Out of the Swamp: New Cellulite Treatments

Doreen Wu (00:00):
Welcome to Park Avenue Plastic Surgery Class, a podcast where we explore controversies and breaking issues in plastic surgery. I'm your co-host, Doreen Wu, a clinical assistant at Bass Plastic Surgery in New York City. I'm excited to be here with Dr. Lawrence Bass, Park Avenue plastic surgeon, educator and technology innovator. The title of today's episode is "Out of the Swamp: New Cellulite Treatments." We're back with another title that piques my curiosity. Where does this one come from, Dr. Bass?

Dr. Lawrence Bass (00:32):
I promise to answer that, but first, let's talk a little about cellulite and what it is.

Doreen Wu (00:39):
Okay, first things first. That makes sense. So tell me, Dr. Bass, what is cellulite and where in the body does it form?

Dr. Lawrence Bass (00:48):
A good definition of cellulite goes something like this. It's a surface skin surface deformation from a smooth and level shape, and this occurs on the outer part of the thighs, the back of the thighs, and on the buttocks. It shows itself in a few different forms, dimples and also in ridges or waviness. It's not the same as laxity, which is loose skin, and it's not the same as crepiness, which is that sort of irregularity of the skin surface like crepe paper. And those things really relate to other issues of skin quality and skin support different from cellulite.

Doreen Wu (01:47):
So who gets this, or actually, let me put it another way. What causes it?

Dr. Lawrence Bass (01:53):
So it's not really an abnormality because it's present to at least some degree on about 95% of adult women. So it's not really a disorder, it's just a manifestation of how body structures are put together. And the important thing to remember in trying to understand cellulite is this is something we see in young women. It's something we see in older women, we see it in thin people, and we see it in heavy people. We see it in people with fair skin and thin skin, and we see it in people with dark and thicker skin. So that tells us a little bit about how we should start to think about causes and we have a better understanding of the causes over the past few years. This is something I've written and lectured about in recent years. People have blamed fat, problems with the skin, and problems with connective tissue elements that hold the skin to underlying muscle and compartmentalize the fat.

(03:08):
So all of those have had the finger pointed at them, but as best we understand it today, there's causative factors and aggravating factors, things that make it worse. So the big causative factor is a gender dimorphism in the fibroseptal network. So put simply their collagen fibers under the skin that hold the skin to the underneath muscle, and that also divide groups of fat cells from one another to create fat lobules. And these are organized very differently in men and women. That's the gender dimorphism, the vertical orientation of the fibrous septa in women pulled down on the skin, creating a dimple. These fibers are more obliquely oriented in men in a sort of crisscross fashion, and that tends to tint the skin smooth and flat by comparison. There are a number of other differences which amplify the imbalance of pulling down forces and pushing up forces that end up resulting in a surface, deformation, deforming, or shape change in the surface of the skin that we call cellulite. So factors like skin aging and obesity may aggravate or worsen the appearance of cellulite, but they don't seem to cause it per se. To effectively treat cellulite. It's essential to understand the basis on which it forms. That's why this subject is so important, and I've gone into some detail about it because it speaks in a big way to how we need to approach treatment and what we can expect from different treatments that are aimed at different targets, skin, fat, connective tissue, in terms of how effective they're going to be.

Doreen Wu (05:22):
Great. So now that I have an understanding of the causes of cellulite, let's circle back to the episode title, "Out of the Swamp."

Dr. Lawrence Bass (05:30):
So this goes back to something I've said for many years. In fact, for decades I called cellulite treatments the Swamp of Broken Promises. And the reason for that was first cellulite is a really hard problem to treat. It's like stretch marks, large pores in the skin. It's just not easy to get rid of. And it's fundamental to, again, the structure of how our connective tissue is put together. The other problem was that almost every device or treatment for the skin was aimed at cellulite. And almost anything we do will have at least a tiny effect, at least temporarily. And so a device might be designed for wrinkles or for tightening of the skin, and they would say, but it also treats cellulite without really any study or data. And that wasn't a really good way to approach things. And just tacking cellulite on as an added benefit of the treatment was kind of a way of creating a broken promise that pretty much for sure was not going to be met. So that was historical cell treatments the way they worked out.

Doreen Wu (07:00):
I'm a little confused though. Can't I just have liposuction to fix the cellulite?

Dr. Lawrence Bass (07:05):
So that's a great question and that's actually a common misconception. Liposuction reduces the amount of fat, but again, we said the focus of what causes the cellulite is not the fat, but it's actually the connective tissue fibers around the fatty tissue under the skin. So typically in liposuction will flatten a bulge or fullness, that's the result of fat, but cellulite typically does not get better, and in fact may even be slightly worse. But there's a "but" in there, in the late 1980s, early 1990s, some of the Brazilian plastic surgeons were working with what they called superficial liposuction or superficial liposculpture. And what they would do if cellulite was present was use a little liposuction cannula with a little sharp fork on the end to cut some of the fibrous septa, the connective tissue strands that run between the skin and the muscle, to release the tension on the dimple. And that would work to a degree, but because it was done by hand, because it wasn't a controlled depth, there were risks and there was variable effectiveness.

Doreen Wu (08:35):
How is it different today? What are the main treatments that are available and how well do they work?

Dr. Lawrence Bass (08:41):
So we're really in a totally different era, and that's why I wanted to do this episode. I feel like we're out of the swamp and we've got definitely a range of devices with good data demonstrating effectiveness. And this has led to specific FDA clearances for devices to treat cellulite and even in the FDA drug approval for the treatment of cellulite. One of the earlier devices was a laser called Cellulaze, and instead of using a fork liposuction cannula like the Brazilians, a laser fiber was used that could help break up some of the fat during a liposuction, but could also fire from the side and cut some of these little connective tissue strands. And that actually worked very well, but it required a great deal of surgical skill and was very tedious and time consuming. But that was a way of using a laser to do what's called subcision, to cut those fiber strands that pull down the dimples.

(09:57):
So from there, a device called Cellfina was developed, and this was a mechanical subcision, but it used a vacuum assisted plate to pull the skin flat against it and then perform that subcision or cutting at a very controlled depth. And that made the subcision much more reliable. And eventually, as this device was out for several years, they generated a good body of data that demonstrated the clearance of cellulite persisted even at five years. At five years, 80% or 85% of the effect was still present. In other words, the dimples didn't come back that percentage of the time, even after five years. So the issue is that's still a little bit of a procedure, the area has to be numbed. There's bruising and recovery time. More recently, a chemical subcision or pharmacologic subcision was approved by FDA and this was an injectable medication called QWO.

(11:16):
This was a collagenase enzyme that breaks down collagen. And when it was injected under the dimple where that little strand runs down under the skin, it could chemically break down that little fiber. And there's a new device out called Avéli, which likewise targets individual dimples by introducing a little hook underneath that has a little cutting device on it. And once you are able to hook the fiber, you fire it and it cuts the little fiber underneath the skin. The issue with all of these treatments, they're effective, but they all have a degree of bruising and recovery time, and they're at least minimally invasive. Not the QWO injection, that's just an injection, but definitely bruising and recovery time. So another approach is to use energy devices that either target the fat, the fibrous septa or the skin. And these have been much more variable in effectiveness. So the final thing that's happening, which is an off-label use of injectable fillers, is people are taking the fillers that are collagen stimulators, basically Radiesse and Sculptra, hyper diluting them and injecting them in the area. And this is effective as well.

Doreen Wu (12:54):
So it sounds like there's been a lot of progress. Do we have the ideal treatment? Does that exist yet? And what would that look like?

Dr. Lawrence Bass (13:03):
I think the experiences we've had with these effective techniques tell us a little bit about what we ideally want. We'd like something non-invasive, very clear that patients would pick that over even a minimally invasive procedure if they have the option. They really, really want a treatment with no big recovery, for example, not a lot of bruising that takes two, three weeks to go away. And the other important issue is that cellulite tends to affect fairly large areas, and if you just treat the three or five, four dimples, I mean, that's nice. That's progress, but it still doesn't make you look good enough to feel comfortable going out in a bathing suit or in short shorts. So we'd really like to have a treatment that can treat the whole zone that's affected rather than just cherry pick individual spots.

Doreen Wu (14:09):
Alright, so now we've reached the takeaways portion of the episode, Dr. Bass, what takeaways would you like to share with our listeners?

Dr. Lawrence Bass (14:17):
So the first thing we mentioned right at the beginning, cellulite is distinct from skin laxity and skin crepeness, but those are often confused by patients or they're all sort of collapsed down into one entity. So it's very important cellulite treatments will work for cellulite and things that are designed for skin smoothing or skin tightening are more appropriate for the other problems. That's the first big point. The second point is we said what's the ideal treatment? And a feature I didn't mention because we don't have it, is that different treatments do better for some of the different manifestations of cellulite. So the subcision treatments work really well for dimples, but the waviness or rigidness that's formed, and that's more often seen on the thighs, although you can see it on the buttock as well, that responds better to things that more globally structure, the connective tissue under the skin, not things that simply divide the little fibrous strand because it's not a discreet dimple, it's more of an irregular effect.

(15:38):
And so structuring and thickening, that connective tissue under there as a response to the treatment creates a fibroseptal network. That's more like what's in men's tissues that don't manifest cellularly than in women's tissues that do. So we have to pick the right treatment based on what's showing on your skin surface. Subcision definitely has a proven track record with excellent durability for dimples, but that more global fibroseptal remodeling is going to be needed for best results. And as new treatments come out, we really want ones that have specific study data on cellulite to avoid going back into that swamp of broken promises.

Doreen Wu (16:35):
Definitely some important things to keep in mind. Thank you, Dr. Bass, for sharing your insight and expertise with us. Thank you for listening to the Park Avenue Plastic Surgery Class podcast. Follow us on Apple Podcasts, write a review, and share the show with your friends. Be sure to join us next time to avoid missing all the great content that's coming your way. If you want to contact us with comments or questions, we'd love to hear from you. Send us an email at podcast@drbass.net or DM us on Instagram at @drbassnyc.