July 23, 2024
Out of the Swamp: New Cellulite Treatments
Cellulite can appear as dimples, ridges, or waves on the thighs and buttocks, affecting anyone regardless of age, body type, or skin type. It's not the same as laxity or crepiness, and it’s a tough issue to tackle.
Subcision-based treatments like Avéli and Cellfina are effective for cellulite dimples but come with bruising and recovery time. Less invasive options like hyper diluted Radiesse or Sculptra injections can help but still fail to treat the entire area. Energy based treatments can treat large areas but often with only temporary effects or mild improvement.
Find out what causes cellulite, what makes it worse, and what options are available to improve it. Learn about past failed treatments, current options, and Dr. Bass's vision for improving future treatments.
About Dr. Lawrence Bass
Innovator. Industry veteran. In-demand Park Avenue board certified plastic surgeon, Dr. Lawrence Bass is a true master of his craft, not only in the OR but as an industry pioneer in the development and evaluation of new aesthetic technologies. With locations in both Manhattan (on Park Avenue between 62nd and 63rd Streets) and in Great Neck, Long Island, Dr. Bass has earned his reputation as the plastic surgeon for the most discerning patients in NYC and beyond.
To learn more, visit the Bass Plastic Surgery website or follow the team on Instagram @drbassnyc
Subscribe to the Park Avenue Plastic Surgery Class newsletter to be notified of new episodes & receive exclusive invitations, offers, and information from Dr. Bass.
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Welcome to Park Avenue
Plastic Surgery Class,
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a podcast where we explore controversies
and breaking issues in plastic surgery.
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I'm your co-host, Doreen Wu,
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a clinical assistant at Bass
Plastic Surgery in New York City.
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I'm excited to be here with Dr. Lawrence
Bass, Park Avenue plastic surgeon,
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educator and technology innovator.
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The title of today's episode
is "Out of the Swamp:
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New Cellulite Treatments." We're back
with another title that piques my
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curiosity. Where does this
one come from, Dr. Bass?
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I promise to answer that, but first,
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let's talk a little about
cellulite and what it is.
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Okay, first things first. That
makes sense. So tell me, Dr. Bass,
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what is cellulite and where
in the body does it form?
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A good definition of cellulite
goes something like this.
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It's a surface
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skin surface deformation from a smooth and
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level shape,
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and this occurs on the outer part
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of the thighs, the back of the
thighs, and on the buttocks.
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It shows itself in a few different forms,
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dimples and also in ridges or
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waviness. It's not the same as laxity,
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which is loose skin,
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and it's not the same as crepiness,
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which is that sort of irregularity
of the skin surface like crepe paper.
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And those things really relate to
other issues of skin quality and skin
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support different from cellulite.
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So who gets this, or actually,
let me put it another way.
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What causes it?
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So it's not really an abnormality
because it's present to at least some
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degree on about 95% of adult women.
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So it's not really a disorder,
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it's just a manifestation
of how body structures are
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put together.
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And the important thing to
remember in trying to understand
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cellulite is this is something
we see in young women.
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It's something we see in older
women, we see it in thin people,
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and we see it in heavy people.
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We see it in people with
fair skin and thin skin,
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and we see it in people
with dark and thicker skin.
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So that tells us a little bit about how
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we should start to think about causes and
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we have a better understanding of
the causes over the past few years.
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This is something I've written and
lectured about in recent years.
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People have blamed fat,
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problems with the skin,
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and problems with connective tissue
elements that hold the skin to
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underlying muscle and
compartmentalize the fat.
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So all of those have had
the finger pointed at them,
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but as best we understand it today,
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there's causative factors
and aggravating factors,
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things that make it worse.
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So the big causative factor is a
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gender dimorphism in
the fibroseptal network.
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So put simply their collagen
fibers under the skin
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that hold the skin to
the underneath muscle,
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and that also divide groups
of fat cells from one another
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to create fat lobules.
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And these are organized very
differently in men and women.
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That's the gender dimorphism,
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the vertical orientation
of the fibrous septa in
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women pulled down on the skin,
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creating a dimple.
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These fibers are more
obliquely oriented in men
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in a sort of crisscross fashion,
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and that tends to tint the
skin smooth and flat by
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comparison.
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There are a number of other differences
which amplify the imbalance of pulling
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down forces and pushing up
forces that end up resulting in a
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surface, deformation, deforming,
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or shape change in the surface of
the skin that we call cellulite.
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So factors like skin aging
and obesity may aggravate or
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worsen the appearance of cellulite,
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but they don't seem to cause it per
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se. To effectively treat cellulite.
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It's essential to understand
the basis on which it forms.
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That's why this subject is so important,
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and I've gone into some detail about
it because it speaks in a big way
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to how we need to approach
treatment and what we can expect
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from different treatments that are
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aimed at different targets, skin, fat,
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connective tissue, in terms of
how effective they're going to be.
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Great. So now that I have an
understanding of the causes of cellulite,
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let's circle back to the episode
title, "Out of the Swamp.".
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So this goes back to something
I've said for many years. In fact,
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for decades I called
cellulite treatments the
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Swamp of Broken Promises.
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And the reason for that was first
cellulite is a really hard problem
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to treat. It's like stretch marks,
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large pores in the skin. It's
just not easy to get rid of.
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And it's fundamental to, again,
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the structure of how our
connective tissue is put together.
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The other problem was that
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almost every device or
treatment for the skin
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was aimed at cellulite.
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And almost anything we do will
have at least a tiny effect,
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at least temporarily.
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And so a device might be designed for
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wrinkles or for tightening of
the skin, and they would say,
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but it also treats cellulite
without really any study or data.
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And that wasn't a really
good way to approach things.
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And just tacking cellulite on as
an added benefit of the treatment
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was kind of a way of creating
a broken promise that
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pretty much for sure
was not going to be met.
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So that was historical cell treatments the
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way they worked out.
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I'm a little confused though.
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Can't I just have liposuction
to fix the cellulite?
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So that's a great question and that's
actually a common misconception.
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Liposuction reduces the
amount of fat, but again,
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we said the focus of what causes
the cellulite is not the fat,
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but it's actually the connective
tissue fibers around the
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fatty tissue under the skin.
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So typically in liposuction will
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flatten a bulge or fullness,
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that's the result of fat, but cellulite
typically does not get better,
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and in fact may even be slightly worse.
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But there's a "but" in
there, in the late 1980s,
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early 1990s,
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some of the Brazilian plastic
surgeons were working with what
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they called superficial liposuction
or superficial liposculpture.
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And what they would do if
cellulite was present was use a
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little liposuction cannula
with a little sharp fork
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on the end to cut some
of the fibrous septa,
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the connective tissue strands that
run between the skin and the muscle,
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to release the tension on the dimple.
And that would work to a degree,
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but because it was done by hand,
because it wasn't a controlled depth,
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there were risks and there
was variable effectiveness.
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How is it different today?
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What are the main treatments that are
available and how well do they work?
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So we're really in a
totally different era,
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and that's why I wanted
to do this episode.
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I feel like we're out of the
swamp and we've got definitely
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a range of devices with
good data demonstrating
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effectiveness.
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And this has led to
specific FDA clearances for
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devices to treat cellulite
and even in the FDA drug
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approval for the treatment of cellulite.
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One of the earlier devices was a laser
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called Cellulaze,
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and instead of using a fork
liposuction cannula like the
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Brazilians,
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a laser fiber was used that
could help break up some of the
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fat during a liposuction,
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but could also fire from
the side and cut some
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of these little connective tissue strands.
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And that actually worked very well,
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but it required a great deal
of surgical skill and was very
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tedious and time consuming.
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But that was a way of using a laser
to do what's called subcision,
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to cut those fiber strands
that pull down the dimples.
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So from there, a device
called Cellfina was developed,
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and this was a mechanical subcision,
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but it used a vacuum
assisted plate to pull the
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skin flat against it and then
perform that subcision or
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cutting at a very controlled depth.
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And that made the subcision
much more reliable.
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And eventually, as this device
was out for several years,
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they generated a good body
of data that demonstrated the
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clearance of cellulite
persisted even at five
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years. At five years,
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80% or 85% of the effect was still
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present. In other words,
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the dimples didn't come
back that percentage of the
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time, even after five years.
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So the issue is that's
still a little bit of a
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procedure, the area has to be numbed.
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There's bruising and recovery time.
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More recently,
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a chemical subcision or pharmacologic
subcision was approved by
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FDA and this was an injectable
medication called QWO.
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This was a collagenase enzyme
that breaks down collagen.
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And when it was injected under the
dimple where that little strand
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runs down under the skin,
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it could chemically break
down that little fiber.
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And there's a new device out called Avéli,
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which likewise targets individual dimples
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by introducing a little hook
underneath that has a little
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cutting device on it. And once
you are able to hook the fiber,
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you fire it and it cuts the
little fiber underneath the skin.
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The issue with all of these treatments,
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they're effective,
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but they all have a degree of
bruising and recovery time,
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and they're at least minimally invasive.
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Not the QWO injection,
that's just an injection,
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but definitely bruising and recovery time.
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So another approach is to use energy
devices that either target the
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fat, the fibrous septa or the skin.
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And these have been much more
variable in effectiveness.
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So the final thing that's happening,
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which is an off-label use
of injectable fillers,
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is people are taking the
fillers that are collagen
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stimulators, basically
Radiesse and Sculptra,
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hyper diluting them and
injecting them in the area.
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And this is effective as well.
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So it sounds like there's
been a lot of progress.
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Do we have the ideal
treatment? Does that exist yet?
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And what would that look like?
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I think
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the experiences we've had with
these effective techniques tell
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us a little bit about
what we ideally want.
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We'd like something non-invasive,
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very clear that patients would
pick that over even a minimally
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invasive procedure if they
have the option. They really,
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really want a treatment with
no big recovery, for example,
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not a lot of bruising that takes
two, three weeks to go away.
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And the other important
issue is that cellulite
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tends to affect fairly large areas,
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and if you just treat the three
or five, four dimples, I mean,
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that's nice. That's progress,
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but it still doesn't make you look good
enough to feel comfortable going out in
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a bathing suit or in short shorts.
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So we'd really like to have a treatment
that can treat the whole zone that's
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affected rather than just
cherry pick individual
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spots.
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Alright, so now we've reached the
takeaways portion of the episode,
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Dr. Bass, what takeaways would you
like to share with our listeners?
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So the first thing we mentioned
right at the beginning,
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cellulite is distinct
from skin laxity and skin
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crepeness,
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but those are often confused by patients
or they're all sort of collapsed down
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into one entity.
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So it's very important cellulite
treatments will work for cellulite and
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things that are designed for skin
smoothing or skin tightening are more
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appropriate for the other problems.
That's the first big point.
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The second point is we said
what's the ideal treatment?
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And a feature I didn't mention
because we don't have it,
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is that different treatments do
better for some of the different
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manifestations of cellulite.
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So the subcision treatments
work really well for
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dimples,
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but the waviness or
rigidness that's formed,
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00:15:13,910 --> 00:15:16,220
and that's more often seen on the thighs,
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00:15:16,250 --> 00:15:18,440
although you can see it
on the buttock as well,
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00:15:20,390 --> 00:15:25,250
that responds better to things
that more globally structure,
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00:15:25,490 --> 00:15:27,770
the connective tissue under the skin,
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00:15:27,980 --> 00:15:32,420
not things that simply divide the little
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00:15:32,420 --> 00:15:36,230
fibrous strand because
it's not a discreet dimple,
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00:15:36,230 --> 00:15:41,060
it's more of an irregular effect.
And so structuring and thickening,
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00:15:41,060 --> 00:15:44,630
that connective tissue under
there as a response to the
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00:15:44,630 --> 00:15:45,470
treatment
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00:15:47,030 --> 00:15:51,650
creates a fibroseptal network.
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00:15:51,650 --> 00:15:56,270
That's more like what's in men's
tissues that don't manifest
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00:15:56,300 --> 00:15:59,030
cellularly than in
women's tissues that do.
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00:15:59,390 --> 00:16:03,830
So we have to pick the right
treatment based on what's
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00:16:03,830 --> 00:16:06,890
showing on your skin surface.
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00:16:07,550 --> 00:16:12,200
Subcision definitely has a proven
track record with excellent durability
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00:16:12,200 --> 00:16:13,550
for dimples,
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00:16:13,880 --> 00:16:18,650
but that more global fibroseptal
remodeling is going to be needed
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00:16:19,010 --> 00:16:23,090
for best results. And as
new treatments come out,
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00:16:23,090 --> 00:16:27,560
we really want ones
that have specific study
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00:16:27,560 --> 00:16:32,330
data on cellulite to
avoid going back into that
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swamp of broken promises.
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Definitely some important things to
keep in mind. Thank you, Dr. Bass,
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00:16:38,840 --> 00:16:41,120
for sharing your insight
and expertise with us.
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00:16:42,710 --> 00:16:46,400
Thank you for listening to the Park
Avenue Plastic Surgery Class podcast.
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00:16:46,850 --> 00:16:49,070
Follow us on Apple
Podcasts, write a review,
258
00:16:49,100 --> 00:16:50,450
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00:16:50,840 --> 00:16:53,960
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00:16:57,470 --> 00:16:58,430
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262
00:16:58,880 --> 00:17:03,380
Send us an email at podcast@drbass.net
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00:17:03,930 --> 00:17:04,010
@drbassnyc.
00:00:00,660 --> 00:00:03,330
Welcome to Park Avenue
Plastic Surgery Class,
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00:00:03,630 --> 00:00:07,800
a podcast where we explore controversies
and breaking issues in plastic surgery.
3
00:00:08,190 --> 00:00:09,780
I'm your co-host, Doreen Wu,
4
00:00:09,990 --> 00:00:13,140
a clinical assistant at Bass
Plastic Surgery in New York City.
5
00:00:13,620 --> 00:00:18,060
I'm excited to be here with Dr. Lawrence
Bass, Park Avenue plastic surgeon,
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00:00:18,360 --> 00:00:20,460
educator and technology innovator.
7
00:00:21,360 --> 00:00:24,420
The title of today's episode
is "Out of the Swamp:
8
00:00:24,690 --> 00:00:29,220
New Cellulite Treatments." We're back
with another title that piques my
9
00:00:29,220 --> 00:00:32,070
curiosity. Where does this
one come from, Dr. Bass?
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00:00:32,880 --> 00:00:35,340
I promise to answer that, but first,
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00:00:35,340 --> 00:00:38,940
let's talk a little about
cellulite and what it is.
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00:00:39,960 --> 00:00:44,760
Okay, first things first. That
makes sense. So tell me, Dr. Bass,
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00:00:44,820 --> 00:00:47,670
what is cellulite and where
in the body does it form?
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00:00:48,570 --> 00:00:52,680
A good definition of cellulite
goes something like this.
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00:00:52,710 --> 00:00:53,760
It's a surface
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00:00:55,350 --> 00:01:00,180
skin surface deformation from a smooth and
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00:01:00,180 --> 00:01:01,320
level shape,
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00:01:02,250 --> 00:01:07,140
and this occurs on the outer part
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00:01:07,150 --> 00:01:10,980
of the thighs, the back of the
thighs, and on the buttocks.
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00:01:11,280 --> 00:01:15,540
It shows itself in a few different forms,
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00:01:16,200 --> 00:01:20,610
dimples and also in ridges or
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00:01:20,610 --> 00:01:25,350
waviness. It's not the same as laxity,
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00:01:25,830 --> 00:01:27,540
which is loose skin,
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00:01:28,740 --> 00:01:31,320
and it's not the same as crepiness,
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00:01:31,330 --> 00:01:36,330
which is that sort of irregularity
of the skin surface like crepe paper.
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00:01:38,100 --> 00:01:43,020
And those things really relate to
other issues of skin quality and skin
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00:01:43,020 --> 00:01:46,500
support different from cellulite.
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00:01:47,310 --> 00:01:51,360
So who gets this, or actually,
let me put it another way.
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00:01:51,690 --> 00:01:52,523
What causes it?
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00:01:53,350 --> 00:01:58,200
So it's not really an abnormality
because it's present to at least some
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00:01:58,200 --> 00:02:02,370
degree on about 95% of adult women.
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00:02:03,180 --> 00:02:04,830
So it's not really a disorder,
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00:02:04,830 --> 00:02:09,660
it's just a manifestation
of how body structures are
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00:02:09,660 --> 00:02:10,493
put together.
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00:02:11,220 --> 00:02:15,690
And the important thing to
remember in trying to understand
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00:02:15,690 --> 00:02:19,590
cellulite is this is something
we see in young women.
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00:02:19,590 --> 00:02:23,940
It's something we see in older
women, we see it in thin people,
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00:02:23,940 --> 00:02:25,980
and we see it in heavy people.
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00:02:26,610 --> 00:02:30,210
We see it in people with
fair skin and thin skin,
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00:02:30,210 --> 00:02:33,300
and we see it in people
with dark and thicker skin.
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00:02:33,870 --> 00:02:38,760
So that tells us a little bit about how
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00:02:38,760 --> 00:02:43,590
we should start to think about causes and
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00:02:43,950 --> 00:02:48,780
we have a better understanding of
the causes over the past few years.
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00:02:48,780 --> 00:02:51,960
This is something I've written and
lectured about in recent years.
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00:02:52,470 --> 00:02:56,460
People have blamed fat,
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00:02:56,460 --> 00:02:58,160
problems with the skin,
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00:02:58,160 --> 00:03:02,710
and problems with connective tissue
elements that hold the skin to
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00:03:02,710 --> 00:03:07,090
underlying muscle and
compartmentalize the fat.
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00:03:08,350 --> 00:03:11,290
So all of those have had
the finger pointed at them,
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00:03:11,740 --> 00:03:15,010
but as best we understand it today,
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00:03:15,490 --> 00:03:19,480
there's causative factors
and aggravating factors,
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00:03:19,630 --> 00:03:20,890
things that make it worse.
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00:03:20,890 --> 00:03:25,270
So the big causative factor is a
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00:03:25,270 --> 00:03:29,980
gender dimorphism in
the fibroseptal network.
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00:03:30,370 --> 00:03:35,020
So put simply their collagen
fibers under the skin
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00:03:35,230 --> 00:03:38,320
that hold the skin to
the underneath muscle,
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00:03:38,590 --> 00:03:43,120
and that also divide groups
of fat cells from one another
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00:03:43,450 --> 00:03:46,150
to create fat lobules.
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00:03:47,440 --> 00:03:51,100
And these are organized very
differently in men and women.
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00:03:51,100 --> 00:03:53,620
That's the gender dimorphism,
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00:03:55,180 --> 00:03:59,500
the vertical orientation
of the fibrous septa in
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00:03:59,500 --> 00:04:03,250
women pulled down on the skin,
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00:04:03,280 --> 00:04:04,690
creating a dimple.
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00:04:06,160 --> 00:04:10,600
These fibers are more
obliquely oriented in men
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00:04:11,020 --> 00:04:13,270
in a sort of crisscross fashion,
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00:04:13,270 --> 00:04:17,530
and that tends to tint the
skin smooth and flat by
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00:04:17,530 --> 00:04:18,400
comparison.
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00:04:19,750 --> 00:04:24,490
There are a number of other differences
which amplify the imbalance of pulling
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00:04:24,490 --> 00:04:29,170
down forces and pushing up
forces that end up resulting in a
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00:04:29,170 --> 00:04:32,770
surface, deformation, deforming,
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00:04:32,770 --> 00:04:36,910
or shape change in the surface of
the skin that we call cellulite.
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00:04:37,600 --> 00:04:42,460
So factors like skin aging
and obesity may aggravate or
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00:04:42,460 --> 00:04:44,230
worsen the appearance of cellulite,
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00:04:44,980 --> 00:04:47,500
but they don't seem to cause it per
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00:04:47,500 --> 00:04:51,880
se. To effectively treat cellulite.
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00:04:51,910 --> 00:04:55,810
It's essential to understand
the basis on which it forms.
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00:04:55,820 --> 00:04:58,150
That's why this subject is so important,
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00:04:58,150 --> 00:05:02,890
and I've gone into some detail about
it because it speaks in a big way
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00:05:02,890 --> 00:05:07,360
to how we need to approach
treatment and what we can expect
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00:05:07,660 --> 00:05:12,280
from different treatments that are
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00:05:12,280 --> 00:05:16,420
aimed at different targets, skin, fat,
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00:05:16,660 --> 00:05:21,070
connective tissue, in terms of
how effective they're going to be.
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00:05:22,330 --> 00:05:26,800
Great. So now that I have an
understanding of the causes of cellulite,
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00:05:26,890 --> 00:05:29,800
let's circle back to the episode
title, "Out of the Swamp.".
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00:05:30,670 --> 00:05:35,530
So this goes back to something
I've said for many years. In fact,
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00:05:35,530 --> 00:05:40,150
for decades I called
cellulite treatments the
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00:05:40,180 --> 00:05:42,670
Swamp of Broken Promises.
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00:05:43,360 --> 00:05:48,310
And the reason for that was first
cellulite is a really hard problem
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00:05:48,320 --> 00:05:52,000
to treat. It's like stretch marks,
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00:05:52,000 --> 00:05:56,350
large pores in the skin. It's
just not easy to get rid of.
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00:05:56,350 --> 00:05:58,220
And it's fundamental to, again,
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00:05:58,220 --> 00:06:02,360
the structure of how our
connective tissue is put together.
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00:06:04,370 --> 00:06:06,230
The other problem was that
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00:06:07,970 --> 00:06:11,630
almost every device or
treatment for the skin
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00:06:12,950 --> 00:06:14,840
was aimed at cellulite.
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00:06:14,900 --> 00:06:19,790
And almost anything we do will
have at least a tiny effect,
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00:06:19,790 --> 00:06:21,200
at least temporarily.
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00:06:22,100 --> 00:06:25,700
And so a device might be designed for
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00:06:26,330 --> 00:06:31,160
wrinkles or for tightening of
the skin, and they would say,
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00:06:31,170 --> 00:06:35,780
but it also treats cellulite
without really any study or data.
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00:06:36,140 --> 00:06:40,100
And that wasn't a really
good way to approach things.
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00:06:40,430 --> 00:06:45,380
And just tacking cellulite on as
an added benefit of the treatment
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00:06:45,990 --> 00:06:50,660
was kind of a way of creating
a broken promise that
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00:06:51,290 --> 00:06:53,660
pretty much for sure
was not going to be met.
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00:06:54,020 --> 00:06:58,820
So that was historical cell treatments the
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00:06:58,820 --> 00:07:00,200
way they worked out.
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00:07:00,710 --> 00:07:01,910
I'm a little confused though.
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00:07:01,910 --> 00:07:04,730
Can't I just have liposuction
to fix the cellulite?
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00:07:05,270 --> 00:07:10,190
So that's a great question and that's
actually a common misconception.
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00:07:10,790 --> 00:07:14,270
Liposuction reduces the
amount of fat, but again,
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00:07:14,270 --> 00:07:18,800
we said the focus of what causes
the cellulite is not the fat,
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00:07:19,220 --> 00:07:24,170
but it's actually the connective
tissue fibers around the
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00:07:24,170 --> 00:07:26,240
fatty tissue under the skin.
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00:07:26,930 --> 00:07:31,250
So typically in liposuction will
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00:07:31,550 --> 00:07:35,240
flatten a bulge or fullness,
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00:07:35,240 --> 00:07:39,620
that's the result of fat, but cellulite
typically does not get better,
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00:07:39,620 --> 00:07:42,620
and in fact may even be slightly worse.
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00:07:43,610 --> 00:07:48,170
But there's a "but" in
there, in the late 1980s,
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00:07:48,260 --> 00:07:49,970
early 1990s,
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00:07:50,120 --> 00:07:54,950
some of the Brazilian plastic
surgeons were working with what
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00:07:54,950 --> 00:07:59,750
they called superficial liposuction
or superficial liposculpture.
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00:07:59,750 --> 00:08:04,700
And what they would do if
cellulite was present was use a
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00:08:04,700 --> 00:08:09,680
little liposuction cannula
with a little sharp fork
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00:08:09,680 --> 00:08:14,630
on the end to cut some
of the fibrous septa,
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00:08:14,630 --> 00:08:19,610
the connective tissue strands that
run between the skin and the muscle,
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00:08:19,850 --> 00:08:23,970
to release the tension on the dimple.
And that would work to a degree,
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00:08:25,100 --> 00:08:29,420
but because it was done by hand,
because it wasn't a controlled depth,
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00:08:29,840 --> 00:08:34,580
there were risks and there
was variable effectiveness.
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00:08:35,510 --> 00:08:36,650
How is it different today?
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00:08:36,920 --> 00:08:40,520
What are the main treatments that are
available and how well do they work?
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00:08:41,420 --> 00:08:44,570
So we're really in a
totally different era,
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00:08:44,570 --> 00:08:47,660
and that's why I wanted
to do this episode.
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00:08:47,820 --> 00:08:52,730
I feel like we're out of the
swamp and we've got definitely
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00:08:52,880 --> 00:08:57,510
a range of devices with
good data demonstrating
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00:08:57,750 --> 00:08:58,800
effectiveness.
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00:08:58,800 --> 00:09:03,600
And this has led to
specific FDA clearances for
137
00:09:04,020 --> 00:09:08,760
devices to treat cellulite
and even in the FDA drug
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00:09:08,770 --> 00:09:10,800
approval for the treatment of cellulite.
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00:09:12,360 --> 00:09:17,100
One of the earlier devices was a laser
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00:09:17,100 --> 00:09:18,450
called Cellulaze,
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00:09:18,480 --> 00:09:22,920
and instead of using a fork
liposuction cannula like the
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00:09:22,920 --> 00:09:23,880
Brazilians,
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00:09:24,210 --> 00:09:29,130
a laser fiber was used that
could help break up some of the
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00:09:29,130 --> 00:09:30,840
fat during a liposuction,
145
00:09:30,840 --> 00:09:35,760
but could also fire from
the side and cut some
146
00:09:35,760 --> 00:09:38,340
of these little connective tissue strands.
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00:09:39,540 --> 00:09:41,370
And that actually worked very well,
148
00:09:41,370 --> 00:09:46,050
but it required a great deal
of surgical skill and was very
149
00:09:46,050 --> 00:09:48,090
tedious and time consuming.
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00:09:48,090 --> 00:09:52,080
But that was a way of using a laser
to do what's called subcision,
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00:09:52,380 --> 00:09:56,910
to cut those fiber strands
that pull down the dimples.
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00:09:57,780 --> 00:10:01,200
So from there, a device
called Cellfina was developed,
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00:10:01,200 --> 00:10:04,530
and this was a mechanical subcision,
154
00:10:04,540 --> 00:10:09,480
but it used a vacuum
assisted plate to pull the
155
00:10:09,480 --> 00:10:14,310
skin flat against it and then
perform that subcision or
156
00:10:14,320 --> 00:10:17,370
cutting at a very controlled depth.
157
00:10:18,330 --> 00:10:22,500
And that made the subcision
much more reliable.
158
00:10:23,460 --> 00:10:27,150
And eventually, as this device
was out for several years,
159
00:10:27,420 --> 00:10:31,740
they generated a good body
of data that demonstrated the
160
00:10:31,740 --> 00:10:36,510
clearance of cellulite
persisted even at five
161
00:10:36,520 --> 00:10:37,920
years. At five years,
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00:10:37,920 --> 00:10:42,480
80% or 85% of the effect was still
163
00:10:42,690 --> 00:10:44,880
present. In other words,
164
00:10:44,880 --> 00:10:49,320
the dimples didn't come
back that percentage of the
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00:10:49,320 --> 00:10:52,380
time, even after five years.
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00:10:52,890 --> 00:10:57,480
So the issue is that's
still a little bit of a
167
00:10:57,480 --> 00:10:59,940
procedure, the area has to be numbed.
168
00:11:00,210 --> 00:11:02,910
There's bruising and recovery time.
169
00:11:03,960 --> 00:11:05,610
More recently,
170
00:11:05,670 --> 00:11:10,440
a chemical subcision or pharmacologic
subcision was approved by
171
00:11:10,440 --> 00:11:14,820
FDA and this was an injectable
medication called QWO.
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00:11:16,470 --> 00:11:20,280
This was a collagenase enzyme
that breaks down collagen.
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00:11:20,280 --> 00:11:24,750
And when it was injected under the
dimple where that little strand
174
00:11:24,750 --> 00:11:26,610
runs down under the skin,
175
00:11:26,610 --> 00:11:29,970
it could chemically break
down that little fiber.
176
00:11:31,080 --> 00:11:34,050
And there's a new device out called Avéli,
177
00:11:34,440 --> 00:11:38,160
which likewise targets individual dimples
178
00:11:38,550 --> 00:11:43,500
by introducing a little hook
underneath that has a little
179
00:11:43,500 --> 00:11:48,270
cutting device on it. And once
you are able to hook the fiber,
180
00:11:48,720 --> 00:11:52,860
you fire it and it cuts the
little fiber underneath the skin.
181
00:11:54,520 --> 00:11:57,970
The issue with all of these treatments,
182
00:11:59,380 --> 00:12:00,730
they're effective,
183
00:12:00,880 --> 00:12:05,470
but they all have a degree of
bruising and recovery time,
184
00:12:05,560 --> 00:12:08,830
and they're at least minimally invasive.
185
00:12:10,750 --> 00:12:14,140
Not the QWO injection,
that's just an injection,
186
00:12:14,140 --> 00:12:18,010
but definitely bruising and recovery time.
187
00:12:18,460 --> 00:12:22,930
So another approach is to use energy
devices that either target the
188
00:12:22,930 --> 00:12:25,840
fat, the fibrous septa or the skin.
189
00:12:25,900 --> 00:12:29,590
And these have been much more
variable in effectiveness.
190
00:12:30,400 --> 00:12:32,500
So the final thing that's happening,
191
00:12:32,500 --> 00:12:36,340
which is an off-label use
of injectable fillers,
192
00:12:36,580 --> 00:12:41,500
is people are taking the
fillers that are collagen
193
00:12:41,500 --> 00:12:45,070
stimulators, basically
Radiesse and Sculptra,
194
00:12:45,820 --> 00:12:49,510
hyper diluting them and
injecting them in the area.
195
00:12:49,840 --> 00:12:53,470
And this is effective as well.
196
00:12:54,580 --> 00:12:57,250
So it sounds like there's
been a lot of progress.
197
00:12:57,700 --> 00:13:01,360
Do we have the ideal
treatment? Does that exist yet?
198
00:13:01,540 --> 00:13:03,010
And what would that look like?
199
00:13:03,970 --> 00:13:04,803
I think
200
00:13:05,740 --> 00:13:10,660
the experiences we've had with
these effective techniques tell
201
00:13:10,660 --> 00:13:13,540
us a little bit about
what we ideally want.
202
00:13:14,200 --> 00:13:16,540
We'd like something non-invasive,
203
00:13:17,320 --> 00:13:22,120
very clear that patients would
pick that over even a minimally
204
00:13:22,120 --> 00:13:25,840
invasive procedure if they
have the option. They really,
205
00:13:25,840 --> 00:13:29,650
really want a treatment with
no big recovery, for example,
206
00:13:29,650 --> 00:13:33,790
not a lot of bruising that takes
two, three weeks to go away.
207
00:13:34,990 --> 00:13:39,610
And the other important
issue is that cellulite
208
00:13:40,180 --> 00:13:43,270
tends to affect fairly large areas,
209
00:13:43,570 --> 00:13:47,980
and if you just treat the three
or five, four dimples, I mean,
210
00:13:47,980 --> 00:13:50,230
that's nice. That's progress,
211
00:13:50,680 --> 00:13:55,450
but it still doesn't make you look good
enough to feel comfortable going out in
212
00:13:55,450 --> 00:13:57,970
a bathing suit or in short shorts.
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So we'd really like to have a treatment
that can treat the whole zone that's
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affected rather than just
cherry pick individual
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spots.
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Alright, so now we've reached the
takeaways portion of the episode,
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Dr. Bass, what takeaways would you
like to share with our listeners?
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So the first thing we mentioned
right at the beginning,
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cellulite is distinct
from skin laxity and skin
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crepeness,
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but those are often confused by patients
or they're all sort of collapsed down
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into one entity.
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So it's very important cellulite
treatments will work for cellulite and
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things that are designed for skin
smoothing or skin tightening are more
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appropriate for the other problems.
That's the first big point.
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The second point is we said
what's the ideal treatment?
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And a feature I didn't mention
because we don't have it,
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is that different treatments do
better for some of the different
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manifestations of cellulite.
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So the subcision treatments
work really well for
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dimples,
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but the waviness or
rigidness that's formed,
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and that's more often seen on the thighs,
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although you can see it
on the buttock as well,
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that responds better to things
that more globally structure,
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the connective tissue under the skin,
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not things that simply divide the little
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fibrous strand because
it's not a discreet dimple,
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it's more of an irregular effect.
And so structuring and thickening,
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that connective tissue under
there as a response to the
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treatment
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creates a fibroseptal network.
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That's more like what's in men's
tissues that don't manifest
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cellularly than in
women's tissues that do.
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So we have to pick the right
treatment based on what's
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showing on your skin surface.
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Subcision definitely has a proven
track record with excellent durability
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for dimples,
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but that more global fibroseptal
remodeling is going to be needed
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for best results. And as
new treatments come out,
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we really want ones
that have specific study
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data on cellulite to
avoid going back into that
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swamp of broken promises.
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Definitely some important things to
keep in mind. Thank you, Dr. Bass,
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for sharing your insight
and expertise with us.
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Thank you for listening to the Park
Avenue Plastic Surgery Class podcast.
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00:16:46,850 --> 00:16:49,070
Follow us on Apple
Podcasts, write a review,
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00:16:49,100 --> 00:16:50,450
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00:16:58,880 --> 00:17:03,380
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