in orthostatism and in posterior and lateral views (right and left). The camera used will be the same in all the photos and will be positioned on a tripod at a height of 66 cm from the floor, it will be placed at a distance of 55 cm from the volunteer, for better visualization and standardization of the photos. In the same position, photography with a thermographic camera will be carried out. Subsequently, they will undergo an ultrasound examination of the affected region. The exam will be carried out with the volunteers positioned in the prone position, in the gluteal and posterior region of the thigh, in an area of 10 cm², which will be delimited by a mold made of rubber E.V.A. A high-frequency ultrasound device (12MHZ) model XG, Samsung brand will be used. The volunteers will also undergo an evaluation of magnetic resonance, which will investigate changes related to cellulite in the skin's architecture, as described in previous studies.
3. PROCEDURES For the treatment, the volunteers will receive 15 sessions in total, being held 3 times a week, lasting 50 minutes. The treatment protocol was distributed as follows: Session 1 - Manual therapy only Sessions 2 to 6 - Carboxytherapy and phototherapy or radiofrequency Session 7 - Manual therapy only Sessions 8 to 14 - Carboxytherapy and phototherapy or radiofrequency Session 15 - Manual therapy only Volunteers will be instructed to wear compressive shorts during treatment. The interventions will be performed using Ibramed™ Carboxitherapy equipment, model Aires™, phototherapy equipment from Ibramed™, model Antares™, radiofrequency equipment from Ibramed™, model Neartek™ In the end, the volunteers will answer the adapted questionnaires from the analysis of patient satisfaction, Segot-chicq et al. (2007) and the Global Aesthetic Improvement Scale - GAIS, by Narins (2003), which is used to classify the response to treatments, allowing a comparative assessment at different times after the therapeutic intervention. The reassessment will be made after the last session, with the repetition of all the procedures mentioned and photos. The volunteers will be seen in a dermatofunctional physical therapy treatment outpatient clinic adequately structured for the proposed study, containing an appropriate environmental refrigeration system and good hygiene and lighting conditions, in accordance with the standards of the local Health Surveillance, it will be at the physical therapy clinic, located at Av. Antônio Basílio - Lagoa Seca/ Natal-RN owned by Dr. Eneida Carreiro.
4. DATA ANALYSIS

The collected data will be organized in Excel tables, quantitative data will be submitted to statistical analysis. Statistical analysis will be performed using the Statistical Package for Social Sciences (SPSS) version 17.0 for Windows. First, the Kolmogorov-Smirnov(K-S) test was performed to verify the normality of the data. In inferential statistics, the Two-way ANOVA variance test with repeated measures will be used to verify differences between the groups before and after the interventions. Throughout the statistical analysis, a significance level of 5% and a confidence interval of 95% (95% CI) will be assigned. Qualitative data (descriptive analysis of ultrasound and magnetic resonance images) will be described based on medical reports.