Cellulite cottage-cheese-thighs

Aaron Stone MD - Plastic Surgery: Cellulite - Cottage Cheese Thighs
Aaron Stone MD - Plastic
Surgery
A board certified cosmetic and reconstructive plastic surgeon
performing plastic surgery of the eyes, face, ears, nose, breast,
abdomen, thighs in Los Angeles, California.
Wednesday, September 16, 2009
Cellulite - Cottage Cheese Thighs
Cellulite (Gynoid lipodystrophy in medical jargon) is the only word we have to describe the uneven
pitted surface or dimpling of the skin commonly seen on the thighs of women. The appearance often is
described to resemble the surface of an orange peel or that of cottage cheese. The term cellulite was
first used by Alquin and Pavot in France to describe this condition. It is common in women, rarely seen
in men and begins at various ages depending on body habitus, genetic makeup, etc. Most middle aged
women have it. The remainder thinks they have it. As sure as a woman will grow breasts after puberty,
she will get dimples and lumps on her skin. Cellulite affects only the buttocks, thighs and legs to about
four inches above the knees. I see many patients requesting correction of their cellulite and an equal
number of proposed treatments. These include aminophylline wraps, liposuction, liposuction with forked
metal tubes to cut fascial strands to the skin and combinations of liposuction with lasers. None are truly
effective.
If cellulite were solely due to the amount of fat present under the skin then men and women with the
equal amounts of thigh fat would show similar degrees of cellulite. This is clearly not the case. Even
very obese men rarely have cellulite but cellulite can even be seen in slender women with good muscle
tone who exercise regularly. After weight loss surgery the majority of patients have an improvement in
cellulite with weight loss, but the condition worsens for others. Cellulite is a complex condition, and
treatments such as weight loss have variable effects on the improvement or worsening of this condition
CAUSES
There are many predisposing factors that contribute to cellulite development. These include:
* Gender: Due to the underlying structure of fat and connective tissue described below, 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 and African-American women are more likely to develop cellulite than Asian women.
* Increased fat under the skin.
* 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 skin.
Currently there is no cure or gold standard for treatment of cellulite. This is due in part to the minimal
understanding of what exactly causes cellulite and poor therapeutic effectiveness of most available
modes of treatment.
The outer skin is separated from the underlying muscle by a layer of fat. The fat has little strength
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therefore lying parallel to the skin throughout the fat layer is a sheet of connective tissue called
superficial fascia. This fascia in turn is connected via finger like septal extensions through the fat to the
overlying skin and underlying muscle. We call the superficial fascia and the septal extensions the
superficial fascial system. This architecture helps hold the fat together and keep the skin from falling
down like a loose sock.
In some areas the distance between skin, superficial fascia and muscle or bone is very small or adherent.
It is this relationship that produces the normal body surface contours of creases, folds, valleys, plateaus,
and bulges and allows for sliding of the different layers over the bone framework with body movement.

The black bands represent adherent areas. The gray zones represent areas of intermediate thickness.
The white zones are areas with the greatest distance between components, the least adherent. Overly
aggressive liposuction in these white zone areas always give bad results because after removal of the fat
there is nothing to hold the skin in place. Since the skin can not shrink enough it just hangs there.
With age and sun damage, the entire skin-superficial fat-superficial fascial system unit relaxes and
stretches, resulting in hanging soft tissues, pseudo-fat deposit deformity and cellulite. In men the
superficial fascia is much thicker/denser than it is in women and the septal extensions are crosshatched
lying oblique to the plane of the skin. In women the septal extensions are fewer and lie perpendicular to
the skin surface. Looking from above the skin surface downward the tissues are arranged like a down
quilt with fat cells between the threads and the thread lines of the quilt are equivalent to the finger like
septal extensions. Thus in men the quilt seen from above would have more and thicker thread lines
crisscrossing in more directions lying oblique to the plane of the skin and less space between the thread
lines versus women with fewer thread lines that are perpendicular to the skin plane.

Notice that the thickness of the female thigh is much greater than the male thigh, the fat globules are
larger and some of these fat cells protrude into the skin layer contributing to a pitted skin surface
appearance.
The thicker fat layer and lower zone of adherence (below the pelvic bone) in women contributes to the
female shape and predisposes women to cellulite. That is cellulite is to women what baldness is to men.
The hormonal cycles that women go through after puberty creating the menstrual cycle may contribute
to the weakening of this superficial fascial system.
From this microscopic anatomy we can surmise 3 causes of the skin surface dimpling and a combination

of them:
1. Swollen fat cells swell that push up into the overlying skin. Since the septal extensions are fixed or
shrink with scarring and aging this creates a puckered appearance on the skin surface. This is also called
primary cellulite, or cellulite of adiposity, is not amenable to surgery and is usually seen in younger
women. It is present when the patient is supine and erect and is, therefore, not related to skin laxity or
gravity.
2. A contracting muscle pulling on the septal extensions or shortening of these septa resulting in pitting
of the overlying skin. This is easily treated by cutting the responsible septa.
3. Descent of the skin and fat that normally occurs with aging resulting in skin pitting due to the pull of
septa whose length is unchanged. This is more common in women who have an inherently weaker fascial
support system to hold the skin up. This problem is aggravated by smoking, sun damage, massive weight
loss or gain, and in some cases after liposuction. This is also called secondary cellulite, or cellulite of
laxity and is surgically correctable by lifting techniques that tighten both the skin and the superficial
fascia system. It usually appears after 35 years of age and is present when the patient is standing but
not when lying down. The appearance approves dramatically when the skin at the hip level is pinched to
correct the laxity. The body areas with the least adherence between the skin, fat, superficial fascial
system and bone or muscle will have the greatest degree of skin laxity.
4. some combination of the above 3
Now you can see why men rarely have cellulite and all of this can become more visible as the skin thins
with aging. Diet and exercise may improve the appearance by shrinking the size of the fat cells in
primary cellulite but cannot alter the structure of the superficial fascial system connecting the skin to
the muscles through the fat and thus cannot eliminate cellulite in its entirety. The skin usually is
incapable of shrinking once the superficial fascial system is damaged.
There are also 3 levels of cellulite severity

Level (1) the skin has to be pinched or muscles have to contract in order to see surface dimpling
---------------------

Level (2) cellulite is only visible when standing
----------------------
Level (3) cellulite is visible when standing or sitting with raised and depressed areas and nodules
----------------------
TREATMENTS

The market for cellulite-reduction devices in the United States was more than $47 million in 2008. It is
projected to grow to $62 million by 2013. Therapeutic options to manage cellulite can be characterized
as topical treatment, injected agents, non-invasive physical modalities and invasive physical modalities
(surgery, lasers, liposuction…).
Topical management consists of gels, ointments, foams, creams and lotions applied to the skin surface.
In 2008, 40 percent more anti-cellulite creams were introduced than the previous year. Most active
ingredients, including antioxidants and blood vessel dilators, are included to increase blood flow and
lymphatic drainage. Some irritate the skin to cause skin swelling and thereby camouflage the cellulite.
Other agents may actually promote the breakdown of fat cells or attempt to locally increase cell
metabolism. Some topical ingredients, such as vitamin C, and vitamin A derivatives have been included
to stimulate circulation, and affect the superficial fascial system. Some have tried to increase the
effectiveness of anti-cellulite creams by using bio-ceramic-coated neoprene garments to increase the
penetration of the active ingredients in the various creams. The best subjective assessment, by the
patients themselves, revealed that only 3 of 35 aminophylline cream-treated legs had their cellulite
appearance improved after 12 weeks of treatment. There is no difference in fat metabolism in areas of
cellulite vs. areas without cellulite. Thus, aminophylline, resveratrol and other such creams have no
effect. Save your money and stay away from these.
Some creams contain anti-estrogen compounds usually derived from plants. These may prevent the onset
or progression of cellulite by blocking the effects of body hormones on the superficial fascial system.
Once the damage is done it is unlikely that these could be effective.
The direct injections of pharmacologic agents into the veins, or local infiltration just under the skin
referred to as intradermotherapy or mesotherapy, has been used to breakdown fat cells in an attempt to
improve the look of cellulite. My views on this are quite negative and are fully elucidated in my blog
Mesotherapy, Lipo-Dissolve, or Injection Lipolysis
A 2006 published study postulated that if the anchoring connective tissue septae and/or enlarged fat
cells could be destroyed by the enzyme, collagenase that the cellulite would be improved. This enzyme
destroys collagen in the superficial fascial system. They showed improvement with just one injection of
collagenase. Cellulite area was reduced by 77% by day 1 in comparison to baseline and the resulted
lasted with reductions of 74% at 1 week, 89% at 1 month, 86% at 3 months and 76% at 6 months. The
patient satisfaction score was 1.75 at 6 months (1= completely satisfied, 4= not satisfied) while weight
and thigh circumference did not change. Side effects included injection area soreness, bruising and mild
swelling that resolved within a week or two. As yet this has not been FDA approved and the treatment
may be hard to control. This may end up making the problem worse by further destroying a stretched
and weakened superficial fascial system.
Non-invasive physical modalities include non-invasive modalities such as Endermologie® (LPG Systems,
Valence, France). Endermologie is a French-designed form of external mechanical 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. The massage stimulates the body to thicken the superficial fascial system
by laying down more collage and ruptures some fat cells. There has been no evidence to date whether or
not after a certain number of treatments you can stop and will have permanent reduction of cellulite.
For less severe forms of cellulite endermologie may turn out to be the treatment of choice.

Invasive physical modalities include surgery, laser and liposuction.
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.
Subcision is a simple surgical procedure that has been noted to improve moderate to severe cellulite.
With the use of local anesthesia, this technique is performed by inserting a notched metal tube into the
fat 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 skin to the muscle. This should only
be used for cause #2 listed above. Over use of this can cause the skin to sag with gravity creating other
unsightly problems that may be impossible to fix.
Liposuction 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. Liposuction removes fat, but doesn’t solve connective tissue or skin
thickness issues that contribute to cellulite. My malpractice insurance carrier requires me to add the
disclaimer that liposuction does not cure cellulite on my liposuction consent forms.
In 2005 lasers that were preferentially absorbed by fat were developed. Others have worked on
radiofrequency removal of fat. Another proposed treatment was selectively heating the superficial
fascial system basically cooking it to the point where it shrinks. This sounds great but in reality did not
deliver as promised.
SmoothShapes is one machine recently promoted in Shape and InStyle magazines as a worthy weapon.
This device combines massaging rollers with a laser and a light source that is meant to smooth skin and
influence circulation. Another in-office machine garnering attention is VelaSmooth, which uses infrared
light, radiofrequency and mechanical massage.
The F.D.A. still accepts before-and-after photos as proof of a cellulite treatment’s effect, despite the
fact that photos are easily manipulated. The lighting, the angle that someone’s leg is at in the picture —
all those will affect the appearance of the dimpling. Pressing a palm down hard on the back of the thigh
for a few seconds is enough to make cellulite pits appear shallower, at least for the seconds it takes to
snap a photo. When the buttock is tensed or clenched, the cellulite on it will look worse. All of these
methods have been used in photo ads to sell cellulite treatments.
Thigh buttock lifts or belt lipectomies (removal of a section of skin that lies under what is normally
covered by underwear or a bathing suit) tighten both the skin and the superficial fascial system.

The photo on the left shows a woman with secondary cellulite or cellulite of laxity. The middle photo
shows the degree of improvement achieved by lifting the skin and fat layers and verifies this is cellulite
of laxity. The photo on the right shows the improvement achieved after a belt lipectomy surgery.
However I do not recommend this surgery unless there is very severe skin sagging and/or excess skin
especially in younger women. The degree of improvement after surgery for simple cellulite does not
warrant the severity of the surgery. Also the patient with excess skin will be much happier after surgery
than the patient who just has some cellulite because the procedure cannot completely smoothen the
skin surface. The superficial fascial system can stretch out further after the surgery so that the result
diminishes over time but with lifestyle changes to maintain a level body weight the patient will not get
excessive sagging skin again. For all of my abdominoplasty/tummy tuck patients I design the skin
removal to achieve some tightening of the thigh with improvement in their cellulite. In those cases the
primary reason for the surgery is the abdomen and as long as the abdomen looks good the patient is
happy. Of course they are even happier with the thigh improvements. I will have to leave that for a
future blog.
Here are photos of abdominoplasty patients in which you can see the improvement in the thighs after
surgery.

Cellulite cottage-cheese-thighs

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