Cellulite: A Surgical Treatment Approach

Cellulite: A Surgical Treatment Approach Abstract Background Cellulite is one of the most common skin and subcutaneous tissue conditions, affecting predominantly the thighs and hips in postadolescent women. Its etiology is not well defined, and multiple available treatments show variable efficacy. Objectives To describe a technique for treatment of cellulite of the gluteal region, thighs, and hips through superficial liposuction utilizing a special cannula, combined with subcutaneous autologous fat grafting. Methods A retrospective review was performed of patients treated over 26 years at the Hospital São Lucas, Pontifical Catholic University of Rio Grande do Sul, Porto Alegre, Brazil. Patients underwent pretreatment evaluation as to the extent of their cellulite, and pretreatment and posttreatment photographs were obtained for visual evaluation of the results. Results Procedures were performed on 126 patients: 121 (96%) women and 5 (4%) men. The majority considered their results good or excellent. The complication rate was low, with the most common complications being ecchymosis, contour irregularities, partial recurrence of cellulite, seroma, and numbness. Conclusions We describe an effective method for the treatment of cellulite. Whereas subcision techniques utilize a needle or microblade to cut fibrous septa, we utilize a special cannula; larger areas can be treated than with subcision. Fat grafting is utilized to correct depressions and improve skin quality, which are added benefits compared to traditional subcision. Considering the multiple available cellulite treatments and their limitations, and the high patient satisfaction rate we achieved, with a low recurrence and complication rate, this technique can be a safe and effective option for patients with cellulite. Level of Evidence: 4 Cellulite, also known as gynecoid lipodystrophy, edematous fibrosclerotic panniculopathy, or local lipodystrophy, is a local anatomical and metabolic disturbance of the subcutaneous tissue that leads to changes in body contour, causing an unaesthetic appearance of the skin known as either “orange peel” or “cottage cheese” deformity (Figure 1). The exact etiology and optimal diagnostic methods for cellulite are not well defined. An accumulation of fat occurs in the gluteal region, thighs, and hips during puberty. The skin acquires changes that vary from an orange-peel appearance to undulations, with transverse dimpling, nodularity, and cutaneous folds. Cellulite and lipodystrophy are commonly found concurrently, especially in the gluteal region and thighs, causing superficial skin irregularities.1 Figure 1. View largeDownload slide A 28-year-old woman with severe cellulite of the thighs (A, C) at rest and (B, D) with manual compression (A and B, right side; C and D, left side). Figure 1. View largeDownload slide A 28-year-old woman with severe cellulite of the thighs (A, C) at rest and (B, D) with manual compression (A and B, right side; C and D, left side). Despite the nuisance to patients, cellulite is not considered a disease and does not increase morbidity or mortality. Approximately 85% to 90% of postadolescent women are affected by cellulite.2,3 Men can also be affected, although in a much smaller proportion due to the smaller quantity of adipocytes in male compared to female fatty tissue.4 Many patients opt for minimally or noninvasive treatment methods to attenuate cellulite. Creams and Topical Treatments Among the active ingredients utilized in cellulite creams are vegetable extracts, such as ginkgo biloba, which helps stimulate the microcirculation, and retinol, which stimulates collagen synthesis, both of which demonstrate a clinically significant reduction in cellulite when applied topically.5 Xanthines (such as caffeine), herbal extracts, retinoic acid receptors (RAR), and peroxisome proliferator-activated receptor (PPAR) inhibitors are all topical treatments for cellulite that decrease adipogenesis, increase thermogenesis, enhance collagen synthesis, and improve microcirculation.6,7 Lymphatic Drainage Controversy persists as to the efficacy of local massage or lymphatic drainage in improving cellulite. On one hand, removal of interstitial and lymphatic fluid is accelerated, decreasing the appearance of cellulite2; however, a recent clinical trial showed no benefit in the improvement of cellulite, despite improvements in the patient’s quality of life.8 Endermologie ESI (LPG Systems, Valence, France) is a nonpharmacological method that employs mechanical means to mobilize subcutaneous fat from affected areas, although with high cost and a paucity of evidence for improvement of cellulite. Proponents of the system advocate that the massage and suction improve the disorganized subcutaneous fat and accelerate lymphatic drainage.5 Ultrasound Through its thermal and vasodilatory effects, ultrasound induces lipolysis and a reduction in localized fat. Lysis of adipocytes is induced by cavitation and thermal damage. Although ultrasound can be a useful adjuvant therapy when utilized alongside other therapies for cellulite, its efficacy as a sole method of treatment has not been proven. Additionally, it is unknown whether the ultrasound-induced alterations in the cellular architecture of cellulite are long lasting.5 Radiofrequency Radiofrequency (RF) also shows positive cosmetic results. RF application has a goal of maintaining a temperature at the epidermal level between 40°C and 42°C. Results have been shown to last at least 6 months.9 Bipolar RF systems are based on heat generation; the temperature reached is sufficient to cause thermal damage to the surrounding adipose tissue and connective tissue septa. The combination of bipolar RF, infrared heat, and pulsatile suction into one system has been demonstrated to decrease body circumference and improve the appearance of cellulite.10 Laser Lipolysis Treatment of cellulite with a 1440-nm laser has shown clinical improvement and induction of collagen neoformation.11-13 Histological studies demonstrate the laser’s effects, including adipocyte rupture, reorganization of the reticular dermis, and coagulation of collagen and adipose tissue.14-16 Laser-assisted liposuction with wavelengths between 1064 nm and 1320 nm is frequently utilized to treat cellulite and leads to skin tightening. Lysis of adipocyte membranes by laser-assisted energy reduces the traumatic removal of fat and increases the coagulation of blood vessels, leading to decreased hematomas and ecchymosis and a quicker recovery. Mesotherapy Mesotherapy consists of the injection of multiple substances into the subcutaneous tissue to dissolve fat, but studies show inconsistent results with this treatment. Multiple different substances have been proposed, including xanthines such as caffeine, aminophylline, and theophylline, which lead to lipolysis through the inhibition of phosphodiesterase (PDE) and an increase in the levels of cyclic adenosine monophosphate (cAMP). Hormones, enzymes, herbal extracts, vitamins, and minerals are also utilized. In addition, phosphatidylcholine (an extract of soy lecithin) is commonly utilized, because of its lipolytic effects secondary to beta-adrenergic receptor activation. After the subcutaneous injection of phosphatidylcholine, lobular panniculitis, fat necrosis, and serous lipoatrophy are seen.17 The use of mesotherapy has been limited due to the lack of standardized treatment regimens,18 erratic results, and the risk of adverse local effects, such as edema, ecchymosis, subcutaneous nodules, infection, urticarial reactions, and skin irregularities.9 Carboxytherapy Carboxytherapy involves the injection of carbon dioxide into the subcutaneous tissue, with the goal of affecting the adipose tissue and circulation. Its purported mechanism of action is through an increase in capillary blood flow induced by hypercapnia and a decrease in cutaneous oxygen consumption (right-hand shift of the oxygen dissociation curve, or Bohr effect). This may help explain its positive effects on lipolysis.19 Subcision Originally described for the treatment of acne scars and small areas of skin dimpling,20 subcision is a technique in which a needle is inserted into the subcutaneous tissue; when its deepest point has been reached (approximately 1.5-2 cm deep), the needle is redirected parallel/tangential to the epidermis and swept, with the goal of cutting fibrous septa at the subdermal level (reticular dermis), to improve the area affected by cellulite and depressed or retracted scars.21,22 Improvement in the appearance of affected areas may also be due, in part, to the redistribution of tension forces in the subcutaneous tissue.23 Pain and ecchymosis may occur posttreatment, but results are satisfactory in a majority of patients.24 Recently, a new tissue stabilized-guided subcision system (Cellfina, Merz North America, Inc., Raleigh, NC) was FDA approved for long-term improvement in cellulite of the thighs and buttocks, with follow up at 3 years demonstrating consistent improvements in patient satisfaction (93% “satisfied” or “very satisfied” at 3 years compared to baseline) as well as the Cellulite Severity Scale and Physician Global Aesthetic Improvement Scores.25 Surgery Multiple advances in liposuction have improved results since its introduction by Illouz in the 1980s.26-30 The two most common methods of liposuction are conventional power-assisted liposuction, which decreases the deeper subcutaneous fat, and superficial liposuction, described by Bolivar de Souza Pinto et al31 and later by Gasparotti,32 close to the dermis, which releases subcutaneous fibrous septa. Tumescent infiltration, along with smaller cannula diameters, brought a new dimension, allowing for aspiration of large volumes of fat with greater precision. Ultrasound-assisted liposuction (Vaser, Solta Medical, Inc., Hayward, CA) demonstrates increased skin retraction and, when utilized with a cutting cannula (VaserSmooth), may be an effective treatment for areas of cellulite, with decreased blood loss compared to traditional liposuction.33 Although liposuction is an excellent method for improving body contour, some authors warn about a possible increase in skin irregularities after traditional liposuction. Therefore, conventional liposuction is not yet a standard treatment for cellulite. In part, this may be because the adipose tissue of cellulite is very superficial, with only a very thin overlying dermal layer.9 Liposuction performed too close to the skin surface can result in irregularities and a subsequent poor cosmetic result,9 especially when executed by untrained surgeons. However, when associated with autologous fat grafting of the undermined areas, which possess significant dead spaces, liposuction can improve results and offer excellent satisfaction to patients with cellulite. METHODS Patients were selected from our institution’s division of Plastic Surgery (Hospital São Lucas, Pontifical Catholic University of Rio Grande do Sul, Porto Alegre, Brazil) between January 1991 and April 2017. Patients were included if they met the following criteria: had cellulite of the thighs, buttocks, hips, or trochanteric region; were between the ages of 16 and 65 years old; and had a body mass index (BMI) between 21 and 35 kg/m2. Patients undergoing other treatment types for cellulite (with the exception of topical creams) were excluded. All patients were evaluated pretreatment for their body fat distribution (1 = thighs; 2 = buttocks; 3 = hips; and 4 = trochanteric regions) and their skin quality (1 = good and elastic; 2 = good and less elastic; and 3 = poor with flaccidity). Pretreatment and posttreatment standardized photographs were utilized for the visual assessment of results and were evaluated subjectively at 18 months posttreatment by the main author (C.U.) and 3 other plastic surgery staff members. The aesthetic result was evaluated with a scale (1 = excellent; 2 = good; and 3 = poor,) and patient satisfaction was evaluated with a simple questionnaire (1 = very satisfied; 2 = satisfied, but could be better; and 3 = dissatisfied), which was completed anonymously in our division’s outpatient clinic at the 18-month posttreatment visit (a blank copy of the questionnaire is available online as Supplementary Material at www.aestheticsurgeryjournal.com). All patients gave signed informed consent as per our institution’s protocol for surgery and publication. The study was conducted in accordance with the Declaration of Helsinki for research involving human subjects and approved by the Hospital São Lucas—Pontifical Catholic University of Rio Grande do Sul’s Institutional Review Board. Surgical Technique After the induction of general endotracheal or epidural anesthesia, depending on anesthesiologist and patient preference, the patient is positioned prone and all areas to be treated are prepped with chlorhexidine solution. Tumescent infiltration with 1:500,000 epinephrine and 0.9% normal saline solution is performed in the subcutaneous tissue of the thighs, buttocks, hips, and trochanteric regions. After 10 minutes to allow for adequate vasoconstriction, we harvest approximately 240 cc of fat from the hips or trochanteric areas (Figure 2) utilizing a 60 cc syringe attached to a 3 mm diameter cannula. No centrifugation or other processing of the fat is performed. Figure 2. View largeDownload slide Fat harvesting with a 60 cc syringe from the hips. Figure 2. View largeDownload slide Fat harvesting with a 60 cc syringe from the hips. In the second step, we perform a superficial liposuction utilizing a 3 mm cannula conceived by the main author with a flattened, wedge-shaped tip, similarly to a “duck beak” (Figure 3A). This cannula ruptures the fibrous connective ligaments, thereby releasing the skin from the subcutaneous tissue (Figure 3B). In contrast to a traditional subcision technique, in which a blade or needle sharply cuts through the subdermal level (potentially cutting blood vessels that supply the overlying skin), the maneuver we perform, utilizing superficial liposuction, limits damage to the subdermal blood vessels. We believe that this is important to keep the skin well vascularized, therefore avoiding the risk of necrosis that could potentially occur with extensive areas of undermining. We also feel that by keeping subdermal and subcutaneous blood vessels as intact as possible, subsequent take of grafted fat may be increased. A pinch test confirms the degree of skin looseness (Figure 4). Figure 3. View largeDownload slide (A) This cannula, which was developed by the main author, has a wedge-shaped tip, similar to a “duck beak” to release fibrous septa. (B) This schematic illustration shows rupture of the fibroelastic fibers tethering the skin to the fascia and subcutaneous tissue. Figure 3. View largeDownload slide (A) This cannula, which was developed by the main author, has a wedge-shaped tip, similar to a “duck beak” to release fibrous septa. (B) This schematic illustration shows rupture of the fibroelastic fibers tethering the skin to the fascia and subcutaneous tissue. Figure 4. View largeDownload slide Superficial liposuction has been performed in all areas of cellulite with a 3 mm “duck beak” cannula. (A) Pinch test of the thigh and (B) pinch test of the buttock both confirm an adequate degree of release of fibrous attachments to the skin. Figure 4. View largeDownload slide Superficial liposuction has been performed in all areas of cellulite with a 3 mm “duck beak” cannula. (A) Pinch test of the thigh and (B) pinch test of the buttock both confirm an adequate degree of release of fibrous attachments to the skin. The third step is to reinject a fine layer of the harvested fat subcutaneously. We gently distribute the grafted fat throughout all of the areas where we have performed surgical disruption of the connective tissue septa, maintaining a subcutaneous fat layer with approximate thickness of 5 mm to 8 mm (Figure 5). Figure 5. View largeDownload slide (A, B) The reserved aspirated fat is reinjected subcutaneously in all areas that were undermined, producing (C, D) an approximately 5 mm to 8 mm thick fat “scaffold” to fill the resultant dead space. Figure 5. View largeDownload slide (A, B) The reserved aspirated fat is reinjected subcutaneously in all areas that were undermined, producing (C, D) an approximately 5 mm to 8 mm thick fat “scaffold” to fill the resultant dead space. Finally, we apply 5 cm wide paper tape strips (Micropore, 3M Health Care, St. Paul, MN) to decrease edema and help maintain the grafted fat in place. This paper tape is kept in place for 3 weeks (Figure 6), and a compression garment is placed at the end of surgery. After 3 weeks, we remove the strips (Figure 7) and maintain the compression garment for an additional month. Figure 6. View largeDownload slide (A, B) A 5 cm wide Micropore paper tape is applied to all treated areas for 21 days to help decrease edema and keep the grafted fat in place. Figure 6. View largeDownload slide (A, B) A 5 cm wide Micropore paper tape is applied to all treated areas for 21 days to help decrease edema and keep the grafted fat in place. Figure 7. View largeDownload slide (A-E) A 28-year-old woman (the same patient from Figure 1) 3 weeks after paper tape strips were removed, showing marked improvement in cellulite, both at rest and under manual compression. Figure 7. View largeDownload slide (A-E) A 28-year-old woman (the same patient from Figure 1) 3 weeks after paper tape strips were removed, showing marked improvement in cellulite, both at rest and under manual compression. A video demonstrating this technique is available as Supplementary Material. Video 1. Watch now at https://academic.oup.com/asj/article-lookup/doi/10.1093/asj/sjy028 Video 1. Watch now at https://academic.oup.com/asj/article-lookup/doi/10.1093/asj/sjy028 Close RESULTS Procedures were performed on 126 patients over 26 years (Table 1). Women comprised 96% (121 patients) of patients, and men made up 4% (5 patients). All of the patients were white. The mean patient age was 29 years old (range, 17-58 years). The mean BMI was 27.1 kg/m2 (range, 24-33 kg/m2). The mean follow-up period was 38 months (range, 18-110 months). Regarding cellulite distribution, the hips were more frequently affected (88.8%), followed by the thighs (76.1%), buttocks (71.4%), and trochanteric region (53.1%). Nine patients (7%) required additional corrections due to skin irregularities, retractions, or partial recurrent cellulite. These corrections were performed under local anesthesia and sedation with additional liposuction and fat grafting (Figure 8). Table 1. Patient Characteristics: Age, Sex, Complications, and Results   Mean  Range  Age (years)  29  17-58  BMI (kg/m2)  27.1  24-33  Follow-up (months)  38  18-110    No. of patients  Percentage (%)  Number of patients  126  100  Sex   Female  121  96   Male  5  4  Race (White)  126  100  Complications   Temporary ecchymosis  12  9.5   Irregularities, retractions, or undulations  5  3.9   Partial recurrent cellulite  4  3.1   Seroma  2  1.5   Temporary numbness  2  1.5   Hematomas  0  0   Skin necrosis  0  0  Body fat distribution   Hips  112  88.8   Thighs  96  76.1   Buttocks  90  71.4   Trochanteric  67  53.1  Skin quality   Good and elastic  96  76.1   Good and less elastic  23  18.2   Poor with flaccidity  7  5.7  Aesthetic result   Excellent  22  17.4   Good  95  75.3   Bad  9  7.3  Patient satisfaction   Very satisfied  101  80.1   Satisfied but could be better  25  19.8   Dissatisfied  0  0  Follow up   18 months  126  100   24 months  68  54   5 years  43  34    Mean  Range  Age (years)  29  17-58  BMI (kg/m2)  27.1  24-33  Follow-up (months)  38  18-110    No. of patients  Percentage (%)  Number of patients  126  100  Sex   Female  121  96   Male  5  4  Race (White)  126  100  Complications   Temporary ecchymosis  12  9.5   Irregularities, retractions, or undulations  5  3.9   Partial recurrent cellulite  4  3.1   Seroma  2  1.5   Temporary numbness  2  1.5   Hematomas  0  0   Skin necrosis  0  0  Body fat distribution   Hips  112  88.8   Thighs  96  76.1   Buttocks  90  71.4   Trochanteric  67  53.1  Skin quality   Good and elastic  96  76.1   Good and less elastic  23  18.2   Poor with flaccidity  7  5.7  Aesthetic result   Excellent  22  17.4   Good  95  75.3   Bad  9  7.3  Patient satisfaction   Very satisfied  101  80.1   Satisfied but could be better  25  19.8   Dissatisfied  0  0  Follow up   18 months  126  100   24 months  68  54   5 years  43  34  BMI, body mass index. View Large Table 1. Patient Characteristics: Age, Sex, Complications, and Results   Mean  Range  Age (years)  29  17-58  BMI (kg/m2)  27.1  24-33  Follow-up (months)  38  18-110    No. of patients  Percentage (%)  Number of patients  126  100  Sex   Female  121  96   Male  5  4  Race (White)  126  100  Complications   Temporary ecchymosis  12  9.5   Irregularities, retractions, or undulations  5  3.9   Partial recurrent cellulite  4  3.1   Seroma  2  1.5   Temporary numbness  2  1.5   Hematomas  0  0   Skin necrosis  0  0  Body fat distribution   Hips  112  88.8   Thighs  96  76.1   Buttocks  90  71.4   Trochanteric  67  53.1  Skin quality   Good and elastic  96  76.1   Good and less elastic  23  18.2   Poor with flaccidity  7  5.7  Aesthetic result   Excellent  22  17.4   Good  95  75.3   Bad  9  7.3  Patient satisfaction   Very satisfied  101  80.1   Satisfied but could be better  25  19.8   Dissatisfied  0  0  Follow up   18 months  126  100   24 months  68  54   5 years  43  34    Mean  Range  Age (years)  29  17-58  BMI (kg/m2)  27.1  24-33  Follow-up (months)  38  18-110    No. of patients  Percentage (%)  Number of patients  126  100  Sex   Female  121  96   Male  5  4  Race (White)  126  100  Complications   Temporary ecchymosis  12  9.5   Irregularities, retractions, or undulations  5  3.9   Partial recurrent cellulite  4  3.1   Seroma  2  1.5   Temporary numbness  2  1.5   Hematomas  0  0   Skin necrosis  0  0  Body fat distribution   Hips  112  88.8   Thighs  96  76.1   Buttocks  90  71.4   Trochanteric  67  53.1  Skin quality   Good and elastic  96  76.1   Good and less elastic  23  18.2   Poor with flaccidity  7  5.7  Aesthetic result   Excellent  22  17.4   Good  95  75.3   Bad  9  7.3  Patient satisfaction   Very satisfied  101  80.1   Satisfied but could be better  25  19.8   Dissatisfied  0  0  Follow up   18 months  126  100   24 months  68  54   5 years  43  34  BMI, body mass index. View Large Figure 8. View largeDownload slide A 42-year-old female with cellulite treated by our approach. (A, C) Preoperative views and (B, D) 18-month postoperative views show some residual irregularities of the left lateral thigh. This was corrected by an additional 20 cc of fat grafting under local anesthesia. No further intervention was performed. Figure 8. View largeDownload slide A 42-year-old female with cellulite treated by our approach. (A, C) Preoperative views and (B, D) 18-month postoperative views show some residual irregularities of the left lateral thigh. This was corrected by an additional 20 cc of fat grafting under local anesthesia. No further intervention was performed. Ecchymosis was the most common complication (12 patients; 9.5%), lasting on average 3 to 4 weeks; patients were counseled that this would reabsorb with massage with creams and sunblock. There were 2 cases (1.5%) of small-volume seromas (15 cc and 10 cc), which were treated with simple aspiration at the 1-week posttreatment visit. Both of these seromas occurred in females of normal BMI. One of these cases had an identifiable cause, because the patient’s compression tape and garment were of insufficient length and thus did not compress the entire area of the thigh that had been treated (Figure 9). Figure 9. View largeDownload slide A 29-year-old female who underwent surgical treatment of cellulite of the thighs. (A) She presented with a seroma of the left lower thigh, in a noncompressed area, on postoperative day 7. (B) This resolved after two aspirations of 15 cc of serosanguinous fluid. This case occurred early in our experience and illustrates the importance of adequate postoperative compression. Figure 9. View largeDownload slide A 29-year-old female who underwent surgical treatment of cellulite of the thighs. (A) She presented with a seroma of the left lower thigh, in a noncompressed area, on postoperative day 7. (B) This resolved after two aspirations of 15 cc of serosanguinous fluid. This case occurred early in our experience and illustrates the importance of adequate postoperative compression. According to the evaluation of the standardized photographs at 18 months posttreatment by the main author and 3 members of our division’s plastic surgery staff, the overall results have been good to excellent, especially in young patients with good skin elasticity. Eight patients (6.3%) were over 50 years old, two (1.5%) of which developed posttreatment skin flaccidity that improved with manual lymphatic drainage twice a week for 45 days. The majority of the patients described being “very satisfied” with their results (Figures 10-14). Figure 10. View largeDownload slide A 28-year-old woman, the same patient from Figures 1 and 7. (A, C) Preoperative and (B, D) 2-year postoperative views of her left thigh. Figure 10. View largeDownload slide A 28-year-old woman, the same patient from Figures 1 and 7. (A, C) Preoperative and (B, D) 2-year postoperative views of her left thigh. Figure 11. View largeDownload slide A 28-year-old woman, the same patient from Figures 1, 7, and 10. (A, C) Preoperative and (B, D) 2-year postoperative views of her right thigh. Figure 11. View largeDownload slide A 28-year-old woman, the same patient from Figures 1, 7, and 10. (A, C) Preoperative and (B, D) 2-year postoperative views of her right thigh. Figure 12. View largeDownload slide A 35-year-old woman with cellulite of the thighs. (A, C) Preoperative and (B, D) postoperative views at 32 months. (E) Intraoperative views demonstrating superficial liposuction. (F) Pinch test confirming adequate release of skin tethering. (G) Micropore and a compression garment are applied (H) to reduce postoperative edema and maintain grafted fat in place. Figure 12. View largeDownload slide A 35-year-old woman with cellulite of the thighs. (A, C) Preoperative and (B, D) postoperative views at 32 months. (E) Intraoperative views demonstrating superficial liposuction. (F) Pinch test confirming adequate release of skin tethering. (G) Micropore and a compression garment are applied (H) to reduce postoperative edema and maintain grafted fat in place. Figure 13. View largeDownload slide A 46-year-old woman with severe cellulite of the thighs. (A) Preoperative and (B) 3-year postoperative photographs of her right thigh. Figure 13. View largeDownload slide A 46-year-old woman with severe cellulite of the thighs. (A) Preoperative and (B) 3-year postoperative photographs of her right thigh. Figure 14. View largeDownload slide A 32-year-old woman with severe cellulite of the thighs. (A, C) Preoperative and (B, D) 30-month postoperative views. Figure 14. View largeDownload slide A 32-year-old woman with severe cellulite of the thighs. (A, C) Preoperative and (B, D) 30-month postoperative views. DISCUSSION Cellulite is a topographical skin alteration that is almost universally present in postpubertal women and is defined as a metabolic and structural disorder localized to the subcutaneous tissue, causing changes in body contour. Evaluation of the severity of cellulite can be performed through anthropometric measurements, photography, bioelectric impedance, thermography, Doppler flowmetry, high-resolution 2-dimensional ultrasonography, magnetic resonance imaging (MRI), and skin biopsy with histopathological examination.34-38 The subcutaneous adipose tissue is composed of two layers: the first, which is more superficial, contains compacted globules of fat and a large quantity of fibrous septa; the second is the deeper fat layer, which contains irregular amorphous fat pads. Cellulite presents itself at the interface of the dermis with the superficial subcutaneous fat and possesses a complex anatomical structure. The protuberances and skin depressions related to weight gain are formed in the deeper adipose layer.39 Dimpling and irregular skin elevations are caused by the combination of tight septal bands as well as herniated adipose tissue.40,41 Besides these changes, adipose cells, which are contained inside the perimeter of this area, can expand with water resorption, leading to stretching of the connective tissue. This connective tissue may contract and become thickened, anchoring the skin with an inflexible length while the surrounding tissue continues to expand with weight and/or water gain. This expansion results in skin undulations and an orange-peel appearance.14 Compounding the problem, fibrosis occurs due to the proliferation of fibroblasts around adipose cells, and is associated with a worsening of peripheral circulation and metabolic failure in surrounding normal tissue. This in turn worsens the metabolic failure in adipose tissue and leads to advanced fibrosis in surrounding tissues.42-45 Numerous factors may play a role in the appearance of cellulite. Hormonal alterations seem to be very important, especially during adolescence. Estrogen stimulates fibroblast proliferation; increases interstitial pressure, leading to edema; alters collagen, leading to the formation of septa in the connective tissue; and stimulates lipogenesis. Risk factors include female sex, white ethnicity, and biotype (ie, body fat distribution). Latina women are found to have more cellulite in the hips, whereas women of Northern European origin tend to have more abdominal cellulite. Aging leads to a reduction of skin thickness and a decrease in elasticity, exacerbating cellulite topography, and eventually turning the disease almost immune to multiple treatment methods.5 Multiple structural alterations occur in the dermis. Deficient microcirculation, production of the vasodilating protein hormone adiponectin by subcutaneous tissue, as well as changes to adipocytes, are factors that lead to these alterations.44 These changes may be associated with chronic venous insufficiency, sharing signs and symptoms such as telangiectasias, microhemorrhages, paresthesias, pain on palpation, and a decrease of local skin temperature.1 Emotional disorders, including acute stressful situations, and medications, such as exogenous estrogens, antihistamines, and beta blockers, may lead to the formation of cellulite through an increase in lipogenesis. Elevated prolactin and insulin levels, as well as a decrease in venous return due to the enlarged uterus with resultant pressure on the inferior vena cava, seen in pregnancy, may also exacerbate cellulite. Numerous treatment methods are currently utilized for cellulite, with variable results, although most have no substantial evidence for efficacy.45 These unpredictable results may be related to the physiological and biochemical differences between normal subcutaneous tissue and the fatty tissue found in areas of cellulite.5 Treatment must be accompanied by the control of predisposing factors, including a well-balanced diet (low in carbohydrates), exercise, and preferably the use of nonhormonal contraceptive methods. Most patients in our series were between 24 and 36 years of age. Although many patients do not have severe resting cellulite, most complained of the increased appearance of cellulite and skin dimpling when sitting or crossing their legs, which may hinder their ability to wear a skirt, for example. Posttreatment, common comments such as “being able to wear a bikini” or “I no longer need to wear tights” are illustrative of subjective but important improvements in the patient’s self-esteem and overall well being. All of our patients were white with diets rich in carbohydrates and fats, and had a generally high salt intake, leading to fluid retention, with adipose cell edema and subsequent worsening of cellulite. Patients with a diet poor in fiber have an increased incidence of constipation, leading to an increase in peripheral vascular resistance, venous stasis, and increased capillary permeability, all of which can worsen cellulite. Therefore, all patients were instructed to maintain follow up with a nutritionist in the posttreatment period to help maintain a balanced diet with adequate levels of proteins, fat, and carbohydrates. Patients were also recommended to maintain a minimum of 150 minutes of moderate physical activity per week, as per American Heart Association (AHA) guidelines.46 A sedentary lifestyle leads to decreased muscle mass and greater muscle flaccidity, with a greater proportion of fatty tissue, worsening cellulite. Although cellulite is not specific to patients who are overweight or obese, weight gain may exacerbate the condition. Histologically, weight loss leads to a retraction of fat globules from within the dermis back into the subcutaneous layer.47 In a study of patients who lost significant amounts of weight through bariatric surgery, medication, or diet and lifestyle modifications, most patients had an improvement in cellulite, although some patients paradoxically were found to have a worsening of their condition. According to the authors, some patients had worsening of cellulite due to irreversible alterations in dermal and subcutaneous architecture. Tight clothing, high heels, and prolonged periods of time spent in the same position lead to venous stasis and possible worsening of cellulite. Smoking leads to changes in microcirculation and decreased tissue oxygen levels, as well as increased free radical formation. Exaggerated alcohol intake increases lipogenesis, also exacerbating cellulite.1 The procedure we describe here is different from previously published subcision techniques, in which only small, localized dimples or retractions are treated.48 We include wide areas of undermining and release of fibrous septa with a cannula and subsequent fat grafting for smooth structural support of the subcutaneous tissue. One of the advantages of our technique compared to traditional subcision is that larger areas can be treated than with other previously described subcision techniques, although we acknowledge that techniques that are potentially less operator dependent, such as laser lipolysis, may be easier to learn, with the additional benefit of yielding more skin retraction, but with the need for a high investment for device purchase or lease. Because liposuction may be less traumatic to blood vessels compared to the cutting of the reticular dermis performed during subcision,23 we feel that the blood supply to the overlying skin remains more robust, decreasing the risk of skin necrosis, especially considering the very extensive undermining we perform. Additionally, we believe that the improvement in cellulite from our technique derives not only from the release of septa, as in traditional subcision, but also from the fat grafting,49 which introduces adipose-derived stem cells that may help improve the local subcutaneous tissue and skin quality, as has been shown in multiple studies with fat grafting for scars, ulcers, and burns. The grafted fat also acts as a scaffold, around which the subcutaneous tissue rearranges; the sustained long-term results from our series seem to corroborate this hypothesis. Limitations The limitations of our study include the subjective nature of the cosmetic outcome evaluation and our study being a retrospective case series. In addition to the main author, three plastic surgeons from our division also evaluated the pretreatment and posttreatment photographs. Additionally, as is well known, it should be noted that superficial liposuction is a more advanced technique, with the risk of leaving significant irregularities and skin ischemia/necrosis if performed by an unexperienced surgeon. This has been incorporated into the training of our division’s residents, who are first taught traditional, deep liposuction, before being allowed to perform superficial liposuction. CONCLUSIONS During the last 26 years, we have utilized a combination of superficial liposuction and fat grafting to treat deformities caused by cellulite, and we have obtained safe, predictable, and reproducible results. The major advantages of this method are a high level of patient satisfaction, sustained results after long-term follow up, and a low incidence of surgical revision and posttreatment complications. Supplementary Material This article contains supplementary material located online at www.aestheticsurgeryjournal.com. Disclosures The authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article. Funding The authors received no financial support for the research, authorship, and publication of this article. REFERENCES 1. Rossi AB, Vergnanini AL. Cellulite: a review. J Eur Acad Dermatol Venereol . 2000; 14( 4): 251- 262. Google Scholar CrossRef Search ADS PubMed  2. Draelos ZD, Marenus KD. Cellulite. Etiology and purported treatment. Dermatol Surg . 1997; 23( 12): 1177- 1181. Google Scholar CrossRef Search ADS PubMed  3. Rosenbaum M, Prieto V, Hellmer Jet al.   An exploratory investigation of the morphology and biochemistry of cellulite. Plast Reconstr Surg . 1998; 101( 7): 1934- 1939. Google Scholar CrossRef Search ADS PubMed  4. Katz B, McBean J, Cheung JS. The new laser liposuction for men. Dermatol Ther . 2007; 20( 6): 448- 451. Google Scholar CrossRef Search ADS PubMed  5. Khan MH, Victor F, Rao B, Sadick NS. Treatment of cellulite: Part II. Advances and controversies. J Am Acad Dermatol . 2010; 62( 3): 373- 384; quiz 385. Google Scholar CrossRef Search ADS PubMed  6. Rawlings AV. Cellulite and its treatment. Int J Cosmet Sci . 2006; 28( 3): 175- 190. Google Scholar CrossRef Search ADS PubMed  7. Herman A, Herman AP. Caffeine’s mechanisms of action and its cosmetic use. Skin Pharmacol Physiol . 2013; 26( 1): 8- 14. Google Scholar CrossRef Search ADS PubMed  8. Schonvvetter B, Soares JL, Bagatin E. Longitudinal evaluation of manual lymphatic drainage for the treatment of gynoid lipodystrophy. An Bras Dermatol . 2014; 89( 5): 712- 718. Google Scholar CrossRef Search ADS PubMed  9. Goldberg DJ, Fazeli A, Berlin AL. Clinical, laboratory, and MRI analysis of cellulite treatment with a unipolar radiofrequency device. Dermatol Surg . 2008; 34( 2): 204- 209; discussion 209. Google Scholar CrossRef Search ADS PubMed  10. Wanitphakdeedecha R, Manuskiatti W. Treatment of cellulite with a bipolar radiofrequency, infrared heat, and pulsatile suction device: a pilot study. J Cosmet Dermatol . 2006; 5( 4): 284- 288. Google Scholar CrossRef Search ADS PubMed  11. Kulick MI. Evaluation of a noninvasive, dual-wavelength laser-suction and massage device for the regional treatment of cellulite. Plast Reconstr Surg . 2010; 125( 6): 1788- 1796. Google Scholar CrossRef Search ADS PubMed  12. Goldman A, Gotkin RH. Laser-assisted liposuction. Clin Plast Surg . 2009; 36( 2): 241- 253, vii; discussion 255. Google Scholar CrossRef Search ADS PubMed  13. Goldman A, Schavelzon D, Blugerman G. Laser lipolysis: liposuction using Nd:YAG laser. Rev Soc Bras Cir Plast . 2002; 17: 17- 26. 14. Ichikawa K, Tanino R, Wakaki M. Histologic and photonic evaluation of a pulsed Nd:YAG laser for ablation of subcutaneous adipose tissue. Tokai J Exp Clin Med . 2006; 31( 4): 136- 140. Google Scholar PubMed  15. Goldman A. Submental Nd:Yag laser-assisted liposuction. Lasers Surg Med . 2006; 38( 3): 181- 184. Google Scholar CrossRef Search ADS PubMed  16. DiBernardo BE, Reyes J. Evaluation of skin tightening after laser-assisted liposuction. Aesthet Surg J . 2009; 29( 5): 400- 407. Google Scholar CrossRef Search ADS PubMed  17. Rose PT, Morgan M. Histological changes associated with mesotherapy for fat dissolution. J Cosmet Laser Ther . 2005; 7( 1): 17- 19. Google Scholar CrossRef Search ADS PubMed  18. Duncan DI, Palmer M. Fat reduction using phosphatidylcholine/sodium deoxycholate injections: standard of practice. Aesthetic Plast Surg . 2008; 32( 6): 858- 872. Google Scholar CrossRef Search ADS PubMed  19. Pianez LR, Custódio FS, Guidi RM, de Freitas JN, Sant’Ana E. Effectiveness of carboxytherapy in the treatment of cellulite in healthy women: a pilot study. Clin Cosmet Investig Dermatol . 2016; 9: 183- 190. Google Scholar CrossRef Search ADS PubMed  20. Orentreich DS, Orentreich N. Subcutaneous incisionless (subcision) surgery for the correction of depressed scars and wrinkles. Dermatol Surg . 1995; 21( 6): 543- 549. Google Scholar CrossRef Search ADS PubMed  21. Pereira O, Bins-Ely J, Paulo EM, Lee KH. Treatment of skin depression with combined upward suture traction and percutaneous subcision. Plast Reconstr Surg Glob Open . 2015; 3( 10): e534. Google Scholar CrossRef Search ADS PubMed  22. Sasaki GH. Comparison of results of wire subcision performed alone, with fills, and/or with adjacent surgical procedures. Aesthet Surg J . 2008; 28( 6): 619- 626. Google Scholar CrossRef Search ADS PubMed  23. Friedmann DP, Vick GL, Mishra V. Cellulite: a review with a focus on subcision. Clin Cosmet Investig Dermatol . 2017; 10: 17- 23. Google Scholar CrossRef Search ADS PubMed  24. Hexsel DM, Mazzuco R. Subcision: a treatment for cellulite. Int J Dermatol . 2000; 39( 7): 539- 544. Google Scholar CrossRef Search ADS PubMed  25. Kaminer MS, Coleman WP3rd, Weiss RA, Robinson DM, Grossman J. 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( 10): 1240- 1248. Google Scholar CrossRef Search ADS PubMed  26. Illouz YG. Body contouring by lipolysis: a 5-year experience with over 3000 cases. Plast Reconstr Surg . 1983; 72( 5): 591- 597. Google Scholar CrossRef Search ADS PubMed  27. Shridharani SM, Broyles JM, Matarasso A. Liposuction devices: technology update. Med Devices (Auckl) . 2014; 7: 241- 251. Google Scholar PubMed  28. Klein JA. Tumescent technique for liposuction surgery. J Am Acad Cosmet Surg . 1987; 4: 263- 267. Google Scholar CrossRef Search ADS   29. Avendaño-Valenzuela G, Guerrerosantos J. Contouring the gluteal region with tumescent liposculpture. Aesthet Surg J . 2011; 31( 2): 200- 213. Google Scholar CrossRef Search ADS PubMed  30. Triana L, Triana C, Barbato C, Zambrano M. Liposuction: 25 years of experience in 26,259 patients using different devices. Aesthet Surg J . 2009; 29( 6): 509- 512. Google Scholar CrossRef Search ADS PubMed  31. Bolivar de Souza Pinto E, Indaburo PE, Muniz Ada Cet al.   Superficial liposuction. Body contouring. Clin Plast Surg . 1996; 23( 4): 529- 548; discussion 549. Google Scholar PubMed  32. Gasparotti M. Superficial liposuction: a new application of the technique for aged and flaccid skin. Aesthetic Plast Surg . 1992; 16( 2): 141- 153. Google Scholar CrossRef Search ADS PubMed  33. Khan MH, Victor F, Rao B, Sadick NS. Treatment of cellulite: part I. Pathophysiology. J Am Acad Dermatol . 2010; 62( 3): 361- 370; quiz 371-372. Google Scholar CrossRef Search ADS PubMed  34. Sadick NS. Overview of ultrasound-assisted liposuction, and body contouring with cellulite reduction. Semin Cutan Med Surg . 2009; 28( 4): 250- 256. Google Scholar CrossRef Search ADS PubMed  35. Quatresooz P, Xhauflaire-Uhoda E, Piérard-Franchimont C, Piérard GE. Cellulite histopathology and related mechanobiology. Int J Cosmet Sci . 2006; 28( 3): 207- 210. Google Scholar CrossRef Search ADS PubMed  36. Smalls LK, Hicks M, Passeretti Det al.   Effect of weight loss on cellulite: gynoid lypodystrophy. Plast Reconstr Surg . 2006; 118( 2): 510- 516. Google Scholar CrossRef Search ADS PubMed  37. Bielfeldt S, Buttgereit P, Brandt M, Springmann G, Wilhelm KP. Non-invasive evaluation techniques to quantify the efficacy of cosmetic anti-cellulite products. Skin Res Technol . 2008; 14( 3): 336- 346. Google Scholar CrossRef Search ADS PubMed  38. Hexsel DM, Dal’forno T, Hexsel CL. A validated photonumeric cellulite severity scale. J Eur Acad Dermatol Venereol . 2009; 23( 5): 523- 528. Google Scholar CrossRef Search ADS PubMed  39. Markman B, Barton FEJr. Anatomy of the subcutaneous tissue of the trunk and lower extremity. Plast Reconstr Surg . 1987; 80( 2): 248- 254. Google Scholar CrossRef Search ADS PubMed  40. Omi T, Sato S, Kawana S. Ultrastructural assessment of cellulite morphology: clues to a therapeutic strategy? Laser Ther . 2013; 22( 2): 131- 136. Google Scholar CrossRef Search ADS PubMed  41. DiBernardo BE, Sasaki GH, Katz BE, Hunstad JP, Petti C, Burns AJ. A multicenter study for cellulite treatment using a 1440-nm Nd:YAG wavelength laser with side-firing fiber. Aesthet Surg J . 2016; 36( 3): 335- 343. Google Scholar CrossRef Search ADS PubMed  42. Rossi AM, Katz BE. A modern approach to the treatment of cellulite. Dermatol Clin . 2014; 32( 1): 51- 59. Google Scholar CrossRef Search ADS PubMed  43. Zerini I, Sisti A, Cuomo Ret al.   Cellulite treatment: a comprehensive literature review. J Cosmet Dermatol . 2015; 14( 3): 224- 240. Google Scholar CrossRef Search ADS PubMed  44. Emanuele E, Minoretti P, Altabas K, Gaeta E, Altabas V. Adiponectin expression in subcutaneous adipose tissue is reduced in women with cellulite. Int J Dermatol . 2011; 50( 4): 412- 416. Google Scholar CrossRef Search ADS PubMed  45. Luebberding S, Krueger N, Sadick NS. Cellulite: an evidence-based review. Am J Clin Dermatol . 2015; 16( 4): 243- 256. Google Scholar CrossRef Search ADS PubMed  46. Haskell, W. L., Lee, I-M., Pate, R. R., Powell, K. E., Blair, S. N., Franklin, B. A., ... Bauman, A. (2007). Physical activity and public health: Updated recommendation for adults from the American College of Sports Medicine and the American Heart Association. Circulation, 116(9), 1081-1093. 47. Smalls LK, Lee CY, Whitestone J, Kitzmiller WJ, Wickett RR, Visscher MO. Quantitative model of cellulite: three-dimensional skin surface topography, biophysical characterization, and relationship to human perception. J Cosmet Sci . 2005; 56( 2): 105- 120. Google Scholar PubMed  48. Lau YS, Offer GJ. Treatment of soft tissue contour defects by a combination of surgical subcision with a Beaver tympanoplasty blade and autologous fat grafting. Aesthetic Plast Surg . 2010; 34( 3): 406- 407. Google Scholar CrossRef Search ADS PubMed  49. Covarrubias P, Cárdenas-Camarena L, Guerrerosantos Jet al.   Evaluation of the histologic changes in the fat-grafted facial skin: clinical trial. Aesthetic Plast Surg . 2013; 37( 4): 778- 783. Google Scholar CrossRef Search ADS PubMed  © 2018 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Aesthetic Surgery Journal Oxford University Press

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Abstract

Abstract Background Cellulite is one of the most common skin and subcutaneous tissue conditions, affecting predominantly the thighs and hips in postadolescent women. Its etiology is not well defined, and multiple available treatments show variable efficacy. Objectives To describe a technique for treatment of cellulite of the gluteal region, thighs, and hips through superficial liposuction utilizing a special cannula, combined with subcutaneous autologous fat grafting. Methods A retrospective review was performed of patients treated over 26 years at the Hospital São Lucas, Pontifical Catholic University of Rio Grande do Sul, Porto Alegre, Brazil. Patients underwent pretreatment evaluation as to the extent of their cellulite, and pretreatment and posttreatment photographs were obtained for visual evaluation of the results. Results Procedures were performed on 126 patients: 121 (96%) women and 5 (4%) men. The majority considered their results good or excellent. The complication rate was low, with the most common complications being ecchymosis, contour irregularities, partial recurrence of cellulite, seroma, and numbness. Conclusions We describe an effective method for the treatment of cellulite. Whereas subcision techniques utilize a needle or microblade to cut fibrous septa, we utilize a special cannula; larger areas can be treated than with subcision. Fat grafting is utilized to correct depressions and improve skin quality, which are added benefits compared to traditional subcision. Considering the multiple available cellulite treatments and their limitations, and the high patient satisfaction rate we achieved, with a low recurrence and complication rate, this technique can be a safe and effective option for patients with cellulite. Level of Evidence: 4 Cellulite, also known as gynecoid lipodystrophy, edematous fibrosclerotic panniculopathy, or local lipodystrophy, is a local anatomical and metabolic disturbance of the subcutaneous tissue that leads to changes in body contour, causing an unaesthetic appearance of the skin known as either “orange peel” or “cottage cheese” deformity (Figure 1). The exact etiology and optimal diagnostic methods for cellulite are not well defined. An accumulation of fat occurs in the gluteal region, thighs, and hips during puberty. The skin acquires changes that vary from an orange-peel appearance to undulations, with transverse dimpling, nodularity, and cutaneous folds. Cellulite and lipodystrophy are commonly found concurrently, especially in the gluteal region and thighs, causing superficial skin irregularities.1 Figure 1. View largeDownload slide A 28-year-old woman with severe cellulite of the thighs (A, C) at rest and (B, D) with manual compression (A and B, right side; C and D, left side). Figure 1. View largeDownload slide A 28-year-old woman with severe cellulite of the thighs (A, C) at rest and (B, D) with manual compression (A and B, right side; C and D, left side). Despite the nuisance to patients, cellulite is not considered a disease and does not increase morbidity or mortality. Approximately 85% to 90% of postadolescent women are affected by cellulite.2,3 Men can also be affected, although in a much smaller proportion due to the smaller quantity of adipocytes in male compared to female fatty tissue.4 Many patients opt for minimally or noninvasive treatment methods to attenuate cellulite. Creams and Topical Treatments Among the active ingredients utilized in cellulite creams are vegetable extracts, such as ginkgo biloba, which helps stimulate the microcirculation, and retinol, which stimulates collagen synthesis, both of which demonstrate a clinically significant reduction in cellulite when applied topically.5 Xanthines (such as caffeine), herbal extracts, retinoic acid receptors (RAR), and peroxisome proliferator-activated receptor (PPAR) inhibitors are all topical treatments for cellulite that decrease adipogenesis, increase thermogenesis, enhance collagen synthesis, and improve microcirculation.6,7 Lymphatic Drainage Controversy persists as to the efficacy of local massage or lymphatic drainage in improving cellulite. On one hand, removal of interstitial and lymphatic fluid is accelerated, decreasing the appearance of cellulite2; however, a recent clinical trial showed no benefit in the improvement of cellulite, despite improvements in the patient’s quality of life.8 Endermologie ESI (LPG Systems, Valence, France) is a nonpharmacological method that employs mechanical means to mobilize subcutaneous fat from affected areas, although with high cost and a paucity of evidence for improvement of cellulite. Proponents of the system advocate that the massage and suction improve the disorganized subcutaneous fat and accelerate lymphatic drainage.5 Ultrasound Through its thermal and vasodilatory effects, ultrasound induces lipolysis and a reduction in localized fat. Lysis of adipocytes is induced by cavitation and thermal damage. Although ultrasound can be a useful adjuvant therapy when utilized alongside other therapies for cellulite, its efficacy as a sole method of treatment has not been proven. Additionally, it is unknown whether the ultrasound-induced alterations in the cellular architecture of cellulite are long lasting.5 Radiofrequency Radiofrequency (RF) also shows positive cosmetic results. RF application has a goal of maintaining a temperature at the epidermal level between 40°C and 42°C. Results have been shown to last at least 6 months.9 Bipolar RF systems are based on heat generation; the temperature reached is sufficient to cause thermal damage to the surrounding adipose tissue and connective tissue septa. The combination of bipolar RF, infrared heat, and pulsatile suction into one system has been demonstrated to decrease body circumference and improve the appearance of cellulite.10 Laser Lipolysis Treatment of cellulite with a 1440-nm laser has shown clinical improvement and induction of collagen neoformation.11-13 Histological studies demonstrate the laser’s effects, including adipocyte rupture, reorganization of the reticular dermis, and coagulation of collagen and adipose tissue.14-16 Laser-assisted liposuction with wavelengths between 1064 nm and 1320 nm is frequently utilized to treat cellulite and leads to skin tightening. Lysis of adipocyte membranes by laser-assisted energy reduces the traumatic removal of fat and increases the coagulation of blood vessels, leading to decreased hematomas and ecchymosis and a quicker recovery. Mesotherapy Mesotherapy consists of the injection of multiple substances into the subcutaneous tissue to dissolve fat, but studies show inconsistent results with this treatment. Multiple different substances have been proposed, including xanthines such as caffeine, aminophylline, and theophylline, which lead to lipolysis through the inhibition of phosphodiesterase (PDE) and an increase in the levels of cyclic adenosine monophosphate (cAMP). Hormones, enzymes, herbal extracts, vitamins, and minerals are also utilized. In addition, phosphatidylcholine (an extract of soy lecithin) is commonly utilized, because of its lipolytic effects secondary to beta-adrenergic receptor activation. After the subcutaneous injection of phosphatidylcholine, lobular panniculitis, fat necrosis, and serous lipoatrophy are seen.17 The use of mesotherapy has been limited due to the lack of standardized treatment regimens,18 erratic results, and the risk of adverse local effects, such as edema, ecchymosis, subcutaneous nodules, infection, urticarial reactions, and skin irregularities.9 Carboxytherapy Carboxytherapy involves the injection of carbon dioxide into the subcutaneous tissue, with the goal of affecting the adipose tissue and circulation. Its purported mechanism of action is through an increase in capillary blood flow induced by hypercapnia and a decrease in cutaneous oxygen consumption (right-hand shift of the oxygen dissociation curve, or Bohr effect). This may help explain its positive effects on lipolysis.19 Subcision Originally described for the treatment of acne scars and small areas of skin dimpling,20 subcision is a technique in which a needle is inserted into the subcutaneous tissue; when its deepest point has been reached (approximately 1.5-2 cm deep), the needle is redirected parallel/tangential to the epidermis and swept, with the goal of cutting fibrous septa at the subdermal level (reticular dermis), to improve the area affected by cellulite and depressed or retracted scars.21,22 Improvement in the appearance of affected areas may also be due, in part, to the redistribution of tension forces in the subcutaneous tissue.23 Pain and ecchymosis may occur posttreatment, but results are satisfactory in a majority of patients.24 Recently, a new tissue stabilized-guided subcision system (Cellfina, Merz North America, Inc., Raleigh, NC) was FDA approved for long-term improvement in cellulite of the thighs and buttocks, with follow up at 3 years demonstrating consistent improvements in patient satisfaction (93% “satisfied” or “very satisfied” at 3 years compared to baseline) as well as the Cellulite Severity Scale and Physician Global Aesthetic Improvement Scores.25 Surgery Multiple advances in liposuction have improved results since its introduction by Illouz in the 1980s.26-30 The two most common methods of liposuction are conventional power-assisted liposuction, which decreases the deeper subcutaneous fat, and superficial liposuction, described by Bolivar de Souza Pinto et al31 and later by Gasparotti,32 close to the dermis, which releases subcutaneous fibrous septa. Tumescent infiltration, along with smaller cannula diameters, brought a new dimension, allowing for aspiration of large volumes of fat with greater precision. Ultrasound-assisted liposuction (Vaser, Solta Medical, Inc., Hayward, CA) demonstrates increased skin retraction and, when utilized with a cutting cannula (VaserSmooth), may be an effective treatment for areas of cellulite, with decreased blood loss compared to traditional liposuction.33 Although liposuction is an excellent method for improving body contour, some authors warn about a possible increase in skin irregularities after traditional liposuction. Therefore, conventional liposuction is not yet a standard treatment for cellulite. In part, this may be because the adipose tissue of cellulite is very superficial, with only a very thin overlying dermal layer.9 Liposuction performed too close to the skin surface can result in irregularities and a subsequent poor cosmetic result,9 especially when executed by untrained surgeons. However, when associated with autologous fat grafting of the undermined areas, which possess significant dead spaces, liposuction can improve results and offer excellent satisfaction to patients with cellulite. METHODS Patients were selected from our institution’s division of Plastic Surgery (Hospital São Lucas, Pontifical Catholic University of Rio Grande do Sul, Porto Alegre, Brazil) between January 1991 and April 2017. Patients were included if they met the following criteria: had cellulite of the thighs, buttocks, hips, or trochanteric region; were between the ages of 16 and 65 years old; and had a body mass index (BMI) between 21 and 35 kg/m2. Patients undergoing other treatment types for cellulite (with the exception of topical creams) were excluded. All patients were evaluated pretreatment for their body fat distribution (1 = thighs; 2 = buttocks; 3 = hips; and 4 = trochanteric regions) and their skin quality (1 = good and elastic; 2 = good and less elastic; and 3 = poor with flaccidity). Pretreatment and posttreatment standardized photographs were utilized for the visual assessment of results and were evaluated subjectively at 18 months posttreatment by the main author (C.U.) and 3 other plastic surgery staff members. The aesthetic result was evaluated with a scale (1 = excellent; 2 = good; and 3 = poor,) and patient satisfaction was evaluated with a simple questionnaire (1 = very satisfied; 2 = satisfied, but could be better; and 3 = dissatisfied), which was completed anonymously in our division’s outpatient clinic at the 18-month posttreatment visit (a blank copy of the questionnaire is available online as Supplementary Material at www.aestheticsurgeryjournal.com). All patients gave signed informed consent as per our institution’s protocol for surgery and publication. The study was conducted in accordance with the Declaration of Helsinki for research involving human subjects and approved by the Hospital São Lucas—Pontifical Catholic University of Rio Grande do Sul’s Institutional Review Board. Surgical Technique After the induction of general endotracheal or epidural anesthesia, depending on anesthesiologist and patient preference, the patient is positioned prone and all areas to be treated are prepped with chlorhexidine solution. Tumescent infiltration with 1:500,000 epinephrine and 0.9% normal saline solution is performed in the subcutaneous tissue of the thighs, buttocks, hips, and trochanteric regions. After 10 minutes to allow for adequate vasoconstriction, we harvest approximately 240 cc of fat from the hips or trochanteric areas (Figure 2) utilizing a 60 cc syringe attached to a 3 mm diameter cannula. No centrifugation or other processing of the fat is performed. Figure 2. View largeDownload slide Fat harvesting with a 60 cc syringe from the hips. Figure 2. View largeDownload slide Fat harvesting with a 60 cc syringe from the hips. In the second step, we perform a superficial liposuction utilizing a 3 mm cannula conceived by the main author with a flattened, wedge-shaped tip, similarly to a “duck beak” (Figure 3A). This cannula ruptures the fibrous connective ligaments, thereby releasing the skin from the subcutaneous tissue (Figure 3B). In contrast to a traditional subcision technique, in which a blade or needle sharply cuts through the subdermal level (potentially cutting blood vessels that supply the overlying skin), the maneuver we perform, utilizing superficial liposuction, limits damage to the subdermal blood vessels. We believe that this is important to keep the skin well vascularized, therefore avoiding the risk of necrosis that could potentially occur with extensive areas of undermining. We also feel that by keeping subdermal and subcutaneous blood vessels as intact as possible, subsequent take of grafted fat may be increased. A pinch test confirms the degree of skin looseness (Figure 4). Figure 3. View largeDownload slide (A) This cannula, which was developed by the main author, has a wedge-shaped tip, similar to a “duck beak” to release fibrous septa. (B) This schematic illustration shows rupture of the fibroelastic fibers tethering the skin to the fascia and subcutaneous tissue. Figure 3. View largeDownload slide (A) This cannula, which was developed by the main author, has a wedge-shaped tip, similar to a “duck beak” to release fibrous septa. (B) This schematic illustration shows rupture of the fibroelastic fibers tethering the skin to the fascia and subcutaneous tissue. Figure 4. View largeDownload slide Superficial liposuction has been performed in all areas of cellulite with a 3 mm “duck beak” cannula. (A) Pinch test of the thigh and (B) pinch test of the buttock both confirm an adequate degree of release of fibrous attachments to the skin. Figure 4. View largeDownload slide Superficial liposuction has been performed in all areas of cellulite with a 3 mm “duck beak” cannula. (A) Pinch test of the thigh and (B) pinch test of the buttock both confirm an adequate degree of release of fibrous attachments to the skin. The third step is to reinject a fine layer of the harvested fat subcutaneously. We gently distribute the grafted fat throughout all of the areas where we have performed surgical disruption of the connective tissue septa, maintaining a subcutaneous fat layer with approximate thickness of 5 mm to 8 mm (Figure 5). Figure 5. View largeDownload slide (A, B) The reserved aspirated fat is reinjected subcutaneously in all areas that were undermined, producing (C, D) an approximately 5 mm to 8 mm thick fat “scaffold” to fill the resultant dead space. Figure 5. View largeDownload slide (A, B) The reserved aspirated fat is reinjected subcutaneously in all areas that were undermined, producing (C, D) an approximately 5 mm to 8 mm thick fat “scaffold” to fill the resultant dead space. Finally, we apply 5 cm wide paper tape strips (Micropore, 3M Health Care, St. Paul, MN) to decrease edema and help maintain the grafted fat in place. This paper tape is kept in place for 3 weeks (Figure 6), and a compression garment is placed at the end of surgery. After 3 weeks, we remove the strips (Figure 7) and maintain the compression garment for an additional month. Figure 6. View largeDownload slide (A, B) A 5 cm wide Micropore paper tape is applied to all treated areas for 21 days to help decrease edema and keep the grafted fat in place. Figure 6. View largeDownload slide (A, B) A 5 cm wide Micropore paper tape is applied to all treated areas for 21 days to help decrease edema and keep the grafted fat in place. Figure 7. View largeDownload slide (A-E) A 28-year-old woman (the same patient from Figure 1) 3 weeks after paper tape strips were removed, showing marked improvement in cellulite, both at rest and under manual compression. Figure 7. View largeDownload slide (A-E) A 28-year-old woman (the same patient from Figure 1) 3 weeks after paper tape strips were removed, showing marked improvement in cellulite, both at rest and under manual compression. A video demonstrating this technique is available as Supplementary Material. Video 1. Watch now at https://academic.oup.com/asj/article-lookup/doi/10.1093/asj/sjy028 Video 1. Watch now at https://academic.oup.com/asj/article-lookup/doi/10.1093/asj/sjy028 Close RESULTS Procedures were performed on 126 patients over 26 years (Table 1). Women comprised 96% (121 patients) of patients, and men made up 4% (5 patients). All of the patients were white. The mean patient age was 29 years old (range, 17-58 years). The mean BMI was 27.1 kg/m2 (range, 24-33 kg/m2). The mean follow-up period was 38 months (range, 18-110 months). Regarding cellulite distribution, the hips were more frequently affected (88.8%), followed by the thighs (76.1%), buttocks (71.4%), and trochanteric region (53.1%). Nine patients (7%) required additional corrections due to skin irregularities, retractions, or partial recurrent cellulite. These corrections were performed under local anesthesia and sedation with additional liposuction and fat grafting (Figure 8). Table 1. Patient Characteristics: Age, Sex, Complications, and Results   Mean  Range  Age (years)  29  17-58  BMI (kg/m2)  27.1  24-33  Follow-up (months)  38  18-110    No. of patients  Percentage (%)  Number of patients  126  100  Sex   Female  121  96   Male  5  4  Race (White)  126  100  Complications   Temporary ecchymosis  12  9.5   Irregularities, retractions, or undulations  5  3.9   Partial recurrent cellulite  4  3.1   Seroma  2  1.5   Temporary numbness  2  1.5   Hematomas  0  0   Skin necrosis  0  0  Body fat distribution   Hips  112  88.8   Thighs  96  76.1   Buttocks  90  71.4   Trochanteric  67  53.1  Skin quality   Good and elastic  96  76.1   Good and less elastic  23  18.2   Poor with flaccidity  7  5.7  Aesthetic result   Excellent  22  17.4   Good  95  75.3   Bad  9  7.3  Patient satisfaction   Very satisfied  101  80.1   Satisfied but could be better  25  19.8   Dissatisfied  0  0  Follow up   18 months  126  100   24 months  68  54   5 years  43  34    Mean  Range  Age (years)  29  17-58  BMI (kg/m2)  27.1  24-33  Follow-up (months)  38  18-110    No. of patients  Percentage (%)  Number of patients  126  100  Sex   Female  121  96   Male  5  4  Race (White)  126  100  Complications   Temporary ecchymosis  12  9.5   Irregularities, retractions, or undulations  5  3.9   Partial recurrent cellulite  4  3.1   Seroma  2  1.5   Temporary numbness  2  1.5   Hematomas  0  0   Skin necrosis  0  0  Body fat distribution   Hips  112  88.8   Thighs  96  76.1   Buttocks  90  71.4   Trochanteric  67  53.1  Skin quality   Good and elastic  96  76.1   Good and less elastic  23  18.2   Poor with flaccidity  7  5.7  Aesthetic result   Excellent  22  17.4   Good  95  75.3   Bad  9  7.3  Patient satisfaction   Very satisfied  101  80.1   Satisfied but could be better  25  19.8   Dissatisfied  0  0  Follow up   18 months  126  100   24 months  68  54   5 years  43  34  BMI, body mass index. View Large Table 1. Patient Characteristics: Age, Sex, Complications, and Results   Mean  Range  Age (years)  29  17-58  BMI (kg/m2)  27.1  24-33  Follow-up (months)  38  18-110    No. of patients  Percentage (%)  Number of patients  126  100  Sex   Female  121  96   Male  5  4  Race (White)  126  100  Complications   Temporary ecchymosis  12  9.5   Irregularities, retractions, or undulations  5  3.9   Partial recurrent cellulite  4  3.1   Seroma  2  1.5   Temporary numbness  2  1.5   Hematomas  0  0   Skin necrosis  0  0  Body fat distribution   Hips  112  88.8   Thighs  96  76.1   Buttocks  90  71.4   Trochanteric  67  53.1  Skin quality   Good and elastic  96  76.1   Good and less elastic  23  18.2   Poor with flaccidity  7  5.7  Aesthetic result   Excellent  22  17.4   Good  95  75.3   Bad  9  7.3  Patient satisfaction   Very satisfied  101  80.1   Satisfied but could be better  25  19.8   Dissatisfied  0  0  Follow up   18 months  126  100   24 months  68  54   5 years  43  34    Mean  Range  Age (years)  29  17-58  BMI (kg/m2)  27.1  24-33  Follow-up (months)  38  18-110    No. of patients  Percentage (%)  Number of patients  126  100  Sex   Female  121  96   Male  5  4  Race (White)  126  100  Complications   Temporary ecchymosis  12  9.5   Irregularities, retractions, or undulations  5  3.9   Partial recurrent cellulite  4  3.1   Seroma  2  1.5   Temporary numbness  2  1.5   Hematomas  0  0   Skin necrosis  0  0  Body fat distribution   Hips  112  88.8   Thighs  96  76.1   Buttocks  90  71.4   Trochanteric  67  53.1  Skin quality   Good and elastic  96  76.1   Good and less elastic  23  18.2   Poor with flaccidity  7  5.7  Aesthetic result   Excellent  22  17.4   Good  95  75.3   Bad  9  7.3  Patient satisfaction   Very satisfied  101  80.1   Satisfied but could be better  25  19.8   Dissatisfied  0  0  Follow up   18 months  126  100   24 months  68  54   5 years  43  34  BMI, body mass index. View Large Figure 8. View largeDownload slide A 42-year-old female with cellulite treated by our approach. (A, C) Preoperative views and (B, D) 18-month postoperative views show some residual irregularities of the left lateral thigh. This was corrected by an additional 20 cc of fat grafting under local anesthesia. No further intervention was performed. Figure 8. View largeDownload slide A 42-year-old female with cellulite treated by our approach. (A, C) Preoperative views and (B, D) 18-month postoperative views show some residual irregularities of the left lateral thigh. This was corrected by an additional 20 cc of fat grafting under local anesthesia. No further intervention was performed. Ecchymosis was the most common complication (12 patients; 9.5%), lasting on average 3 to 4 weeks; patients were counseled that this would reabsorb with massage with creams and sunblock. There were 2 cases (1.5%) of small-volume seromas (15 cc and 10 cc), which were treated with simple aspiration at the 1-week posttreatment visit. Both of these seromas occurred in females of normal BMI. One of these cases had an identifiable cause, because the patient’s compression tape and garment were of insufficient length and thus did not compress the entire area of the thigh that had been treated (Figure 9). Figure 9. View largeDownload slide A 29-year-old female who underwent surgical treatment of cellulite of the thighs. (A) She presented with a seroma of the left lower thigh, in a noncompressed area, on postoperative day 7. (B) This resolved after two aspirations of 15 cc of serosanguinous fluid. This case occurred early in our experience and illustrates the importance of adequate postoperative compression. Figure 9. View largeDownload slide A 29-year-old female who underwent surgical treatment of cellulite of the thighs. (A) She presented with a seroma of the left lower thigh, in a noncompressed area, on postoperative day 7. (B) This resolved after two aspirations of 15 cc of serosanguinous fluid. This case occurred early in our experience and illustrates the importance of adequate postoperative compression. According to the evaluation of the standardized photographs at 18 months posttreatment by the main author and 3 members of our division’s plastic surgery staff, the overall results have been good to excellent, especially in young patients with good skin elasticity. Eight patients (6.3%) were over 50 years old, two (1.5%) of which developed posttreatment skin flaccidity that improved with manual lymphatic drainage twice a week for 45 days. The majority of the patients described being “very satisfied” with their results (Figures 10-14). Figure 10. View largeDownload slide A 28-year-old woman, the same patient from Figures 1 and 7. (A, C) Preoperative and (B, D) 2-year postoperative views of her left thigh. Figure 10. View largeDownload slide A 28-year-old woman, the same patient from Figures 1 and 7. (A, C) Preoperative and (B, D) 2-year postoperative views of her left thigh. Figure 11. View largeDownload slide A 28-year-old woman, the same patient from Figures 1, 7, and 10. (A, C) Preoperative and (B, D) 2-year postoperative views of her right thigh. Figure 11. View largeDownload slide A 28-year-old woman, the same patient from Figures 1, 7, and 10. (A, C) Preoperative and (B, D) 2-year postoperative views of her right thigh. Figure 12. View largeDownload slide A 35-year-old woman with cellulite of the thighs. (A, C) Preoperative and (B, D) postoperative views at 32 months. (E) Intraoperative views demonstrating superficial liposuction. (F) Pinch test confirming adequate release of skin tethering. (G) Micropore and a compression garment are applied (H) to reduce postoperative edema and maintain grafted fat in place. Figure 12. View largeDownload slide A 35-year-old woman with cellulite of the thighs. (A, C) Preoperative and (B, D) postoperative views at 32 months. (E) Intraoperative views demonstrating superficial liposuction. (F) Pinch test confirming adequate release of skin tethering. (G) Micropore and a compression garment are applied (H) to reduce postoperative edema and maintain grafted fat in place. Figure 13. View largeDownload slide A 46-year-old woman with severe cellulite of the thighs. (A) Preoperative and (B) 3-year postoperative photographs of her right thigh. Figure 13. View largeDownload slide A 46-year-old woman with severe cellulite of the thighs. (A) Preoperative and (B) 3-year postoperative photographs of her right thigh. Figure 14. View largeDownload slide A 32-year-old woman with severe cellulite of the thighs. (A, C) Preoperative and (B, D) 30-month postoperative views. Figure 14. View largeDownload slide A 32-year-old woman with severe cellulite of the thighs. (A, C) Preoperative and (B, D) 30-month postoperative views. DISCUSSION Cellulite is a topographical skin alteration that is almost universally present in postpubertal women and is defined as a metabolic and structural disorder localized to the subcutaneous tissue, causing changes in body contour. Evaluation of the severity of cellulite can be performed through anthropometric measurements, photography, bioelectric impedance, thermography, Doppler flowmetry, high-resolution 2-dimensional ultrasonography, magnetic resonance imaging (MRI), and skin biopsy with histopathological examination.34-38 The subcutaneous adipose tissue is composed of two layers: the first, which is more superficial, contains compacted globules of fat and a large quantity of fibrous septa; the second is the deeper fat layer, which contains irregular amorphous fat pads. Cellulite presents itself at the interface of the dermis with the superficial subcutaneous fat and possesses a complex anatomical structure. The protuberances and skin depressions related to weight gain are formed in the deeper adipose layer.39 Dimpling and irregular skin elevations are caused by the combination of tight septal bands as well as herniated adipose tissue.40,41 Besides these changes, adipose cells, which are contained inside the perimeter of this area, can expand with water resorption, leading to stretching of the connective tissue. This connective tissue may contract and become thickened, anchoring the skin with an inflexible length while the surrounding tissue continues to expand with weight and/or water gain. This expansion results in skin undulations and an orange-peel appearance.14 Compounding the problem, fibrosis occurs due to the proliferation of fibroblasts around adipose cells, and is associated with a worsening of peripheral circulation and metabolic failure in surrounding normal tissue. This in turn worsens the metabolic failure in adipose tissue and leads to advanced fibrosis in surrounding tissues.42-45 Numerous factors may play a role in the appearance of cellulite. Hormonal alterations seem to be very important, especially during adolescence. Estrogen stimulates fibroblast proliferation; increases interstitial pressure, leading to edema; alters collagen, leading to the formation of septa in the connective tissue; and stimulates lipogenesis. Risk factors include female sex, white ethnicity, and biotype (ie, body fat distribution). Latina women are found to have more cellulite in the hips, whereas women of Northern European origin tend to have more abdominal cellulite. Aging leads to a reduction of skin thickness and a decrease in elasticity, exacerbating cellulite topography, and eventually turning the disease almost immune to multiple treatment methods.5 Multiple structural alterations occur in the dermis. Deficient microcirculation, production of the vasodilating protein hormone adiponectin by subcutaneous tissue, as well as changes to adipocytes, are factors that lead to these alterations.44 These changes may be associated with chronic venous insufficiency, sharing signs and symptoms such as telangiectasias, microhemorrhages, paresthesias, pain on palpation, and a decrease of local skin temperature.1 Emotional disorders, including acute stressful situations, and medications, such as exogenous estrogens, antihistamines, and beta blockers, may lead to the formation of cellulite through an increase in lipogenesis. Elevated prolactin and insulin levels, as well as a decrease in venous return due to the enlarged uterus with resultant pressure on the inferior vena cava, seen in pregnancy, may also exacerbate cellulite. Numerous treatment methods are currently utilized for cellulite, with variable results, although most have no substantial evidence for efficacy.45 These unpredictable results may be related to the physiological and biochemical differences between normal subcutaneous tissue and the fatty tissue found in areas of cellulite.5 Treatment must be accompanied by the control of predisposing factors, including a well-balanced diet (low in carbohydrates), exercise, and preferably the use of nonhormonal contraceptive methods. Most patients in our series were between 24 and 36 years of age. Although many patients do not have severe resting cellulite, most complained of the increased appearance of cellulite and skin dimpling when sitting or crossing their legs, which may hinder their ability to wear a skirt, for example. Posttreatment, common comments such as “being able to wear a bikini” or “I no longer need to wear tights” are illustrative of subjective but important improvements in the patient’s self-esteem and overall well being. All of our patients were white with diets rich in carbohydrates and fats, and had a generally high salt intake, leading to fluid retention, with adipose cell edema and subsequent worsening of cellulite. Patients with a diet poor in fiber have an increased incidence of constipation, leading to an increase in peripheral vascular resistance, venous stasis, and increased capillary permeability, all of which can worsen cellulite. Therefore, all patients were instructed to maintain follow up with a nutritionist in the posttreatment period to help maintain a balanced diet with adequate levels of proteins, fat, and carbohydrates. Patients were also recommended to maintain a minimum of 150 minutes of moderate physical activity per week, as per American Heart Association (AHA) guidelines.46 A sedentary lifestyle leads to decreased muscle mass and greater muscle flaccidity, with a greater proportion of fatty tissue, worsening cellulite. Although cellulite is not specific to patients who are overweight or obese, weight gain may exacerbate the condition. Histologically, weight loss leads to a retraction of fat globules from within the dermis back into the subcutaneous layer.47 In a study of patients who lost significant amounts of weight through bariatric surgery, medication, or diet and lifestyle modifications, most patients had an improvement in cellulite, although some patients paradoxically were found to have a worsening of their condition. According to the authors, some patients had worsening of cellulite due to irreversible alterations in dermal and subcutaneous architecture. Tight clothing, high heels, and prolonged periods of time spent in the same position lead to venous stasis and possible worsening of cellulite. Smoking leads to changes in microcirculation and decreased tissue oxygen levels, as well as increased free radical formation. Exaggerated alcohol intake increases lipogenesis, also exacerbating cellulite.1 The procedure we describe here is different from previously published subcision techniques, in which only small, localized dimples or retractions are treated.48 We include wide areas of undermining and release of fibrous septa with a cannula and subsequent fat grafting for smooth structural support of the subcutaneous tissue. One of the advantages of our technique compared to traditional subcision is that larger areas can be treated than with other previously described subcision techniques, although we acknowledge that techniques that are potentially less operator dependent, such as laser lipolysis, may be easier to learn, with the additional benefit of yielding more skin retraction, but with the need for a high investment for device purchase or lease. Because liposuction may be less traumatic to blood vessels compared to the cutting of the reticular dermis performed during subcision,23 we feel that the blood supply to the overlying skin remains more robust, decreasing the risk of skin necrosis, especially considering the very extensive undermining we perform. Additionally, we believe that the improvement in cellulite from our technique derives not only from the release of septa, as in traditional subcision, but also from the fat grafting,49 which introduces adipose-derived stem cells that may help improve the local subcutaneous tissue and skin quality, as has been shown in multiple studies with fat grafting for scars, ulcers, and burns. The grafted fat also acts as a scaffold, around which the subcutaneous tissue rearranges; the sustained long-term results from our series seem to corroborate this hypothesis. Limitations The limitations of our study include the subjective nature of the cosmetic outcome evaluation and our study being a retrospective case series. In addition to the main author, three plastic surgeons from our division also evaluated the pretreatment and posttreatment photographs. Additionally, as is well known, it should be noted that superficial liposuction is a more advanced technique, with the risk of leaving significant irregularities and skin ischemia/necrosis if performed by an unexperienced surgeon. This has been incorporated into the training of our division’s residents, who are first taught traditional, deep liposuction, before being allowed to perform superficial liposuction. CONCLUSIONS During the last 26 years, we have utilized a combination of superficial liposuction and fat grafting to treat deformities caused by cellulite, and we have obtained safe, predictable, and reproducible results. The major advantages of this method are a high level of patient satisfaction, sustained results after long-term follow up, and a low incidence of surgical revision and posttreatment complications. Supplementary Material This article contains supplementary material located online at www.aestheticsurgeryjournal.com. Disclosures The authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article. Funding The authors received no financial support for the research, authorship, and publication of this article. REFERENCES 1. Rossi AB, Vergnanini AL. Cellulite: a review. J Eur Acad Dermatol Venereol . 2000; 14( 4): 251- 262. Google Scholar CrossRef Search ADS PubMed  2. Draelos ZD, Marenus KD. Cellulite. Etiology and purported treatment. Dermatol Surg . 1997; 23( 12): 1177- 1181. Google Scholar CrossRef Search ADS PubMed  3. Rosenbaum M, Prieto V, Hellmer Jet al.   An exploratory investigation of the morphology and biochemistry of cellulite. Plast Reconstr Surg . 1998; 101( 7): 1934- 1939. Google Scholar CrossRef Search ADS PubMed  4. Katz B, McBean J, Cheung JS. The new laser liposuction for men. Dermatol Ther . 2007; 20( 6): 448- 451. Google Scholar CrossRef Search ADS PubMed  5. Khan MH, Victor F, Rao B, Sadick NS. 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Aesthetic Plast Surg . 2010; 34( 3): 406- 407. Google Scholar CrossRef Search ADS PubMed  49. Covarrubias P, Cárdenas-Camarena L, Guerrerosantos Jet al.   Evaluation of the histologic changes in the fat-grafted facial skin: clinical trial. Aesthetic Plast Surg . 2013; 37( 4): 778- 783. Google Scholar CrossRef Search ADS PubMed  © 2018 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)

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Aesthetic Surgery JournalOxford University Press

Published: Feb 8, 2018

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