Cellulite Treatments; At A Glance
- Best Results2-5 sessions
- Treatment Recovery0-2 weeks
- Procedure Time30 to 90 min
- Skin SpecialistDavin Lim
- Duration of Results5+ years
- AnaestheticLocal, gas, sedation
- Back to Work1-5 days
Predictable & effective cellulite treatments are now available. Current research has shown that results can extend beyond 5 years. I use a combination of collagen stimulation & surgical techniques to improve the appearance of cellulite. Devices including radiofrequency are useful adjunctive treatments to help with lymphatic flow & collagen stimulation.
FactsFacts on Cellulite Treatments
- Over the past 3 years there has been a greater understanding of how to treat cellulite
- The consensus is a multimodal approach to address the causes
- Surgical subcision breaks thickened vertical bands
- Collagen stimulating dermal fillers supports the overlying dermis
- RF or radiofrequency, infrared & suction devices aids microcirculation
- Electromagnetic field therapy can improve lymphatic drainage & decrease secondary inflammation
- New FDA approved collagenase injections are novel treatments
What causes cellulite?
We now know how cellulite forms. In knowing so, we can have effective treatments that target one of the three factors.
- Thin dermal layer. People who are prone to cellulite will often have a thin dermal layer. This layer acts to compartmentalise the lower fat layer. A thin dermis does not support the extrusion forces that originate from the lower fat layer.
- Enlarged adipose network. Below the dermis lies the fat. People with cellulite have more volume. This increased volume pushes up, leading to herniation of pockets of fat.
- Thicker fibrous bands known as septae separate the pockets of fat. These bands attach to the dermis, leading to divots.
Secondary pathology includes altered lymphatic flow & inflammation of the fibrous compartments.
What is the truth behind cellulite treatments?
The most important aspect to understand is that multimodality treatments are required to effectively treat cellulite. The answer does not lie in a device, cream, nor injection but the combination of correct methods pertaining to the pattern of cellulite.
Let’s dispel some myths regarding cellulite treatments.
Fact 1. A cream for cellulite removal does not exist. Creams can be used as adjunctively to complement surgical & energy devices. The results from creams as monotherapy is marginal at best. Creams are best combined with deep tissue massage.
Fact 2. A predictable device for cellulite treatment does not exist. Devices including mono, bi, & multipolar RF, lasers & shock wave therapy can be used as adjunctive global treatment for cellulite improvement. Devices are best combined with surgical procedures & dermal fillers.
Fact 3. Diffuse cellulite is harder to treat than focal divots. The former requires remodelling of the fibrous bands, thickening of the dermal-epidermal junction to improve extrusion forces outwards, as well as reduction of adipose tissue.
Fact 4. Liposuction does not treat cellulite. However, if combined with subcision, lasers & dermal fillers, the appearance of cellulite can be improved.
What is the best way to approach cellulite?
A logical way to treat cellulite is to combine modalities that address the cause. I employ 3 methods as follows-
RF bipolar & multipolar devices. These machines are used to stimulate collagen in the deeper tissues. A thicker collagen layer in the dermal-fat junction is more resistant to extrusion forces, hence can reduce the out-pocketing of adipose tissue. Devices can also modulate blood & lymphatic flow, further reducing the appearance of cellulite.
Surgical breakage of fibro septal network with various devices & techniques. This is most useful for isolated divots. Breaking the bonds of collagen holding down the upper layers of skin results in ‘release’.
Dermal fillers can be used to stimulate collagen production to support the dermis. I use a variety of collagen stimulation techniques including hyper dilute PLLA & calcium hydroxyapatite fillers.
Which forms of cellulite responds best?
Localised cellulite is easier to treat compared to diffuse or general cellulite.
Localised or focal cellulite consists of discrete divots or depressions. These are treated with surgical subcision followed by stimulation of collagen using dermal fillers & RF devices.
Can liposuction treat cellulite?
Liposuction as a sole modality does not treat cellulite, however in combination with other modalities including Cellulaze, subcision, Cellfina, & laser assisted liposuction, it can help reduce the appearance of cellulite.
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Can injections melt cellulite?
There are 3 injections that can treat cellulite.
Firstly, a new product called QWO has been approved by the FDA. This enzyme releases the fibrous bands under the skin, redistributes fat cells & stimulates new collagen production.
The second type of injection is known as PLLA or Sculptra. This dermal filler stimulates the production of collagen & thickens the dermis.
The third injectable is called calcium hydroxyapatite or Radiesse. It too thickens the collagen bundles to support the dermis-fat junction.
Can lasers treat cellulite?
Side firing lasers in the 1440 nm wavelength can treat cellulite. This laser is called Cellulaze. It works by subcision of the fibrous septae, coagulation of fat & stimulation of dermal collagen.
There are no head-to-head studies that suggest lasers are better than other methods. Devices including lasers, RF, ultrasound, shock wave therapy, are all instruments that can be useful as adjunctive treatment that complements dermal fillers & surgical subcision.
How do dermal fillers treat cellulite?
Dermal fillers including collagen stimulating fillers can improve some cases of cellulite. This procedure is often combined with subcutaneous subcision of cellulite bands. Collagen stimulating fillers provide strength to the fibro septal network of fat as well as provide volumetric correction of divots.
I prefer the use of hyper diluted PLLA or poly-L-lactic acid. Why? Because it stimulates collagen & is much more cost effective than hyaluronic acid. Most patients will require 2-4 sessions over a period of 2-3 months. Expect bruising for a week (especially if I subcise). Dermal fillers last 2-4 years in most cases. Costs range from $1900 to $5990 per area.
I often combine RF or radiofrequency with dermal fillers to improve the chances of success.
What is Cellfina?
I was involved in the launch of Cellfina in Europe & the United States by Merz in 2015-2016. This is a FDA approved treatment for cellulite, & is essentially sharp subcision with a modified Nokor under vacuum. It is effective for the treatment of cellulite, with follow up studies spanning over 48 months.
The procedure takes 45 to 90 minutes to perform from start to finish. The first step involves marking of the dimples (easier with angled or tangential lighting). Once marked local anaesthetic & vacuum is applied. The latter is designed to lift the skin from the fibro septal areas. A special blade on the end of a needle transects the bands pulling down on the skin.
Downtime? Over a week. I disagree with the studies that state ‘mild bruising’. Majority of patients will have significant bruising for one week or longer. Nevertheless, this is probably one of the most effective treatments for cellulite as each dimple is manually treated. Once these bands are released, dimpling decreases as the skin is able to bounce back to its original & natural state.
Side effects of any surgical procedure are significant. These include bruising, typically taking 1-3 weeks to settle. Hemosiderin staining is also common. This is due to iron extravasation to the tissue. It can take up to 6-9 months to resolve, however with pico lasers we can hasten fading.
What is Venus Legacy & does it work?
Venus Legacy is my preferred treatment for cellulite. This is a multi-polar radiofrequency device that combines electromagnetic energy fields with intermittent positive & negative pressure.
Legacy works by increasing dermal thickness through the use of radiofrequency energy. Electromagnetic fields modulate microcirculation. Intermittent pressure improves lymphatic drainage.
Patients undergo a series of 5 to 8 treatments, spaced 2-4 weeks apart. Treatments are painless & typically take 20 to 60 minutes to perform.
What is Velashape, & does it work?
VelaShape is a non-invasive body contouring treatment that can be used for cellulite. This treatment is FDA approved for temporary cellulite reduction. The latest model by Candela is known as the Velashape 3. This device uses a combination of four modalities to target cellulite: infrared light, bipolar radiofrequency (RF) energy, suction & massage.
Suction brings fat, cellulite & connective tissue closer to the energy source inside the handheld device. Massage to help relax and stretch the stiff fibrous bands under the skin that cause the dimpling and orange peel texture known as cellulite. Energy delivery via IR & radiofrequency heats the skin, improving collagen production in the fibro septal network, as well as tightening the tissue & reducing the volume of fat cells.
This device may be paired with other modalities including RF microneedling, RF, subcision, Cellfina, shock wave therapy & topicals.
Like any other energy device for cellulite, treatment success is highly variable. Velashape can be used on the thighs, buttocks, upper arms, and stomach.
Disclaimer: as of 2021,I am not using Velashape for cellulite. I did trial this device, & in my experience it has similar results to most energy devices for cellulite. As with all cellulite treatments, the best outcomes are with dimpled isolated bands, using devices as adjunctive treatments to manual revision.
What is shockwave therapy for cellulite?
Shock wave therapy or SWT is also known as AWT or Acoustic Wave Therapy & EPAT extracorporeal pulse activation therapy. This is a non-invasive, low yield solution for some cases of cellulite.
These techniques employ the use of sound delivered via high pressure sound waves targeted to the affected areas. Shock wave therapy has medical applications including treatment of sports injury, kidney stones & even after Coolsculpting for fat reduction. High pressure sound causes cavitation & break down of the targeted tissue.
The discovery of SWT for cellulite was a serendipitous event. A clinician demonstrated an improvement in cellulite whilst treating a hamstring injury. The mechanism of action is unclear, however cavitation, increased blood flow & upregulation of collagen has been proposed.
The level of evidence for shock wave therapy as monotherapy has not been confirmed by reputable studies, however company sponsored white papers exist. I do use show wave therapy for other conditions, but I do not employ this method for cellulite. Shock wave therapy, much like RF devices should be combined with other cellulite treatments.
Do cellulite creams work?
Caffeine modulates blood flow, & can metabolise fat. This is why it is banned in some countries for long distance cycling & running. The concentration of topical caffeine 3% is about one quarter the amount in a cup of coffee. A simple DIY application is with coffee grounds. You can repurpose this in compost for your garden.
Jojoba seed oil which is a plant wax that is commonly used to moisturize skin. It is claimed that it “reverses the appearance of cellulite on the skin and defend against the formation of more cellulite on the legs, arms, or tummy areas”. This is a very budget friendly option & in the best case acts as a moisturizer.
Centella Asiatica– also called gotu kola or tiger’s herb, this has been shown to increase blood flow and allow for better absorption of nutrients. Another theoretical blood flow modulator for cellulite areas.
Peptides– these are amino acids that serve as the building blocks for collagen and elastin. Those are the things that make up the connective tissue in your skin that becomes weakened and allows for cellulite to show. Research is still ongoing when it comes to peptides.
Can HIFU or micro-focused ultrasound treat cellulite?
An Italian dermatologist has produced a great paper on the use of HIFU (Ultherapy) combined with Radiesse (Ca OH apatite dermal filler) for the treatment of cellulite. These two treatments complement each other & can stimulate collagen within the fibro septal network of cellulite. This can result in better support.
The biggest drawback with this combined treatment is the cost of consumables- namely the three transducer depths of 4.5, 3.0 & 1.5 mm, in addition to the cost of Radiesse at a 1:1 dilution. This means the average cost per session for the patient ranges between $5,500 to $8,000 depending on the extent of cellulite treatment. On this basis I prefer poly-l-lactic acid over Radiesse. The opposite holds true for facial atrophy as the G Prime for calcium hydroxyapatite is several hundred magnitudes higher than poly-l.
Are cellulite treatments permanent?
There are no long-term studies past 5 years, though there are ongoing studies that should reach the 5-year mark in 2022. These include studies on subcision, as well as combination collagen stimulation fillers such as Radiesse & poly-l-lactic acid (Sculptra).
To date, studies have shown that physical disruption of fibro septal networks (subcision/Cellfina), have given the longest remission rate.
Davin’s Viewpoint on treating cellulite
Cellulite is seen in over 95% of women, & despite its prevalence & impact, it still remains challenging to treat. This is one of the most difficult conditions to treat well, even though billions have been spent on research over the past decade. Only recently has the anatomy & physiology of cellulite been understood, & hence directed treatments based upon clinical examination will give higher yields compared to a one size fits all device. The best results are achieved via manual methods, much like the surgical work I perform on acne scars. If one approaches cellulite analytically, the chance of success is infinitely higher.
There has been a dearth of reports on the use of magical cellulite creams with theoretical value. The usual list of ingredients includes caffeine or ground coffee to modulate blood flow (one of the causes of cellulite), peptides, retinoic acid, retinol to build up collagen in the fibroseptal network, niacinamide to reduce inflammation seen in the superficial fat layer, as well as a plethora of natural lipolytic topicals that claim to improve or accelerate fat breakdown. The reality is that there is no formulation that is the gold standard. If you are after a cost-effective method, you can try ground coffee, it has the highest concentration of caffeine, combine this with a retinol of your choice.
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