Cellulite is the name for collections of fat that push against the connective tissue beneath the skin. It is a herniation os subcutaneous fat within the fibrous connective tissue that manifests as skin dimpling and nodularity.
Cellulite may have many different presentations; however, it is normally recognized to have two typical lesions: the widespread alteration of the texture of the skin and dimpling.
Widespread alteration of the skin texture gives the lumpy bumpy appearance so called orange peel, cottage cheese, or mattress aspect. This is the most frequent type of lesion from cellulite. It almost always occurs in women with cellulite. The skin is irregular, uneven and no longer smooth. It has a pitting appearance. This normally is found in the trochanteric area, buttocks and back of thighs but can also be found in secondary areas such as the front of the thighs, knees, calves and inner thighs.
Dimpling consists of inward drawn lesions. Dimpling can be seen with the alteration of skin texture and there is no variation in change as is common with the widespread lesions. Dimpling is caused by hypertrophic fibrous septa of the extracellular matrix of the superficial adipose tissue which retract the shins surface. This fibrous tissue pulls the skin down giving the dimpling. Since the septa are at right angles to the skins surface, the thickened septa retract in that angle.
Note that in men, the fibrous septa is not at right angles and is more randomized. Therefore, cellulite is almost predominantly a problem in women. In men, these septa can be foung parallel to the skin surface and at 45 degrees.
Causes of Cellulite
There are many mechanisms responsible for cellulite and they are yet to be recognized. Some mechanisms include hyperpolymerization matrix mucopolysaccharides, alteration of the microcirculation, enzymatic and mechanical proteolysis of the interlobular septa, adipocytes hypertrophy, hypoxia and inflammation.
Because gender is a primary influencer of the biomechanical forces at the subdermal junction, the female sex hormone estrogen likely plays a pivotal role in the development of cellulite. In addition, high estrogen states, such as pregnancy, nursing, chronic oral contraceptive use or hormone replacement appear to exacerbate or worsen the progression of cellulite.
Current Treatments for Cellulite
In any treatment where the cutting of the septa is accomplished by dissection the side effects that can be seen are as follows; Bruising, numbness, pain after the procedure, blood dripping post procedure, nodules lasting greater than 1 month, hyperpigmentation from hemosideric deposition, permanent nodules lasting greater than 1 month, paradox bulging effect, skin irregularities, seroma and localized sensory disorders.
- Laser treatment- Typically laser treatments are invasive. A laser fiber is inserted beneath the skin and as the laser is fired, the energy breaks up the bands that cause cellulite. Results can last for 6 months or longer, but some dimpling usually returns.
- Subcision- This is a surgical procedure where a needle is inserted under the skin and the tough bands are broken. Studies show that this is effective but again some dimpling may return.
- Vacuum assisted tissue release- This is a vacuum assisted subcision where small blades are used to cut the tough bands and the tissue fills out the void to give a normal contour of the skin.
- Laser assisted liposuction- Liposuction can remove the fat very effectively but the cellulite can persist after the treatment. It can make the dimpling more obvious.
- Ultrasound- By itself, ultrasound can destroy fat but there is no evidence that ultrasound alone destroys cellulite.
- Supplements- there is no evidence that supplements remove cellulite. Some supplements that have been tried including, grape seed extract, caffeine and gingko biloba.
- Mesotherapy- This procedure involves injections of caffeine, hormones, enzymes and or herbal extracts under the skin to digest or cause the cellulite to be digested. There are no studies that show this works effectively. Common side effects of this procedure include redness, swelling, infection, allergic reactions, skin color changes and tender painful lumps.
- Cryolipolysis- This treatment freezes the fat but there have been no studies showing it treats the cellulite.
- Creams and Lotions
Research has shown some creams and lotions may reduce the appearance of cellulite. Products such as caffeine dehydrate the cells and make the appearance less obvious.Caffiene acts by inhibiting phosphodiesterase inducing lipolysis. It also stimulates the cutaneous microcirculation and is an antioxidant.
Retinol may thicken the skin and may reduce the appearance. Retinoids act by increasing dermal thickness, increasing angiogenesis, synthesizing new connective tissue components and increasing dermal fibroblasts.
Some of these lotions contain aminophylline which can produce tachycardia in some patients.
- Radiofrequency- This treatment combines radiofrequency with a laser, suction and massage to the cellulite areas. Studies suggest little change in the treated areas.
- Ionithermie Cellulite Reduction- This procedure is usually done in a spa setting where the body is covered in clay or algae or a mixture of both. Then electrodes are attached, and a current is applied. Then the area is covered in plastic. Some patients experience pain with this treatment. Studies do not show these procedure works other than toning the area.
- Weight loss- Weight gain makes cellulite more visible. However, weight loss can also make the cellulite much more visible.
- Exercise- Muscle reduces the fat and make the appearance of the cellulite less but it is still present.
- Acoustic Wave Therapy- This treatment involves the use of sound waves to improve the appearance of the skin as well as dimpling. No cutting is involved, and no anesthesia is necessary.
- Improvement in the Appearance of Cellulite and Skin Laxity Resulting from a Single Treatment with Acoustic Subcision: Findings from a Multicenter Pivotal Clinical Trial, Lasers Surg Med 2022. Jan;54(1):121-128 PMID 34224601
Purpose: Surface depressions and skin laxity together play a role in the appearance of cellulite. Cellulite depressions can be improved through disruption of the subcutaneous fibrous structures. Some currently utilized approaches accomplish this through invasive techniques requiring local anesthesia and potential down time. Skin laxity can exacerbate the appearance of cellulite, however current invasive approaches do little to improve skin laxity. The objective of this study was to evaluate a noninvasive approach to improving both cellulite depressions and skin laxity through the use of rapid acoustic pulses (acoustic subcision). Safety, efficacy, tolerability and participant satisfaction results were measured.
Conclusion: A single noninvasive acoustic subcision session can safely provide meaningful improvement in the appearance of cellulite in terms of depressions, as well as skin laxity, with minimal treatment pain and no posttreatment down time.
Aesthet Surg J Open Forum 2023;5:ojad050 PMID 37424836
Purpose: This review provides an update on the current state of knowledge about cellulite, with an emphasis on patient assessment and an individualized treatment approach. The efficacy of most treatments is unpredictable, and improvements are short lived, although significant progress has been made with the newer treatments. These will be investigated.
Conclusion: treatments that target the fibrous septa appear to produce more significant improvement that is more durable. (such as acoustic subcision)
Dermatol Surg 2023. Apr 1;49(4S):S8-S14 PMID 37000913
Objective: To discuss current cellulite treatment options and effective clinical management
Results: Advanced interventions for cellulite treatment such as physical and acoustic subcision, radiofrequency and injectable biostimulators are gradually being established with accumulating evidence showing efficacy, patient satisfaction and long-lasting outcomes.
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