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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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Although quite a bit is known about the physiology of the menstrual cycle, science is very far from understanding everything. For instance, it is not known how estrogen is related to MMP production and utilization.

Following the late secretory phase in the menstrual cycle, there is a fall in the plasma levels of estrogen and progesterone, which is believed to be a critical—if not pivotal—step in the cycle leading to actual menstruation. Keep in mind that the endometrium is a thick mass of collagen and blood vessels, and it needs to be shed within a matter of days to make way for the new growth of endometrium. This requires a vigorous and swift lysis of the interstitial matrix by MMPs under tight control. Although the entire answer is not known, it is known that the fall level of the ovarian steroids, estrogen and progesterone, initiates the stimulation of endometrial fibroblasts to secrete MMP-1. This secretion appears to be controlled by an interleukin, specifically interleukin IL-1alphaf. This occurs around the perimenstrual phase, probably five to seven daysg.

This is the key step relating menses to the genesis of cellulite. MMP-1 is triggered to form in and be secreted from the fibroblasts not only in the uterus, but also in other fibroblasts of the body. This statement is based on the fact that women get MMP-associated diseases, such as temporomandibular joint disease2 and anterior cruciate ligament disease.3 In the case of the adipose tissue in the thighs and legs, the main target is the connective tissue, that is, the fibrous bands that support and separate the fatty tissue into discrete compartments. As these bands are broken down in a manner not yet known though it appears rather random, the fatty tissue will move upward and laterally to fill the space available. The bands that are not destroyed remain attached to the dermis and create an undulating pattern of hills (no bands) and valleys (bands still attached).

Let’s step back and look at this devastation. Here is a picture of what the inside of a cellulite area may present to a viewer.

The trabeculations, or fatty septae are fragmented in a chaotic fashion; fatty tissue is no longer confined to anatomical compartments; fat is allowed to expand in a nonphysiological manner, even producing new fat cells in the newly created spaces; every month, a new MMP insult assails this damaged tissue making it quite impossible to repair; a shattered landscape results with great globs of unorganized fatty tissue and fragmented collagen littering the interstitial spaces.