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CELLULITE. THE VERY WORD

MAKES WOMEN—AND SOME

MEN—CRINGE. It’s a condition

that affects people of all ages and body

types. For decades, treatment options

have been numerous and sometimes

downright medieval, ranging from

machines that vibrate wide canvas

belts surrounding the hips and buttocks

to electrical muscle stimulators,

mechanical massage, and a host of

creams, serums and injectables. The

problem: Until recently, no treatment

modality has offered long-term results.

The introduction of minimally invasive

systems that promise results of two

years or more—including the laser-

based Cynosure Cellulaze and Sciton

CelluSmooth; and Ulthera’s Cellfi na,

which does not rely on heat or energy—

have spurred renewed interest in

cellulite treatment. We asked physicians

who have worked with these systems

to share their experiences in patient

selection, degree of improvement and

longevity of results.

How to manage expectations and

identify the best candidates for

minimally invasive and noninvasive

cellulite treatment options.

By Shelley Moench-Kelly, MBA

SmoothOperators

size of the area treated. Local anesthesia is administered

to the treatment area. Using suction and subcision, the

needle-like device administers pressure on the fi brous

septae. Repeated pressure eventually releases the fi bers

to smooth the skin surface. It can take as little as three

days to see results, which are expected to last at least two

years, and side effects—including soreness, tenderness and

bruising—are minimal.

Clinical trials have posted patient satisfaction rates at

94% after one year and 96% after two years. “I’ve been

in private practice for 28 years. We’ve been trying to fi nd

something that works on cellulite ever since. We kept

being told, ‘This works’ and ‘That works,’ and each time

those options failed,” says Daniel Mills, MD, founder of the

Aesthetic Plastic Surgical Institute in Laguna Beach, California.

“With Cellfi na, there’s minimal discomfort with little or no

downtime, and it only takes one treatment. It is promising.”

Dermatologist Joel L. Cohen, MD, director of AboutSkin

Dermatology and DermSurgery in Englewood and Lone

Tree, Colorado, notes that the ideal Cellfi na patient is one

who “maintains a stable weight, works out regularly, eats a

healthy diet, but simply has some focal areas of persistent

dimple-cellulite.” His patients are seeing improvement in

dimple-release in 10 to 14 days. “We know that some of

that is likely still swelling, but patients have been happy with

the improvement even weeks after treatment,” he says.

The key difference between the two is Cellfi na treats

large focal areas of dimpling but does not address dermal

remodeling, though the lack of laser energy makes Cellfi na

a better choice for some patients. “With Cellulaze, the heat

may trigger hyperpigmentation. But to be fair, I think it’s

accurate to say that less well-defi ned cellulite can benefi t

more from the Cellulaze because it covers a larger area

compared to Cellfi na, which treats more discrete bands,”

says Dr. Kilmer.

Other minimally invasive energy-based options include

Sciton’s CelluSmooth, which uses a 1319nm laser wavelength

to cut fi brous septae, emulsify fat and tighten the dermis to

improve the appearance of dimpled skin, and the VASERsmooth,

a device that ultilizes ultrasound rather than laser energy.

NONINVASIVE OPTIONS

For patients who want a truly noninvasive option, suction and

manipulation treatment methods include: Real Aesthetics’

Bella Contour, a body-shaping treatment method that uses

non-focused ultrasound to promote fat release from cells;

electric currents to help fat penetrate the cells; and vacuum

therapy to help the body fl ush the fat. Patients typically

undergo 10 to 15 treatment sessions.

CELLULITE BASICS

The top layer of fat just under the skin on the thighs, hips

and buttocks is connected to the lower layers of fat by

vertical collagen fi bers (fi brous septae). When estrogen

levels decrease due to factors such as age, so does

circulation and collagen production. As fat cells become

larger, the lack of collagen allows them to protrude through

the fi bers and become visible on the surface of the skin in

a cottage cheese or orange rind appearance.

Cellulite most commonly affects women because

estrogen stimulates subcutaneous fat storage. It appears

in the fat-prone areas of the body: the knees, thighs

and buttocks as well as the stomach and backs of the

arms. The male hormone testosterone, on the other

hand, stimulates protein resulting in more dense layers

of connective tissue and thicker skin layers, which help

to prevent cellulite. “Ninety-eight percent of women

have cellulite because it’s estrogen-based. It’s a female

characteristic,” says Suzanne Kilmer, MD, founder of

the Laser & Skin Surgery Center of Northern California

in Sacramento. “If you put men on estrogen therapy

to treat, for example, prostate cancer, they will actually

develop cellulite.”

MINIMALLY INVASIVE TREATMENT OPTIONS

Two of the most talked-about treatments today are

Cynosure’s Cellulaze and Ulthera’s Cellfi na. Both are

FDA-approved and promise long-term improvement

in the appearance of cellulite in a single treatment.

Cellulaze is a 1440nm laser-based procedure that

takes 60-90 minutes and delivers long-lasting (one year

or more) results after one treatment. Local anesthesia is

applied and tiny incisions are made in the treatment area.

The proprietary laser fi ber is threaded through a cannula

that’s inserted through the incision(s). It levels out fatty

bumps, releases fi brous septae and stimulates collagen

production to increase skin thickness and elasticity.

Clinical trials have noted patient satisfaction rates at 93%

one year after treatment. Side effects include bruising and

general soreness that can last up to a few weeks. Some

patients experience hyperpigmentation. “It works. It’s very

effective. It’s long lasting. But you have to fi nd the right

patient type,” says Cynthia Poulos, MD, founder of Classique

Medical Spa in Northborough, Massachusetts, who was

an early adopter of the procedure that debuted in 2011.

“When you have someone who has reasonable tissue tone

and moderate cellulite, it’s a fantastic procedure.”

Cellfi na, launched in 2016, is a subcision-based, in-offi ce

procedure that takes about one hour, depending on the

“It’s easy to be proud of good results, but you also have to show modest results.”

medestheticsmagazine.com | MARCH 2016 29

SMOOTH OPERATORS

30 MARCH 2016 | MedEsthetics

LPG Systems Endermologie is a handheld treatment

device that grabs about an inch of skin between its rollers

and squeezes it, increasing blood and lymphatic fl ow and

stretching out the fi brous septae. The recommended

number of treatments is about 14.

Radiofrequency (RF)-based treatments are another

alternative. They include the Thermi250, Valeant/Solta

Medical Thermage, BTL Exilis, EndyMed 3DEEP and

Syneron-Candela VelaShape (formerly VelaSmooth). All

are indicated for temporary improvement in the appearance

of cellulite, and Dr. Kilmer confi rms: “VelaShape and

VelaSmooth improve the appearance of cellulite but they

are temporary, with results lasting about one month.”

Topical creams may offer a very short-term improvement

in the appearance of cellulite. There are two key actives

to look for: Caffeine-infused creams help even out the

appearance of cellulite due to the temporary tightening

effects they have on the skin; and creams that contain a

vitamin A derivative can eventually thicken the outer layer

of the skin, making lumps less visible. “Topical creams that

contain caffeine have been shown to reduce swelling and

can lead to a temporary improvement in the appearance

of cellulite,” says Tina Alster, MD, founding director of the

Washington Institute of Dermatologic Laser Surgery in

Washington, D.C.

COMBINING MODALITIESEven with more effective, minimally invasive tools, patients are

best served with a combination of modalities. “For patients

with discrete dimples, Cellfi na treatment is the best option and

can be used in a single session to release the dermal bands

that are responsible for the skin indentations. For patients

with loose skin and contour irregularities, I recommend bulk

tissue heating using Thermage RF to tighten the underlying

skin and build collagen, and VelaShape treatments can be

used to further recontour the skin,” says Dr. Alster.

Dr. Mills combines the subcision of Cellfi na with fat grafting

to provide more signifi cant improvement. “I’ve done Cellfi na

and put in a fat graft if the dimpling is a little bit deeper,” he

says, noting that KYBELLA (Allergan/KYTHERA) may be an

option in the future to address fat bulges, but it remains too

early to know if the product would be effective.

MANAGING PATIENT EXPECTATIONSAs with any procedure, managing patient expectations

can be a challenge. The onslaught of airbrushed, poreless,

smooth-skinned models and celebrities appearing on

magazine covers can cloud the reality that patients face

in their consultations. “Patients should be forewarned

that cellulite will likely not be totally eradicated with these

treatments,” says Dr. Alster. “The best results are obtained

TINA S. ALSTER, MDWashington Institute of

Dermatologic Laser Surgeryskinlaser.com

JOEL L. COHEN, MDAboutSkin Dermatology

aboutskinderm.com

SUZANNE KILMER, MDLaser & Skin Surgery Center

of Northern Californiaskinlasers.com

DANIEL MILLS, MDAesthetic Plastic Surgical Institutedanmillsmd.com

CYNTHIA POULOS, MDClassique Medical Spa

drpoulos.com

SMOOTH OPERATORS

32 MARCH 2016 | MedEsthetics

when patients are able to work in partnership with their

physicians—undergoing in-offi ce treatments to reduce

the cellulite and then maintaining those results with a

good diet, regular exercise and occasional maintenance

treatments as needed.”

Dr. Poulos adds, “You need to show pictures that are

really accurate. It’s easy to be proud of good results, but

you also have to show modest results. I’d rather under

promise and over deliver,” she says. “If a patient hesitates

when I ask if a 50% improvement is acceptable, I’ll tell her

that the procedure is probably not for her. If a patient says, ‘I

don’t want any dimples left,’ I won’t treat her. But if you leave

a patient with the caveat that she might need a touch-up, then

usually she can accept that.”

Another facet to patient satisfaction is patient selection.

Age, health and skin condition are all factors to consider.

“If someone has laxity in her skin and she’s in her 50s, then

she really needs a thigh lift,” says Dr. Mills. “Cellfi na isn’t

going to address that. It’s not going to take care of the extra

skin. If you’re looking at treating the cellulite only, it might

make it look 15% to 20% better. I use before and after

pictures. If the patient thinks it’s not a reasonable result, she

should not have the procedure. Sometimes you need to

turn patients away. Either they have unrealistic expectations,

they’re not good candidates or they don’t need it.”

When treating cellulite with subcision, Dr. Kilmer

considers the age of the patient when mapping out her

treatment plan and explaining potential outcomes. “Because

patients in their 20s, 30s and sometimes early 40s have

much more collagen and elastin, the skin can rebound and

they’re much more likely to respond well,” she says. “As you

get older, skin laxity stays around more. With a younger

patient, we know we can do more releases in a treatment

because we know the skin will tighten up. It isn’t just going

to hang there looking saggy. With older patients, you’re

always assessing to see if they have good skin and if it has

the ability to retract.”

Our panel of experts agrees that genetics and overall

health play a big role in cellulite. “It is safe to say that

maintaining a decent weight—a healthy BMI—good

hydration and getting regular exercise help to keep skin

tone healthy and cellulite at bay. People who bounce up

and down weight-wise have more issues with tissue tone,”

says Dr. Poulos. “There is a genetic component you can’t

do anything about. But you can counsel patients to stay

within a reasonable BMI and use common sense when

it comes to diet, good nutrition and hydration. There

is cumulative trauma to the skin when we’re younger.

Whatever you do shows up on your body later in life.”

Shelley Moench-Kelly is a Vermont-based writer and editor. Treating cellulite requires a combination of septae release, dermal remodeling, and reduction or destruction of adipose cells.

“Topical creams may offer a very short-term improvement in the appearance

of cellulite.”

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