Supplemental Digital Content is Available in the Text.
Abstract
BACKGROUND
Cellulite is an aesthetically displeasing rippling or dimpling of the skin, primarily on the buttocks/thighs. A recent study showed a novel acoustic subcision device produced significant short-term (12-week) improvement in the appearance of cellulite after a single rapid acoustic pulse (RAP) treatment.
OBJECTIVE
To evaluate the long-term (>52-weeks) efficacy and safety of RAP treatment for improvement in the appearance of cellulite.
MATERIALS AND METHODS
In this prospective, multicenter trial, female participants (n = 42) with severe cellulite were treated with the acoustic subcision device in a single visit. At >52 weeks, blinded board-certified dermatologists assessed efficacy by correctly identifying post-treatment photographs and using a 6-point simplified Cellulite Severity Scale (CSS). Participant satisfaction was also collected. Safety was assessed throughout.
RESULTS
The blinded panel correctly identified post-treatment photographs at a rate of 95.2%; 70.4% of participants had a >1-point reduction in the CSS score from baseline (mean reduction of 1.09). All participants (100%) reported improved cellulite appearance. Overall pain during treatment was rated as 2.4 and 0.3 post-treatment (pain scale 0–10). No device or treatment-related adverse events were reported at the >52-week follow-up.
CONCLUSION
Rapid acoustic pulse treatment significantly improved the long-term appearance of cellulite and was well-tolerated.
Cellulite is a dermatologic condition characterized by a rippling or dimpling of the skin.1 The prevalence of cellulite in women is estimated to be 80% to 98% and is attributable to differences in skin and subcutaneous tissue architecture relative to men.2–5 In normal skin, adipose tissue is separated into quilt-like chambers by fibrous bands of connective tissue called septa.1 In individuals with cellulite, the septa are contracted and sclerosed, keeping the skin at a fixed length with continuous tension.1,6 In men, the septa stretch from the dermal undersurface at a 45° angle and form a crisscross pattern, resulting in smaller fat lobules and a denser subdermal arrangement.2,3,7–9 In women, the septa are oriented perpendicularly to the skin and are less numerous, resulting in larger fat lobules and less structural stability, thereby allowing subdermal adipose tissue to become displaced.9,10 Estrogen may also play a role in cellulite development because of involvement in adipocyte hypertrophy, lipogenesis, and collagen formation.11 Studies and surveys have demonstrated that cellulite can negatively affect self-esteem, body image, and quality of life.12,13
Current treatment options for cellulite include vacuum-assisted manual subcision of septa via microblade, thermal lipolysis of adipocytes and thermal subcision of septa by lasers, or chemical subcision via collagenase clostridium histolyticum injections.14–16 Recently, Kaminer and colleagues17 showed lasting improvement in the appearance of cellulite via mechanical subcision of fibrous septa. Invasive approaches may cause pain and significant bruising and require localized anesthetic, thereby increasing recovery time. Noninvasive treatments include massage and topical creams.18,19 However, they have limited efficacy, particularly when used as monotherapy.20–22
A noninvasive acoustic subcision device (Resonic; Allergan Aesthetics, an AbbVie company, Irvine, CA) was recently shown to produce short-term (12-week) improvements in the appearance of cellulite.23 This acoustic subcision device induces physical shearing of fibrous septa through rapid acoustic pulses (RAPs). In contrast to current treatment options, the acoustic subcision device requires no anesthesia or downtime and was well-tolerated based on an average pain score of 2.4 (scale of 0–10) during treatment.23 Furthermore, the high frequency of the acoustic shock waves and fast rise time allows for the microscopic shearing of fibrous septa without inducing changes in the number or thickness of septa, as observed with other treatments.24,25 Given the short-term results,23 the objective of the current publication is to report the long-term (>52-weeks) efficacy and safety results of the acoustic subcision device 1 year after a single treatment visit from the same study that reported the short-term improvements in the appearance of cellulite.
Materials and Methods
Study Design
This was a prospective, single-arm, self-controlled, multicenter trial conducted at 4 US sites from July 2019 through December 2020. This study conformed to the ethical guidelines of the 1975 Declaration of Helsinki. Institutional Review Board (IRB) approval was obtained from Quorum Review IRB (Seattle, WA). All participants provided informed consent before treatment. This study is registered at ClinicalTrials.gov (NCT#04065711). This study comprised 4 visits: screening, a single treatment visit, and follow-up visits at 12- and >52-weeks post-treatment. As a result of the COVID-19 pandemic, several participants were unable to attend follow-up visits because of stay-at-home orders, lockdowns, or COVID-19 exposure, resulting in follow-up visits beyond the 52-week time-point.
Participants
Eligible participants were females (≥18–50 years; BMI ≤30 kg/m2) who had severe cellulite (≥4.0) as assessed by the clinical investigators on a validated 6-point Cellulite Severity Scale (CSS; See Supplemental Digital Content 1, Figure 1, http://links.lww.com/DSS/B334)26 at baseline, on at least 1 thigh and/or buttock (scale of 0–5; 0 = none, 1–2 = mild, 3 = moderate, 4–5 = severe). Additional inclusion criteria included: weight (±5% of body weight) stable for at least 6 months before the study; no invasive or energy-based cellulite treatments (e.g., liposuction, subcision, laser) for the previous 12 months; and no use of topical-based cellulite treatments for the previous 6 months.
Key exclusion criteria included: current pregnancy or planning to become pregnant during the duration of the study; metal or plastic implants in the area of the treatment (e.g., vascular stent, or implants in the hips, knees, etc); active electronic implants (e.g., pacemakers, defibrillators); a medical disorder that would hinder wound healing or immune response (e.g., blood disorder, inflammatory disease, etc); coagulopathy(ies) and/or is on anticoagulant medication; skin disorders (e.g., skin infections or rashes, extensive scarring, psoriasis, etc.) in the treatment area; any surgical procedure in the previous 3 months, or planned in the duration of the study; and current smoker.
Treatment
The acoustic subcision device was used to administer a single RAP treatment during a single treatment visit after completion of screening, enrollment, and obtaining informed consent from each participant. The investigator selected the right or left buttock/thigh with the most marked or severe cellulite and outlined (or demarcated) regional treatment areas (i.e., depressions, dimples, and ridges). After completion of the study, participants were offered 1 treatment visit to treat the untreated buttock/thigh after commercial availability. The baseline buttock/thigh photographs of the treated area served as the control. The participant was then positioned in the lateral decubitus or prone position and an acoustic coupling hydrogel pad and hydrogel was applied to the marked treatment areas. Participants did not receive anesthesia or other pain medications before, during, or after the procedure. One to 2 1-minute RAP doses were administered at a pulse rate of 50 Hz to each treatment area. The total number of treatment doses was determined by the number of identified treatment areas. Additional 1-minute doses were administered to deep dimples and ridges and to areas between and around the marked treatment areas. Treatment areas were cleaned immediately post-treatment and evaluated for any adverse events (AEs). No post-treatment bandages, compressions garments, or other care were needed. Post-treatment photography was taken at 12-week and 52-week visits; the mean time for the 52-week visit was 59.7 weeks (range: 52.0–67.0 weeks).
Efficacy Endpoints
Three blinded, independent, board-certified dermatologists (reviewers) identified post-treatment images from randomly ordered side-by-side baseline and >52-week photographs, then graded the baseline and post-treatment images using a simplified 6-point CSS (scale of 0–5, with 5 being the most severe).26 The percentage of participants with a ≥1- point change in CSS score at the 12- and >52-week follow-up visit was also calculated. The primary efficacy endpoint was correct identification of the >52-week post-treatment photographs from baseline photographs by at least 2 of 3 blinded reviewers at an average rate of ≥80%. Serial clinical photographs (QuantiCare 3D LifeViz stereoscopic camera system) were collected at baseline and the 12- and >52-week post-treatment time-points. Participants stood on a rotatable platform in a relaxed position and photographs were taken of the thighs, buttocks, and the thighs and buttocks together from 8 angles. Photographs were taken under standardized conditions, including the angle of the lights and the distance between the platform, lights, and camera.
Finally, after reviewing their own baseline and >52-week post-treatment photographs, participants were given a satisfaction survey and asked to rate their level of agreement with the following statement, “In comparison to the pretreatment photo, the 52-week photograph of the treatment area appears improved,” using a 5-point Likert scale from “strongly agree” to “strongly disagree.” Agreement was defined as responses of “strongly agree” or “agree.” The secondary efficacy endpoint was met if ≥80% study participants agreed that the appearance of their cellulite was improved post-treatment. Participants were also asked to respond to the following statements using the same 5-point Likert scale, “I feel there is good improvement in the appearance of my cellulite” and “the RAP treatment was relatively pain-free.”
Safety Endpoints
Immediately after treatment, the participants were evaluated for AEs. Expected AEs included mild-to-moderate erythema, mild pain, mild heat, and mild bruising or contusions. The primary safety endpoint was that there would be freedom from unexpected AEs (UAEs) or serious AEs (SAEs) directly attributable to the device or treatment immediately after acoustic subcision treatment throughout the conduct of the study. In addition, participants were asked to grade pain during and after the procedure on a scale from 0 (no pain) to 10 (worst pain possible). Finally, participants were asked to respond “yes” or “no” to the following question on a procedure tolerability questionnaire, “was the RAP treatment procedure tolerable?”
Statistical Analyses
Baseline and >52-week data are summarized descriptively. The primary efficacy endpoint, the rate of correct identification by at least 2 of the 3 blinded reviewers, was assessed for statistical significance using the χ2 test. The difference in baseline and long-term (>52-week) CSS scores was assessed using the Student t-test (paired, two-sided). Statistical significance was set at p < .05 (See Supplemental Digital Content 2, Appendix 1, http://links.lww.com/DSS/B367).
Results
Participants
Of 67 enrolled and treated participants, 25 were lost to follow-up, exclusionary criteria, or camera malfunction at the >52-week follow-up visit. A total of 42 participants were included in the efficacy and safety analyses. The mean age and BMI of participants was 43.5 years and 23.9 kg/m2, respectively. Table 1 provides a summary of participant demographics at the 12- and >52-week follow-up visits.23
TABLE 1.
Participant Demographics and Baseline Characteristics
| Characteristic | 12-week (n = 56) | >52-weeks (n = 42) |
| Sex (female), n (%) | 56 (100) | 42 (100) |
| Mean age, yr (SD) | 43.0 (6.7) | 43.5 (6.4) |
| (Range) | (25.7–50.8) | (25.7–50.8) |
| Age distribution, n (%) | ||
| 24–34 | 9 (16.1) | 5 (11.9) |
| 35–44 | 20 (35.7) | 15 (35.7) |
| 45–50 | 27 (48.2) | 22 (52.4) |
| Mean weight, pounds (SD) | 150 (21.8) | 153.1 (20.3) |
| (Range) | (102.0–191.4) | (120.0–186.0) |
| Mean BMI, kg/m2 (SD) | 23.5 (3.4) | 23.9 (3.4) |
| (Range) | (17.0–30.5) | (17.0–32.5) |
| Average treatment dose, minutes (SD) | 28.4 (3.67) | 28.55 (3.94) |
BMI, body mass index.
Efficacy: Blinded Reviewer Assessment & Participant Satisfaction
The efficacy results are shown in Table 2. At least 2 of the 3 blinded reviewers correctly identified the >52-week post-treatment photographs at a rate of 95.2% when presented with random pre-/post-treatment photographs (p < .001), thereby meeting the primary efficacy endpoint. This is similar to the correct selection rate of 96.4% reported at 12-weeks post-treatment.23 In addition, 70.4% of participants had >1-point reduction in CSS score from baseline, with a mean CSS score reduction of 1.09 (p < .0001). There was no significant difference in the proportion of patients with >1-point reduction in CSS score at 12 weeks post-treatment versus >52-weeks (p > .05; Mann–Whitney U test). Representative participant photographs of cellulite appearance and severity at baseline, 12 weeks, and >52 weeks are shown in Figures 1,2.
TABLE 2.
Short-Term and Long-Term Efficacy Results
| 12 weeks (n = 56) | >52 weeks (n = 42) | |
| Correct identification rates | ||
| Correct ID of post-Tx photo, n (2 of 3 reviewers) | 54 | 40 |
| % Correct ID of post-Tx photo | 96.4 | 95.2 |
| χ2 of 3 reviewers (expected = 50/50 chance) | <0.0001 | <0.0001 |
| Baseline CSS, mean (SD) | 3.41 (0.90) | 3.19 (0.99) |
| CSS reduction, mean (SD) | 1.01 (0.51) | 1.09 (0.75) |
| % Mean CSS reduction | 29.5 | 34.1 |
| p-value (Paired t-test) | <.0001 | <.0001 |
| % Responders (≥1-point change CSS Score) | 80.4 | 70.4 |
CSS, cellulite severity score; ID, identification; Tx, treatment.
Figure 1.
Photographs of a representative participant showing (left to right) baseline cellulite severity (CSS = 3.33) and improvement after 12 (CSS = 2.33) and >52 weeks (CSS = 1.67). (Age: 44; baseline weight: 138 lbs; >52-week weight: 132 lbs). CSS scores are derived from independent panel review assessment.
Figure 2.
Photographs of a representative participant showing (left to right) baseline cellulite severity (CSS = 3.33) and improvement after 12 (CSS = 1.67) and >52 weeks (CSS = 1.67). (Age: 37; baseline weight: 185 lbs; >52-week weight: 177 lbs). CSS scores are derived from independent panel review assessment.
The secondary long-term efficacy endpoint for participant satisfaction was met. When comparing side-by-side before and after photographs, 100% (n = 42/42) of participants agreed that the treated area had improved in appearance (Figure 3). In addition, 97.6% (n = 41/42) of participants felt there was good improvement in the appearance of their cellulite and 78.6% (n = 33/42) agreed that the RAP treatment was relatively pain-free.
Figure 3.
Participant satisfaction with cellulite appearance at 12- and >52-week follow-up visits. Participants rated their level of agreement with the statement “In comparison to the pretreatment photo, the 52-week photograph of the treatment area appears improved” compared with baseline on a 5-point Likert scale from strongly agree to strongly disagree. The 12-week data have previously been reported.23
Safety
Immediately after treatment, 85.7% (n = 48/56) of participants reported an expected AE attributable to device or treatment, including mild-to-moderate erythema (76.7%, n = 43), mild pain (1.7%; n = 6), mild heat (1.7%, n = 2), and mild contusion/bruise (5.3%; n = 4). All expected AEs were resolved without intervention. At the >52-week follow-up visit, no new device or treatment-related AEs were reported. Furthermore, no participant reported any SAEs. Three participants reported UAEs at the >52-week follow-up visit, but they were determined to be unrelated to the acoustic subcision treatment or device. One report involved the discovery of a hernia, which was resolved surgically as a day case. Two other participants had endometriosis or gastroesophageal reflux disease, respectively, which was documented as continuing as of May 2021. None of the participants discontinued the study because of UAEs. Thus, the primary safety endpoint was met. Most participants (97.6%, n = 41/42) agreed that RAP treatment was tolerable (See Supplemental Digital Content 1, Table 1, http://links.lww.com/DSS/B334), and participant-rated mean pain scores were 2.4 during 1-minute treatment doses and 0.3 immediately after the treatment visit (See Supplemental Digital Content 1, Table 2, http://links.lww.com/DSS/B334).
Discussion
In this prospective, multicenter study, significant long-term improvement in the appearance of cellulite following a single, noninvasive RAP treatment was shown in patients with moderate to severe cellulite. Blinded reviewers correctly identified post-treatment photographs at a rate of 95.2%, further supporting the long-term efficacy of the acoustic subcision device. The long-term durability of the RAP treatment was shown by 70.4% of participants having a >1-point reduction in the CSS score compared with baseline and a mean CSS score reduction of 1.09. In comparison, at 12 weeks, 80.4% of participants had a >1-point reduction in CSS score and a mean decrease in score of 1.01.23 The difference in mean CSS reduction scores between 12 weeks and >52 weeks was not statistically significant after a direct comparison of 12-week and >52-week photographs by the blinded reviewers.
Significant improvements were observed in participant satisfaction ratings of cellulite appearance after treatment, indicating that the improvements seem durable. Similar patterns were observed in participants' rated feelings about the treatment results. Previous studies have indicated that women with cellulite often experience psychological distress and low self-esteem, particularly in social settings.12,13 Future studies that elucidate the potential impact of RAP treatment on psychological distress and quality of life are warranted. Treatment with the acoustic subcision device was also well-tolerated, as evidenced by the lack of device or treatment-related UAEs or SAEs in participants. The level of participant-reported pain was low during treatment (mean score of 2.4 on a 0–10 scale) and was minimal immediately after treatment (mean score of 0.3), which is lower than that reported in a multicenter trial using mechanical subcision.14
Several studies have demonstrated the long-term efficacy of invasive treatments. In a multicenter study evaluating cellulite improvement in 57 female participants after laser-assisted subcision, 76% of participants demonstrated a ≥1-point improvement in dimple count or contour irregularity at 2 months post-treatment, with 90% of treated areas maintaining results after 1 year27 In another study, Kaminer and colleagues found that improvements in cellulite appearance and patient satisfaction were maintained for up to 3 years after treatment with a tissue-stabilized guided subcision device, although patients must be anesthetized before treatment.14,17 These invasive treatments have demonstrated long-term efficacy, but have varying degrees of effectiveness and require the delivery of localized anesthesia, compression garments postprocedure, and avoidance of certain activities for up to 2 weeks.14–16,27 Another potential drawback is that the operation of these devices requires a skilled physician to ensure an adequate treatment depth is chosen.28 In contrast, treatment with the acoustic subcision device is noninvasive, eliminating the need to determine treatment depth, anesthetize treatment areas, or counsel patients on post-treatment activities to avoid.
One potential limitation of this study is the lack of a true control group. All participants received the treatment, thus limiting the comparability of participant photos. Another limitation is that each participant only underwent a single treatment visit, regardless of the severity of the cellulite. Additional treatment visits may be more beneficial to ensure the durability of improvements in cellulite appearance, but further studies are required to evaluate this. In addition, participants' Fitzpatrick skin phototype was not noted, thereby limiting knowledge of the acoustic subcision device's effectiveness in various skin types. The lack of skin laxity measurement is also a limitation, because improvements in cellulite appearance may influence this aesthetic characteristic. The nature of the study design did not allow for differentiation between the effectiveness of the acoustic subcision device on the buttocks versus the thighs. Future studies should focus on assessing differences between these treatment areas, because the thighs are generally more difficult to treat from a clinical perspective. When comparing the assessment of the severity of cellulite for eligibility and then for an assessment of efficacy, a difference in severity scoring was noted—implying the importance of physical assessment in addition to photography to assess the severity of cellulite in the clinical setting accurately. Finally, the trial was conducted during the COVID-19 pandemic, resulting in challenges when scheduling follow-up visits. Stay-at-home orders, lockdowns, and participant self-quarantine increased the number of “no-show” visits, thereby contributing to the dropout rate between the 12-week and >52-week follow-up visits.
Conclusion
The acoustic subcision device is an effective and well-tolerated RAP treatment for long-term improvement in the appearance of cellulite. These results build upon the 12-week results and show that a single treatment visit can provide long-term improvement up to approximately 52 weeks.
Supplementary Material
Acknowledgments
AbbVie participated in the interpretation of data, review, and approval of the publication. Medical writing support and editorial assistance were provided by Shenavia Balcom-Luker, PhD, of AbbVie Inc, and was funded by AbbVie Inc.
Footnotes
Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (www.dermatologicsurgery.org).
E. Tanzi, D. Robertson, B. LaTowsky, and C. Jacob have indicated no significant interest with commercial supporters. C. C. Capelli is an employee and patent holder for AbbVie and may own AbbVie stock/stock options. S. Balcom-Luker is an employee of AbbVie and may own AbbVie stock/stock options. O. Ibrahim is a consultant and advisory board member for AbbVie. M.S. Kaminer is a consultant for AbbVie and Revelle Aesthetics.
The design, study conduct, and financial support for the study were provided by Soliton, Inc, Houston, Texas, prior to its acquisition by AbbVie Inc. C. C. Capelli, S. Balcom-Luker, O. Ibrahim and M. S. Kaminer are either employees, consultants, advisory board members or have stock options in AbbVie.
Contributor Information
Elizabeth Tanzi, Email: etanzi@capitalskinlaser.com.
David Robertson, Email: drobertson@asystmedical.com.
Brenda LaTowsky, Email: blatowsky@investigatemd.com.
Shenavia Balcom-Luker, Email: shenavia.balcomluker@abbvie.com.
Carolyn Jacob, Email: cjacob@chicagodermatology.com.
Omer Ibrahim, Email: oibrahim@chicagodermatology.com.
Michael S. Kaminer, Email: mkaminer@skincarephysicians.net.
References
- 1.Christman MP, Belkin D, Geronemus RG, Brauer JA. An anatomical approach to evaluating and treating cellulite. J Drugs Dermatol 2017;16:58–61. [PubMed] [Google Scholar]
- 2.Nürnberger F, Müller G. So-called cellulite: an invented disease. J Dermatol Surg Oncol 1978;4:221–9. [DOI] [PubMed] [Google Scholar]
- 3.Rudolph C, Hladik C, Hamade H, Frank K, et al. Structural gender dimorphism and the biomechanics of the gluteal subcutaneous tissue: implications for the pathophysiology of cellulite. Plast Reconstr Surg 2019;143:1077–86. [DOI] [PubMed] [Google Scholar]
- 4.Avram MM. Cellulite: a review of its physiology and treatment. J Cosmet Laser Ther 2004;6:181–5. [DOI] [PubMed] [Google Scholar]
- 5.Friedmann DP, Vick GL, Mishra V. Cellulite: a review with a focus on subcision. Clin Cosmet Investig Dermatol 2017;10:17–23. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Piérard GE, Nizet JL, Piérard-Franchimont C. Cellulite: from standing fat herniation to hypodermal stretch marks. Am J Dermatopathol 2000;22:34–7. [DOI] [PubMed] [Google Scholar]
- 7.Querleux B, Cornillon C, Jolivet O, Bittoun J. Anatomy and physiology of subcutaneous adipose tissue by in vivo magnetic resonance imaging and spectroscopy: relationships with sex and presence of cellulite. Skin Res Technol 2002;8:118–24. [DOI] [PubMed] [Google Scholar]
- 8.Hexsel DM, Abreu M, Rodrigues TC, Soirefmann M, et al. Side-by-side comparison of areas with and without cellulite depressions using magnetic resonance imaging. Dermatol Surg 2009;35:1471–7. [DOI] [PubMed] [Google Scholar]
- 9.Cotofana S, Kaminer MS. Anatomic update on the 3-dimensionality of the subdermal septum and its relevance for the pathophysiology of cellulite. J Cosmet Dermatol 2022;21:3232–9. [DOI] [PubMed] [Google Scholar]
- 10.Bass LS, Kaminer MS. Insights into the pathophysiology of cellulite: a review. Dermatol Surg 2020;46 Suppl:S77–S85. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Rossi AB, Vergnanini AL. Cellulite: a review. J Eur Acad Dermatol Venereol 2000;14:251–62. [DOI] [PubMed] [Google Scholar]
- 12.Hexsel D, Siega C, Schilling-Souza J, Stapenhorst A, et al. Assessment of psychological, psychiatric, and behavioral aspects of patients with cellulite: a pilot study. Surg Cosmet Dermatol 2012;4:131–6. [Google Scholar]
- 13.Wang JV, Bajaj S, Mehrabi JN, Geronemus RG. Real-world experiences of patients with cellulite: implications for newer treatment modalities. Dermatol Surg 2022;48:1023–4. [DOI] [PubMed] [Google Scholar]
- 14.Kaminer MS, Coleman WP, 3rd, Weiss RA, Robinson DM, et al. Multicenter pivotal study of vacuum-assisted precise tissue release for the treatment of cellulite. Dermatol Surg 2015;41:336–47. [DOI] [PubMed] [Google Scholar]
- 15.Sasaki GH. Single treatment of grades ii and iii cellulite using a minimally invasive 1,440-nm pulsed nd:Yag laser and side-firing fiber: an institutional review board-approved study with a 24-month follow-up period. Aesthet Plast Surg 2013;37:1073–89. [DOI] [PubMed] [Google Scholar]
- 16.Sadick NS, Goldman MP, Liu G, Shusterman NH, et al. Collagenase clostridium histolyticum for the treatment of edematous fibrosclerotic panniculopathy (cellulite): a randomized trial. Dermatol Surg 2019;45:1047–56. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Kaminer MS, Coleman WP, 3rd, Weiss RA, Robinson DM, et al. A multicenter pivotal study to evaluate tissue stabilized-guided subcision using the cellfina device for the treatment of cellulite with 3-year follow-up. Dermatol Surg 2017;43:1240–8. [DOI] [PubMed] [Google Scholar]
- 18.Dupont E, Journet M, Oula ML, Gomez J, et al. An integral topical gel for cellulite reduction: results from a double-blind, randomized, placebo-controlled evaluation of efficacy. Clin Cosmet Investig Dermatol 2014;7:73–88. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19.Collis N, Elliot LA, Sharpe C, Sharpe DT. Cellulite treatment: a myth or reality: a prospective randomized, controlled trial of two therapies, endermologie and aminophylline cream. Plast Reconstr Surg 1999;104:1110–4; discussion 1115-7. [PubMed] [Google Scholar]
- 20.Güleç AT. Treatment of cellulite with lpg endermologie. Int J Dermatol 2009;48:265–70. [DOI] [PubMed] [Google Scholar]
- 21.Emanuele E. Cellulite: advances in treatment: facts and controversies. Clin Dermatol 2013;31:725–30. [DOI] [PubMed] [Google Scholar]
- 22.Wanner M, Avram M. An evidence-based assessment of treatments for cellulite. J Drugs Dermatol 2008;7:341–5. [PubMed] [Google Scholar]
- 23.Tanzi EL, Capelli CC, Robertson DW, LaTowsky B, et al. Improvement in the appearance of cellulite and skin laxity resulting from a single treatment with acoustic subcision: findings from a multicenter pivotal clinical trial. Lasers Surg Med 2022;54:121–8. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24.Emilia del Pino M, Rosado RH, Azuela A, Graciela Guzmán M, et al. Effect of controlled volumetric tissue heating with radiofrequency on cellulite and the subcutaneous tissue of the buttocks and thighs. J Drugs Dermatol 2006;5:714–22. [PubMed] [Google Scholar]
- 25.Mlosek RK, Woźniak W, Malinowska S, Lewandowski M, et al. The effectiveness of anticellulite treatment using tripolar radiofrequency monitored by classic and high-frequency ultrasound. J Eur Acad Dermatol Venereol 2012;26:696–703. [DOI] [PubMed] [Google Scholar]
- 26.Hexsel DM, Dal'forno T, Hexsel CL. A validated photonumeric cellulite severity scale. J Eur Acad Dermatol Venereol 2009;23:523–8. [DOI] [PubMed] [Google Scholar]
- 27.DiBernardo BE, Sasaki GH, Katz BE, Hunstad JP, et al. A multicenter study for cellulite treatment using a 1440-nm nd:Yag wavelength laser with side-firing fiber. Aesthet Surg J 2016;36:335–43. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 28.Green JB, Cohen JL. Cellfina observations: pearls and pitfalls. Semin Cutan Med Surg 2015;34:144–6. [DOI] [PubMed] [Google Scholar]