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Course Objectives:
Describe the microanatomy of skin tissue and cellulite development.
Compare and contrast gender differences in skin tissue and subcutaneous fat.
Discuss the efficacy of various cellulite treatment therapy options.
Cellulite: A Review of Its Anatomy, Physiology and
Treatment
There is more to cellulite than meets the eye.
By Len Kravitz, PhD, and Nicole J. Achenbach
Cellulite is a skin alteration often described as an "orange peel," "mattress" or "dimpling" appearance
on the thighs, buttocks and sometimes lower abdomen and upper arms of otherwise healthy women.
Approximately 85% of postpubertal women have a form of cellulite (Avram 2004; Rawlings 2006).
The condition is rarely observed in males. Men presenting with cellulite are commonly deficient in
male hormones (Avram 2004). The name first appeared in French medical literature in the early 19th
century (Scherwitz & Braun-Falco 1978). The original name cellulite implied that it was a disease;
however, years of study have now disproved this theory. As a matter of fact, some of the scientific
literature refers to this changed skin condition as "so-called cellulite, an invented disease"
(Nurnberger & Muller 1978; Scherwitz & Braun-Falco 1978). What follows is a comprehensive
review of cellulite research, along with answers to several pressing questions and a discussion of
purported treatments.
What Is Cellulite?
To better understand cellulite, a review of skin microanatomy is needed (see Figure 1). The outermost
layer of skin is referred to as the
epidermis.
Immediately under this is the
dermis
(also called the
corium), which is richly filled with hair follicles, sweat glands, blood vessels, nerve receptors and
connective tissue. The next layer of tissue is the first of two layers of
subcutaneous
(beneath the skin)
fat (Rawlings 2006). The prevailing evidence-based understanding is that cellulite originates in this
first region of the subcutaneous fat (called the
areolar layer,
where fat cell chambers [or lobules] are
arranged vertically in females) (Wanner & Avram 2008; Rawlings 2006; Avram 2004) (see Figure 2).
According to this scientific explanation, cellulite is caused by small protrusions of fat (called papillae
adiposae) into the dermis. This structural alteration of subcutaneous fat protruding (or herniating) into
the dermis gives skin the bumpy appearance referred to as cellulite (Sadick & Magro 2007). This
theory has been confirmed using magnetic resonance imaging (Querleux et al. 2002), sonography
(imaging with high-frequency sound waves) (Rosenbaum et al. 1998) and skin biopsy (Nurnberger &
Muller 1978). A second, similar theory is that cellulite results from a laxity (or weakening) in the
connective-tissue bands in the dermis, with the fat protrusions occurring as a consequence (Pierard,
Nizet & Pierard-Franchimont 2000).
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Figure 1. Skin Microanatomy
Cellulite and Males
Rosenbaum and colleagues (1998) and Nurnberger and Muller (1978) explain that men and women
have a different connective-tissue organizational structure in the first layer of subcutaneous fat. With
females, the adipose tissue is contained in chamberlike structures that favor the expansion of the
adipose tissue into the dermis (see Figure 2). Conversely, men have a network of crisscrossing
connective-tissue architecture, forming smaller polygonal units that allow for subcutaneous fat
deposits to expand laterally and internally, but with little protrusion (if any) into the dermis. Men also
have thicker layers of epidermis and dermis tissue in the thighs and buttocks than females (Wanner &
Avram 2008; Nurnberger & Muller 1978).
Figure 2. Schematic Diagram of Structural Orientation of Female and Male Skin and Subcutaneous
Fat
Source: Adapted from Nurnberger & Muller 1978 and Angehrn, Kuhn & Voss 2007.
Observe in the first layer of subcutaneous fat how the fat cell chamber structure in female skin allows
fat to protrude more readily into the dermis compared with the crisscrossing connective-tissue
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structure in men. Men also have a slightly thicker dermis and epidermis in the skin of the thighs and
buttocks.
Gender Differences in Subcutaneous Fat Cell Organization
According to Nurnberger and Muller (1978), who examined male and female fetuses, there is no
recognizable difference in subcutaneous tissue for up to 7 or 8 months of fetal development. During
the end of the third trimester of fetal development, the gender structure differences become apparent
and manifest themselves at birth. Variations in hormones between genders largely explain this skin
structure deviation. It has been shown that men who are born deficient in male hormones will often
have a subcutaneous fat cell appearance similar to females (Wanner & Avram 2008).
Connective Tissue in the Dermis
The connective tissue in the dermis provides the framework, insulation and stability for the dermis
layer below the epidermis. The tissue offers necessary insulation and stability between the various
organelles, permitting their proficient function without inhibiting adjacent structures. Connective
tissue is composed primarily of collagen (an inelastic tissue with great tensile strength), ground
substance (mainly water; its major role is to provide a route for diffusion transport between tissues)
and elastic tissue (which gives the skin its ability to extend and return to normal resting length).
Proposed Treatments for Cellulite
Nature’s Way.
Improving diet and exercise is an excellent way to start improving cellulite
appearance (Avram 2004). It has been shown that visible cellulite is reduced in females who lose
weight (Sadick & Magro 2007). A calorie-restricted diet plan combined with a comprehensive
exercise program (cardiovascular exercise and resistance training) should be implemented to reduce
some of the underlying body fat. Histological research (examining the microscopic structure of tissue)
shows that the fat cells do retract slightly from the dermis with weight loss (Rawlings 2006).
That said, what follows is a review of surgical options, injectable interventions, noninvasive devices,
thermal treatments, topical ointments, herbals, lasers and shock wave treatments that have all been
used in the treatment of cellulite. It is important to note that many of the cellulite treatment studies
have used relatively small sample sizes and have generally not followed up with their participants for
extended periods of time. Also, some of the methods used to analyze patient results have often been
based more on human observation rather than scientific assessment. Last, it is difficult to rule out
external factors, such as changes in diet and exercise, when interpreting the results of some studies.
Liposuction.
Liposuction is a controversial intervention for the treatment of cellulite. Although there
are some subjective reports that it has improved appearance, others have noted that it actually worsens
the dimpled-skin look (Van Vliet et al. 2005; Avram 2004). Thus, Van Vliet and Avram do not
recommend liposuction as a cellulite treatment.
Subcision.
Subcision involves inserting a needle into the dermis of the cellulite site (after injection of
a local anesthetic). The needle serves to alter the connective-tissue structure to purportedly improve
the cellulite appearance. Adverse side effects include pain, bruising for 3-6 months and skin
pigmentation alterations for 2-10 months (Van Vliet et al. 2005). No objective scientific assessment
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data are available for this technique (Van Vliet et al. 2005).
Injectables.
Phosphatidylcholine, which is a major component of biological membranes, is one
injectable intervention that has been proposed for cellulite. Advocates of injecting a biological agent
into the subcutaneous tissue argue that it promotes local lipolysis (i.e., fat cell shrinkage from the
breakdown of fat) and reduces the appearance of cellulite. Currently, no scientific evidence is
available to prove the effectiveness of these injections in treating cellulite (Van Vliet et al. 2005).
Mesotherapy was originally developed in Europe to offer pain relief for certain skin inflammatory
conditions (Rotunda & Kolodney 2006). The technique involves a series of microinjections into the
tissue layer just beneath the skin. Now, mesotherapy is also being employed as a cosmetic treatment
for fat and cellulite reduction using medications and homeopathic substances (such as vitamins,
minerals, amino acids and enzymes) injected into a cellulite site in the body. The ingredient most
consistently used in mesotherapy is phosphatidylcholine (Alster & Tanzi 2005). Although there are
findings to indicate that mesotherapy can induce lipolysis and slightly improve the appearance of
cellulite (Caruso et al. 2008), Goldberg, Fazeli and Berlin (2008) note that owing to the lack of a
precise treatment protocol and the risk of adverse effects (including swelling, infection and irregular
contours), the use of this therapy is discouraged. Alster and Tanzi note that the Brazilian National
Agency of Health banned mesotherapy in 2003 because of its undesirable effects.
Endermologie®.
Endermologie is a suction massage technique developed in France in the 1980s. It is
performed using an electrically powered device with two roller components. Recipients often wear
nylon stockings to decrease the amount of friction as the skin is drawn into the machine (with a
low-pressure vacuum) and kneaded by the two revolving rollers. Treatments last 10-45 minutes and
consist of rolling the skin of the hips, thighs, legs, buttocks and stomach. Claims are that
Endermologie improves fat tissue architecture, lymphatic drainage and capillary circulation. Research
on the mechanobiology (the science that integrates mechanics, molecular biology and genetics) of the
skin shows that deep mechanical massage will induce changes in the dermis connective tissue (Silver,
Siperko & Seehra 2003). However, in a review of the published research on Endermologie--which is
minimal--this device does not show meaningful efficacy in the treatment of cellulite (Avram 2004;
Van Vliet et al. 2005).
Massage.
Massage and tissue manipulation techniques are employed to enhance the removal of
accumulated fluid in the dermis area. These techniques do not remove the cellulite but may have a
temporary effect in reducing the dimpling appearance. Similar to Endermologie, deep massage may
induce alterations in dermis connective tissue (Silver, Siperko & Seehra 2003). However, massage
appears to offer only short-term minor skin changes, probably more related to the removal of excess
fluid (Rawlings 2006).
Thermotherapy.
Thermotherapy is a heat application technique that promotes blood flow and
vasodilation. Van Vliet and colleagues (2005) note that no studies demonstrate any effectiveness with
this treatment and that it may even aggravate the appearance of cellulite.
Topical Ointments.
The role of topical treatments in cellulite removal is divisive. An initial challenge
for any topical cream is that it must be able to penetrate the skin and dermis to reach the targeted fat
tissue before being absorbed by the tissue. Although numerous topically applied ointments are
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advertised as cellulite-diminishing creams, there are minimal data substantiating any of these claims.
The majority of the creams function to promote fat lipolysis. Methylxanthines (e.g., caffeine,
aminophylline and theophylline) are agents that stimulate lipolysis. In the review by Wanner and
Avram (2008), the authors note that the research on methylaxanthines shows a modest decrease in
thigh circumference and/or subcutaneous fat thickness, but no reduction in cellulite.
Some topical cellulite creams use retinoids. Retinoids are similar in chemical structure to vitamin A, a
well-known anti-aging ingredient in many facial creams. Retinoids, like vitamin A, have been found
to increase the denseness of the epidermis of facial skin when applied for years. The hypothesis is that
treating cellulite sites with retinoids will promote dermis thickness. Some research suggests modest
improvements in cellulite appearance with retinoid creams over a treatment period of 6 months
(Kligman, Pagnoni & Stoudemayer 1999). However, other randomized, placebo-controlled research
on retinol treatment for cellulite shows little or no change in the cellulite appearance (Pierard-
Franchimont et al. 2000). Alster and Tanzi (2005) observe that the downside of topical treatments is
their inability to appreciably penetrate skin in order to render more than a superficial effect on tissue.
On the other hand, new studies show that iontophoresis may enhance the transport of some of these
creams across the skin (Akomeah, Martin & Brown 2009), thereby increasing their efficacy.
Iontophoresis is a skin permeation enhancement strategy that delivers a charged substance across the
epidermis using an electrical current (which helps drive other molecules across the membrane).
Akomeah and colleagues suggest that this "electroperturbation" of the epidermis may potentially
improve delivery of topical cellulite creams.
Herbals.
The basis of most of the herbal treatments is to enhance microcirculation in the dermis area
and to promote lipolysis of subcutaneous fat (Rawlings 2006). It is interesting to note that research
has shown a slight decrease in thigh girth with herbal treatments but a return to normal when the
application ceases (Rawlings 2006).
Lasers.
Within the past few years, researchers have begun testing lasers, also referred to as
radiofrequency energy, as a treatment for cellulite. Radiofrequency current is defined as a
high-frequency electric current in the 0.3-100 MHz range (del Pino et al. 2006). It produces a thermal
effect (light heat) on living tissue and is currently used in surgery for various dermatological
applications. As a cellulite intervention, the application of a radiofrequency current is being tested to
observe whether it can cause weakening dermis connective tissue in the hips, thighs and buttocks to
"tighten up." The heating process from the current leads the collagen proteins in connective tissue to
denaturalize (undergo changes in their protein structure) and then "tighten" as they regain their
structural integrity, similar to the way a wound heals. It is also theorized that laser treatment increases
local blood flow and fat metabolism at the cellulite site (Sadick & Mulholland 2004).
In the del Pino et al. study, 26 healthy female patients (aged 18-50) with cellulite received two
treatment sessions (15 days apart) of unipolar radiofrequency. An appropriate energy level was set,
and the treatment was delivered in three passes of 30 seconds each. Researchers evaluated the
thickness of the subcutaneous tissue in subjects’ buttocks and thighs before the first and second
treatment, then 15 days after the second treatment, using a real-time scanning image ultrasound. The
treatment resulted in visually (and with ultrasound imagery) observable decreases in cellulite
appearance, with improvements still visible 6 months following the treatment. Goldberg, Fazeli and
Berlin (2008) also employed radiofrequency treatments (six treatments every other week) and noted
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