Dr Rosh Ravindran discusses the formation of cellulite and his treatment preference.
Cellulite was first described by French scientists Alquier and Paviot in 1920 as a ‘complex cellular dystrophy of the mesenchymal tissue caused by a disorder of water metabolism’.1 From more recent literature, an increased understanding of the anatomy of cellulite has shown the alteration in cutaneous topography caused by fibrous septa that is perpendicular to the skin’s surface.2 This results in the dimpled surface characteristic of cellulite.2 Although cellulite is not a disease, it is considered a non-inflammatory phenomenon3 that can lead to aesthetic, social and psychological consequences for patients. The prevalence in 2012 of cellulite was 85% amongst the 1.4 billion women aged 25-60 across the world, of whom 80% are concerned with their cellulite.4
Magnetic resonance imaging (MRI) and transmission electron micrograph studies have confirmed that cellulite depressions are associated with a significant increase in the presence and thickness of underlying subcutaneous fibrous septa.5,6 Figure 1 shows an MRI visualising the depressed cutaneous topography caused by subcutaneous fibrous septum. Although fibrous septa can be found parallel to the skin surface, in women with cellulite, a greater increase in the thickness of the inner fat was noted with MRI. A study that involved 3D reconstruction of the fibrous septae network showed a higher percentage of tortuous network septae in a direction perpendicular to the skin surface.6 I have found that standing, pinching, or muscle contraction can lead to increased tension on the fibrous septae and worsens the clinical appearance of cellulite, whereas they tend to disappear when tension is minimised with the patient lying down.7
Assessment and treatment
In 2009, dermatologist Dr Doris Hexsel et al. released a validated photonumeric Cellulite Severity Scale (CSS)8 that has become the new standard in assessment as it provides greater detail. The Severity Scale of Cellulite by Hexsel et al. is based on five criteria (refer to Figure 2):
- Number of evident depressed lesions
- Depth of depressed lesions
- Morphologic appearance of skin surface alterations
- Degree of flaccidity or loose skin
- Degree of cellulite (Nürnberger and Müller scale)9
The severity of each item is graded from one to three, allowing a final sum of scores that range numerically from one to 15. The overall grades are mild (1-5), moderate (6-10), and severe (11-15). The CSS refers to the multi-factorial causes, showing that a loose skin envelope, increased fat lobules and structural fibrous septal bands can all lead to cellulite. Numerous topical treatments and devices have been trialled; at most they show mild improvement which is not maintained.10,11 Despite the many advertorials and testimonials in women’s magazines, there is currently no scientifically-proven treatment for cellulite. Most of the evidence supporting their efficacy is anecdotal, subjective or non-existent.12 With regards to liposuction, part of the pre-procedural counselling includes the knowledge that removal of the fat with a cannula will not lead to improvement of cellulite. This is due to the fact it is not effective at removing the fibrosclerotic bands that lead to structural cellulite.13 Radiofrequency has been used as a method of attempting to tighten the skin that may help skin laxity and contouring around the buttock and thigh area.14,15 Recently calcium hydroxylapatite (CaHA) has been used as a filler by itself or in combination with microfocused ultrasound with visualization (MFU-V) to help with skin laxity and the appearance of cellulite on the buttocks and thighs.16,17
Tissue Stabilised Guided Subcision
There is, however, a new approach to permanent cellulite removal that I have found through Tissue Stabilised Guided Subcision (TSGS).19 This focal subcision study began in 2015 and was based on the foundation of manual subcision (free hand), a surgical technique first described in 1995 where a needle or cannula is used to release the dermis from tethering caused by underlying fibrous septal bands. This results in reduction of the dimpled skin topography caused by cellulite.20,21
Manual subcision is dependent on the skill and technique of the surgeon, however TSGS can be performed by a GMC-registered doctor. Superficial subcision can result in excessive elevation or necrosis of the skin, whereas subcision performed too deep may produce negligible improvement in the targeted depressions.22 A retrospective study of 232 subjects with advanced cellulite of the buttocks/thighs by Hexsel and Mazzuco demonstrated 78.87% subject satisfaction after a single treatment.20 Given the technique dependence and potential inconsistency of results with manual subcision, a vacuum-assisted system was developed. It provides tissue stabilisation through the vacuum-assisted capture platform, giving control of anaesthesia infiltration (integrated 22 gauge needle) and guided subcision to user-selected treatment depth (6 or 10mm) and area (5cm or 3×6cm) with a mechanical action of a reciprocated razor-thin needle (0.45mm).19,23,24 This is designed to provide precise focal release of subcutaneous tissue to improve the appearance of cellulite.
A recent study demonstrated the effectiveness and safety of TSGS. Kaminer et al.’s study18 held in 2015, was a multicentre non-randomised, open label pivotal study that recruited 55 participants who were aged 18-55 with a body mass index of under 35. Each adult female subject with moderate to severe cellulite, identified through the validated CSS score, underwent a single treatment of TSGS. The depth of release was in the main 6mm with a one year follow-up period. Outcome measures included blinded assessments of subject photographs, CSS, and the Global Aesthetic Improvement Scale (GAIS).25 Subject satisfaction and pain ratings were also recorded. Results showed the mean baseline CSS score of 3.4 decreased by 2.1 points to 1.3 at three months (p <0.0001) and 2.0 points to 1.4 at one year (p <0.0001), with 47 subjects (93%) having ≥1-point improvements. Subject satisfaction was 85% at three months and 94% at one year. Transient treatment-related adverse events were mild in severity and there were no device-related serious adverse events (SAE).19 The highest level of procedural pain occurred during anaesthetic infiltration and was moderate (mean score, 4.5 out of 10) and 90% of subjects displayed no bruising after four weeks, with limited down time. There were no reports of pain, treatment effects, or adverse effects at the two-year follow-up. Patient satisfaction was 96% at two years23 and 93% at three years.24 This data shows high patient satisfaction and a positive safety profile, although it is lacking in quantitative analysis on the cellulite anatomy improvement outside of the CSS and GAIS.
I believe that vacuum-assisted subcision may be the missing piece of the jigsaw, offering a strategy that can treat cellulite and provide long-lasting results. It is important to note that for skin laxity, one can consider a course of radiofrequency or CaHa filler with MFU-V but these need further studies to show their long-term benefit. I have found vacuum-assisted subcision to be safe, efficacious and the results reproducible, leading to the long-term removal of structural cellulite.
Disclosure: Dr Rosh Ravindran is a KOL for Merz Aesthetics which distributes the vacuum-assisted subcision device Cellfina that he uses.