Miscellaneous Aesthetic Procedures

Lindsey M. Voller, BA

Rachit Gupta, BS

Noora S. Hussain, BS

Charles E. Crutchfield, III MD

Javed A. Shaik, PhD, MS

Maria K. Hordinsky, MD

Neil S. Sadick, MD

Ronda S. Farah, MD

Chapter Highlights

Microdermabrasion utilizes mild mechanical abrasion to resurface the outer epidermis, promoting skin rejuvenation and enhancing cosmesis.
Cellulite is a common complaint of the female aesthetic patient; treatments include topicals, injectables, subcision, and the use of various energy-based devices.
Microneedling is an aesthetic technique that uses focal tissue injury to stimulate remodeling and neocollagenesis.
Platelet-rich plasma has numerous uses in the aesthetic medicine, including for rejuvenation, treatment of alopecia, and improvement in the appearance of scars.

MICRODERMABRASION

Introduction

Microdermabrasion (MDA) is a simple, nonsurgical exfoliation procedure that utilizes mild mechanical abrasion to resurface the outer epidermis.¹ The superficial injuries induced by MDA promote skin rejuvenation and improve cosmetic appearance as the tissue heals. Monteleone first described the clinical use of MDA in 1988 following its development in Italy in 1985.² MDA has since become a commonly performed minimally invasive procedure across a variety of clinical settings. The American Society for Aesthetic Plastic Surgery estimates that MDA is the third most widely utilized skin rejuvenation procedure after chemical peels and intense pulsed light (IPL).³ MDA has been used to address an assortment of aesthetic concerns, including photodamage, wrinkles, uneven skin tone and texture, melasma, striae, pores, tattoo removal, and superficial acne scars.¹^,⁴^,⁵ MDA has also been shown to improve transdermal delivery of certain medications via increased permeability of the skin barrier.⁶ This section provides an overview of microdermabrasion and its current utility in clinical practice.

Devices

MDA devices are classified as type I devices with the US Food and Drug Administration (FDA) exemption.⁷ Traditional MDA consists of two main elements constituting a closed-loop system: an abrasive, exfoliating component and a vacuum pump or compressed air power source (Figure 10.1).⁵ The abrasive component may contain inert crystals—typically aluminum oxide—that are projected onto the skin under negative pressure from a sterilizable or disposable handpiece. The propelled crystals subsequently transfer their kinetic energy to the stratum corneum, which causes corneocyte detachment and removal of surface debris.¹^,⁵ Alternatively, crystal-free systems utilize diamond- or crystal-embedded handpieces or bristles as the abrasive stimulus (Table 10.1). Level of abrasiveness can vary based on handpiece coarseness. Vacuum suction simultaneously collects debris as the device moves along the skin.

In addition to stratum corneum removal, MDA causes melanosome redistribution within the epidermis and flattening of the dermal-epidermal junction.¹^,⁸^,⁹^,¹⁰ Increased density of collagen has also been reported.¹^,⁸^,¹¹ Rajan et al. demonstrated increased stratum corneum hydration with concurrent decrease in transepidermal water loss 1 week after MDA, suggesting improved skin barrier function associated with the procedure.¹² Improvement in lipid barrier function through enhanced ceramide production has also been documented.¹³ The combined effects of MDA improve cosmesis as the skin undergoes remodeling.

Since the introduction of the first MDA system in 1985, devices have evolved considerably. Crystal-free systems are largely replacing traditional aerosolized crystal devices due to their decreased risk of ocular irritation and particle inhalation.¹⁴ Certain devices also incorporate topical medication administration to enhance transdermal drug absorption. Some authors have administered low-molecular-weight compounds such as vitamin C and 5-fluorouracil in conjunction with MDA; however, additional studies are needed investigating this purpose.⁶^,¹⁵ Notably, at-home devices are becoming exceedingly popular among skincare consumers, and numerous options are now on the market. While
these devices are often considered less aggressive than in-office systems, patients should consider completing a pretreatment visit with a board-certified dermatologist to ensure they are an appropriate candidate.

FIGURE 10.1 Schematic depicting a typical microdermabrasion device.

(Image courtesy of Ronda S. Farah, MD, University of Minnesota, Department of Dermatology, MN, USA.)

TABLE 10.1 Comparison of Crystal and Crystal-free Devices

	Crystal Devices	Crystal-Free Devices
Abrasive medium	Inert crystals (e.g., aluminum oxide or sodium chloride)	Diamond- or crystal-embedded handpiece
Mechanism	Crystals propelled onto skin, causing corneocyte detachment	Abrasive handpiece directly exfoliates and disrupts skin surface
Risks	Increased risk of particle inhalation, corneal abrasion	No risk of particle inhalation or corneal abrasion

An additional crystal-free alternative is the newly developing technique of hydradermabrasion. Hydradermabrasion employs an abrading system consisting of an oxygen- and water-based solution, suction pressure cleansing, and MDA to exfoliate the outer epidermis.¹⁶ Through hydradermabrasion, microcanals are widened in the epidermis and dermis while also providing cutaneous hydration. The effects of hydradermabrasion were investigated in a 2008 trial by Freedman et al.¹⁷ Ten healthy female volunteers underwent six treatment sessions of hydradermabrasion with polyphenolic antioxidant serum at 7 to 10 day intervals, while 10 volunteers received antioxidant serum only. Skin biopsy demonstrated significantly increased epidermal and papillary dermal thickness compared to pretreatment in the hydradermabrasion + antioxidant serum group; changes were nonsignificant in the serum-only group.¹⁷ Administration of topical polyphenolic antioxidants in this setting may enhance overall treatment effects of MDA, leading to greater clinical improvements in fine lines, skin texture, pore size, and hyperpigmentation.¹⁸ As hydradermabrasion becomes increasingly widespread, it will likely become a routine alternative to traditional MDA. However, current literature on this technique is sparse and further investigation is warranted.

Reported Uses

Many patients are suitable candidates for MDA given its minimally invasive nature and overall excellent safety profile. Indeed, MDA can be performed safely on any Fitzpatrick skin type (I-VI), although authors have suggested proceeding more conservatively with patients of darker skin tones (types IV-VI) to decrease the risk of postinflammatory pigmentary changes.⁵

As procedure effectiveness depends largely on presenting skin concern, practitioners should select patients on the basis of projected responsiveness to treatment. However, few well-designed clinical trials exist that evaluate MDA and compare its efficacy to other minimally invasive procedures.¹ Among existing evidence, it appears that patients with superficial skin conditions—such as facial rhytides, fine lines, skin dullness, enlarged pores, and/or texture concerns—are likely to derive the most benefit from MDA treatment.⁷^,¹⁹^,²⁰ MDA may be useful in treating select cases of acne scarring but may require longer treatment and/or deeper ablation.⁹^,²¹ Mild to moderate improvements in striae distensae have also been reported.¹ Evidence is mixed on the utility of MDA for treatment of acne vulgaris, dyspigmentation disorders such as melasma, and erythematous disorders including rosacea and telangiectasias.¹⁴^,¹⁹^,²²^,²³ Patients interested in undergoing MDA should therefore receive appropriate counseling on treatment
indications, alternatives, risks, and benefits; it is also critical to set realistic expectations prior to a patient’s first treatment session. Furthermore, a thorough medical history and skin examination should be conducted to ensure there are no major contraindications to treatment.

An additional consideration when planning MDA with interested patients is treatment cost. As a cosmetic procedure, MDA is not typically covered by insurance companies and prices may differ based on provider, geographic region, and extent/duration of treatment. Ballpark treatment costs may be $100 or more and prices vary widely across the United States. Additionally, multiple sessions are recommended to achieve maximum results.¹⁴ Estimated total cost must be discussed upfront with patients to ensure understanding of financial implications prior to initiating a treatment plan.

Technique

MDA is performed in outpatient clinical and nonclinical settings (e.g., clinics, salons, and medical spas) by various trained professionals—including dermatologists, plastic surgeons, nurses, and licensed aestheticians (Figure 10.2). Topical anesthetic is not required, and the procedure should be discontinued if the patient is experiencing excessive discomfort. A general operating procedure as adapted from Small et al. and Karimipour et al. is outlined in Table 10.²^,¹⁴^,¹⁹ although standard technique may differ significantly based on the practitioner. Treatment technique will also vary based on device manufacturer recommendations. Note that surface ablation may be altered through adjustments to device head size, particle size, number of passes, speed of probe movement, abrasion depth, crystal flow rate, exposure time, and vacuum pressure.⁶

Postprocedure instructions may also vary based on treatment parameters. Similar to laser-based procedures, moisturizers, sunscreen, avoidance of irritants, and sun avoidance are typically recommended. More pronounced results may be achieved through multiple sessions over a longer period of time; weekly or biweekly treatments for 4 to 6 weeks are often recommended for visible improvement.¹⁹ Following treatment plan completion, touch-up sessions may be provided on an individual basis to maintain and/or enhance results.

FIGURE 10.2 Photograph depicting a typical microdermabrasion procedure.

(Courtesy of Dr. Charles E Crutchfield III, Crutchfield Dermatology, Eagan, MN.)

TABLE 10.2 Description of Typical Microdermabrasion Preparations and Treatment Techniques

1-2 weeks prior to procedure	Consider discontinuing irritating skin products (e.g., retinoids, glycolic acid) Consider herpes and varicella prophylaxis in patients with history of herpes simplex virus (HSV) or varicella zoster virus (VZV) infection
Day of procedure	Consent patient Confirm patient has not been recently tanned Inspect skin for active infection, severe pustular acne, cutaneous malignancy in the treatment area, and other dermatoses Obtain baseline photographs Consider performing test spot in nontreatment area (especially in higher Fitzpatrick skin types)
Procedure preparation	Provide protective eyewear Cleanse skin and degrease treatment area Allow area to dry completely Select device treatment settings. Recommended parameters depend on device being utilized; follow manufacturer guidelines accordingly
Procedure	Confirm device treatment settings Place device handpiece on skin Consider application of tension and constant, even pressure Perform passes per manufacturer recommendations; use of three passes in varying directions has been proposed¹⁸ Consider using decreased suction and pressure on areas with thinner skin
Patient monitoring	Continuously monitor patient for signs of excessive discomfort, irritation, or development of immediate petechiae/purpura Continue until treatment end point of mild erythema
Postprocedure	Remove debris with moistened washcloth Apply moisturizer and broad-spectrum sunscreen Counsel patient to avoid skin irritants (e.g., retinoids, glycolic acid) for 1-2 wk Sanitize or sterilize device per manufacturer recommendations

Treatment Pearls

At separate treatment visits, patients can be offered adjunct aesthetic procedures, including light-based devices, injectables, chemical peels, and skin tightening. This may enhance overall treatment effect. However, the authors do not recommend performing these procedures on the same day as MDA.

Risks and Contraindications

As a minimally invasive procedure, MDA is highly safe overall with a low risk of serious adverse events. Minor complications include tenderness at the treatment site, edema, and bruising. Patients should be counseled that mild redness can be expected shortly after the procedure, but it should resolve within 1 to 5 days.¹⁴ For significant erythema, ice packs can be applied and topical steroids may be considered. Patients may also report mild transient discomfort and tingling. However, pain is not expected and should be reported immediately to the supervising physician. Lack of appropriate eye protection may lead to corneal irritation.¹⁹ Similar to other dermatologic surgical procedures, excessive bruising
may result if the patient has particularly thin skin or is taking an antiplatelet agent or anticoagulant at time of the procedure. Scarring and abrasions are rare but may occur if MDA is performed with overly aggressive treatment settings. As with any skin procedure, physicians should caution patients on the risks of hypo- and hyperpigmentation. Autoinoculation of viral infections (e.g., herpes simplex virus, warts, molluscum contagiosum) may occur; certain authors suggest pretreatment prophylaxis with acyclovir or valacyclovir among patients with a history of herpes simplex or varicella infection.¹⁴ Devices should always be cleaned thoroughly or sterilized after use to avoid transmission of infectious disease. For staff members, there has been suggestion that inhalation of aluminum oxide crystals may be related to risk of fibrotic lung disease or Alzheimer dementia. Further research is needed to identify a direct relationship.⁹^,¹⁹

Contraindications to MDA include, but are not limited to, pregnancy or breastfeeding, active infection, growing or bleeding lesions, history of keloidal or hypertrophic scarring, immunosuppression, skin atrophy, bleeding abnormality, dermatoses in the treatment area, cutaneous malignancy in the area, and severe pustular acne.¹⁴ While dermabrasion was discussed in the 2017 isotretinoin consensus guidelines by Waldman et al. in Dermatologic Surgery, use of isotretinoin in conjunction with MDA was not explicitly addressed.²⁴

Conclusion

This section highlighted the clinical utility of microdermabrasion, a minimally invasive procedure that utilizes mechanical abrasion to resurface the outer layer of the epidermis, promoting collagen formation and improving cosmesis as the skin heals. From its early introduction, MDA evolved quickly into a routine cosmetic procedure that can be incorporated into a variety of outpatient settings. Many patients are appropriate candidates for MDA given its low risk of adverse events, although clinical trials are limited due to FDA exemption status. Further research is needed to define the appropriate patient population that may benefit the most from treatment.

TREATMENT OF CELLULITE

Introduction

Also known as gynoid lipodystrophy, adiposis edematosa, edematous fibrosclerotic paniculopathy, and nodular liposclerosis, cellulite is characterized by uneven dimpling or nodularity of the skin (Figure 10.3).²⁵^,²⁶^,²⁷^,²⁸ Cellulite is extremely common in women; it has been perpetuated in the literature that somewhere between 85% and 98% of women across all races experience some form of cellulite during their lifetime.²⁵^,²⁹^,³⁰ However, original publications examining the prevalence of cellulite are lacking. Cellulite occurs much less frequently in men with a prevalence of 1% to 2%, generally occurring only among men who have conditions presenting with relative androgen deficiency such as Klinefelter syndrome and congenital hypogonadism.³⁰^,³¹^,³²^,³³ Despite the high prevalence of cellulite, data on epidemiology are sparse; it is, however, thought to be more common in Caucasian women compared to Asian women.³⁰ Cellulite typically tends to present in women between 20 to 30 years of age, but can be noticed by some women immediately after puberty, as early as 15 years old.³¹

Upon a search of PubMed, original articles studying the effect of cellulite on quality of life are limited. In a study performed by Hexsel et al. (published in Cellulite: Pathophysiology and Treatment by Goldman) evaluating 62 female patients with cellulite between the ages
of 18 and 45 years, 70% of all participants reported that cellulite “hampered their lives greatly.”³⁴ Published in abstract form and also published in Cellulite: Pathophysiology and Treatment by Goldman, Hexsel et al. again evaluated 50 female volunteers and found that cellulite caused women to restrict their outdoor activities, types of clothes worn, resulted in feelings of poor self-esteem, and caused fear of spouses’ attention and judgment.³⁵ However, full details of this study are not available. Additional studies needed to quantify cellulite’s effect of quality on life are needed.

FIGURE 10.3 This image illustrates a 34-year-old female with cellulite, displaying uneven dimpling and nodularity.

(Courtesy of Dr. Charles E Crutchfield III, Crutchfield Dermatology, Eagan, MN.)

Although the term “cellulite” was first coined by the French in the mid-1800s, this condition was first studied in 1920 and thought to be an abnormality of water metabolism by French scientists Alquier and Paviot.³²^,³⁶ It would take another 50 years before the concept of cellulite made its way to households across the United States, due to an immensely popular book, titled Cellulite: Those Lumps, Bump, and Bulges You Couldn’t Lose Before, about cellulite published by Nicole Ronsard, a New York salon owner.³⁷^,³⁸ Cellulite took hold of popular culture in the 1970s, sparking the development of an entire industry focused on treating this condition. The earliest treatments for cellulite focused on improving lymphatic flow and improving circulation to the affected areas, typically involving a combination of physical therapies, such as massage and topical anticellulite creams.³¹ Treatments have gradually evolved to focus on the structural abnormalities seen in cellulite.³¹

In the 21st century, treatment of cellulite has become a large and still rapidly growing industry across the world. Several major categories of treatments have evolved over the last few decades: physical decompression, topical therapies, radiofrequency, acoustic wave therapy, microfocused ultrasound, cryolipolysis, injectables, and subcision. While many of these treatments are established for cellulite, others are used in off-label fashion and involve several major categories: a combination of physical and topical therapies, radiofrequency devices, subcision, and injectable treatments.³¹ Treatments for patients can be quite costly. Peer-reviewed data on average cost of patients undergoing cellulite treatment are lacking. However, online websites hosting community reviews and costs for popular cosmetic procedures report that the average patient undergoing treatment for cellulite spends approximately $1,650 total, but can spend up to $5,000.³⁹

Etiology

Goldman and Hexsel describe cellulite as a physiologic rather than pathologic state; it is thought that the purpose of cellulite is to ensure adequate stores of adipose tissue in postpubertal women to guarantee sufficient calories for high energy-requirement states such as pregnancy and lactation.⁴⁰ The etiology of cellulite is poorly understood, but there are numerous known risk factors that cause a predisposition for development of cellulite. In addition to genetics, increasing age, female sex at birth, Caucasian race, estrogen, pregnancy, other hormonal changes, a diet excessively rich with carbohydrates, and sedentary lifestyle have all been associated with cellulite development (Table 10.3).²⁷^,³¹^,³⁶

The pathophysiology of cellulite development is controversial and has not been definitively elucidated, although there have been several major theories: anatomical differences between sexes, connective tissue laxity, and vascular and lymphatic dysfunction.³⁰ Originally described by Nürnberger and Müller, subcutaneous fat lobules protruding into the overlying layer of dermis termed “papillae adiposae” in women are larger in size and positioned more upright compared to fat lobules in men.³³^,⁴³ However, other studies have found an unclear correlation between the degree of fat lobule herniation and the appearance of cellulite.³³^,⁴⁵^,⁴⁶^,⁴⁷ Pierard et al. proposed that instead, vertical stretch of the hypodermis results in laxity of connective tissue, predisposing to papillae adiposae and the appearance of cellulite.⁴⁵ Meanwhile, other studies propose the role of lymphatic outflow abnormalities, chronic inflammation, and localized edema in the development of cellulite.³⁰^,³⁶^,⁴⁸^,⁴⁹ In reality, the development of cellulite is quite complex and likely involves a combination of the three pathways.

Clinical Evaluation and Physical Examination

As described by Goldman and Hexsel, cellulite is a physiologic state more common in women.²⁵^,²⁹^,⁴⁰ Cellulite typically presents asymptomatically in women; XXY syndrome, hypogonadism, and hormone therapy for prostate malignancy, however, may result in
cellulite in men.³⁰^,³¹^,³²^,³³ During the physical examination, the area of skin suspected to have cellulite should be evaluated by the clinician in an effort to differentiate it from obesity or other cellulite-mimicking processes. While obesity and cellulite may appear similar, cellulite tends to occur more so in the skin of the abdomen, pelvic region, buttocks, and lower extremities.²⁷ Other abnormalities that can appear similar to cellulite and should be considered in the differential diagnosis include lipoedema, lymphedema, lipoatrophy, or infragluteal folds.³¹^,⁵⁰ It is important for physicians to understand the differences between cellulite and skin findings associated with cellulite-mimicking processes, as treatments for cellulite can lead to worsening of other skin conditions.³¹

TABLE 10.3 Proposed Risk Factors for Cellulite³¹^,³⁶

Genetics	Variability in ACE and HIF1A⁴¹ Possible reduction in expression of the adiponectin gene⁴²
Demographics	Postpubertal patients³¹,³³ Increased age⁴³ Female sex at birth³²,³³,⁴⁰,⁴³ Increased in Caucasian women (compared to Asian or African-American women)³¹,³⁶
Hormones	Estrogen, possibly promoting lipogenesis³⁶ Pregnancy and lactation³⁶ Insulin promotes net production of adipose tissue³⁶ Prolactin worsens cellulite appearance via localized edema³⁶
Nutrition	High-carbohydrate diet³⁰,³⁶ High-salt diet results in worsened appearance of cellulite due to increased fluid retention³⁶,⁴⁴
Social factors	Low-activity lifestyles³⁶ Alcohol use³⁶ Increased body mass index (BMI)³⁶,⁴³ Tobacco use is associated with increased prevalence of cellulite³⁶
ACE, angiotensin-converting enzyme; HIF1A, hypoxia-inducible factor 1-alpha.

There are several methods for evaluating patients with cellulite. Examination of patients while standing can make underlying cellulite more evident.²⁶ A pinch test or muscle contraction can also be performed to make underlying cellulite more prominent.²⁶ High-definition photographs should be taken prior to starting any treatments, so as to document efficacy or lack of response to treatment.³¹ It is important to ensure that lighting, background, and body positioning during photography are kept as consistent as possible; Nikolas et al. outlined a standardized method of photography for cellulite.³¹^,⁵¹^,⁵² Diagnostic tools such as two-dimensional (2D) magnetic resonance imaging (MRI) and ultrasound imaging have also been utilized for evaluation of cellulite.²⁶

Cellulite Grading

The severity of cellulite can be graded using several scales; two commonly used are the Nürnberger-Müller Scale and the Cellulite Survey Scale (CSS).³³^,⁵³^,⁵⁴ The Nürnberger-Müller Scale, one of the first scales devised for grading cellulite, describes the severity of cellulite based on what positions it can be visualized in and based on response to a pinch test or muscle contraction.³³^,⁴⁷ The CSS is a newer scale, incorporating other morphological features in addition to features assessed as part of the Nürnberger-Müller Scale. The CSS incorporates five factors into the overall score: number of depressions, depth of depressions, skin laxity, morphology of skin alterations, and the Nürnberger-Müller Scale.⁵⁴ Based on overall CSS scoring, different treatments can be considered on a per-patient basis. Most recently, new scales known as “Cellulite Dimples-At Rest” and “Cellulite Dimples-Dynamic” have been developed and validated by Hexsel et al.⁵⁵ The impact of cellulite on patients can also be measured in effect on quality of life; one way to assess this is the CelluQOL survey, created by Hexsel et al. in 2011.³⁵^,⁵⁶

Interventions (Table 10.4)

Physical Decompression Therapy

One of the oldest methods of treating cellulite is simply with physical manipulation, including traditional massage. Recent device advances are combining positive pressure massage with negative pressure provided by vacuum-assisted technology.²⁶^,⁴⁷ With minimal side effects and contraindications, massage therapy is thought to help with outflow of lymphatic fluid and improve local blood flow, improving the appearance of cellulite.²⁶ The most commonly reported FDA-cleared massage device for cellulite on the market is Endermologie^® (LPG Systems, Valence, France), a device that involves a combination of tissue massage, rolling, and manipulation.⁵⁷^,⁵⁸ The terminology Endermologie^® originates from the words “ende” and “derm,” meaning under and skin, respectively.⁵⁸ Endermologie^®, a handheld device consisting of one vacuum compartment and two tissue
rollers, aims to mobilize deep tissue and subcutaneous fat by providing negative pressure and tissue manipulation.⁵⁷^,⁵⁸ The typical treatment regimen consists of ten 45-minute sessions twice a week, until an improvement in cellulite appearance is seen.³⁰^,⁵⁷^,⁵⁸ Despite being a popular treatment for cellulite, data on efficacy are limited. Some studies show mild improvement in cellulite,⁵⁷^,⁵⁸ while others show no statistically significant difference.⁵⁹ Collis et al. conducted a study on 52 women with cellulite, randomizing them to two treatment arms consisting of Endermologie^® and topical aminophylline cream. Only 10 of 35 women treated with Endermologie^® had improvement in cellulite appearance when assessed by study subjects. No statistical significance was found for either topical aminophylline cream or Endermologie^®.⁵⁹ Evaluation for improvement by investigators did not reach this level of efficacy. Kutlubay et al. describe a statistically significant reduction in cellulite grade, as well as in mean body circumference. Gulec also demonstrated a mild statistically significant reduction in cellulite grade. Patient’s weight loss and hydration status may also be impacting the results of these studies; Additional studies are needed to delineate efficacy of this therapy.

TABLE 10.4 Cellulite Treatments at a Glance^a

Physical decompression	Massage Massage with vacuum suction and tissue manipulation (e.g., Endermologie^®)
Topicals	Methylxanthines Retinoids Herbal creams
Radiofrequency	Monopolar (e.g., Thermage^®, Exilis^®, TruScuplt^®) Bipolar (e.g., Profound^®, VelaShape^®, VelaSmooth^®) Multipolar (e.g., Venus Freeze^®, Venus Legacy^®) Unipolar (e.g., Accent^®)
Acoustic wave	For example, Cellactor^®, Z-wave^®
Microfocused ultrasound with visualization	For example, UltraShape^®, Ultherapy^®
Cryolipolysis	For example, CoolSculpt^®
Injectables	Collagenase Fillers Phosphatidylcholine
Carboxytherapy
Subcision	Manual Vacuum-assisted (e.g., Cellfina^®) Laser (Cellulaze^®)
^aDisclaimer: While many of these treatments are specifically cleared by the FDA for treatment of cellulite, several of these treatments are not and instead used in an off-label fashion for cellulite treatment.

Topical Therapies

The earliest available and least invasive pharmacologic treatments for cellulite are cosmeceuticals. However, as these are topical products, their efficacy is limited by cutaneous penetration.²⁸ While cosmeceuticals are heavily marketed to consumers for treatment of cellulite, efficacy is limited and no topicals are known to cure cellulite.⁵⁷ While mechanism of action is not definitive, cosmeceuticals have been touted to increase circulation, promote lipolysis, stimulate production of collagen, and reduce inflammation.³¹^,⁶⁰^,⁶¹

While there are numerous options for topicals, the most commonly used and best evaluated treatments are methylxanthines, such as caffeine and aminophylline, and retinoid compounds. Methylxanthines are grouped as beta-agonists and exert their effects by encouraging lipolysis and reducing lipogenesis. Methylxanthines are additionally thought to increase levels of cAMP through inhibition of phosphodiesterase.³¹^,⁶² Anecdotally, caffeine is thought to be the safest and most effective methylxanthine anecdotally, but literature search supporting the use of methylxanthines is limited.⁶⁰^,⁶³

Topical retinoids are thought to decrease the appearance of cellulite primarily by increasing the formation of blood vessels and encouraging the synthesis of collagen and other connective tissue.²⁸^,⁶² In a study by Kligman et al. evaluating the effect of 0.3% retinol cream on 19 patients, almost 70% of patients reported improvement in treated areas compared to the control group.⁶⁴ However, a study by Piérard-Franchimont concluded that despite improvements in elasticity and viscosity of skin, the overall dimpled appearance of cellulite showed little to no improvement.⁶⁵

In addition to methylxanthines and retinoids, other cosmeceuticals have also been investigated for treatment of cellulite.⁶⁰ Hexsel and Soirefmann published a literature review in 2011 discussing other cosmeceutical options, including the following: Ginkgo biloba, pentoxifylline, Centella asiatica, Ruscus aculeatus, silicium, papaya (Carica papaya), pineapple (Ananas sativus), red grapes (Vitis vinifera), Cynara Scolymus, ivy, Melilotus officinalis, vitamin E, and vitamin C.⁶⁰ As with methylxanthines and retinoids, little data exist currently to support their use for cellulite treatment.⁶⁰

In general, topical treatments are tolerated very well by most patients. However, patients should be counseled about the mixed and often disappointing results of these treatments, as well as risks of allergic reactions such as contact dermatitis.⁶¹^,⁶⁶ Additionally, long-term efficacy of these treatments is not well established as most publications examining these medications have been limited by sample size and duration of follow-up.²⁸

Radiofrequency Device Therapies

The use of the medical devices for the management of cellulite has exploded over the last few decades. Radiofrequency (RF) has long been an FDA-cleared option for treatment of cellulite. RF devices have many other applications in aesthetic dermatology including but not limited to tightening of loose skin, body contouring, diminishment of scar appearance, and cellulite reduction.⁶⁷^,⁶⁸^,⁶⁹ RF devices generate thermal energy and deliver this in a targeted manner to the area of cellulite.²⁸ RF is thought to work by locally increasing temperature of body tissue, which stimulates production of new collagen while also degrading and remodeling existing collagen.²⁸ Several different categories of RF devices exist based on the number of electrodes used. The earliest generations of radiofrequency devices included unipolar, monopolar, bipolar, and tripolar options. More recent generations of RF devices are being released in multipolar, multigenerator, and temperature-controlled options (Figure 10.4).²⁸^,⁷⁰ RF devices can also be combined with other therapies, including vacuum, massage, ultrasound, targeted pressure energy, and more.²⁸^,⁷¹^,⁷²

Monopolar RF therapy is characterized by current administered between a single electrode and a grounding plate.⁶⁸^,⁷³ In general, monopolar devices penetrate more deeply than unipolar or bipolar devices, which may result in more pain experienced by patient.⁶⁸ Thermage^® (Solta Medical, Hayward, CA) was the first monopolar RF device cleared by the FDA for cellulite (in 2002), but new devices cleared by the FDA for cellulite have since been released onto the market such as Exilis^® (BTL Aesthetics, Prague, Czech Republic), TruSculpt^® (Cutera, Brisbane, CA), and more.⁶⁸ Monopolar RF has supportive studies that demonstrate tolerability and improvement.⁷²

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