Gynoid lipodystrophy, or cellulite, affects 85% of women worldwide. It is a complex problem involving various factors. Although its pathophysiology is not clearly established, knowledge on cellulite has progressed and effective treatments can now be proposed. The aim of this article is to describe targeted treatments for different clinical forms of cellulite.
Cellulite’s pathophysiology is not completely understood. It seems that three main physiological changes are involved: Increase of proteoglycan concentration leads to an edema. Local microcirculation alteration leads to lymphedema, lipoedema, lipolymphedema, hypoxia and inflammation. An abnormal arrangement of collagen structures leads to compartmentation of fat tissue formed by hypertrophic adipocytes.
Histology of cellulite has been explained by high-resolution imaging, that shows small protrusions of subcutaneous fat into the dermis. This herniating fat gives skin the bumpy appearance. Connective tissue bands, known as fibrous septae, pull down the skin, creating dimpling on skin surface.
Cellulite is observed in hips, buttocks, thighs, and abdomen. Two typical types of lesions are observed: widespread alteration of skin texture, so called orange peel, and dimpling.
Orange peel is the most frequent type of lesion. It occurs in nearly all women with cellulite. The skin texture is irregular and uneven. Its severity can vary over time, depending on local and general factors.
Dimpling consists of single inward-facing lesions. It is not in relation to the amount of orange peel or degree of cellulite’s severity. Unlike orange peel, it is stable over time. It is caused by hypertrophic fibrous septae in subcutaneous adipose tissue, which retract the skin’s surface. Greater tension on these fibrous septae, from standing or pinching, worsens their clinical appearance.
Grade 0: no orange peel, even when pressure is applied
Grade 1: orange peel when pressure is applied
Grade 2: orange peel when standing, disappears when lying down
Grade 3: orange peel while both, standing and lying down
Laxity can also accentuate orange peel and dimpling. Clinical laxity is due to loss in firmness of the skin (dermis and connective tissues) and subcutaneous structures (hypoderm, fascia superficialis, muscles, connective tissues). It can be present or absent independently of cellulite severity or dimpling.
Lifestyle changes such as diet and exercise are a good way to start improving cellulite’s appearance. Cellulite is visibly reduced and histologically fat cells retract from the dermis with weight loss. As subcutaneous fat is layered on top of muscles, in case of muscle weakness and flaccidity, the skin surface will look uneven. Muscle training will fight this.
Complementary therapy is provided by: lymphatic massage, mechanical massage-rolling technique, mesotherapy, acoustic wave therapy, radiofrequency and more recently Microfocused Ultrasound with Visualization MFU-V as well as tissue stabilized-guided subcision.
Lymphatic massage leads to improved microcirculation, less edema, lymphedema and lipolymphedema.
You can also reduce the appearance of cellulite with a device based mechanical massage-rolling technique. This device can also improve skin tone. The technology sets the standard in bodily cellular stimulation.
Mesotherapy is efficient on orange peel. Skin appearance, tonicity, microcirculation and edema are improved. A mixture of different serums (containing non-reticulated hyaluronic acid, L-carnitine, artichoke and melilot extracts, troxerutine and minerals) can be used to support the treatment. Eight treatments are recommended in one week intervals.
Acoustic wave therapy potentiates results of mesotherapy. It is a sound wave device combined with vibromassage treating fibrosis in connective tissue and fat herniation. It also allows connective tissue tightening, circulation improvement and collagen production, which enhances skin elasticity and firmness. Six sessions are recommended in parallel of mesotherapy, two sessions a week.
A combination system of ultrasound therapy and radiofrequency can be used to achieve body contouring, fat removal and skin tightening, by specific warming of the deep fat layers. Six sessions are needed, every 10 to 15 days.
Radiofrequency devices can be used to achieve a firming and lifting effect. A controlled heating effect stimulates collagen in the dermis. The existing collagen contracts and tightens, and at the same time, new collagen fibers are produced. One session is sufficient, and can be renewed every two to three years.
Furthermore, there is MFU-V, an ultrasound technology which is FDA approved for tissue lifting. It utilizes a micro-focused ultrasound technology and visualizes precisely the targeted superficial fascia. It allows precise delivery of collagen coagulation points, while sparing the intervening tissues, to lift and tighten the skin and deeper soft tissues. This treatment is performed once a year.
A combination of this ultrasound technology and diluted calcium hydroxylapatite (CaHA) at a dilution ratio of 1:1 induces neocollagenesis and improves skin laxity, to treat orange peel. It can be repeated once a year.
Tissue stabilized-guided subcision is a minimally invasive technique of subcision, involving mechanical cutting of the retracting hypertrophic fibrous septae. It is aimed to each individual dimpling lesion and immediately leads to a change on skin surface. Tissue stabilized-guided subcision eliminates the traction on the skin from the retracting fibrous septae, improves fat protrusion by reallocating fat lobules into the spaces created and it boosts new connective tissue formation via hematomas. Tissue stabilized-guided subcision is FDA approved showing long lasting results and very high patient satisfaction in clinical studies.
Fig. 1 How tissue stabilized-guided subcision improves the appearance of cellulite
Combined treatments are recommended as there is no single exclusive treatment for the different types of cellulite. For orange peel: lifestyle changes, lymphatic massage, mesotherapy, acoustic wave therapy, a combination system of ultrasound and radiofrequency, mechanical massage rolling technique can be combined. For dimples: Tissue stabilized-guided subcision. For skin and subcutaneous tightening: physical exercise, radiofrequency, a combination of micro-focused ultrasound technology and diluted calcium hydroxylapatite (CaHA). All these three categories can be combined.
Cellulite is a frequent multifactorial ailment. It appears on the skin as orange peel and dimpling, and is worsen by laxity. Comprehensive histological and clinical understanding permits to combine efficient targeted treatments. Complete understanding of its physiopathology might one day give us the key to a unique overall treatment.