Accepted Manuscript: Cellulite: A Surgical Treatment Approach

Cellulite: A Surgical Treatment Approach
Carlos Oscar Uebel, MD, PhD; Pedro Salomao Piccinini, MD; Alessandra Martinelli, MD; Daniela
Feijó Aguiar, MD; and Renato Franz Matta Ramos, Md
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From the Plastic Surgery Division, Hospital São Lucas, Pontifical Catholic University of Rio
Grande do Sul (PUCRS), Porto Alegre, Brazil.
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Corresponding Author: Dr Carlos Oscar Uebel, Pontifical Catholic University of Rio Grande do
Sul, Division of Plastic Surgery – Rua Victor Hugo, 78 – Porto Alegre, RS, 90630-070 – Brazil
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E-mail: [email protected]
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Disclosures: The authors declared no potential conflicts of interest with respect to the
research, authorship, and publication of this article.
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Funding: The authors received no financial support for the research, authorship, and
publication of this article.
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Level of Evidence: 4 (Therapeutic)

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© 2018 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission:
[email protected]
Downloaded from https://academic.oup.com/asj/advance-article-abstract/doi/10.1093/asj/sjy028/4844025

by Mount Royal University user
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ABSTRACT
Background: Cellulite is one of the most common skin and subcutaneous tissue conditions,
affecting predominantly the thighs and hips in post-adolescent women. Its etiology is not well
defined, and multiple available treatments show variable efficacy.
Objective: 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.
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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.
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Patients underwent pretreatment evaluation as to the extent of their cellulite, and
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pretreatment and posttreatment photographs were obtained for visual evaluation of the
results.
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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
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cellulite, seroma, and numbness.

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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
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cannula; larger areas can be treated than with subcision. Fat grafting is utilized to correct
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depressions and improve skin quality, which are added benefits compared to traditional
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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.
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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
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either “orange peel” or “cottage cheese” deformity (Figure 1). The exact etiology and optimal
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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
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orange-peel appearance to undulations, with transverse dimpling, nodularity, and cutaneous
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folds. Cellulite and lipodystrophy are commonly found concurrently, especially in the gluteal
region and thighs, causing superficial skin irregularities.1
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Despite the nuisance to patients, cellulite is not considered a disease and does not
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increase morbidity or mortality. Approximately 85% to 90% of post-adolescent women are

affected by cellulite.2,3 Men can also be affected, although in a much smaller proportion due to
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the smaller quantity of adipocytes in male compared to female fatty tissue.4

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Many patients opt for minimally or noninvasive treatment methods to attenuate

cellulite.
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Creams and Topical Treatments

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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, retinoids, 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

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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
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Endermologie
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ESI® (LPG Systems, Valence, France) is a nonpharmacological method that employs mechanical
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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
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Ultrasound
Through its thermal and vasodilatory effects, ultrasound induces lipolysis and a reduction in
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localized fat. Lysis of adipocytes is induced by cavitation and thermal damage. Although
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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
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unknown whether the ultrasound-induced alterations in the cellular architecture of cellulite

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are long-lasting.5
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Radiofrequency
Radiofrequency (RF) also shows positive cosmetic results. RF application has a goal of
maintaining a temperature at the epidermal level between 40ºC and 42ºC. 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

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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
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membranes by laser-assisted energy reduces the traumatic removal of fat and increases the
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coagulation of blood vessels, leading to decreased hematomas and ecchymosis and a quicker
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recovery.
Mesotherapy
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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
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substances have been proposed, including xanthines such as caffeine, aminophylline, and
theophylline, which lead to lipolysis through the inhibition of phosphodiesterase (PDE) and an
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increase in the levels of cyclic adenosine monophosphate (cAMP). Hormones, enzymes, herbal
extracts, vitamins, and minerals are also utilized. In addition, phosphatidylcholine (an extract
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of soy lecithin) is commonly utilized, because of its lipolytic effects secondary to beta-
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adrenergic receptor activation. After the subcutaneous injection of phosphatidylcholine,

lobular panniculitis, fat necrosis, and serous lipoatrophy are seen.17 The use of mesotherapy
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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,
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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

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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
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retracted scars.21,22 Improvement in the appearance of affected areas may also be due, in part,
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to the redistribution of tension forces in the subcutaneous tissue.23 Pain and ecchymosis may
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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
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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”
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or “very satisfied” at 3 years compared to baseline) as well as the Cellulite Severity Scale and
Physician Global Aesthetic Improvement Scores.25
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Surgery
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Multiple advances in liposuction have improved results since its introduction by Illouz in the
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1980s.26-30 The two most common methods of liposuction are conventional power-assisted
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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
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releases subcutaneous fibrous septa. Tumescent infiltration, along with smaller cannula
diameters, brought a new dimension, allowing for aspiration of large volumes of fat with
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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

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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.
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METHODS
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Patients were selected from our institution’s division of Plastic Surgery (Hospital São Lucas,
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Pontifical Catholic University of Rio Grande do Sul, Porto Alegre, Brazil) between January 1991
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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
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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
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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
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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
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aesthetic result was evaluated with a scale (1=excellent; 2=good; and 3=poor,) and patient
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satisfaction was evaluated with a simple questionnaire (1=very satisfied; 2=satisfied, but could
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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
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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

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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.
In the second step, we perform a superficial liposuction utilizing a 3 mm cannula
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conceived by the main author with a flattened, wedge-shaped tip, similarly to a “duck beak”
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(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
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which a blade or needle sharply cuts through the subdermal level (potentially cutting blood
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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
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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
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increased. A pinch test confirms the degree of skin looseness (Figure 4).
The third step is to reinject a fine layer of the harvested fat subcutaneously. We gently
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distribute the grafted fat throughout all of the areas where we have performed surgical
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disruption of the connective tissue septa, maintaining a subcutaneous fat layer with
approximate thickness of 5 mm to 8 mm (Figure 5).
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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
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3 weeks, we remove the strips (Figure 7) and maintain the compression garment for an
additional month.
A video demonstrating this technique is available as Supplementary Material.
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.

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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).
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Ecchymosis was the most common complication (12 patients; 9.5%), lasting on average
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3-4 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
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treated with simple aspiration at the 1-week posttreatment visit. Both of these seromas
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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).
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According to the evaluation of the standardized photographs at 18 months
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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
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posttreatment skin flaccidity that improved with manual lymphatic drainage twice a week for
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45 days. The majority of the patients described being ‘’very satisfied’’ with their results
(Figures 10-14).
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DISCUSSION
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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 two-dimensional ultrasonography, magnetic resonance imaging (MRI), and skin
biopsy with histopathological examination.34-38

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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
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water resorption, leading to stretching of the connective tissue. This connective tissue may
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contract and become thickened, anchoring the skin with an inflexible length while the
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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
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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
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turn worsens the metabolic failure in adipose tissue and leads to advanced fibrosis in
surrounding tissues.42-45
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Numerous factors may play a role in the appearance of cellulite. Hormonal alterations
seem to be very important, especially during adolescence. Estrogen stimulates fibroblast
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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
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female sex, white ethnicity, and biotype (ie, body fat distribution). Latina women are found to
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have more cellulite in the hips, whereas women of Northern European origin tend to have
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more abdominal cellulite.
Aging leads to a reduction of skin thickness and a decrease in elasticity, exacerbating

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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

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Emotional disorders, including acute stressful situations, and medications, such as
exogenous estrogens, anti-histamines, 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
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related to the physiological and biochemical differences between normal subcutaneous tissue
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and the fatty tissue found in areas of cellulite.5
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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
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contraceptive methods.
Most patients in our series were between 24 and 36 years of age. Although many
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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
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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
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improvements in the patient’s self-esteem and overall well-being.

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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
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worsening of cellulite. Patients with a diet poor in fiber have an increased incidence of
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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
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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

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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
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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
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areas of undermining and release of fibrous septa with a cannula and subsequent fat grafting
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for smooth structural support of the subcutaneous tissue.
One of the advantages of our technique compared to traditional subcision is that

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larger areas can be treated than with other previously described subcision techniques,
although we acknowledge that techniques that are potentially less operator-dependent, such
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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
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dermis performed during subcision,23 we feel that the blood supply to the overlying skin
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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
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from our technique derives not only from the release of septa, as in traditional subcision, but
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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
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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.

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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
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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
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reproducible results. The major advantages of this method are a high level of patient
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satisfaction, sustained results after long-term follow-up, and a low incidence of surgical
revision and posttreatment complications.
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Supplementary Material
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This article contains supplementary material located online at

www.aestheticsurgeryjournal.com.
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26. Illouz YG. Body contouring by lipolysis: a 5-year experience with over 3000 cases. Plast
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Reconstr Surg. 1983;72(5):591-597.
27. Shridharani SM, Broyles JM, Matarasso A. Liposuction devices: technology update. Med
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Devices (Auckl). 2014;7:241-251.
28. Klein JA. Tumescent technique for liposuction surgery. J Am Acad Cosmet Surg. 1987;4:263-
267.
29. Avendaño-Valenzuela G, Guerrerosantos J. Contouring the gluteal region with tumescent

liposculpture. Aesthet Surg J. 2011;31(2):200-213.
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.

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31. Bolivar de Souza Pinto E, Indaburo PE, Muniz Ada C, et al. Superficial liposuction. Body
contouring. Clin Plast Surg. 1996;23(4):529-548; discussion 549.
32. Gasparotti M. Superficial liposuction: a new application of the technique for aged and
flaccid skin. Aesthetic Plast Surg. 1992;16(2):141-153.
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.
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34. Sadick NS. Overview of ultrasound-assisted liposuction, and body contouring with cellulite
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reduction. Semin Cutan Med Surg. 2009;28(4):250-256.
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35. Quatresooz P, Xhauflaire-Uhoda E, Piérard-Franchimont C, Piérard GE. Cellulite
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histopathology and related mechanobiology. Int J Cosmet Sci. 2006;28(3):207-210.
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lipodystrophy. Plast Reconstr Surg. 2006;118(2):510-516.
37. Bielfeldt S, Buttgereit P, Brandt M, et al. Non-invasive evaluation techniques to quantify

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the efficacy of cosmetic anti-cellulite products. Skin Res Technol. 2008;14(3):336-346.
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Acad Dermatol Venereol. 2009;23(5):523-528.

te
39. Markman B, Barton FE Jr. Anatomy of the subcutaneous tissue of the trunk and lower
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extremity. Plast Reconstr Surg. 1987;80(2):248-254.

ce
40. Omi T, Sato S, Kawana S. Ultrastructural assessment of cellulite morphology: clues to a

therapeutic strategy? Laser Ther. 2013;22(2):131-136.
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41. DiBernardo BE, Sasaki GH, Katz BE, et al. A multicenter study for cellulite treatment using a
1440-nm Nd:YAG wavelength laser with side-firing fiber. Aesthet Surg J. 2016;36(3):335-343.
42. Rossi AM, Katz BE. A modern approach to the treatment of cellulite. Dermatol Clin.
2014;32(1):51-59.
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Cosmet Dermatol. 2015;14(3):224-240.
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tissue is reduced in women with cellulite. Int J Dermatol. 2011;50(4):412-416.

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45. Luebberding S, Krueger N, Sadick NS. Cellulite: an evidence-based review. Am J Clin
Dermatol. 2015;16(4):243-256.
45. American Heart Association. American Heart Association Recommendations for Physical
Activity in Adults.
http://www.heart.org/HEARTORG/HealthyLiving/PhysicalActivity/FitnessBasics/American-
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Adults_UCM_307976_Article.jsp#.WeT1PEzOrX8. Accessed October 16, 2017.
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47. Smalls LK, Lee CY, Whitestone J, et al. Quantitative model of cellulite: three-dimensional
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skin surface topography, biophysical characterization, and relationship to human perception. J
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Cosmet Sci. 2005;56(2):105-120.
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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.
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49. Covarrubias P, Cárdenas-Camarena L, Guerrerosantos J, et al. Evaluation of the histologic
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changes in the fat-grafted facial skin: clinical trial. Aesthetic Plast Surg. 2013;37(4):778-783.
d
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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 (%)
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Number of patients 126 100
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Sex
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Female 121 96
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Male 5 4
Race (White) 126 100

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Complications
Temporary ecchymosis 12 9.5

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Irregularities, retractions, or undulations 5 3.9
Partial recurrent cellulite 4 3.1

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Seroma 2 1.5
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Temporary numbness 2 1.5

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Hematomas 0 0
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Skin necrosis 0 0
Body fat distribution

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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

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Poor with flaccidity 7 5.7
Aesthetic result
Excellent 22 17.4
Good 95 75.3
Bad 9 7.3
Patient satisfaction
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Very satisfied 101 80.1
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Satisfied but could be better 25 19.8
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Dissatisfied 0 0
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Follow-up
18 months 126 100

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24 months 68 54
5 years 43 34
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FIGURE LEGEND
Figure 1. 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 2. Fat harvesting with a 60 cc syringe from the hips.
t
ip
Figure 3. (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
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of the fibroelastic fibers tethering the skin to the fascia and subcutaneous tissue.
us
Figure 4. Superficial liposuction has been performed in all areas of cellulite with a 3 mm “duck
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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.
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Figure 5. (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
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resultant dead space.

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Figure 6. (A, B) 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.
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Figure 7. (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 8. 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

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thigh. This was corrected by an additional 20 cc of fat grafting under local anesthesia. No
further intervention was performed.
Figure 9. 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
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postoperative compression.
ip
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Figure 10. A 28-year-old woman, the same patient from Figures 1 and 7. (A, C) Preoperative
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and (B, D) 2-year postoperative views of her left thigh.
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Figure 11. 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.
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Figure 12. A 35-year-old woman with cellulite of the thighs. (A, C) Preoperative and (B, D)
te
postoperative views at 32 months. (E) Intraoperative views demonstrating superficial

liposuction. (F) Pinch test confirming adequate release of skin tethering. (G) Micropore and a
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compression garment are applied (H) to reduce postoperative edema and maintain grafted fat
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in place.
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Figure 13. 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. A 32-year-old woman with severe cellulite of the thighs. (A, C) Preoperative and (B,
D) 30-month postoperative views.

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Figure 1a.
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Cellulite: A Surgical Treatment Approach

Level of Evidence: 4 (Therapeutic)

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cellulite, seroma, and numbness.

Conclusions: We describe an effective method for the treatment of cellulite. Whereas

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increase morbidity or mortality. Approximately 85% to 90% of post-adolescent women are

the smaller quantity of adipocytes in male compared to female fatty tissue.4

Many patients opt for minimally or noninvasive treatment methods to attenuate

Creams and Topical Treatments

Xanthines (such as caffeine), herbal extracts, retinoids, and peroxisome proliferator-

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Controversy persists as to the efficacy of local massage or lymphatic drainage in improving

unknown whether the ultrasound-induced alterations in the cellular architecture of cellulite

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adrenergic receptor activation. After the subcutaneous injection of phosphatidylcholine,

urticarial reactions, and skin irregularities.9

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Ultrasound-assisted liposuction (Vaser, Solta Medical, Inc., Hayward, CA) demonstrates

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After the induction of general endotracheal or epidural anesthesia, depending on

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In the second step, we perform a superficial liposuction utilizing a 3 mm cannula

A video demonstrating this technique is available as Supplementary Material.

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Cellulite is a topographical skin alteration that is almost universally present in postpubertal

Evaluation of the severity of cellulite can be performed through anthropometric

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more abdominal cellulite.

Aging leads to a reduction of skin thickness and a decrease in elasticity, exacerbating

Multiple structural alterations occur in the dermis. Deficient microcirculation,

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improvements in the patient’s self-esteem and overall well-being.

constipation, leading to an increase in peripheral vascular resistance, venous stasis, and

instructed to maintain follow-up with a nutritionist in the posttreatment period to help

Patients were also recommended to maintain a minimum of 150 minutes of moderate

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One of the advantages of our technique compared to traditional subcision is that

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This article contains supplementary material located online at

3. Rosenbaum M, Prieto V, Hellmer J, et al. An exploratory investigation of the morphology and

Downloaded from https://academic.oup.com/asj/advance-article-abstract/doi/10.1093/asj/sjy028/4844025

for the regional treatment of cellulite. Plast Reconstr Surg. 2010;125(6):1788-1796.

15. Goldman A. Submental Nd:YAG laser-assisted liposuction. Lasers Surg Med.

Downloaded from https://academic.oup.com/asj/advance-article-abstract/doi/10.1093/asj/sjy028/4844025

follow-up. Dermatol Surg. 2017;43(10):1240-1248.

Reconstr Surg. 1983;72(5):591-597.

Devices (Auckl). 2014;7:241-251.

29. Avendaño-Valenzuela G, Guerrerosantos J. Contouring the gluteal region with tumescent

30. Triana L, Triana C, Barbato C, Zambrano M. Liposuction: 25 years of experience in 26,259

Downloaded from https://academic.oup.com/asj/advance-article-abstract/doi/10.1093/asj/sjy028/4844025

37. Bielfeldt S, Buttgereit P, Brandt M, et al. Non-invasive evaluation techniques to quantify

the efficacy of cosmetic anti-cellulite products. Skin Res Technol. 2008;14(3):336-346.

Acad Dermatol Venereol. 2009;23(5):523-528.

extremity. Plast Reconstr Surg. 1987;80(2):248-254.

40. Omi T, Sato S, Kawana S. Ultrastructural assessment of cellulite morphology: clues to a

44. Emanuele E, Minoretti P, Altabas K, et al. Adiponectin expression in subcutaneous adipose

Downloaded from https://academic.oup.com/asj/advance-article-abstract/doi/10.1093/asj/sjy028/4844025

Downloaded from https://academic.oup.com/asj/advance-article-abstract/doi/10.1093/asj/sjy028/4844025