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Dr. Barry Eppley

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Archive for the ‘cellulite’ Category

An Injectable Approach for Cellulite

Monday, April 22nd, 2013


The sheer number of cellulite therapies that have appeared over the years is a testament to two basic issues. First, cellulite is a difficult aesthetic problem that defies one single effective treatment. While Cellulazae and Cellusmooth are two new laser treatments, they are invasive. Otherwise, topical treatments of either creams or energy-based devices have dominated the non-surgical approaches before them. Secondly, short of the more recent laser treatments none of them have worked extremely well or have had any sustained results.

But an intermediate approach between an external non-invasive and an internal invasive cellulite treatment is on the horizon. An injectable drug that has been used for the treatment of Duputryn’s contracture, Xiaflex, is in FDA-approved phase II clinical trials for cellulite treatment. Known as CCH for clostridial collagenase histolyticun, it is an injectable form of the enzyme collagenase. The mechanism of action is that the injections break down the collagen bands that pull down on the skin creating the classic dimpled and irregular skin appearance.

The initial phase I pilot study with the cellulite injections were done on 10 women on the back of their thighs. The average reduction in the appearance of cellulite was 77% and was seen as early as the next day after injection. After six months, these same patients had a lasting 76% reduction in their cellulite. The injections were initially associated with temporary bruising, mild discomfort and swelling…as would be expected based on the experience of using it in the release of Duputryn’s contractures and its mechanism of action. This study served as evidence of its safety and effectiveness in the treatment of cellulite and allowed the aforementioned phase II clinical trial to be initiated.

While it is going to be a few years before this injectable approach for the treatment of cellulite will be commercially available, it will likely fall into the current array of injectable aesthetic therapies like Botox, fillers and sclerotherapy.

Dr. Barry Eppley

Indianapolis, Indiana

A Review Of Available Cellulite Treatment Approaches

Sunday, February 26th, 2012

Cellulite remains a challenging aesthetic problem. While it is fairly well understood what comprises it anatomically, there remains no concensus on its etiology and ideal treatment. New technologies are emerging, however, that have begun to show improved and sustained results. Given these promising improvements in cellulite treatment, it is relevant to review what we know about this common aesthetic deformity and the cadry of treatment options available to treat it.

While cellulite appears as an external skin irregularity, often called an orange peel, dimpling or mattress appearance, its origin is much deeper. It is known to be the result of multiple anatomic conditions of the subcutaneous tissues including decreased elasticity of the skin, fat hypertrophy, contraction of the fibrous septae and increased compression of fat into the underside of the skin. Studies have shown that the fat in cellulite is no different in any way than that of fat in non-cellulite areas. It most commonly affects the thighs, buttocks and lower abdomen and predominantly occurs in women.

The earliest forms of cellulite treatment where cosmeceutical, the application of topical drugs and herbs applied to the skin. These have included a variety of agents including derivatives of the aminophylline family, caffeine, yohimbine, carnitine and a variety of herbal extracts. Improvements from this approach have been largely anectodal and few if any scientific studies can show any consistent improvement in the appearance of cellulite.

Mesotherapy injections are often touted for cellulite treatment. They became more popular in the ‘lipodissolve’ craze from a few years ago. Using primarily phosphatidylcholine and deoxycholic acid formulations, these detergents primarily work on breaking down fat cell walls. They are more proven to have a fat reduction effect, mild as it may be, than they are at improving the overlying skin irregularities.

Endermologie has been around for over 15 years and is FDA approved for body contouring and cellulite reduction. It is essentially a suction massage approach applied manually through a roller-type device. Studies have shown some skin contour improvement that to be maintained requires regular maintenance treatments.

Carbon dioxide therapy is the instillation of a gas under the skin with low pressure infusion. This purportedly breaks the septae and stimulates collagen production in the skin to help even it out. There has been no conclusive and reproduced studies that have documented this effect.

UltraShape is a body contouring device that uses pulsed focused ultrasound energy for fat cell destruction by cavitation. While it has some fat reduction and body shaping effects, it is not approved for cellulite treatment in the U.S.

Ultherapy is another form of focused ultrasound that is used in the face for lifting sagging tissues. It is FDA cleared for eyebrow lifts and forehead rejuvenation. It is also being studies for cellulite treatment but these studies are ongoing and not yet available for review.

Liposonix is a high-intensity focused ultrasound device that is FDA cleared for non-invasive waist circumference reduction. It has no proven effect in cellulite reduction.

TriActive is an FDA cleared device for cellulite reduction that combines differing treatment methods as the name implies. It uses an 808nm infrared diode laser, cooling and suction massage.

VelaSmooth  is another FDA cleared device for cellulite. It uses radiofrequency, infrared light and suction as  its multimodality treatment method.

SmoothShape is also FDA cleared for cellulite. It uses  a dual wavelength laser combined with suction massage.

Subcision is a limited surgical technique using an 18 gauge needle under local anesthesia. The objective is to release the septal bands by percutaneous severing of them in the depth of an indentation. It ahs failed to show consistent improvement.

Laser-assisted liposuction is an FDA-approved device for fat reduction but not cellulite. It is well known that fat reduction can even make the appearance of cellulite worse if not done judiciously. Thus Smartlipo and other laser liposuction devices should not be used primarily for cellulite reduction.

Cellulaze is the newest FDA cleared device in 2012 specifically for the improvement of cellulite. It uses a 1440nm pulsed laser with a side-firing fiber. Based on how it is angled, it can be used to release the fibrous septal bands, liquefy fat (no suctioning) and apply heat to the underside of the skin for collagen stimulation. Besides the unique delivery method, it is designed to be a single treatment.

While there are numerous available cellulite treatments methods, the most effective ones are device or energy-driven. Amongst such devices, most provide temporary improvement and require multiple treatments for maintenance. Only the newset device, Cellulaze, offers a single treatment with a lasting result. 

Dr. Barry Eppley

Indianapolis, Indiana   

Plastic Surgery Product Review: Cellulaze Laser For The Treatment Of Cellulite

Tuesday, February 7th, 2012

Cellulite remains the cosmetic bain of many women even those who otherwise have good size to their thighs and buttocks. While the anatomy of cellulite is well understood, why it is there and what causes it is not. Even worse is that a truly effective treatment for it remains elusive. The sheer fact that dozens of cellulite therapies have been proposed over the past several decades illustrates that none of the them work very well.

Surgical solutions for cellulite have been tried including liposuction and an instrument technique known as pickling. While initially effective, cellulite was seen to return once all the swelling went away and the tissues retracted. But an effective surgical solution appears to now be available as the FDA has just cleared a laser system from Cynosure called Cellulaze.

Cellulaze is a surgical procedure that is a spin-off of the popular Smartlipo procedure. Using a fiberoptic cable inserted under the skin, laser energy of different wavelength is delivered in a 360 fashion radiating out from the probe to melt fat, stimulate skin thickening and release vertical fascial bands. This causes the reduction in the dimpling effect that is a well recognized appearance of cellulite. These are the three components of the anatomic make-up of cellulite which would explain its effectiveness. After one treatment, results are said to be visible within a few weeks and continues to build over the next several months.

According to the clinical results published in the Aesthetic Surgery Journal in 2011 (and presumably part of the data submitted to the FDA for evaluation and approval), Cellulaze treatments can increase the thickness of the skin by 25% and the elasticity of the skin by 29% at one year after treatment. Most pertinently, a single treatment creates a noticeable improvement in the appearance of cellulite at one year after treatment. The majority of patients in the study (93%) were satisfied or very satisfied with their treatment results and would recommend the treatment to their friends.

The relevance of this new cellulite laser treatment is that it has significant and lasting benefits without the need for maintenance sessions. That is a major advance over previous surgical efforts for cellulite

Dr. Barry Eppley

Indianapolis, Indiana   

Plastic Surgery Product Review: Cellulaze Laser Treatment For Cellulite

Wednesday, January 4th, 2012

One of the most difficult problems to improve, let alone solve, in cosmetic plastic surgery is that of cellulite. It is particularly frustrating given that there are large numbers of women who are afflicted with cellulite and would love to invest in an effective treatment. While there have been a significant number of  device-based technologies over the past decade, none have lived up to their expectations and most have failed to produce a good return on a patient’s investment.

Cellulite is comprised of numerous anatomic elements that create the classic orange peel appearance which makes it easily recognized and disliked. The first defect is an overall undulation of the fatty tissue. The second known issue is the contraction and hardening of the vertical fibrous septae which causes the skin to be inward creating the overlying dimpling effect. Thirdly, the skin is usually thinner and weaker and this allows the fat to herniated upward. For a cellulite treatment to be truly effective, it has to address all three of these tissue elements.

One of the more promising cellulite technologies is Cynosure’s Cellulaze. This uses a side-firing 1440nm laser delivered through a fiberoptic cable. This wavelength has a great affinity for fat. It has many similarities to the more well known Smartlipo used for fat reduction which uses a forward-firing laser. By firing to the side, the laser can be directed in many directions including downward, sideways and upward by simply twisting the cannula. This is important since cellultite is a problem that is not just isolated to one tissue plane.

The Cellulaze laser treats the three components of cellulite with its 1440nm wavelength. By turning the cannula downward, energy is delivered to smooth the uneven fatty base. Turning the cannula 90 degrees, parallel to the skin’s surface, the laser can be used to  cut and release the vertical fibrous septae. When the cannula is turned upward the underside of the skin is heated, stimulating the growth of new collagen and elastin.

While Cellulaze is currently marketed and sold in Canada, Europe and Australia, it is awaiting FDA approval in the U.S.  In a clinical study conducted in the U.S., a single treatment for thigh cellulite was done. At evaluations at one, three, six and twelve months after treatment, measurements of skin thickness and elasticity showed significant increases at each visit. Patient satisfaction was high with minimal side effects other than expected amounts of swelling.

It is likely that Cellulaze will receive approval sometime in 2012 in the U.S. Many prospective patients will be anxiously awaiting.

Dr. Barry Eppley

Indianapolis, Indiana

The Search For Effective Cellulite Treatments

Sunday, January 30th, 2011

Cellulite, like its close cousin stretch marks, is a cosmetic scourge for many women. While there is no medical reason to treat cellulite, which is normal in the skin of many females and is not associated with any health risks, many women are concerned about it anyway. The unsavory presence of skin irregularities, lumps and bumps, and a ‘cottage cheese’ appearance across the thighs and buttocks run contrary to the smooth skin of endless beauty ads.



It is a  regular question from many female patients and some consults are exclusively about a surgical treatment or solution to the cellulite problem. As a result, treatment offerings for cellulite is a multibillion-dollar industry… of largely unproved therapies. Some machine or device-based treatments that claim to lessen cellulite do have some minor but temporary improvements. But their effects or benefits are not permanent and many of the touted clinical studies have some serious flaws in their design and reporting. It does not help that the quantitative assessment of cellulite is difficult and patients are more interested in eradication than a percent visual improvement.

Many patients misunderstand cellulite, believing that it is somehow a medical condition or defect in the skin. In reality, it is simply a gender-related difference in the structure of the subcutaneous fat lobules and the connective tissue septae that divide them. The constricted septa create bulging lobules creating the classic skin appearance. This is most manifest in the thighs. Cellulite is nearly universal in postpubertal females even if they are lean, but interestingly most obese males do not have cellulite unless they have androgen deficiency. Trying to correct this normal element of subcutaneous anatomy is much more challenging than treating an abnormality.

While I realize that women do not like the appearance of cellulite, it is important to understand that it is a totally normal condition. There is nothing wrong with embarking on many of the offered treatments but they are at best only mildly helpful and only for a short period of time. To keep up any effects of these various treatments, they must be maintained. None of them have any harmful effects other than potentially on your pocketbook. As new cellulite treatments appear, it is important to remain skeptical. Past history has shown a consistent pattern of overstated and unsubstantiated claims of results.

One misconception is that liposuction will improve the appearance of cellulite. This has become particularly prevalent since the emergence of Smartlipo or laser liposuction. Because of its potential skin tightening effects, it is believed that it will help cellulite as well. Liposuction methods, however, have no permanent effect on cellulite (it may temporarily look better due to swelling) because it can not eliminate the presence of the connective tissue septae.

 It is also important to realize the weight and exercise, two lifestyle issues in which we do have control, are not unfortunately effective at improving cellulite. You can’t exercise or burn cellulite off since it is not primarily a fat accumulation problem.

Dr. Barry Eppley

Indianapolis Indiana

Facts and Myths about Cellulite

Sunday, August 15th, 2010

If there is one body concern in plastic surgery that remains both ubiquitous in occurrence and refractory to treatment. is that of cellulite. So many women have it that the only comparable beauty affliction is that of stretch marks and wrinkles. Largely located on the thighs and buttocks, it interestingly affects almost no men. It is a true gender-biased concern.

Suffice it to say that there is no one definitive solution for the cellulite problem. The only thing we know for sure about it is its appearance can be lessened with weight loss and being very fit. Thin women tend to have less cellulite than those who are heavier.

But once one has it, it is basically impossible to get completely rid of it. The testament to its difficulty in treatment is the many topical products and even medical devices that purport to offer a solution to your cellulite concerns.

Because it is hard to treat, numerous fallacies and myths exist about cellulite. One of the most common is that it is composed of a different kind of fat. While its outer classic cottage cheese appearance on the skin may suggest otherwise, the fat in cellulite-afflicted areas is just plain fat. It is the surrounding fibrous bands that run between the underside of the skin to the deeper tissues that is the key anatomic difference. Like the quilted appearance of a spring mattress, the fat between these band is squeezed upward as the bands keep the skin where they attach pulled down. This is why it is important to keep one’s weight down if possible…increased fat deposits makes the appearance of cellulite worse.

Despite the many product and treatment claims, the myth (hope) of a cellulite cure persists. From massages and body wraps to topical creams and supplements, there are countless products promising to make your cellulite disappear. Quick fixes to cellulite are not reality. Surgical solutions have equally been unsatisfactory. While liposuction and the technique of pickling (a forked instrument that passes right under the skin) do disrupt the fibrous bands, the improvement in the appearance of cellulite is only short-term. The use of laser liposuction (Smartlipo), because of the heat generated in the fat along with fibrous band disruption, offers some theoretical improvement over traditional liposuction. Once can also use the small fiberoptic laser probe like a pickling instrument to disrupt the fibrous bands. I have see improvement in some of my Indianapolis liposuction patients but I certainly wouldn’t call it a cellulite cure.

The current use of the Zerona cold laser for body slimming says that it will also improve cellulite. But this treatment approach also employs intake of water, use of exercise, and oral supplements, all components of an active healthy lifestyle. Such a lifestyle combined with the inevitable weight loss which will occur makes the most sense in the battle against cellulite. Decreasing the fat between the bands and improving the lymphatic outflow of that same fat will improve its physical appearance.

Other medical devices employing external skin disruption and penetrating energies such as ultrasound, acoustic and infrared can also be of benefit. They have visible short-term improvement but they also require long-term maintenance treatments. Their adjunctive use  to lifestyle changes is a matter of a cost:benefit assessment. For the improvement seen are they worth the cost?

Dr. Barry Eppley

Indianapolis, Indiana

Cellulite – What is It and What To Do With It?

Wednesday, June 3rd, 2009

Everyone knows what the dimpling appearance of cellulite looks like.  The vast majority of women will experience cellulite at some time in their life and, once it appears, it is likely there  forever.  While some choose to ignore it, many women  are interested in pursuing treatment, whether it be through surgical or non-invasive options.

While its appearance is well known, few understand why it is there and what causes it. Cellulite is not really based on being overweight (although thinner people usually have less of it), but rather genetics, hormones, and age play the dominant causes. It clearly appears much more often in women than men due to the different subcutaneous anatomies of the way fat is stored.

From an anatomical standpoint, cellulite refers to the fatty deposits that form uneven and dimpled skin found mainly on the thighs, hips and buttocks of many women. Cellulite is not caused by being overweight. The subcutaneous connective tissue that holds fat is made up of fibers and these fibers act as anchors between the muscles and the skin. Between these fibers are chambers that hold fat cells. Cellulite develops when, for unknown reasons,  these connective tissue fibers beneath the skin that compartmentalize the fat shrink and stiffen. This results in areas where the skin is held down while other sections bulge out, resulting in that lumpy “cottage-cheese” appearance. Men are very much less prone to this problem because their connective tissue fibers run more diagonally rather than completely vertical.

The burning and never-ending question is…what can you do for cellulite?  What I can say is that there is nothing that you can buy on the internet and slather on the affected areas that will produce a miracle cure. Of course, there are many creams, oils, and lotions promoted  to improve cellulite.  Time and again these products are proven ineffective, yet millions of consumers still purchase them in hopes of an easy answer.  But there are newer and promising treatments that can provide some improvement although most results are not permanent. The search for more permanent solutions, like the Loch Ness monster,  is ongoing.

Liposuction is still widely perceived as a cellulite treatment since it removes fat. However, it has proven to not be an effective treatment and can even make it look worse if too much fat is removed or removed too close to the skin. In my Indianapolis plastic surgery practice, I emphasize this point to patients and how we must be careful in performing liposuction in areas underneath cellulite-laden skin.

Pickling or subcision is a procedure that has been used for decades to alleviate scarring from acne and has a more recent history of use in cellulite. The procedure is done by special long instruments that have a cutting edge to them, like a pickle fork. They work by detaching the tight fibers that run beneath the skin that cause cellulite. Unfortunately the initial smoothing benefits are not usually maintained once all swelling has subsided months later. For this reason, cellulite pickling has largely been abandoned. I have recently applied the Smartlipo technology as a ‘laser pickling’ method. The heat from the laser may yield better results in causing a more permanent cellulite improvement but more patient treatments and follow-up are needed.

Several ultrasound and laser external machines, such as TriActive and VelaShape, are FDA-approved and do produce some cellulite reduction benefits. They both use the concept of different energies being driven into the skin toincrease blood flow, improve  lymphatic drainage, and tighten a little skin. Their benefits are real but, again, only temporary for many. Maintenance treatments are necessary for sustained benefits.

In conclusion, an effective and permanent solution for reducing the appearance of cellulite does not yet exist. Superficial subcutaneous laser treatments are promising but that still requires an invasive approach. Non-invasive device-driven technologies do work but results require long-term maintenance. If it comes out of a bottle or jar…save your money (and hope) for more proven methods.

Dr. Barry Eppley

Indianapolis, Indiana

Severe Cellulite Treatment with Laser and Fat Injections

Monday, March 9th, 2009

The search for an effective treatment for cellulite is ongoing and is far from reaching a consistent solution. Various methods of treating cellulite have been espoused including liposuction, fat injections, endermologie and other mechanical disruption methods, injection lipolysis, subcutaneous carbon dioxide infusions,  herbal and dietary supplements, and numerous creams and lotions. While some of these do have a mild beneficial effect, none work consistently or have scientific data supporting their long-term efficacy. Some of these treatments, such as liposuction, can even make cellulite appear worse.

Cellulite is caused by bands of fibrous tissue that connect the skin down to the muscle from the skin. Because the bands are tight, the fat between the skin and the muscle bulges out between them creating dimpling around each band. Women are much more predisposed to cellulite due to genetic predisposition, hormonal changes and weight gain although some men can get it too.

A new study published in the November/December 2008 issue of Aesthetic Surgery Journal shows that a combination treatment of laser energy and fat injections improves cellulite. The treatment uses a 1064-nm Nd:YAG laser passed underneath the skin to help melt fat and tighten the overlying skin. The laser treatment is followed by spot injections of the patient’s own fat into the depressed cellulite dimples. In the study, 52 women between the ages of 18 to 47 with severe cellulite were treated. After the laser tightening and fat injections, the women had weekly massage therapy treatments to help evenly distribute the fat. Patients were followed for at least one year or longer and nearly 85% of the patients rated their results as good or excellent.

While this studied treatment was not non-invasive (it was actually surgery), it does appear to offer some real effectiveness in cases of severe cellulite. I am not surprised that this approach worked as it disrupts the contracting bands from the heat of the laser probe (e.g. smart lipo) and adds select areas of fat to fill in the dimples. The postoperative massage  therapy helps smooth out the injected fat which may help the cellulite from reforming. For milder cases of cellulite, which makes up many cellulite problems, this approach is not appropriate and is too invasive. Milder cases of cellulite must rely on non-invasive external treatment methods of which none have shown significant effectiveness.

Dr. Barry Eppley

Indianapolis, Indiana

Cellulite: Searching for an Effective Treatment

Thursday, November 29th, 2007

Cellulite: Difficult Problem, No Permanent Solutions


Much like scars and stretch marks, the problem of cellulite is common and questions as to how to treat it equally so. Cellulite remains, however, an aesthetic problem that defies a single effective answer. The testament to that can be seen on the internet with hundreds of cellulite treatments and ‘cures’. I have always held to the theory that if many options exist to treat a problem, probably none of them work well. If one single treatment method was good, we would all know about it….and there would only be one treatment method, not hundreds. The large number of cellulite treatment methods exist for one simple reason…..hope. When results aren’t available, hope is the next best sales method!

The problem of cellulite is fairly well understood. These are pockets of enlarged fat that are trapped between fibers (septa) that run between the skin and the underlying tissues. The fat pockets become enlarged, due to fluid retention from lymphatic obstruction, and creates that ‘quilting’ effect much like the surface of a spring mattress. It is a phenomenon that is common in women but rare in most men. The hormonal differences have been blamed as a cause although this has never been conclusively proven. It most commonly occurs on the thighs and buttocks.

Treatment options have been plentiful but can be divided into topical creams, various forms of lymphatic massage/manipulation, and surgery. Despite many grandiose claims, few topical treatments have ever been shown to create a significant improvement. Creams containing aminophylline (an asthma medication) have been most promising, but the rest mainly moisturize and soften the skin. If they have any effect, it is likely due to the luffing or sponging of the area which is often done as part of the at-home treatment. Lymphatic massage, particularly mechanized methods such as Endermologie, definitely produce visible results, albeit temporary. By using rollers under suction, the skin is lifted, the fibers disrupted, and fluid drainage from the fat encouraged. When on a long-term program with maintenance treatments, good results are consistently seen. The only question is…..is the effort (time and money) invested worth what is achieved for not a permanent result. Most recently, a minimally-invasive procedure called Carboxytherapy, appears promising. By injecting carbon dioxide under pressure underneath the skin, the cellulitic fat is remodeled and reshaped. While promising (maybe very hopeful), long-term results and studies need to be done before we jump on this bandwagon. Surgery, specifically liposuction and a method called pickling, have not panned out to be worth the effort. Liposuction of an area with cellultite can make it look even worse if not done conservatively and at a deep level. Pickling is a surgical method where a small tube with a sharp end is run under the skin to cut the fibers loose from the underside of the skin, making it smooth. While initially promising years ago, the results are not long-term and certainly not worth undergoing surgery to do.

While the search for a cellulite cure continues, non-surgical options are best although only temporary. They cause no harm, the question is merely are they worth the expense.

Dr Barry Eppley

Indianapolis,  Indiana

Dr. Barry EppleyDr. Barry Eppley

Dr. Barry Eppley is an extensively trained plastic and cosmetic surgeon with more than 20 years of surgical experience. He is both a licensed physician and dentist as well as double board-certified in both Plastic and Reconstructive Surgery and Oral and Maxillofacial Surgery. This training allows him to perform the most complex surgical procedures from cosmetic changes to the face and body to craniofacial surgery. Dr. Eppley has made extensive contributions to plastic surgery starting with the development of several advanced surgical techniques. He is a revered author, lecturer and educator in the field of plastic and cosmetic surgery.

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