Collagenase injections for cellulite: the delusion is over

Breaking down collagen with collagenase injections to "get rid of cellulite"? What could possibly go wrong?

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• Collagenase injections for cellulite and the medicalisation of beauty

• Injecting collagenase to break down collagen in people’s skin: where is the logic in that?

• Collagenase clostridium histolyticum-aaes dissolves skin ligaments that are essential for skin firmness

• Collagenase clostridium histolyticum-aaes dissolves collagen in your skin without discriminating between good collagen and “bad collagen”

• The rise and fall of collagenase injectables for the treatment of cellulite

• Why stop at melting away your cellulite? Have you ever thought of melting away your thigh muscles? How awesome would that be?

• Stimulative treatments vs destructive treatments

• New Considerations in the Use of Collagenase Clostridium Histolyticum for the Treatment of Cellulite

• Check our professional consultancy in radiofrequency, ultrasound cavitation, cellulite and skin tightening

Collagenase injections for cellulite and the medicalisation of beauty

The last few years we have witnessed the medicalisation of beauty, based on injectables and on harsh “minimally invasive”, “one-off” medical procedures aiming to burn / chop / scrape / dissolve / undercut tissue to make aesthetic problems look like they have instantly disappeared.

According to this brave new paradigm, clients are no more healthy people with some aesthetic concern. They are now called “patients” - as if their aesthetic concern was a medical condition.

Normal sized lips, frown lines, wrinkles, normal sized cheekbones, normal or small buttocks, cellulite and a host of other aesthetic attributes or aesthetic concerns are now medical conditions that must be treated with invasive or “minimally invasive” procedures.

In fact, some doctors have the audacity to claim that facial ageing should be treated as a disease. I suppose, the next step would be to ask the NHS to pay for all those “anti-ageing”, “minimally invasive” injections and procedures, instead of the government wasting public money on unglamorous and boring things like treating cancer or heart disease…

(To be honest I find it unconscionable that some of the brightest people in the country waste so many public and personal resources (talent, intelligence, 10+ years of medical school and £230,000 of public money spent on training them) just to inject people’s lips, cheekbones and bottoms, instead of making use of their God-given gifts and taxpayers’ money to save lives and improve people’s health. But hey, that’s just me...)

And for those new “medical conditions”, out are the old affordable procedures based on gentle treatments that aim not to burn, undercut or dissolve anything, but to naturally and safely stimulate tissues to improve.

And in are dangerous, unsafe, sometimes extortionately priced procedures for purportedly “instant” results - after, of course the obligatory 6-month downtime/recovery phase of bruising, inflammation, swelling, scar tissue, fibrosis etc. How “instant” 6 months of downtime and what kind of “result” that is, it eludes me.

These medicalised beauty procedures have quite often led to:

• an artificial or even deformed look on the face or the body

• quite a lot of adverse reactions

• little actual benefit

A good example of this trend for instant results via the unnecessary and irrational butchering of internal tissues, are collagenase injections to literally melt the excess collagen found in cellulite.

This is achieved with a collagen-dissolving enzyme found in an injectable called “collagenase clostridium histolyticum-aaes”, previously sold under the trade name of Qwo (the company that makes has recently become bankrupt and Qwo is not available on the market any more).

Injecting collagenase to break down collagen in people’s skin: where is the logic in that?

Indeed, shortened and enlarged collagen fibres are one of the hallmarks of advanced cellulite.

In severe cellulite (and to a much lesser extent in medium severity cellulite) the “collagen bands” that tether the skin onto the underlying fascia tissue are thickened and shortened.

These ‘retinaculae cutis" (a.k.a. skin ligaments) are surrounded by fat globules. As the fat globules enlarge and push up and as the skin ligaments next to them contract and pull down, the familiar cellulite “look” appears.

So it would appear if one can dissolve the retinaculae cutis into nothingness with a collagen-melting enzyme injection then the cellulite appearance would disappear, right?

Just “melt away” collagen with just one, very expensive, unsafe, medicalised, “convenient lunchtime procedure” and cheer “cellulite begone”, right?

Wrong. Obviously biology does not work that way.

• First of all, the most important factor of cellulite, the conveniently forgotten elephant in the room, is FAT. Skin / hypodermal fat to be precise. Just by making the skin ligaments disappear does not make cellulite “begone”, because the hypodermal fat is still there.

• And then we have the issue of loose skin, which almost always accompanies cellulite and which a collagenase injection, of course, can do nothing about. In fact, as we will see below, as a collagenase injection aims to break down collagen, it can only weaken loose skin and make everything loose worse.

• And then we have the water retention / poor circulation, common aspect of cellulite, which a collagenase injection, of course, cannot do anything about

• And then we have all the inflammation that accompanies cellulite, which a collagenase injection, of course cannot do anything about. In fact, as we will see below, collagenase injections increase inflammation - as if cellulite affected tissues did not have enough inflammation in the first place.

So with this and other similar “magical procedures” (such as subcision / cellfina surgery) which focus just on retinaculae, we can conveniently forget all other aspects of cellulite and we can just focus on evaporating the skin ligaments.

What can possibly go wrong, right?

Collagenase clostridium histolyticum-aaeS (Qwo) dissolves skin ligaments that are essential for skin firmness

To find out what can possibly go wrong, we have to consider that skin ligaments were not placed there by nature in all mammals in order to torment women in the western world with cellulite (there is no cellulite in natural living cultures in the developing world). These skin ligaments serve a crucial purpose.

Retinaculae cutis (collagen bands) and septae (collagen sheaths) between skin and fascia are there for a reason: to prevent skin from gliding upon the underlying tissues and to maintain skin firmness.

Dissolve them and you end up with loose, flabby, shaggy, hanging skin. Sure, skin with a bit less cellulite (and not even that is guaranteed) and with a lot more skin laxity.

So what can go wrong by dissolving your firmness endowing collagen bands with a collagen-dissolving enzyme injection, is that you can end up with loose skin.

All right, but apart from loose skin, what else can go wrong?

Collagenase clostridium histolyticum-aaes (Qwo) dissolves collagen in your skin without discriminating between good collagen and “bad collagen”

The first question that comes to the mind of even someone naive to the anatomy and physiology of the skin is:

“How do we ensure that the collagenase enzyme melts only the collagen of skin ligaments and not the collagen of the rest of the skin, fascia and other tissues, just right next to the skin ligaments?”

This is an obvious question that even school children - let alone doctors - would have spontaneously asked if they were presented with this idea. This is what I thought the first time I heard about collagenase injections, a few years ago: how do you tell an enzyme in liquid form to stay put exactly where it is injected and not spill everywhere around the injection site in an area full of liquids, as everything inside the body is?

Before we go any further, let’s note here that collagen is literally what keeps our body intact and gives it shape. Collagen is the most important component of skin, fascia, tendons, ligaments, muscles and blood vessels. Without collagen to form the frame of our tissues we would literally be blobs, not much different to slugs.

How can we keep the essential “good” collagen that keeps our body intact, and which happens to be right next to the so-called “bad” collagen of retinaculae cutis, from dissolving?

Exactly. We can’t. There is no way to prevent collateral damage on nearby tissues, such as skin, fascia and even blood vessels, by dissolving their collagen.

What an irresponsible and stupid idea.

All right, but apart from loose skin due to melting away skin ligaments and apart from even looser skin due to melting away other skin collagen, what else can go wrong?

The rise and fall of collagenase injectables / qwo for the treatment of cellulite

Well, there’s plenty more of collateral damage.

One provider of collagenase injectables listed the possible adverse reactions of the procedure as follows: “bruising, pain, areas of hardness, itching, redness, discoloration, swelling, and warmth in the treated areas”. In simple words all these things mean: inflammation, tissue damage and scar tissue.

But hey, damaging good collagen and blood vessels next to bad collagen proved, for several years, to be a small insignificant detail to both the aesthetic industry and the regulators. The collagenase enzyme injectable got approved and dozens of studies in aesthetic medicine journals parroted again and again the claims of its amazing safety and efficacy.

(Let’s make the salient point here that a large percentage of articles on aesthetic medicine journals are sponsored by manufacturers and are not worth the paper they are written on.)

Until the real reality surfaced: consumers got fed up of all the “pain, areas of hardness, itching, redness, discolouration, swelling, warmth and bruising”. And despite all the industry sponsored studies’ talk of safety and efficacy, complaints mushroomed, the company folded and the product was taken out of the market.

(Official company statement from the manufacturer of collagenase clostridium histolyticum-aaes / Qwo): “For more than a year, Endo worked to address those concerns, including launching an open-label study in June 2022, APHRODITE, to test different interventions and whether they might mitigate bruising. Although certain APHRODITE study cohorts' results reflected a modest reduction of bruising area and severity, none achieved a consistent level of reduced bruising following initial treatment to adequately alleviate the market's concerns.”)

Look at the horrific pictures and decide for yourself if the risks of such an “instant”, “convenient”, “one-off”, “minimally invasive”, miracle lunchtime procedure are worth those pictures.

All right, but apart from loose skin due to melting away skin ligaments and apart from even looser skin due to melting away other skin collagen, and apart from tissue damage, inflammation and scar tissue, what else can go wrong?

Why stop at melting away your cellulite? Have you ever thought of melting away your thigh muscles? How awesome would that be?

Do you have big thighs? Just melt them away with a “minimally invasive collagen dissolving injection”.

Aesthetic medicine may not have found a way to melt away your fat yet (despite all the misleading claims everywhere on the internet and on instagram) but it has found a way to melt away your muscles, with, what else, a collagenase clostridium histolyticum injection.

This is exactly what happened to a 58-year old woman who had three collagenase treatments on her front thighs, in order to reduce her cellulite.

Of course, no cellulite reduction occurred but she ended up with not just the usual “bruising” and “persistent pain” but also - as an extra gift from the “convenient, minimally invasive, miracle, lunchtime procedure” - with an 1cm tear on one of her rectus femoris muscle (one of the ‘quad’ thigh muscles) and an 1.5cm tear on her other rectus femoris muscle.

Marvellous…

All right, but apart from loose skin due to melting away skin ligaments and apart from even looser skin due to melting away other skin collagen, and apart from tissue damage, inflammation and scar tissue, and apart from suffering muscle tears, what else can possibly go wrong?

Now does all this also remind you of a Monty Python sketch or is it just me?

(In this Monty Python sketch ‘Reg’ asks his fellow revolutionaries about the Romans: “All right, but apart from sanitation, medicine, education, wine, public order, irrigation, roads, a fresh water system, and public health, what have the Romans ever done for us?”)

This would indeed be very funny, as long as nice, normal everyday people who just wanted to look a little bit better, did not suffer from all of those “instant”, “miracle”, “minimally invasive” procedures.

Moral of the story: if it looks too good, fast and miraculous to be true, it probably is.

Stimulative treatments vs destructive treatments

The fact of the matter is that the human body has limits and any aesthetic intervention needs to take those physiological limits into account.

Any treatment which is so harsh and which needs to be applied with an anaesthetic cream or injection to cover the extreme pain is a sure indication that you go over the body’s limits.

Cross those limits for “faster” results (and for 5-10 times faster profits for practitioners) and you run the risk of injury. And this is the risk of those hyped-up, instant, convenient, one-off, super expensive, minimally invasive, “miracle” lunchtime procedures entail, without even offering better results than safe procedures.

• On the one hand we have attempts for instant results - that quite often don’t even materialise - based on burning, cutting, scraping or melting tissue over 1, 2 or 3 destructive treatment sessions (such as extreme intensity HIFU, extreme intensity RF, microneedling RF, collagenase injections and the like).

• And on the other hand we have natural, safe, gradual improvement, based on stimulating change in the tissues by respecting the body’s limits, over 5, 10, 15 stimulative treatment sessions (such as professionally provided high-power deep tissue radiofrequency, high-power ultrasound cavitation or even strong, cellulite-specific massage).

I don’t know what you would choose, but I want to sleep well at night, either being a client or as a practitioner, and I would never choose the former.

I’m happy to take a bit more time to receive (as a client) or to offer (as a practitioner) natural, functional results, safely.

New Considerations in the Use of Collagenase Clostridium Histolyticum for the Treatment of Cellulite

• Research paper link: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10387738/

• Abstract: We appreciate the thorough review of collagenase clostridium histolyticum (CCH) and its use in clinical practice for the treatment of cellulite by Graivier et al. The authors highlight the need for alternative injection techniques in the treatment of the thighs (when compared with the buttocks) without commenting on the anatomic reasons why this may be necessary. We would like to emphasize the importance of such alternative injection techniques by presenting an interesting adverse event currently unreported in the literature. A 58-year-old female patient presented to the clinic for the evaluation of cellulite after completing treatment with CCH by an outside, non-physician provider. The patient reported completing 3 rounds of treatment for areas of concern along the buttocks as well as both the posterior and anterior thighs. She was disappointed with the results and complained of bruising as well as persistent pain along bilateral anterior thighs with ambulation, as well as typical levels of exercise. Following thorough evaluation and imaging, it was discovered that the patient had developed a moderate 1.0 cm tear of the right and a moderate-to-high grade 1.5 cm tear of the left rectus femoris muscles. The patient denied any significant trauma or other injury that might have triggered the bilateral tear, making treatment of the anterior thighs with CCH the most likely culprit. Of note, CCH carries an additional FDA indication in the United States for the treatment of other collagen-associated disorders, including Dupuytren's contracture and Peyronie's disease, where there are reports of severe adverse events including complete tendon rupture and corporeal or penile fractures, respectively. We could find no translatable reports of skeletal muscle rupture in the literature with the use of CCH for cellulite. It should be emphasized, though, that CCH currently carries approval for the treatment of cellulite in the buttocks. Types I and III collagen, the target of CCH, are prominent components of skeletal muscle endomysium and perimysium, which could make damage to skeletal muscle possible with exposure to sufficient doses of CCH. Anatomically, skeletal muscle may lie much more superficially along the thighs compared to the buttocks; hence, injection in these areas should be performed much more superficially to minimize the risk of direct intramuscular injection, particularly anteriorly. The rectus femoris is the most superficial component of the quadriceps muscle and thus may be particularly vulnerable to CCH injection and subsequent rupture, as observed here. With continued investigation and use of CCH for the treatment of cellulite in broader anatomic locations, it is likely that the overall risk of skeletal muscle complications will become more evident. It is also probable that a more detailed evaluation of the underlying tissues should be utilized when administering CCH to more anatomically sensitive areas, such as the anterior thighs. Doing so will further guide and instruct users on alternative injection techniques such as injecting much more superficially, which may be necessary to avoid complications, such as muscle tears as observed in this case. Given the relatively new indication and use of CCH for the treatment of cellulite, it is important for providers to continue to report on all possible adverse events and how best to mitigate them.

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