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Surgery and Cosmetics

Doris M. Hexsel, MD


Doris M. Hexsel, MD

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 patients.

Figure 1. Patient with 3rd degree cellulite in the upper part of the thigh and lower part of the buttock

Figure 1: Patient with 3rd degree cellulite in the upper part of the thigh and lower part of the buttock

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 The fibrous septa were also demonstrated by MRI in a recent unpublished study by Hexsel, Abreu, et al., in which the images were taken with a special filter and round skin marker (see Figure 2).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 cellulite

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 cellulite.


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 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

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 veins.

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 appearance.

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 behaviors.6


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 5: A patient presenting with 2nd degree cellulite

Figure 6. The same patient pictured in Figure 5, 20 days after subcision

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 treatment.

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 directed massage.

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.


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  2. Rossi ABR, Vergnanini AL. Cellulite: a review. J Eur Acad Dermatol Venerol. 2000;14:251-62.
  3. Laguese P. Sciatique et infiltration cellulalgique. These Méd. Lyon. 1929.
  4. Nürnberger F, Muller G. So-called cellulite: an invented disease. J Dermatol Surg Oncol. 1978 Mar;4(3):221-9.
  5. 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 Aug;10(3):161-8.
  6. 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.
  7. 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.
  8. Hexsel DM, Mazzuco R. Subcision: a treatment for cellulite. Int J Dermatol. 2000;39(7):539-44.
  9. Katz B, Hexsel D. Cellulite. In: Lebwohl M, et al., eds. Treatment of Skin Disease. In press.
  10. 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.
  11. 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 Mar-Apr;22(2):145-53.
  12. 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.
  13. Hexsel D, Orlandi C, Zechmeister do Prado D. Botanical extracts used in the treatment of cellulite. Dermatol Surg. 2005 Jul;31(7Pt2):866-72.
  14. Goldman M. Cellulite: a review of current treatments. Cosmetic Dermatol. 2002;15(2):17-20.