Cellulite Treatments: Injectables and Other Options (Body Contouring II)
This is the full text of my column in the February 2026 issue of D&PS.
Can fat-dissolving injections and carboxytherapy help cellulite and swelling?
Injection lipolysis
Injection lipolysis places medication in the subcutaneous fat layer to disrupt adipocytes or promote fat breakdown. One formulation combines phosphatidylcholine (PPC) and deoxycholic acid (DC). It acts through cytolysis, disrupting cell-membrane phospholipids. DC is a bile acid with a detergent effect that is not specific to fat cells; treatment therefore depends on accurate placement within the intended fat layer.
Lipids released from disrupted adipocytes are processed into fatty acids and glycerol and cleared through local vascular and lymphatic pathways for further metabolism. Lymphatic drainage is an important part of this clearance process. If the treating clinician’s aftercare plan allows, appropriate activity or massage after treatment may help clear these breakdown products.
Injection approaches to lymphatic drainage
Some injection approaches focus on tissue drainage. Hyaluronidase breaks down hyaluronic acid in the interstitium, reducing viscosity and allowing fluid and dispersed material to move more readily. This provides a rationale for its use in selected treatments intended to improve local drainage, swelling and cellulite.
By hydrolyzing components of the tissue matrix, hyaluronidase can increase tissue permeability and help reduce edema. Mesotherapy formulations have combined PPC or DC with ingredients such as L-carnitine for fatty-acid metabolism, caffeine for lipase activity, and hyaluronidase for dispersion. The intended effects include fat reduction and improved drainage, with changes in circumference, surface irregularity and swelling.
Carboxytherapy
Carboxytherapy injects medical-grade carbon dioxide (CO₂) into the dermal or subcutaneous layer. Through the Bohr effect, increased local CO₂ shifts oxygen release from hemoglobin and is associated with capillary dilation. The resulting changes in blood flow and tissue metabolism may support collagen synthesis and repair.
Injected CO₂ diffuses rapidly and is cleared by the body; increased local circulation may also support lymphatic drainage. Carboxytherapy originated in vascular medicine as an approach to tissue oxygenation in venous and peripheral arterial disease. It was later adopted in aesthetics for skin firmness, localized fat and cellulite.
Small studies have reported improved cellulite grades after CO₂ treatment, with proposed effects on lipolysis and lymph drainage. Carboxytherapy has also been explored for postoperative lymphedema. Reports of reduced swelling in chronic lymphedema after cancer surgery suggest a possible role in addressing fluid stasis.
Effects and supporting evidence
Studies of injection lipolysis have reported reductions in localized subcutaneous fat. A 2019 paper, “Injection Lipolysis: A Systematic Review of Literature and Our Experience with a Combination of Phosphatidylcholine and Deoxycholate over a Period of 14 Years in 1269 Patients of Indian and South East Asian Origin,” described PPC–deoxycholate injections as an option for localized contour improvement, particularly in the face and smaller areas. Effects are generally smaller and slower than those of surgical liposuction, so realistic goals should be agreed with the patient.
A small 2016 pilot study, “Effectiveness of Carboxytherapy in the Treatment of Cellulite in Healthy Women,” reported improvement in cellulite. A 2023 Journal of Cosmetic Dermatology review, “An Overview of the Role of Carboxytherapy in Dermatology,” discussed its potential applications in skin aging, localized fat, cellulite, striae, scars and lymphedema, describing a broad range of uses and a generally favorable safety profile.
Figure 1. Mechanisms of major injectable approaches to nonsurgical body contouring and skin improvement.
Contraindications
These treatments are generally avoided during pregnancy or breastfeeding and in patients with severe epilepsy or renal failure. Allergy to a formulation’s ingredients is a contraindication. Infection or inflammation at the injection site should resolve before treatment. Patient selection also matters: these procedures target localized contour concerns and are not treatments for overall weight loss in severe obesity.
Adverse effects
Common reactions to injection lipolysis include swelling, bruising and pain, usually improving over several days. Superficial placement or leakage into the skin can cause ulceration, so correct depth is important. Carboxytherapy can cause temporary discomfort and a crackling sensation known as crepitus; these reactions are generally mild.
Figure 2. (A) CO₂ infusion points; (B) needle position and angle, at a depth of approximately 10 mm using a 30G × ½-inch needle. Source: Effectiveness of Carboxytherapy in the Treatment of Cellulite in Healthy Women: A Pilot Study, Luana Ramalho Pianez et al., Clin Cosmet Investig Dermatol. 2016 Aug 22;9:183–90. doi: 10.2147/CCID.S102503. eCollection 2016.
Rapid delivery of excessive CO₂ may cause temporary dizziness or palpitations. Although these approaches are nonsurgical and generally well tolerated in appropriate patients, outcomes depend on technique, and patients should understand that several sessions may be needed.
How does liposuction affect body contours and cellulite?
Surgical liposuction
Liposuction physically removes subcutaneous fat through a cannula. It has long been a standard approach to excess localized fat in areas such as the abdomen and thighs. Direct removal allows a larger reduction in one procedure and can address deposits that have not responded to weight management or noninvasive treatment.
Liposuction is among the most frequently performed aesthetic operations worldwide, with improvements in technique increasing precision and safety. It remains invasive, however, and requires local or general anesthesia, recovery time, and consideration of risks such as bleeding, infection and anesthetic complications. These limitations helped drive the development of nonsurgical alternatives.
Liposuction and lymphatic circulation
Cannula movement and fat removal inevitably disrupt some small blood and lymphatic vessels in the treated layer. Temporary postoperative swelling is therefore expected. Compression bandages or garments help manage retained fluid and support recovery of drainage.
Post-liposuction edema usually improves over several weeks as remaining vessels compensate and tissues recover. Specialist liposuction is also used in selected cases of lymphedema or lipedema involving chronic fluid stasis and abnormal fat accumulation. Reports describe substantial, sustained volume reduction when fibrotic adipose tissue is removed with lymphatic-sparing techniques, including in advanced leg lymphedema with persistent enlargement after lymphatic bypass procedures.
Careful lymphatic-sparing liposuction has been associated with less pain, better mobility and improved symptoms without worsening drainage. Removing abnormal adipose tissue may reduce the space available for retained fluid and the local inflammatory burden. Liposuction does not directly restore normal lymphatic function, but it can create conditions that make fluid management easier.
Effects on body contours
Surgery provides a larger and more immediate volume reduction than the noninvasive methods discussed above. Depending on the case, several thousand cubic centimeters of fat may be removed in one operation. As postoperative swelling resolves, circumference and contours change visibly, on a different scale from the gradual 1–2 cm reductions reported with some RF or injection protocols.
Surgical fat removal may be considered when localized deposits cause substantial disproportion or other methods have been insufficient. In lipedema, abnormal leg fat may not respond to weight loss alone; carefully performed lymphatic-sparing liposuction can improve pain, swelling and satisfaction with appearance. For cosmetic liposuction, however, pre-existing laxity or cellulite can leave surface irregularities, and laser assistance or skin excision may sometimes be considered. Smaller cannulas, VASER and water-assisted techniques have expanded the options for precise removal and complication reduction.
Contraindications
Liposuction is unsuitable when anesthetic risk is unacceptable, such as in severe cardiopulmonary disease, or when there is active infection or a bleeding disorder. Diabetes, hypertension and other chronic conditions need appropriate control. Smoking increases complication risk, so cessation is advised.
Older patients with substantial skin laxity need careful assessment because fat removal alone may leave more sagging. In patients with a BMI of 35 or above, limits on removal volume and greater risks, including thromboembolism, may require a staged approach.
Complications and aftercare
Complications include bleeding, infection, hematoma, fat embolism and fluid imbalance. Tumescent techniques help limit bleeding, while drainage and compression manage postoperative fluid. Reduced sensation or altered touch may persist for months but usually improves. Excessive removal can cause depressions or asymmetry, making operator experience important. Compression garments and appropriate lymphatic care over the following weeks help control swelling and support skin retraction.
Clinical rationale
Despite its invasiveness, liposuction remains an established contouring treatment because it can produce substantial, predictable volume reduction, particularly for localized concerns in patients without marked overall obesity. When swelling and impaired drainage dominate the presentation, I favor addressing lifestyle and nonsurgical options first, then considering selective removal of residual fat.
Research also explores combining liposuction with nonsurgical treatments, such as RF or lasers for residual cellulite or laxity after surgical volume reduction. Combined lymphatic surgery and liposuction protocols are being developed for patients with lymphatic disease. Careful technique that respects lymphatic anatomy, together with thorough aftercare, is essential to achieving a satisfactory surgical result.
How does CELLULAZE treat cellulite?
CELLULAZE is a minimally invasive laser system for cellulite that received FDA 510(k) clearance in 2012. It was an early laser-based approach designed to achieve sustained improvement after a single procedure.
Mechanism of action
CELLULAZE places a 1440 nm Nd:YAG laser fiber beneath the skin to address three features of cellulite. Laser energy partially reduces protruding fat lobules, releases or weakens fibrous septa that pull the skin inward, and provides thermal stimulation intended to increase dermal collagen, thickness and firmness.
The technique addresses fat protrusion, septal tethering and reduced dermal support together. Over the following months, collagen remodeling and increased dermal thickness can help the treated skin appear firmer and smoother.
Effects on local and lymphatic circulation
CELLULAZE primarily changes tissue structure; improved lymphatic flow is not its main mechanism. Local heating and collagen remodeling may also influence microcirculation and metabolism. Some disrupted fat is cleared through macrophage and lymphatic pathways, so appropriate massage or compression may assist postoperative fluid clearance. Its central actions remain septal release and collagen remodeling, rather than treatment of lymphatic dysfunction itself.
Indications and clinical outcomes
CELLULAZE is mainly used for moderate to severe cellulite on the buttocks and posterolateral thighs of adult women. It is suited to localized dimples where skin laxity is not severe, and a single procedure may provide sustained improvement.
Clinical studies have reported improvement lasting at least one year after one treatment. One multicenter study found an average improvement of more than two cellulite grades, with the change in appearance maintained at one year. Patient satisfaction was also high, with most participants in one study reporting satisfaction at that point.
These longer-term effects are attributed to structural remodeling. However, CELLULAZE may be less effective on its own for widespread laxity or edema-dominant cellulite. Other contouring approaches may be needed according to the presentation.
Adverse effects and precautions
CELLULAZE is a minimally invasive surgical procedure performed under local anesthesia. Bruising, swelling and pain are relatively common. The small fiber-entry incisions may briefly ooze or bleed. Less common complications include burns, pigmentation changes, residual irregularities or palpable nodules as the released tissue heals.
Even energy delivery and consistent septal release help reduce these risks. The operator monitors temperature to limit dermal injury, while postoperative compression and appropriate lymphatic care help manage swelling and hematoma. Patients with coagulation disorders or a tendency to keloid scarring need particular caution, and strict aseptic technique is required.
How does CELLFINA release cellulite dimples?
CELLFINA is a minimally invasive, vacuum-assisted tissue-release system that mechanically cuts the fibrous bands responsible for cellulite dimples. Its July 2015 FDA clearance covered improvement lasting two years, followed by expanded duration claims of three years in 2016 and five years in 2019. These long-term data distinguish it from many other cellulite approaches.
Mechanism of action
The handpiece uses a small cutting blade measuring a few millimeters. Suction lifts and stabilizes the tissue, and under local anesthesia a rapidly oscillating blade releases the subcutaneous septa at a controlled depth. The vacuum-assisted design helps protect the epidermis and dermis while targeting the tethering bands.
Once a band is released, the skin is no longer pulled inward and the dimple can rise. Surrounding fat occupies the released space, while healing deposits collagen and other matrix components to form new connective tissue. This mechanical subcision addresses a structural cause of cellulite and can produce a lasting surface change.
Effects on tissue and lymphatic circulation
CELLFINA does not directly target lymphatic flow. However, releasing local compression from tight septa may improve the environment for small blood vessels and lymphatics to function.
Appropriate massage or compression may help resolve postoperative bruising and swelling. These are supportive measures; CELLFINA’s primary role is fibrous-band release, and its relationship to drainage-based body contouring is indirect.
Indications and clinical outcomes
CELLFINA is used for localized cellulite dimples on the buttocks and thighs of adult women. Results tend to be best when there are distinct depressions and the skin remains relatively elastic, without marked sagging. Several dimples can be treated in one session, with the released surface often appearing smoother immediately.
Studies reported visible improvement in more than 85% of treated patients at three months and satisfactory outcomes in more than 90% at one year. Improvement persisted in over 95% at two years, while independent clinician assessment found significant improvement in 98%.
At five-year follow-up, most patients retained their initial improvement. The durability is thought to reflect stable tissue remodeling after the tethering bands have been released.
Adverse effects and precautions
Although CELLFINA is a minor procedure performed under local anesthesia, widespread bruising, tenderness and swelling can occur. Small-vessel bleeding during septal release may leave bruising or hemosiderin discoloration. These reactions generally improve within two weeks and are usually absorbed without specific treatment.
Pain varies from mild to moderate and may require analgesia. Strict aseptic technique is essential. Excessive or uneven release can leave depressions or irregularities, so an experienced clinician should target only the necessary bands at an appropriate depth, generally 6–10 mm. Anticoagulant use or a tendency to hematoma requires particular caution. Avoiding strenuous exercise for the first few days and using appropriate compression or gentle massage can support recovery.
What is AVELI?
Developed by Revelle Aesthetics, AVELI is a minimally invasive cellulite device that received FDA clearance in 2021 for cellulite dimples on the buttocks and thighs of adult women. In 2022, clinical evidence supporting improvement maintained for at least one year was added to its clearance.
Mechanism of action
AVELI identifies and releases the specific fibrous septa responsible for a dimple. Under local anesthesia, a slender probe and cutting device is introduced through a small incision. Integrated illumination and a hook mechanism help the clinician locate a tethering band, engage it and release it precisely.
After each release, the clinician can check whether the surface dimple has resolved. This feedback helps identify the relevant bands while limiting unnecessary dissection. Like CELLFINA, AVELI uses mechanical subcision, but it allows individual bands to be assessed during treatment. Subsequent connective-tissue healing helps support the corrected surface.
Effects on tissue and lymphatic circulation
AVELI targets fibrous bands rather than lymphatic or blood flow. Limiting unnecessary tissue injury may reduce postoperative edema and hematoma and support tissue recovery, providing an indirect circulatory benefit.
Release of a tight band may improve local microcirculation, although this is not its main clinical purpose. Appropriate massage or light activity may assist recovery, but AVELI is not a treatment designed to restore lymphatic circulation systematically.
Indications and clinical outcomes
AVELI is suited to distinct cellulite dimples on the buttocks and thighs. It can be performed as an outpatient procedure under local anesthesia. Unlike a vacuum-assisted system, it releases septa directly with a probe. Multiple areas can be addressed in one session, and the surface change can be assessed immediately.
Clinical reports cited satisfaction of approximately 80% at three months and 93% at one year. Significant improvement remained at one-year follow-up, with clearance-supporting studies confirming an effect lasting at least 12 months. Clinical reports also describe persistence for two to three years in some patients, suggesting that released bands may remain free of recurrent tethering for a prolonged period. These findings make AVELI an option for patients seeking sustained improvement in defined cellulite dimples.
Adverse effects and precautions
Localized pain, bruising and swelling are usually mild to moderate. Many patients return to routine activities quickly, although small entry scars, tenderness and discomfort can occur. Bruising commonly resolves within two weeks. Infection is uncommon, but remains possible with any procedure that enters the skin.
The clinician must avoid excessive traction on the skin or surrounding tissue. Accurate identification and controlled release of each causative band are central to the technique.
Aftercare commonly includes avoiding strenuous exercise and saunas for one to two weeks and using cool compresses for bruising as directed. AVELI can be technically demanding, and clinicians should complete the manufacturer’s training before use. Anticoagulant use and a tendency to keloid scarring require careful assessment.
What is RESONIC?
RESONIC is a noninvasive device developed by Soliton that uses Rapid Acoustic Pulse (RAP) technology. It received a tattoo-removal adjunct clearance in 2019, followed by FDA clearance for temporary improvement in cellulite appearance in February 2021. Soliton was subsequently acquired by Allergan Aesthetics. Research has also explored whether improvement can persist beyond the temporary indication.
Mechanism of action
RESONIC rapidly delivers high-energy acoustic pulses through the skin, generating brief pressure waves, vibration and shear forces in subcutaneous septa. These forces can weaken or disrupt fibrous bands without a mechanical blade, an approach described as acoustic subcision.
The pulses also stimulate the surrounding ECM and adipose tissue, potentially influencing microcirculation and collagen remodeling. Their short rise time and rapid repetition are designed to disrupt fibrous tissue while limiting injury to adjacent structures. This acoustic disruption of septa is the central treatment mechanism.
Effects on local and lymphatic circulation
Acoustic energy can also influence vascular dilation, metabolism and tissue repair. Reports after RAP treatment describe increased skin blood flow and lymphatic activity, which may reduce edema and improve the local tissue environment. Effects on fibrosis and collagen organization may complement drainage-based contour care. Released tissue fragments, including collagen debris, are cleared through normal pathways; suitable light activity or massage may support this process after treatment.
Indications and clinical outcomes
RESONIC has been used for moderate cellulite on the thighs and buttocks of adult women. It requires no incision or separate anesthesia, and each area generally takes from several minutes to just over ten minutes.
Studies reported an average improvement of more than 30% in cellulite scores after a single RAP session. In one multicenter study of 67 patients using the untreated leg as a comparison, 85% showed visible improvement, with significant reductions in dimple number and depth. More than 90% reported improvement and satisfaction, and results persisted beyond three months.
Additional follow-up suggested that a single treatment’s effect could last at least one year. At that point, independent blinded assessors distinguished before-and-after photographs with more than 95% accuracy, and all participants reported improvement. These findings suggest the possibility of sustained benefit from a noninvasive approach.
Results vary with baseline severity and skin condition. Severe cellulite may not become completely smooth. Additional treatment may be considered, although the protocols discussed here were designed around a single session.
Adverse effects and precautions
Treatment discomfort is generally mild, with reported average pain scores of 2–3 out of 10. Most participants tolerated treatment without anesthesia and required no dedicated recovery period.
Mild redness and warmth may occur and usually settle within a day. Small petechiae or bruises can occasionally appear and resolve over several days. The studies discussed here did not report serious adverse effects, scarring or pigmentation changes. Preserving the skin surface also avoids the infection risks associated with an incision.
Treatment is generally avoided during pregnancy and over metal implants. Skin weakened by prolonged steroid use warrants caution. Adequate hydration and gentle movement, such as walking or light stretching rather than strenuous exercise immediately afterward, are commonly recommended to support recovery and drainage.
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