Wednesday, January 04, 2006
Cellulite, a condition of the skin and subcutaneous tissue, can
be considered a dermatologic condition. The number of affected
patients is enormous. Thus, it is possible that dermatologists will
become more interested in studying and treating this condition in
the coming years, and the industry may develop new treatments for
this common condition.
The term "cellulite" originated in the French literature and has
had various synonyms. It was described in 1920 as an unaesthetic
condition by Alquier and Paviot.1,2 In the same decade,
Lagueze described cellulite as a hypodermic disease characterized
by an increase in fat and interstitial edema.3 As the
suffix "ite" usually means inflammation, the term "cellulite" is
incorrect, but it's widely used and accepted by physicians and the
population in general.
Cellulite is characterized by alterations in the skin surface,
occurring mainly in the thighs and buttocks of female patients (see
Figure 1). It may also be found on the arms, abdomen, and legs.
Cellulite usually appears after puberty and is more common in obese
Figure 1. Patient with 3rd degree
cellulite in the upper part of the thigh and lower part of the
On physical exam, two clinical aspects can be seen in cellulite
patients: the orange-peel skin and the mattress appearance.
The mattress appearance is caused by raised and depressed
lesions in the skin surface. The depressed lesions are caused by
the traction of subcutaneous septa to the skin surface while the
raised areas are usually due to tension of the fat lobules. These
findings were confirmed in 1978 by Nürnberg and Müller4
when they studied anatomical aspects of cellulite in deep-tissue
biopsies from 180 patients. These authors described the anatomical
basis of cellulite as well as the crucial differences in fat
distribution between men and women.
Magnetic resonance imaging (MRI) recently contributed to the
understanding of this condition. The fibrous septa were also
demonstrated by MRI in a recent unpublished study by Hexsel, Abreu,
et al., in which the images were taken with a special
filter and round skin marker (see Figure 2). Furthermore, the
orange-peel appearance may be caused by the dermic extrusion of
superficial fat, as shown in another MRI.5
Figure 2. Patient with cellulite at
MRI. The left round marker was positioned on a depressed lesion of
2nd degree cellulite, showing thick fibrous septa. The
right round marker was positioned on a normal area without
There are no alterations in skin color in cellulite lesions, and
they are usually asymptomatic. The diagnosis of cellulite is based
on the clinical appearance and topographic aspects of the
condition. Histopathology does not show relevant alterations to the
skin or subcutaneous structures. Further exams are generally
unnecessary for diagnostic purposes. However, they play a role in
research for future better understanding of the condition, as some
important aspects remains unclear.
Patients should be examined in a standing position, with relaxed
gluteus muscles. Factors that can make lesions more evident are
direct light from ceiling to floor as well as the contraction of
the gluteus muscles contraction and the pinching of the skin (see
Figures 3 and 4).
Figure 3. A patient presenting with
2nd degree cellulite
Figure 4. The same patient pictured in
Figure 3, showing a worsening of the lesion by muscular contraction
and manual pressure in the affected area
Cellulite is classified by the following scale of degrees:
- 0 degree: no alteration in the skin surface
- 1st degree: no alteration in the skin surface at
rest, but alterations are present during muscular contraction of
the affected area or by the pinch test
- 2nd degree: alterations to the skin surface are
visible with the patient standing, with relaxed muscles and without
the use of any manipulation
- 3rd degree: same alterations as seen in
2nd degree, plus raised areas and nodules
It is still unclear which factors play a role in cellulite.
Hormonal status can possibly play a role, as cellulite often
appears in female patients but is rare in men. Alterations to the
microcirculation are also cited, as well as the conditions that can
alter the microcirculation, such as smoking. Nonetheless, our
sample of more than 1,700 patients with high degrees of cellulite
showed that more than 80% of the patients did not smoke and a very
small number had circulatory problems, such as abnormal leg
Two clinical conditions can aggravate cellulite lesions:
localized fat and flaccidity or loose skin.
The main aggravating factor for cellulite is weight gain.
Depositing the fat into the fat lobules can worsen cellulite
lesions, especially since in females the fat tends to accumulate in
the areas of the body affected by cellulite (a pear-shaped
distribution of fat). Additionally, this may cause mechanic
compression to the small vessels between the fat lobes.
Flaccidity is another aggravating factor for cellulite, which
increases with age and the force of gravity over the years. It is
characterized by a permanent and progressive hyperdistention of the
skin, especially in the inner part of thighs and arms, which become
loose, worsening the surface alterations with draped
Sixty-two patients with cellulite were invited to answer a
questionnaire in order to check how cellulite was affecting their
lives. Questions involved their social, recreational, professional,
and psychological behaviors. Sixty-seven percent reported that the
presence of cellulite in their bodies interferes with their lives,
causing embarrassment in their social, recreational, and sexual
activities. For example, a significant number of patients reported
being embarrassed to be naked. Patients also avoided the beach due
to fear of exposing their bodies, and they avoided wearing light
and tight clothing as well as practiced other avoidance
Many treatments have been proposed for cellulite, but few
studies have proved their efficacy.
Cellulite can be treated surgically. Subcision for the treatment
of cellulite was initially published in 1997,7 and a
step-by-step of the procedure was published later.8
Subcision can be considered a first-line therapy for this
condition, as it is an efficient treatment for high-degree
cellulite7-9 (see Figures 5 and 6).
Liposuction can secondarily improve cellulite lesions by
decreasing the amount of fat in the subcutaneous
tissue.10 Yet, the most frequent liposuction sequel can
worsen cellulite by resulting in a new surface alteration.
Furthermore, this sequel can also be treated by subcision.
Figure 5. A patient presenting with
2nd degree cellulite
Figure 6. The same patient pictured in
Figure 5, 20 days after subcision
For lower degrees of cellulite, which can also be present in
some patients with higher degree cellulite, some alternatives may
be used, such as mechanic treatments, lasers, and topical
Spa therapy relies on the belief that cellulite is caused by
lymphatic obstruction and that massage will treat it. Mechanical
treatments include massages performed manually (especially
lymphatic drainage) or by machines. Endermology is the most popular
method of mechanic massage and suction technique for cellulite that
allows positive pressure rolling, in conjunction with applied
negative pressure to the skin and subcutaneous tissues, using rolls
that promote suction of the skin and drainage.11,12 Some
machines promote mechanic massages without suction, such as the
MD-2000™. They lipo modulate the affected areas by deep and
New lasers recently were developed for the treatment of
cellulite. The first machines currently in the market use massage,
diode laser and cooling (TriActive™), or bi-polar radiofrequency
and infrared light (Vela-Smooth™). Both intend to promote tissue
mobilization to effectively recontour the skin surface. Tightening
machines can also be helpful, such as Thermacool™ and Titan™, as
they can treat flaccidity or loose skin, another important
aggravating factor. There are no published studies as of this
writing that evaluate these devices.
Topical treatment is indicated in mild cellulite cases
(1st degree) and is also used as an adjuvant for
surgical, mechanical, and laser treatments. Many active ingredients
are used, such as methylxantines, retinoids, alpha-hydroxy acids,
silanols, iodized organic complexes, Coenzyme A, Bladderwrack,
Butcher's Broom, Gingko Biloba, Horse Chestnut, Asiatic Centella,
Fuccus, and others botanicals.2,13 Recently a
bioceramic-coated neoprene pant14 was cited in the
literature as useful in the treatment of this condition.
Moreover, simple measures are very important in the treatment of
cellulite, such as lifestyle changes, including weight control
through diet and exercise as well as reduced hormone intake. These
should be recommended to all patients.
- Bacci PA, Leibaschoff G. Celulitis. Med Book.
- Rossi ABR, Vergnanini AL. Cellulite: a review. J Eur Acad
Dermatol Venerol. 2000;14:251-62.
- Laguese P. Sciatique et infiltration cellulalgique.
These Méd. Lyon. 1929.
- Nürnberger F, Muller G. So-called cellulite: an invented
disease. J Dermatol Surg Oncol. 1978 Mar;4(3):221-9.
- Mirrashed F, Sharp JC, Krause V, et al. Pilot study of dermal
and subcutaneous fat structures by MRI in individuals who differ in
gender, BMI, and cellulite grading. Skin Res Technol. 2004
- Hexsel D, Hexsel C. Social impact of cellulite and its impact
on quality of life. In: Goldman, Hexsel, Bacci, Leibashoff, eds.
Cellulite: Pathophysiology and Treatment. New York, NY:
Marcel Dekker, Inc.; 2005.
- Hexsel DM, Mazzuco R. Subcision: uma alternativa cirúrgica para
a lipodistrofia ginóide ("celulite") e outras alterações do relevo
corporal. An Bras Dermatol. 1997;72(1):27-32.
- Hexsel DM, Mazzuco R. Subcision: a treatment for cellulite.
Int J Dermatol. 2000;39(7):539-44.
- Katz B, Hexsel D. Cellulite. In: Lebwohl M, et al., eds.
Treatment of Skin Disease. In press.
- Katz B. Update in liposuction and how it can affect cellulite.
[Oral communication]. 1st International Symposium on Cellulite.
June 3-4, 2005. Porto Alegre, Brazil.
- Chang P, Wiseman J, Jacoby T, Salisbury AV, Ersek RA.
Noninvasive mechanical body contouring: (Endermologie) a one-year
clinical outcome study update. Aesthetic Plast Surg. 1998
- Collis N, Elliot LA, Sharpe C, Sharpe DT. Cellulite treatment:
a myth or reality: a prospective randomized, controlled trial of
two therapies, endermologie and aminophylline cream. Plast
Reconstr Surg. 1999 Sep;104(4):1110-4.
- Hexsel D, Orlandi C, Zechmeister do Prado D. Botanical extracts
used in the treatment of cellulite. Dermatol Surg. 2005
- Goldman M. Cellulite: a review of current treatments.
Cosmetic Dermatol. 2002;15(2):17-20.