We finally have effective interventions that address the root cause of cellulite (fibrous tethers). Now, patient education and selection becomes paramount. Long horizontal lines and the infragluteal cleft or bulge, the so-called “banana-roll” cannot be corrected with these interventions. Prior to performing cellulite procedures we must impart this knowledge to our patients to ensure realistic expectations.
Cellulite is a remarkably prevalent condition, affecting up to 90% of women. Whether it’s a “by the way” question posited during a skin check, or a specific cosmetic consult, patients often turn to their dermatologist for advice on its treatment. Cellulite is characterized by dimpling and uneven skin texture on the buttocks and thighs starting at puberty.
Although cellulite presents no health risk, it can be psychosocially debilitating for those who suffer from it. Men can also rarely be affected. The precise etiology of cellulite is unknown, though it is presumed to be a hormonal process due to estrogen, given the timing of its onset as well as the potential for exacerbation during pregnancy, nursing and use of oral contraceptives.
In recent years the pathogenesis of the clinical appearance of cellulite has been elucidated. Fibrous bands attached to the deep fascia, coursing through the subcutaneous fat in a perpendicular orientation to the surface of the skin, insert into the undersurface of the skin. When a patient is standing the fat around these cords (or tethers) protrudes, causing a dimpled appearance to the skin. Cellulite results in skin described by many colorful terms-including peau d’orange, mattress-like, tufted-cushions, and cottage cheese-none of which are desirable. Consequently, clinicians have attempted multiple interventions including exercise, weight loss, topical products, and non-invasive and invasive devices.
Topical preparations including vitamins A, C, E, caffeine and Gingko biloba, among others, are widely used by cellulite sufferers, but there is no published data to support their efficacy.1 Purported mechanisms of action of these topicals include restoring the normal structure of the dermis and subcutaneous tissues, preventing free-radical formation, reducing lipogenesis and increasing microcirculation flow.
Despite the enthusiasm of our patients for topically applied products, in-office treatments offer the best hope of improving the appearance of their cellulite. Recent reports suggest the effectiveness of acoustic wave therapy (AWT), whereby high-intensity ultrasound waves disrupt the cellular membrane of adipocytes by causing shear stress and inducing lipolysis. One group treated 15 women with AWT on the lateral thighs and hips eight times in four weeks.2 At three-month follow-up, they observed a 1.7 cm reduction in thigh circumference versus the untreated control side and noted that this improved the appearance of cellulite.
Radiofrequency (RF) energy has also been utilized for cellulite. It uses an electric current to heat the dermis and subcutaneous tissues, purportedly tightening the fibrous septae as well as inducing apoptosis of adipocytes.3
Infrared light (IR) has also been used for cellulite, and is thought to denature collagen, thereby inducing its contraction and thickening, leading to skin tightening. TriActive (DEKA) uses 6 diode lasers with massage, suction and cooling, whereas SmoothShapes (Cynosure) utilizes diode laser with heat induction and massage. Some devices combine massage, RF and IR (Velashape), whereas others use ultrasound energy to treat fat and improve the appearance of cellulite (Ultrashape [Syneron/Candela]).
With our understanding of the pathophysiology of cellulite, it follows that any long-lasting successful treatment would directly impact the tethered bands. One such technology utilizes a 1440-nm Nd:YAG side-firing laser to treat the fibrous septae, (Cellulaze, Cynosure). After cellulite dimples are marked and prepped, tumescent anesthesia is introduced, followed by the laser cannula. A three-step treatment approach is undertaken, whereby first the laser fiber is angled downward to treat fat (1 - 2 cm depth), next parallel to the skin surface for thermal subcision (3 - 5 mm depth), then upwards towards the undersurface of the skin to induce dermal remodeling.4 In the study cited, 15 women were treated with Cellulaze and, at six month follow-up on 3-D imaging, there was a 49% mean decrease in depth of skin dimples, and 66% of patients showed improvement in overall skin contour.
Subcision, with manual needle release of the fibrous tethers, has been performed for many years, however it is not widely practiced due to its non-reproducibility and morbidity including pain and bruising. The Cellfina System (Ulthera/Merz) has updated the subcision technique in a way that makes it depth-controlled, reproducible, reliable and safe. With the patient standing in proper overhead light to accentuate the contours of the skin of the thighs and buttocks, the dimples are individually marked. The patient is then placed in a prone position. A vacuum-assisted suction handpiece is placed over each marked area for tissue acquisition, and tumescent anesthesia is delivered using a multi-hole 22-gauge needle at a depth of 6 mm for a total of approximately 500cc. The same suction handpiece is then applied to each site and mechanical release of the fibrous septae is performed using a reciprocating (forward and backward) microblade in a sweeping motion at 6 mm or 10 mm depth.
In the pivotal trial5 55 women were treated. Average discomfort was 4.5/10 during anesthetic infiltration, and 3/10 during tissue release. Bruising occurred in 37/54 subjects at 2-week follow-up. At three-month follow-up there was a mean 2.1 point improvement in cellulite appearance on a five-point scale and a 93% improvement in lesions per independent assessment of before and after images by blinded physicians. The Cellfina device is FDA-cleared for one year. However there are patients treated by the original investigators (including MSK) in 2010 that have experienced no recurrence of their cellulite lesions.
We have found that patients describe any undesirable feature on their skin from the umbilicus to the knees as cellulite. Now that we finally have effective interventions that address the root cause of cellulite (fibrous tethers), patient education and selection becomes paramount. Long horizontal lines and the infragluteal cleft or bulge, the so-called “banana-roll” cannot be corrected with these interventions. Prior to performing cellulite procedures we must impart this knowledge to our patients to ensure realistic expectations. As with any treatment in medicine, aesthetic in particular, primum non nocere should be our guiding principle.
Disclosures: Drs. Green and Kaminer perform research and are on the speakers bureau for Ulthera (Cellfina). Drs. Green and Kaufman have served on the speakers bureau for Cynosure.
Hexsel D, Soirefmann M. Cosmeceuticals for cellulite. Semin Cutan Med Surg. 2011;30(3):167-70.
Sadick NS, Nassar AH, Dorizas AS, Alexiades-armenakas M. Bipolar and multipolar radiofrequency. Dermatol Surg. 2014;40 Suppl 12:S174-9.
Zelickson BD, Kist D, Bernstein E, et al. Histological and ultrastructural evaluation of the effects of a radiofrequency-based nonablative dermal remodeling device: a pilot study. Arch Dermatol. 2004;140(2):204-9.
Katz B. Quantitative & qualitative evaluation of the efficacy of a 1440 nm Nd:YAG laser with novel bi-directional optical fiber in the treatment of cellulite as measured by 3-dimensional surface imaging. J Drugs Dermatol. 2013;12(11):1224-30.
Kaminer MS, Coleman WP, Weiss RA, Robinson DM, Coleman WP, Hornfeldt C. Multicenter pivotal study of vacuum-assisted precise tissue release for the treatment of cellulite. Dermatol Surg. 2015;41(3):336-47.