Cellulite Formation and Treatment: New Evidence Based Medicine
Dr. Kenneth Hughes, Harvard-trained, board-certified plastic surgeon in Los Angeles, has been developing cellulite reducing mechanisms for a decade and the technology to treat cellulite has been evolving. Cellulaze several years ago and then Cellfina have become big business in the plastic surgery industry. Many of these technologies are touted as less invasive. However, cellulite does not lend itself to simple characterization or minimally invasive treatment. Dr. Kenneth Hughes has been performing cellulite reduction surgery for years and feels that the article presented largely underscores the same issues he has promulgated for years.
The article details are listed below.
The Anatomical Basis of Cellulite Dimple Formation: An Ultrasound-Based Examination. Plastic and Reconstructive Surgery: September 2021 – Volume 148 – Issue 3 – p 375e-381e
This study used ultrasound to visualize subcutaneous changes of cellulite to aid with treatment guidance and complication avoidance.
Cellulite dimples were examined on the bilateral thigh and buttock regions of 50 consecutive women and each dimple was scored with the Hexsel Cellulite Scoring System based on severity. Cellulite dimples were then analyzed by ultrasound to identify the presence, orientation, and origination of subcutaneous fibrous bands and the presence of associated vascular structures.
Two hundred total sites were examined, with 173 dimples identified. Of these, 169 demonstrated the presence of fibrous bands (97.6 percent). The majority of bands demonstrated an oblique (versus perpendicular) orientation to the skin (84.4 percent), with the majority (90.2 percent) taking origin from the superficial fascia (versus the deep fascia). Overall, 11 percent of bands had an associated vascular structure. When stratified by body mass index, overweight and obese patients had a higher likelihood of having an associated blood vessel visualized.
Ultrasound appears to be a valid technique to image the subcutaneous architecture of cellulite. This technology can help guide surgeons in real time to improve outcomes and minimize complications while performing cellulite treatments.
Although ultrasound is not an unreasonable technical adjunct to cellulite reduction procedures, Dr. Hughes has found it unnecessary. Dr. Kenneth Hughes is able to feel the release of the cellulite bands during surgery and their subsequent release. In addition, he observes the concomitant improvement in the surface dimpling.
As the cause of cellulite remains unclear, recent research into this topic has shifted from prevention of cellulite toward its treatment. Previously proposed treatments have included topical treatments with caffeine and retinoids, laser and radiofrequency devices, and cryolipolysis. One treatment option that has been gaining interest in the literature recently is the tissue stabilized-guided subcision approach or “subcision approach,” where a needle is inserted beneath the skin into the area of subcutaneous depression to release any potential tethering of the skin to the underlying fascia, postulated to cause dimpling. Several newly developed devices that use the tissue stabilized subcision technique have been associated with high levels of patient satisfaction and give promising results for a treatment option. Despite this array of treatments modalities, there has been little prior research regarding the anatomical basis of cellulite to support or refute such interventions. A 2002 study by Querleux et al. used magnetic resonance imaging to demonstrate that areas of cellulite have a higher percentage of fibrous septa in the subcutaneous tissue, perhaps contributing to the indentations appreciated as cellulite dimples. Unfortunately, this study was unable to determine the precise orientation of these septa (perpendicular or oblique to skin) or where in the subcutaneous tissue these bands originated.
PATIENTS AND METHODS
Between February of 2019 and April of 2020, 50 consecutive female volunteers were examined for the presence of cellulite.
Cellulite Dimple Analysis
The paired right and left posterior thigh and buttocks of each patient were visually inspected, and the most severe cellulite dimples were selected. For the purposes of analysis, each area was considered separately (buttock and thigh) and the contralateral regions considered independently. Accordingly, each of the 50 patients had four sites evaluated for a total of 200 anatomical sites. If no cellulite dimple was present in the areas examined, no further ultrasound analysis of that anatomical area was performed. Each dimple was graded with the Hexsel Cellulite Severity Scale, which takes into account the number, extent, and severity of the dimple.
Ultrasound Measurements and Analysis
After visual analysis, an ultrasound probe with a 15-MHz transducer was applied to the preselected dimples to identify any subcutaneous related anatomical structures such as fibrous bands or blood vessels. First, the skin depth at each dimple was measured to further characterize the morphology of skin at the level of the cellulite. This measurement was from the epidermis to dermis and was clearly delineated on the ultrasound image. Next, measurements were made from the skin to the superficial fascia and skin to the deep fascia to identify the thickness of the superficial and deep subcutaneous tissues at the level of the dimple, respectively. The superficial fascia, identified as a hyperechoic area within the subcutaneous tissue, is analogous to the Scarpa’s fascia over the abdomen. The deep fascia lies anatomically just superficial to the muscles.
After measurements were taken, each cellulite dimple was examined on ultrasound for an associated fascial band extending from the skin through the subcutaneous tissue toward the fascia. If a fascial band was present, it was further characterized by its orientation as either straight (perpendicular in orientation to the skin) or oblique (at a nonperpendicular angle to the skin). Furthermore, the fascial band was further defined as originating from either the superficial fascia or the deep fascia
A total of 50 female patients were included in the study, with a potential 200 anatomical sites for examination. Of these, 173 sites (86.5 percent) had evidence of clinically identifiable cellulite dimples, and the remaining 27 sites (13.5 percent) were excluded from ultrasound examination. Of these 173 sites, 81 (46.8 percent) were on the thigh and 92 were on the buttock (53.2 percent). Patients presented to the office for a variety of different reasons; none presented for consultation related to body contouring, liposuction, or cellulite. Patient age ranged from 21 to 55 years, with an average of 36 years; the average body mass index was 25.7 kg/m2. Recorded Hexsel Cellulite Severity Scale grades for both the buttock and thigh cellulite dimples ranged from 1 to 15. On evaluation of each buttock dimple, the average Hexsel Cellulite Severity Scale score was 7.12, with a most severe dimple scale score of 1.78. In comparison, the average Hexsel Cellulite Severity Scale thigh grade was 7.69, with a most severe dimple scale score of 1.87.
By ultrasound examination, skin thickness was measured at the exact location of each dimple selected. The average skin thickness was 0.28 cm for the buttock dimples and 0.26 cm for the thigh (p value not statistically different). The mean distances from the skin to the superficial fascia and the skin to the deep fascia were not statistically different between the buttock dimples and thigh dimples (0.84 cm versus 0.82 cm, and 1.60 cm versus 1.62 cm, respectively). Cellulite dimple bands, if present, were further characterized into having either an oblique or straight orientation through the subcutaneous tissues. Of the fascial bands present, the majority (92.31 percent) had an oblique orientation compared to a straight arrangement (7.69 percent). The obliquely oriented fascial band was the dominant variant seen in both the buttock (83.7 percent) and the thigh (85.2 percent) sample sites.
Multiple causes are thought to contribute to cellulite formation, including vascular, inflammatory, hormonal, and structural causes, but little is known about the anatomy of cellulite. Several proposed treatments, especially minimally invasive options, have been used with limited success likely because of the uncertainty regarding the underlying anatomical structural causes of cellulite. Despite this gap in knowledge, various treatment options continue to be used with varying efficacy because of the lack of comprehensive data regarding patient-specific anatomy and cellulite morphology. This study aimed to demonstrate the use of ultrasound as a reliable, point-of-care tool for the anatomical analysis of cellulite to aid in the understanding of its subcutaneous composition, which can be used to further the development and evaluation of treatment options.
This study demonstrated a preponderance of obliquely oriented fibrous bands that originated from the superficial fascial layer of the subcutaneous tissues, which has previously not been reported in the literature to date. In addition, and perhaps equally importantly, the ultrasound examination reported approximately 10 percent of bands to contain an associated blood vessel. Interestingly, these findings were not statistically different when comparing the buttock and thigh locations, which are two of the most common anatomical locations to find cellulite. These characteristics, and their consistency across anatomical sites, have a significant impact on the development and efficacy of proposed treatments for cellulite, and the complication risk. Several minimally invasive treatments specifically target the release of these fibrous septa contributing to cellulite dimples; however, until this point, it was unclear precisely where in the subcutaneous tissue these bands existed so they could be released accurately and precisely. These results provide insight into the clinical observation that the depth of subcision is a major determining factor for outcomes. Because the majority of facial bands originate from the superficial fascia, it is possible that a surgeon using a depth below the superficial fascial system might fail to lyse the causative band, leading to disappointing results. In addition, given that the fascial bands are most commonly obliquely oriented away from the dimple, surgeons might need to release the subcutaneous tissue in a radius wider than previously considered. Given the traditionally high rates of recurrence of cellulite after treatment, it seems likely that real-time visualization of these fascial bands with an ultrasound device during release might be able to improve the outcomes and decrease recurrence rates.
Understanding the subcutaneous anatomy—including the orientation, origin, and presence of blood vessels in relation to these bands—could improve efficacy and longevity of results, decrease hematoma rates, and limit pain and discomfort of excessive tissue dissection. The use of ultrasound to evaluate cellulite may lead to great advances in potential treatment options.
Some limitations of this study that must be acknowledged include a relatively small sample size given this pilot study, the user-dependent nature of the ultrasound examination of soft tissues, and the subjectivity of the photonumeric cellulite severity scale (despite its previous validation). We aimed to control for the latter by having two independent examiners score the cellulite dimples independently at the same office visit. Future prospective studies will be needed on a significantly greater number of patients to confirm the results of this study and to more closely examine the real-time application of ultrasound evaluation during subcision release of cellulite.
The knowledge of fibrous band orientation and origination and the presence of blood vessels may improve current treatment options for cellulite reduction, specifically, treatment modalities aimed at fascial band lysis. In addition, these findings may be used in conjunction with ultrasound to guide treatment in real time, by avoiding blood vessels and performing the subcision technique at the correct depth, allowing surgeons to achieve the optimal treatment while avoiding complications.