Smooth Operators

How to manage expectations and identify the best candidates for minimally invasive and noninvasive cellulite treatment options.

Smooth Operators

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 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 Cellfina, 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.

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 fibers (fibrous 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 fibers 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 Cellfina. 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 fiber is threaded through a cannula that’s inserted through the incision(s). It levels out fatty bumps, releases fibrous 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 find 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.”

Cellfina, launched in 2016, is a subcision-based, in-office procedure that takes about one hour, depending on the 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 fibrous septae. Repeated pressure eventually releases the fibers 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.

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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 find 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 Cellfina, 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 Cellfina 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 Cellfina treats large focal areas of dimpling but does not address dermal remodeling, though the lack of laser energy makes Cellfina 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-defined cellulite can benefit more from the Cellulaze because it covers a larger area compared to Cellfina, 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 fibrous 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 flush the fat. Patients typically undergo 10 to 15 treatment sessions.

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 flow and stretching out the fibrous 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 confirms: “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.

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Combining Modalities

Even with more effective, minimally invasive tools, patients are best served with a combination of modalities. “For patients with discrete dimples, Cellfina 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 Cellfina with fat grafting to provide more significant improvement. “I’ve done Cellfina 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 Expectations

As 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 when patients are able to work in partnership with their physicians—undergoing in-office 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, ‘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. “Cellfina 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.

Photo copyright Getty Images.

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