Cellulite:
What It Is And How We Can Help Make It Better

by Mitchel P. Goldman, M.D.

Multiple topical agents, internal supplements, exercise and diet programs, massage, and even surgery have been and are being evaluated to cure this problem. The pathophysiology of cellulite is poorly understood, and a literature review demonstrates a paucity of studies to scientifically validate currently popular treatments.

The term “cellulite” describes the dimpled or puckered skin of the posterior and lateral thighs and buttocks seen in many women. The appearance often is described to resemble the surface of an orange peel or that of cottage cheese. The condition is a normal physiologic state in post-adolescent women, which maximizes adipose retention to ensure adequate caloric availability for pregnancy and lactation.

At the histological level, cellulite is the result of localized adipose deposits and edema within the subcutaneous tissue. In women, longitudinal fibers of connective tissue fascia segregate fat into channels resembling a down quilt. As the fat layer expands, the perpendicular connective tissue remains fixed, creating a superficial puckered appearance of the skin.

This skin dimpling rarely is found in men, as the connective tissue in males is arranged in a crisscrossing pattern, which is gender-typical for the skin of the thighs and buttocks.

There are many predisposing factors that contribute to cellulite development. These include:

• Gender: Due to the underlying structure of fat and connective tissue described above, women are more likely to develop cellulite.
• Heredity: Empirically, it has been found that the degree and presence of cellulite, as with body habitus, often is similar among females within the same family.
• Race: Caucasian women are more likely to develop cellulite than Asian or African-American women.
• Increased subcutaneous fat: Due to the unique histology of skin with cellulite, more adipose tissue in the subcutaneous layer enhances the appearance of cellulite on the skin surface.
• Age: Women begin to develop cellulite after puberty as part of normal anatomical and physiological development. Cellulite increases in severity with aging as a reflection of the thinning of the epidermis.

Unfortunately, these predisposing factors are difficult if not impossible to alter, thus cellulite prevention currently is not attainable. However, based on our understanding of the etiology and nature of this condition, several treatment modalities have been developed.

Hormones, specifically estrogens and androgens, are thought to influence the formation of cellulite. Estrogen is known to stimulate lipogenesis and inhibit lipolysis, resulting in adipocyte hypertrophy. This may explain the onset of cellulite at puberty, the condition being more prevalent in females, and the exacerbation of cellulite with pregnancy, nursing, menstruation and estrogen therapy (oral contraceptive use and hormone replacement).

As such, regulation of hormone levels may help to minimize the appearance of cellulite. Unfortunately, this treatment option may result in adverse physiological and anatomical sequelae (defeminizing) and therefore has not been widely employed.

Adipose tissue is vascular, leading to the theory that cellulite may develop in predisposed areas when circulation and lymphatic drainage have been decreased, possibly due to local injury or inflammation. It is known that in response to impairment of microvascular circulation, there is increased microedema within the subcutaneous fat layer, causing further stress on surrounding connective tissue fibers and accentuation of skin irregularities. Many of the currently accepted cellulite therapies target deficiencies in lymphatic drainage and microvascular circulation.

Currently there is no cure or gold standard for treatment of cellulite. This is due in part to the minimal understanding of cellulite pathophysiology and poor therapeutic effectiveness of most treatment modalities. Therapeutic options to manage cellulite can be characterized as conservative measures, topical treatment, systemic agents and physical modalities.

Conservative management includes the adoption of a healthy lifestyle. Unfortunately, there is little evidence to support dramatic cellulite reduction with the combination of diet and regular exercise. Diet and exercise cannot alter the histological structure of the perpendicular bands connecting the skin to the underlying fascia and thus cannot eliminate cellulite in its entirety. However, these lifestyle modifications may assist to reduce the appearance of cellulite by decreasing adipocyte volume, thus placing less tension on surrounding connective tissue, resulting in decreased skin puckering.

Topical management consists of gels, ointments, foams, creams and lotions, all aimed to deliver active product to the skin to reduce the appearance of cellulite. Most active ingredients, including antioxidants and vasodilators, are included to increase microvascular flow and lymphatic drainage, which is thought to play a role in cellulite pathogenesis. Other agents may promote lipolysis, with the goal of reducing the size and volume of adipocytes, thereby decreasing tension on surrounding connective tissue and decreasing the clinical appearance of puckering.

Some topical ingredients, such as vitamin C, may help by stabilizing collagen and/or stimulating collagen deposition. Topical retinoic acid and related vitamin A derivatives have been used to stimulate circulation, decrease the size of adipocytes and increase collagen deposition in the dermis.

It is likely that the active agents in most if not all creams act through vasodilatation of capillaries and microlymphatics. Caffeine may work through a variety of mechanisms including the improvement of vascular and lymphatic flow through vasodilatation, as well as by lipolysis. The combination of mechanisms of caffeine may be responsible for noted decreases in thigh circumference.

One way to increase the effectiveness of anti-cellulite creams is the use of bio-ceramic-coated neoprene garments. These are designed to offer maximal occlusion against the skin even during motion to increase penetration of the active ingredients in the various creams. Warmth and external pressure from wearing the garment also improve absorption, which allows the anti-cellulite cream to penetrate the dermis, thereby improving efficacy.

Systemic therapy in the form of hormonal manipulation is not a popular treatment option due to its many potential adverse effects. This may include the avoidance of oral contraceptives and hormone replacement in females and the maintenance of proper androgen levels in males. An even more aggressive systemic treatment option is the direct injection of pharmacologic agents into the venous circulation, or local infiltration into the dermal-subcutaneous junction of the skin. Referred to as intradermotherapy or mesotherapy, this reduces cellulite through lipolysis of fat or size reduction of adipocytes. Studies to demonstrate the safety and efficacy of this therapeutic modality have yet to be published.

Physical therapies vary widely from non-invasive modalities such as Endermologie® (LPG Systems, Valence, France) to surgical procedures including deep subcision and liposculpture.

Endermologie is a French-designed form of deep-tissue massage that the Food and Drug Administration (FDA) has approved to diminish the appearance of cellulite. During the massage, suction is used to pull the skin into a handheld machine where the skin is compressed and rolled to increase blood and lymphatic flow and to modify the underlying connective tissue. This therapy is done in a series of 30- to 45-minute sessions over a period of months. The cellulite-minimizing effect of all forms of deep-tissue massage is temporary, and therapy must be continued to maintain results.

A new laser device recently approved by the FDA combines the rhythmic suction massage with superficial cooling and low-intensity 810-nanometer diode laser pulsation to treat cellulite. This technology, Tri-Active™ (Cynosure, Inc., Chelmsford, Mass.) was designed to increase lymphatic drainage, tighten skin by stimulating underlying muscles and fascia, and increase superficial blood flow, thereby reducing the appearance of cellulite. The treatment regimen mimics that of Endermologie, with greater emphasis directed toward the proposed microcirculation-impairment theory of cellulite formation. Tri-Active has been proven safe and easy to use, and its efficacy in treating cellulite appears to be similar to Endermologie.

Subcision is a simple surgical procedure that has been noted to improve moderate to severe cellulite. With the use of local anesthesia, this technique is performed by inserting a notched catheter into the subcutaneous layer of the skin. The catheter then is manually moved in a repetitive motion parallel to the surface to physically break the connective tissue adhesions that tether the dermis to muscular fascia. Upon rupture of these adhesions, the tethering effect is diminished and cellulite improved. Although reported successful, it is unclear if these beneficial results are long-term and, if not, how long remission time lasts.

Liposculpture involves the removal of local adipose tissue deposits to achieve a greater aesthetic body contour. Performed under local tumescent anesthesia, this surgery uses a small-tip suction cannula to remove fat from unwanted areas without altering other skin tissues. Adipose tissue most commonly is extracted from the thighs, buttocks, abdomen, back, face, neck and arms. Liposculpture may decrease the appearance of cellulite by reducing local fat volume and by disrupting the fibrous bands that cause the dimpling appearance of the skin surface. The procedure will not, however, permanently eliminate cellulite.

It is possible that a combination of liposculpture with other modalities such as subcision and/or Tri-Active may work in synergy to prolong the effects of cellulite reduction. Studies currently are being conducted to verify this hypothesis.

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