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Cellulite


Evidence Levels: A Double-blind study B Clinical trial ≥ 20 subjects C Clinical trial < 20 subjects D Series ≥ 5 subjects E Anecdotal case reports

Cellulite consists of surface relief alterations with depressed and raised areas, located mainly on the thighs and buttocks but also on other areas. Depressed lesions are due to the presence of fibrous septa that pull the skin surface down; raised areas result from the projection of underlying fat to the skin surface. In addition, cellulite is aggravated by progressive skin laxity, localized fat deposition, and obesity. Treatments do not cure cellulite but can improve its appearance. Unfortunately, some studies lack blinding or controls and objective measurements.

Management Strategy

Diagnosis: Clinical

Specific Treatments

  • Subcision, which targets the subcutaneous septa that pull the skin down and addresses cellulite depressions

  • Devices and treatments that target the dermis and thus improve flaccidity and projection of fat and devices that target localized fat

  • Weight control to a normal body mass index (BMI)

  • Oral and topical treatments

Specific Investigations

  • Physical examination: patient in standing position with relaxed gluteus muscles. Determine morphologic characteristics to help guide treatment option selection:

    • Presence and depth of cellulite depressions

    • Presence of localized fat and obesity

    • Presence of flaccidity and fat herniation

  • Pretreatment and posttreatment photographs (relaxed gluteus muscles)

  • Scales: a validated photonumeric scale, cellulite severity scale (CSS), and dimple scales for pre- and posttreatment objective assessment

  • Preoperative investigations for subcision: prothrombin time (PT), partial thromboplastin time (PTT), and international normalization ratio (INR); history of coagulation disorders; use of medications that alter blood coagulation

A validated photonumeric cellulite severity scale

Hexsel DM, Dal’forno T, Hexsel CL. J Eur Acad Dermatol Venereol 2009; 23: 523–8.

A validated photonumeric severity quantitative and qualitative scale of five key morphologic aspects of cellulite. Each item is graded from 0 to 3; their sum allows a final classification of cellulite as mild, moderate, and severe.

Validated assessment scales for cellulite dimples on the buttocks and thighs in female patients

Hexsel D, Fabi SG, Sattler G, et al. Dermatol Surg 2019; 45 (Suppl 1): S2–11.

The cellulite dimple grading scales provide 5-point photonumeric assessments of cellulite severity at rest and in a dynamic state. Overall inter-rater reliability and intra-rater reliability of the scales were both ‘almost perfect’ (at rest) and ‘substantial’ (dynamic).

Side-by-side comparison of areas with and without cellulite depressions using magnetic resonance imaging

Hexsel DM, Abreu M, Rodrigues TC, et al. Dermatol Surg 2009; 35: 1471–7.

Cellulite depressions were associated to the presence of underlying fibrous septa perpendicular to the skin surface ( n = 30).

First-Line Therapies

  • Subcision

  • B

  • Devices

  • B

  • Weight control

  • B

Effect of weight loss on cellulite: gynoid lypodystrophy

Smalls LK, Hicks M, Passeretti D, et al. Plast Reconstr Surg 2006; 118(2): 510–6.

Twenty-eight subjects with visible cellulite recruited from a weight loss program and eight weight-stable subjects without visible cellulite completed a study in which 17 subjects’ cellulite improved and nine worsened.

Subcision: a treatment for cellulite

Hexsel DM, Mazzuco R. Int J Dermatol 2000; 39: 539–44.

Based on clinical assessment of pre- and posttreatment standardized photographs on 232 patients, subcision was shown to be efficacious in the treatment of high-grade cellulite. It specifically targets major cellulite depressions by sectioning the underlying fibrous septa and consequently forming new connective tissue.

Magnetic resonance imaging of cellulite depressed lesions successfully treated by subcision

Hexsel D, Dal Forno T, Hexsel C, et al. Dermatol Surg 2016; 42: 693–6.

A 7-month follow-up of moderate-to-severe cellulite-depressed lesions treated with subcision showing evident reduction in CSS grading (number and depth of the treated lesions) in the two assessed patients. The subdermal portion of the septum underlying the treated lesion was absent after subcision.

A multicenter pivotal study to evaluate tissue stabilized-guided subcision using the Cellfina device for the treatment of cellulite with 3-year follow-up

Kaminer MS, Coleman WP 3rd, Weiss RA, et al. Dermatol Surg 2017; 43(10): 1240–8.

Fifty-five women with moderate-to-severe cellulite underwent one treatment with a vacuum-assisted tissue stabilized-guided subcision (TS-GS). Assessments by subject photographs, CSSs, GAIS (Global Aesthetic Improvement Scale), and subject satisfaction showed significant improvements lasting up to 1 year; 94% of subjects had at least 1-grade improvement in the CSS (mean change of 2 points; p < 0.0001). At 3 years posttreatment, more than 91% of patients sustained improvement.

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