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A New Look at Cellulite, Part 1

By: Peter T. Pugliese, MD
Posted: June 26, 2008, from the July 2008 issue of Skin Inc. magazine.

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Current treatments based on these theories all produce some “emperor’s clothes” effects and perhaps some visual improvement, which, at best, is temporary. No amount of pressure, suction, heat, massage, infrared or wrapping will have a lasting effect on the basic cause of cellulite. The newer modalities, such as laser therapy, high frequency energy and microcurrent, can have a positive effect as adjunct treatments, but they are not effective as sole treatment methods.

Basic facts about cellulite

  • Only women get true cellulite. It requires a serious systemic disease or gross obesity for men to have even mild cellulite. The true incidence in men is not really known, but, judging from reported cases, it must be insignificant.
  • Cellulite has a hereditary component that may be quite complex; to date, it has not been studied. For example, Asian women do not have a significant tendency toward cellulite.
  • Cellulite affects only the buttocks, thighs and legs to about four inches above the knees. Pseudo-cellulite may affect other areas in women later in life.Cellulite is a hormonal disease, sparked by estrogen and driven by the enzyme collagenase.
  • Cellulite is a treatable disease, but not curable with current biological knowledge.

Cellulite as a disease

A diseasea, as defined by the dictionary, suggests cellulite has several components of a true disease. 1. It is a pathological process (the destruction of collagen); 2. It is part of an organ (the skin); 3. It has various causes; and 4. There are specific signs and symptomsb present. These findings shall be explored in more detail as the pathogenesis of cellulite is examined.

Anatomical basis of cellulite

In the year 2000, I wrote an article about cellulite for Skin Inc. magazine that detailed the basic anatomical structures involved in cellulite.1 In that article, the current literature was reviewed and fundamental facts on the fat in cellulite were detailed; that same data will not be presented in this article.

Cellulite is a disease of the connective tissue, otherwise known as collagen. Many articles, both scientific and popular, describe the anatomy of cellulite in an erroneous manner. For example, the upper leg starting from the outside consists of the epidermis, dermis, fatty layers and muscle layer. There are two fatty layers separated by a band of tissue known as fascia. There is little or no difference between women and men in these structures. The fibrous bands that separate the fat into compartments are called trabeculaec. They are somewhat thicker and stronger in a male as seen by ultrasound in Figure 1. Notice the fragmenting of the connective tissue throughout the dermis and subdermis.

The fatty tissue is composed of exactly the same fatty acids in both sexes and is the same as other fat tissue throughout the body. The major difference is that fatty tissue in the thighs and buttocks contains more alpha-2 receptors than the other anatomical regions. The alpha-2 receptors are inhibitory to lipolysis, the utilization of fat. This fat is reserved for the potential nourishment of a baby during hard times when food is scarce. Only under these conditions, or during extreme starvation, will it be mobilized. Figure 2 shows the architecture of gluteal fat. Please see the January 2000 Skin Inc. magazine article about cellulite for more details about the structure and anatomy of the fatty tissue.1

Hormones, the menstrual cycle and enzymes