Cellulite is a well recognized aesthetic skin condition that occurs most commonly in women and involves the buttocks and thighs. The cottage cheese appearance is recognized today to be the result of compartmentalized fat hypertrophy and the contraction of dermal-fascial bands in the involved regions. New device based treatments continue to emerge for its treatment that either focus on fat reduction, fascial release or both.
Exilis is a monopolar radiofrequency device that is used to heat the skin, resulting in collagen remodeling and skin tightening. It was first introduced in early 2011 after FDA clearance for the treatment of loose skin and body contouring. It has proven to be a valuable non-surgical treatment for reducing loose skin and wrinkles on the face and body.
In February 2015 the FDA has approved the use of Exilis for the temporary reduction in the appearance of cellulite. Using a new treatment protocol that can effectively target the fat underneath cellulite involved skin that helps give it its dimple lumpy external appearance, temporary improvement in the appearance of the skin is obtained. It takes multiple treatments, usually four to six, spaced several weeks apart to get the full effect. Full results can take up to three months after treatment.
Exilis Elite joins a growing number of devices for cellulite that offers non-surgical treatments of an aesthetic problem that defies any universally effective solution.
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.
VelaSmoothis another FDA cleared device for cellulite. It uses radiofrequency, infrared light and suction asits multimodality treatment method.
SmoothShape is also FDA cleared for cellulite. It usesa 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.
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 andbuttocks 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 promotedto 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 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.