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The Cellulite Treatment Toolbox

The Cellulite Treatment Toolbox

Injection therapies. When a patient is only concerned about small areas of cellulite or focal indentations in cosmetically sensitive areas of the body, the use of injectable materials can often be an optimal management choice. While any injectable filler can be used, two commonly used injectable fillers are calcium hydroxylapatite (Radiesse) and poly-L-lactic acid (Sculptra).  Both are considered to be biological volumizers; in other words, when injected, they stimulate the creation of new collagen to lift and fill depressed areas of skin while improving the tissue characteristics of the fibrous bands. Hyperdiluted variants of each filler are the best options for reducing the chances of complications such as nodule formation.17-19 Most studies show that you do not need large amounts of filler to have an effective treatment. Combination therapies involving subcision with the use of injectable filler or microfat transfer show even greater efficacy in the treatment of cellulite.20,21

Another novel injection therapy utilizes collagenase enzyme. Cellulite involves thickening of collagen-rich septae attached to the underside of the skin. It is thought that injection of a specific variant of collagenase can help break up these thickened bands of collagen in the septae, which then reduces their tethering effect on the skin. A recent study by Sadick et al22 showed significant improvement in patient Cellulite Severity Scale rating with the use of the collagenase Clostridium histolyticum.

Skin tightening devices. As for skin tightening devices, radiofrequency (RF) and microfocus ultrasound (MFUS) have the most clout. Noninvasive RF devices heat the skin and underlying subcutaneous tissues to specific temperatures associated with skin tightening and lipolysis.23 RF-augmented microneedling devices also are able to improve the appearance of cellulite. These devices can penetrate between 3 mm to 5 mm below the skin’s surface and disrupt the vertical fibrous bands as fat is melted.24

MFUS (Ultherapy) is effective in tightening lax tissues of the face. When used for the focal treatment of cellulite in combination with the injection of dilute calcium hydroxylapatite, improvements in both skin laxity and the appearance of cellulite were noticed after just one treatment session in a study by Casabona et al.25

Lipocontouring techniques. Most specialists treating cellulite will agree that anything that reduces the amount of subcutaneous fat in the body will typically help with the appearance of cellulite. In modern cosmetic medicine, the mainstay of nonsurgical fat reduction happens to be cryolipolysis (CoolSculpting). With this technique, focal areas of fat on the body are placed into an applicator and rapidly cooled to kill fat cells. The treatment has a high success rate for zonal fat reduction but does not improve cellulite alone. However, when the treatment is combined with electromagnetic shockwave therapy, reduction in the appearance of cellulite has been obtained.26,27 The shockwaves work by affecting collagen remodeling in the skin.27,28

Thermal-based laser lipolysis can also improve the appearance of cellulite by reducing focal fat pocket volumes. It provides the added benefit of skin tightening through dermal collagen remodeling from thermal injury. One hypertherimc laser lipolysis device (SculpSure) is an FDA-approved device currently used for noninvasive body contouring. The literature on this device does not focus on cellulite, but the pathway by which cellulite could be improved, especially with multimodality therapy, is thought to be similar.29

Another effective surgical lipocontouring procedure for cellulite involves the use of a 1440-nm Nd-YAG laser liposuction device (Cellulaze) that has a side firing laser port that cuts the fibrous bands to the skin while the laser wavelength itself is ideal for melting fat cells. When used by expert hands, the improvement in the appearance of cellulite can be quite significant. The combination of thermal fat lipolysis and fibrous band excision allows for significant reduction is superficial fat volume while, at the same time, reducing fat compartmentalization. The result is tighter, smoother skin.30,31

Patient satisfaction rates following lipocontouring tend to remain high at the one-year follow-up. However, as with any surgical procedure, there are some risks. Common risks include contour irregularities, loose skin, and skin discoloration, while more severe risks include laser burns and scarring.

Conclusion 

Dermatologists and cosmetic medicine specialists have a variety of tools at their disposal to manage the patient desiring improvement in their cellulite. Each modality has a particular return on investment that can be matched to a patient’s goals. The literature supports the use of multimodality therapies to provide the best
results.21 This makes sense, as cellulite is a multifactorial problem. By developing facility with several therapeutic modalities, clinicians can provide patients with superior results and satisfaction. n

Dr Shah is a clinical assistant professor of surgery at the University of Colorado Health Sciences Center in Denver, where he also maintains a private practice in aesthetic plastic surgery. 

Disclosure: Dr Shah is a consultant for Venus Concepts.

References

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2. Cellulite, the New Word for Fat You Couldn’t Lose Before. Vogue. April 15, 1968.

3. Rossi AB, Vergnanini AL. Cellulite: a review. J Eur Acad Dermatol Venereol. 2000;14(4):251-262. doi:10.1046/j.1468-3083.2000.00016.x

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5. Smalls LK, Hicks M, Passeretti D, et al. Effect of weight loss on cellulite: gynoid lypodystrophy. Plast Reconstr Surg. 2006;118(2):510-516. doi:10.1097/01.prs.0000227629.94768.be

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8. Escalante G,  Bryan P, Rodriguez J. Effects of a topical lotion containing aminophylline, caffeine, yohimbe, l-carnitine, and gotu kola on thigh circumference, skinfold thickness, and fat mass in sedentary females. J Cosmet Dermatol. 2019;18(4):1037-1043. doi:10.1111/jocd.12801

9. Eun Lee K, Bharadwaj S, Yadava U, Gu Kang S. Evaluation of caffeine as inhibitor against collagenase, elastase and tyrosinase using in silico and in vitro approach. J Enzyme Inhib Med Chem. 2018;34(1):927-936. doi:10.1080/14756366.2019.1596904

10. Rosado C, Tokunaga VK, Sauce R, et al. Another reason for using caffeine in dermocosmetics: sunscreen adjuvant. Front Physiol. 2019;10:519. doi:10.3389/fphys.2019.00519

11. Lucassen GW, van der Sluys WL, van Herk JJ, et al. The effectiveness of massage treatment on cellulite as monitored by ultrasound imaging. Skin Res Technol. 1997;3(3):154-160. doi:10.1111/j.1600-0846.1997.tb00180.x

12. Bayrakci Tunay V, Akbayrak T, Bakar Y, Kayihan H, Ergun N. Effects of mechanical massage, manual lymphatic drainage and connective tissue manipulation techniques on fat mass in women with cellulite. J Eur Acad Dermatol Venereol. 2010;24(2):138-142. doi:10.1111/j.1468-3083.2009.03355.x

13. Jameson TB, Black AD, Sharp MH, Wilson JM, Stefan MW, Chaudhari S. The effects of fascia manipulation with fascia devices on myofascial tissue, subcutaneous fat and cellulite in adult women. Cogent Med. 2019;6(1):1-13. doi:10.1080/2331205X.2019.160614

14. Friedmann DP, Vick GL, Mishra V. Cellulite: a review with a focus on subcision. Clin Cosmet Investig Dermatol. 2017;10:17-23. doi:10.2147/CCID.S95830

15. Kaminer MS, Coleman WP 3rd, Weiss RA, Robinson DM, Grossman J. A multicenter pivotal study to evaluate tissue stabilized—guided subcision using the Cellfina device for the treatment of cellulite with 3-year follow-up. Dermatol Surg. 2017;43(10):1240-1248. doi:10.1097/DSS.0000000000001218

16. Green JB, Cohen JL. Cellfina observations: pearls and pitfalls. Sem Cutan Med Surg. 2015;34:144-146. doi:10.12788/j.sder.2015.0176

17. de Albuquerque GC. Fillers and Collagen Stimulator for Body Rejuvenation and Cellulitis. In: Issa M, Tamura B, eds. Botulinum Toxins, Fillers and Related Substances - Clinical Approaches and Procedures in Cosmetic Dermatology. Cham, Switzerland: Springer; 2018:373-379.

18. Goldie K, Peeters W, Alghoul M, et al. Global consensus guidelines for the injection of diluted and hyperdiluted calcium hydroxylapatite for skin tightening. Dermatol Surg. 2018;44(Suppl 1):S32-S41. doi:10.1097/DSS.0000000000001685

19. Sadick N. Treatment for cellulite. Int J Women Dermatol. 2019;5(1):68-72. doi:10.1016/j.ijwd.2018.09.002

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21. Davis DS, Boen M, Fabi SG. Cellulite: patient selection and combination treatments for optimal results - a review and our experience. Dermatol Surg. 2019;45(9):1171-1184. doi:10.1097/DSS.0000000000001776

22. Sadick NS, Goldma MP, Liu G, et al. Collagenase clostridium histolyticum for the treatment of edematous fibrosclerotic panniculopathy (cellulite): a randomized trial. Dermatol Surg. 2019;45(8):1047-1056. doi:10.1097/DSS.0000000000001803

23. Bravo BSF, Torrado CM, Issa MCA. Non-ablative Radiofrequency for Cellulite (Gynoid Lipodystrophy) and Laxity. In: Issa MCA, Tamura B, eds. Lasers, Lights and Other Technologies. Clinical Approaches and Procedures in Cosmetic Dermatology. Cham, Switzerland: Springer; 2016:1-14.

24. Narsete T, Narsete DS. Evaluation of radiofrequency devices in aesthetic medicine: a preliminary report. J Dermatol Ther. 2017;1(1):5-8. 

25. Casabona G, Pereira G. Microfocused ultrasound with visualization and calcium hydroxylapatite for improving skin laxity and cellulite appearance. Plast Reconstr Surg Glob Open. 2017;5(7):e1388. doi:10.1097/GOX.0000000000001388

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27. Knobloch K, Kraemer R. Extracorporeal shock wave therapy (ESWT) for the treatment of cellulite – a current metaanalysis. Int J Surg. 2015;24(Part B):210-217. doi:10.1016/j.ijsu.2015.07.644

28. Modena DAO, da Silva CN, Grecco C, et al. Extracorporeal shockwave: mechanisms of action and physiological aspects for cellulite, body shaping, and localized fat - systematic review. J Cosmet Laser Therapy. 2017;19(6):314-319. doi:10.1080/14764172.2017.1334928

29. Schilling L, Saedi N, Weiss R. 1060nm diode hyperthermic laser lipolysis: the latest in non-invasive body contouring. J Drugs Dermatol. 2017;16(1):48-52.

30. DiBernardo BE. Treatment of cellulite using a 1440-nm pulse aaser with one-year follow-up. Aesthet Surg J. 2011;31(3):328-341. doi:10.1177/1090820X11398353

31. Petti C, Stoneburner J, McLaughlin L. Laser cellulite treatment and laser-assisted lipoplasty of the thighs and buttocks: combined modalities for single stage contouring of the lower body. Lasers Surg Med. 2016;48(1):14-22. doi:10.1002/lsm.22437

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