1. History of Acoustic

Acoustics, the science of sound, starts as far back as Pythagoras in the 6th century BC, who wrote on the mathematical properties of stringed instruments and represented the harmonic overtone series on a string.

Pythagoras (570-490 BC) Aristotle (384-322 BC)

Aristotle understood that sound consists of contraction and expansion of the air and gave the best expression of the nature of the wave motion. In the 16-17th centuries, Aristotle’s approach was theoretically developed by Galileo Galilei and Marin Mersenne. Newton (1642–1727) gave the physical understanding of acoustical processes by experimental measurements of the speed of sound and the theoretical formulization of a relationship for wave velocity in solids.

In the 18-19th centuries, the application of new techniques of calculus and new approaches in mathematics made the major contribution in acoustic theory. The major figures of mathematical acoustics were Helmholtz in Germany, who developed the field of physiological acoustics, and Lord Rayleigh in England, who described his theoretical approach in his main work, The Theory of Sound (1877). Also, Wheatstone, Ohm, and Henry showed the physical analogy between electricity and acoustics.

In 1880, brothers, Jacques and Pierre Curie discovered the piezoelectric acoustic effect. They found that pressure of an alternate current polarizes certain non-conducting crystals (ex. quartz). These crystals contract and expand at the same frequency at which the current changes polarity. The sound field generated by these crystals, in turn, makes the molecules vibrate and oscillate in the sound field to produce an ultrasound effect. The modern ultrasound equipment use a widely-known synthetic crystal called a plumbium zirconium titanate (PZT) crystal. The piezoelectricity (from the Greek word meaning “to press”) was an important scientific discovery.

In 1893, Sir Francis Galton constructed a whistle that produced ultrasound. The first technological application of ultrasound was an attempt to detect icebergs by Paul Langevin in 1917. Paul Langevin, a student of Pierre Curie's, found that inverse piezoelectricity causes

piezoelectric quartz in alternating fields to emit high-frequency sound waves. This led to the use of quartz in a variety of applications including the first practical transducer (an electronic device that converts energy from one form to another) for ultrasonic pulse-echo detection, which was used to detect submarines and explore the ocean's floor.

Ultrasound is used in many different fields. Ultrasound devices operate with frequencies from 20 kilohertz up to several gigahertzes, and detect objects and measure distances. Ultrasonic imaging (sonography) is used in human and veterinary medicine. Also, ultrasound is used to detect invisible flaws in non-destructive testing of products and structures. Industrially, ultrasound is used for cleaning and mixing, and for accelerating chemical processes.

Application of ultrasound to produce an effect on human tissue must range from 0.7 to 5.0 MHz

2. Sound

What is sound? Sound is a form of energy, just like electricity and light. Sound is made when air molecules vibrate and move in a pattern called waves, or sound waves. Sound waves are caused by the vibration of objects and radiate outward from their source in all directions. The vibrating object compresses the surrounding air molecules (squeezing them closer together) and then rarefies them (pulling them further apart). This vibration produces fluctuations in air pressure that travels outward from the object. When these changes in air pressure vibrate your eardrum, nerve signals are sent to your brain and are interpreted as sound.

Also, mechanical vibrations perceived as sound travel through all forms of matter: gases, liquids, solids, and plasmas. Solids and liquids consist of molecules that are held together by elastic forces, which behave like rubber bands connecting each molecule to each of its nearest neighbors. If one molecule is set in vibration, then it will cause its immediate neighbors to vibrate, and in turn their neighbors, and so on until the vibration has propagated throughout the entire material. This sound wave or sound energy is transmitted from one molecule to the next. A sound wave cannot travel by itself. It needs a medium for transmission (solid, liquid, gas). The matter that supports the sound is called the medium.

The word "acoustic" is derived from the Greek, word ἀκουστικός (akoustikos), meaning "of or for hearing, ready to hear." The Latin term “sonic” used to be a synonym for acoustics and later became a branch of acoustics.

Frequencies above and below the audible range are called "ultrasonic" and "infrasonic," respectively.

As shown in the image above, the audible frequency range for humans is typically between about 20 Hz and 20,000 Hz (20 kHz). Ultrasound is, therefore, not separated from "normal" (audible) sound based on differences in physical properties, the only difference is that humans cannot hear it. Although the upper frequency limit of the audible range varies from person to person, it is approximately 20 kilohertz (20,000 hertz) in healthy, young adults. This limit in humans is due to limitations of the middle ear, which acts as a low-pass filter. Ultrasonic hearing can occur if ultrasound is fed directly into the skull bone and reaches the cochlea through bone conduction without passing through the middle ear. Children can hear some high-pitched sounds that older adults cannot hear, because the upper limit pitch of hearing tends to become lower with age.

Many animals, such as dogs, cats, dolphins, bats, and mice have an upper frequency limit that is higher than that of the human ear and, thus, can hear ultrasound.

Bats use ultrasounds to navigate in the darkness.

Bats use a variety of ultrasonic ranging (echolocation) techniques to detect their prey. They can detect frequencies beyond 100 kHz.

Many insects have good ultrasonic hearing and most of these are nocturnal insects listening for echolocating bats. This includes many groups of moths, beetles, and praying mantis. Upon hearing a bat, the insects will make evasive maneuvers to escape being caught by the bat.

Dogs can hear sound at higher frequencies than humans. For example, many dog whistles emit sound in the upper audible range of humans, but some, such as the silent whistle, emit ultrasound at a frequency in the range 18–22 kHz.

Whales and dolphins can hear ultrasound and use ultrasonic sounds in their navigational system (biosonar) to orient and capture prey. Porpoises have the highest known upper hearing limit, at around 160 kHz.

3. Physics of Sound and Ultrasound Waves

The simplest kind of sound wave is a sine wave. According to Wikipedia: “The sine wave or sinusoid is a mathematical curve, which describes a smooth repetitive oscillation.” The sine wave is important in physics because it retains its wave shape when added to another sine wave of the same frequency. Generally, the shape of the acoustic wave is much more complicated than the sine wave. The diagram below is used to show the simplest model of a wave to explain physical characteristics.

Wavelength (ƛ)

One oscillation(Frequency is number of oscillations per second)

The most important characteristics of sine acoustic waves are: frequency, wavelength, amplitude and speed.

Frequency is measured in number of cycles or waves passing every second. It is measured in units called hertz (Hz). Frequency is usually denoted in literature by a Latin letter f or by the Greek letter ν [nu].

Wavelength is a distance between two nearest peaks or two nearest troughs. It is measured in meters (m). Wavelength is usually denoted by the Greek letter λ [lambda].

Amplitude is the wave’s height. It is the distance from the midline of a wave to the top of a crest or to the bottom of a trough.

Wave speed (denoted as c), wavelength λ and frequency ν of the sine wave are related in the following equation:

c (m/s) = λ (m) · ν (Hz)

Wave is an energy transport phenomenon when wave transports energy along a medium without transporting matter. The amount of energy E (denoted as J) carried by a wave is related to the amplitude A of the wave. A high-energy wave is characterized by high amplitude; a low-energy

wave is characterized by low amplitude. The energy transported by a wave is directly proportional to the power P (denoted as W) or square of the amplitude of the wave.

E(J) P(W) = A2 ( means proportional). Energy contained within a wave is decreased as it travels through the matter (in this case, tissue). Different things can happen. The wave energy could be absorbed, reflected or transmitted by the tissue.

The possibility of a sound wave to pass with various speeds through the tissue (medium) depends on the closeness of molecules that determines density of the medium. Closely-located molecules very quickly collide with each other and, thus, lose all energy of the incident wave in a short distance in the tissue depth. The energy of wave is absorbed and we do not hear a sound. For example, the sound quickly absorbs in the brick wall due to its high atomic density, while the sound very quickly propagates in the air because molecules of air are located far apart from each other.

As a result of absorption of energy, heat is formed. The electrons of atoms have a natural frequency at which they tend to vibrate. When a wave impinges upon an atom, the electrons will absorb the energy of the wave and transform it into vibration motion. During its vibration, the electrons interact with neighboring atoms to produce friction and convert its vibration energy into thermal energy. The reflection of sound follows the law "angle of incidence equals angle of reflection," sometimes called the law of reflection. The reflected waves can interfere with incident waves, producing patterns of constructive and destructive interference. This can lead to resonances called standing waves. It also means that the sound intensity near a hard surface is enhanced because the reflected wave adds to the incident wave, giving pressure amplitude that is twice as great in a thin "pressure zone" near the surface.

4. Ultrasound and Human Tissue

Ultrasound is widely used for diagnostics to visualize a condition of internal organs of the person, especially in an abdominal cavity and a pelvic cavity. Ultrasound is safe and simple in comparison with X-rays and magnetic and resonant tomography. Ultrasound energy is non-ionizing radiation and, therefore, its use does not impose the hazards, such as cancer production and chromosome breakage attributed to ionizing radiation. Ultrasound’s ability to break off membranes of biological cells is very popular (i.e., if necessary, to separate a cell from enzymes or destroy fatty cells.) Besides its wide use in diagnostic purposes, ultrasound is applied in medicine as a remedy. Ultrasound acts as an anti-inflammatory, resorbable, analgesic,

antispasmodic, cavitation strengthening of permeability of skin. It can decrease pain and increase the healing effect.

The mechanical, heating and cavitation effects are the main effects of ultrasound in human tissue. The detailed explanation is shown below.

4.1 Mechanical Effect

Ultrasonic short waves penetrate into the skin, causing vibration of human cells and generating a gentle massage. The periodic changes of a cell’s volume increase the blood and lymph circulation.

One of the results of the mechanical effect is pain control. Vibration can help reduce some types of pain. When ultrasound is applied to painful areas, pain signals have been prevented from traveling to the central nervous system by inhibiting conductivity of nerve impulses.

A combination of mechanical, heating and healing powers of ultrasound not only reduces pain, but also helps muscles to be stretched and strengthened. Ultrasound causes tiny vibrations (microvibration) in the cells of the soft tissue. This mechanical effect prevents the formation of scarring of the tissue and in some instances, can break down already-formed keloids.

An intense ultrasonic field improves and increases tone of the skin tissue. It can promote stimulation of biological active agents, decreases spasms in muscles, reduces wrinkles, and helps to eliminate the serum from clogged pores by emulsifying them.

4.2 Warming Effect

Heat or a warming effect is the one of the main effects that is produced by ultrasound. It plays an important role in physical therapy. The action of ultrasound in human skin tissue cells and water molecules produces intensive fluctuation and friction on them. The result of these actions is heat production. It can increase temperature of skin tissues as deep as 2-3 mm. Generated heat stimulates the body’s circulatory system and skin cell activity. It also increases the function of metabolic rate and nutrient intake. Heat stimulating the nervous system also minimizes pain sensation, and softens and decreases tissue tension in the body. 4.3 Deep Heat

As was explained before, the heat generated by vibration of sound waves has the ability to appear all the way down to the molecular level. This is a benefit of ultrasound over a traditional hot pack, which cannot penetrate into deeper muscular or joint tissues. Ultrasound heads can target a variety of depths according to different frequencies (the longer the wavelength, the deeper it can penetrate). That gives a skilled therapist the ability to send heat exactly where she or he wants it to go. Some conditions that may benefit from this deeper heat include osteoarthritis and phantom limb pain.

Other benefits of ultrasonic deep heat stimulation are increased speed of the healing process and relaxed tension of muscle spasms. Generated by ultrasound, the deep heat can accelerate metabolism of tissue cells by the increased blood flow. Tissue cells get more receptive to body chemicals responsible for the healing.

Because of this, ultrasound’s healing benefits may be useful in treating surgical wounds and soft tissue lesions. Also, the deep heat can help relax a tense or strained muscle. This can help minimize muscle spasms often associated with tension or injury. Studies indicate that ultrasound therapy has the added benefit of increasing range of motion.

4.4 Cavitation

The main effect of ultrasound on the human body is cavitation. What is cavitation?

Cavitation (from Latin- cavitas emptiness) is a process of formation of cavities or void (cavitation bubbles) in liquid, sometimes filled with gas, steam or their mix. However, later research showed that the gases, which are found inside of created bubbles, play an important role in formation of a cavitational effect. The liquid always contains these gases, and when the local pressure decreases, those gases start to move intensely inside the specified bubbles.

The cavitation bubble can move from an area with low pressure to an area with high pressure, thus changing the sizes. It can pass some periods of increase and decrease. Moving with a stream to an area with higher pressure, the cavitation bubble can be broken off and, thus, emits a large amount of the energy capable of influencing any matter.

For example, this energy easily breaks a membrane of a fatty cell which releases fat substances into intercellular space. Oscillating bubbles make vigorous circulating movements in this area and make a "diluting" or liquefying effect in the fat substance. The effect of emulsification is very important for the lymphatic system, which has to eliminate fatty substances from the body.

As mentioned before, heat is a result of absorption of a wave’s energy. Because the cavitation bubbles can sharply contract and expand, gas temperature in bubbles fluctuate over a wide range. In some spots, the temperature during cavitation can rise up to 5000oK or 8540oF. It is necessary to also consider that the gases dissolved in liquid contain more oxygen than in air. Thus, those gases in cavitation bubbles are chemically more aggressive than atmospheric air. The result is an oxidizing reaction in substances.

Cavitation can be hydrodynamic and acoustic. Hydrodynamic cavitation results from decreasing pressure in liquid. This change can be caused by an increase in speed of its movement (i.e., behind the propeller of vessels).

Acoustic cavitation arises when acoustic waves of high intensity pass through liquid. The most noticeable principle of cavitation can be observed by boiling water or bottle stirring with sunflower oil when hollow bubbles form in liquid and "cavitation circulation" begins. These types of cavitation are used in esthetic medicine.

Cavitation is usually divided into two classes of behavior: inertial (or transient) cavitation and non-inertial cavitation.

Inertial cavitation is the process of rapidly-collapsed bubbles that produce a shockwave.

According to Encyclopedia Britannica, a shock wave is a strong pressure wave in water or other mediums produced by explosions of collapsed bubbles. The explosions of shock waves create a violent change in pressure, density, and temperature. Because of this, shock waves propagate in a manner different from that of ordinary acoustic waves. In particular, shock waves travel faster than sound, and their speed increases as the amplitude is raised; but the intensity of a shock wave also decreases faster than a sound wave, because some of the energy of the shock wave is converted to heat at the medium in which it travels. Inertial cavitation occurs in nature in the strikes of mantis shrimps and pistol shrimps. In man-made objects, it can occur in control valves, pumps, propellers, and impellers.

The non-inertial cavitation forms when the acoustic field stimulates small bubbles to oscillate in a liquid. These bubbles do not collapse easily. This form of cavitation causes significantly less erosion than inertial cavitation, and is often used for the cleaning of delicate materials. Acoustic streaming, heat production, and radiation forces on surrounding particles can be caused by the motion of the bubbles in non-inertial cavitation.

4.5 General Cavitation Damage Effects

Significant damage of moving parts of different machines (turbines or propellers) could be formed by cavitation. When the cavitation bubbles collapse, they force energetic liquid into very small volumes. These movements create the spots of high temperature, emitting shock waves and generating a source of noise. Also, collapse of a cavity can erode metals, such as steel, to produce the pitting or chipping and great wear of components over time. Concentrated energy of ultrasound in very small volumes can cause such phenomena, as a rupture of chemical bonds of macromolecules, initiation of chemical reactions, an erosion of surfaces of solid bodies and a luminescence. In industry, the principle of cavitation is widely used to homogenize (mix) and break down suspended particles in a liquid.

The similar cavitation effects can be observed in biological objects and, in particular, can be utilized for biomedical applications in the body.

5. Biomedical Application of Cavitation.

Detailed studying and medical tests of the ultrasound waves with a frequency of 35-45 KHZ in the biological objects showed and confirmed the safety of the biomedical application of cavitation.

The difference of pressure forms micro bubbles which violently blow up and destroy surrounding solid bodies, including fatty deposits.

Also, in the field of medicine, cavitation is applied to removal of kidney stones (lithotripsy) which are crushed by micro bubbles. Ultrasound is sometimes used to increase bone formation, for instance post-surgical applications. It has been proven that cavitation can be used for movement of big molecules into biological cells.

A detailed explanation of the cavitation process and possible results that can affect biological cells follows.

The cavitation mechanism occurs when there is a pressure gradient over a bubble. These bubbles are usually smaller than the acoustic wavelength of the ultrasound source. When two bubbles are close to each other and a force is exerted on the first bubble, energy is scattered from the first bubble and affects the second bubble. The scattered energy from that bubble also affects the first bubble. This scattered acoustic wave may affect smaller particles, such as biological cells. The result of the application of cavitation in the biological objects is heat generation, micro streaming and shock waves.

5.1 Microstreaming

A vigorous circulatory motion of oscillating bubbles in a sound field produces micro streaming. These oscillating bubbles can be pushed by an acoustic force of the traveling wave. The fluid velocity is greatest near the bubble surface and can be changed with respect to distance from the bubble surface (velocity decreases when distance from the bubble increases) and creates the differences in forces or velocity gradient. This unequal distribution of forces from the fluid onto the exterior of the cell results in shearing stresses or forces that are likely to distort and tear the cell membrane. The exposure of a high-stress field produces significant damage in a cell.

5.2 Shock Waves

As mentioned before, the shock waves are produced when a bubble is exposed to high acoustic pressures in conjunction with higher amplitudes and oscillations in bubble volume. The bubble contraction from minimum to maximum produces rapid changes in pressure of surrounding fluid. This fluid gains momentum of pressure and bubbles are not able to resist and rapidly collapse. The shock in the surrounding fluid will propagate outward. If a biological cell or tissue is exposed to the shock wave, it will experience much stress. This stress may be enough to damage exposed biological materials.

5.3 Heat

During cavitation, the ultrasound kinetic energy can also be converted into heat if it is absorbed by tissue. When the cavitation bubbles grow to the critical size, they collapse violently under the pressure, and these implosions produce large, local pressure and temperature. During cavitation, generated temperature in tissue between 40oC to 45oC has the same physiological effects as heat generated by ultrasound.

6. Effects of Cavitation in the Aesthetic Field

Ultrasound Cavitation, also known as Liposuction Cavitation or Fat Cavitation, is a relatively new aesthetic treatment of reshaping the body by eliminating fat cells under the skin. Using leading-edge technology, it converts fat cells into fluid, which can then be naturally drained by the body’s own natural filtration system.

The most important physiological effects of cavitation are:

The effect of cavitation on fatty tissues leading to fragmented, emulsified and converted fat into the blood lipids (triglycerides).

Removal of emulsified fat by means of natural metabolic process.

The low-frequency ultrasonic waves pass through the skin and reach subdermis fatty tissue and accumulate enough energy to destroy a membrane of a fat cell. There is a selective destruction of fat without damage to other nearby tissues, such as small arteries, veins, or muscles.

Cavitation of fatty tissues happens under the influence of a certain frequency range (35-45 KHZ). With this frequency, the maximum quantity of bubbles of the optimum size is formed. Increasing in size, they dilute fat and force it out from fat cells. A collapse of bubbles in fatty tissue releases a large amount of energy in the form of micro explosion. This micro explosion damages cellular membranes of the fat cells. The most damage occurs where there is the greatest tension of fat cell membranes, especially for the cells most filled with fat. The emulsified fat, under the action of heat and ultrasonic cavitation, is converted to triglycerides. Triglycerides, known as blood lipid, usually derive from glycerol (water-soluble substance) and three fatty acids.

The released triglycerides of the fat cells are removed from intercellular space by means of natural metabolic processes. 90% of products of the emulsified fat are removed through the lymphatic system and 10% are absorbed in the blood stream where released triglycerides will be transformed to glucose molecules.

At the time of cavitation, other cells and tissues (muscular fibrilla, cells of epidermis, an endothelial of vessels, etc.) are not damaged due to their strength and sufficient coefficient of elasticity. Much scientific research proves efficiency and safety of cavitation procedures.

“Ultra- Focus” devices allow using cavitation and radiofrequency (RF) procedures in one treatment. Destruction of fat and strengthening of the tissues are the main goals to satisfy all

clients’ demands. It also helps to eliminate lipomas (fatty bumps) that often occur after invasive liposuction and make skin even and smooth. The influence of radio frequency accelerates the process of regeneration, promotes removal of liquids and toxins, and eliminates symptoms of cellulite. The tissue becomes more elastic and fresh without an effect of the "blown-off" flabby skin.

Ultrasonic cavitation is becoming a leading method in the field of esthetic medicine for reduction and destruction of the fatty deposits and cellulite.

The technology and devices used for ultrasonic cavitation are becoming very popular due to availability, simplicity of use, and reasonable prices.

7. Contraindication to Ultrasonic Cavitation

Even though studies have proven the treatment safe, cavitation is not to be used on clients with the following health issues:

Compromised liver function, chronic diseases of the liver, HBV& HCV, and cirrhosis Any type of cancer, including cancer treatments, history of chemo-radiotherapy (requires

MD release paper) Active tuberculosis Psoriasis Epilepsy and convulsions Decreased circulation Infection/inflammation Pregnancy Central nervous system disorder Implants (metal, plastic), pacemakers Thrombophlebitis Uncontrolled bleeding or blood-thinning medication (Aspirin, Coumadin)

When using cavitation in esthetic medicine, it is important to not only consider the location and depth of cellulite and fatty deposits, but also the existence of anatomic formations which can be incidentally affected by ultrasound of low frequency. On the basis of this data, a choice of the power used during the procedure and frequency of the ultrasound device becomes very important. These characteristics are important as well as an assessment of the equipment existing in the market, different types of apparatus, the sizes and shapes of hand pieces, and so on.

Ultrasound energy is absorbed mostly in tissues with high collagen content (bone, cartilage, ligaments, scar tissue). Ultrasound at high intensity near boney areas can be painful because of high energy accumulation and a heating effect on the soft tissue as sound waves hit the bone. This is why the technician must follow these recommendations:

Avoid direct application on the anatomic formations such as eyes, kidneys, heart, sex organs and endocrine gland locations.

Avoid exposure of ultrasound on bones where there is thin skin to reduce pain sensation.

Do not treat areas where there are insignificant amounts of fat layers. Hold the hand piece perpendicular to the treated area Do not hold the sound hand piece in one place. Do not apply heavy pressure to the area of treatment.

8. Ultrasonic Cavitation for Body Sculpting

8.1 Chronology of the protocol of procedures:

1. Fill out the medical history of the patient. Obtain general information, medical questions list, and signature for informed consent.

2. Photo (if some lesions exist).3. Measurement of a fatty layer by a tape (an anthropometrical method).4. Putting ultrasonic gel on treated areas.5. Use the “Ultra-Focus” cavitation machine no more than 20 minutes on each zone.6. After cavitation treatment, use RF modality for eliminating a sagging effect (see

section 9). It also improves tone and toughness of the skin (20 minutes on each zone).

7. Remove remaining ultrasonic gel and clean treated area with a paper towel or gauze.

Additional Recommendations:

8. It is recommended to use a lymphatic drainage machine at the end of the procedure for acceleration of removal of disintegration products from treated area (20 minutes on each zone).

9. A facial treatment such as a calming mask and nutrient creams, lifting facial massage, or other facial treatments to significantly improve tone texture and strengthen skin.

10. It is more effective if the cavitation is combined with Fractional Laser, and an IPL skin tightening procedure.

The cavitation treatment does not require any special pretreatment. It starts with a circumference measurement of the targeted body area, continues with circular movements of the applicator over the treatment site, and ends with another circumference measurement (see section 8.3).

For better results of the patient, it is recommended to measure the treated area three times before the first treatment, in the middle of the treatments, and at the end of the treatments.

In certain cases, the treatment can start with a short RF application (around 5 minutes) to “warm up” the tissue that increases the effectiveness of cavitation.

The duration of the treatment can vary from 20 to 40 minutes, depending on the size of the area and the thickness of the fat layer.

It is suggested that the time and intensity of the first and second cavitation treatments has to be shorter (no longer than 20 minutes) and lower (power level at 4-5). That gives the client’s body a chance to adopt emulsified fat and help the lymphatic and urine systems to eliminate the fat. The duration of the following treatments can be longer than 30-40 minutes and in higher intensity. For the same reason, the time between treatments has to be at least 5 to 7 days apart, depending on the quantity and density of fat in the area. Six to twelve sessions are recommended in order to achieve a notable result, but further treatments may be needed to attain desired results. The new procedures package can start after 2 -3 months.

A fully-trained therapist will apply a specifically-designed hand piece to client’s skin. As mentioned before, the hand piece will transmit low-level ultrasound waves which consist of compression-expansion impulses that travel in high-speed cycles. This back and forth cycle then causes an infinite quantity of micro-cavities or micro-bubbles that gradually enlarge. This progressive enlargement finishes as micro-bubbles start to collide and implode, producing shock waves that favor emulsification and elimination of fat tissues (the process of cavitation). The cavitation causes the fat to emulsify, converting it into a substance that is then easily eliminated out of the body through the lymphatic and urinary systems.

The treatment does not require anesthesia. Most clients consider the procedure painless and comfortable. There may be, however, a slight discomfort due to the specific ringing noise spreading inside the patient’s body, but it poses no harm and disappears as soon as the skin breaks contact with the applicator. The patient may experience a little warmth during the treatment. If during treatment the area begins to feel hot for the client, apply more ultrasound gel to the site.

There is a slight possibility of mild side effects such as transient redness, excessive thirst, frequent urination and nausea immediately after the treatment, which can be resolved by drinking water. They are all short-term effects that disappear within a few hours.

The effects from cavitation are noticeable immediately after the first session. Research has shown that it can reduce up to 15 cm3 of fat that corresponds to volume loss in the waist, and from 3 to 5 cm after one session of cavitation. After removal of the disintegration products, accumulation of fat in the processed area becomes extremely difficult. The patient loses both volume and weight after the procedure. A large amount of fatty tissue has low density and is lightweight, which is why all of the clients notice volume loss. It is necessary to recommend to the client an active lifestyle and healthy nutrition and drinking habits. The results may vary with different tissue structures, treatment areas, age, metabolism, medications, and changes in hormones. Proper diet and increased physical activity will certainly improve and help to maintain the results. All patients have to follow a low calorie diet and drink plenty of fluids of at least 2L a day. Regular exercise such as walking or other aerobic/cardio activities for 25-30 minutes should also be strongly recommended to better process the fat elimination after treatment. Areas where treatment is most effective are those that have localized fat - the thighs, abdomen, and buttocks. However, there is no real limitation as to areas of the body.

Cavitation is not a method to lose weight but to reshape the body. It is particularly effective for the reduction of fat deposits in the “estrogenic” area (“the love handles” and abdominal stubborn

areas that will not go away with diet and exercise). Ultrasound cavitation is similar to liposuction in that it removes cellulite, thus preventing it from recurring in the treated areas without damaging the vascular system.

8.2 Benefits of an Ultrasonic Cavitation Treatment

Improved blood circulation and lymph circulation Improved skin texture Body tightening Excellent performance of body shaping Removal of fat cells permanently Non-invasive, no pain No anesthesia, no post-operative care No down time Cellulite therapy Connective tissue tightening

 

Figure 1: Before treatment. Fat cells basic structureFigure 2: 5 minutes after beginning treatment, the image shows a decompression of

the fat tissue along with formation of small bubbles because of weakening of the cellular membrane

Figure 3: 10 minutes after the cavitation begins, the image shows destruction of fatty membranes and considerable emulsification in places of processing

Figure 4: Distinctly shows full emulsification of a fatty layer

8.3 The schematic illustration of movements for Ultrasonic Cavitation treatment.

Common recommendations:

Avoid direct application on the anatomic formations such as eyes, kidneys, heart, sex organs and endocrine gland locations.

Avoid exposure of ultrasound on bones. Do not treat areas where there are insignificant amounts of fat layers. Do not apply heavy pressure to the area of treatment. Do not hold the ultrasound hand piece in one place. Hold the hand pieces perpendicular to the treated area. Do not apply heavy pressure. Movements in cavitation are very similar to circular “dough kneading” movements. During cavitation, the circular movements of hand pieces must be clockwise in

abdominal area and counter clockwise in other areas which can help to eliminate decompose fat (see Fig.1).

Fig.1 Schematic illustrations of movements for body in ultrasonic cavitation treatment.

At the end of procedure use lymphatic technique.

During lymphatic technique, hand piece pressure has to be about two times less than in cavitation movements. This technique can stimulate the lymphatic system easily and quickly eliminate emulsified fat from the body (see Fig.2).

Fig.2 Schematic illustrations of movements for body in lymphatic technique treatment.

Abdomen area:

Begin your work with small circular, clockwise movements around belly button, gradually increasing movement radius (see Fig.1).

Work on this area around 15 or 25 minutes, depending on treatment number. At the end of procedure use lymphatic technique: The free hand pulls skin towards

the ribs. With straight-line movements, slowly pull down the hand piece towards the groin area where lymph nodes are. Work on this area for the remaining 5 minutes (Fig.2).

Back area: Push hand piece up and down with small circular, counter clockwise movements on

the applied area (see Fig.1). At the end of procedure use lymphatic technique: For upper back: The free hand

pulls skin towards the waist. With straight-line movements, slowly pull up hand piece towards axilla (armpit) areas, where lymph nodes are (see Fig.2). For lower back and buttocks: The free hand pulls skin towards the ribs. With straight-line movements, slowly pull the hand piece towards the right and left buttocks side area where lymph nodes are.

Work on these areas the remaining 5 minutes (see Fig.2).

Thighs areas:

Push hand piece right and left with small circular, counter clockwise movements on the applied area (see Fig.1).

At the end of procedure use lymphatic technique: The free hand pulls skin towards the knee. With straight-line movements, slowly pull

up the hand piece towards the groin or buttocks area where lymph nodes are. Work on these areas the remaining 5 minutes (see Fig.2).

Arms area:

Push hand piece up and down from inside elbow to armpit with small circular, counter clockwise movements on applied area (see Fig.1).

At the end of procedure use lymphatic technique: The free hand pulls skin towards the elbow. With straight-line movements, slowly pull up hand piece towards axilla (armpit) areas, where lymph nodes are.

Work on these areas the remaining 5 minutes (see Fig.2).

Face area: Double chin and jowls

Always push hand pieces from down to up and from the center of the face towards the ears.

Using the schematic illustration below, work with small circular, clockwise movements on left side of face and counter clockwise movements on the right side of face (see Fig.3).

Fig.3 Schematic illustrations of movements for face in ultrasonic cavitation treatment.

At the end of procedure use lymphatic technique: The free hand pulls the skin towards the ears. With a straight-line movement, slowly pull down hand piece towards low jaw (mandible) and upper neck where lymph nodes are. All facial lymphatic movements have to be from up to down and from the center of the face towards the ears. Work on these areas the remaining 5 minutes (see Fig.4).

Fig.4 Schematic illustrations of movements for face in lymphatic technique treatment.

9. Radiofrequency

9.1 What are Radio Waves?

Radio waves are the electromagnetic radiation that travels in space with velocity of light (300,000 km/s) and transfers the energy. These waves are generated by atoms of all chemical elements. Electromagnetic radiation is transferred by means of photons. Photons are uncharged particles which do not have weight, behave as waves, and carry the minimum quantity of energy. Electromagnetic waves carry together the electric and magnetic fields which have been initially generated by a certain atom in an exited state.

Similar to sound waves, the electromagnetic waves are also described by sine waves and characterized by the frequency, wave length and power of transferable energy. The frequency of electromagnetic waves shows how many times per second the value of electric and magnetic fields changes in each point of space. Electromagnetic waves freely pass through air or a space (vacuum) and they don’t require a medium like a sound wave does.

Above is an illustration that shows an electromagnetic spectrum of radiation. It is broken down into smaller groups based upon their frequencies and wavelengths. They are gamma, x-rays, ultraviolet, visible light, infrared, microwaves, and radio frequency. The larger group of waves is radio waves or radiofrequency.

The radio waves can appear when alternating current, with frequency in the range between 10 kHz and 300 MHz, passes through the conductor.

The radio waves are not ionizing radiation and can easily penetrate into biological tissues without damaging the tissue’s structure. Quickly-fluctuating electromagnetic fields cause movement of the polarized particles in tissue and water molecules. The result of these actions (vibrations and friction) is heat production that is proportional to electric resistance of these tissues.

This phenomenon became a breakthrough in esthetic medicine.

9.2 Radio Frequency and Heat in Esthetic Medicine.

Radiofrequency treatment is a thermal procedure which uses radio waves for restoration of deep layers of tissues under the skin. It is a new trend in the non-surgical field of face lifting and tightening of the skin.

Generated heat stimulates production of collagen in a zone of influence, improves micro blood and lymph circulation, and reduces inflammation as well.

Deep and uniform heat causes partial compression of fibers of collagen, and makes them more dense and compact. This process happens because of destruction of thermolabile cross-bonds in collagen molecules that reduce residual tension between them. The increase in temperature stimulates fibroblasts to synthesize new collagen and gives the prolonged effect of deep reconstruction of tissues. Created heat increases density and elasticity of skin and provides an effect of lifting.

Radiofrequency treatment is used for facial tightening of clients with mild to moderate sagging of facial tissue.

The electromagnetic field created by radio frequency is capable of strengthening movement and drainage of liquids in skin and fatty tissue. It renders a positive effect to reduce puffiness and also promotes removal of toxins. This is why it is very important to use radiofrequency in conjunction with ultrasonic cavitation to eliminate emulsified fat and tighten the skin in the same area where the cavitation treatment has taken place.

The new type of ultrasonic device “Ultra-Focus” includes two distinct modalities, ultrasonic cavitation and radiofrequency, which perfectly complement each other.

Tripolar (facial) and multi-polar (body) hand pieces deliver the current that flows only through the tissue which is between the electrodes on the hand piece. The purpose of these electrodes is to complete the electrical circuit. Hence, no current flows through the rest of the body, so no grounding or return pad is needed. The hand piece transmits radio waves through the upper layers of the skin to the dermis. The radiation heats up the deep targeted area between 40 and 55 degrees Celsius and does not burn the skin’s surface.

The heat causes not only local contraction of the collagen fibers, but also stimulates new collagen production. It also immediately tightens the skin, but sometimes a tightening effect can be delayed from 3 to 6 months to be visible. Also, a high temperature reaches a deep fatty layer and produces partial lipolysis or, in other words, melts fat.

As mentioned before, RF will also improve the blood and lymphatic flow. This helps with a better oxygen supply and greater toxin clearance to further reduce the effects of aging.

9.3 Contraindications to Radiofrequency Treatments:

Any skin diseases, inflammation or infections in the area being treated Pregnancy Pacemakers, dental and body metal implants Thyroid gland disease Cancer and cancer history (requires MD release paper) Epilepsy Umbilical hernia Endometriosis Varicose veins Herpes in an active form Skin sensitivity Retin-A, Accutane (postpone for 6 months as it is highly possible it will produce

post-treatment hyperpigmentation on the treated area).

9.4 Pre- and Post-Treatment Considerations for RF Treatment:

It is very important for the technician to start the procedure with a detailed discussion about the client’s medical conditions and medications. Each time they are treated, the technician must update their medical information.

Before and after treatment, the client should avoid any irritation of skin including sun exposure and any exfoliation procedures (microdermabrasion, acidic peels, etc.).

After treatment, mild redness and itching can appear that disappears after 30 minutes.

9.5 Chronology of the Protocol of Procedures for RF Treatment:

If RF is a continued procedure after Ultrasonic Cavitation:

1. Put additional amount of ultrasonic gel on treated areas.2. Use “Ultra-Focus” appropriate RF hand piece no more than 20 minutes on each

zone.3. Remove remaining ultrasonic gel and clean treated area with paper towel or

gauze.4. Soothing gel or moisturizing lotion may be applied to the skin after treatment.

Use only “alcohol-free” gel.

If RF is a separate procedure:

1. Fill in the medical history of the patient. Obtain general information, medical questions list, and signature on informed consent.

2. Photo (if some lesions exist).3. The client’s face or body should be washed with soap and warm water

prior to treatment in order to remove any makeup and oil.4. Put ultrasonic gel on treated areas.5. Use “Ultra-Focus” appropriate RF hand piece no more than 20 minutes on each

zone.6. Remove remaining ultrasonic gel and clean treated area with paper towel or

gauze.7. Soothing gel or moisturizing lotion may be applied to the skin after treatment.

Use only “alcohol-free” gel.

9.6 The Schematic Illustration of Movements for Radiofrequency Treatment.

Common recommendations:

Do not hold the RF hand piece in one place. Do not apply heavy pressure to the area of treatment. Movements in RF are very similar to painting a wall, with light, gliding movements.

During radiofrequency, the movement of the hand piece must be clockwise in the abdominal area. In other body areas, all movements are straight, which can help to tighten and lift the skin (see schematic illustrations shown below (Fig.5).

Fig.5 Schematic illustrations of movements for body in radiofrequency treatment.

Abdomen area:

Begin your work with circular movements clockwise around belly button, gradually increasing movement radius. At the end of the procedure, all movement must follow massage body lines shown in Fig.5, above.

Work on this area about 20 minutes.

Back area and buttocks:

Move hand piece up-down and right-left with light, straight movements on the applied area. At the end of the procedure, all direction must follow massage body lines shown in Fig.5.

Work on this area about 20 minutes.

Thighs areas:

Move hand piece up-down and right-left with light, straight movements on the applied area. At the end of the procedure, all direction must follow massage body lines shown in Fig.5.

Work on this area about 20 minutes.

Arms area:

Move hand piece up-down and right-left with light, straight movements on the applied area. At the end of the procedure, all direction must follow massage body lines shown in Fig.5.

Work on this area about 20 minutes.

Face area:

The facial lifting lines for RF movements are shown below in Fig.6.

Fig.6 Schematic illustrations of movements for face in radiofrequency treatment

ULTRASOUND CAVITATION AND RADIOFREQUENCY EXAM

1. Ultrasonic is a range of sound frequencies that is _____ the human hearing range?

a. Aboveb. Belowc. Withind. None of the above

2. The range of ultrasonic frequencies is defined as?

a. A constant frequency of 40 kHzb. 20 kHz – 70 kHzc. 20 kHz and aboved. 20 kHz and below

3. Ultrasound is generated by a process known as?

a. Piezoelectricityb. 40,000 Hzc. Inverse piezoelectricityd. Micro-bubbles

4. The frequency at which the piezoelectric crystal expands and contracts is determined by?

a. The technicianb. Crystal timing mechanismc. Amount of triglycerides in the area being treatedd. The frequency at which the current changes polarity

5. Local temperatures during radiofrequency can be as high as?

a. 36.9o Cb. 50o Cc. 55o Cd. 70o C

6. Two modalities of “Ultra-Focus” cavitation devices are?

a. Ultrasonic and lymphaticb. Ultrasonic and radiofrequencyc. Ultrasonic and fractional laserd. Radiofrequency and IPL

7. A technique that helps flush clogged lymphatic vessels and glands is known as?

a. Ultrasonic cavitationb. Lymphatic drainagec. Body wrappingd. Massage therapy

8. To facilitate the treatment and to obtain the best results, the patient should:

a. Consume a high calorie dietb. Avoid drinking waterc. Drink plenty of waterd. Avoid exercise

9. How many ultrasonic cavitation treatments are recommended for optimal results?

a. 6 - 12b. Only 1 is sufficientc. 20 – 30 d. A minimum of 70

10. Contraindications to receiving ultrasonic cavitation include the following, except?

a. Liver failureb. Active tuberculosis c. Pacemakerd. Cellulite

11. The crystal commonly used in an ultrasound unit is called?

a. Plumbium zirconium titanateb. Rubyc. Alexandrited. Neodymium yttrium aluminum garnet

12. During ultrasonic treatment, the technician should avoid all of the following except?

a. Using over the bonesb. Talking to the patientc. Holding the sound head in one placed. Applying heavy pressure to area of treatment

13. Triglycerides are broken down into what water-soluble product?

a. Adipose tissueb. Fatty acids

c. Glycerold. Glucose

14. The effective frequency range for ultrasonic cavitation is?

a. 35-45 kHzb. 20 – 70 kHzc. 10,000oC to 70,000oC d. 98.6oF - 108.6oF

15. The matter that supports the sound is called?

a. Medium b. Transmitter c. Gas

d. Liquid

16. The number of oscillations per second is known as?

a. Velocityb. Forced cavitationc. Timed eventd. Frequency

17. Ultrasonic cavitation is similar to what cosmetic procedure?

a. Liposuctionb. CO2 laser resurfacingc. Erbium treatmentd. Fat transfer

18. During lymphatic technique, hand piece pressure has to be about?

a. Two times less than in cavitation movements. b. Two times more than in cavitation movements. c. The same as in cavitation movements. d. None of the above

19. When performing radiofrequency, all of the below are common recommendations, except?

a. Do not hold the RF hand piece in one placeb. Do not apply heavy pressure to the area of treatmentc. Direction in RF must follow massage body linesd. None of the above

20. What processes are stimulated when radiofrequency heats up the deep targeted area between 40 and 55 degrees Celsius and do not damage the surfaces of skin.

a. Synthesize new collagen b. Contraction of the collagen fibers c. Tightens the skin d. All of the above

21. During a radiofrequency skin tightening treatment, what layer of skin is being affected?

a. The collagen tissueb. Dermis and subdermisc. Epidermisd. Fat tissue

22. 10% products of the emulsified fat are reabsorbed in the blood stream where released triglycerides will be transformed to:

a. Glycolb. Glucosec. Glycogend. All of the above

23. Contraindications to receiving radiofrequency are all, except?

a. Kidney failure b. Pregnancy c. Pacemaker d. Fair skin

24. The name of uncharged particles that represent the radio waves?

a. Electrons b. Protonsc. Photonsd. Neutrons

25. During cavitation and radiofrequency, direction of the movement of the hand piece must be _________in the abdominal area.

a. Clockwise b. Counter clockwise c. Simple d. Does not matter