Harmless, but unpleasant

CELLULITE FROM A DERMATOLOGICAL POINT OF VIEW, PART 1 – Visible dents on the surface of the skin are the typical appearance of cellulite. However, it is not a real disease. Rather, those affected suffer from the visual effects. Dr. Christine Schrammek- Drusio and Christina Drusio examine the topic from a dermatological point of view.

Cellulite is a non-inflammatory change of the subcutaneous fat tissue, mainly in the thighs and buttocks. The word should not be confused with “cellulitis”, which is an inflammation of the subcutaneous fatty tissue. The typical appearance of cellulite is often called “orange-peel skin”: The skin structure is not even and firm, because visible waves and dents form on the surface of the skin.

Cellulite thus describes a cosmetically aesthetic functional condition of the skin and subcutaneous fatty tissue, but is not a real disease. Nevertheless, many women suffer from the visual effects. Data from studies estimate that about 80 to 98 percent of women are affected after puberty. And even men can get cellulite. So far, however, only a few cases are known, and they are always associated with hormone imbalance (androgen deficiency or oestrogen therapy).

How cellulite is formed
To this day, the mechanisms that lead to cellulite are not completely understood. In the past, it was assumed that the development of cellulite was connected to metabolic disorders, microcirculation and the deposition of waste products. It is striking that almost exclusively women are affected. This suggests that a gender-specific difference in the composition of the skin and the subcutaneous tissue (fat and connective tissue under the skin) plays an essential role. In the subcutaneous fat tissue there are fat cells (adipocytes) arranged in clusters, which are grouped together by connective tissue partitions (septa) in so-called fat lobules or fat chambers. In women, the connective tissue fibres (septa) run perpendicular to the skin surface, parallel to each other. These parallel strands of tissue are connected to the epidermis. In pregnancy, this ensures the necessary stretchability and elasticity of the tissue. In men, the connective tissue fibres are arranged in a lattice-like cross and are thicker. The fat cells are stuck like in a corset, are therefore held much tighter and can bulge less into the skin.

Also of importance are the sex hormones. Women tend to store fat superficially under the skin in the form of subcutaneous fat tissue on the hips, buttocks and thighs.

The female sex hormones are responsible for this: the typical female curves are formed. Men, on the other hand, tend to store fat in the abdominal area and also more frequently around the abdominal organs (visceral fat). This is due to the male sex hormones. The latest findings also show that the male sex hormones (especially progesterone) ensure that connective tissue breakdown is inhibited. This means that the supporting “connective tissue corset” around the fat chambers in men is much better preserved with increasing age than the parallel strands of connective tissue in women.
Another difference between women and men is the structural differences between the individual fat cell chambers, as clinical studies have shown. In women, the fat cell chambers differ in both height and width.

This may explain why the fat cell chambers in women can press into the overlying skin from below. If weight gain occurs due to an unhealthy high-calorie diet and a lack of exercise, the fat cells also increase in volume and the fat cell chambers become larger and larger. In addition, the capacity of the body to break down fat decreases with age. Those who know the causes of cellulite formation can now also understand what causes the visual appearance of cellulite: On the one hand, fat chambers located under the skin (subcutaneous) press against the surface of the skin – the bulges above the skin level are formed. On the other hand, the connective tissue strands (septa) contract and dents appear on the surface of the skin, similar to the stitching of a mattress. These two “target tissues” – in addition to improving the quality of the skin – are therefore also the focus of cellulite treatments.

SCHEME OF SUBCUTANEOUS TISSUE

Severity levels
Cellulite is clinically classified into different degrees of severity. In order to treat it effectively, an analysis of the severity is carried out in advance. In this way, the possible treatment effects can be narrowed down, because the success depends strongly on the initial severity and the final treatment approach.

Severity 1: The skin surface on the buttocks and thighs shows no bulges when standing or lying down. Only when the skin is pushed together does an orange peel effect appear. In this case one does not usually speak of cellulite. Significant improvements are possible.

Severity 2: The typical wavy surface appears when the muscles are tensed or when the skin is pinched. It is not visible when standing or lying down. Here, too, significant improvements can be expected through various procedures.
Severity 3: When standing or lying down, a wavy skin surface with dimples appears (spontaneously, without a pinch test). Combined therapy methods are often used here.

Severity 4: When standing or lying down, the skin shows clearly raised and sunken areas, and a bumpy, sometimes also knotty skin surface can be felt. Again, improvements can be achieved to a certain extent, but only through combined therapies.

The second part of the article focuses on cosmetic and medical treatment options for cellulite.