Análise termográfica comparativa pós-cryolipólise

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Comparative thermographic analysis at pre- and
postcryolipolysis treatment: Clinical case report
Paloma de S. Oliveira BS1 | Mylana A. de Carvalho BS2 | Mariana A. Braga BS3 |
M�arcia M. P. Leite MS1 | Alena P. Medrado PhD1
1Federal University of Bahia, Salvador, Brazil
2Technological Superior Course in Aesthetic
and Cosmetic of Unijorge, Salvador, Brazil
3Jorge Amado University Center, Salvador,
Brazil
Correspondence
Alena Ribeiro Alves Peixoto Medrado,
Federal University of Bahia, Salvador, Brazil.
Email: alenamedrado@hotmail.com
Summary
Introduction: Although the exact cryolipolysis mechanisms on adipose tissue remain
unknown, the current literature indicates that it may occur a crystallization followed
by an ischemic reaction which generates an inflammatory process.
Objective: To evaluate thermographically, the tissue’s circulatory pattern of a
patient submitted to the cryolipolysis technique and the beginning of the inflamma-
tory process, through variations of temperature gradients and the evaluation of the
pains degree of the patient in these same moments.
Methods: A descriptive study, of an interventional case report, performed in an 18-
year-old patient who had clearly visible fat in the lower abdomen area, with a skin
fold greater than 2 centimeters and body mass index ≤ 30 kg/m2.
Results: Comparing the maximum temperatures showed on the last thermography
with the pre-application image, an increase of 0.4°C was observed, which is sugges-
tive of abnormality. Regarding the minimum temperatures verified, there was a sig-
nificative decrease in the temperature with the procedure, which was observed on
the last 5 minutes (DT = 9.8°C). However, in 48 hour, the minimum temperature
began to recover (DT = 0.3°C).
Conclusion: The observed data indicate that there was a significant decrease in the
temperature during the cooling phase, whereas in the recovery phase, the inverse
was found.
K E YWORD S
abdominal fat, adipose tissue, Cryolipolysis, inflammation, thermography
1 | INTRODUCTION
Cryolipolysis is a noninvasive therapeutic resource which consists in
the reduction of localized fat through the exposure to low degree
temperatures. This procedure is performed through goblet-shaped
applicator directed to the target area with two cooling panels. To
extract heat in a specific temperature, the tissue is pulled into the
piece, under moderate vacuum, by means of a combined suction sys-
tem, exposing it to a sequence of high (60°C) and low (�10°C) tem-
perature, during a predetermined time period.1-3
In general, the expected side effects on cryolipolysis are pain,
temporary erythema, ecchymosis, and temporary numbness that
can be observed in two-third of the patients and usually disappear
within 14 days after the treatment.1,4 The paradoxical adipose
hyperplasia is a rare side effect, most commonly reported in men,
in which additional fat grows at the treatment site a few months
after the procedure.5 The pathogenesis of such alteration is
unknown, and possible treatments are liposuction or abdomino-
plasty, because no spontaneous resolution has been reported until
the present moment.1
Accepted: 2 March 2018
DOI: 10.1111/jocd.12546
J Cosmet Dermatol. 2018;1–6. wileyonlinelibrary.com/journal/jocd © 2018 Wiley Periodicals, Inc. | 1
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Alterations in the subcutaneous adipocytes are not visible imme-
diately after the treatment. Studies argue that the mechanism of
action of this therapeutic modality comes from the freezing of the
adipose tissue followed by an ischemic injury that results in an
inflammatory process.1This inflammatory process is initiated in
24-48 hours due to the stimulation of a possible adipocyte apopto-
sis. From 14 days onwards, the adipocytes become surrounded by
neutrophils, histiocytes, lymphocytes, and other mononuclear cells.
About 14-30 days, defense cells surround, phagocyte, and digest the
lipid cells, as part of the body’s natural response to injury.1 At this
time, the inflammatory process decreases, and the volume of fat in
the treated area is gradually decreased.1,6,7 Based on the foregoing,
a possible increase in the circulatory pattern may occur, a fact that
could generate an increase in the temperature in the treated area.
In this context, the infrared thermography, which is a noninva-
sive, contactless, and painless image detection examination that
maps the patient’s body and converts the detected infrared emis-
sions from each region into temperature, becomes a timely resource
to verify the thermic pattern in the tissue that was submitted to cry-
olipolysis. This technique does not provide information about the
morphological characteristics, but rather the functional, thermal, and
vascular alterations of the tissue.8 For this reason, it is widely
applied in the diagnosis of diverse diseases such as dermatitis, vascu-
lar dysfunction, sensory nerves damage, inflammatory processes, and
the monitoring of breast cancer.9
Facing the inflammatory process, through the capitation of infra-
red image, it would be possible to evaluate in loco the temperature
oscillation in the treated area and thus infer if the technique may
exert any negative impact on the microcirculation or exacerbate the
inflammation.
It is known that the greater the degree of inflammation more will
be demanded of the tissues defense mechanisms to return to its
normality. In this sense, the infrared thermography technique will
allow to measure indirectly the degree of inflammation through the
variation of the determined values by the temperature coefficient.
For this reason, the present case report aimed to evaluate thermo-
graphically the circulatory pattern of a patient’s tissue submitted to
the cryolipolysis technique and the beginning of the inflammatory
process, through the variations of temperature gradients and to eval-
uate the patient’s degree of pain in these moments.
2 | MATERIALS AND METHODS
This study describes the case report of a patient submitted to the
cryolipolysis technique, performed in the location of a dermatofunc-
tional physiotherapy clinic located in the city of Salvador, Bahia in
2017, with the approval of the Research Ethics Committee/
Fundac�~aoBahiana para Desenvolvimento das Ciências, resolution
numbered 2.361.588. The adopted inclusion criteria for this study
were as follows: being female, over 18 years old, with clearly visible
fat located on the inferior abdomen, skinfold above 2 cm and body
mass index (BMI) ≤30 kg/m2.
It was excluded from the research patients who had been
through surgical procedures in the area in the last 12 months or
those submitted to noninvasive physiotherapy in the last 6 months,
including cryolipolysis procedure. In addition, individuals with a
known history cryoglobulinemia, cold urticaria, paroxysmal cold
haemoglobinuria, umbilical hernia, obesity (BMI ≥30 kg/m²), preg-
nancy, tissue flaccidity, tissue discontinuity, infectious processes or
metabolic alterations of any nature were refused, as such conditions
represent formal contraindications for performing cryolipolysis.
2.1 | case report
A 23-year-old female patient attended the physiotherapy service,
complaining of localized fat in the lower abdomen. The research
began after the previous clarification for the participant about the
development of the work, the objectives, the benefits, and the possi-
ble side effects, which could come temporarily from this type of
treatment, and later signing of the term of free and informed con-
sent.
The patient was submitted to an evaluation that included filling
out a standard form of anamnesis, through which possible con-
traindications were questioned. Inspectionwas performed to verify
the presence of lesions, striations, irritation, edema or scars, and pal-
pation to evaluate the presence of tissue flaccidity, fibrosis or any
other sign that contraindicated the performance of the technique at
that time. In addition, abdominal circumference, adipometry (22 cm)
and height (1 m and 70 cm) measurements, weighing (70.2 kg), body
mass index (BMI: 24.29 kg/m2) and percentage of body fat (BF:
29.03%), and photodocumentation.
The perimetric points measured were 5 cm above the umbilical
scar, in the middle of the umbilical scar and 5 cm below it, finding as
respective values, 84, 90, and 95 cm. The measurement point of the
skin fold was 3 cm to the side and 1 cm below the umbilical scar,
and this was measured vertically. To calculate body mass index and
fat percentage, the following formulas were used: BMI = (Height)²/
Weight and BF = (1.20 9 BMI) + (0.23 9 age) � (10.8 9 sex) � 5.4,
respectively. The formula for the percentage of body fat is specific
for each gender, so in men, the formula variable is replaced by 1 and
women by 0. The tools used in the evaluations were as follows: a
clinical adipometer (Sanny, S~ao Paulo, Brazil), a common tape
measure and an electronic digital scale (Camry EB9013, S~ao Paulo,
Brazil).
The patient was placed in an orthostatic position, in a room with
a temperature of 16°C to obtain the thermographic photographs.
The infrared camera used to evaluate the local circulatory pattern
was a FLIR-E brand (Victoria, Australia) with 320 9 240 pixels reso-
lution and 60 Hz image frequency. The first thermographic image,
used for basal control, was removed after 15 minutes of acclimatiza-
tion, and then the intervention was started. To obtain a standard of
the images, the height of the camera relative to the ground and its
distance from the patient was established in 1 m. The adopted
parameters for the treatment of Cryolipolysis are described in
Table 1.
2 | OLIVEIRA ET AL.
For the precise applicators positioning, the localized fat ovoid
area was delineated with a marker pen with the patient in the ortho-
static position. The antifreeze membrane specific to cryolipolysis,
which description is in Table 1, was placed over the marked skin to
facilitate the full coupling and to protect the patient’s tissue that
was between the opposite plates of the applicator. The room tem-
perature was maintained below 16°C. Immediately after the 50 min-
utes of the procedure, a new thermographic photography was made,
in orthostasis, following the same standard for the positioning of legs
and arms of the basal thermography.
To evaluate the discomfort and improve the treated area’s
appearance, the procedure was finalized with an activating mas-
sage for 5 minutes using deep sliding movements, followed by
kneading.
The last thermography was made 48 hour after the application
was ended. The patient was then instructed to not use anti-inflam-
matory drugs before the first 2 months of the procedure and to
avoid changing her lifestyle during the study period to maintain her
weight approximately constant in comparison with the initial weigh-
ing. During the procedure and on follow-up days for the collection
of thermographic photographs, the visual analogue scale (VAS) was
used to assess the intensity of the patient’s pain, if the pain was pre-
sent.
The measured temperatures and respective mean values
between the maximum and minimum temperature were obtained,
and normality and abnormality criteria adopted were based on the
study of Dibenedetto et al10 which established the clinical abnormal-
ity pattern according to the temperature variation, described in
Table 2. In this way, it is possible to determine whether there was a
significant temperature change in each period corresponding to the
studied area.
3 | RESULTS
3.1 | Perception of pain
Through the analysis of the indices indicated by the patient in the
Analog Pain Scale, it was observed that in the immediate period that
preceded the cryolipolysis technique, the degree of pain was 8, in
comparison with the basal control obtained before the beginning of
this one. Five minutes after the end of the procedure, it decreased
to grade 4. Forty-eight hours after cryolipolysis, the final grade of
pain fell to 1.
3.2 | Thermal oscillation pattern
The images were analyzed using a temperature ranging from 36.0°C
to 27.0°C, with a mean temperature of 28.5°C, following the values
of the Continuous Colorimetric Scale, in which the colors white, red,
yellow, green, blue, purple, and black, represented, respectively, a
decreasing range of temperature areas, from the hottest to the cold-
est.11
The quantitative analysis of Figure 1(A,B), used for basal control,
according to the area, shape, symmetry, and temperature distribution
showed an asymmetric pattern due to the presence of fat located in
the lower abdomen and showed a higher temperature in Sp2 (32.
2°C).
Five minutes after procedure ending (Figures 2A, B), the thermal
pattern showed that the temperature in the application area was not
uniform. The quantitative analysis showed that the central zone
(Sp2) presented a slight temperature increase (26.3°C) when com-
pared to the other areas and the peripheral zone (Sp4) maintained
the lower temperature of 21.8°C, evidencing a thermal variation (DT)
compared with the basal photo of 9.8°C.
The thermographic photography 48 hour after the procedure
ending (Figure 3A, B) showed that both qualitative and quantitative
analyses presented a change in the exhibition pattern. The central
temperature reached its highest value (32.6°C).
Table 3 exposes the maximum, medium, and minimal tempera-
tures that were obtained through the analysis of the reference
points Sp1, Sp2, and Sp4. Correlating the maximum temperatures
presented in the last thermography when compared to the image
before the application, it was possible to observe an increase of
0.4°C, which is suggestive of abnormality. Regarding the minimum
temperatures found, it is evident that there was a decrease in the
temperature with the procedure, it was preserved in the last 5 min-
utes (DT = 9.8°C). However, after 48 hours, a minimum temperature
started to reestablish itself (DT).
TABLE 1 Parameters for Cryolipolysis treatment
Equipment Fusiomed- Biotec Italia
Parameter LipoShok- combined suction
Temperature �8° to �10° in the equipment’s monitor,
regulated by the equipment itself from
the skinfold.
Time of application 50 minutes
Negative pressure Approximately 50 mm Hg
Applicator size Medium-size maniple
Width: 14.8 cm
Height: 5 cm
Depth: 6 cm
Treatment surface: 444 cm³
Room temperature 16°
Manta Iceprotection antifreeze membrane, Brazil
Blanket’s grammage
and size
130 g/30 9 38 cm
TABLE 2 Clinical abnormalities according to the temperature
variation
Thermal variation Normality standard
<0.24°C Normal
>0.30°C Suggestive of abnormality
>0.60°C Strongly suggested
1.0°C Significant abnormality
Dibenedetto et al. (2002)10.
OLIVEIRA ET AL. | 3
4 | DISCUSSION
By means of thermography, which reflects the microcirculatory
dynamics of the skin surface through infrared radiation,12 it became
possible to analyze quantitatively the thermic oscillations obtained in
this study. The data observed here indicated that the subdermal
temperature decreased during the cooling phase, mainly in the final
minutes, and gradually recovered over the reperfusion-recovery
phase. These results suggest that this temperature variation occurred
because the subdermal tissue was subjected to rapid machine-
induced hypothermia (temperatures ranging from �8 to �10°C).
At the end of the procedure, the temperature started to recover
because there was no longer the active effect of the machine, and
the tissue was subject to the ambient temperature, once the body is
capable to return to homeostasis. This aspect was reported in the
study by Sasaki et al13 in which the tissue temperaturesof 6 treated
individuals had a reduction at the beginning of the refrigeration
cycle, and after removing the applicator and performing the massage,
the skin maintained itself firm and cold for 5 minutes. Within sixty
minutes after treatment, the temperature was gradually returning to
normal. In the present study, in the recovery phase, the temperature
increased even more than the pretreatment. It is likely that the onset
of the inflammatory process contributed to this change because of
increased heat generation as a result of increased local metabolism.
According to Haddad, skin temperature is established as a func-
tion of blood flow and is usually controlled by the neurovegetative
nervous system. In this clinical trial, the author states that asymmet-
ric patterns equal to or greater than 0.3°C usually occur when there
is a sympathetic change or presence of traumatic injury, local inflam-
matory or vascular changes.12 As the research problem of the pre-
sent study was limited to the investigation of the thermal
oscillations triggered by the initial inflammatory process, the values
of temperature variation were limited only to those measured after
immediate intervention and 48 hour postintervention. This analysis
of the initial periods is unpublished in the literature. Nevertheless,
prospective studies to establish a longer patients’ follow up period
could broaden understanding and increase knowledge about local
metabolism under the influence of cryolipolysis.
Regarding the treated area microcirculation, despite there was a
significative temperature variation, it was not possible to verify
whether the cryolipolysis technique also directly affected the adipo-
cytes metabolism. Studies have shown that no relevant changes in
liver function or changes in serum lipid levels have been reported
during and after cryolipolysis.14,15 Although this aspect has not been
verified in this case report, this information is important because,
according to Ingargiola et al16 there is a possibility that patients may
be exposed to additional risks, particularly cardiovascular disorders,
such as embolism and formation of fat streaks or atheromatous pla-
ques.
Studies have shown a good impact of cryolipolysis in the reduc-
tion of localized adiposity. In a clinical study in 2009, after 2 months
of a single treatment, 10 patients exhibited a 20.4% reduction in the
thickness of the flank subcutaneous fat, and after 6 months, they
(A)
(B)
F IGURE 1 A, Basal thermography of the lower abdomen area. B,
Reference points from the thermal gradients
(A)
(B)
F IGURE 2 A, Thermography of the low abdomen area 5 minutes
after the procedure ending. B, Reference points from the thermal
gradients
4 | OLIVEIRA ET AL.
showed a reduction of 25.5%, as measured by ultrasound.4 Another
retrospective study that evaluated 518 patients through gauge mea-
surements, evidenced after 3 months of treatment a reduction up to
23% in the thickness of fat layer. Abdomen, back, and flank were
the areas where treatment was most effective.17 Therefore, it was
decided to perform the present study in the abdomen region,
because in its area, the technique has good efficacy, as it concen-
trates a large amount of adipose tissue and is a much-sought treat-
ment area.
Although the treatment in question generates pain during the
application, it has been well tolerated by the patients. In the study
by Wanitphakdeedechaet al2 pain was also measured using the
visual analogue scale of 0-10. Painful intra- and postprocedural sen-
sations were described as mild to moderate by most patients, with
an average score of 7 ranging from 1-10. In the present study, the
patient reported pain grade 8, but at the end of the procedure, the
pain decreases to 4. It is known that the perception of pain is a sub-
jective data that can undergo temporal, hormonal, emotional, and
psychosocial influence. The fact that the patient reported an intense
and moderate degree of pain in the first moments after performing
the technique seems to suggest that these periods of time are more
critical for patients’ perception of pain sensation.
Due to few side effects and the expressive reduction of localized
adiposity, the satisfaction rate of patients reported in studies is
always high. In the study by Dierickx et al17 improvements were
seen in 86% of treated individuals, and in 73%, the patient satisfac-
tion rate was higher than when other noninvasive technologies that
aimed lipolysis were used.17 The patient treated in this study
reported satisfaction level 9 on a scale of 0-10, and when asked if
she would repeat the procedure or indicate it to a friend, both
answers were affirmative.
5 | CONCLUSION
Through the comparative analysis of the thermographic images
before and after application, it became possible to identify the tem-
perature oscillation pattern due to the cryolipolysis technique.
There was a significant decrease in temperature during the cooling
phase, which was gradually re-established at the end of the treat-
ment and after 48 hours. In the recovery phase, an increase in
temperature was observed; being an indication of a probable begin-
ning of the inflammatory process, corroborating with the studies
that try to clarify the mechanism of action of this therapeutic pro-
cedure.
Regarding the pain reported by the patient during the study, it
was seen that the biggest complaint was in the immediate period
to the procedure, due to the suction pressure exerted by the mani-
ple. Nevertheless, over time, the tissue was adapting to the noci-
ceptive stimuli and by the end of the thermographic capture the
patient only referred a mild discomfort, which contributes to the
success of the technique. We suggest the continuation and pro-
gression of new research to guarantee a better foundation and per-
petuation of the results obtained with this noninvasive therapeutic
resource.
ORCID
Paloma de S. Oliveira http://orcid.org/0000-0002-8070-2744
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F IGURE 3 A, Thermography of the low abdomen area 48 hours
after the procedure ending. B, Reference points from the thermal
gradients
TABLE 3 Descriptive analysis of temperature variations
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Initial
temperature
Temperature
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Temperature
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Max 32.2°C 26.3°C 5.9°C 32.6°C 0.4°C
Med.31.9°C 24.5°C 7.4°C 31.7°C �0.2°C
Min.31.6°C 21.8°C 9.8°C 31.3°C 0.3°C
OLIVEIRA ET AL. | 5
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How to cite this article: Oliveira PDS, Carvalho MAD, Braga
MA, Leite MMP, Medrado AP. Comparative thermographic
analysis at pre- and postcryolipolysis treatment: Clinical case
report. J Cosmet Dermatol. 2018;00:1–6. https://doi.org/
10.1111/jocd.12546
6 | OLIVEIRA ET AL.
https://doi.org/10.1111/jocd.12546
https://doi.org/10.1111/jocd.12546