International Journal of Cosmetic Science, 2006, 28, 191206

Efcacy of a multifunctional plant complex in the treatment of the so-called cellulite: clinical and instrumental evaluation
F. Distante*, P. A. Bacci and M. Carrera
*Department of Dermatology, University of Pavia, Pavia, School of Surgery, University of Siena, Siena and San Gallicano Dermatological Institute, Rome, Italy

Received 25 January 2006, Accepted 15 February 2006

Keywords: cellulite, multifunctional plant extracts

Synopsis Cellulite or more correctly oedemateous brosclerotic panniculopathy, or local lipodystrophy, is a common aesthetic problem for many women, visually characterized by the orange peel or dimpled look of the skin, mainly on the buttocks and thighs. The cause of cellulite is still a matter of debate. It is currently considered an endocrine-metabolic microcirculatory disorder that causes interstitial matrix alterations and structural changes in subcutaneous adipose tissue. The rst step in cellulite treatment is stimulation of microcirculation and the removal of accumulated uids and toxic elements. This can improve the interstitial matrix basal regulation, broblast activity and decrease interstitial oedema, with subsequent increase in lipolysis and a better oxygen and nutrition of the adipose tissue. In this paper are reported two trials aimed at evaluating clinically and instrumentally the effects of different orally administered multifunctional plant extractsbased formulations in the treatment of cellulite compared with a placebo. Resume La cellulite, ou plus correctement la panniculo pathie oedemato-brosclereuse, ou lipodystrophie

localisee, represente un inconvenient esthetique frequent pour de nombreuses femmes, caracterise du point de vue clinique par laspect a peau dorange ou capitonne de la peau, principalement au niveau des cuisses et des fesses. La cause de la cellulite est encore aujourdhui mati` ere de debat. Elle est actuellement consideree un trouble endocrinien, metabolique et microcircula toire qui comporte des alterations de la matrice interstitielle ainsi que des modications du tissu adipeux sous-cutane. Stimuler la microcirculation ` et eliminer les liquides et les toxines en exces, representent le premier pas pour traiter la cellu lite. Ceci peut ameliorer la regulation de base de la matrice interstitielle ainsi que lactivite des ` ` broblastes et reduire loedeme interstitiel, avec par consequent une augmentation de la lipolyse et une meilleure oxygenation et nutrition du tissu adipeux. Dans cet article, nous rapportons deux etudes qui evaluent, cliniquement et dun point de vue instrumental, les effets de differentes ` formulations orales a base dextraits multifonctionnels de plantes pour le traitement de la cel lulite, comparees avec un placebo. Introduction Cellulite or more correctly oedemateous brosclerotic panniculopathy (EFP) or local lipodystrophy, is a common aesthetic problem for many women, visually characterized by the orange peel or dimpled look of the skin, mainly on the buttocks and thighs.

Correspondence: Enzo Berardesca, San Gallicano Dermatological Institute, Via Chianesi 53, 00144 Rome, Italy. Tel.: +39 06 52666157; fax: +39 06 52666158; e-mail: berardesca@berardesca.it

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It is well-known among dermatologists that cellulite is not the same as cellulitis [1], which is an actual inammation of the adipose tissue. The cause of cellulite is still a matter of debate. It is currently considered an endocrine metabolic microcirculatory disorder that causes interstitial matrix alterations and structural changes in subcutaneous adipose tissue [2, 3]. Some authors, including Curri, believe that the rst cause lies in a circulatory defect of septal vessels leading to oedema, followed by sclerosis of the septa and nally alteration of lipocyte metabolism [4, 5]. Other authors regard the vascular damage, oedema and brosis as secondary events to compression caused by the hypertrophy of the fat lobule itself. In fact, the continuous and progressive vertically oriented stretch in the subcutis may induce fat herniation and, as a consequence, focally enlarged brosclerotic strands portioning the subcutis [6]. Others regard cellulite as a physiological event, with cosmetic implications, due to normal vertical elongation of fat lobules in females [7]; nally, an up-todate theory considers cellulite as the result of a number of biochemical and metabolic alterations (such as pH alterations, free radicals increase, temperature alterations, oxide-reduction alterations and lymphatic stasis), which start on an interstitial matrix (to which the periangium belongs) and connective structures level [2, 6, 8, 9]. According to this new theory these structures, as well as the microcirculatory system, have an essential role in purifying the organism since they are thus a sort of junction where the various fundamental trophic substances, which are essential for cell life, ow and should functionally balance. The lack of these substances or the presence of an excessive amount of elements with toxic characteristics (e.g. heavy metals, oxidizing substances, excessive sugar, etc.) lead, in time, to imbalance and local alterations of the dermal hypodermal tissue, which also concerns the adipose and the supporting connective tissues [9, 10]. The main histological modications that characterize the onset and the clinical evolution of cellulite where described by Curri and Ryan [1]. In the normal situation, the vascular supply to the adipose tissue is characterized by a ne and regular mesh of blood and lymph vessels, which provides oxygen and the necessary nutrition and allows the removal of toxic substances. In the initial stages of the pathological process there is an increase in

subcutaneous adipose tissue and a leakage of blood plasma from the vessels (lipoedema), which swells the adipose tissue. In addition, malfunctioning lymph circulation hampers removal of accumulating uids (lipolymphoedema) (stage 1). The aggregation of adipose cells and the growth of collagen brils interconnecting it hampers blood circulation leading to circulatory stasis (stage 2). Adipose cells isolated from nutrition and waste removal, swell into micronodule surrounded by a stiff collagen layer (brosis, stage 3). The size of these micronodules are in the order of millimiters. Finally, many of these nodules agglomerate into macro-nodules with sizes as large as 220 nm (sclerosis, stage 4). As nerves may be squeezed by the larger nodules, persons with severe cellulite often suffer from a sensitive or painful skin. It was believed that the rst stages are more or less reversible, whereas the latter are irreversible [1]. Therefore, despite the different opinions on the physiopathological evolution of cellulite, the early diagnosis and treatment in initial stages is fundamental. The rst step in cellulite treatment is stimulation of microcirculation and the removal of accumulated uids and toxic elements. This can improve the interstitial matrix basal regulation, broblast activity and decrease interstitial oedema, with subsequent increase in lipolysis and a better oxygen and nutrition of the adipose tissue. To this end various methods have been devised, such as manual and mechanical massage of the skin, topical application of cosmetics, mesotherapy, change of diet and several plant-based dietary supplementations [11, 12]. In this paper are reported two trials aimed at evaluating clinically and instrumentally the effects of different orally administered multifunctional plant extracts-based formulations in the treatment of cellulite compared with a placebo [13, 14]. The investigated formulations differ each other only for the presence/absence of few ingredient and for the dosage of each ingredient. The main active ingredients of the three formulations and their effects are reported in Tables III. Study no. 1 This was a prospective, longitudinal, double-blind designed study [13]. The complete tested formulation was a plant complex based on seed extracts of

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Table I Main active ingredients contained in the tested products

Study 1 (18) Study 1 (18) Study 2 (19) Study 2 (19)

Plant

Cellasene Cellasene Vascolarys Cellulase without Fucus gold Vitis vinifera X X X X Fatty acids X X Recaptacell X Fish oil X X Borage oil X X Ginkgo biloba X X X X Ruscus X X Melilotus X X X X Centella X X X X Fucus X X X

grape (Vitis vinifera), Ginkgo biloba, Asiatic centella, mellilotus (Mellilotus ofcinalis), fucus (fucus vesiculosus), sh oil and borage oil (Cellasenea and Medestea) administered orally (Tables I and II). Materials and methods Forty-ve female patients with cellulite were investigated. They were organized into three groups: group A (11 patients) received the capsules containing the tested formulation (labelled P00821); group B (13 patients) received the capsules containing the tested formulation missing of fucus

(labelled 6977); group C (13 patients) received a placebo (labelled 6930). All capsules were given in anonymous package and looked the same. The content of the capsules was divulged neither to the patients nor to the observers until the end of the study. Each group received the medication in the same way and according to equal indications: two capsules per day for 60 days. Inclusion criteria were presence of cellulite, ages between 20 and 50 years and interest in participating in the trial. Exclusion criteria were receiving of any anti-cellulite treatment in the 30 days prior to the study entry, hormonal alterations, oral contraceptive administration, endocrinological disorders, any hormonal or endocrinological therapy, metabolic disorders (diabetes), pregnancy or breastfeeding; history of cardiac, renal and/or liver disorders, and obesity. Clinical, iconographical and instrumental noninvasive evaluations (videocapillaroscopy with digital image processing, echography and photoplethysmography) were carried out at baseline, before starting the treatment, and after 20 and 60 days of products administration. Three observer teams performed the different types of evaluations independently: team I carried out the clinicaliconographical assessment; team II carried out the echographicalphotoplethysmographical assessment; and team III carried out the videomicroscopy with digital image processing assessment.

Table II The active components and the detailed effects of each plant extract
Plant Active component Effects

Vitis Vinifera

Leucocyanidines

Antioxidant, free radical scavenger competitive inhibitor of elastase, collagenase, ialuronidase, beta-glucuronidase capillaries protection increase of tissue oxigenation prevents arterial vessels from atherosclerosis

Borage oil Ginkgo biloba Ruscus Melilotus Recaptacell Ginkgo-avonoid glucosids, terpenoids Anti-platelet-activating factor (PAF) improvement of blood ow strong antioxidant Capillaries resistance Vascular permeability decrease of tissue oedema enhancement of lymphatic circulation Fibroblast activity Collagen synthesis, Mucopolysaccharides turnover venous tonic action Enhancement of metabolism reduction of oedema and intestinal inammation

Flavonoids, melilotin, hydroxycumarin acid

Centella

Pentacyclictriterpenes (Asiatic acid, Madecassic acid, Asiacoside and Madecasspsode) Polysaccharides, bromine and iodine

Fucus

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Clinicaliconographical assessment The clinicaliconographical evaluation made by team I included the recording of patients past medical history, body weight, body mass index (BMI) and of patients current symptoms and signs relating to cellulite, such as heaviness, pain, cramps, tingling sensation, oedema and supercial and deep tenderness in lower limbs. Iconographical images of the whole body contour and macroimages of the skin surface with telephoto lens were obtained (Nikon 5005, Tokyo, Japan). Echographicalphotoplethysmographical assessment The equipment used included Colour Echo-Doppler ATL (Philips Electronic n.v., Eindoven, the Netherlands), model HDI 5000, with 7, 5 and 10 MHz linear transducers. With the patient in orthostatic position, images of the thighs external side, 20 cm from the antero-superior iliac spine were obtained. The following features were analysed at each control visit: morphological characteristics of subcutaneous cellular tissue; measurement of the distance between skin and muscular fascia; study of permeability and valve function of deep and supercial venous system and of perforans in order to verify or rule out associations between cellulite and supercial and deep chronic venous failure; study of changes in the microvessel caliber at the subcutaneous cellular tissue level. Modication values were statistically analysed through the Students t-test, with a reliability coefcient of 5% (P < 0.05). A Digital Elcat Photoplethysmograph (Elcat GMBH, Woldratshausen, Germany) was also used. The transducer was placed on the legs internal side, in the supramalleolar area 10 cm from the planta pedis, and on the thighs external side, 20 cm from the anterosuperior iliac spine. The transducer emitted an infrared light that was reected on the venous subdermal plexuses of both regions, in a 100 mm3 area that was 3-mm deep. The haemodynamic changes in each site secondary to tiptoe exercises were recorded before, during, and at the end of the medication regimen. The objective was to measure the venous lling time due to bed emptying after exercise. The

venous lling time was >20 s. When valve reux and venous stasis existed, the time was shortened to 1020 s (moderate) or <10 s (severe). Videocapillaroscopy with digital image processing As EFP physiopathology involves signs of circulatory stasis, vasodilatation, and capillary permeability increase, videocapillaroscopy was included as a diagnostic method in the study protocol. Capillary images were obtained with a videocapillaroscope of 200 power lenses in oil immersion, and an optical bre halogen white light source. Images were saved in a computer. The software for digital image processing provided a qualitative analysis through image improvement. Quantitative analysis offered values for the different variables through special lters. Results were based on analysis of variance (ANOVA) with a reliability coefcient of 5% (P < 0.05). The images were captured in the following standardized procedure: patients lay in rest position for 15 min. They were neither allowed to drink nor to smoke from 1 h prior to the test. The room temperature was kept at 20 5C. Images from the thighs external side area, 20 cm from the antero-superior iliac spine, in the right subgluteal groove were obtained. The patient lay in ventral recumbent position and then stood 5 min in orthostatic position. The following features were analysed through videocapillaroscopy: capillary density (number of vertical capillaries per mm2), capillary area (vertical capillary area samples measured through randomized images), capillary perimeter (vertical capillary perimeter samples measured through randomized images) and capillary diameter (vertical capillary diameter samples measured through randomized images). The following formula was used to obtain the benet percentage (%) of vertical capillary density: Benet%(N capillaries day 0)N capillaries day n)100/N capillaries day 0 where day n 20 or 60. Results From a total of 45 patients who entered the study, 82% (37 patients) completed the trial. Their mean age was 37 13 years. Two patients had to withdraw from the trial: one patient because of an increase in intestinal discharges, and another because of an itching papulo-erythemateous reaction. Six patients retired for reasons unrelated to the study.

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After the ofcial notication of the content of the capsules under study, the number of patients in each group (group A: active complete formulation; group B: active the same as group A, but deprived of Fucus vesiculosus content; group C: placebo) was checked and the following conclusions were stated from the analysis of the results. It was proved that clinicalinstrumental modications (between 68% and 71% according to the team) were observed in patients treated with the active product with or without fucus content (groups A and B). In particular, clinicaliconographical assessment showed symptom improvement (i.e. oedema and pain) in 71% of patients who had received the active treatment. These patients also showed mild variations in mean blood pressure between the beginning of the trial and the 60 day control. In the same group no signicant changes in body weight and BMI was observed. Patients with iconographical changes in body contour (30%) had received the active treatment with fucus content (Cellasene). This explains fucus effect on peripheral fat tissue. Echographic assessment showed a decrease of all signs related to tissue oedema in 70% of patients who had received the active treatment (Cellasene), with and without fucus, with an average improvement of 18% and a maximum of 26%. The most signicant event was the decrease in lipoedema, reected in the thickness reduction of the subcutaneous cellular tissue with lipoedema before and after treatment. The reduction was not observed in patients who had received placebo. An increase in subcutaneous cellular diameter was observed in 29.7% (11 patients) of population, who had in fact received the placebo. At 20 and 60 day controls, no changes in the brosis signs were observed at the micro- or macro-nodule level in any group. It can be hypothetized that further modications may appear with longer durations of treatment. The photoplethysmographic results showed a moderate vascular stasis in the hip area documenting the EFP microcirculatory alterations without signicant changes during the study in any group. The results in the malleolar area were normal. Videocapillaroscopy assessment was based on the analysis of an average of 12 images per session, for an average of 36 images per patient, and a total of about 1500 images under study. A marked increase in the vertical capillary density (a benet of 43 5% in the 0- to 60-day period) in the groups who had received the active

treatment (with and without fucus content) was detected. A greater perfusion at the dermal papilla level could be expected from such increase. This in fact led to relevant improvement in fat tissue circulation, as shown from the analysis of the angioarchitectural and functional relationship between subpapillar and subdermal plexus (the latter is the fat tissue irrigation source). It is important to remark that vertical capillary density increased when the duration of treatment increased (12% of capillary increase between days 20 and 60), and that no microhaemorrhages were found after 60 days of treatment administration. Important modications in the morpho-architectural pattern (vertical capillary area, diameter and perimeter) were not observed in patients who received the active medication from days 0 to 60. In fact, the most signicant modications were observed in capillary diameters. It is possible that such modications may occur along with longer durations of treatment. Study no. 2 This was a prospective, longitudinal, double-blind designed study [14]. The aim of the study was to evaluate the effect of administration of two different dietary phytotherapic products vs. a placebo in the improvements of a number of clinical and instrumental parameters commonly related with cellulite and to detect possible differences in clinical results in relation to the different formulae (Tables I and II). Materials and methods A group of 145 patients, aged 1845 (average 31.6) years, with cellulite for at least 2 years, was recruited from April to July 2001. Inclusion criteria were: presence of oedematous cellulite, adipoedematous cellulite, brous cellulite (according to the physiopathological condition of cellulite) and compact cellulite (according to cutaneous tone type); ages between 18 and 50 years and interest in participating in the trial. Exclusion criteria were BMI exceeding 30, saphenous and collateral varicosis, phlebolymphoedema, systemic lymphoedema (positive Stemmers test), venous insufciency (instrumental and clinical diagnosis), adipose cellulite, post-liposculpture, other anti-cellulite treatments in progress or in the 30 days

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prior to the study entry, menopause and premenopause, patients affected by sagging or evident pathologies in progress. All clinicalinstrumental evaluations were conducted on each patient over a 24-h period. Patients were asked not to drink coffee or smoke for at least 2 h prior to evaluations. The rst test was carried out from 1 to 3 weeks after the end of the patients menstrual cycle. After obtaining an informed written consent, the subjects underwent the clinical and instrumental tests described below. One hundred and forty-ve patients were randomized into three groups and received three different treatments according to the double-blind method. Group A included 58 patients, group B 29 patients and group C 58 patients. The three products were formulated as follows: group A consisted of bioavonoids expressed as polyphenols (Vitis vinifera), fatty acids (essential polyunsaturated acidsEPA-, DHA, y-linoleic acid), Vitamin E, Ginkgo biloba, Ruscus, Melilotus, Centella (Vascolarys; Medestea Internazionale, Turin, Italy); group B consisted of inert substances (natural bres and soya oil) administered to a group of 29 patients as a placebo. Group C consisted of bioavonoids expressed as polyphenols (Vitis vinifera), Recaptacell, Ginkgo biloba, Ruscus, Melilotus, Centella and Fucus (Cellulase Gold; Medestea Internazionale). Each box given to the patients contained the amount of product needed for the entire treatment, i.e. three capsules a day for a total of 47 days (only two capsules for the last day). Each blister contained 20 capsules and each patient received a total of 140 capsules. The boxes, containing seven blisters each, were sequentially numbered from 1 to 145. Only the main investigator, who never took part in the tests, knew the product randomization key. This is because, as explained below, some tests were carried out on only 50% of patients. For this reason, the main investigator, being aware of the randomization key, could maintain the correct proportion of placebo and active product also in this group of individuals. The active products could not be differentiated from the placebo based on their appearance. Instrumental evaluations The following parameters were evaluated on all 145 patients: height, weight and arterial pressure,

oxidative stress (Roms test, Carratelli) [15], Fat Mass Index (FMI, impedometric method) [16]; abdominal, thigh and ankle circumference (circumferences where evaluated according to the Lohamann, Roche and Martorell standards) [17]; clinical cellulite evaluation; self-assessment. Most of the tests to which the patients underwent are included in the European anti-cellulite treatment diagnosis and evaluation protocol [18]. Clinical and subjective evaluations were conducted by answering a questionnaire and assigning a score from 2 to 8, with 5 designed as the limit between adequacy and inadequacy. The physicians and patients questionnaire included questions regarding changes in leg swelling, cellulite appearance, weight, overall products efcacy, satisfaction with treatment and tolerability. According to the main investigators indications, aimed at maintaining the ratio between active products and placebo constant, the following additional parameters were evaluated on half of the patients: Blood chemistry tests: measurement of saturated transferrin, unsaturated transferrin, free iron, cholesterol, triglycerides, non-ester fat acids NEFA, glycaemia, azotaemia, creatinine, sodium level, potassium level, chloraemia, blood calcium level, TSH, T3, and T4; Videocapillaroscopy: baseline ow and capillary density [19]; Doppler laser owmetry: resting ow, transcapillar power (TCP)O2 [18, 20]; Echography [18, 21]; Pain ultrasonic test [22, 23]; Echo colour Doppler [24]; Light reection rheography [25]; Thermography [26]. Results After 47 days of treatment, 127 patients were examined, with conrmation that they had taken the capsules regularly. The patients were included in the following groups: A: 50 individuals (of whom 26 underwent also additional instrumental evaluations); B: 26 individuals (of whom 14 underwent also additional instrumental evaluations); C: 51 individuals (of whom 26 underwent also additional instrumental evaluations). Eighteen dropouts were observed for reasons unrelated to the treatment. The statistical analysis

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of results was conducted through t-test for paired data. Weight slightly decreased in groups C and A (the latter to a lesser extent), although patients claimed that they did not modify their normal habits (Table III). Fat Mass Index statistically decreased in groups C and A, while the result is not statistically signicant in the placebo group (Table IV). This result, correlated to loss of weight, leads one to believe that the loss mainly concerned fatty mass. This could be consequent to the improvement of microvascular function and of the interstitial matrix regulating and purifying activity that causes greater cell membrane uidity, with consequent increase of cell metabolism [27, 28]. Abdominal circumference was signicantly reduced in group A and even more so in group C. The decrease in the placebo group was not statistically signicant (Table V).
Table III Weight
Group A Group B Group C

Table VI Hip circumference

Group A Group B Group C

Baseline Final Finalbaseline Baseline vs. nal

91.94 91.79 )0.15 ()0.2%) P > 0.001

93.20 93.08 )0.12 ()0.1%) P > 0.001

93.38 92.92 )0.46 ()0.5%) P < 0.001

Baseline Final Finalbaseline Baseline vs. nal

62.77 62.11 )0.65 ()1.1%) P < 0.001

61.88 61.69 )0.19 ()0.3%) P > 0.001

64.64 62.45 )2.19 (3.4%) P < 0.001

Hip circumference was signicantly reduced in group C. The decrease in groups A and B was not statistically signicant (Table VI). Bitrochanteric circumference and thigh circumference were signicantly reduced in group A and even more so in group C. The decrease in the placebo group was not statistically signicant (Tables VII and VIII). The analysis of ankle circumference variations shows that product C caused higher quantitative variations compared with product A (Table IX). Observation of these values indicates that the active substances used are effective on local lymphatic adipose metabolism and that the results were more evident in patients in group C, whose product contained Recaptacell, a component with a greater action on local adipose metabolism. The reduction of abdominal circumference which justies the feeling of well-being reported by all patients treated with the active products is

Table IV Fat Mass Index

Group A Group B Group C

Table VII Bitrochanteric circumference

Group A Group B Group C

Baseline Final Finalbaseline Baseline vs. nal

24.84 24.13 )0.72 ()3%) P < 0.001

26.36 26.37 0.01 P > 0.001

28.29 26.29 )2.00 ()7.1%) P < 0.001

Baseline Final Finalbaseline Baseline vs. nal

91.28 90.59 )0.69 ()0.7%) P < 0.001

91 90.92 )0.08 (0.1%) P > 0.001

92.40 90.88 )1.52 ()1.6%) P < 0.001

Table V Abdominal circumference Table VIII Thigh circumference

Group A Group B Group C Group A Baseline Final Finalbaseline Baseline vs. nal 75.31 74.36 )0.95 ()1.3%) P < 0.001 73.61 73.00 )0.61 ()0.8%) P > 0.001 77.54 74.29 )3.2 ()4.1%) P < 0.001 Group B Group C

Baseline Final Finalbaseline Baseline vs. nal

59.62 58.59 )1.03 ()1.7%) P < 0.001

59.5 58.92 )0.58 ()1%) P > 0.001

60.66 58.50 )2.15 ()3.6%) P < 0.001

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Table IX Ankle circumference

Group A Group B Group C

Table XI Roms test and oral contraceptive

Group A Group B Group C

Baseline Final Finalbaseline Baseline vs. Final

23.31 22.94 )0.37 ()1.6%) P < 0.001

22.73 22.65 )0.08 ()0.4%) P > 0.001

23.55 22.90 )0.65 ()2.7%) P < 0.001

No contraceptive pill Baseline 256 Final 246 ()4%) Yes contraceptive pill Baseline 437 Final 330 ()24%)

307 313 (+2%) 372 356 ()4%)

288 249 ()14%) 414 310 ()25%)

particularly interesting. The apparent lesser reduction of ankle circumference is justied by the fact that none of the patients suffered from venous lymphatic insufciency. The balanced reduction of all circumferences could most likely be correlated with the reduction of local lymphatic stasis due to improvement of the entire mesenchymal structure rather than the direct effect on vessel walls (phlebo-lymphotrophic tonic action) [29, 30]. Data on oxidative stress evaluated with Roms test (according to Caratelli) show the distinctive antioxidizing protective action of the substances used (Table X). This action directly affects interstitial matrix functionality, vessel wall trophism, endothelial calcium metabolism and above all, cellular membrane uidity. The positive clinical response may therefore be related also to the antioxidizing action of the plant-based ingredients taken. This is consistent with the theory that considers cellulite as the expression of tissue and cellular oxidative alterations [31, 32]. Analysing the results more in detail, it can be seen that the antioxidizing effect was higher in the patients who took oral contraceptive (Table XI). This is probably related to the fact that the physiological antioxidizing activity of the organism is correlated to the use of oxygen. This physiological activity is regulated by a sophisticated system,
Table X Roms test
Group A Group B Group C

which is altered especially by the action of hormones, as well as stress, infections and tobacco smoke. This is why the antioxidizing supporting role of the products examined in the trial is more evident in patients whose physiological functions related to oxidative stress defence were more engaged. It is interesting to note that the oxidative stress values remained within normal limits, although the patients kept taking oral contraceptive during the treatment. We may speculate that this justies dietary supplementation for long-term prevention in individuals subjected to oxidative risk or who are dieting and who take oxidizing substances [33]. Microcirculation examinations Tests conducted using optical probe video capillaroscopy (VCSO) showed that patients with cellulite presented typical microangiopathy related to medium degree mixed capillary-venous stasis (3-A-I and 3-A-II on the AlbergatiCurri scale) [34] associated with the typical reduced juxta-capillary arteriole sphygmic activity (Table XII).

Table XII Videocapillaroscopy

Group A Group B Group C

Baseline Intermediate Final Finalbaseline Baseline vs. nal

339 317 ()6.8%) 284 )55 ()16.4%) P < 0.001

334 331 ()0.7%) 331 )3 ()0.7%) P > 0.001

332 304 ()8.4%) 271 )62 ()18.4%) P < 0.001

Flow Baseline Final Finalbaseline Baseline vs. nal Capillary density* Baseline Final Finalbaseline Baseline vs. nal

1.74 2.02 0.28 (16%) P < 0.001 0.81 1.08 0.27 (33%) P < 0.001

1.76 1.77 0.01 (0.6%) P > 0.001 0.81 0.84 0.03 (3.7%) P > 0.001

1.73 2.18 0.45 (25.5%) P < 0.001 0.75 2.21 1.46 (196%) P < 0.001

*Capillary density for eld of observation (200 eld/test)

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The measurements made using optical probe video capillaroscopy focused on the front part of the thigh on the vertical line, 15 cm from the saphenofemoral junction of the left leg, demonstrating that the baseline ow and capillary density increased in groups C and A, expressing a microvasomotion effect, with increased perfusion in the various capillary-venule-venous zones and consequent increased pan-zonal vascularization. No statistically signicant variation was observed in the placebo group. The direct correlation between capillary density and baseline ow appears particularly important. This is because an increase of the former without a similar increase of the latter would be due to venule-venous stasis and not to increased perfusion. Laser Doppler tests (PF3 TS 1.5 s with 30 mV gain) were conducted at the same time (Table XIII). It is noted that normally major arterial lesions are never observed in cellulite syndromes while ramus dysrhythmia with low vasomotion is more common. The results show signicant microvessel activation response in individuals treated with the two active products, as seen in the changes in vasomotion, observed in every treated individual, with increased resting ow and TCPO2. No noticeable statistical variations were found in the group of patients treated with the placebo. These results may be related to products capability of signicantly increasing microvascular ow and favouring arteriole contraction normalization in a statistically signicant way. Considering the overall improvement of the microcirculatory structures, it can be postulated that these evident variations in microvascular functionality do not only refer to the sphygmic activity of the products ingredients involving the juxta-capillary arterioles
Table XIII Flowmetry
Group A Group B Group C

but also, and above all, to improvement of the entire interstitial matrix metabolism and that of the perivascular space, called the periangium where the most important tissue exchanges and the most delicate colloid-osmotic events occur [35, 36]. Echography The test was carried out with a high resolution device (Sigma 330 High Performance, 7.5 12 MHz probe; Kontron Medical, Plaisir Cedex, France). The reference point for the test was the front area of the thigh on the vertical line at 15 cm from the saphenofemoral junction. The echography test was carried out after the microcirculatory and termographic tests so as not to distort the data obtained. Ultrasonography of cellulite syndromes typically shows small, thin hyperechogenic connective septa which are morphologically altered and disharmonic. The trend shows the recovery of normal hypoechogenicity associated with improved balance and the tendency for parallel, horizontal arrangement following treatment with the trial products, indicating recovered metabolic and microvasomotion activity (Table XIV, Fig. 1). The results also demonstrate a signicant reduction of subcutaneous thickness with the tendency to balance connective septa, thus demonstrating localized lipoedema reduction. Ultrasonic pain test This test is used to attempt to make a more precise physiopathological diagnosis and to quantify responses to specic treatment of the different types of cellulite syndrome. It correlates echography indications with the pain response to compression of the probe on the tissues. The level of pain, due to dermalhypodermal nocireceptor activation, reveals typical tissue cellulitic alterations and lymphatic stasis (Table XV).
Table XIV Echography
Group A Group B Group C

Resting ow Baseline Final Finalbaseline Baseline vs. nal TCPO2 Baseline Final Finalbaseline Baseline vs. nal

10.02 19.89 9.87 (98.4%) P < 0.001 62.09 87.10 25.01 (40.2%) P < 0.001

9.34 9.53 0.19 (2%) P > 0.001 65.48 66.88 1.2 (2.1%) P > 0.001

9.34 23.11 13.77 (147%) P < 0.001 68.71 95.11 26.4 (38.4%) P < 0.001

Baseline Final Finalbaseline Baseline vs. nal

1.71 1.19 )0.52 ()30%) P < 0.001

1.72 1.70 )0.02 ()1.3%) P > 0.001

1.69 1.06 )0.63 ()37%) P < 0.001

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Esempi di ECOGRAFIA

1) Prima

1) Dopo

2) Prima

2) Dopo

Examples of ECHOGRAPHY
1) Before 2) Before 1) After 2) After

Figure 1 Examples of echography

Table XV Pain test

Group A Group B Group C

Baseline Final Finalbaseline Baseline vs. nal

20.91 13.24 )7.67 (36.6%) P < 0.001

19.66 20.85 1.19 (6%) P > 0.001

19.91 11.39 )8.52 ()42.7%) P < 0.00.1

Lipoedema and lipolymphoedema, as well as lipodistrophy, normally present spontaneous pain following compression with the ultrasound probe. Pain corresponds to the quantity and quality of extracellular oedema and to the degenerative or inammatory process, which is typically related to cellulite and not to the amount of fatty tissue present. Normal subcutaneous tissue can be compressed with the probe well beyond 30% of its thickness while lipoedema is painful at about 1520% of its thickness with the possibility of compressing the subcutaneous layer on the muscular fascia. Considerable pain is reported in the event of lipolymphoedema and lipodystrophy, on the other hand, at about 10% with a typical reduction of the possibility of compressing the subcutaneous tissue on the muscular fascia [37, 38].

The tested area usually corresponds to Hunters venous perforating region on the medial thigh, where the tissue is particularly sensitive due to the presence of important venolymphatic and neural stations [39]. In medical practice several measurements, expressed in mean values, are recorded, in relation to the quantity of compressed tissue, measured in millimeters from the skin to the muscular fascia, until the moment that compression causes pain. Variations in the quantity of compressed tissue give an idea of the local metabolic variation related to the treatment carried out. The results show a considerable, predictable and statistically signicant improvement in the possibility of tissue compression, with a negative effect in the placebo cases. These results demonstrate functional and nutritional improvement of the interstitial and connective tissue previously observed in clinical practice and other trials. Pain reduction obtained after treatment with the active products, associated with a feeling of well-being, leads to considerable thought about the role of the improved metabolic and vascular functionality of the interstitial matrix, consequent tissue lymphatic depuration and the direct or indirect phlebolymphotrophic and phlebolymphotonic action [40, 41].

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Colour ow Doppler imaging The test was carried out using a high-resolution colour ow Doppler imaging device (Sigma 330 High Performance; Kontron Medical) to evaluate the saphenofemoral junction variations measured upstream to the preterminal valve in the clinostatic and orthostatic position. Mean values were recorded (Table XVI). None of the patients presented venous pathologies, as required by the inclusion criteria; consequently, the data observed before and after treatment are not signicant, neither for the active products nor for the placebo, predictable as the individuals were healthy from a macro-vascular point of view. Light reection rheography The light reection rheography (LRR) test is routinely used in phlebolymphology and demonstrates the venous-lymphatic activity pattern as a therapeutic response by determining depletion or recovery times for dermalhypodermal vein-lymphatic stasis. We used a PPG 400 (Elcat GMBH, Woldratshausen, Germany) with a 1 cm transmitting receiving infrared probe applied to the medial malleolus; the signal reects microvascular recovery after plantar and calf pump activation by 10 s of 10 rhythmic dorsal-exion with tourniquet on Boyds perforation [42]. Given the absence of venous-capillary insufciency and macro-venous pathologies, the increased ankle lling time evaluated by means of LRR is neither relevant nor clinically signicant. A statistically signicant positive effect on lymphokinetic level as well as improved metabolic activity was found (Table XVII). The LRR and colour ow Doppler imaging data are very signicant for speculation because they show that:

Table XVII Light reection rheography

Group A Group B Group C

Baseline Final Finalbaseline Baseline vs. nal

20.32 21.12 0.8 (3.9%) P < 0.001

20.91 20.22 )0.69 ()3.2%) P > 0.001

21.07 21.87 0.80 (3.8%) P < 0.001

1. cellulite is not directly correlated to varicose diseases; 2. cellulite is above all a microvascular connective and dismetabolic condition, a mesenchymalopathy; 3. cellulite may be one of the causes of angiohypotony and consequently of leg pain and swelling symptoms; 4. the administered products favour microvasokinetic activity related to improving the metabolic activity of the periangium. Lymphoscintigraphy For ethical reasons, lymphoscintigraphy of the lower limbs was carried out only on patients treated with the active products. To maintain the double-blind condition, only the main investigator was aware of this experimental approach and personally selected the patients to be subjected to lymphoscintigraphy. The test was carried out according to standard methods using 99mTc-nanocoll 37 Meq instilled through the back of the foot. No morphological alterations of ow in peripheral lymphatic vessels were observed, as was predicted (Table XVIII). Cellulite, in fact, is neither a lymphopathy nor a disease caused by venous-capillary stasis. It is a variegated interstitial-adipo-connective alteration,
Table XVIII Lymphoscintigraphy*
Group A Group B Group C

Table XVI Colour ow Doppler imaging

Group A Group B Group C Baseline Final Finalbaseline Baseline vs. nal 412.33 ND 348.94 ND )63.39 ()15.4%) P < 0.001 427.72 353.89 )73.83 ()17.2%) P < 0.001

Baseline Final Finalbaseline Baseline vs. nal

3.76 3.79 0.03 (0.8%) P > 0.001

3.81 3.8 )0.01 ()0.3%) P > 0.001

3.94 3.78 )0.16 ()4%) P > 0.001

ND, not determined. *The time of lymphatic reux (seconds).

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which can also involve local venous-lymphatic stasis. In all the cases analysed, lymphoscintigraphy demonstrated an interesting, constant improvement in lymphatic ow speed in the lower limbs, demonstrating that the substances used have a genuine lymphokinetic action. As there is no lymphatic vessel damage or a pathological reduction in speed of lymphatic deuxion, such lymphokinetic action must be related not only to direct action on the vessel, but above all to action on the mesenchyma, and consequently lymphangial action. This data may be signicant as they allow mesenchymalinterstitial activity to be attributed to the product used. Thermal plate thermography The results of thermal plate thermography, as in the case of video capillaroscopy and laser Doppler, are difcult to interpret and must be correlated to the general clinical context. Despite this, thermal plate thermography remains one of the most used diagnostic methods for classifying cellulite and controlling the efcacy of treatments. Thermography was carried out using the IPS Thermo-Cell-Test-Mac (International Products & Services, San Donato Milanese, Italy) High Resolution system (eight colours), with RW-S Professional Kit micro-encapsulated liquid crystal plates. All patients were examined before and after treatment in the supine position at room temperature in the range from 18 to 25C. The test was carried out before the video capillaroscopy and laser Doppler test, on the front of the thigh on the vertical and 15 cm from the right leg saphenofemoral junction. Data were collected and interpreted according to the formula of Curri [26]. Results were evaluated on a scale from 0 to 25, as shown in Table XIX. Values from 0 to 3 are normal (T0), from 4 to 7 indicate initial microcirculation alterations (T1),
Table XIX Thermography
Group A Group B Group C

values from 8 to 13 indicate venous-capillary stasis (T2), values from 14 to 19 mean cold areas with hypothermal black holes (T3), and nally values from 20 to 25 indicate clear brosis and liposclerosis (T4). The collected data show a distinctive trend to microvascular perfusion and metabolic activity improvement in the cases treated with active products, which is consistent with the general clinical context and can be compared to the data from video capillaroscopy and laser Doppler tests. Three reasons may be behind this improvement: less connective brosis, better interstitial exchange and higher vascularization. It is difcult to determine whether the products used act directly with a vascularizing effect or as metabolic activators. The fact is that the nal result shows improvement of the basic clinical parameters vascular, metabolic and structural which fully justify the simultaneous improvement aesthetically related to the cellulite, as also seen in the patients self-assessment tests. Blood tests No signicant variations were found, conrming the good level of tolerability of the products used. Clinical evaluations Analysis of the questionnaires lled out by physicians showed denite satisfaction on the products used concerning both clinical and cosmetic appearance (Table XX). Data were analysed on a specically prepared scale. The evaluation criteria were based on ve parameters to which scores from 2 to 8 were assigned (5 being the borderline between adequacy and inadequacy). The evaluated parameters were cellulite, oedema, fat, tolerance and global efciency. Table XX indicates substantial clinical and cosmetic satisfaction expressed for all parameters which, in the case of active treatments, are all adequate. The difference between active products and placebo evaluations is statistically signicant. Subjective evaluations Patient questionnaires mainly focused on the feeling of well-being and how the product used matched the patients cosmetic expectations. All

Baseline Final Finalbaseline Baseline vs. nal

12.96 7.86 )5.10 ()39.4%) P < 0.001

13.88 13.48 )0.4 ()2.9%) P > 0.001

13.02 7.12 )5.90 ()44.6%) P < 0.001

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Table XX Clinical evaluations

Tolerance Cellulite Oedema Fat Efciency

Group A Group B Group C C vs. B A vs. B

7.70 7.92 8.31 P > 0.001 P > 0.001

5.63 4.21 6.09 P < 0.001 P < 0.001

5.76 4.14 5.57 P < 0.001 P < 0.001

5.42 4.30 6.35 P < 0.001 P < 0.001

5.78 4 6.35 P < 0.001 P < 0.001

values were positive and statistically signicant with respect to the placebo group. The self-assessment questionnaire (Table XXI) was extremely important for physicians because the results indicate the motivation and the objectives for which the patients involved had spontaneously asked for medical attention, namely an anti-cellulite treatment. The data show that the administration of active products, with a slight preference for product C, was satisfying for patients. The placebo group, on the other hand, provided inadequate scores for four of ve parameters. Statistical analysis of the results conrmed the speculative analysis and showed subjective improvement in 46 of 50 patients in group A (92%), four of 26 patients in group B (15.4%) and 50 of 51 patients in group C (98%). Table XXII, documenting symptomatic improvements over the 47 days of the trial is very interesting. It shows that a feeling of well being was reported only after 3 days by the patients in the groups treated with products A or C. No signicant improvements were reported by the group of patients treated with the placebo. Discussion The overall analysis of clinical and instrumental results of these two trials shows the efcacy of all the tested phytotherapic formulations in the treatment of the so-called cellulite, when compared with the placebo.
Table XXI Self-assessment questionnaires
Group A Group B Group C C vs. B A vs. B

The instrumental data show a general improvement of all the investigated parameters: an increase in vertical capillaries density associated with a signicant increase of resting ow and TCPO2 was found, respectively, by capillaroscopy examination and laser Doppler tests. A statistically signicant positive effect on lymphokinetic level as well as an improved metabolic activity was found by LRR test. In all the cases analysed, lymphoscintigraphy demonstrated an improvement in lymphatic ow speed in the lower limbs. Such lymphokinetic action must be related not only to direct action on the vessel, but above all to action on the mesenchyma, and consequently lymphangial action. These effects explain the relevant improvement of microvascular perfusion and metabolic activity observed at the thermography assessment and the signicant decrease of oedema and subcutaneous thickness found at the ultrasound examination. An improvement of all clinical signs associated to cellulite (legs oedema, heaviness, pain and orange peel appearance) was in fact observed in the patients who received the active product at both physicians evaluation and subjective selfassessment. A trend to weight loss associated with a statistically signicant decrease of FMI, as found in study 2, may indicate that the weight loss mainly concerns fatty mass. The balanced reduction of all circumferences could most likely be correlated with the efcacy
Cellulite Oedema Fat Satisfaction

Subjective improvement

6.25 4.81 6.60 P < 0.001 P < 0.001

6.20 5.12 6.59 P < 0.001 P < 0.001

6.05 4.75 6.11 P < 0.001 P < 0.001

5.46 4.27 5.99 P < 0.001 P < 0.001

6.83 4.82 6.90 P < 0.001 P < 0.001

Numerical values (scale 010) from subjective evaluations.

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Group

Symptoms

After 3 days

After 10 days

After 15 days

After 30 days

After 47 days

Table XXII Symptomatic improvements

51

26

50

Oedema Heaviness Cellulite Oedema Heaviness Cellulite Oedema Heaviness Cellulite

8 24 0 0 0 0 10 26 0

19 39 5 0 0 0 17 32 0

27 46 9 0 1 1 31 43 6

37 51 35 2 2 1 43 48 29

42 51 48 3 3 2 43 48 41

of the active ingredients on local lymphatic adipose metabolism, that induces a decrease of local lymphatic stasis. This effect was enhanced in the group whose product contained Recaptacell, a component with a greater action on local adipose metabolism (group C, study 2). The combination of the active ingredients in the orally administered products may explain the results obtained in these trials: Vitis vinifera leucoanthocyanin is a powerful antioxidant (active at a concentration 50 times lower than vitamin E) that shows good bioavailability in oral administration and shows trophism towards tissues rich in glycosaminoglycans. Therefore, it has direct action on microvascular and interstitial structures [43, 44]. The Ginkgo biloba extract has the property of increasing blood perfusion, both at the central and peripheral level, in arterioles and capillaries. It contributes to the effect of endothelial-deriving relaxing factor, a vasodilatating substance. It also has an antagonist effect on platelet activator factor, which contributes to circulatory slowing down [4547]. Puried Asiatic centella, triterpenes as phytosomas, favours lymphatic drainage, activates collagen production mainly through its effect on broblasts, has activity on lysine and proline metabolism, increases tropocollagen synthesis, and stimulates connective tissue mucopolysaccharide exchange [43]. The Mellilotus ofcinalis extract proved effective for increasing capillary resistance, reducing vascular permeability, and favouring venous and lymphatic return. These activities had been demonstrated in animals [43, 48, 49]. The Fucus vesiculosus extract has activity mainly on the sucutaneous lipidic catabolism. Its chemical structure is characterized by polysaccharides containing bromine and iodine. The latter shows high bioavaila-

bility and inuences metabolic activity in the subcutaneous fat [43, 49, 50]. As predictable on the basis of the effect of the different ingredients, the product containing Recaptacell obtained the best results, especially in relation to the decrease in volumes and circumferences, due to the better metabolic action locally induced on adipocyte membranes by this component. The important effect of fucus on peripheral fat tissue must also be pointed out: in study 1 relevant changes in body contour were found in the group of patients who had received the product with fucus but not in the group who had taken the product deprived of this component. An additional interesting result was obtained in relation to oxidative stress. A signicant reduction of oxidation-related parameters was found in the treated patients after only 15 days of treatment. It is important to notice that the reduction in Roms test values was higher in patients with a higher oxidative stress, i.e. in patients taking oestroprogestin hormones. The products showed a high level of tolerability: no relevant systemic side effect was reported. Furthermore, the thyroid function and the other main blood parameters investigated were not inuenced, of the products used. In conclusion, the data obtained prove that the mixture of the plant extracts contained in the products under investigation are effective in contrasting several physiopathological steps involved in the pathogenesis of cellulite thus improving all clinical signs and symptoms associated to this condition. In particular, the results focus on the role of the interstitial matrix and the periangium, as well as the mesenchyma, in the evolution of cellulite and are signicant as they allow mesenchyma interstitial activity to be attributed to the product used.

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References
1. Curri, S.B. and Ryan, T.J. Panniculopathy and brosclerosis of the female breast and thigh. In: Cutaneous adipose tissue (Ryan, T.J. and Curri, S.B., eds), pp. 107119. Lippincott, Philadelphia, PA (1989). 2. Comel, M. Histangeiologie et phlebologie. Folia Angiol. 7, 3 (1960). 3. Bacci, P.A. Il lipolinfedema: riessioni e osservazioni cliniche (Minerva Medica, ed.) In: Flebologia Oggi, vol. 2, pp. 1021, Minerva Medica, Torino (1997). 4. Curri, S.B. Cellulite and fatty tissue microcirculation. Cosmet. Toilet. 108, 5158 (1993). 5. Curri, S.B. and Bombardelli, E. Local lipodystrophy and districtual micro-circulation. Cosmet. Toilet. 109, 5165 (1994). ` ` 6. Pierard, G.E., Nizet, J.L. and Pierard-Franchmont, C. Cellulite. Am. J. Dermatopathol. 22, 3437 (2000). 7. Draelos, Z.D. and Marenus, K.D. Cellulite etiology and purported treatment. Dermatol. Surg. 23, 1177 1181 (1997). 8. Allegra, C., Pollari, G., Antonini, V. and Curri, S.B. Pannicolopatia edematobrosclerotica. Minerva Mesoterapica, 1, 2426 (1986). 9. Bacci, P.A., Alberti & Co., ed. Arezzo. In: Le celluliti, pp. 4046. (2000). 10. Rosenbaum, M., Prieto, V., Hellmer, J. et al. An exploratory investigation of the morphology and biochemistry of cellulite. Plast. Reconstr. Surg. 101, 19341939 (1998). 11. Di Salvo, R.M. Controlling the appearance of cellulite. Cosmet. Toilet. 110, 5059 (1995). 12. Soler-Rouanet, B., Adhoute, H. et al. Study of the slimming efcacy of the nutritional supplement Cellulase urto. Int. J. Cosm. Surg. Aesth. Derm. 2, 247254 (2000). 13. Leibaschoff, G.H., Coll, L.R. and Desimone, J.G. Noninvasive assessment of the effectiveness of Cellasene in patients with edematous brosclerotic panniculopathy (Cellulite): a double-blind prospective study. Int. J. Cosm. Surg. Aesth. Derm. 3, 265273 (2001). 14. Bacci, P.A., Allegra, C., Albergati, F., Brambilla, E., Botta, G. and Mancini, S. Randomized, placebo-controlled double blind clinical study of the efcacy of a multifunctional plant complex in the treatment of so-called Cellulite. Int. J. Cosm. Surg. Aesth. Derm. 5, 5368 (2003). 15. Belcaro, G., Caratelli, M., Cornelli, U. et al. A simple test to monitor oxidative stress. Int. Angiol. 18, 127 130 (1999). 16. Ceccarelli, M. La visita in Medicina estetica (Timograf Ed.), pp. 3842. Spezzano Albanese (CS) (1996). 17. Lohman, T.G., Roche, A.F. and Martorell, R. Circumferences. In: Anthropometric standardization reference manual (Lohman, T.G., Roche, A.F. and Martorell, X. eds), pp. 5165. Human Kinetics Book, Champaign, IL (1988).

18. Rona, C. and Berardesca, E. Anticellulite. In: Cosmetics: controlled efcacy studies and regulation 13 (Elsner, P., Merrk, H.F., Maibach, H.I. eds), pp. 167 174. Springer, Germany (1999). 19. De Simone, J., Coll, R. and Leibashoff, G. Evaluacion clinica e instrumental no invasiva de la efectividad de un produco toterapeutico en pacientes portadoras de paniculopatia edematobroesclerotica. Flebologia (Ofcial of Sociedad Argentina de Flebologia y Linfologia) Buenos Aires 25, 1720 (2001). 20. Albergati, F., Menegon, L., Turatelo, X. and Bacci, P.A. Valutazione degli effetti microcircolatori dopo terapia della matrice extracellulare in pazienti con ebolinfedema. Linfologia, 1 Spec.??, 811 (2001). 21. Ceccarelli, M., Giannini, S., Valeriani, M. and Bartoletti, C.A. Verica istologica dei quadri ecograci caratteristici della PEFS. Atti III Congresso Internazionale di Flebolinfologia. n. 16/10, Ferrara, 1821 Settembre (1991). 22. Marshall, M. and Breu, F.X. Diagnostic procedures in venous thrombosis of the legs. Med. Monastsschr Pharm. 21, 173178 (1998). 23. Marshall, M. and Breu, F.X. Duplex scanning of lipedema and lymphedema. Scope Phlebol. Lymphol. 8, 309313 (2001). 24. Fitzerald, K.M., Kupinski, A.M. et al. B-mode ultrasound vein mapping. J. Vascular Technol. 12, 6366 (1998). 25. Nicolaides, A.N. and Miles, C. Photopletismography in the assessment of venous insufciency. J. Vasc. Surg. 5, 405412 (1987). 26. Curri, S.B. Inquadramento nosologico e classicazione delle panniculopatie da stasi. In: Flebologia, vol. 1, pp. 1519. Minerva Medica, ed., Torino (1990). 27. Broccali, G.P., Berti, M., Pistolesi, E. and Cestaro, B. A sucrose and cholesterol rich diet impairs insulin sensitivity and promotes lipoprotein peroxidation in rats: the protective role of a sh oil enriched in policosanols, D-limonene and antioxidants. Int. J. Food Biochem. 27, 1933 (2002). 28. Brambilla, E., Patti, M-E., Kahn, C.R. and Luzi, L. Resistance to insulin effects on protein and glucose metabolism in obese Zucker rat. American Society for Parenteral and Enteral Nutrition Meeting Abstract Book (1996). 29. Allegra, C., Bartolo, M., Carioti, B. and Curri, S.B. Effectiveness of Daon 500 mg on microlymphatics proceedings. World Congress for Microcirculation, Munich, August 12 (1966). 30. Botta, G. and Piccinetti, A. Anatomia del sistema venoso degli arti inferiori. In: Anatomia e Flebologia (Manani, S. ed.), vol. 1, pp. 4150. Utet, Torino (2001). 31. Cheeseman, K.H., Slater, T.F. and Vaisman, S. Mensuracao das reacoes dos radicals livres in vivo. In: Radicais livres em medicina, Interlivros, pp. 1525. Rio de Janeiro (1996).

2006 International Journal of Cosmetic Science, 28, 191206

205

Multifunctional plant complex in the treatment of cellulite

F. Distante et al.

32. Vassalle, C., Lubrano, V., Boni, C., LAbbate, A. and Zucchelli, G.C. Valutazione dei livelli di stress ossidativo in vivo mediante metodo colorimetrico ed immunoenzimatico. Report of CNR (recherche national center), Istituto di Fisiologia Clinica, Pisa, Italy (2001). 33. Bacci, P.A., Izzo, M., Botta, G. and Mancini, S. Evaluacion de la accion antioxidante de productos tofarmacologicos empleados en los sindromes de celulitis con respecto al cigarro y a las hormonas. Int. J. Aesth. Surg. 2, 234240 (2002). 34. Curri, S.B. Local lipodistrophy and districtual microcirculation. In: Microcircolazione. Inverni della Beffa, Roma (Inverni della Beffa, ed.) (1982). 35. Granger, H.J. Role of the interstitial matrix and lymphatic pump in regulation of transcapillary uid balance. Microvasc. Res. 2, 209216 (1979). 36. Piller, N.B. Lymphedema macrophages and benzopyrones. Lymphology 13, 109119 (1980). ` 37. Bacci, P.A. Prise en charge de loedeme de linsufsance veineuse chronique. In: Angiology Today, (Mineva Medica, ed.) n. 34, vol. 2, pp. 34 (1998). 38. Bacci, P.A. Il cosiddetto Lipolinfedema. In: Flebologia Oggi (Mineva Medica, ed.), n.1 vol. 2, pp. 2732. (1998). 39. Griton, P. and Cloarec, M. Venous pain, 30 year after the 1st Inter. Cong. of Phlebology in Chambery. Phlebologie. 45, 2130 (1992). 40. De Simone, J., Coll, R. and Leisbashoff, G. Cellulitis. In: ANME (Ofcial de Asociacion Nacional Medicina Estetica de Mexico) n. 0, pp. 2936. Buenos Aires, Dermoestetica, ed. (2002). 41. Martignani, A. and Scondotto, G. Terapia farmacologica del linfedema con estratto narurale del meliloto. Gazz. Med. Ital. 156, 8558 (1997). 42. Andreozzi, G.M. Manuale di semeiotica strumentale angiologia (Grasso, X. ed.) Bologna (1992).

43. Albergati, F., Lattarulo, P., Bacci, P.A. and Leibasch` off, G. El uso de la medicacion toterapeutica para el ` tratamiento de la paniculopata edemato bro escle` rosa. Flebologa 24, 1923 (2000). 44. Merillon, J.M., Fauconneau, B., Teguo, P.W., Barrier, L., Vercauteren, J. and Huguet, F. Antioxidant activity of the stilbene astringin, newly extracted from vitis vinifera cell cultures. Clin. Chem. 43, 1092 1093 (1997). 45. Goodman, X. and Gilman, X. Las bases farmacologicas de la terapeutica, 9th edn, pp. 654657. McGraw-Hill Interamericana, Mexico (1996). 46. Pittler, M.H. and Ernst, E. Ginkgo biloba extract for the treatment of intermittent claudication: a metaanalyis of randomized trials. Am. J. Med. 108, 276 281 (2000). 47. Pepe, C., Rozza, A. and Veronesi, G. The evaluation by video capillaroscopy of the efcacy of a Ginkgo biloba extract with L-arginine and magnesium in the treatment of trophic lesions in patients with stage IV chronic obliterating arteriopthy. Min. Cardioangiol. 47, 223230 (1999). 48. Pastura, G., Mesiti, M., Saitta, M. et al. Lymphedema of the upper extremity in patients operated for carcinoma of the breast: clinical experience with coumarinic extract from Melilotus ofcinalis. Clin. Ter. 150, 403408 (1999). 49. Morris, C.A., Nicolaus, B., Sampson, V., Harwood, J.L. and Kille, P. Identication and characterization of a recombinant metallothionein protein from a marine alga, Fucus vesiculosus. Biochem. J. 338, 553 560 (1999). 50. Durig, J., Bruhn, T., Zurborn, K.H., Gutensohn, K., Bruhn, H.D. and Beress, L. Anticoagulant fucoidan fractions from Fucus vesiculosus induce platelet activation in vivo. Thromb. Res. 85, 479491 (1997).

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