By Moench-Kelly, Shelley MBA Smooth cellulite treatment options. treatment cellulite andnoninvasive invasive minimally for candidates best the identify and expectations manage to How Operators longevity ofresults. improvement of and degree selection, to share their in patient experiences who have with worked these systems cellulite treatment. Weasked physicians have spurred renewed interest in on heatorenergy— which rely not does andCelluSmooth; Ulthera’s Cellfi na, based Cellulaze Cynosure and Sciton ormore—includingyears the laser- systems that promise results oftwo invasive minimally of introduction The modality long-term has offered results. Untilproblem: recently, notreatment creams, serums and injectables. The mechanical massage, and of ahost muscleto electrical stimulators, belts surrounding the hips and buttocks machines that vibrate wide canvas downright medieval, ranging from and numerous sometimes have been Fordecades, treatment optionstypes. that people ofall affects ages and body MEN—CRINGE. SOME WOMEN—AND MAKES WORD VERY THE CELLULITE. It’s acondition

© GETTY IMAGES “It’s easy to be proud of good results, but you also have to show modest results.”

CELLULITE BASICS size of the area treated. Local anesthesia is administered The top layer of fat just under the skin on the thighs, hips to the treatment area. Using suction and subcision, the and buttocks is connected to the lower layers of fat by needle-like device administers pressure on the fi brous vertical collagen fi bers (fi brous septae). When estrogen septae. Repeated pressure eventually releases the fi bers levels decrease due to factors such as age, so does to smooth the skin surface. It can take as little as three circulation and collagen production. As fat cells become days to see results, which are expected to last at least two larger, the lack of collagen allows them to protrude through years, and side effects—including soreness, tenderness and the fi bers and become visible on the surface of the skin in bruising—are minimal. a cottage cheese or orange rind appearance. Clinical trials have posted patient satisfaction rates at Cellulite most commonly affects women because 94% after one year and 96% after two years. “I’ve been estrogen stimulates subcutaneous fat storage. It appears in private practice for 28 years. We’ve been trying to fi nd in the fat-prone areas of the body: the knees, thighs something that works on cellulite ever since. We kept and buttocks as well as the stomach and backs of the being told, ‘This works’ and ‘That works,’ and each time arms. The male hormone testosterone, on the other those options failed,” says Daniel Mills, MD, founder of the hand, stimulates protein resulting in more dense layers Aesthetic Plastic Surgical Institute in Laguna Beach, California. of connective tissue and thicker skin layers, which help “With Cellfi na, there’s minimal discomfort with little or no to prevent cellulite. “Ninety-eight percent of women downtime, and it only takes one treatment. It is promising.” have cellulite because it’s estrogen-based. It’s a female Dermatologist Joel L. Cohen, MD, director of AboutSkin characteristic,” says Suzanne Kilmer, MD, founder of Dermatology and DermSurgery in Englewood and Lone the Laser & Skin Surgery Center of Northern California Tree, Colorado, notes that the ideal Cellfi na patient is one in Sacramento. “If you put men on estrogen therapy who “maintains a stable weight, works out regularly, eats a to treat, for example, prostate cancer, they will actually healthy diet, but simply has some focal areas of persistent develop cellulite.” dimple-cellulite.” His patients are seeing improvement in dimple-release in 10 to 14 days. “We know that some of MINIMALLY INVASIVE TREATMENT OPTIONS that is likely still swelling, but patients have been happy with Two of the most talked-about treatments today are the improvement even weeks after treatment,” he says. Cynosure’s Cellulaze and Ulthera’s Cellfi na. Both are The key difference between the two is Cellfi na treats FDA-approved and promise long-term improvement large focal areas of dimpling but does not address dermal in the appearance of cellulite in a single treatment. remodeling, though the lack of laser energy makes Cellfi na Cellulaze is a 1440nm laser-based procedure that a better choice for some patients. “With Cellulaze, the heat takes 60-90 minutes and delivers long-lasting (one year may trigger hyperpigmentation. But to be fair, I think it’s or more) results after one treatment. Local anesthesia is accurate to say that less well-defi ned cellulite can benefi t applied and tiny incisions are made in the treatment area. more from the Cellulaze because it covers a larger area The proprietary laser fi ber is threaded through a cannula compared to Cellfi na, which treats more discrete bands,” that’s inserted through the incision(s). It levels out fatty says Dr. Kilmer. bumps, releases fi brous septae and stimulates collagen Other minimally invasive energy-based options include production to increase skin thickness and elasticity. Sciton’s CelluSmooth, which uses a 1319nm laser wavelength Clinical trials have noted patient satisfaction rates at 93% to cut fi brous septae, emulsify fat and tighten the dermis to one year after treatment. Side effects include bruising and improve the appearance of dimpled skin, and the VASERsmooth, general soreness that can last up to a few weeks. Some a device that ultilizes ultrasound rather than laser energy. patients experience hyperpigmentation. “It works. It’s very effective. It’s long lasting. But you have to fi nd the right NONINVASIVE OPTIONS patient type,” says Cynthia Poulos, MD, founder of Classique For patients who want a truly noninvasive option, suction and Medical Spa in Northborough, Massachusetts, who was manipulation treatment methods include: Real Aesthetics’ an early adopter of the procedure that debuted in 2011. Bella Contour, a body-shaping treatment method that uses “When you have someone who has reasonable tissue tone non-focused ultrasound to promote fat release from cells; and moderate cellulite, it’s a fantastic procedure.” electric currents to help fat penetrate the cells; and vacuum Cellfi na, launched in 2016, is a subcision-based, in-offi ce therapy to help the body fl ush the fat. Patients typically procedure that takes about one hour, depending on the undergo 10 to 15 treatment sessions.

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LPG Systems Endermologie is a handheld treatment device that grabs about an inch of skin between its rollers TINA S. ALSTER, MD and squeezes it, increasing blood and lymphatic fl ow and Washington Institute of stretching out the fi brous septae. The recommended Dermatologic Laser Surgery number of treatments is about 14. skinlaser.com 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.” JOEL L. COHEN, MD Topical creams may offer a very short-term improvement AboutSkin Dermatology in the appearance of cellulite. There are two key actives aboutskinderm.com 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 SUZANNE KILMER, MD Washington Institute of Dermatologic Laser Surgery in Laser & Skin Surgery Center Washington, D.C. of Northern California COMBINING MODALITIES skinlasers.com Even 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 DANIEL MILLS, MD skin and build collagen, and VelaShape treatments can be Aesthetic Plastic used to further recontour the skin,” says Dr. Alster. Surgical Institute Dr. Mills combines the subcision of Cellfi na with fat grafting danmillsmd.com 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 EXPECTATIONS As with any procedure, managing patient expectations CYNTHIA POULOS, MD can be a challenge. The onslaught of airbrushed, poreless, Classique Medical Spa smooth-skinned models and celebrities appearing on drpoulos.com 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

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“Topical creams may when patients are able to work in partnership with their physicians—undergoing in-offi ce treatments to reduce offer a very short- the cellulite and then maintaining those results with a good diet, regular exercise and occasional maintenance term improvement treatments as needed.” Dr. Poulos adds, “You need to show pictures that are in the appearance really accurate. It’s easy to be proud of good results, but you also have to show modest results. I’d rather under of cellulite.” 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.” Treating cellulite requires a combination of septae release, dermal remodeling, and

reduction or destruction of adipose cells. Shelley Moench-Kelly is a Vermont-based writer and editor. GETTY© IMAGES

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