Cellulite: Patient Selection and Combination Treatments for Optimal Results—A Review and Our Experience

Clinical and Ultrasound Efficacy of Topical Hypertonic Cream (Jovita Osmocell®) in the Treatment of Cellulite: A Prospective, Monocentric, Double-Blind, Placebo-Controlled Study

Background and Objectives: Cellulite, or edemato-fibro-sclerotic panniculopathy (EFP), is characterized by dermal and hypodermal changes leading to adipose tissue accumulation and compromised venous circulation. This study investigates the efficacy of a hypertonic cream containing concentrated sodium chloride (Jovita Osmocell®) in addressing water retention and structural alterations in adipose tissue, aiming to interrupt the cellulite formation process. Materials and Methods: A 12-week, prospective, monocentric, double-blind, placebo-controlled study enrolled 30 female subjects with grade II or III cellulite. Patients were randomized to receive hypertonic cream or a placebo. Thigh circumference, ultrasound evaluations, and standardized photographs were collected at baseline, intermediate, and endpoint visits. Adverse events were monitored. Results: After 84 days, the hypertonic cream group exhibited a significant reduction in thigh circumference compared to the placebo group (p = 0.0037). B-mode ultrasound examinations revealed significant changes in the parameters studied, such as the thickness of the subcutaneous tissue. No statistically significant changes were noticed in the placebo group. Volunteers reported the investigational product's pleasantness and good anti-cellulite activity, with no reported adverse events. Conclusions: The hypertonic cream demonstrated efficacy in reducing thigh circumference, addressing water retention and structural alterations in adipose tissue. The proposed mechanism involves osmosis, releasing accumulated fluids between fat cells, supporting drainage, and reducing inflammation. This study supports the efficacy and safety of hypertonic sodium chloride emulsions in cellulite treatment and confirms safety and user satisfaction.

Cellulite and the Aesthetic Management of the Buttocks and Thighs: 6 Cases Illustrating Targeted Verifiable Subcision as Part of a Multimodal Approach to Lower Body Rejuvenation

Background

In the buttocks and thighs, skin quality, focal adiposity, volume deficiency, skin laxity, and/or textural issues each contribute to overall appearance. For patients undergoing rejuvenation/beautification procedures, global improvement is desired, making multimodal treatment the standard of care to address these mechanistically distinct concerns. Resolution of cellulite depressions is central to patient satisfaction and aesthetic outcomes: without management, the overall aesthetic suffers, and patients are left partially unsatisfied with treatment results. With minimally invasive Targeted Verifiable Subcision (TVS; Avéli [Revelle Aesthetics, Inc., Mountain View, CA]), septa with a confirmed role in dimple formation can be released through mechanically verified subcision, permitting consistent outcomes.

Objectives

Discuss the application of TVS as part of a multimodal approach to buttock and thigh rejuvenation and share best practices for obtaining optimal improvement.

Methods

A group of 6 experts in aesthetic plastic surgery and dermatology convened for a 2 h roundtable discussion of select case studies, best practices, and their approaches for obtaining optimal outcomes in clinical practice.

Results

Clinical cases from 6 patients who presented for buttock and/or thigh rejuvenation/beautification are presented where TVS was applied as part of a multimodal approach. Before and after images, details of patient cases, and a discussion of best practices for patient education and evaluation, treatment planning, technique, safety, postprocedure care, and open research questions are included.

Conclusions

TVS is emerging as a valuable tool for the treatment of cellulite in the buttocks and thighs that may potentially be used alongside surgical and nonsurgical approaches, often on the same day.

Level of Evidence 4

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.

Update: Cellulite Therapies and Optimizing Treatment Combinations

Cellulite in the proximal lower extremities is a reported concern among many adult females. The unsightly appearance of cellulite leads many affected individuals to seek treatment by trained specialists. The objective of this review is to provide the reader with an update on new and innovative therapies for cellulite including various treatment combinations to maximize therapeutic outcomes, and strategies for minimizing adverse events. The availability of new technologies and the results from recent clinical trials provide additional tools and data to consider when creating treatment plans for cellulite patients. This update to previous treatment recommendations is based on the most recent developments in cellulite management including the personal experiences of the authors with an emphasis on injectable enzymes, acoustic subcision, targeted verifiable subcision, and biostimulators. Formal clinical studies are warranted to compare various treatment modalities and further investigate combination regimens.

LEVEL OF EVIDENCE: 5

Buttocks Beautification 3D with Calcium Hydroxylapatite (RadiesseTM): An Individualized Approach to Diagnosing and Treating Contour, Sagging, and Cellulite of the Buttocks in Seven Cases

Background

The demand for body procedures is increasing, and buttocks beautification is one of the most sought-after procedures in dermatological and plastic surgery clinics. Several aspects affect the beauty of this area, including sagging, cellulite, contour irregularity, and volume reduction. This makes treatment of the area more challenging. Calcium hydroxylapatite (CaHA), which may be injected into the buttocks, stimulates local neocollagenesis, provides volume replacement, increases the strength and elasticity of the dermis, and thickens the underlying superficial fascia. However, no protocol for buttocks beautification tailors the dilution and deep application of CaHA filler simultaneously according to clinical assessments and personal priorities regarding contour, sagging, and cellulite.

Purpose

To report the results of a minimally invasive protocol using different dilutions of CaHA (Buttocks Beautification 3D) in the buttocks with application in different planes. The treatment was performed according to a previous individualized evaluation to improve the area aesthetically.

Patients and methods

Six women and one man were submitted to the protocol. An assessment was performed to determine the shape, sagging, cellulite (in women), and patients' preferences for buttocks beautification. The dilution, volume, depth, and injection technique for CaHA were based on these assessments. The results of the treatment were then assessed using standardized photographs and patient satisfaction.

Results

We reported favorable results in six women and one man with different grades of sagging, female cellulite, and shapes of the gluteal region who were treated with CaHA injections according to a tailored protocol. All participants reported high satisfaction with the procedure.

Conclusion

Highly satisfactory results were achieved in seven adult patients who were assessed and treated for the buttocks with CaHA using an individualized protocol. Prospective studies should be performed to corroborate our findings and optimize the use of Buttocks Beautification 3D as a reliable modality of treatment for this body area.

Cellulite: Current Understanding and Treatment

Cellulite is an aesthetically distressing skin condition that manifests as dimples and depressions, producing an uneven surface to the skin. Occurring in 80% to 90% of females, mostly on the thighs, buttocks, and hips, it is associated with profound negative psychosocial and quality of life issues. Its ethiopathogenesis and pathophysiology are likely to be multifactorial and complex and not fully understood. There is no effective treatment for cellulite, although a number of different treatment modalities are available, from noninvasive to minimally invasive. The efficacy of most treatments is unpredictable and improvements in cellulite appearance are short lived, although significant progress has been made with newer treatments. This review provides an update on the current state of knowledge about cellulite, with an emphasis on patient assessment and an individualized treatment approach for optimal results.

Level of Evidence 5

A Randomized, Single-Center, Double-Blinded, Split-Body Clinical Trial of Poly- l -Lactic Acid for the Treatment of Cellulite of the Buttocks and Thighs

BACKGROUND

More than 90% of women report concerns of cellulite on their skin. Poly- l lactic acid (PLLA-SCA) is a biocompatible, semipermanent, synthetic filler that induces neocollagenesis.

OBJECTIVE

To investigate the safety and efficacy of PLLA-SCA for the treatment of cellulite of the buttock and thigh regions.

METHODS

This was a prospective, single-center, double-blinded, split-body, clinical trial of 20 women with slight to moderate skin laxity of the buttocks and/or thighs contributing to mild-to-moderate cellulite. Each subject's buttocks and thighs were randomized to receive injections with up to 2 vials of PLLA-SCA or the equivalent volume of bacteriostatic water per treatment area. Subjects received at total of 3 treatments 4 weeks apart and were followed for 330 days.

RESULTS

Treatment of the buttocks with PLLA-SCA resulted in significant reduction of depression depth, improvement in the morphological appearance of the skin, improvement in the grade of skin laxity, and overall improvement in cellulite appearance. Treated thighs showed reduction in the depth and number of depressions and an improvement in overall cellulite appearance. No significant procedure side effects were found.

CONCLUSION

Poly- l lactic acid offers an effective and safe method for treating cellulite of the buttocks and thighs.

Cellulite: Clinical Challenges and Future Perspectives

BACKGROUND

Existing cellulite interventions pose various clinical challenges related mostly to ecchymosis and recovery time.

OBJECTIVE

To discuss the current treatment options for minimizing recovery time, efficacy of these options, and investigations into possible future approaches.

METHODS

A roundtable meeting was convened to discuss and share views on the clinical challenges seen in the present practice of cellulite treatments along with future approaches and mitigation strategies. The participants' views helped guide a narrative review on this topic.

RESULTS

Cosmetic clinicians have a range of new interventions to choose from for cellulite improvement, each with different benefits and safety aspects. Bruising is a typical side effect that is seen with treatments targeting the fibrous septa, such as subcision and injectable treatments, and in some cases may produce long-lasting hyperpigmentation from postinflammatory hyperpigmentation or hemosiderin staining. Various strategies that could potentially mitigate bruising and other adverse effects of cellulite treatment are under clinical investigation, including, but not limited to, different injection techniques and dilutions, compression garments, cold packs, arnica gel, pulsed dye laser treatment, intralesional epinephrine, and tranexamic acid.

CONCLUSION

Clinical challenges including varying treatment outcomes and certain treatment sequelae remain, and further research is needed to prevent side effects and improve treatment outcomes.

Cellulite: Current Treatments, New Technology, and Clinical Management

BACKGROUND

Cellulite is a well-known concern for many women; however, treatment can prove challenging because of the complexities of cellulite etiology, the various factors contributing to its appearance, and the multitude of therapies and procedures available.

OBJECTIVE

To discuss current cellulite treatment options and effective clinical management.

METHODS

A roundtable meeting was convened to discuss and share views on current cellulite treatment options, new technologies, and clinical management. The participants' views helped guide a narrative review on this topic.

RESULTS

Advanced interventions for cellulite treatment-such as physical and acoustic subcision, radiofrequency, and injectable biostimulators-are gradually being established, with accumulating evidence showing efficacy, patient satisfaction, and potentially long-lasting outcomes. Cellulite severity rating scales are necessary for assessing treatment outcomes, but these can be complex to use in clinical practice, and the majority do not include patient or clinician perspectives.

CONCLUSION

With the advent of new treatments and technologies, cosmetic surgeons and dermatologists will need to tailor their approach to each patient's needs and manage patient expectations because multimodal methods are likely to be required to address the various factors underlying cellulite appearance.

Real-World Experience With Collagenase Clostridium Histolyticum-aaes for Buttock and Thigh Cellulite: Focus on Administration and Safety Profile

Background

Collagenase clostridium histolyticum-aaes (CCH-aaes) is approved for the treatment of moderate-to-severe buttock cellulite in adult women.

Objectives

To report on real-world experience with CCH-aaes in the treatment of buttock and thigh cellulite.

Methods

Retrospective analysis of medical records from a single treatment center.

Results

The population comprised 28 consecutively treated women; mean age was 40.5 years (range, 23-56 years) and mean body mass index was 25.9 kg/m2 (range, 19.6-41.0 kg/m2). Treatment areas were buttocks only (78.6% of patients), thighs only (10.7%), or both buttocks and thighs (10.7%). Most patients (89.3%) were treated in 2 areas (buttocks or thighs) at each visit; however, 3 patients were treated in 4 areas. At each session, the CCH-aaes dose was 0.07 mg per dimple (0.3 mL of 0.23 mg/mL for buttock cellulite; 1.5 mL of 0.046 mg/mL for thigh cellulite). The mean number of treatment sessions was 2.6 (range, 1-4) for buttock cellulite and 2.5 (range 1-3) for thigh cellulite. The mean number of dimples treated was 11.5 (range, 3-17) per buttock, 11.0 (range, 1-14) per thigh, and 23.4 (range, 8-32) overall per treatment session. Injection site-related adverse events of special interest were experienced by all 28 patients: bruising (100%), edema (96.4%), tenderness (85.7%), nodules (39.3%), pruritus (32.1%), and hyperpigmentation indicative of hemosiderin staining (7.1%). Mean duration of injection-site bruising was 8.8 days (range, 2-15 days).

Conclusions

CCH-aaes is an effective, well-tolerated, minimally invasive treatment option for buttock and thigh cellulite in women.

Level of Evidence 3

Collagen Stimulators in Body Applications: A Review Focused on Poly-L-Lactic Acid (PLLA)

The number of aesthetic procedures performed worldwide continues to grow together with an increase in the population seeking the restoration or preservation of a youthful appearance. Requests for non-surgical body rejuvenation are increasing. Patients are looking for safe and effective minimally invasive aesthetic procedures. Soft-tissue dermal fillers can meet these expectations. Based on the beneficial outcomes of these treatments in many facial areas, a new trend is developing to target body areas. Different dermal fillers are available and include collagen stimulators initially developed to restore facial volume. Furthermore, they are associated with long-lasting efficiency, a high level of patient satisfaction and a good safety profile, with mainly minor adverse events reported. In appropriate conditions of use, they are now used for body rejuvenation in clinical practice. Their use is expanding and allows addressing various issues including volume loss, skin laxity, cellulite, striae distensae and wrinkles. This review focuses on poly-L-lactic acid (PLLA), used in the first collagen stimulator and one of the most investigated in facial and in off-facial body applications. The available published data, although still limited, are presented by body area, neck and chest, buttocks, abdomen, upper arms, thighs, knees, and hands. Key features of the concerned zones and the main clinical signs affecting the body part as well as the injection modalities are provided along with the aesthetic results. This represents the state of the art on which to base further developments necessary for optimal and safe outcomes of treatment with the PLLA-based collagen stimulators and others in this class for body rejuvenation.

Cellulite: Presentation and Management

Cellulite is a common dermatological condition with a female preponderance, affecting up to 90% post-pubertal females. It is characterized with dimpling and denting of the skin surface, giving it a Peau d'orange appearance. Once considered to be a benign physiological isolated skin condition of only an aesthetic concern, cellulite is now considered a pathological entity with systemic associations and a negative psychological impact on patients. Several treatment options from lifestyle modifications, topical cosmetic therapies to energy-based devices have been studied for its treatment. However, treatment remains a challenge despite many new modalities in the armamentarium. Laser and light therapies along with radiofrequency are useful treatment options with good safety profile. Acoustic wave therapy, subcision, and 1440-nm Nd:YAG minimally invasive laser are beneficial in cellulite reduction. Methodological differences in the trials conducted, makes it difficult to compare different treatment modalities. Overall, treatment needs to be individualized based on the patient characteristics and severity of the condition. Combination of treatments is often required in most patients for reducing cellulite.

Collagenase Clostridium Histolyticum-aaes for the Treatment of Cellulite in Women: Results From Two Phase 3 Randomized, Placebo-Controlled Trials

BACKGROUND

Fibrous septae play a role in contour alterations associated with cellulite.

OBJECTIVE

To assess collagenase clostridium histolyticum-aaes (CCH) for the treatment of cellulite.

MATERIALS AND METHODS

Two identically designed phase 3, double-blind, randomized studies (RELEASE-1 and RELEASE-2) were conducted. Adult women with moderate/severe cellulite (rating 3-4 on the Patient Reported Photonumeric Cellulite Severity Scale [PR-PCSS] and Clinician Reported PCSS [CR-PCSS]) on the buttocks received up to 3 treatment sessions of subcutaneous CCH 0.84 mg or placebo per treatment area. Composite response (≥2-level or ≥1-level improvement from baseline in both PR-PCSS and CR-PCSS) was determined at Day 71.

RESULTS

Eight hundred forty-three women received ≥1 injection (CCH vs placebo: RELEASE-1, n = 210 vs n = 213; RELEASE-2, n = 214 vs n = 206). Greater percentages of CCH-treated women were ≥2-level composite responders versus placebo in RELEASE-1 (7.6% vs 1.9%; p = .006) and RELEASE-2 (5.6% vs 0.5%; p = .002) and ≥1-level composite responders in RELEASE-1 (37.1% vs 17.8%; p < .001) and RELEASE-2 (41.6% vs 11.2%; p < .001). Most adverse events (AEs) in the CCH group were injection site related; few CCH-treated women discontinued because of an AE (≤4.3%).

CONCLUSION

Collagenase clostridium histolyticum-aaes significantly improved cellulite appearance and was generally well tolerated.

Efficacy, Safety, and Durability of Response of Collagenase Clostridium Histolyticum-aaes for Treating Cellulite

Background:

Collagenase clostridium histolyticum-aaes (CCH) enzymatically releases fibrous septa that contribute to the skin dimpling characteristic of cellulite. Long-term safety/duration of efficacy (durability) results from an open-label extension (OLE) of a randomized, double-blind, placebo-controlled trial (RCT) evaluating CCH efficacy/safety for moderate-to-severe cellulite of the buttocks or posterolateral thighs in women was assessed. Efficacy/safety of CCH treatment/retreatment during OLE was also evaluated.

Methods:

After RCT unblinding, women could enroll in OLE for assessment of long-term CCH durability (observation only, up to day 720) or CCH treatment/retreatment, the latter in women with moderate-to-severe buttock/posterolateral thigh cellulite [Clinician Reported Photonumeric Cellulite Severity Scale (CR-PCSS) and Patient Reported PCSS (PR-PCSS) scores of 3/4; Hexsel Cellulite Severity Scale score ≤13]. A treatment/retreatment course comprised 1 or 2 courses of 3 sessions (0.84-mg CCH injected at days 1, 22, and 43). CCH efficacy/safety was assessed at baseline, days 22, 43, 71, and quarterly at day 360.

Results:

Of the 259 OLE participants, 53 were observed for long-term CCH durability. For those who were ≥2-level composite responders during RCT (≥2-point CR-PCSS/PR-PCSS score improvements), CCH effect was durable (scores did not reach RCT baseline levels) in all women on days 180 (19/19), 360 (16/16), and 720 (7/7). Of the 200 women receiving CCH treatment/retreatment, more than 75% had ≥1-level improvement in patient and clinical assessments at day 71. The most common adverse events were injection-site bruising and pain.

Conclusions:

CCH treatment provided durable improvement in moderate-to-severe buttock/thigh cellulite and was generally well tolerated. Repeated CCH exposure did not increase adverse event risk or reduce efficacy.