Post on 08-Jul-2020
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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.”
© G
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IM
AG
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