American Society of Plastic Surgeons
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Why is cellulite so hard to address and what are my options?
Help is on the horizon

Cellulite can be, quite literally, an annoying pain in the butt. It could also be considered the great equalizer because it doesn't discriminate: Women young and old, slim and stodgy, gym rats and couch potatoes alike, can find themselves with stubborn, uneven texture and dimpling.

There are a few treatments and devices designed to alleviate – but not cure – cellulite. Even with their hefty price tags and multiple rounds of treatment, the results tend to be temporary and subtle, at best.

As many as 80 to 90% of American women experience cellulite dimpling at some point in their life. Reliable, medical research has only just begun to learn more about the condition on a cellular level, including what causes it and how to treat it – for good.

Last year, two surgeons from the American Society of Plastic Surgeons released a brief study of the cellular structure of cellulite dimple formation via ultrasounds, with the hope that by knowing and understanding more about the condition they could help discover improved treatment options.

Why is cellulite so hard to treat?

First things first – this seemingly impervious condition has confounded and bewildered surgeons for decades. Diet and exercise help enormously, of course, but dimpling and uneven texture can appear even in the most athletic among us.

"Cellulite is a common complaint among our patients, yet we have never understood what exactly causes it and what is the most effective way to treat it," explains Lauren A. Whipple, MD, a leading author for the cellulite study released last year.

"I always used to say to every patient I saw for cellulite, that as soon as I could invent something to take care of cellulite, I was going to retire immediately and go buy an island in Miami," laughs Washington D.C.-based plastic surgeon and ASPS member, Troy Pittman, MD, highlighting the lack of effective treatment options.

"The issue with cellulite is a skin support issue," says Dr. Pittman. "I think that most patients look at cellulite in the mirror and they think of it as fat that could or should be treated the way we treat fat with liposuction. And the truth is, liposuction takes support away from the skin, it devolumizes the skin and can make cellulite exceedingly worse."

One key finding in last year's cellulite study is that "there's a high degree of fascial banding associated with the cellulite dimples," says co-author, Joseph Ricci, MD. "When we actually put the ultrasound on people to visualize what was happening beneath the skin, we saw that there is something tethering the skin to a deeper structure, which creates the dimple."

These fibrous bands run perpendicular to the skin, says Dr. Pittman, and the crater that is formed at the intersection of the band and the skin "can only be permanently resolved by breaking those fibrous bands" underneath the skin.

The newbies

Qwo

Qwo, an injectable, received FDA approval in the summer of 2020 to treat banana rolls and cellulite on the buttocks via an injectable enzyme that pinpoints and destroys the collagen within the tethered fibrous bands, releasing the dimpled skin to bounce back to a normal, smooth skin equilibrium, while leaving the surrounding area safe and untouched.

"Qwo is an enzyme, collagenase, that targets those bands and chemically melts them," says Dr. Pittman, adding that physicians will inject Qwo directly into the dimple and around it as well to melt the bands as much as possible. Think of the process as similar to the way Kybella melts fat.

But there is, of course, a catch. "If you think about this collagenase," says Dr. Pittman, "It's breaking down collagen structures, so it's not only breaking the band, but all of the little veinules – these tiny, tiny veins that run through the skin – it breaks those, too."

The disruption of so many fibrous bands at once leads to a "shocking" level of bruising – 10 times worse than liposuction, Dr. Pittman estimates. To make matters worse, the typical course of treatment is three rounds of injections, spaced six weeks apart. Meaning that your entire area of treatment will be the color of a bright berry smoothie for four solid months. But the bright side? The treated cellulite dimples will never return, and you also won't feel as awful as the bruising might suggest, with patients reporting only minimal soreness.

Resonic

Launched in the summer of 2021, this hotly awaited in-office device uses a first-of-its-kind, FDA-cleared Rapid Acoustic Pulse (RAP) technology to noninvasively improve the appearance of cellulite on the buttocks and thighs by delivering rapid-fire, high-pressure acoustic shockwaves – up to 100 pulses per second – to break the septa bands beneath the skin, without damaging the surround skin.

Some dermatologists swear that it also addresses uneven texture that isn't quite cellulite, but isn't not cellulite, either. It's FDA cleared for short-term improvement, but sun exposure and lifestyle changes will quickly diminish the already temporary results.

Avéli by Revelle

The launch of this new device is shrouded in secrecy, with the manufacturer only inviting 40 doctors to trial the next-gen handheld device. Like some of the older cellulite models, it is a handheld device that cuts the fibrous bands under the skin's surface to release the dimple. As opposed to other treatments, which sever many surrounding bands unnecessarily, Avéli's technology allows doctors to identify and target exactly the band they want to cut, but leaving the others intact.

While the clinical study has not yet been released and only a small number of dermatology and plastic surgery practices have the device, Avéli should become more widely available by the end of 2022. This is definitely a procedure that everyone in the medical field is keeping a close eye on.

The OG treatments

VelaShape

One of the first treatments for cellulite deserves a spot on the list of options, but VelaShape has been phased out of doctor's offices over the years in place of newer, more advanced technology than the massage and suction with radiofrequency VelaShape delivers.

Cellfina

Designed to relieve dimpling associated with cellulite, Cellfina actually cuts the fibrous bands underneath the skin via a small device that's inserted through (very numbed) skin on top of, or next to, each cellulite dimple.

Dr. Pittman describes the experience, which begins with the placement of a suction cup-looking device over the dimple, which suctions the dimple up, then a needle is inserted into the center of the suction cup and then the provider "kind of waves the needle back and forth over and over again to basically cut the fibrous band."

This time-consuming process is repeated for each dimple, resulting in major swelling for two weeks, a few days worth of downtime and the possibility of permanent scarring at the injection sites.

Although it's advertised as a one-and-done procedure, Dr. Pittman cautions that it won't prevent new dimples from popping up over time.

Cellulaze

"Cellulaze is basically a laser that puts heat energy on the skin and uses radiofrequency energy to cut the connective bands," explains Dr. Pittman. The heat energy also amps up collagen production to make skin bouncier and stronger, with results appearing within three to six months, and lasting up to a year.

The challenge with Cellulaze, says Dr. Pittman is that "you need to hit those little rubber band-size fibrous bands, right on target with the energy" or else the band won't be cut effectively, and the dimples will still be visible.

"Many surgeons I know like Cellulaze better than Cellfina," says Dr. Pittman. "But they're not going crazy over the results."

To find a qualified plastic surgeon for any cosmetic or reconstructive procedure, consult a member of the American Society of Plastic Surgeons. All ASPS members are board certified by the American Board of Plastic Surgery, have completed an accredited plastic surgery training program, practice in accredited facilities and follow strict standards of safety and ethics. Find an ASPS member in your area.

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