What Every Aesthetic Physician Needs to Know About Qwo

Cellulite results from a myriad of dermal and subdermal conditions, with the primary cause being associated with fibrous septae tethering the skin to the underlying muscle fascia. The sequelae are contour irregularities hallmarked by dimpling and undulations that afflict up to 90 percent of adult women of all races and ethnicities. Until now, the mainstay treatments often led to suboptimal to no correction, as the focus of treatment was rarely at the root cause.

A completely new category in aesthetics was created last July with the FDA approval of Qwo (collagenase clostridium histolyticum-aaes, Endo Aesthetics), the first injectable treatment for moderate to severe cellulite in the buttocks of adult women. This revolutionary treatment, which will be available in days/weeks, will add a much-needed solution to our aesthetics armamentarium and provide patients who are used to getting other aesthetic injectables with a novel treatment option in a similar modality.

How Qwo Works

The mechanism of action for Qwo is enzymatic subcision of the septations to release the tethered skin and remodeling of the dermis, leading to neocollagenesis. This process of enzymatic subision and remodeling is dubbed ESR. The remodeling in ESR further rebuilds small septae that, rather than tethering, reduce tension and thicken the dermis, yielding a smoother overall appearance.

Qwo preferentially cleaves Type I and Type III collagen, which we know contribute substantially to those septations. Microscopically, we’ve seen that treatment does not affect other critical structures, such as the basement membrane of blood vessels, comprised of Type IV collagen.

The Evidence

What has given me tremendous confidence is the robust science backing the outcomes. Endo conducted two clinical trials of Qwo—the largest trials in the history of cellulite investigation—to help determine the safety and efficacy of this injectable. The trials enrolled 845 women with moderate to severe cellulite in the buttocks who represented diverse populations, ages (18 and older), ethnicities, and BMIs. All Fitzpatrick skin types were included with nearly 30 percent of those treated with Qwo being Fitzpatrick IV, V, and VI.

As an investigator in the clinical trials, we found that patients had a tremendous amount of improvement in the appearance of their cellulite after being treated with Qwo. Those who met the primary endpoint achieved a 2-level improvement on both the patient- and physician-reported scales of cellulite severity. Ongoing studies are being conducted to determine the long-term durability of Qwo.

The Experience

Receiving treatment with Qwo is straightforward for patients and their doctors. It is essential that physicians understand each patient’s specific concerns. With the patient standing upright, mark the dimples to be treated and then obtain photographs of the area to be treated. You only ever have one chance to take “before” images. Then, the patient should lie down in a prone position and get comfortable.

Treatment is administered in about 10 minutes, using a small-gauge needle to inject each area individuals. The solution itself has similar viscosity to normal saline, so there is no discomfort associated with injection.

There is no “downtime,” and patients can resume normal activities immediately after treatment. Within 24-48 hours of the first treatment, most patients develop bruises. This bruising is thought to result from damage to venules in the treatment area as the tissues redrape and remodel. This bruising is not associated with pain or reduction of function, but patients should be made aware of it prior to treatment, both to minimize undue concern post-treatment and so that patients can defer treatment, if necessary, for social reasons. For example, I advise patients that this is not a treatment to have on Friday if they plan to spend the weekend at the pool.

Some patients have bruising after the second treatment. Such bruising, if it develops, is typically less than is seen with the first treatment.

A Comprehensive Approach

Qwo demonstrates impressive efficacy for diminishing the appearance of dimpling and smoothing the skin. However, some patients may have additional aesthetic concerns in the leg area. Injectable poly-L-lactic acid can be used for additional textural improvement, while energy-based devices can be used to tighten the skin.

It remains essential to fundamentally understand each patient’s goals and recognize there may be a host of different ways to treat the overall aging thighs/buttocks.

I feel that first-in-class Qwo will make a significant impact in my clinical practice and help me care for existing patients along with grow my practice. I can reach a large subset of the population who have not been able to effectively be treated for cellulite.