The Dr Prager Guide to Cellulite

Historically a sign of beauty and wealth, the presence of cellulite now is considered undesirable. Cellulite is the unsightly skin dimpling frequently seen on the thighs and buttocks of women, regardless of body shape and size. It is estimated that 85 percent of women over age 20 have some degree of cellulite, and the other 15 percent think they do.

Multiple topical agents, internal supplements, exercise and diet programs, massage, and even surgery have been and are being evaluated to cure this problem.

Definition And Nature

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. The term cellulite implies an inflammatory reaction of the connective tissue. However, the condition is a normal physiologic state in post-adolescent women. The purpose is to maximize adipose retention to ensure adequate reserves for pregnancy and lactation.

At the histological level, cellulite is the result of localized adipose deposits and oedema within the subcutaneous tissue. In women, longitudinal fibres 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 ethiology and nature of this condition, several treatment modalities have been developed.

Influences

Hormones, specifically estrogens and androgens, are thought to influence the formation of cellulite. Oestrogen is known to stimulate fat tissue and inhibit lipolysis (breaking down fat cells) resulting in enlarged fat cells. 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 oestrogen therapy (oral contraceptive use and hormone replacement).

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 an impairment of circulation, there is increased water retention within the subcutaneous fat layer. This causes further stress on the surrounding connective tissue fibres, which accentuates skin irregularities. Many of the currently accepted cellulite therapies target deficiencies in lymphatic drainage and microvascular circulation.

Treatments

So far there was 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. At least this is going to change to some degree now with the use of LipoSmooth

Conservative management includes the adoption of a healthy lifestyle. These lifestyle modifications may assist to reduce the appearance of cellulite by decreasing fat cell volume, thus placing less tension on surrounding connective tissue, resulting in decreased skin puckering.

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.

Ultrasound applied to the skin offers an easy way of increasing the absorption of active ingredients. During a LipoSmooth treatment these active substances are applied to the treated areas before the ultrasound pads are attached. This way penetration is greatly increased and results are improved.

An even more aggressive systemic treatment option is the direct injection of pharmacological 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.

Physical Modalities

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

Endermologieis 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.

Smart Lipo is a laser probe that is guided through keyhole surgery into the subcutaneous fat layer. The laser energy is heating up the tissue and causes the fat cells to eventually disintegrate. The mechanism is in principal similar as liposuction with the difference that instead of ripping the fat tissue out the laser heats it up to a degree that causes the fat cells to release some of the fat and eventually to perish with the result that there is less volume in the treated areas. This does take some time, between 2 to 4 months. The precise mechanism is still unknown as are the long-term effects. Certainly however the treatment is more invasive and traumatic as it appears at first. The damage to the microvascular and the lymph system would be as extensive as with liposuction since the laser needs to be powerful enough to vaporise fat cells. This will therefore result in similar long term reduction of circulation of the dermis and epidermis in the treated areas which in turn can lead to premature skin ageing, discolouration, increased skin dimpling as seen in some liposuction patients.

Subcision is a simple surgical procedure that has been noted to improve moderate to severe cellulite. With the use of local anaesthesia, 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 anaesthesia, 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.

About Surgical Intervention

It is known that in response to impairment of circulation, there is increased microedema within the subcutaneous fat layer, causing further stress on surrounding connective tissue fibres and accentuation of skin irregularities. Many of the currently accepted cellulite therapies target deficiencies in lymphatic drainage and microvascular circulation.

As you can see from this statement above the role of healthy blood supply to the skin especially through the very small blood vessels plays a huge part in treating cellulite successfully and with long lasting results. Imagine the effects of surgical intervention: A suction device or laser probe is guided through the layers of the skin where the fat cells are and the tissue is either ripped out (liposuction or liposculpture) or heated to boiling point (Smart Lipo) in an attempt to destroy the fat cells. Certainly this is extremely traumatic to the skin and the connective tissue. Of course this will cause scarring in the affected tissue, but since the blood supply of the superficial skin depends on the tissue underneath even the visible skin is going to suffer damage. The surgical trauma will be especially severe to those structures which we would like to preserve and which we know are essential in the rehabilitation of cellulite: The very small blood and lymph-vessels. As noted above the impairment of circulation causes microedema, enlarged fat cells and subsequently cellulite.

It is well known that circulation and vascularisation is the key to healthy tissue structures. Reduced circulation causes poor tissue turnover and reduced repair and cell renewal. All this is happening in scar tissue or simply: Defect healing. If vascularisation is permanently compromised, the skin reduces elasticity and skin tone, skin colour is darker and skin temperature is slightly lower compared to healthy areas. The structure of the tissue is of poorer quality compared to the unaffected tissue.

The consequences are: Premature skin ageing. This process increases over time so that often patients who underwent liposuction are unable to show off the bikini body they always wanted because of unsightly skin ageing in the previously treated areas.

What difference does LipoSmooth make in all this?

LipoSmooth is a non-invasive body reshaping system. LipoSmooth works by reversing the very causes for cellulite and stubborn fat deposits. Session after session LipoSmooth re-establishes healthy circulation and tissue conditions important for visible and long lasting results. The combination of Ultrasound Therapy, Endermology, Lymphatic Drainage, Venous Stimulation, Muscle Stimulation and the use of topical active ingredients make the system unique in its action. Each treatment module has proven to be successful in the use of cosmetic medicine, Ultrasound is effective for breaking up triglycerides into free fatty acids and to break up tissue fibrosis, Endermology is providing venous stimulation for improved tissue vascularisation. Lymphatic drainage provides the disposal of the released fatty acids and muscle stimulation helps to increase metabolic rate and improves body shape.