Cellulite is a prevalent, multifactorial, condition that is extremely recalcitrant to a wide array of treatments. This article discusses patient characteristics, selection, and the vast armamentarium in the treatment of cellulite.
Key points
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Cellulite is a well-documented condition and, although many treatment options have been purported, few have lasting clinical results.
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The use of laser and light-based devices, in both a noninvasive and a minimally invasive fashion, has augmented the understanding and approach to the treatment of cellulite.
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Understanding the structural components that underpin cellulite anatomy allows for a more specific targeting approach.
Introduction
Cellulite is a topographic alteration of the skin and subcutaneous adipose that has been reported as early as 150 years ago but yet still affects patients today. It is quite prevalent, almost ubiquitous in postpubertal women and can be thought of as a female secondary sex characteristic. Cellulite formation has a complex pathophysiology that includes expansion of subcutaneous fat, fibrotic dermal septae, as well as dermal laxity and atrophy. Many factors are also thought to influence the formation of cellulite; a genetic predisposition, along with hormonal influences, structural adipose differences, and inflammation may all contribute. It is thought that in cellulite the adipose cells are arranged in chambers surrounded by bands of connective tissue called septae, which span to connect muscle to the inferior portion of the dermis. The adipose cells that are encased within the perimeters of this area expand with water absorption, thereby stretching the connective tissue. This connective tissue can contract and thicken, holding the skin at a nonflexible length, while the surrounding tissue continues to expand with weight, or water gain. This expansion results in skin dimpling and an orange peel appearance, mainly in the pelvis, thighs, and abdominal areas. Many devices and treatments have focused on these purported structural alterations as targets for therapy, some with better results than others. Even with many technological and pharmacologic advances, cellulite has been extremely recalcitrant to a wide array of treatments.
Introduction
Cellulite is a topographic alteration of the skin and subcutaneous adipose that has been reported as early as 150 years ago but yet still affects patients today. It is quite prevalent, almost ubiquitous in postpubertal women and can be thought of as a female secondary sex characteristic. Cellulite formation has a complex pathophysiology that includes expansion of subcutaneous fat, fibrotic dermal septae, as well as dermal laxity and atrophy. Many factors are also thought to influence the formation of cellulite; a genetic predisposition, along with hormonal influences, structural adipose differences, and inflammation may all contribute. It is thought that in cellulite the adipose cells are arranged in chambers surrounded by bands of connective tissue called septae, which span to connect muscle to the inferior portion of the dermis. The adipose cells that are encased within the perimeters of this area expand with water absorption, thereby stretching the connective tissue. This connective tissue can contract and thicken, holding the skin at a nonflexible length, while the surrounding tissue continues to expand with weight, or water gain. This expansion results in skin dimpling and an orange peel appearance, mainly in the pelvis, thighs, and abdominal areas. Many devices and treatments have focused on these purported structural alterations as targets for therapy, some with better results than others. Even with many technological and pharmacologic advances, cellulite has been extremely recalcitrant to a wide array of treatments.
Cellulite anatomy and grading
The topographic appearance of cellulite is multifactorial in nature. The overall contour deformity is that of skin depression admixed with lax inelastic epidermis. The area of cellulite can comprise isolated depressions or a cluster of such that leads to an overall rippled appearance. The depressed areas can be either ovoid or linear in shape. Ovoid areas of cellulite tend to be more prominent on the buttocks or posterior thigh regions. Cellulite can be broken down into 3 main structural components: (1) adipocytes and collections of fat cells that are arranged in clusters surrounded by bands of connective tissue; (2) these connective tissue septae, which connect underlying muscle to the subdermal layer; (3) cells held within the perimeters of this area expand and stretch the connective tissue. Eventually this connective tissue contracts and sclerosis holds the skin at a nonflexible length, while the surrounding tissue continues to expand with weight, or water gain. Nurnberger and Muller described an anatomic hypothesis of cellulite based on gender-related differences in the structural characteristics of dermal architecture. They reported that dermal septae of affected women are thinner and more radially oriented than those of unaffected men; this facilitates herniation of adipose tissue into the dermis.
Grading
There are multiple scales of cellulite grading based on the clinical severity. Nurnberger and Muller described a scale of 3 grades:
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Grade I: Skin is smooth when standing.
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Grade II, mild, moderate, severe: Grade II is defined as orange peel or mattress appearance when standing.
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Grade III, mild, moderate, severe: Grade III is defined as grade II cellulite plus raised and depressed areas and nodules when standing ( Fig. 1 ).
Fig. 1
Modified Muller Nuremberger scale showing different grades of cellulite.
Curri also described a cellulite grading scale, ranging from grade 0 (absence of cellulite) to grade III cellulite (skin dimpling on standing as well as in supine position and can be exacerbated by skin pinching). It is important to grade the severity of cellulite properly to gauge which treatment would be most effective.
Before any procedure, the physician should take a thorough medical history and physical examination of the area ( Box 1 ). It is important to note any bleeding problems or infections in the past. The time course when the patient first noted the cellulitic areas should be ascertained along with a history of any previous surgical or noninvasive procedures. Any trauma of the area should be ascertained. Also any lymphatic or vascular insufficiency or surgery of the area should be assessed. For any nonsurgical or surgical procedures, a medication and allergy history should be taken, highlighting any medications that interact with the cytochrome P450 enzymes.
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Past medical history
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Past surgical history—related to the area
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Medication use and drug allergies
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Physical examination—standing position
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Baseline body weights and circumference of area of interest, and body mass index
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Baseline 2D and 3D images
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Consent forms
The physical examination should be done with the patient standing to account for the force of gravity and any asymmetry should be meticulously noted. When examining the area of cellulite, the pinch test can be used, or the patient can contract the muscles in the area, to accentuate the dimpling of the cellulite. The pinch test is done by pinching the area of interest between the thumb and index finger. Tangential lighting can also aid in the visualization of cellulite because this allows for more inspection of contour irregularities. Baseline body weight and body mass index should be recorded. Also circumferential measurements of the area being evaluated (bilateral thighs, hips, or waist) may be taken. Even depths of individual cellulite depressions can be measured at baseline to compare after treatment.
Baseline photography
Appropriate imaging pretreatment is important to gauge any improvement after treatment. Cellulite photography and imaging can be quite altered by lighting and shadowing due to the undulating and rippling topographic nature of the condition. Therefore proper lighting and positioning of the patient is key. Overhead or tangential illumination of the areas should be used to visualize the surface area better. Photographs should be taken with the patient standing and muscles relaxed. A total body photograph as well as multiple close-up photos of the individual areas should be taken. These photographs can then be used to have an open and frank discussion with the patient about the severity and grading of the cellulite, as well as realistic outcomes that are possible. Another option for imaging is a 3D imaging system, such as the Vectra system (Canfield Scientific, Fairfield, NJ, USA). This technology is passive stereo photogrammetry that uses stereo-paired cameras to map out surface features. Passive stereo photogrammetry is immune to subject movement and also negates the effects of ambient room lightening. The imaging software also calculates the surface height and volume change within the treatment area ( Fig. 2 ).
Pharmacologic treatment options
The treatment armamentarium targeted toward cellulite includes weight loss, topical pharmacologic agents, and physical mechanisms. The main pharmacologic treatment options include methylxanthines (caffeine, aminophylline, and theophylline) and retinol.
Methylxanthines
Aminophylline is a compound formed from the combination of ethylene diamine in anhydrous alcohol and theophylline. It acts as an inhibitor of phosphodiesterase, which breaks down cyclic adenosine monophosphate. Its purported mechanism in cellulite treatment is through the “metabolism” of fat and cellulite by stimulating αβ2-adipocyte receptors, which can release adipose stores.
In one study 12 patients applied 5 mL of 2% aminophylline solution on the thigh and buttocks area twice a day. Patients were assessed 1 hour after first application and then subsequently at 3 weeks, 6 weeks, and 3 months. Although photographs showed varying degrees of improvement, 8 subjects demonstrated thinning of the subcutaneous layer on ultrasound taken at 3 months compared with baseline. However, Collis and colleagues evaluated the effectiveness of topical aminophylline gel in combination with 10% glycolic acid and reported no statistically significant improvement.
Retinoids
The idea that cellulite is partly composed of a weakened dermis and herniating fat protuberance leads to the thought that retinoids could treat such weakened dermis and herniating fat protuberance. Retinoid compounds are known to increase dermal collagen fibers and this is speculated to improve cellulite by preventing further herniation of fat. Kligman and colleagues conducted a study of 19 women, who were given 0.3% retinol cream over a period of 6 months twice a day and showed improvement in the side treated with retinol compared with placebo. The observer noted improvement in 12 of the 19 subjects, rating 5 subjects as having good improvement and 7 subjects as having fair improvement. Laser Doppler velocimetry was also used and showed an increase in blood flow in the area treated with the retinoid compound as opposed to the placebo-treated thigh. Ultrasound measured an increase in dermal thickness from 1.44 mm to 1.60 mm, which is statistically significant compared with placebo.
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