The Cellulite Treatment Toolbox

Cellulite might sound like a sexy name for a high-tech fabric, but it is not. When called by its actual name, edematous fibrosclerotic panniculopathy, it definitely does not sound so sexy! While cellulite poses no significant health risk, it can cause a significant amount of cosmetic embarrassment. While cellulite affects up to 90% of the female population, its prevalence indicates that it is a physiologic, rather than pathologic, process.¹

The term cellulite was first used in the 1920s to market the services of beauty spas and was first seen in English-language periodicals such as Vogue in 1968.² A myriad of treatments have been developed to treat cellulite, though most have limited success. Today’s slim-fit, revealing clothing make surface irregularities associated with cellulite harder to hide, driving the desire in consumers for effective treatments.

What It Is

Cellulite is caused by the herniation of subcutaneous fat within vertical fibrous connective tissue bands that manifests topographically as skin dimpling and nodularity. It is most commonly found in the pelvic region (specifically the buttocks), lower limbs, and abdomen,and cellulite occurs in most post-pubescent women.³ There are several factors that can enhance the appearance of cellulite: poor diet, yo-yo weight loss, slow metabolism, lack of physical activity, reduction in estrogen levels causing reduction in the production of good collagen, dehydration, excess total body fat, thin skin, and lighter colored skin.⁴ These factors affect one or more of the following: volume of fat, strength of fibrous connective tissue, or thickness of skin. 

Current Treatment Options

While many treatment modalities have been developed in recent years, not many have had much success. Researchers have been able to show some reproducible success in the treatment of the condition with multimodality therapies. While there is no “cure” for cellulite, these treatments have the potential to improve the appearance of cellulite and patient satisfaction.

Weight loss. Any patient who is overweight and presents with complaints of cellulite will need to recognize that one thing they can do at home is create a lifestyle that aids in gentle, consistent weight loss. Reducing excessive subcutaneous fat reduces the stress on the fibrous compartments in the superficial skin and results in less obvious cobblestone appearance. This is in stark contrast to yo-yo dieting, which causes cellulite to worsen by repeatedly stretching and shortening collagen fibers in the skin to the point of failure. Reduction in tensile strength of these fibers increases their laxity, causing visual malformation of the skin’s surface.⁵

Topical creams. The cosmeceutical market is filled with creams that promise the impossible: a cure for cellulite. Most simply never live up to those claims.⁶ There are a few topical ingredients, however, that have been shown to have an effect. One such ingredient is 0.3% retinol. Vitamin A-derivative retinoids such as retinol are known to help increase the thickness and strength of the skin. Research has shown that using topical 0.3% retinol for at least 6 months can help improve the appearance of cellulite.⁷

Another ingredient shown to be effective for treating cellulite is topical caffeine. Caffeine is added to antiaging skin care creams because of its ability to “tighten” skin as a vasoconstrictor that reduces intracellular edema and a promoter of lipolysis. This, in turn, shrinks the fluid-filled fat cells and causes a tightening effect in the superficial skin, resulting in smoother looking skin.^8,9 Caffeine is also a known antioxidant, and its use promotes the reduction of free radicals in the skin and can augment the protective effects of sunscreen against UV photoaging.¹⁰ Caffeinated creams must be used daily to maintain the effects. 

Aminophylline/theophylline creams function in a way similar to caffeine. In one study that compared patients using a topical preparation containing aminophylline vs placebo, results showed a significant reduction in the appearance of cellulite.⁸

Tissue massage. Over the last 20 years, there has been exploration of the idea that massage (soft tissue massage, manual lymphatic drainage, connective tissue manipulation, and vacuum massage [eg, Endermologie]) can improve the appearance of cellulite. While the exact mechanism by which massage helps is unknown, it has been shown to help skin by draining excess lymphatic fluid, redistributing and reducing fat cell mass, and improving microcirculation in the skin.^11-13 While this may sound great, these studies^11-13 showed the appearance of cellulite returned within 3 months after cessation of treatment protocols. Additionally, the risks of deeper massage techniques include skin injury, bruising, hematoma, and hemosiderin deposition. Though not a cure, massage may be a valuable adjunct for patients, especially in terms of at-home management.  

Subcision modalities. Subcision is known to help improve the appearance of indented scars by cutting and releasing fibrous connections to the skin’s surface using specialized cutting needles or forked liposuction cannulas. It is also an excellent technique to reduce the appearance of cellulite in more limited or focal areas.¹⁴

Vacuum subcision is one particular technical variant of this approach. One vacuum subcision device (Cellfina) has shown excellent results; with this device, larger indentations can be suctioned into the device and cut at two different depths to provide significant and complete tissue release. Patient satisfaction is extremely high with this treatment, with a low incidence of significant side effects and results maintained for at least 3 years.^15,16

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

1. Luebberding S, Krueger N, Sadick N. Cellulite: an evidence-based review. Am J Clin Dermatol. 2015;16(4):243-256. doi:10.1007/s40257-015-0129-5

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

4. Terranova F, Berardesca E, Maibach H. Cellulite: nature and aetiopathogenesis. Int J Cosmet Sci. 2006;28(3):157-167. doi:10.1111/j.1467-2494.2006.00316.x

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

6. Hexsel D, Soirefmann M. Cosmeceuticals for cellulite. Sem Cutan Med Surg. 2011;30(3):167-170. doi:10.1016/j.sder.2011.06.005

7. Kligman A, Pagnoni A, Stoudemayer T. Topical retinol improves cellulite. J Dermatol Treatment. 1999;10(2):119-125. doi:10.3109/09546639909056013

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

20. Uebel CO, Piccinini PS, Martinelli A, Aguiar DF, Ramos RFM. Cellulite: a surgical treatment approach. Aesth Surg J. 2018;38(10):1099-1114. doi:10.1093/asj/sjy028

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

26. Angehrn F, Kuhn C, Voss A. Can cellulite be treated with low-energy extracorporeal shock wave therapy? Clin Interv Aging. 2007;2(4):623-630.

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

Cellulite might sound like a sexy name for a high-tech fabric, but it is not. When called by its actual name, edematous fibrosclerotic panniculopathy, it definitely does not sound so sexy! While cellulite poses no significant health risk, it can cause a significant amount of cosmetic embarrassment. While cellulite affects up to 90% of the female population, its prevalence indicates that it is a physiologic, rather than pathologic, process.¹

The term cellulite was first used in the 1920s to market the services of beauty spas and was first seen in English-language periodicals such as Vogue in 1968.² A myriad of treatments have been developed to treat cellulite, though most have limited success. Today’s slim-fit, revealing clothing make surface irregularities associated with cellulite harder to hide, driving the desire in consumers for effective treatments.

What It Is

Cellulite is caused by the herniation of subcutaneous fat within vertical fibrous connective tissue bands that manifests topographically as skin dimpling and nodularity. It is most commonly found in the pelvic region (specifically the buttocks), lower limbs, and abdomen,and cellulite occurs in most post-pubescent women.³ There are several factors that can enhance the appearance of cellulite: poor diet, yo-yo weight loss, slow metabolism, lack of physical activity, reduction in estrogen levels causing reduction in the production of good collagen, dehydration, excess total body fat, thin skin, and lighter colored skin.⁴ These factors affect one or more of the following: volume of fat, strength of fibrous connective tissue, or thickness of skin. 

Current Treatment Options

While many treatment modalities have been developed in recent years, not many have had much success. Researchers have been able to show some reproducible success in the treatment of the condition with multimodality therapies. While there is no “cure” for cellulite, these treatments have the potential to improve the appearance of cellulite and patient satisfaction.

Weight loss. Any patient who is overweight and presents with complaints of cellulite will need to recognize that one thing they can do at home is create a lifestyle that aids in gentle, consistent weight loss. Reducing excessive subcutaneous fat reduces the stress on the fibrous compartments in the superficial skin and results in less obvious cobblestone appearance. This is in stark contrast to yo-yo dieting, which causes cellulite to worsen by repeatedly stretching and shortening collagen fibers in the skin to the point of failure. Reduction in tensile strength of these fibers increases their laxity, causing visual malformation of the skin’s surface.⁵

Topical creams. The cosmeceutical market is filled with creams that promise the impossible: a cure for cellulite. Most simply never live up to those claims.⁶ There are a few topical ingredients, however, that have been shown to have an effect. One such ingredient is 0.3% retinol. Vitamin A-derivative retinoids such as retinol are known to help increase the thickness and strength of the skin. Research has shown that using topical 0.3% retinol for at least 6 months can help improve the appearance of cellulite.⁷

Another ingredient shown to be effective for treating cellulite is topical caffeine. Caffeine is added to antiaging skin care creams because of its ability to “tighten” skin as a vasoconstrictor that reduces intracellular edema and a promoter of lipolysis. This, in turn, shrinks the fluid-filled fat cells and causes a tightening effect in the superficial skin, resulting in smoother looking skin.^8,9 Caffeine is also a known antioxidant, and its use promotes the reduction of free radicals in the skin and can augment the protective effects of sunscreen against UV photoaging.¹⁰ Caffeinated creams must be used daily to maintain the effects. 

Aminophylline/theophylline creams function in a way similar to caffeine. In one study that compared patients using a topical preparation containing aminophylline vs placebo, results showed a significant reduction in the appearance of cellulite.⁸

Tissue massage. Over the last 20 years, there has been exploration of the idea that massage (soft tissue massage, manual lymphatic drainage, connective tissue manipulation, and vacuum massage [eg, Endermologie]) can improve the appearance of cellulite. While the exact mechanism by which massage helps is unknown, it has been shown to help skin by draining excess lymphatic fluid, redistributing and reducing fat cell mass, and improving microcirculation in the skin.^11-13 While this may sound great, these studies^11-13 showed the appearance of cellulite returned within 3 months after cessation of treatment protocols. Additionally, the risks of deeper massage techniques include skin injury, bruising, hematoma, and hemosiderin deposition. Though not a cure, massage may be a valuable adjunct for patients, especially in terms of at-home management.  

Subcision modalities. Subcision is known to help improve the appearance of indented scars by cutting and releasing fibrous connections to the skin’s surface using specialized cutting needles or forked liposuction cannulas. It is also an excellent technique to reduce the appearance of cellulite in more limited or focal areas.¹⁴

Vacuum subcision is one particular technical variant of this approach. One vacuum subcision device (Cellfina) has shown excellent results; with this device, larger indentations can be suctioned into the device and cut at two different depths to provide significant and complete tissue release. Patient satisfaction is extremely high with this treatment, with a low incidence of significant side effects and results maintained for at least 3 years.^15,16

Cellulite might sound like a sexy name for a high-tech fabric, but it is not. When called by its actual name, edematous fibrosclerotic panniculopathy, it definitely does not sound so sexy! While cellulite poses no significant health risk, it can cause a significant amount of cosmetic embarrassment. While cellulite affects up to 90% of the female population, its prevalence indicates that it is a physiologic, rather than pathologic, process.¹

The term cellulite was first used in the 1920s to market the services of beauty spas and was first seen in English-language periodicals such as Vogue in 1968.² A myriad of treatments have been developed to treat cellulite, though most have limited success. Today’s slim-fit, revealing clothing make surface irregularities associated with cellulite harder to hide, driving the desire in consumers for effective treatments.

What It Is

Cellulite is caused by the herniation of subcutaneous fat within vertical fibrous connective tissue bands that manifests topographically as skin dimpling and nodularity. It is most commonly found in the pelvic region (specifically the buttocks), lower limbs, and abdomen,and cellulite occurs in most post-pubescent women.³ There are several factors that can enhance the appearance of cellulite: poor diet, yo-yo weight loss, slow metabolism, lack of physical activity, reduction in estrogen levels causing reduction in the production of good collagen, dehydration, excess total body fat, thin skin, and lighter colored skin.⁴ These factors affect one or more of the following: volume of fat, strength of fibrous connective tissue, or thickness of skin. 

Current Treatment Options

While many treatment modalities have been developed in recent years, not many have had much success. Researchers have been able to show some reproducible success in the treatment of the condition with multimodality therapies. While there is no “cure” for cellulite, these treatments have the potential to improve the appearance of cellulite and patient satisfaction.

Weight loss. Any patient who is overweight and presents with complaints of cellulite will need to recognize that one thing they can do at home is create a lifestyle that aids in gentle, consistent weight loss. Reducing excessive subcutaneous fat reduces the stress on the fibrous compartments in the superficial skin and results in less obvious cobblestone appearance. This is in stark contrast to yo-yo dieting, which causes cellulite to worsen by repeatedly stretching and shortening collagen fibers in the skin to the point of failure. Reduction in tensile strength of these fibers increases their laxity, causing visual malformation of the skin’s surface.⁵

Topical creams. The cosmeceutical market is filled with creams that promise the impossible: a cure for cellulite. Most simply never live up to those claims.⁶ There are a few topical ingredients, however, that have been shown to have an effect. One such ingredient is 0.3% retinol. Vitamin A-derivative retinoids such as retinol are known to help increase the thickness and strength of the skin. Research has shown that using topical 0.3% retinol for at least 6 months can help improve the appearance of cellulite.⁷

Another ingredient shown to be effective for treating cellulite is topical caffeine. Caffeine is added to antiaging skin care creams because of its ability to “tighten” skin as a vasoconstrictor that reduces intracellular edema and a promoter of lipolysis. This, in turn, shrinks the fluid-filled fat cells and causes a tightening effect in the superficial skin, resulting in smoother looking skin.^8,9 Caffeine is also a known antioxidant, and its use promotes the reduction of free radicals in the skin and can augment the protective effects of sunscreen against UV photoaging.¹⁰ Caffeinated creams must be used daily to maintain the effects. 

Aminophylline/theophylline creams function in a way similar to caffeine. In one study that compared patients using a topical preparation containing aminophylline vs placebo, results showed a significant reduction in the appearance of cellulite.⁸

Tissue massage. Over the last 20 years, there has been exploration of the idea that massage (soft tissue massage, manual lymphatic drainage, connective tissue manipulation, and vacuum massage [eg, Endermologie]) can improve the appearance of cellulite. While the exact mechanism by which massage helps is unknown, it has been shown to help skin by draining excess lymphatic fluid, redistributing and reducing fat cell mass, and improving microcirculation in the skin.^11-13 While this may sound great, these studies^11-13 showed the appearance of cellulite returned within 3 months after cessation of treatment protocols. Additionally, the risks of deeper massage techniques include skin injury, bruising, hematoma, and hemosiderin deposition. Though not a cure, massage may be a valuable adjunct for patients, especially in terms of at-home management.  

Subcision modalities. Subcision is known to help improve the appearance of indented scars by cutting and releasing fibrous connections to the skin’s surface using specialized cutting needles or forked liposuction cannulas. It is also an excellent technique to reduce the appearance of cellulite in more limited or focal areas.¹⁴

Vacuum subcision is one particular technical variant of this approach. One vacuum subcision device (Cellfina) has shown excellent results; with this device, larger indentations can be suctioned into the device and cut at two different depths to provide significant and complete tissue release. Patient satisfaction is extremely high with this treatment, with a low incidence of significant side effects and results maintained for at least 3 years.^15,16

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

1. Luebberding S, Krueger N, Sadick N. Cellulite: an evidence-based review. Am J Clin Dermatol. 2015;16(4):243-256. doi:10.1007/s40257-015-0129-5

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

4. Terranova F, Berardesca E, Maibach H. Cellulite: nature and aetiopathogenesis. Int J Cosmet Sci. 2006;28(3):157-167. doi:10.1111/j.1467-2494.2006.00316.x

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

6. Hexsel D, Soirefmann M. Cosmeceuticals for cellulite. Sem Cutan Med Surg. 2011;30(3):167-170. doi:10.1016/j.sder.2011.06.005

7. Kligman A, Pagnoni A, Stoudemayer T. Topical retinol improves cellulite. J Dermatol Treatment. 1999;10(2):119-125. doi:10.3109/09546639909056013

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

20. Uebel CO, Piccinini PS, Martinelli A, Aguiar DF, Ramos RFM. Cellulite: a surgical treatment approach. Aesth Surg J. 2018;38(10):1099-1114. doi:10.1093/asj/sjy028

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

26. Angehrn F, Kuhn C, Voss A. Can cellulite be treated with low-energy extracorporeal shock wave therapy? Clin Interv Aging. 2007;2(4):623-630.

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

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

1. Luebberding S, Krueger N, Sadick N. Cellulite: an evidence-based review. Am J Clin Dermatol. 2015;16(4):243-256. doi:10.1007/s40257-015-0129-5

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

4. Terranova F, Berardesca E, Maibach H. Cellulite: nature and aetiopathogenesis. Int J Cosmet Sci. 2006;28(3):157-167. doi:10.1111/j.1467-2494.2006.00316.x

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

6. Hexsel D, Soirefmann M. Cosmeceuticals for cellulite. Sem Cutan Med Surg. 2011;30(3):167-170. doi:10.1016/j.sder.2011.06.005

7. Kligman A, Pagnoni A, Stoudemayer T. Topical retinol improves cellulite. J Dermatol Treatment. 1999;10(2):119-125. doi:10.3109/09546639909056013

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

20. Uebel CO, Piccinini PS, Martinelli A, Aguiar DF, Ramos RFM. Cellulite: a surgical treatment approach. Aesth Surg J. 2018;38(10):1099-1114. doi:10.1093/asj/sjy028

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

26. Angehrn F, Kuhn C, Voss A. Can cellulite be treated with low-energy extracorporeal shock wave therapy? Clin Interv Aging. 2007;2(4):623-630.

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