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Treatment for cellulite


Abstract and Figures

Cellulite is a multifactorial condition that is present in 80% to 90% of postpubertal women and is one of the most intolerable esthetic imperfections. There are several theories on the pathophysiology of cellulite, and a number of different therapeutic regimens have been developed, from topical treatments to mechanical or energy-based devices. In this brief review, we summarize the scientific landscape to determine the clinical evidence with regard to the safety and efficacy of cellulite treatment options. Clinical protocols and the author's experience using a combination of internal and external procedures are also discussed. Studies using laser and light modalities along with radiofrequency have shown improvements in cellulite and a good safety profile, but acoustic wave therapy, subcision, and the 1440-nm Nd:YAG minimally invasive laser have demonstrated the most beneficial results in cellulite reduction. Although there is paucity of scientific evidence for treatments that improve cellulite, future emerging options and their combination may pave the way to eradicate this primarily cosmetic esthetic concern.
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Treatment for cellulite
Neil Sadick, MD
Department of Dermatology, Weill Cornell Medical College, New York, New York
Sadick Dermatology, New York, New York
abstractarticle info
Article history:
Received 14 June 2018
Received in revised form 10 September 2018
Accepted 11 September 2018
Cellulite is a multifactorial condition that is present in 80% to 90% of postpubertal women and is one of the
most intolerable esthetic imperfections. Thereare several theories on thepathophysiologyof cellulite, and a
number of different therapeutic regimens have been developed, from topical treatments to mechanical or
energy-based devices. In this brief review, we summarize the scientic landscape to determine the clinical
evidence with regard tothe safety and efcacy of cellulite treatment options.Clinical protocols and the au-
thors experience using a combination of internal and external procedures are also discussed. Studies using
laser and light modalities along with radiofrequency have shown improvements in cellulite and a good
safety prole, but acoustic wave therapy, subcision, and the 1440-nm Nd:YAG minimally invasive laser
have demonstrated the most benecial results in cellulite reduction. Although there is paucity of scientic
evidence for treatments that improve cellulite, future emerging options and their combination may pave
the way to eradicate this primarily cosmetic esthetic concern.
© 2018 Women'sDermatologic Society. Published by ElsevierInc. This is an open access articleunder the CC
BY-NC-ND license (
Cellulite is a skin condition that affects up to 80% of postpubertal
women (Luebberding et al., 2015). Cellulite is different from general-
ized obesity because with obesity, adipocytes undergo hypertrophy
and hyperplasia; cellulite is characterized by large, metabolically sta-
ble adipocytes that are limited to lower body areas (e.g., pelvis,
thighs, and abdomen; Quatresooz et al., 2006). Also known as edem-
atous brosclerotic panniculopathy, cellulite was rst described by
Alquin and Pavot in 1920 and originally thought to be interstitial
edema associated with an increase in fat content.
The phenotype of this condition is distinct, with the skin topogra-
phy changing to a surface that resembles an orange peel. This is due
to the herniation of subcutaneous fat lobules through the
dermohypodermal junction, where brosis of the collagen septa
leads to their shortening and ultimatelytheir retraction,which causes
the depressions that characterize cellulite. Although several factors
are known to contribute to the development of cellulite (sex, genet-
ics, lifestyle; Querleux, 2004; Querleux et al., 2002), the exact patho-
physiology is not understood. The most prevalent models that have
been proposed span from vascular/inammatory to hormonal and/
or structural causes.
Understanding the etiology of cellulite is key to developing targeted
approaches, and a plethora of options is available to dermatologists
to offer to their patients with cellulite. Topical agents, energy-based
devices, subcision,injectable biologic medications, and more recently
dermal llers have all been used and studied in peer-reviewed publi-
cations for their safety and efcacy to treat cellulite (Table 1).
Topical agents
Topical agents, combined with vigorous massage, were the earli-
est attempts to treat cellulite. As with all topical treatments, the
main challenge of these therapies is for the active ingredients to
reach their target in sufcient concentration to have a therapeutic ef-
fect. Methylxanthines (aminophylline, theophylline, and caffeine)
and retinoids have been the most extensively evaluated ingredients
used in topical formulations for cellulite.
Methylxanthines are hypothesized to improve cellulite by stimu-
lating lipolysis and inhibiting the enzyme phosphodiesterase, which
increases the concentration of cyclic adenosine monophosphate. Ret-
inoids, on the other hand, are thought to reduce cellulite by increas-
ing dermal thickness, increasing angiogenesis, synthesizing new
connective tissue components, and increasing the number of active
broblasts. For both agents, there have been several peer-reviewed
publications with promising data, but the studies have been small
with no long-term follow-up. Overall, certain formulations can
International Journal of Women's Dermatology 5 (2019) 6872
Department of Dermatology, Weill Cornell Medical College, New York, New York.
E-mail address:
2352-6475/© 2018 Women's Dermatologic Society. Published by Elsevier Inc. Thisis an open access article under theCC BY-NC-ND license (
Contents lists available at ScienceDirect
International Journal of Women's Dermatology
improve collagen production and reduce skin laxity, but they are
rarely effective on cellulite, which requires extensive fat, collagen,
and connective tissue remodeling (Bertin et al., 2001; Green et al.,
2015; Lupi et al., 2007; Pierard-Franchimont et al., 2000).
Energy-based devices
Energy-based devices that harness power from various sources
such as lasers, light, radiofrequency (RF), and acoustic waves have
been extensively tested for the treatment of localized adiposities
and/or skin laxity.
RF devices deliver thermal energy to the dermal/subcutaneous
plane via electrode(s). By elevating the tissue temperature at the tar-
get area, collagen denaturation, remodeling and neocollagenesis is
stimulated, but lipolysis is also triggered. Depending on theelectrode
or generator conguration, RF devices come in various iterations,
starting with the rst generation (e.g., unipolar, monopolar, and bi-
polar) to the latest generation (e.g., multipolar, multigenerator, and
temperature-controlled) devices. Some RF devices also integrate
other energies in their technological design, such as infrared light,
vacuum suction, and pulsed-electromagnetic elds (Sadick, 2007;
Sadick and Rothaus, 2016a, 2016b; Sadick and Sorhaindo, 2005;
Sadick et al., 2014).
The latest generation of RF devices have been studied and shown
to be effective in clinical trials to reduce the appearance of cellulite
(Luebberding et al., 2015; Romero et al., 2008; Sadick, 2009; Sadick
and Magro, 2007; Sadick and Mulholland, 2004; Wanitphakdeedecha
et al., 2017). Specically, Velasmooth and Velashape systems
(Syneron Medical, Israel) that combine infrared light, bipolar RF,
and mechanical manipulation of the skin with suction and massage
have been shown to reduce cellulite.
In a study by Sadick and Magro (2007) where 16 subjects with
cellulitewere treated twice weekly for 6 weeks with the VelaSmooth
system, there was a 71.87% decrease in thigh circumference and 25%
improvement of cellulite in N50% of subjects at the end of the study.
In another study, where 35 female subjects with cellulite were re-
ceived eight to 16 treatments twice weekly with the VelaSmooth de-
vice, 70% of patients showed a reduction in thigh circumference after
4 weeks of treatment,and 100% of patients showed some level of im-
provement in skin texture and cellulite (Sadick and Mulholland,
2004). Researchers have hypothesized that this is achieved due to in-
creased circulation, stimulation of the adipocyte metabolism, and
mechanical stretching of the brous cords.
Other devices that have been approved by the U.S. Food and Drug
Administration (FDA) for the noninvasive treatment of cellulite in-
clude Exilis Elite (BTL Aesthetics, United Kingdom), which is a
monopolar RF device; Venus Legacy (Venus Concept, Ontario, Can-
ada), which is a multipolar RF device with pulsed magnetic elds;
Endymed Body Shaper (Endymed), a multigenerator RF device, and
ThermiRF (Thermi Aesthetics, Hayward, CA), a novel temperature-
controlled RF device with internal probes (Fig. 1).
Recently, the Venus Legacy devices were used to evaluate their ef-
cacy to treat abdominal cellulite in 25 healthy adult women who
underwent eight weekly treatments. A reduction in subcutaneous
thickness in the axial and sagittal plane of the abdomen was observed
at 1 week after treatment initiation, and assessments by a blinded in-
vestigator at 1, 4, and 12 weeks after the nal treatment demon-
strated a signicant improvement in cellulite appearance. No
adverse effects were reported, and the treatment was well tolerated
(Wanitphakdeedecha et al., 2017).
Laser and light
Laser and light devices, depending on their wavelength, emit en-
ergy to the dermis/subcutaneous plane; by heating the local tissue
they can stimulate collagen remodeling and increase microcircula-
tion, which can improve the appearance of cellulite. The impact of
these devices is not very substantial in terms of adipolysis or even
disruption of the brous septa that characterize cellulite, but they
can improve the appearance of the skin and smooth the surface.
The main laser technology that has been proven effective to treat
cellulite is a minimally invasive side-ring ber 1440-nm Nd:YAG
laser (DiBernardo et al., 2013, 2016; Sasaki, 2013). This technology
provides a highly targeted means of delivering laser energy into the
targeted anatomical structures that underlie the cellulite as the ther-
mal-sensing cannula is integrated with the laser delivery system to
provide a safe and even distribution of energy to the treatment site.
Only one treatment is required, and aside from the clinical improve-
ment of cellulite, there is high subject satisfaction and minimal ad-
verse events (Fig. 2).
In a multicenter clinical trial, where 57 patients underwent a
three-step cellulite treatment with a 1440-nm Nd:YAG laser with a
side-ring ber and temperature-sensing cannula, the average im-
provement score was 1.7 for dimples and 1.1 for contour irregulari-
ties at the 6-month follow-up examination. The average satisfaction
score was 5.6 for the physician and 5.3 for the patient on a 6-point
scale. Treatment was well tolerated by patients (DiBernardo et al.,
Acoustic wave therapy
Acoustic wave therapy (AWT) is another energy-based therapy,
whereby pressure waves are transmitted to the subcutaneous tissue
and promote lipolysis, improve local blood ow, enable lymphatic
drainage, and stimulate the production of new collagen. Two types
of acoustic waves have been used to treat cellulite: focused shock
waves (ESWT) and radial shock waves. The main devices that have
been used for cellulite include Cellactor (Storz, Switzerald) and Z-
wave (Zimmer, Irvine, CA; Angehrn et al., 2007; Knobloch and
Kraemer, 2015; Nassar et al., 2015; Russe-Wilingseder et al.,
2013). On average, AWT requires seven treatment sessions, does
not require topical anesthesia, and results in only minor pain (Fig.
3;Schlaudraff et al., 2014).
AstudybyNassar et al. (2015) evaluated the efcacy of ESWT in
15 individuals, and eight sessions during 4 weeks were carried out.
The authors concluded that ESWT was efcient in the improvement
of body contour (i.e., reduction of circumference and fat layer) as
well as in the appearance of cellulite 3 months after treatment. Hexsel
et al. (2017) also recently evaluated the efciency of ESWT in the
treatment of cellulite in 30 women who received 12 sessions over 6
weeks. The treatment reduced cellulite severity from baseline up to
12 weeks after the last treatment session (subjects with severe cellu-
lite: 60%-38%), and the average thickness of the subcutaneous fat tis-
sue decreased (28.3 ± 6.5 mm to 26.7 ± 6.1 mm; pb.001). The
Table 1
Treatment type Brand
Topical agents Bliss, Clarins, Shisheido, Glytone
Radiofrequency devices Venus Legacy (Venus Concept), Endymed
PRO (Endymed), Velashape (Cynosure)
Laser/light devices Cellulaze (Cynosure)
Acoustic wave therapy Z-wave (Zimmer), Cellactor (Storz)
Subcision Cellna (Merz)
Injectable biologic treatments EN3835 (Endo)
Fillers Calcium hydroxyapatite (Radiesse),
poly-l-lactic acid (Sculptra)
69N. Sadick / International Journal of Women's Dermatology 5 (2019) 6872
treatment also improved patientsquality of life, and no serious ad-
verse events were reported (Hexsel et al., 2017).
Manual subcision has also been evaluated for the treatment ofcel-
lulite. During this procedure, the areas are numbed with a topical an-
esthetic agent (vasoconstrictor with lidocaine), a needle (18 G) is
inserted under the skin, and a fanning technique is used to release
the brous cords of cellulite. Although efcacious, the main draw-
backs of this treatment are the side effects, including edema, discom-
fort, pain, and bruising (Hexcel and Mazzuco, 2000).
Recently, a novel tissue stabilized-guided subsicion (TS-GS) sys-
tem (Cellna System;Merz North America, Inc., Raleigh, NC) was de-
veloped and FDA approved for the improvement of cellulite in the
buttocks and thigh areas of adult women. The benets of Cellna
over traditional manual subscision with a needle are its precise con-
trol of treatment depth and area of tissue (brous septae) and a
unique vacuum-assisted design.Cellna has been shown in multicen-
ter clinical studies to improve cellulite with results lasting N3 years
(Kaminer et al., 2017).
In the latest clinical study, 45 subjects were followed for an ex-
tended period of up to 3 years after receiving a single treatment
using the TS-GS system. The results of this trial supported an FDA
clearance of the device for the long-term reduction in the appearance
of cellulite following TS-GS (Kaminer et al., 2017).
Injectable treatments for cellulite
Among minimally invasive procedures for cellulite, active biologic
agents and dermal llers have been used to treatcellulite, with prom-
ising results.
Collagenase Clostridium histolyticum
Collagenase enzymes isolated and puried from the fermentation
of Clostridium histolyticum are used in clinical trials for the treatment
of cellulite. Collagenase I (AUX-I, Clostridial class I collagenase) and
Collagenase II (AUX-II; Clostridial class II collagenase) are not immu-
nologically cross-reactive and have different specicities; mixed in a
1:1 ratio, theybecome synergisticand provide a very broad hydrolyz-
ing reactivity toward collagen (Yang and Bennett, 2015). Thus, they
can hydrolyze the triple-helical region of collagen and have the
Fig. 1. Before (left) and after (right) seven treatments in the outer thigh with Venus Legacy (Venus concept, Toronto, Ontario, Canada).
Fig. 2. Before (left) and after (right) one treatment in the buttocks with 1440 nm Cellulaze (photograph courtesy of Cynosure).
70 N. Sadick / International Journal of Women's Dermatology 5 (2019) 6872
potential to be effective in lysing subdermal collagen, such as those
observed in the dermal septa (underlying cause of cellulite).
In phase 2b trials, a collagenase mixture, EN3835 (Endo pharma-
ceuticals, Malvern, PA), has been shown to be well tolerated by all
dose groups, and most adverse events were mild to moderate and
primarily limited to the local injection area. A phase 3 multicenter,
randomized, double-blind, placebo-controlled study is currently un-
derway to evaluate the safety and efcacy of this agent in reducing
the appearance of cellulite (Callaghan et al., 2017).
Dermal llers
Another up-to-date option to treat cellulite is the new generation
dermal llers injections, such as calcium hydroxyapatite (CaHa) and
poly-l-lactic acid microspheres (Fig. 4). These llers have been used
extensively to treatscars and can also be applied to smoothen thecel-
lulite-induced skin irregularities. A recent study evaluated the effects
of microfocused ultrasound with visualization (Ultherapy) in combi-
nation with diluted calcium hydroxylapatite (CaHA; Radiesse) on cel-
lulite appearance in 20 women. The results showed statistically
signicant improvements compared with baseline for each item on
the cellulite severity scale (pb.001) with a 4.5-point improvement
in mean overall score (pb.001) after a single microfocused ultra-
sound with visualization/CaHA treatment. Both procedures were
well tolerated, and subject satisfaction was high (Casabona and
Pereira, 2017).
Despite multiple therapeutic approaches that attempt to treatcel-
lulite, no procedures have been proven successful long term. Topical
agents, injectable treatments, and energy-based devices can
ameliorate the appearance of cellulite, sometimes to a satisfactory
degree, but never eradicate cellulite because this involves extensive
tissue remodeling.
In the authors opinion, a combination approach where internal
and external approaches are used strategically and in a staged man-
ner to yield synergistic results has the best clinical outcome. For ex-
ample, injections with CaHa followed by ve weekly treatments
with an RF device can result in improvements of severe cellulite
around 3 months after the nal treatment. Other examples of com-
bining strategies can be six sessions ofweekly acoustic wave therapy,
followed by a one-side ring of an 1440 nm laser.
More large-scale studies, particularly with respect to combination
approaches, need to be conducted to evaluate the long-term results
of therapies for cellulite in terms of safety, efcacy, and patient
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... Celiulitas yra daugiaveiksnė būklė, kuri pasireiškia 80-90 proc. lytiškai subrendusių moterų [1,2]. Jis susijęs su riebalinio audinio pakitimais ir gali paveikti bet kurią kūno vietą, kur yra poodinis riebalinis audinys, dažniausiai šlaunų, sėdmenų, pilvo srityse, rečiau -kelių, blauzdų ir išorinėje rankų dalyje [3,4]. ...
... Tiksli celiulito etiologija nežinoma, tačiau yra keletas hipotezių: kraujagyslinė, struktūrinė ir uždegiminė [2,5]. Manoma, kad celiulito fiziologiją sudaro uždegiminiai veiksniai ir kraujagyslių ar jungiamojo audinio pertvarų pakitimai; yra ir atitinkamas hormoninis komponentas, pasireiškiantis beveik visoms moterims ir retai − vyrams [4,6]. ...
... Atlikta pakankamai tyrimų, siekiant įvertinti įvairių metodų poveikį, sprendžiant šią estetinę problemą [2,3,8,11,12], tačiau, kaip minėti odos ir poodžio struktūriniai pokyčiai veikia celiulitą turinčių moterų gyvenimo kokybę, Lietuvoje nėra plačiai nagrinėta. ...
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Celiulitas yra daugiaveiksnė būklė, kuri pasireiškia 80– 90 proc. lytiškai subrendusių moterų ir yra vienas iš la­biausiai netoleruojamų kūno estetinių trūkumų. Atlikta daug tyrimų, siekiant įvertinti įvairių metodų poveikį, sprendžiant šią estetinę problemą, tačiau odos ir poodžio struktūrinių pokyčių poveikis moterų gyvenimo kokybei Lietuvoje plačiai nenagrinėtas. Tyrimo tikslas – įvertinti moterų celiulito ir įvairių gy­venimo kokybės aspektų sąsajas. Tyrimo medžiaga ir metodai. Atliktas kiekybinis tyrimas, apklausa raštu. Duomenų rinkimui naudotas validuotas klausimynas pagal D. Hexsel ir kt. (2011). Tyrimas atlik­tas 2019 m. lapkričio – 2020 m. gruodžio mėn. Klaipėdos miesto grožio ir SPA salonuose, apklaustos 376 moterys, pirmą kartą atvykusios dėl estetinių kūno odos priežiūros procedūrų, esant įvairioms celiulito stadijoms. Tyrimo metu buvo laikomasi etikos principų: anonimiškumo, sa­vanoriškumo, pagarbos ir konfidencialumo. Duomenims analizuoti buvo naudojama statistinė programa SPSS 25. Tyrimo rezultatai. Kas penktai (20,3 proc.) respondentei celiulitas turėjo gana stiprios įtakos gyvenimo kokybei; beveik kas dešimtai (9,4 proc.) ši estetinė problema sti­priai paveikė gyvenimo kokybę. Trečdaliui apklaustųjų (33,3 proc.) celiulitas turėjo šiek tiek įtakos gyvenimo kokybei. 37 proc. respondenčių celiulitas neturėjo įtakos gyvenimo kokybei. Stipriausi priklausomybės ryšiai nu­statyti tarp celiulito įtakos kūno išvaizdai ir aprangos stiliui (p<0,001); celiulito įtakos laisvalaikio ar fizinei veiklai viešose vietose ir laisvalaikio ar fizinei veiklai, esant ribotam žmonių skaičiui (p<0,001); tarp neigiamos savijautos bei jaudinimosi dėl anticeliulitinių procedūrų poveikio (p<0,001). Pastebėtas tiesioginis priklauso­mybės ryšys tarp skirtingų gyvenimo kokybės aspektų, kai didėjant neigiamai įtakai vienoje gyvenimo srityje, didėja ir kitose. Išvados. Tyrimas parodė, kad kas trečiai apklaustai mote­riai celiulitas turi neigiamos įtakos gyvenimo kokybei. Iš visų tirtų gyvenimo kokybės aspektų celiulitas didžiau­sią neigiamą įtaką turi moterų pasitenkinimui savo kūno išvaizda (p<0,05). Kuo didesnę neigiamą celiulito įtaką moteris jaučia vienoje gyvenimo srityje, tuo ji ryškesnė ir kitoje (p<0,001). Siekiant pagerinti celiulitą turinčių moterų gyvenimo kokybę, rekomenduojama sukurti ir įgyvendinti holistines sveikatos stiprinimo strategijas, kuriomis būtų siekiama moterų informuotumo, sveikatos ugdymo, medijų raštingumo, individualizuotų kūno prie­žiūros programų skirtingoms celiulito stadijoms sklaidos.
... The association of the depressions, dimpling (indentations) with increased thickness of the fibrous septae was confirmed by MRI. [74][75][76] This multifactorial condition is a real concern and the consequence is increased interest in buttock aesthetics. 77 hip ratio of 0.6 to 0.65 for women 78 and 0.85 for men 79 are relevant indicators for physicians to define an aesthetic strategy. ...
... 22,73 Non-surgical treatments for buttocks augmentation with the use of HAs or collagen stimulators such as PCL, 88 CaHA 12 PMMA, 89 are increasing with the advantage of their long-lasting effect 1,70,90 and are indicated for those patients as well as for patients looking for improved contouring, reshaping, skin quality, striae distensae and cellulite appearance. 76,91 Thanks to its biostimulatory properties, PLLA is increasingly used for gluteal augmentation and to treat contour irregularities. 22,[26][27][28]90,[92][93][94][95][96][97][98][99] Its use to treat buttocks is the first off-facial application of the product according to a recent American survey. ...
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The number of aesthetic procedures performed worldwide continues to grow together with an increase in the population seeking the restoration or preservation of a youthful appearance. Requests for non-surgical body rejuvenation are increasing. Patients are looking for safe and effective minimally invasive aesthetic procedures. Soft-tissue dermal fillers can meet these expectations. Based on the beneficial outcomes of these treatments in many facial areas, a new trend is developing to target body areas. Different dermal fillers are available and include collagen stimulators initially developed to restore facial volume. Furthermore, they are associated with long-lasting efficiency, a high level of patient satisfaction and a good safety profile, with mainly minor adverse events reported. In appropriate conditions of use, they are now used for body rejuvenation in clinical practice. Their use is expanding and allows addressing various issues including volume loss, skin laxity, cellulite, striae distensae and wrinkles. This review focuses on poly-L-lactic acid (PLLA), used in the first collagen stimulator and one of the most investigated in facial and in off-facial body applications. The available published data, although still limited, are presented by body area, neck and chest, buttocks, abdomen, upper arms, thighs, knees, and hands. Key features of the concerned zones and the main clinical signs affecting the body part as well as the injection modalities are provided along with the aesthetic results. This represents the state of the art on which to base further developments necessary for optimal and safe outcomes of treatment with the PLLA-based collagen stimulators and others in this class for body rejuvenation.
... a cellulite dimple, CCH-aaes disrupts the fibrous septae tethered to the underside of the dermis, thereby alleviating the local tension thought to cause the skin topography characteristic of cellulite. [4][5][6] Cellulite itself is a multifactorial condition, with skin laxity and/or thickness as well as patient body weight potentially exacerbating its appearance. 4,7 While a number of hypotheses exist as to the true underlying physiologic cause of the condition, the actual appearance of cellulite is thought to be a function of the type (thickness and organization) of fibrous septae, the capacity of the dermis to support the underlying tissues, and the architecture of both the deep and superficial fat layers. ...
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Background Collagenase Clostridium histolyticum (CCH-aaes; QWO [Endo Aesthetics, Malvern, PA]) is an injectable, enzyme-based treatment indicated for the treatment of moderate to severe cellulite on the buttocks of adult women. The minimally invasive nature of the treatment makes it an attractive option for targeted disruption of the fibrous septae which give rise to the dimples characteristic of cellulite in buttocks and thighs. Objectives The article provides an overview of cellulite treatment with CCH-aaes, including patient identification and education, treatment planning, CCH-aaes dilution, injection technique, safety, and early experience with mitigation of adverse events, including bruising. Methods As part of a continuing medical education (CME; xMedica, Alpharetta, GA) event on developments in cellulite treatment, a panel of experts developed a course and roundtable, which included lectures on cellulite physiology, new developments in the field of cellulite treatment, demonstrations of injection technique for CCH-aaes, and a review of considerations for the use of CCH-aaes in real-world clinical practice. Results The practical guidance presented here is based upon real-world experience with CCH-aaes. The discussion includes strategies based on early experience for how to obtain the best results as well as suggestions on how to mitigate bruising. Conclusions CCH-aaes has been a welcome addition to the armamentarium for the treatment of cellulite. With knowledge of proper patient evaluation and injection technique, thorough patient education, diligent photography, and developing research on bruising mitigation, CCH-aaes shows great promise as an effective and safe modality for the management of cellulite. Level of Evidence: 5
... A fisiopatologia da celulite ainda não é totalmente elucidada, embora alguns estudos tenham afirmado que o comprometimento circulatório pode influenciar tanto para a sua manifestação quanto para a sua exacerbação 15,28 . A hipóxia local, inflamações e polimerização estão diretamente ligados à implicação nesta circulação, e não somente reflete em sinais físicos, como também em sintomas como a sensação de peso nas pernas, dores e diminuição da sensibilidade, incluindo sensibilidade local maior ao frio 17,24 . ...
... 2 This technique is among the top trends that may safely provide favorable outcomes with high satisfaction and no downtime, rivaling traditional and modern methods. [3][4][5][6][7][8][9] The combined application of HIFEM+RF is effective for simultaneous muscle toning and fat reduction. [10][11][12][13] HIFEM generates an electromagnetic field that activates neuromuscular tissue by induced electric current, leading to supramaximal muscle contractions, which create a significant energy demand causing muscles to utilize the energy stored in the adipocytes in free fatty acid form. ...
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Background: Inevitable signs of aging are especially noticeable in middle to elder age when stretch marks, loose skin, cellulite, and body-contour changes naturally appear. Aims: To verify efficacy of high-intensity focused electromagnetic field (HIFEM), radiofrequency (RF), and Targeted Pressure Energy (TPE) combination treatment to address unfavorable changes in skin, fat, and muscle tissue. Methods: The device simultaneously emitting monopolar RF and TPE energies was consecutively combined with simultaneous HIFEM+RF procedure in 32 subjects (21-64 years, 17.4-33.5 kg/m2 ) for treatment of thighs (N = 15; back, inner, or front), buttocks/saddlebags (N = 7), abdomen (N = 8), and upper arms (N = 2). All patients underwent four weekly, combined treatments of 30-min HIFEM+RF procedure followed by 15-30 min RF+TPE, depending on treatment area. Circumferential measurements, digital photographs, subject satisfaction, and comfort questionnaires were assessed up to 3-months post-treatment. Results: Majority of participants found treatments comfortable, no adverse events occurred. Subjects showed substantial improvement in all treated areas from 1-month follow-up. Combination of HIFEM+RF, monopolar RF, and TPE resulted in significant circumference decrease. Generally, more pronounced results were seen at 3 months when subjects showed -5.2 cm on abdomen, -3.0 cm on thighs, and -5.5 cm on saddlebags, respectively. Ninety-four percent of subjects were satisfied with treatment results, most noticed improvement in cellulite, skin laxity, and muscle definition. Conclusions: Results showed high patient satisfaction and efficacy in improving body contour and skin quality. Combining simultaneous HIFEM+RF procedure with simultaneous monopolar RF+TPE treatments considerably enhanced body contour and skin tissue. The procedure proved versatile and may effectively treat multiple body parts.
... 16,17 Current treatments for cellulite include injectable biologic treatments, dermal fillers, topical agents, massage, laser and light, acoustic and vacuum assisted subcision, and radiofrequency devices. 23,24 Although some of these treatments may require minimal downtime or no local anesthesia, most require multiple treatments to achieve some level of efficacy. 11 Additionally, nonsubcision treatments do not directly impact the fibrous septa, which are believed to be the primary cause of cellulite. ...
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Background: Cellulite is an aesthetic condition affecting the appearance of skin in certain body regions and is associated with body dissatisfaction, psychosocial stress, and decreased quality of life. Previous studies have established the safety and feasibility of a novel, minimally-invasive device utilized for precisely identifying and verifiably releasing septa responsible for cellulite depressions. The single procedure is known as Targeted Verifiable Subcision (TVS). Objectives: The objective of this single-arm, open-label, multicenter study was to evaluate the safety and efficacy of TVS for reducing the appearance of moderate to severe cellulite in the buttock and thighs of adult women. Methods: Adult women 21-55 years of age and a BMI <30 kg/m2 with moderate or severe cellulite on the buttocks and/or thighs were eligible to be enrolled at 9 sites. Endpoint data includes results from 4 of the postprocedural follow-up visits at 24 hours, 7 days, 30 days, and 90 days (3 months). The primary endpoints were a mean ≥ 1 point reduction in the Cellulite Severity Scale (CSS) at 90 days and no related serious adverse events (SAEs) at 30 days. Results: Seventy-four female participants with a mean BMI of 24.8 ± 2.7 and age of 41.4 ± 7.4 years received this single procedure. The mean improvement in CSS (N=68) was 1.5 ± 0.9 (p < 0.0001). There were no device-related SAEs at 30 days. Conclusions: Targeted Verifiable Subcision for selectively identifying and verifiably releasing septa responsible for cellulite depressions is an effective and safe means for improving the appearance of moderate to severe cellulite in adult women.
Objective: The objective of this work was to develop a self-emulsifying drug delivery system (SEDDS) containing caffeine for the treatment of cellulite. Methods: SEDDS were prepared by the solution method. 0.5% (w/v) caffeine was added to previously selected excipients. The system was characterized by droplet size, zeta potential, emulsification time, and long-term stability. In vitro release and skin permeation were investigated in Franz-type diffusion cells. The cytotoxicity was evaluated on normal human keratinocytes. Results: Caffeine SEDDS were thermodynamically stable, with Zeta Potential less than - 22mV and droplet size around 30 nm, and long-term stable. The permeation study showed that the formulation promotes caffeine accumulation in the skin layers, suggesting an increase in local circulation. Cytotoxicity studies on HaCaT cells were not conclusive since the surfactant used indicates false positive results due to high molar mass. Conclusion: It was possible to obtain a stable SEDDS that can cause an increase in blood flow in the applied area, resulting in cellulite reduction.
In this introductory article to this special supplement in radiofrequency (RF), we aim to summarize the scientific foundation of RF therapy and its role in aesthetic dermatology. Monopolar, bipolar, and multipolar RF systems are described in detail, along with the different delivery methods such as stamping, dynamic or continuous movement, fractional, fractionated (FR) needling, and non‐contact devices as well as the minimally invasive platforms that use subdermal probes. The characteristics of different tissues and the technical parameters that influence the effect of RF therapy, such as the penetration of energy, are summarized. This article expands on the various treatment applications for these devices and the mechanism of action behind skin and adipose tissue remodeling, and also discussed are safety concerns, treatment endpoints, and specific considerations when using RF therapy to provide effective treatment outcomes with reduced patient downtime.
Objective: The aim of the study was to assess the correlation between the cellulite severity and the thickness of the fat fold. Material and methods: The study comprised 62 women aged 22 to 26 years. A palpation and visual evaluation of cellulite severity was performed on the basis of the Nurnberger and Muller classification, and the thickness of adipose tissue (fatty tissue) was measured with the use of a skinfold caliper. Results: The H0 hypothesis was rejected in favour of the H1 hypothesis (p <0.001) in Chi square independence test, therefore, a relationship between the thickness of the adipose tissue fold and the severity of cellulite was confirmed. Moreover, on the basis of obtained results, the hypothesis of the independence of the studied variables (p <0.0000001) was also rejected. It can be concluded that there is an association between the thickness of adipose tissue and the degree of cellulite. Moreover, the values of the obtained coefficients are greater than zero (the correlation is positive), and the obtained Spearman's R (0.89) and Kendall's tau (0.79) values indicate a very strong correlation between the studied variables. Conclusions: On the basis of obtained results and their statistical analysis, we can state that there is a relationship between the degree of cellulite and the thickness of the fat fold - the degree of cellulite increases with the increase in the thickness of the measured fat fold.
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Background:. Age-associated skin laxity contributes to worsening of cellulite appearance. This study evaluated the effects of microfocused ultrasound with visualization (MFU-V; Ultherapy) in combination with diluted calcium hydroxylapatite (CaHA; Radiesse) on cellulite appearance and on neocollagenesis. Methods:. Twenty women (18–55 years old) with skin laxity and moderate-to-severe cellulite on the buttocks and thighs were retrospectively enrolled. MFU-V was applied using 4 and 7 MHz transducers (25 lines/transducer/site) and immediately followed by subdermal CaHA injection (1 ml/buttock or thigh). Photographs at baseline and 90 days were assessed by 2 independent, blinded evaluators using a 5-item cellulite severity scale. One subject scheduled for thighplasty received treatment with 6 different CaHA dilutions (0.3 ml/5 cm2) followed by MFU-V. Tissue specimens from each dilution site were examined under polarized light microscopy to assess neocollagenesis. Results:. Both evaluators reported statistically significant improvements compared with baseline for each item on the cellulite severity scale (P < 0.001) with a 4.5-point improvement in mean overall score (P < 0.001) after a single MFU-V/CaHA treatment. At 90 days, histologic analysis showed peak neocollagenesis in samples treated with the 1:1 dilution, whether with CaHA alone or in combination with MFU-V. The highest conversion of collagen type III into collagen type I at month 3 occurred in samples injected with 1:1 and 1:0.6 CaHA dilutions without subsequent MFU-V treatment. Both procedures were well tolerated, and subject satisfaction was high. Conclusions:. Combination treatment with MFU-V and diluted CaHA is effective for improving skin laxity and the appearance of cellulite on the buttocks and upper thighs.
Cellulite is a condition that affects the majority of postpubertal women and can negatively impact quality of life. This review discusses several proposed pathophysiologies of cellulite, and examines treatment options that have been utilized, focusing on the etiologic factor targeted by the therapies. This approach aims to help clarify the pathogenesis of cellulite and provide a road map for developing effective treatment paradigms for patients.
Background: Cellulite is a common female cosmetic concern for which no single treatment option had been proven effective over the long term. A novel tissue stabilized-guided subsicion system (TS-GS system) has demonstrated significant reduction in the appearance of cellulite after treatment. Objective: The objective of this extended follow-up period was to assess the effectiveness of TS-GS out to 3 years after initial treatment. Patients and methods: After completing an open-label, multicenter, pivotal study, 45 subjects were followed for an extended period of up to 3 years after receiving a single treatment using the TS-GS system. Treatment areas were photographed prior to the procedure and at multiple time points post-treatment throughout the 3 years. In this open-label study, subjects served as their own controls. Effectiveness was assessed based on blinded independent physician panel assessments of improvement from baseline using a cellulite severity scale. Subject aesthetic improvement and patient-reported satisfaction were also collected. Results: The results of this trial supported Food and Drug Administration clearance of the device for the long-term reduction in the appearance of cellulite following TS-GS. Conclusion: These data further demonstrate the safety and efficacy of this treatment with no reduction in treatment benefits out to 3 years.
Introduction: Cellulite is a metabolic condition, predominately seen in females, that affects the subcutaneous tissue of the posterolateral thighs, buttocks, pelvic region, and abdomen. This condition has a distinct histologic pathology compared to obesity, that is characterized by skin dimpling and lumpiness resembling an orange peel. Despite the wide range of treatment options for cellulite, there is paucity of empirical data supporting their efficacy. The objective of this study was to evaluate the efficacy of a new generation multipolar radiofrequency device for the treatment of cellulite. Methods: A multipolar radiofrequency device with pulsed magnetic fields was used to treat abdominal cellulite. Twenty-five healthy adult females with stage II or stage III abdominal cellulite underwent 8 weekly treatments. Assessments were performed at baseline and at weeks 1, 4, and 12 following the final treatment. Results: Reduction in subcutaneous thickness in the axial and sagittal plane of the abdomen was observed at 1 week following the treatment initiation. Results from self-reported questionnaires revealed a significantly high patient satisfaction (60%). Assessments by blinded investigator at one, four, and twelve weeks after the final treatment demonstrated significant improvement of cellulite appearance. No adverse effects were reported and the treatment was well tolerated. Conclusion: This study demonstrates the safety, efficacy, and subject satisfaction of multipolar RF with pulsed magnetic fields in the treatment of abdominal cellulite.
This article reviews minimally invasive radiofrequency options for skin tightening, focusing on describing their mechanism of action and clinical profile in terms of safety and efficacy and presenting peer-reviewed articles associated with the specific technologies. Treatments offered by minimally invasive radiofrequency devices (fractional, microneedling, temperature-controlled) are increasing in popularity due to the dramatic effects they can have without requiring skin excision, downtime, or even extreme financial burden from the patient's perspective. Clinical applications thus far have yielded impressive results in treating signs of the aging face and neck, either as stand-alone or as postoperative maintenance treatments.
Radiofrequency (RF)-based devices are used to improve face and neck laxity, a major feature of aging that until recently could only be addressed with surgery. Although these treatments are not meant to replace surgical procedures, patient satisfaction studies have been consistently high. For physicians offering these skin rejuvenation procedures, it is essential to have intimate knowledge of how the devices work, select appropriate candidates, set realistic expectations, and combine treatments to optimize outcomes. This article discusses the various noninvasive RF technologies currently in use and reviews pertinent clinical studies evaluating their efficacy and safety.
Background: Treatment of cellulite using a 1440-nm YAG wavelength laser with side-firing fiber has proven safe and effective, lasting at least 6 months. Objectives: The authors evaluate the safety and efficacy of a single, subdermal procedure to treat the underlying structure of cellulite for at least 1 year. Methods: Fifty-seven patients underwent a 3-step cellulite treatment with a 1440-nm Nd:YAG laser with a side-firing fiber and temperature-sensing cannula. Efficacy was measured by the blinded evaluators to distinguish baseline photos from those taken at 12 months posttreatment, with results on a 5-point, 2-category ordinal photonumeric scale when comparing baseline photos to 12 months posttreatment. Subject and physician satisfaction was assessed based on completion of a satisfaction survey. Adverse events (AE) were recorded throughout the study. Twelve month data were analyzed and compared to 6 month data. Results: Evaluators chose baseline photographs 97% on average from 6 (-1, +2) months and 91% from the 12 (-3, +2) months posttreatment photographs. At 6 (-1, +2) months, the average improvement score was 1.7 for dimples and 1.1 for contour irregularities. At 12 (-3, +2) months, the average improvement score was 1.4 for dimples and 1.0 for contour irregularities. The average satisfaction score for the physician was 5.6 and the patient was 5.3 on a 6-point scale. Conclusions: A single, 3-step, minimally invasive laser treatment using a 1440-nm Nd:YAG laser, side-firing fiber, and temperature-sensing cannula to treat the underlying structure of cellulite proved to be safe and maintained effectiveness at least 1 year post treatment. LEVEL OF EVIDENCE 2: Therapeutic.
Cellulite is a condition that affects the vast majority of women. Although it is of no danger to one's overall health, cellulite can be psychosocially debilitating. Consequently, much research has been devoted to understanding cellulite and its etiopathogenesis. With additional insights into the underlying causes of its clinical presentation, therapeutic modalities have been developed that offer hope to cellulite sufferers. This review examines evidence for topical treatments, noninvasive energy-based devices, and recently developed minimally invasive interventions that may finally provide a solution.
The aim of this metaanalysis was to investigate the effectiveness of extracorporeal shock wave therapy (ESWT) in cellulite. Electronic databases (such as Ovid MEDLINE, Scopus and Ovid) as well as reference lists of the available studies were evaluated in June 2015 by two expert examiners. Assessment of each study's methodological quality was performed with the help of the published quality index tool by Downs and Black. This metanalysis included a total of eleven clinical trials on the effects of ESWT on cellulite with a total of 297 included females. Among the eleven clinical trials five randomized controlled trials on ESWT in cellulite with a total number of 123 females have been published so far. Both, focused as well as radial ESWT devices have been found effective in treating cellulite so far. Typically, one or two sessions per week and six to eight sessions overall were studied in the published clinical trials. Overall, outcome parameters mainly focused on digital standardized photographs, circumference measurements and specific ultrasound examinations. Reporting quality showed substantial heterogenity from 22 to 82 points with a mean of 57 points. This metanalysis identified eleven published clinical studies on ESWT in cellulite with five randomized-controlled trials among them. There is growing evidence that both, radial as well as focused ESWT and the combination of both are able to improve the degree of cellulite. Typically, six to eight treatments once or twice a week have been studied. Long-term follow-up data beyond one year are lacking as well as details on potential combination therapies in cellulite such as with low level laser therapy (LLLT), cryolipolysis and others. Copyright © 2015. Published by Elsevier Ltd.
Introduction After its U.S. FDA approval in 2013, Collagenase Clostridium histolyticum (CCh) has seen increasing use as a nonoperative treatment for Peyronie's disease (PD). We review the history of CCh and trials that led to its adoption. Aim To provide a historical and contemporary context for the evolution of Collagenase Clostridium histolyticum as a treatment modality for Peyronie's disease. Methods A comprehensive search of peer-reviewed literature was performed pertaining to CCh and its biochemical and clinical significance. Main Outcome Measure The main outcome studied was the efficacy and safety profile of CCh in PD. CCh use in other diseases processes and its associated outcomes are also described. Results CCh injection yields objective improvement in penile curvature across multiple trials in PD patients. Recently, level 1 strength of evidence has emerged supporting its widespread use. As such, CCh stands as the only FDA-approved injectable therapy for PD. Adverse events were namely limited to local reactions. Serious systemic complications and need for intervention were rare. Conclusions CCh is a safe and effective treatment for PD patients with deformities and plaque configuration amenable to injectable therapy. Multiple trials have demonstrated improvements in objective and subjective metrics such as penile curvature and bother scores. However, multiyear follow-up is needed to assess durability and its sustained clinical significance. Currently, refinement in dosing and technique has established a niche for CCh in PD patients who are affected by their symptoms but are not yet committed to surgical intervention. Yang KK and Bennett N. The history of collagenase clostridium histolyticum.