## 4 Discussion
### Lymphedema, Drainage, and Pheolymphology  
As a result of endermologie treatments, specific tissue drainage occurs. This may be the result of metabolic stimulation and the activation of the autonomous nervous system. This treatment works on the principle of physical decongestion while improving extracellular fluid and lymphatic drainage. Endermologie in combination with intensive decongestive treatment improves upper limb volume reduction compared with the standard of care for breast cancer lymphedema. After treatments, there was a reduction in excess fluid volume in the upper limb. The effect also improved patient psychological and social well-being [15]. The LPG technique combined with compression bandaging improved the subjective symptoms of lymphedema. Treatments resulted in a reduction in arm volume and arm and truncated fluid and a softening in lymphatic territories [13]. Studies using endermologie have shown that it improves lymphatic transport capacity and superficial lymphatic drainage and decreases fibrotic tightness, induration, heaviness, and functional discomfort [38].  
[PERSON] [PERSON] et al., in their ELOCS Phase II, randomized, controlled trial, investigated a new approach to breast cancer-related lymphedema (BCRL) treatment by incorporating endermologie alongside standard intensive decongestive therapy (IDT). The study compared three groups: IDT alone, IDT with manual lymphatic drainage (MLD) and endermologie, and IDT with endermologie only over a 5-day period. Although the predefined success threshold (\(\geq\)30% volume reduction in at least 21/31 patients) was not met, endermologie showed comparable effectiveness to conventional therapy, with mean limb volume reductions of 38% (IDT), 33% (IDT + MLD + endermologie), and 34% (IDT + endermologie). The success rate was highest in the IDT + endermologie group (64.5%), suggesting that mechanical stimulation can be a valuable adjunct in BCRL management. However, 16% of patients reported pain and 15% found the treatment unpleasant, highlighting the need for further optimization. Despite these limitations, the study validated a standardized and reproducible endermologie protocol, supporting its potential role in lymphedema care [15].  
Findings supporting the use of endermologie suggest that this therapy may enhance lymphatic flow, leading to a reduction in limb volume. [PERSON] et al. analyzed the physiological effects of vacuum therapy on the skin, demonstrating an increase in fibroblast and collagen production as well as improved tissue elasticity, which promotes lymphatic drainage [3]. [PERSON]'s study showed that endermologie can improve range of motion (e.g., flexion, abduction), reduce pain, and decrease limb volume, ultimately enhancing patients' quality of life. [PERSON] et al. evaluated the efficacy of endermologie vs. decongestive lymphatic therapy (DLT) in reducing post-mastectomy lymphedema and pain and improving shoulder mobility. Forty women (30-50 years) with unilateral post-mastectomy lymphedema were randomized into an endermologie group (n = 20), DLT group (n = 20), and endermologie group with 4 sessions/week for 4 weeks. There was a greater reduction in limb volume and pain and improved ROM in the endermologie group (\(p\) < 0.001). A comparison of endermologie with low-level laser therapy in [PERSON]'s study revealed no significant differences in lymphedema reduction at the start of therapy. However, by the end of treatment, endermologie resulted in more substantial changes in arm volume and circumference compared to laser therapy. This discrepancy in findings highlights the need for further research to understand the mechanisms and long-term efficacy of this method [16].