Cellulite – the dimpled, uneven skin that mars the backsides and thighs of women everywhere – is a scourge to bikini-wearers and a squelcher of lights-on romps in bed. No wonder the search for a solution has women shelling out millions. Some of the new light was shed recently in a New York Times article by a few cellulite experts.
Miracle cures advertised on billboards and all over internet are greatly exaggerated. “At this point, there is no outstanding treatment for cellulite,” said Dr. Molly Wanner, an instructor in dermatology at Harvard Medical School and an author of an evidence-based review of existing treatments in 2008. A lasting remedy would have to address the interplay between skin, fat, connective tissue and underlying muscle.
Still, treatments abound, from contour-refining lotions and liposuction to massage machines with lasers and light sources. And there’s no shortage of takers. The market for cellulite-reduction devices in the United States was more than $47 million in 2008, said Amy Krohn, a spokeswoman for the Millennium Research Group. It is projected to grow to $62 million by 2013.
But no treatment has emerged as the gold standard. “Most studies show a 25 to 50 percent improvement after multiple treatments,” Dr. Wanner said. “Some patients have even less improvement, and the effects may go away over time so patients may require additional treatments.”
Cellulite is a telltale sign that life is a crapshoot. Most women get cellulite after puberty. But men usually don’t. That’s because the connective tissue bands under men’s skin are crisscrossed like a net, keeping their fat more evenly restrained. By contrast, women’s tissue bands are organized in vertical columns, so fat may bulge irregularly.
“At a normal weight your fat cells fall nicely into valleys of connective tissue,” said Dr. Michael D. Jensen, a clinical professor of medicine at the Mayo Clinic, who has studied fat for 25 years. “When you get too many fat cells or too big of fat cells now they push up on the roof.” Or, your skin.
What’s more, women don’t have as thick a roof as men, all the better to show dimples. And thanks to estrogen, women have more fatty reserves.
It doesn’t stop there. As we age, the connective tissue strands between our skin and muscle, which used to stretch to accommodate weight fluctuations, become inflexible. “Some of the bands tighten down and you get pockmarks with bulges next to them,” said Dr. Brian M. Kinney, an assistant professor of plastic surgery at the Keck School of Medicine at University of Southern California. Voilà, cottage cheese.
Traditional liposuction removes the fat, but it does not do anything to the inflexible connective tissue or too-thin skin. Laser assisted liposuction does a better job by heating and damaging collagen, which in turn causes connective tissue re-growth. New connective tissue is likely to have a much better flexibility and may result in tighter skin.
Cellulite is an uphill battle and no single treatment or laser modality can offer a complete cure. Cellulite reduction calls for a complex approach involving multiple laser and non-laser treatments and laser modalities. Few doctors can confidently claim that they have completed the puzzle.
Cellulite is very common. It appears in teenagers and may bother a lot of women throughout their life time. Due to the complexity of the problem, there is no permanent cure for cellulite as the lumpy and dimpling skin over the thighs, hips and buttocks still challenge the best of the cosmetic dermatologists, plastic surgeons and aesthetic physicians.
A new study posted in Longevity and Age Management, Aging, Skin-Hair, Women’s Health, Aesthetic Medicine on Wed May 13, 2009 shows that combination laser treatment and fat transplantation may help combat cellulite.
Robert Gotkin, M.D., F.A.C.S., from the Cosmetique Dermatology, Laser & Plastic Surgery, LLP, in New York, N.Y., co-authored a study to determine the effects of laser energy used in combination with an autologous fat transplant to improve the signs of cellulite.
The study included 52 women with grades 3 and 4 cellulite. Participants were treated with a 1064 nm Nd:YAG laser, after which they underwent an autologous fat transplantation in fat-depleted target areas. The laser was used to break down fat stored in fat cells, then to superficially break up the fibrous bands that connect the muscle to the skin and cause the skin to dimple and have an orange peel-like effect. Autologous fat was then transplanted to the areas with the most severe concave contour deformities. The goal was to fill out those areas in order to provide a smoother, more even contour to the target skin’s surface.
At the conclusion of the study, the participants completed a patient self-assessment questionnaire. Almost 85 percent rated their improvements as either “good” or “excellent.”
Although Dr. Gotkin believes that the results of this combination treatment are lasting, he notes that the effects will lessen over time as the women age. “As a woman gets older and continues to develop skin laxity, cellulite will likely return,” Dr. Gotkin says. “However, in the 12- to 30-month follow-up that we had in our study patients, we could significantly improve the cellulite long-term. Most of the approaches currently used in aesthetic surgery are noninvasive and therefore also achieve minimal results. Our goal was to give some permanent improvement in the appearance of cellulite and we were able to achieve that using this surgical technique.”
J Cosmet Laser Ther. 2009 Mar;11(1):34-44
Bousquet-Rouaud R, Bazan M, Chaintreuil J, Echague AV.
Dermatological Laser Unit, Millenium Clinic, Montpellier, France.
This article presents the first evaluation of the use of a high-power pulsed Nd:YAG laser for the treatment of cellulite. Three of the four authors are employees of Candela Corporation, the maker of the laser.
The study at first appears to be well-designed. Quantitative endpoints of dermis thickness and ultrasound density were chosen, and preliminary studies were performed to show that measurement methods were not subject to intra-observer or inter-observer error. Twelve patients were treated, with one thigh randomized to treatment and the other randomized to control. In addition to pre-treatment ultrasound measurements, follow-up measurements were performed at 1 month and 3 months after the final treatment of the series of three treatments. Adjunctive photographs were taken before each treatment, and presumably at the follow-up visits. The example photograph appears to be of high quality. The treatments were appropriately standardized to minimize the impact of dosage variation on outcome. Likewise, the patient population appears to be reasonably homogenous in terms of age, body mass index, and pre-treatment evaluation of cellulite severity, to minimize the impact of patient variation on outcome variation.
Given the apparent care taken in the study design, the analysis was extremely disappointing. The analysis presents only the variation in ultrasound measurements of the treated thigh, and completely ignores the control thigh. The authors claim that the mean dermal thickness of treated thighs decreases from the beginning to the end of the study, but this is a flawed claim. Because they do not present data on the control thigh, we cannot know if this result stems from a treatment effect, or from a natural variation in the patient population over time. For all we know, the dermal thickness of the control thigh improved more than the treated leg. This is the whole point of having a control thigh. No other control variables, such as BMI or weight, were presented.
Further, the authors include the raw data for the dermal thickness measurements in all 12 patients, but offer no explanation why some patients have increased thickness at 1 month follow-up which then decreases at 3 months, while other patients show decreased thickness at 1 month with subsequent increases at 3 months. Presumably, the treatment effect would go in generally the same direction in this homogeneous group that recieved the same treatment regime. This variation adds to the concern that something else was going on with these patients during the study that might effect dermal thickness. The same comments apply to the raw data on dermal echogenicity.
The exclusion of measurements of the control thigh from the analysis renders any conclusions moot. The authors further present patient satisfaction data. This type of data is notoriously challenging to interpret, as patients often feel satisfied that they are taking steps towards treating a condition. In this case, on average the patients reported being somewhat satisfied, and no patients reported being very satisfied. Readers of the article should not be satisfied at all.
Cutera will preview its Adjustable Depth Selectivity (ADS) Technology at the 67th Annual Meeting of the American Academy of Dermatology in San Francisco, March 6-10, 2009. ADS is the result of five years of clinical research conducted with in-vitro human fat cells at the Cell Culture Facility at the University of California Medical Center, San Francisco (UCSF).
The research determined fat cell survival rates following thermal exposures, which is necessary to establish treatment parameters and to make the next step in the development of new technologies for non-invasive body contouring. The two key features of this technology are the ability to selectively target and heat fat cells and to vary treatment depths within the fat.
The findings will help physicians develop new protocols for more efficacious treatment of a wide variety of patients and boost new device innovation.
A very important study was recently completed by a group of French doctors, Regine Bousquet-Rouaud, Marie Bazan, Jean Chaintreuil and Agustina Vila Echague in the Dermatological Laser Unit, Millenium Clinic, Montpellier, France.
The objective was to investigate non-invasive laser treatment for cellulite using the 1064 nm Nd:YAG laser and to correlate clinical results with high-frequency skin ultrasound images. Twelve (12) individuals of normal weight were treated on either the left or right posterior side of the thigh with the following parameters: fluence 30 J/cm, 18 mm spot size and dynamic cooling device pulse duration of 30 ms. Three treatments were performed at intervals of 3-4 weeks, and followed-up 1 and 3 months after the last session. Photographs and ultrasound imaging were assessed before each session.
The 1064 nm Nd:YAG laser resulted in a tightening of the skin and an improvement in cellulite. No side effects were reported. High-resolution ultrasound imaging showed a significant improvement in dermis density and a reduction of dermis thickness. The method is described in detail in the published study.
Infra-red lasers may constitute a safe and effective treatment for cellulite as evidenced by the high-frequency ultrasound imaging provides a quantitative and objective measurement of the treatment efficacy.
Published in: Journal of Cosmetic and Laser Therapy on 11 February 2009