Cellulite: Is there a role for injectables?

A Clinical Guide to the Treatment of Cellulite and Comprehensive Review of the Etiology, Pathophysiology, and Utility of Intervention

INTRODUCTION

Cellulite is a common esthetic concern affecting most women. Despite its prevalence, there is no consensus on the optimal treatment approach for cellulite, partly due to the complex and multifactorial nature of its pathophysiology. Understanding the underlying biological processes along with available treatment options is important to be able to effectively counsel patients on effective management of this condition. This review aims to focus on high-quality evidence behind pathophysiology of cellulite, severity and grading, and its available treatment options.

METHODS

A comprehensive review of the literature was performed using PubMed and Embase databases. Manuscripts that provided objective data with respect to pathophysiology, grading scales, and applications of treatment options were utilized.

RESULTS

Using the existing CSS classification, an evidence-based algorithm is proposed for treatment of cellulite. Mild cellulite is best served with lifestyle modifications such as healthy diet, hydration, and exercise. Use of topicals in mild cellulite patients as adjuncts to lifestyle modifications have the highest efficacy, although there are inconsistent data on topical treatments. Moderate cellulite is best targeted with noninvasive treatment options including laser therapy, radiofrequency, and ultrasound. Radiofrequency demonstrates the strongest efficacy in the current peer-reviewed literature. Severe cellulite is recommended to be treated with minimally invasive approaches such as subcision and injectables.

CONCLUSION

Cellulite is a challenging cosmetic problem to treat, and thus multimodal treatment options should be considered in an attempt to achieve optimal outcomes and patient satisfaction. As the pathophysiology of cellulite is further elucidated, more targeted treatments may be developed in the future.

LEVEL OF EVIDENCE V

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Treatment of Dimpling from Cellulite

Background

Cellulite can be seen on the skin in widespread alterations of the skin surface and dimpling. The purpose of this study was to assess the effectiveness and safety of the manual subcision technique to treat dimpling from cellulite, using a specific class IIA medical device (Celluerase).

Methods

The multi-center observational study assessed 200 women treated in a single session for different dimpling, using manual subcision administered by Celluerase. Aesthetic outcomes were evaluated by the authors, and the patients assessed satisfaction levels.

Results

Two hundred women between 20 and 55 years were treated. The medical evaluation of patients saw improvements with an average score of 8.1, whereas the subjective evaluation by patients gave an average improvement score of 7.8. Adverse events were reported.

Discussion

Women have septa orientation at right angels to the skin surface, and those with cellulite have an irregular septa conformation, with some septa being hypertrophic-thickened, and others being narrowed-lysed. Magnetic resonance imaging has confirmed that cellulite depressions are associated with a significant increase of thickness of underlying subcutaneous fibrous septa. Subcision has immediate results because it eliminates traction on the skin.

Conclusion

The study has shown the effectiveness and safety of the manual subcision in the treatment of dimpling. The device used, designed specifically for this technique, has shown itself to be very helpful and effective in terms of practical use, aesthetic outcome and safety, with various advantages compared with other commonly used devices.

Efficacy of intradermal mesotherapy in cellulite reduction - Conventional and high-frequency ultrasound monitoring results

BACKGROUND

Cellulite affects the majority of women and is an unacceptable cosmetic defect. Therefore, effective methods for cellulite reduction are being sought. Intradermal mesotherapy is one of such methods.

OBJECTIVE

The aim of the study was to assess the efficacy of intradermal mesotherapy in cellulite reduction, using conventional and high-frequency ultrasound.

METHODS

Twenty-one women with cellulite underwent a series of intradermal mesotherapy procedures. The following parameters were assessed: thickness of epidermis, dermis and hypodermis, echogenicity of dermis and the surface area of serrated hypodermis-dermis junction. Furthermore, the thigh circumference was measured; body mass index and cellulite severity were assessed based on photographs using Nürnberger-Müller's scale.

RESULTS

Intradermal mesotherapy reduced severity of cellulite. The surface area of serrated hypodermis-dermis junction and hypodermis thickness decreased significantly as compared to baseline. Cellulite reduction was also confirmed by palpation, decreased thigh circumference and the Nürnberger-Müller's grade. There were no statistically significant changes in epidermis or dermis thickness, body weight and the BMI.

CONCLUSION

Intradermal mesotherapy offers effective cellulite reduction. It is a simple and safe treatment, which makes it popular. Further research in mesotherapy is essential due to a limited number of published studies. Ultrasound is a useful method to monitor intradermal mesotherapy and assess its efficacy.

Cellulite treatment: a comprehensive literature review

An effective and long-term treatment of cellulite has not been well established. To our knowledge, no review has analyzed the whole range of treatments for this condition. We conducted a review of in vivo studies on humans adopting the key words "cellulite" and "treatment." The studies were included according to eligibility criteria. We performed an analysis to estimate the overall effect of cellulite treatments from clinical studies. Medline library was screened up to December 2014 to identify eligible studies. We included 73 original studies in the present review. All of them were clinical studies, in most of them, only women were recruited. Above the studies searched up, 66 tested the effectiveness of an exclusive treatment performed without the association to other procedures: 11 topical agents, 10 shock-wave therapy, 10 radio frequency, eight laser therapy, five oral therapy, four manual massage therapy, three carbon dioxide therapy, two compressive therapy, two infrared therapy, one dermabrasion, and 11 devices that use an association of multiple treatments. Seven papers tested a combination of two or more treatments. The mean difference of clinical morphologic features and ultrastructural changes between the treated group and the controlled showed significant heterogeneity between studies. It is still difficult to indicate an exclusive and effective single treatment for this condition. Our analysis purposed to obtain a complete overview of the available treatments in cellulite reduction.

Efficacy of mesotherapy in facial rejuvenation: a histological and immunohistochemical evaluation

BACKGROUND

Mesotherapy, commonly known as "biorejuvenation" or "biorevitalization", is a technique used to rejuvenate the skin by means of a transdermal injection of a multivitamin solution and natural plant extracts that are thought to improve the signs of skin aging.

OBJECTIVES

This prospective study aimed to evaluate the clinical effect of mesotherapy applied to periorbital wrinkles and to quantitatively evaluate histological changes in the skin occurring in response to the same treatment.

METHODS

Six volunteers with Fitzpatrick skin types III or IV and Glogau class I-III wrinkles were subjected to a three-month course of mesotherapy injections in the periocular area (six sessions administered at two-week intervals). Standard photographs and skin biopsies were obtained from the treatment area at baseline, at the end of treatment, and at three months post-treatment. Quantitative evaluation of collagen types I, III, and VII, newly synthesized collagen, total elastin, and tropoelastin was performed using a computerized morphometric analysis.

RESULTS

The clinical evaluation of volunteers at baseline, end of treatment, and three months post-treatment revealed no significant differences. Histological and immunostaining analysis of collagen types I, III, and VII, newly synthesized collagen, total elastin, and tropoelastin showed no statistically significant changes (P > 0.05) after mesotherapy injection.

CONCLUSIONS

The present study indicates that mesotherapy for skin rejuvenation does not result in statistically significant histological changes or clinical improvement.

Cellulite's aetiology: a review

Cellulite, highly prevalent among women, represents a serious problem for many of them, and one of their main aesthetic concerns. It is difficult to pinpoint its aetiology and physiology/pathophysiology, as there are many factors that are involved in it, affect it, and many processes that are taking place simultaneously and sequentially. Our objective is therefore, to review the scientific scholarship on cellulite to explore the causes of its origin. We carried out a preliminary search of the Medline, Cochrane, and Web of Knowledge databases covering the period from 1978 to April 2011. As there is no specific key word for the phenomenon at hand, we used the following descriptors: adipose tissue, subcutaneous fat, subcutaneous tissue, connective tissue, skin, skin disease and dermis. This resulted in a retrieval of 26 articles contributing to relevant information on the aetiology of cellulite. As a result of our first research, we concluded that cellulite is a physiological phenomenon or at least, that it has a physiological origin, which is characteristic of women, and multi-causal, with the coexistence of a number of factors that trigger, perpetuate, or exacerbate it. The outstanding factors include, among others, connective tissue architecture, oestrogen action, microvascular alterations and certain genetic and hormonal characteristics. All of them provide us with future and novel clues to cellulite treatment, and is necessary to take some or all of these factors into account in developing an effective therapy. However, we are aware of the necessity of further investigation in this field.

Skin anti-aging strategies

Skin aging is a complex biological process influenced by a combination of endogenous or intrinsic and exogenous or extrinsic factors. Because of the fact that skin health and beauty is considered one of the principal factors representing overall "well-being" and the perception of "health" in humans, several anti-aging strategies have been developed during the last years. It is the intention of this article to review the most important anti-aging strategies that dermatologists have nowadays in hand, including including preventive measurements, cosmetological strategies, topical and systemic therapeutic agents and invasive procedures.

Oleoma: rare complication of mesotherapy for cellulite

BACKGROUND

Mesotherapy or intradermotherapy is used as a cosmetic procedure for many purposes, among them for cellulite.

METHODS

We report a case of oleoma on the thighs and buttocks that appeared two years after the injection of an unknown substance for improvement of cellulite.

RESULTS

Lesions and associated pruritus resolved with colchicine, leaving depressed scars.

CONCLUSIONS

Serious and peer-reviewed investigations must be performed to certify the efficacy and safety of this procedure.

Bioactive reagents used in mesotherapy for skin rejuvenation in vivo induce diverse physiological processes in human skin fibroblasts in vitro- a pilot study

The promise of mesotherapy is maintenance and/or recovery of a youthful skin with a firm, bright and moisturized texture. Currently applied medications employ microinjections of hyaluronic acid, vitamins, minerals and amino acids into the superficial layer of the skin. However, the molecular and cellular processes underlying mesotherapy are still elusive. Here we analysed the effect of five distinct medication formulas on pivotal parameters involved in skin ageing, that is collagen expression, cell proliferation and morphological changes using normal human skin fibroblast cultures in vitro. Whereas in the presence of hyaluronic acid, NCTF135(®) and NCTF135HA(®) , cell proliferation was comparable to control cultures; however, with higher expression of collagen type-1, matrix metalloproteinase-1 and tissue inhibitor of matrix metalloproteinase-1, addition of Soluvit(®) N and Meso-BK led to apoptosis and/or necrosis of human fibroblasts. The data indicate that bioactive reagents currently applied for skin rejuvenation elicit strikingly divergent physiological processes in human skin fibroblast in vitro.

Mesotherapy: a bibliographical review

Intradermotherapy is a medical procedure introduced by Pistor in 1958 that consists in the application of intradermal injections of diluted pharmacological substances that are given directly into the region to be treated. There are reports of the use of intradermotherapy to treat painful diseases, skin diseases and unaesthetic conditions. Medical clinics have been recently offering the treatment of intradermotherapy, using the more popular name for this practice - mesotherapy. There is only scant scientific information about this subject published in periodicals indexed on MedLine. Only a few states rigorously pursue this method. Most indexed publications about this subject deal with the complications of this technique. Unaesthetic dermatoses have been a common complaint in dermatologic clinics, and it has become necessary to have scientific evidence to give to patients. Therefore, well-researched scientific studies about this technique are necessary to offer data to medical professionals that will clearly explain to patients both the benefits and the risks of these procedures. A bibliographical review was conducted and we verified the need for new studies with adequate methods to confirm the benefits of intradermotherapy as used in dermatologic treatment.

Mesotherapy in Management of Hairloss - Is it of Any Use?

Mesotherapy has received a lot of publicity in the media and internet about its possible role in androgenetic alopecia. However, the subject is controversial in view of lack of documented evidence. This article provides a critical commentary on the use of mesotherapy in the management of androgenetic alopecia.

Cosmetic mesotherapy: between scientific evidence, science fiction, and lucrative business

Mesotherapy, originally conceived in Europe, is a minimally invasive technique that consists of the intra- or subcutaneous injection of variable mixtures of natural plant extracts, homeopathic agents, pharmaceuticals, vitamins, and other bioactive substances in microscopic quantities through dermal multipunctures. Its application in cosmetic medicine and surgery is gaining in popularity and acceptance and is rapidly growing in profile at an alarming rate. Despite their attraction as purported rejuvenating and ''fat-dissolving'' injections, the safety and efficacy of these novel cosmetic treatments remain ambiguous, making mesotherapy vulnerable to criticism by the generally more skeptical medical community. The technique is shrouded in mystery and the controversy surrounding it pertains to its efficacy and potential adverse effects that are subject of much concern. As with any new technology, it is important to assess the benefits, safety, experience, and standardization of mesotherapy. More studies are necessary before it can be advocated as a safe and effective treatment for body contouring and facial rejuvenation. Although the claims made about mesotherapy may be hard to believe at face value, we must be cautious about rejecting new ideas. Just as absence of proof is not proof of absence, lack of scientific validation is not proof that it does not work.

Can cellulite be treated with low-energy extracorporeal shock wave therapy?

The present study investigates the effects of low-energy defocused extracorporeal generated shock waves on collagen structure of cellulite afflicted skin. Cellulite measurement using high-resolution ultrasound technology was performed before and after low-energy defocused extracorporeal shock wave therapy (ESWT) in 21 female subjects. ESWT was applied onto the skin at the lateral thigh twice a week for a period of six weeks. Results provide evidence that low-energy defocused ESWT caused remodeling of the collagen within the dermis of the tested region. Improving device-parameters and therapy regimes will be essential for future development of a scientific based approach to cellulite treatment.

Treatment of cellulite with a bipolar radiofrequency, infrared heat, and pulsatile suction device: a pilot study

BACKGROUND

Very few therapeutic options have proven effective in the treatment of cellulite.

AIMS

To evaluate the effectiveness and adverse effects of a bipolar radiofrequency (RF), infrared (IR) heat and pulsatile suction device for the treatment of cellulite.

METHODS

Twelve subjects were treated with the RF-light-based device. All subjects were treated twice weekly for a total number of eight to nine treatments. Subjects were evaluated using standardized photographs, and measurements of body weight and circumference of treatment sites at baseline, immediately after the last treatment, and four weeks and one year after the last treatment. Clinical improvement scores of comparable photographs using a quartile grading scale (0 = <25%, 1 = 25-50%, 2 = 51-75%, 3 = >75% improvement) were judged independently by two non-treating dermatologists after the series of treatment.

RESULTS

The average body weights at baseline, immediately after the last treatment, and four weeks and one year after the complete treatment were 56.30, 56.05, 56.23, and 56.53 kg, respectively. The average circumferential reductions of the abdomen and thigh at the last treatment visit were 5.17 +/- 1.04 cm (6.32%+/- 1.82%) and 3.50 +/- 2.16 cm (6.23 +/- 3.58%), respectively. At four weeks after the last treatment, the average circumferential reductions of the abdomen and thigh were sustained at 3.17 +/- 2.75 cm (4.04%+/- 3.69%) and 3.50 +/- 2.04 cm (6.26%+/- 3.52%), respectively. At one year follow-up visit, the average circumferential reductions of the abdomen and thigh were maintained at 3.83 +/- 0.76 cm (4.64%+/- 1.15%) and 3.13 +/- 3.54 (5.50%+/- 6.12%), respectively. Average clinical improvement scores of the abdomen and thigh after the series of treatments were 0.75 (corresponding to approximately 25% improvement), and 1.75 (corresponding to approximately 50% improvement), respectively.

CONCLUSIONS

A bipolar RF, IR heat and pulsatile suction device provides a beneficial effect on reduction of abdomen and thigh circumference, and smoothening of the cellulite.

Mesotherapy and phosphatidylcholine injections: historical clarification and review

BACKGROUND

Mesotherapy was originally conceived in Europe as a method of utilizing cutaneous injections containing a mixture of compounds for the treatment of local medical and cosmetic conditions. Although mesotherapy was traditionally employed for pain relief, its cosmetic applications, particularly fat and cellulite removal, have recently received attention in the United States. Another treatment for localized fat reduction, which was popularized in Brazil and uses injections of phosphatidylcholine, has been erroneously considered synonymous with mesotherapy. Despite their attraction as purported "fat-dissolving" injections, the safety and efficacy of these novel cosmetic treatments remain ambiguous to most patients and physicians.

OBJECTIVE

To distinguish mesotherapy from phosphatidylcholine injections by reviewing their history and the relevant experimental or clinical findings.

METHODS

A comprehensive search of Medline indexed literature and conference proceedings.

RESULTS

All the published studies evaluating the clinical efficacy of traditional mesotherapy currently originate from Europe. These reports focus primarily on musculoskeletal pain and vascular disease, rather than cosmetic applications. Although experimental data suggest that a number of traditional mesotherapy ingredients may theoretically reduce fat, these effects have not been supported in peer-reviewed studies. An increasing number of reports demonstrate that subcutaneous injections of a formula containing phosphatidylcholine combined with its emulsifier, deoxycholate, are effective in removing small collections of adipose tissue. Cell lysis, resulting from the detergent action of deoxycholate, may account for this clinical effect.

CONCLUSIONS

Mesotherapy is distinct from a method of treating adipose tissue with subcutaneous injections of deoxycholate alone or in combination with phosphatidylcholine. Additional clinical and experimental studies are necessary to more definitively establish the safety and efficacy of these treatments.