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The American Journal of Cosmetic Surgery
Vol. 22, No.4, 2011S
233
ORIGINAL ARTICLES
Clinical Evaluation of a Device
for the Treatment of Cellulite: Triactive
Sarah Boyce, MD; Anju Pabby, MD; Prapai Chuchaltkaren, MD;
Benedetta Brazzini, MD; Mitchel P. Goldman, MD
C
not much literature on this topic. There are genetic,
endocrine, and postural etiologies. We know that
cellulite begins as an increase in permeability in local
capillaries and venules, causing interstitial edema and
inflammation. The first stage is reversible and is
characterized by edema and an initial alteration in
blood supply. Vessels show an abnormal permeability,
which causes plasma to accumulate in interstitial
spaces. In normal conditions, each fat cell is wrapped
in a network of very thin reticular fibers, and repeated
edema causes an inflammatory reaction around these
fibers. The final result is that these fibers are increased
in number (hyperplasia) and thickness (hypertrophy),
thus worsening the compromised microcirculation.
There is a loss in skin elasticity and softness.
Many options are available for treatment of this
bothersome condition, including topical creams and
lotions, ultrasound, electrolipolysis, iontophoresis, and
mesotherapy. Currently, there is no long-term efficacious way to treat cellulite. The most successful
treatments have been those that create an increase in
local vascular and lymphatic drainage.
Low-energy lasers have wound-healing properties
and biochemical effects on endothelial cells, erythrocytes, and collagen.i" We have evaluated Triactive,
a device with a low-fluence laser and suction massage
that was developed to reduce the appearance of
cellulite. This device combines massage with a lowenergy diode laser, contact cooling, and mild local
suction to oppose the forces that cause and sustain
cellulite.
Received for publication August 5, 2004.
From Dermatology/Cosmetic Laser Associates of La Jolla Inc.
Corresponding author: Sarah Boyce, MD, Assistant Professor, Department of Dermatology, University of Alabama at Birmingham, 2000 6th
Ave South, 4th Floor, Dermatologic Surgery, Birmingham, AL 35233
(e-mail: [email protected]).
Materials and Methods
Subjects consisted of 16 female patients, all of whom
had cellulite on the thighs or hips. The group had an
average age of 36.6 years (range 19-51 years), an
average body mass index of 22.26 (range 19.2-29.3),
Introduction: Cellulite has always been a difficult
condition for patients and cosmetic physicians to treat. Even
if improvement is made in the appearance of cellulite, no
machine or topical treatment exists that can provide longterm results in the treatment of cellulite. We evaluated
a technique that increases lymphatic drainage and vascular
permeation to assist in decreasing the appearance of
cellulite.
Materials and Methods: Sixteen female patients underwent 12 treatments with. a device called Triactive, which
has a triple-pronged mechanism of action consisting of
low-level suction, diode laser, and contact cooling. We measured results by waist, hip, and thigh circumference as
well as elasticity, thermography. and blinded photograph
evaluations.
Results: We found a small decrease in hip and thigh
circumference as well as an increase in elasticity of the
treated cellulite. Evaluation of the photographs yielded an
overall 21% average improvement in the appearance of
cellulite. There was no change in thermography data after
treatments. Results were not present at 1 month.
Discussion: The Triactive offers a method to temporarily
decrease the appearance of cellulite. It appears that
treatments must be continued to maintain results. Further
study and larger patient groups are needed before this
treatment can be recommended above other available
treatments.
ellulite is one of the most frustrating conditions
we treat as cosmetic physicians. The physiology
is poorly understood and there are many theories but
234
The American Journal of Cosmetic Surgery Vol. 22, No.4, 2005
Body Circumference (Waist)
21.00 , 34.00 , -
Thigh Circumference (Median)
--,
----,
20.50
32 .00
g
I
g
30.00
is
20 .00
§.,
~
is
28 .00
Visit to
Figure 1.
Visit t5
19.50
Visit T 10
Results of waist circumference measurements.
and an average starting body fat percentage of 22.18 %
(range 16.46-31.02%).
Each patient underwent twice-weekly treatments for
a total of 12 treatments. The hips and thighs were
treated for 25 to 30 minutes with circular motions with
the hand piece held perpendicular to the skin. Results
were measured by waist, hip, and thigh circumference;
skin elasticity; and thermography data. A tape measure
was used to measure circumference of patients' waists,
hips, and thighs. Elasticity was measured by an
elasticity meter consistently placed in the center of
the posterior thigh, just inferior to the right buttock.
Thermography data were collected via a probe in the
form of a sheet with hundreds of temperature sensors,
and a computer program was used to analyze the data.
Five blinded investigators evaluated the photographs.
Weight was taken before the start and at the end
of treatment.
Figure 3.
Results of thigh circumference measurements.
Results
Measurements of waist circumference showed no
improvement; in fact, there was a very slight increase in
average waist circumference (approximately 0.3 in)
after 10 treatments (Figure 1). Hip and thigh circumference trended downward, although the results were
subtle (Figures 2 and 3). Elasticity trended upward
(Figure 4), but the thermography data revealed no
significant change in mean skin temperature or
uniformity of skin temperature distribution. There was
no change in the weight of patients before and at the
end of treatment.
After they evaluated the photographs, the blinded
investigators completed a data sheet that yielded a 21 %
average improvement among all 16 patients. Specifically, the average improvement was 23% for the
appearance of the actual cellulite, 14% for the skin
Hip Circumference
42.00, -
----,
Tissue Elasticity Trend
41.00 ! - -_
_
---j
--""'i'
't;'
40 .00
~
:if
--,
15 .00
.e-
li
~
20 .00 , -
'<3
'.::;l
~
39.00
is
10.00
IU
Fj
""
E::::
38.00
Visit to
5.00
Visit t5
Figure 2. Results of hip circumference measurements.
Figure 4.
Results of elasticity measurements.
The American Journal of Cosmetic Surgery
Vol. 22, No.4, 2005
235
Patient 1
Tx 10
Figure 5.
Before-and-after photographic evaluation of the appearance of cellulite in patient 1.
tone, and 16% for the texture. Skin tone was defined as
uniformity in skin color in the area. Photos of 2 patients
are shown in Figures 5 and 6.
Of note, all patients thought that the treatment was
pleasant, and none reported any adverse effects after
any treatment. Often, patients fell asleep during the
treatment sessions.
Discussion
The Triactive device provided a small, temporary
decrease in hip and thigh circumference as well as an
increase in tissue elasticity while patients were undergoing treatment. In addition, the blinded investigators found some improvement in appearance of
cellulite, skin tone, and skin texture. However, the
results that had been obtained by all patients were not
present at 1 month after the last treatment.
One difficulty in studying cellulite is quantitating
improvements. There have been many attempts at
measuring improvements in cellulite, including the
measurement of skin laxity, elastic deformation,
stiffness, and energy absorption.' Standardization of
measurements and photographs can present the biggest
challenge, and this may account for the lack of
scientific data on this topic. We used an elasticity
meter and thermography in our study. One component
of cellulite is its inelasticity from the bound-down
connective tissue attachments that cause the reticulated
appearance of cellulite. We believe that the increase in
elasticity accounts for an overall improvement in the
cellulitic skin of our patients. Also, we attempted to
show thermography data that could represent an
improvement in the microcirculation of the affected
areas. We were not able to show this improvement,
possibly because it did not exist. However, this lack of
improvement could also represent the absence of
standardized placement, which would require some
type of permanent mark on the patient, such as a tattoo,
to be certain the temperature sensor sheet was placed in
the exact same location and direction every time the
patient was measured.
In past studies," circumferences of body areas were
used to measure improvement in cellulite. We did see
a small improvement in hip and thigh circumference,
which were both treated areas. There was no improvement in waist circumference, but no improvement
would be expected because we did not treat that area
with Triactive in our study patients.
Many patients are willing to undergo treatments to
try to improve the appearance of their cellulite, even if
236
The American Journal of Cosmetic Surgery
Vol. 22, No.4, 200!
Patient 2
I Tx 10
I
Figure 6. Before-and-after photographic evaluation of the appearance of cellulite in patient 2.
the results are temporary. We believe that Triactive
offers a unique combination of low-energy irradiation,
contact cooling, and local suction to combat the forces
that cause this unpleasant condition of the skin and
subcutaneous tissue. It appears that treatments must be
continued to maintain results. Further study and larger
patient groups are required before this treatment could
be recommended above other available treatments.
References
1. Agaiby AD, Ghali LR, Wilson R, Dyson M. Laser
modulation of angiogenic factor production by Tlymphocytes. Lasers Surg Med. 2000;26(4):357-363.
2. Schindl A, Schindl M, Schindl L, Jurecka W,
Honigsmann H, Breier F. Increased dermal angiogenesis after low-intensity laser therapy for a chronic radiation ulcer determined by a video measuring system.
J Am Acad Dermatol. 1999;40:481-484.
3. Romanos GE, Pelekanos S, Strub JR. Effects of
Nd:YAG laser on wound healing processes: clinical
and immunohistochemical findings in rat skin. Lasers
Surg Med. 1995;16(4):368-379.
4. Stadler I, Evans R, Kolb B, et al. In vitro effects of
low-level laser irradiation at 660 nm on peripheral blood
lymphocytes. Lasers Surg Med. 2000;27(3):255-256.
5. Dobke MK, DiBernardo B, Thompson C, Usal H.
Assessment of biomechanical skin properties: is
cellulitic skin different? Aesthetic Surg 1. 2002;May/
June:260-266.
6. LaTrenta GS, Mick SL. Endermologie after
external ultrasound-assisted lipoplasty (EUAL) versus
EUAL alone. Aesthetic Surg 1. 2001;March/April:128136.
Commentary:
The problem addressed in this article is a most
difficult problem to tackle as shown by previous
literature. There is no consensus on the etiology of the
problem, how it manifests, or even how to photograph
it well. A decade ago Mary Dyson, PhD, hypothesized
that it would be possible to define or at least measure
cellulite with ultrasound techniques. This has not
happened. In the face of such an elusive dysmorphea,
it is no wonder that therapeutic techniques abound that
are often successful in the eye of the beholder.
The skin firming creams containing aminophyllin
derivatives were popular in the last decade. They
The American Journal of Cosmetic Surgery
Vol. 22, No.4, 2005
seemed to work by dehydrating the skin and producing
a smoother, albeit temporary, appearance. Today
researchers are working on the vertical fiber theory
which asserts that undulation is created in the skin by
varying lengths of fibrous septae, as the superficial
fascia traverses from deep fascia to skin. Along with
this is the herniating fat theory in which tufts of fat
allegedly protrude into or elevate the dennis (depending upon the author) leading to the variations of fascial
insertions.
The treatments in vogue today appear to deliver heat
to the underlying tissue in an attempt to (a) reduce
vascularity, or (b)"melt" fat away, or (c) shrink the
"fibrous septae" of the fascia to a uniform length.
Boyce et al. have made a serious attempt to scientifically evaluate a device which delivers infrared light,
radiofrequency energy, and suction to the skin in an
attempt to accomplish some or all of these therapeutic
237
postulates. The danger in this kind of research is getting
too close to the material and endorsing patient
enthusiasm which may reflect a placebo effect.
Terms such as "skin tone" that has never been
adequately defined let alone demonstrated further
confuse evaluation of results. Photography is replete
with difficulty in reproduction as is thigh measurement
and both of the subjects in this study appear to have
had small thigh circumferences to begin with.
In conclusion, this is an excellent paper with which
to review the subject matter and the difficulty of treating
a common and vexing problem. I believe further
experience in the field and additional studies with larger
patient samples will yield insight into how to address
this problem.
Edward Lack, MD
Chicago, Illinois
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