Docs are ditching injectables for this dimple-buster.

Despite its obvious ubiquity, cellulite has long been stigmatized, compelling generations of women, of all sizes and ethnicities, to battle their innate anatomy — scrubbing, pummeling, zapping, and vacuuming dimples, to no avail. The rise of body positivity — or the version of the movement popularized by social media — has mercifully granted cellulite a reprieve of sorts, officially “normalizing” what we’ve always known to be a perfectly natural female feature, born of the interplay of connective tissue bands, fat, and hormones.

We’re now urged to accept our lumpy bottoms and rippled thighs — to reject filters and celebrate our cellulite! Which may come as a relief, really — even if your confidence still slips when hemlines rise — because fighting dimples can be deeply frustrating.

Cellulite treatments have historically been flops. Even the fanciest machines have been woefully underwhelming, disappointing users who saw their cellulite return (or barely budge post-treatment) for more than a decade. “I bought Cellulaze for, like, $200,000 and it was a total bust,” says Dr. Ashley Gordon, a board-certified plastic surgeon in Austin, Texas. FDA-cleared in 2012, Cellulaze was the first “minimally invasive” cellulite device — meaning it works underneath the skin, firing thermal energy at the fibrous bands, or septae, that tug at our skin, imprinting it with dimples.

A few years later, Cellfina launched, promising longer-lasting results. The gizmo is designed to robotically suck up skin and swipe at underlying septa with a micro-blade — sometimes missing the mark, due to its limited reach. “Cellfina’s suction device allows the blade to be used at six- and 10-millimeter depths specifically, and to cut only perpendicular to the skin’s surface,” explains Dr. Laurie Casas, a board-certified plastic surgeon in Chicago. Any bands that don’t fit the machine’s exact parameters are spared, frequently leading to “inconsistent results,” says Dr. Holly Wall, a board-certified plastic surgeon in Shreveport, Louisiana. Ultimately, she adds, “we threw away our set up.”

In 2020, the industry heralded another first: a long-awaited, FDA-approved injectable called QWO, which breaks down collagen-rich septa with the enzyme collagenase. “Can I tell you how excited we all were?” recalls Dr. Gordon. Before being branded as QWO, the drug had established itself as a successful treatment for disfiguring connective tissue disorders. But after less than two years on the aesthetics market, QWO is already drawing criticism. A number of doctors have abandoned the shot, citing subpar results and unmanageable side effects — from staggering bruises to persistent staining to irreparable skin laxity.

Many of the derms and plastic surgeons who’ve quit QWO are turning to the latest tool to take on cellulite: Avéli, a rudimentary subcision wand engineered around novel findings gleaned through cellulite studies undertaken by Revelle Aesthetics, the company behind the FDA-cleared device.

When treating cellulite, doctors have always operated on the assumption that beneath each dimple is a singular vertical septal band anchoring the underside of the skin to the muscle below. The majority of septa are healthy and useful — they buoy the skin — but for reasons that aren’t well understood, some of these cords thicken and tighten over time, pulling down on the skin and pitting it in spots.

Since our septa run through a layer of fat, when they constrict, “they create this false fullness of the fat that sort of herniates around them,” says Dr. Sachin Shridharani, a board-certified New York City plastic surgeon. He likens the effect to a tufted couch or quilted Chanel bag. In most cases, there’s also some degree of skin thinning, laxity, or sluggish lymphatic flow complicating the landscape, Dr. Shridharani notes, but it’s the abnormal septa that are widely believed to be the root cause of cellulite. And, thus, subcision, or disrupting those bands — mechanically, enzymatically, or by some other means — is generally considered key to treatment.

Before designing its cellulite tool, Revelle tapped anatomists to explore the structure and orientation of septa rather than simply relying on long-held theories about cellulite. “No one had ever really looked at cellulite that closely before,” Dr. Gordon tells TZR. Their dissections and imaging studies revealed that septa are not organized in a predictable pattern. They exist at various depths and traverse the fat in myriad directions, some standing perpendicular to the skin, others lying parallel or aslant. And there isn’t just one or even two cords assigned to each dimple — there’s an intricate web. “Each depression has at least eight to 15 septa,” says Dr. Casas, all pulling like parachute strings on the skin.

Avéli is a one-time minimally invasive procedure done under local anesthesia. But compared to its high-tech competitors, Avéli is shockingly basic. The energy-free, handheld device is a thin, cannula-like rod, outfitted with a retractable hook and blade. At its tip, there’s a pinpoint light, which shines through the skin. A dimming of the light tells providers they’ve gone too deep, so they can redirect to a more shallow plane where the septa typically reside.

Beyond this directional cue, Avéli offers tactile and visual feedback, which the experts say is invaluable. “With the hook, you can feel the bands you’re targeting,” says Dr. Nazanin Saedi, a board-certified dermatologist in Plymouth Meeting, Pennsylvania. Upon snaring a septa, “you feel the resistance of the band and you see it pull down and [exacerbate] that dimple.”

Before surgery, each divot is marked while the patient is standing. “The markings are critical,” says Dr. Gordon, because dimples disappear or become harder to see lying down. The goal is to identify and sever all of the bands within the perimeter of the outlined dimple, without harming the neighboring septa, which are keeping the skin strong and firm.

Incisions, which tend to be less than a centimeter long, are hidden in skin creases and folds. After cutting, “you then go back through the area and verify with the hook that you’re not getting caught on anything else,” says Dr. Saedi. “So there’s verification, in real time, that you’ve actually treated every band responsible for that dimple.”

Avéli is prized for its precision, above all. Dr. Wall was one of nine investigators on the soon-to-be-published 12-month Avéli clinical trial. Interestingly, her partner was involved with the QWO trials that preceded the injectable’s 2021 rollout. “After the trials were over,” she says, “our nurses only wanted to learn how to use Avéli, [because] it’s a precise and complete treatment.”

In Dr. Wall’s assessment, “neither Qwo nor Cellfina are precise — these mechanisms will inadvertently damage septa that should not be treated, leading to a flattening of the treated area, [whereas] Avéli leaves the supporting septal system intact.”

Since QWO is a liquid that destroys collagen, some doctors believe it has the potential to spread to unintended targets, causing or exacerbating skin laxity. ”I saw this in one of my patients,” says Dr. Gordon, who no longer uses the injectable treatment. “Even if we’re using a tiny needle and small aliquots, certain people’s anatomy is more open to diffusion of fluid.” Dr. Gilly Munavalli, a board-certified dermatologist in Charlotte, North Carolina, has also seen “mild volume drop” in former QWO patients. “It’s subtle, but people notice it because it shows up as more wrinkling or laxity than they had before.”

QWO’s pathway can’t be 100% controlled once it's injected, meaning it may also miss some of the dent-inducing bands it’s aiming to hit. “There’s no doubt that QWO dissolves the collagen bands it touches,” Dr. Gordon adds. “But let’s say we’re treating a deeper dimple that has 20 of those septa coming up — we just don’t know that we’ve melted them all when we’re putting the needle in only one or two times for each dimple.”

While Avéli is still new with a modest track record, it seems to be less problem-prone than QWO. “The bruising from QWO is absolutely horrific,” says Dr. Saedi. And because it develops due to the drug’s mechanism of action — not poor injection technique or sheer bad luck — bruising is a guaranteed side effect of treatment. With QWO, says Dr. Munavalli, “the entire framework of the dermis falls apart,” leaving fragile blood vessels in the area unsupported and vulnerable to rupture. “You get a shearing effect [on the capillaries] when the skin releases in such rapid fashion,” adds Dr. Shridharani. Since most patients need two or three rounds of injections, they’re commonly black-and-blue for months on end.

Comparatively, with Avéli, Dr. Munavalli notes, “you still get bruising, but because we’re not dropping the bottom out of all these vessels, it’s not nearly as severe.” In Dr. Wall’s experience, “Avéli can be performed year-round — even two weeks before your beach vacation.”

Dr. Shridharani, who served as an investigator for QWO and Avéli, agrees that “the bruising with QWO is concerning and substantial.” He’s currently researching ways to mitigate it with tranexamic acid, a drug used to control bleeding. While he admits that Avéli offers “a little more control and precision,” he still offers both treatments in practice, seeing value in each.

Some folks are put off by the idea of surgery, Dr. Shridharani tells TZR. “They don’t want a minor incision or a tiny stitch — they’ll only do injections.” And if they have just a few divots and can tolerate the bruising and potential darkening, then QWO may be a good choice. But plenty of people go for Avéli, he adds, because they can’t risk trading dimples for months of discoloration.

While Avéli is Dr. Saedi’s go-to for cellulite, QWO remains in her armamentarium as a touch-up treatment. “If a patient has one dimple remaining after Avéli — maybe it got lost in the sea of dimples when we were marking them — that’s where QWO would fit in,” she says. “We’re not going to anesthetize and do Avéli for a single dimple.”

In clinical trials, cellulite is graded on various scales, with improvements measured in points and percentages. In an Avéli study, roughly 80% of subjects were very much improved or much improved three months after treatment. The average pain rating at 24 hours post-op was a 3.8 out of 10, with most people resuming regular activities within a day. While the company data shows benefits lasting through 12 months, doctors expect results to last for years.

The experts interviewed here say their real-world results reflect the study findings, with mild indents looking nearly imperceptible after treatment and deeper divots becoming more shallow.

Still, doctors are careful to manage patients’ expectations, because at $3,500 to $4,500, Avéli isn’t cheap. Distinguishing dimples from skin laxity, which often looks like waviness or sagging, is a crucial part of the process, since Avéli corrects only indentations, leaving background laxity unchecked. “Laxity is a distractor and can make cellulite look worse,” says Dr. Munavalli. “But if you don’t separate out the two, you can wind up with an unhappy patient.”

To more fully smooth the butt and thighs, doctors are pairing Avéli with other treatments. Dr. Saedi follows it with broadband light (to lessen bruising) and a series of TempSure radiofrequency skin-tightening sessions. Dr. Casas uses dilute Radiesse and Ultherapy — both collagen stimulators — to firm up the skin before doing Avéli. If someone is having liposuction alongside Avéli, Dr. Gordon likes to reserve some of the fat, process it into growth factor-rich nanofat, and inject it into the dimples she’s released to help rejuvenate the skin.

These protocols are largely works in progress, mind you — ongoing attempts to solve the cellulite puzzle. Which isn’t to suggest our backsides require figuring and fixing. Cellulite treatments are elective, after all — take ‘em or leave ‘em. Regardless, the irony of this moment — the convergence of acceptance and innovation — can’t be denied. Are we embracing cellulite just as science is finally yielding a legitimate solution? Maybe. And that’s cool — for some. But if cellulite bothers you personally, there’s no shame in addressing it. Luckily, your options are better than ever.