To the Editor,
1.
Cellulite, or edematous fibrosclerotic panniculopathy, affects most post‐pubertal women and arises from vertically oriented fibrous septa that tether the dermis, producing the characteristic dimpling [1]. Conventional modalities seldom achieve durable correction, and high‐volume biostimulator protocols remain financially inaccessible to most patients in low‐resource settings. We describe a combined, low‐volume protocol pairing subcision with diluted calcium hydroxylapatite (CaHA; Radiesse, Merz Pharmaceuticals GmbH, Frankfurt, Germany) for gluteal cellulite in three women.
Three female patients (ages 30–37) with gluteal cellulite were treated by a single practitioner. Focal retractions first underwent subcision with a 22G 50‐mm blunt cannula to release the fibrotic septa, followed by subdermal CaHA at a 1:3 dilution (fanning technique) and focal 1:1 injections through a 27G needle for volumization. Total product was limited to one vial per buttock. Cellulite severity was scored with the Cellulite Severity Scale (CSS) by six blinded specialists (> 8 years' experience) trained on 20 reference images, with discrepancies adjudicated by a third evaluator. Follow‐up was at 3 months (Patients 1 and 3) and 12 months (Patient 2). Written informed consent and ethics approval were obtained.
All three patients improved. Median CSS fell from 12 to 3, a median 71% reduction (range 50%–75%) (Table 1), with consistent reduction in dimpling, smoother skin, and better contour on standardized photographs. The Patient 2 result persisted at 12 months (Figure 1), suggesting sustained remodeling. No bruising, nodules, vascular events, or infection were recorded during early (1–2 week) monitoring or follow‐up.
TABLE 1.
Individual CSS scores before and after treatment.
| Patient | CSS before | CSS after | % reduction |
|---|---|---|---|
| 1 | 6 | 3 | 50 |
| 2 | 14 | 4 | 71 |
| 3 | 12 | 3 | 75 |
| Median [IQR] | 12 [9–13] | 3 [3–3.5] | 71 [50–75] |
FIGURE 1.
Patient 2, pretreatment (gluteal muscles contracted) and 12‐month follow‐up (relaxed): Reduced dimpling, smoother contour, and sustained volumetric correction.
Subcision mechanically severs the oblique, honeycomb‐like septa that generate cellulite dimples and initiates a wound‐healing response that favors collagen deposition [2]. A single subcision session alone can meaningfully improve CSS [3]. We hypothesized that diluted CaHA, by directly activating fibroblasts within the released septal compartments, could enhance and prolong this neocollagenic response [4]. Our intermediate 1:3 dilution departs from conventional hyperdilution (1:4–1:6): it preserves a microsphere density sufficient for fibroblast engagement while improving spread, balancing biostimulation against dispersion [4]. A recent prospective study of cannula subcision with 1:1 CaHA reported comparable CSS gains, supporting the combined rationale [5].
The protocol's principal advantage is volume economy. Contemporary gluteal protocols advocate 10–20 vials [6], a cost prohibitive for most patients in our setting; achieving meaningful correction with one vial per buttock substantially widens access.
This report is limited by its small, uncontrolled cohort, heterogeneous follow‐up, and—most importantly—the absence of a subcision‐only arm, which prevents isolating the additive effect of CaHA on non‐volumetric outcomes such as skin smoothness. One patient also received prior radiofrequency microneedling, further confounding attribution. Findings should be read as preliminary and hypothesis‐generating.
In conclusion, combined subcision and low‐volume diluted CaHA was well tolerated and associated with clinically meaningful improvement in gluteal cellulite severity in three patients. Its low product requirement makes it an accessible candidate protocol that warrants evaluation against subcision alone in controlled trials.
Author Contributions
A.A. performed the research. J.S.R.C. designed the research study. A.A. and J.S.R.C. analyzed the data. L.A.P., V.D., L.V. and A.M.P. contributed essential reagents or tools. All authors wrote the paper and have read and approved the final manuscript.
Ethics Statement
This study was conducted in accordance with the Declaration of Helsinki and was approved by the Ethics Committee for Research on Human Beings HSJ—FUCS (CEISH). The protocol “Retrospective observational clinical study to evaluate the safety and efficacy of injectable medications and medical devices for the improvement of different signs of aging on the body and face” was approved under Act 22 of December 11, 2024 and communication (CEISH) 550–2024.
Consent
Informed consent was obtained from all subjects involved in the study. The consent process included a detailed explanation of the procedures, potential risks and benefits, and the use of photographic material for documentation and publication purposes.
Conflicts of Interest
The authors declare no conflicts of interest.
Acknowledgments
The authors would like to thank the blinded evaluators for their time and expertise in independently rating the Cellulite Severity Scale scores. We also extend our gratitude to the clinical staff involved in patient care and documentation for their invaluable support.
Data Availability Statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.
References
- 1. Bass L. S. and Kaminer M. S., “Insights Into the Pathophysiology of Cellulite: A Review,” Dermatologic Surgery 46 (2020): S77–S85. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2. Friedmann D. P., Vick G. L., and Mishra V., “Cellulite: A Review With a Focus on Subcision,” Clinical, Cosmetic and Investigational Dermatology 10 (2017): 17–23. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3. Stevens W. G., Green J. B., Layt C., et al., “Multicenter Pivotal Study Demonstrates Safety and Efficacy of a New Cellulite Procedure: 3‐Month Results,” Aesthetic Surgery Journal 43, no. 1 (2023): 97–108. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4. Nowag B., Casabona G., Kippenberger S., Zöller N., and Hengl T., “Calcium Hydroxylapatite Microspheres Activate Fibroblasts Through Direct Contact to Stimulate Neocollagenesis,” Journal of Cosmetic Dermatology 22, no. 2 (2023): 426–432. [DOI] [PubMed] [Google Scholar]
- 5. Durairaj K., Baker O., Yambao M., Linnemann‐Heath J., and Shirinyan A., “Safety and Efficacy of Diluted Calcium Hydroxylapatite for the Treatment of Cellulite Dimpling on the Buttocks: Results From an Open‐Label, Investigator‐Initiated, Single‐Center, Prospective Clinical Study,” Aesthetic Plastic Surgery 48, no. 9 (2024): 1797–1806. [DOI] [PubMed] [Google Scholar]
- 6. Silveira I. and Martinez B., “Bilateral Gluteal Augmentation With Hyperdilute Calcium Hydroxylapatite Microspheres Performed Using the Bella Vida Instant Brazilian Butt Lift (BBL),” Cureus 14, no. 6 (2022): e26261. [DOI] [PMC free article] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.