Single treatment of grades II and III cellulite using a minimally invasive 1,440-nm pulsed Nd:YAG laser and side-firing fiber: an institutional review board-approved study with a 24-month follow-up period

Improvement in Cellulite Appearance After a Single Treatment Visit With Acoustic Subcision: Long-Term Findings From a Multicenter Clinical Trial

BACKGROUND

Cellulite is an aesthetically displeasing rippling or dimpling of the skin, primarily on the buttocks/thighs. A recent study showed a novel acoustic subcision device produced significant short-term (12-week) improvement in the appearance of cellulite after a single rapid acoustic pulse (RAP) treatment.

OBJECTIVE

To evaluate the long-term (>52-weeks) efficacy and safety of RAP treatment for improvement in the appearance of cellulite.

MATERIALS AND METHODS

In this prospective, multicenter trial, female participants ( n = 42) with severe cellulite were treated with the acoustic subcision device in a single visit. At >52 weeks, blinded board-certified dermatologists assessed efficacy by correctly identifying post-treatment photographs and using a 6-point simplified Cellulite Severity Scale (CSS). Participant satisfaction was also collected. Safety was assessed throughout.

RESULTS

The blinded panel correctly identified post-treatment photographs at a rate of 95.2%; 70.4% of participants had a >1-point reduction in the CSS score from baseline (mean reduction of 1.09). All participants (100%) reported improved cellulite appearance. Overall pain during treatment was rated as 2.4 and 0.3 post-treatment (pain scale 0-10). No device or treatment-related adverse events were reported at the >52-week follow-up.

CONCLUSION

Rapid acoustic pulse treatment significantly improved the long-term appearance of cellulite and was well-tolerated.

Cellulite: An Update on Pathogenesis and Management

Cellulite is a common cosmetic concern among postpubertal women. Despite its high prevalence, there have been only a few high-quality studies assessing its exact prevalence, risk factors, and pathophysiologic mechanisms. It has been difficult to achieve long-lasting results with the available treatments, including topical agents, energy-based devices, subcision, and injectables. In this review, the authors summarize the proposed etiologic factors, grading scales, and treatment options. Further well-designed studies are essential to improve our knowledge of the condition and lead to improved treatment strategies.

The safety and effectiveness of low-level light therapy (LLLT) with light-emitting diode (LED) bed system and a novel topical anti-cellulite gel on grades 1-2 thigh/buttock cellulite: a randomized, comparative-controlled split-thigh/buttock IRB study

BACKGROUND

Cellulite of the upper lateral and posterior thighs and lower buttocks represents a common unwanted condition.

OBJECTIVES

The author sought to comparea LLLT-LED bed therapy and a novel topical anti-cellulite gel on one thigh/buttock cellulite vs light therapy for cellulite to the opposite side.

METHODS

Eight healthy female subjects were randomly treated with a LLLT-LED bed twice weekly for 20 minutes in prone/supine positions with twice daily application of a novel anti-cellulite gel to one randomized thigh/buttock.

RESULTS

At the end of the 3-month trial, skin elasticity increased after combined therapy on one thigh but decreased with only LLLT-LED bed treatments on the opposite thigh. Thighs treated with active gel and LLLT-LED bed, were downgraded to a lower cellulite grade, while monotherapy did not demonstrate any change from their baseline cellulite grading. Changes in thigh circumference did not correlate with either treatments regimens.Subject and investigator questionnaire evaluations at month-3 were assessed as "satisfactory" results. There were no adverse reactions to treatments.

CONCLUSIONS

The use of LLLT-LED bed therapy and an anti-cellulite gel demonstrated an efficient alternative in the treatment of cellulite-involved thighs/buttocks over similarly affected thighs/buttocks that were treated only with LLLT-LED bed therapy.

Comparison of Cellulite Severity Scales and Imaging Methods

Cellulite is characterized by dimpled contour alterations of the skin and is present in approximately 85% to 90% of postpubertal females. Although the pathophysiology of cellulite remains to be fully elucidated, experimental evidence indicates a multifactorial process involving the number and types of fibrous septae, microvascular dysfunction, subcutaneous inflammation, decreased dermal thickness with age, and fat deposition. Cellulite is a major cosmetic concern for many women, and a number of both noninvasive (eg, massage, cosmeceuticals, laser therapy) and minimally invasive techniques (eg, subcision, collagenase injection) have been evaluated to improve the appearance of the affected skin. However, evidence for many of these treatments is limited, largely due to the lack of a validated, convenient tool for the standardized evaluation of cellulite severity. Various imaging modalities have been employed to characterize cellulite severity and the impact of treatment, but only 2-dimensional and 3-dimensional digital photography have been adequately validated. However, in many cases, imaging findings do not correlate with subjective measures of cellulite severity. A number of cellulite rating scales have been developed; some provide only a qualitative measure, whereas others do not fully capture all clinically relevant aspects of cellulite, including the perspective of the patient. There remains an unmet need for global adoption of a validated scale that can be utilized easily by clinicians and patients in clinical and research settings. We propose features that should be included in an ideal rating scale for assessment of cellulite severity.

Insights Into the Pathophysiology of Cellulite: A Review

BACKGROUND

The etiology of cellulite is unclear. Treatment of cellulite has targeted adipose tissue, dermis, and fibrous septae with varying degrees of success and durability of response.

OBJECTIVE

Results from clinical trials that target different anatomical aspects of cellulite can provide insights into the underlying pathophysiology of cellulite.

MATERIALS AND METHODS

A search of the PubMed database and ClinicalTrials.gov website was conducted to identify clinical trials that have investigated treatments for cellulite.

RESULTS

A lack of trial protocol standardization, objective means for quantification of improvement and reported cellulite severity, and short-term follow-up, as well as variation in assessment methods have made comparisons among efficacy studies challenging. However, the lack of durable efficacy and inconsistency seen in clinical results suggest that dermal or adipose tissue changes are not the primary etiologies of cellulite. Clinical studies targeting the collagen-rich fibrous septae in cellulite dimples through mechanical, surgical, or enzymatic approaches suggest that targeting fibrous septae is the strategy most likely to provide durable improvement of skin topography and the appearance of cellulite.

CONCLUSION

The etiology of cellulite has not been completely elucidated. However, there is compelling clinical evidence that fibrous septae play a central role in the pathophysiology of cellulite.

Collagenase Clostridium Histolyticum for the Treatment of Edematous Fibrosclerotic Panniculopathy (Cellulite): A Randomized Trial

BACKGROUND

Edematous fibrosclerotic panniculopathy (EFP; cellulite) is associated with thickening and contraction of collagen-rich subdermal septae. Collagenase clostridium histolyticum (CCH) may disrupt collagen-rich septae.

OBJECTIVE

To evaluate the safety and efficacy of CCH for treatment of EFP.

MATERIALS AND METHODS

In a randomized, double-blind study, women with moderate or severe EFP of the buttocks or posterolateral thighs (i.e., Clinician Reported Photonumeric Cellulite Severity Scale [CR-PCSS] and Patient Reported Photonumeric Cellulite Severity Scale [PR-PCSS] ratings of 3 to 4, and Hexsel Cellulite Severity Scale score ≤13) received up to 3 treatment sessions (Days 1, 22, and 43) of subcutaneous CCH 0.84 mg or placebo injections. End points included the percentage of 2-level and 1-level composite responders (i.e., had ≥2-level or ≥1-level improvement in CR-PCSS and PR-PCSS) at Day 71.

RESULTS

Three hundred seventy-five women (mean age, 46.5 years; 86.4% white) were randomly assigned to CCH (n = 189) or placebo (n = 186). At Day 71, the percentages of 2-level and 1-level composite responders were greater with CCH (10.6% and 44.6%, respectively) versus placebo (1.6% and 17.9%; p < .001 for both). The most common adverse events were injection-site related.

CONCLUSION

CCH significantly improved EFP appearance versus placebo; further evaluation of CCH for EFP (cellulite) is warranted.

Treatment for cellulite

Cellulite is a multifactorial condition that is present in 80% to 90% of postpubertal women and is one of the most intolerable esthetic imperfections. There are several theories on the pathophysiology of cellulite, and a number of different therapeutic regimens have been developed, from topical treatments to mechanical or energy-based devices. In this brief review, we summarize the scientific landscape to determine the clinical evidence with regard to the safety and efficacy of cellulite treatment options. Clinical protocols and the author’s experience using a combination of internal and external procedures are also discussed. Studies using laser and light modalities along with radiofrequency have shown improvements in cellulite and a good safety profile, but acoustic wave therapy, subcision, and the 1440-nm Nd:YAG minimally invasive laser have demonstrated the most beneficial results in cellulite reduction. Although there is paucity of scientific evidence for treatments that improve cellulite, future emerging options and their combination may pave the way to eradicate this primarily cosmetic esthetic concern.

Treatment of Dimpling from Cellulite

Background

Cellulite can be seen on the skin in widespread alterations of the skin surface and dimpling. The purpose of this study was to assess the effectiveness and safety of the manual subcision technique to treat dimpling from cellulite, using a specific class IIA medical device (Celluerase).

Methods

The multi-center observational study assessed 200 women treated in a single session for different dimpling, using manual subcision administered by Celluerase. Aesthetic outcomes were evaluated by the authors, and the patients assessed satisfaction levels.

Results

Two hundred women between 20 and 55 years were treated. The medical evaluation of patients saw improvements with an average score of 8.1, whereas the subjective evaluation by patients gave an average improvement score of 7.8. Adverse events were reported.

Discussion

Women have septa orientation at right angels to the skin surface, and those with cellulite have an irregular septa conformation, with some septa being hypertrophic-thickened, and others being narrowed-lysed. Magnetic resonance imaging has confirmed that cellulite depressions are associated with a significant increase of thickness of underlying subcutaneous fibrous septa. Subcision has immediate results because it eliminates traction on the skin.

Conclusion

The study has shown the effectiveness and safety of the manual subcision in the treatment of dimpling. The device used, designed specifically for this technique, has shown itself to be very helpful and effective in terms of practical use, aesthetic outcome and safety, with various advantages compared with other commonly used devices.

Cellulite: a review with a focus on subcision

Cellulite is an alteration in skin topography most often found on the buttocks and posterolateral thighs of the majority of postpubertal females. This article aims to review the background, potential pathophysiology, and potential treatment options for cellulite, highlighting subcision as an ideal therapeutic option for this cosmetically distressing condition.

Laser cellulite treatment and laser-assisted lipoplasty of the thighs and buttocks: Combined modalities for single stage contouring of the lower body

BACKGROUND AND OBJECTIVES

Cellulite and lipodystrophy are often found together, especially in areas of the buttocks and thighs, causing skin surface irregularities. Each of these conditions is currently treated independently as two separate surgical procedures. In our practice, we developed a novel combined approach for the simultaneous treatment of cellulite and lipodystrophy, as a single stage procedure in the same anatomic area. For the treatment of cellulite, we used the Nd:YAG laser at a wavelength of 1,440-nm, along with an innovative 1,000-micron directional side-firing fiber optic laser system. For the treatment of lipodystrophy, the Nd:YAG laser with a 1,440 nm wavelength, along with a fiber optic laser system was used. The objective of this study is to determine the efficacy and safety of a combined approach for the simultaneous treatment of cellulite and lipodystrophy.

STUDY DESIGN, PATIENTS AND METHODS

In 2012, 16 subjects with noticeable cellulite, Grade II and Grade III, accompanied by mild-to-moderate lipodystrophy of the lower body received single treatments of the Nd:YAG laser at a wavelength of 1,440-nm along with the 1,000-micron side-firing fiber optic laser system for simultaneous treatments of both cellulite and lipodystrophy. Patients were assessed at baseline and 3-6 months post-treatment by a modified Nurnberger-Muller scale utilized to quantify the cellulite severity. Additionally, patient satisfaction and a global aesthetic improvement scale were used to measure the improvement in lipodystrophy.

RESULTS

Blinded reviewers identified the correct baseline photographs 97% of the time when presented with a set of photographs. The median modified Nurnberger-Muller scale score at baseline was 4.75 ± 1.2 and the average improvement was 2.0 ± 1.2. Global aesthetic improvement scores ranged from 1 to 3 with an average of 1.58 indicating a much-improved overall appearance. Satisfaction was high for both physicians and patients with scores corresponding to extremely satisfied/satisfied.

CONCLUSION

Precise, effective delivery of laser energy to the dermal-adipose tissue, as well as the deep adipose lipodystrophy is feasible as a safe modality for the simultaneous treatment of cellulite and lipodystrophy in the buttocks and thighs, as a single stage procedure.

Cellulite: an evidence-based review

BACKGROUND

Cellulite is a multifactorial condition that is present in 80-90 % of post-pubertal women. Despite its high prevalence, it remains a major cosmetic concern for women. A wide range of products and treatments for cellulite reduction is available; however, no systematic review has been performed so far to evaluate the efficacy of the available treatment options for cellulite.

OBJECTIVE

The objective of this review is to provide a systematic evaluation of the scientific evidence of the efficacy of treatments for cellulite reduction.

METHODS

This systematic review followed the PRISMA guidelines for reporting systematic reviews and meta-analyses. Only original articles in English or German reporting data on the efficacy of cellulite treatments from in vivo human studies were considered. In total, 67 articles were analyzed for the following information: therapy, presence of a control group, randomization, blinding, sample size, description of statistical methods, results, and level of evidence.

RESULTS

Most of the evaluated studies, including laser- and light-based modalities, radiofrequency, and others had important methodological flaws; some did not use cellulite severity as an endpoint or did not provide sufficient statistical analyses. Of the 67 studies analyzed in this review, only 19 were placebo-controlled studies with randomization. Some evidence for potential benefit was only seen for acoustic wave therapy (AWT) and the 1440 nm Nd:YAG minimally invasive laser.

CONCLUSION

This article provides a systematic evaluation of the scientific evidence of the efficacy of treatment for cellulite reduction. No clear evidence of good efficacy could be identified in any of the evaluated cellulite treatments.

Cellulite treatment: a comprehensive literature review

An effective and long-term treatment of cellulite has not been well established. To our knowledge, no review has analyzed the whole range of treatments for this condition. We conducted a review of in vivo studies on humans adopting the key words "cellulite" and "treatment." The studies were included according to eligibility criteria. We performed an analysis to estimate the overall effect of cellulite treatments from clinical studies. Medline library was screened up to December 2014 to identify eligible studies. We included 73 original studies in the present review. All of them were clinical studies, in most of them, only women were recruited. Above the studies searched up, 66 tested the effectiveness of an exclusive treatment performed without the association to other procedures: 11 topical agents, 10 shock-wave therapy, 10 radio frequency, eight laser therapy, five oral therapy, four manual massage therapy, three carbon dioxide therapy, two compressive therapy, two infrared therapy, one dermabrasion, and 11 devices that use an association of multiple treatments. Seven papers tested a combination of two or more treatments. The mean difference of clinical morphologic features and ultrastructural changes between the treated group and the controlled showed significant heterogeneity between studies. It is still difficult to indicate an exclusive and effective single treatment for this condition. Our analysis purposed to obtain a complete overview of the available treatments in cellulite reduction.

Efficacy of Slimming Cream Containing 3.5% Water-Soluble Caffeine and Xanthenes for the Treatment of Cellulite: Clinical Study and Literature Review

Background

Cellulite is a 'cottage cheese-like' cutaneous change caused by subcutaneous fat bulging into the dermis that usually leads to cosmetic problems. Slimming cream containing 3.5% water-soluble caffeine and xanthenes exhibits a lipolytic effect with penetration into the dermis.

Objective

To evaluate the efficacy and safety of slimming cream for the treatment of cellulite.

Methods

Fifteen subjects with cellulite applied slimming cream to the thighs and inner side of the upper arms twice daily for 6 weeks. Efficacy was assessed using a standard visual scale, changes in the circumferences of the thighs and upper arms, and patient satisfaction by a questionnaire at baseline, week 3, and week 6. Safety was assessed by inquiring about adverse events through questionnaires.

Results

The standard visual scale score improved significantly by 0.49 points (19.8%) at week 6. Thigh and upper-arm circumferences decreased by 0.7 cm (1.7%) and 0.8 cm (2.3%), respectively, at week 6. Slight itching and transient flushing were commonly reported, but no serious adverse event occurred.

Conclusion

The slimming cream tested appears to be effective for the treatment of cellulitis without serious adverse effects. However, additional large clinical trials are required to confirm the efficacy and safety of slimming cream for the treatment of cellulitis.

The skin-tightening effects of 1,444-nm Nd:YAG laser on human skin: an in vivo study

BACKGROUND

The 1,444-nm Nd:YAG laser was developed to improve the removal of fat cells and to affect the underlying dermis with the aim of skin tightening. We conducted this study to evaluate whether this laser is effective in tightening the skin and causing histological alterations to dermal collagen fibers, fibroblasts, mucopolysaccharides, and elastin.

METHODS

In a 38-year-old patient who was scheduled to undergo elective abdominoplasty, we subdermally performed laser-assisted treatment with the 1,444-nm Nd:YAG laser using different power settings over periods of 3 months and 1 month and prior to surgery. Postoperatively, we evaluated the skin-tightening effect through histopathologic examination.

RESULTS

On histopathology examination, the thickness of the dermis had gradually increased following the 3-month treatment with laser irradiation. In the treatment groups on the abdomen, the collagen fibers were arranged in a more parallel pattern and became denser than those in the control group. Likewise, fibroblast proliferation and the levels of mucopolysaccharides and elastin were higher in the treatment groups than in the control group.

CONCLUSIONS

The 1,444-nm Nd:YAG laser was effective in promoting the remodeling of the dermis and the regeneration of collagen fibers. As such, the 1,444-nm Nd:YAG laser could be used for skin tightening in addition to its function in lipolysis.

LEVEL OF EVIDENCE II

This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.