THE SKIN AND ITS RESPONSE TO COMPRESSION FORCES COMPRESSION THERAPY TECHNIQUES AGAINST CELLULITE AND POST SURGERY EDEMA DEVELOPMENT

MANUAL COMPRESSION AND EXERCISE, COMPRESSION BANDAGE, COMPRESSION STOCKING/GARMENT& COMPRESSION PUMP TREATMENT

HEALTHY SKIN RESPONDS TO COMPRESSION THERAPY AND EXERCISE

The skin is designed so that health of the outer .3 mm of its surface is maintained by low grade of pressure and exercise. There are two essential working parts of the skin, the outer tissue and the adipose(fatty) tissue. The outer .3 mm of its surface, which includes the EPIDERMIS and its MICROCIRCULATION of blood supply and lymphatic drainage, works to display, to protect and to provide an immune and endocrine system. MOISTURIZING from within keeps the surface resilient but it is balanced by effective fluid removal, venous and lymphatic drainage. The rest of the dermis is in support and deep to the dermis but closely linked to it is the adipose, fatty tissue. This contributes to the body's shape, disperses the forces of pressure and acts as an endocrine and thermoregulatory system. Into this MICROCIRCULATORY SYSTEM enters an arterial blood supply, divided into rich capillary beds in the upper .3 mm of the skin and in the adipose tissue. Both drain into the venous system. The microcirculatory portion of the skin is drained, cleansed, detoxified by a rich plexus of endothelial cells, the lymphatic capillaries. This endothelial capillary bed exists throughout the adipose tissue but provides very little effective drainage of that system.

POOR (ATROPHIC) SKIN DUE TO LACK OF NUTRITION OR TOO MUCH NOURISHMENT AND NOT ENOUGH EXERCISE (HYPERTROPHIC) SKIN RESPONDS LESS WELL TO COMPRESSION

Skin thickness varies throughout the body's surface influencing the skin's function. These regional differences are due to damage from the sun, obesity, gravity or exposure to cold. Variability of the UPPER DERMIS depends upon a range from atrophy to hypertrophy. Healthy skin has an undulating, well moving epidermis, with rete ridges (healthy plexus of blood vessels and nerves). Poor skin condition is a sign of poor microcirculation of the capillary hairpin loop bed in the papillae situated in the CONNECTIVE TISSUE. When the EPIDERMIS is poorly supported and dilated, it may be visible from the surface as TELANGECTASIA. The LYMPHATIC SYSTEM begins just deep in this capillary bed and is surrounded by a network of collagen and elastic fibers which helps it to be responsive to exercise and compression and links it to the overlying epidermis, perhaps providing low resistance pathways for passage of materials from the epidermis. In poor skin condition, the system loses its efficacy often due to loss of elastin which has been shown in contemporary techniques of ultrasound of the skin.

Indentation of the skin as may occur by indenting a thumb or lying on a wrinkeld pillow, provide indentation marks which, on ultrasound viewing, clearly show indentation into the upper dermis, down to the level of the blood and lymphatic capillary bed. This characteristic highlights the superficial level of the structures and the ease with which these structures can be manipulated on the surface.

A compromised lymphatic system associated with poor venous circulation creates significant changes in the proportions of the tissues. If the drainage system of the skin is impaired, collagen fibers are laid down, there is an accumulation of fat cells and the structure of the thickened tissues is altered, leading to excess leakage(edema) and inflammation(cellulitis). Further expansion of the tissue is limited by its sclerotic fibrosis.

HEALTHY SKIN MAINTENANCE

The ideal healthy skin maintenance program besides good nutrition is a regular submaximal natural exercise regimen, such as walking, swimming, stretching, simple movements which tend to empty the lymphatics in the chest and abdominal cavity before activating the lymphatics in the peripheries.

Simple low grade exerises make use of the normal structure of the skin in which the collagen and elastic fibers extend mechanical signals which may be transduced into biomechanical signals at the cellular level. The fibrous network of supportive collagen and elastin is distributed optimally to allow a response to exercise. In the impaired microcirculation of the skin, one of the additions that has proven very effective in tissue health is compression in the form of manual compression of the skin, manual lymphatic drainage, followed by a low stretch compression bandage or garment, which allows the exercise to be felt by the tissues and in which working compression at the surface of the skin may occur when muscles in the deeper tissues contract.

MANUAL COMPRESSION OF THE SKIN

Manual drainage therapy of edema causes volume reduction. Subsequent compression therapy with bandages, compression stockings, and pneumomassage is used to preserve the therapeutic success. Compression results in increased tissue pressure with the following consequences:

• 1. reduction of abnormally increased ultrafiltration into the interstitium
• 2. improved reabsorption from the interstitium
• 3. joint- and muscle pump becomes more effective
• 4. reduction of fibrosis or sclerosis of the interstitium

Compression results in higher drainage activity -motoricity- of the lymphvessels as well as the initial Lymphatics and lymphcapillaries in the epidermis.

The extent of these effects depend upon compression pressure, the used compression and the mobility during compression.

BANDAGING TREATMENT

The bandage material used determines the depth of the compression effect on the epidermis or deep regions. Short stretch bandages are primarily used for the compression of cellulite, primary and secondary lymphedema and combination forms, i.e. venous-lymphedema, venous-lipo-lymphedema. The use of SHORT STRETCH bandages cause high pressure during exercise and general physical activity and relatively low pressure while the body is resting. An ACE or LONG STRETCH bandage is not as useful for compression because the required bandage pressure results in a disturbed skin perfusion. SHORT STRETCH bandages, however, allow adequate drainage of the lymphatic fluid, waste ands toxins. The 'massaging' effect of the bandages on the tissues underneath can be enhanced by special 'padding' foam of high density. Even obstinate connective tissue proliferation can be loosened this way.

COMPRESSION STOCKING/GARMENT TREATMENT

There are four standardized grades of compression stockings/garments available to treat cellulite, edema and the various combination forms. For cellulite and postsurgery edemas three grades of compression are recommended Grade1:Superficial effect;ankle pressure 18-21mmHg Grade2:Medium superficial effect;25-32 mmHg Grade3:Superficial & deep tissue effect:36-46mmHg

Compression stockings/garments are customized following 4-6 weeks of compression drainage therapy-manual lymphdrainage, bandaging, exercise, compression pump.

Sufficient long term therapy vitally depends on the proper adjustment and use of compression stockings/garments. There is no standard formula for the correct adjustment. However, individual differences such as severity and localization of edema, the clients age and the existence of an additional problem must always be considered.

Exact individual adjustment of the compression garment is an important precondition to achieve optimal wearing comfort. The desired effect can only be achieved with full compliance of the client

COMPRESSION PUMP TREATMENT

Intermittant pneumatic compression with multiple chamber instruments and pressure buil up from distal to proximal has been used in Europe to support and conserve the therapeutic effect of the Combined Compression Therapies. Instrumental compression-20-80mmHg- has been beneficial to manage peripheral edemas (and cellulite) of the arms and legs, respectively, because of technical reasons. However, pneumomassage of the legs and arms causes the edema to shift into the adjacant trunk quadrant which must then be treated with manual lymph drainage. Only recently a multi-purpose pneumomassage device- the BALLANCER- has been introduced by the manufacturers of the LYMPHAPRESS compression pump widely known for its effectiveness in the treatment of lymphatic and venous disorders.

The BALLANCER COMPRESSION device is peristaltic and does not exceed 80mmHg compression which is the recommended norm for such kind of device. It activates a full body suit over the trunk quadrants performing a peristaltic massage in two stages. The body suit ensures effective and total treatment from ankles to shoulders. The pressure adjustable jacket -20-80mmHg- gives an upper body massage of the arms and shoulders and the pants provide a lower body massage of the legs, thighs, abdomen, hips and buttock, thus accounting for trunkal drainage. Comprehensive research by plastic surgeons and physiotherapists has been showing promissing results in removal of excess interstitial stagnating fluid accelerating venous and lymph fluid return.

This unique device has also been very effective in fluid activation in pre-and post liposuction procedure, varicose veins, and cellulite (soft connective tissue and venous and lymphatic circulation) problems.

It is important to continuously evaluate the client's progress in edema reduction. Since instrumental compression is limited to peripheral edema it is often necessary to supplement this treatment format with manual lymph drainage and/or bandaging in order to accomplish optimal results.