Article

A validated photonumeric cellulite severity scale

Authors:
  • Hexsel Dermatologic Clinics
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Abstract

With recent advances in the treatment of cellulite and localized fat, a comprehensive objective method of measuring cellulite can be potentially useful, especially since important morphological aspects of cellulite are not part of the current classification. Objective To develop and to validate a new photonumeric cellulite severity. Based on standardized photographs of 55 patients with cellulite, five key morphological aspects of cellulite were identified. A new photonumeric severity scale was developed and validated. The five key morphological features of cellulite were identified and included the number of depressions, depth of depressions, clinical appearance of evident raised lesions, and presence of flaccidity and the grade of cellulite. Each item was graded from 0 to 3, allowing final classification of cellulite as mild, moderate, and severe. Results for validation of the scale are statistically significant (P < 0.05) and are as follows: intraclass correlation coefficient > 0.7; correlation item-total > 0.7, with the exception of the right buttock; intraclass correlation coefficients 0.881-0.922; Cronbach's alpha 0.851-0.989 and factor analysis 68-76%. The proposed photonumeric scale is a consistent, comprehensive, reliable, and reproducible tool for the standardized and objective assessment of the severity of cellulite. Conflicts of interest The authors hereby affirm that neither the manuscript nor any part of it has been published or is being considered for publication elsewhere.

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... Several validated assessment scales developed in parallel to the growing use of PLLA in off-facial areas are presented (Figure 1). [32][33][34][35][36][37][38][39][40][41][42][43][44][45][46][47][48][49] A literature review of the data available on PLLA in off-face areas is proposed. The data are discussed per area and gathered in tabulated summaries focused on efficacy, safety, and treatment protocols. ...
... Interestingly, the development of body applications has stimulated clinical research, the set-up of methods for assessing quantitative effects and particularly assessment scales for the main signs as skin laxity, 32,33,40,44,48 cellulite severity, [37][38][39]41,42 cellulite dimple, 34 wrinkles, 35,36,49 volume, 45,46 and striae distensae. 43 The increasing interest in the body treatment approach is remarkably apparent due to the number of scales published in the recent past years from 2019 to 2021 [32][33][34]37,38,40,[43][44][45] for buttocks/thighs, abdomen and knees in addition to the well-established ones logically concerning the neck and chest, hands and cellulite from 2008 to 2016 (Figure 1). ...
... 43 The increasing interest in the body treatment approach is remarkably apparent due to the number of scales published in the recent past years from 2019 to 2021 [32][33][34]37,38,40,[43][44][45] for buttocks/thighs, abdomen and knees in addition to the well-established ones logically concerning the neck and chest, hands and cellulite from 2008 to 2016 (Figure 1). 35,36,39,42,45,46,48,49,144 Recommendations 6,8,27,100 and reviews 26,73 provide information on practices. Research on implementation on the body has also accentuated the use of product dilution according to area treated and of higher volume injected for large and depressed areas. ...
Article
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The number of aesthetic procedures performed worldwide continues to grow together with an increase in the population seeking the restoration or preservation of a youthful appearance. Requests for non-surgical body rejuvenation are increasing. Patients are looking for safe and effective minimally invasive aesthetic procedures. Soft-tissue dermal fillers can meet these expectations. Based on the beneficial outcomes of these treatments in many facial areas, a new trend is developing to target body areas. Different dermal fillers are available and include collagen stimulators initially developed to restore facial volume. Furthermore, they are associated with long-lasting efficiency, a high level of patient satisfaction and a good safety profile, with mainly minor adverse events reported. In appropriate conditions of use, they are now used for body rejuvenation in clinical practice. Their use is expanding and allows addressing various issues including volume loss, skin laxity, cellulite, striae distensae and wrinkles. This review focuses on poly-L-lactic acid (PLLA), used in the first collagen stimulator and one of the most investigated in facial and in off-facial body applications. The available published data, although still limited, are presented by body area, neck and chest, buttocks, abdomen, upper arms, thighs, knees, and hands. Key features of the concerned zones and the main clinical signs affecting the body part as well as the injection modalities are provided along with the aesthetic results. This represents the state of the art on which to base further developments necessary for optimal and safe outcomes of treatment with the PLLA-based collagen stimulators and others in this class for body rejuvenation.
... Their baseline thigh characteristics showed matching of all outcome parameters (Table 1). 55.4 ± 4.6 cm 55.5 ± 4.6 cm Skin firmness, anterior thigh 0.93 ± 0.02 0.93 ± 0.03 posterior thigh 0.95 ± 0.02 0.95 ± 0.01 Blood flow, posterior thigh 0.40 ± 0.12 PU/mmHg 0.42 ± 0.13 PU/mmHg * Nürnberger and Müller scale [10]. ** Classification of cellulite based on the results of visual scores (Mild 1-5; Moderate 6-10; Severe [11][12][13][14][15]. ‡ Image analysis yields a unitless values reflecting the depth of undulations over the skin. ...
... Pregnancy, lactation, coagulation disorders, scars, local infections or marks that obscured cellulite on the thighs, systemic diseases, a history of dermatitis and/or allergic reactions to herbs, neuropathy, disorders of the skin or its vasculature, use of hormone contraceptives, anti-histamines, steroids, or had non-steroidal anti-inflammatory drugs within 3 days of beginning the study, anti-cellulite treatment within the past 3 months, or major surgery within the past year [10]. ...
... Each image was analysed using two methods: Visual Appearance: Grey scale images were presented separately to three trained judges who graded the severity of cellulite from 0 to 3 according to the Nurnberger and Muller cellulite classification scale [10]. ...
Article
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Cellulite describes unsightly skin overlying subcutaneous fat around thighs and buttocks of post-pubescent females. A herbal ‘emgel’ containing volatile oils and extracts of A traditional Thai herbal compress was tested in a double-blind, placebo-controlled trial with 18 women aged 20–50 year with severe cellulite. Appearance of cellulite (primary outcome), thigh circumferences, skin firmness, and cutaneous blood flow (secondary outcomes) were assessed at baseline, 2, 4, 8 and 12 weeks with a 2-week follow-up. Herbal emgel applied onto the thigh skin twice daily reduced cellulite severity scores in every time point. The score was reduced from 13.4 ± 0.3 (baseline) to 12.1 ± 0.3 (week 2) and 9.9 ± 0.6 (week 12). All secondary outcomes improved with both placebo and herbal emgels suggesting that ingredients in the base-formulation might be responsible. Querying of participants, analysis of their diaries, and physical monthly inspections found no adverse events. The herbal emgel safely improved the appearance of cellulite, while the base emgel may play a role for other endpoints. Further studies on the active constituents and their mechanism of action are needed to further explore these factors.
... To carry out this research, we have chosen a therapeutic tool frequently used nowadaysthat is, Monopolar Dielectric Radio frequency (MDR). In addition, we evaluate its efficacy using a validated toolthe Cellulite Severity Scale (CSS) (18,19) and the ultrasound method. ...
... An intentional and non-probabilistic sampling technique of 11 female participants who live in Seville or in the outskirts of the city was chosen. All of them fulfil the previously established inclusion and exclusion criteria (Table 1) and are aged [18][19][20][21][22][23][24][25][26][27][28][29][30][31][32][33][34][35]. After the intervention process, two samples were lost and as a consequence, nine women constituted the final sample. ...
... The degree of cellulite was evaluated directly on patients by an expert from the research group using the CSS (18,19). Variables were related to this later. ...
Article
Introduction: Despite its high incidence rate, there are few studies regarding cellulite treatment. Most of them present non-validated evaluation tools. Radio frequency is a focused treatment very used in aesthetics to reduce it. Objectives: To know the efficacy of Monopolar Dielectric Radiofrequency (MDR) treatment in dynamic application to reduce cellulite, panniculus adiposus and gluteal and posterior thigh regions. Methods: Experimental study consisting of inferior members of nine women. These received 10 sessions based on dynamic application of MDR. Variables: Cellulite Severity Scale (CSS), appearance of the cutaneous area, flaccidity and ultrasound measurement of the panniculus adiposus. Results: The final CSS score of the inferior member treated reflects statistically significative differences (p=0.023) when compared with control leg (p=0.622). Significative reduction of body perimeters at the level of the great trochanter (p=0.02), the gluteal region (p=0.03) and the midpoint of the posterior thigh (p=0.01) are found. Reduction of the panniculus adiposus measured using ultrasound techniques shows significative changes in the midpoint of the posterior thigh (p=0.028) as well as in the gluteal region (p=0.03). Conclusions: Dynamic application of MDR seems to be effective in order to reduce not only panniculus adiposus thickness but also gluteal and posterior thigh perimeters.
... It can also occur at lower abdomen, shoulders and breast. These are regions where estrogen is responsible for fat deposition [3]. The disease is accompanied by a chronic inflammatory process involving fat tissue, connective and peripheral lymphatic and blood system, as well as osteoarthritis-fibrosis degenerative materials of the subcutaneous tissues. ...
... Hexsel et al. [3] have proposed a photonumeric cellulite severity scale (CSS). Five key clinical morphologic features of cellulite were identified in this scale: ...
... Visual-palpation scale of cellulite progression according to Nürnberger and Müller[3,26] ...
Article
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Cellulite, the problem of dimpled appearance of the skin, affects approximately 85% of female population in developed countries and is classified as one of the worst tolerated by women deteriorating their quality of life and self-esteem. There is a lack of early, objective, quantitative and personalized diagnosis of different stages of cellulite, thus making prevention or early therapeutic intervention difficult. We have demonstrated the efficacy of thermal imaging using IR thermography in a group of female volunteers with different stages of cellulite. By analyzing the superficial temperature distribution of the body, it was possible to diagnose the cellulite stage. The thermal images of posterior site of thighs were recorded, and cellulite areas were identified for further quantitative analysis. We used a custom-designed classification scheme for automatic recognition of the different stages of cellulite as per the well-known Nürnberger–Müller diagnosis scheme. It was possible to diagnose the cellulite stages with over 80% accuracy. The accuracy can be further increased to over 97% using a threshold value correction scheme. Our work has shown that IR thermography when coupled with computer-aided imaging analysis and processing can be a very convenient and effective tool to enable personalized diagnosis and preventive medicine to improve the quality of life of women with cellulite problem.
... A new scale of evaluation of the severity of cellulite was proposed by Hexsel et al., 2009, which consisted of the evaluation of the aspects of skin texture, such as the number and depth of depressions, classification of the morphological appearance of the skin, degrees of flaccidity, and also the scale of Nurnberger and Müller. The evaluator performs the sum of the score of each item and classifies the cellulite between light degree (1-5 points), moderate (6-10 points), and severe (11-15 points). ...
... The evaluator performs the sum of the score of each item and classifies the cellulite between light degree (1-5 points), moderate (6-10 points), and severe (11-15 points). According to the authors, the tool influences the conduction and result of the treatment [8,9]. ...
... The main eligibility criteria were women between 18 and 45 years of ages, with body mass index (BMI) of up to 29.9; nonsmokers; without previous disorders; with light, moderate, and severe degrees of cellulite according to the Cellulite Severity Scale (CSS) [8] in the gluteal and posterior thigh regions. The main criteria of ineligibility were participants with other treatments for cellulite less than 30 days before the study, suffering from dermatitis or dermatosis, hair fragility, history of deep venous thrombosis (DVT), and neoplasia and participants with cardiac pacemaker or other implanted electronic devices. ...
Article
Full-text available
In the past centuries, the human body was undervalued; nowadays, however, it is overvalued, and thus the manifestation of the dissatisfactions regarding the body has been increasing. Most of the time, these dissatisfactions are related to cellulite, which is most common in women. Its treatment is one of the challenges which encourage the development of new therapeutic modalities, among them the shockwave therapy. Objective . To evaluate the efficacy of ESWT in the treatment of cellulite in gluteus and posterior of thigh. Method . This is a prospective and comparative study, in which volunteer women who attended the criteria of inclusion were selected and who were subjected to 10 sessions of ESWT. The following were performed as an evaluation method: anthropometry, perimetry, skin viscoelasticity with the Cutometer®, thickness of hypodermis with diagnostic ultrasound, analysis of the scale of severity of cellulite (CSS), and quality of life by the Celluqol® questionnaire. The evaluations occurred before the first session (baseline), after 6 and 10 sessions, and during a follow-up of 3 months after the last session. The statistical test applied was the ANOVA one-way with post hoc of Tukey (P-value < 0.05). Results . There was significant improvement (P<0.05) for CSS, for the variable referring to gross elasticity and skin deformation ability evaluated in the Cutometer® and improvement of quality of life represented by Celluqol®. The result was maintained particularly in the follow-up of 3 months after the end of the treatment. Conclusion . The results presented demonstrated the effectiveness and safety of ESWT in the treatment of cellulite and in the decrease of the degrees, improvement of the aspect of the skin, and reestablishment of quality of life. This trial is registered with ClinicalTrials: NCT03275259.
... 6,14,15 As new pharmacological and technological medical advances reach the market, reliable and specific methods of cellulite assessment become necessary to identify subjects appropriate for therapy and to measure treatment outcomes. Currently available scales do not meet this need 16,17 because they are not specific for cellulite dimples and because they are time-consuming for use in daily clinical practice. In this article, the authors present the cellulite dimple grading scales for the objective quantification of the severity of cellulite dimples in both static (relaxed or "at rest") and dynamic states, as well as the validity and reliability of these photonumeric scales. ...
... Cellulite can also be influenced by skin laxity, particularly in older individuals, 11,12 and a separate publication in this issue details the development of a new skin laxity scale for the buttock and thigh area that can be used in conjunction with the dimple scale when assessing cellulite severity and deciding on the best treatment options. 27 The cellulite dimple scales differ from other cellulite severity scales 16,17 available in the literature in their specificity for cellulite dimples and in their simplicity. The Nürnberger and Müller 16 classification was developed in 1978 and has 4 severity grades. ...
... Based on the final numeric score, cellulite is classified as mild, moderate, or severe. 17 The Hexsel and colleagues' scale was created to provide an objective method of measuring cellulite severity based on their main characteristics and to guide the choice of different treatment modalities, but the 5 different scale items can be time-consuming to assess. Although it lacks some sensitivity, 30 this was the first attempt to a better clinical evaluation of skin laxity. ...
Article
Background: New treatment methods for cellulite require globally accepted scales for aesthetic research and patient evaluation. Objective: To develop a set of grading scales for objective assessment of cellulite dimples on female buttocks and thighs and assess their reliability and validity. Materials and methods: Two photonumeric grading scales were created and validated for dimples in the buttocks in female patients: Cellulite Dimples-At Rest, and Cellulite Dimples-Dynamic. Sixteen aesthetic experts rated photographs of 50 women in 2 validation sessions. Responses were analyzed to assess inter-rater and intra-rater reliability. Results: Overall inter-rater reliability and intra-rater reliability were both "almost perfect" (≥0.81, intraclass correlation efficient and weighted kappa) for the At Rest scale. For the Dynamic scale, inter-rater reliability and intra-rater reliability were "substantial" (0.61-0.80). There was a high correlation between the cellulite scales and body mass index, age, weight, and skin laxity assessments. Conclusion: Consistent outcomes between raters and by individual raters at 2 time points confirm the reliability of the cellulite dimple grading scales for buttocks and thighs in female patients and suggest they will be a valuable tool for use in research and clinical practice.
... Prior to initiating the treatment protocol, these photographs were analyzed by one of three key study personnel (JRS, MS, LAC) to assess the severity of cellulite affecting the outer thighs using the Hexsel, Dal'forno and Hexsel Cellulite Severity Scale (CSS). 31 Women with a pretreatment CSS score of greater than or equal to 11 were excluded (severe cellulite). ...
... 23,48 In their study, two independent, blinded evaluators used the Hexsel, Dal'forno and Hexsel Cellulite Severity Scale (CSS) to assess standardized photographs taken pretreatment and posttreatment for each patient. 23,31 However, this scale was specifically designed for standardized and objective assessment of the severity of cellulite, and using this data as a surrogate for the assessment of skin laxity may not be appropriate. 31 At present time, validated assessment scales specific to skin laxity on the posterior thighs, buttocks, anterior thighs, and knees in female patients exist. ...
... 23,31 However, this scale was specifically designed for standardized and objective assessment of the severity of cellulite, and using this data as a surrogate for the assessment of skin laxity may not be appropriate. 31 At present time, validated assessment scales specific to skin laxity on the posterior thighs, buttocks, anterior thighs, and knees in female patients exist. 48 These new validated skin laxity scales for the posterior thighs, buttocks, anterior thighs, and knees in female patients will likely prove to be the more appropriate scales for use in future studies, as long as a patient-reported outcome instrument like the BODY-Q is used in conjunction with these validated assessment scales. ...
Article
Background Two procedures that have demonstrated collagen-stimulating properties and improvements in skin laxity in a variety of aesthetic indications are microfocused ultrasound with visualization (MFU-V) and injection with calcium hydroxylapatite (CaHA). Objectives By treating skin laxity with a combination of these therapies, it was hypothesized that our patients would experience improved appearance and quality of life as measured by the BODY-Q. Methods A total of 60 consecutive female patients aged 30-60 years with BMI less than 28 kg/m2 who expressed interest in treatment for skin laxity affecting the outer thighs completed select scales from the BODY-Q within 1 week of treatment. At the time of treatment, MFU-V was directed to the outer thighs (150 lines at focal depths of 3.0 and 4.5 mm per outer thigh). Immediately following MFU-V, patients received treatment with CaHA injected into the subdermis (1.5 mL diluted 1:1 with 1.5 mL of 2% lidocaine solution per outer thigh). At 90 days posttreatment, these patients repeated the BODY-Q. Results At 90 days posttreatment, with 100% follow-up among the 60 consecutive female patients treated, scores from select scales of the BODY-Q showed statistically significant improvement (Body Image, p<0.01; Appraisal of Excess Skin, p<0.01; Satisfaction with Hips and Outer Thighs, p<0.01; Appearance-Related Psychosocial Distress, p<0.01). Conclusions Following treatment of skin laxity on the outer thighs with a combination of MFU-V and CaHA, our patients reported a statistically significant improvement in appearance and quality of life at 90 days posttreatment. This may be applicable to other areas of the body.
... 8,9 The skin above the knee is an area with increasing demand for treatment and, to date, there are very few treatment options proposed. 10 In order to objectively assess the severity of patients' cellulite and any eventual treatment effects, the cellulite severity scale (CSS) 11 has been validated for the buttocks and posterolateral thigh regions. The CSS is a photonumeric scale and it includes the evaluation of the number and depth of evident depressions, morphological appearance of skin surface alterations, grade of skin laxity and the N€ urnberger and M€ uller cellulite classification. ...
... The KCSS includes the evaluation of the number and depth of evident depressions and the severity of skin laxity, according to grades ranging from 0 to 3, following the same standards of the CSS. 11 Briefly, the number of visible depressions is assessed as follows: 0 = absent, 1 = 1-4 depressions, 2 = 5-9 depressions, 3 = ≥10 depressions; the depth of depressions is classified as: 0 = absent, 1 = superficial depressions, 2 = medium depth depressions and 3 = deep depressions; skin laxity (which confers a draped appearance to the affected skin) severity: 0 = absent, 1 = slight draped appearance, 2 = moderate draped appearance and 3 = severe draped appearance. The aspects of the KCSS are outlined in Fig. 1. ...
... Other authors revealed that skin laxity in other areas of the body (namely the buttocks and postero-lateral thighs) reduced the scale's internal consistency, either for both sides or one side only. 1,10 The authors decided to continue to include skin laxity in the CSS because, as Hexsel et al. 11 suggested, cellulite lesions are likely to be related to skin laxity, as it can be observed in oval lesions, with the longest axis lying in parallel to the skin tension lines. ...
Article
Full-text available
Background: Treatment for cellulite above the knees is increasingly requested. However, a classification of cellulite of this area has not yet been developed. Objective: To validate the proposed knee cellulite severity score (KCSS) for the assessment of cellulite and skin laxity above the knee. Materials and methods: Based on standardized photographs of cellulite and skin laxity above the knees of 57 females (114 knees), three key morphological aspects of cellulite were identified. A photonumeric KCSS was developed and validated by 3 independent assessors. Results: The three key cellulite morphological features (number of depressions, depth of depressions and presence of laxity) are each graded from 0 to 3, producing a classification of no lesions (0), mild (1-3), moderate (4-6), and severe (7-9). Evaluators at different time points repeated similar classifications (intraclass correlation coefficient > 0.9), which were also similar among the assessors (inter-observer reliability > 0.9). All three key morphological aspects were deemed necessary, and positively contributed, to the overall scale (item-total correlation analysis values > 0.89, p < 0.05). Conclusions: The KCSS is a consistent, comprehensive, reliable, and reproducible tool for standardized and objective assessment of the severity of cellulite and skin laxity above the knees.
... A number of cellulite severity rating scales have been developed, each of which has particular advantages and limitations (Table 2). 4,6,[20][21][22][23][24][25][26][27][28]31,42,43,45 The Nürnberger-Müller Classification ...
... In contrast to the Nürnberger-Müller classification, the Cellulite Severity Scale (CSS) was developed to incorporate specific clinical and morphologic aspects of cellulite that may affect severity level. 20 The CSS is a widely used photonumeric scale developed from a photographic study of 55 women participating in clinical trials of cellulite therapies. 20 It consists of 5 items, including the Nürnberger-Müller classification, each of which is rated on a scale from 0 to 3; scores of 1 to 5 indicate mild cellulite, 6 to 10 indicate moderate cellulite, and 11 to 15 indicate severe cellulite. ...
... 20 The CSS is a widely used photonumeric scale developed from a photographic study of 55 women participating in clinical trials of cellulite therapies. 20 It consists of 5 items, including the Nürnberger-Müller classification, each of which is rated on a scale from 0 to 3; scores of 1 to 5 indicate mild cellulite, 6 to 10 indicate moderate cellulite, and 11 to 15 indicate severe cellulite. 20 Although this scale provides both qualitative and quantitative measures of cellulite severity, it applies only to Downloaded from https://academic.oup.com/asj/advance-article/doi/10.1093/asj/sjaa226/5891811 by guest on 13 August 2020 A c c e p t e d M a n u s c r i p t cellulite located on the buttocks and thighs; it has not been validated for areas less commonly affected by cellulite, such as the arms or abdomen. ...
Article
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Cellulite is characterized by dimpled contour alterations of the skin and is present in approximately 85% to 90% of postpubertal females. Although the pathophysiology of cellulite remains to be fully elucidated, experimental evidence indicates a multifactorial process involving the number and types of fibrous septae, microvascular dysfunction, subcutaneous inflammation, decreased dermal thickness with age, and fat deposition. Cellulite is a major cosmetic concern for many women, and a number of both noninvasive (eg, massage, cosmeceuticals, laser therapy) and minimally invasive techniques (eg, subcision, collagenase injection) have been evaluated to improve the appearance of the affected skin. However, evidence for many of these treatments is limited, largely due to the lack of a validated, convenient tool for the standardized evaluation of cellulite severity. Various imaging modalities have been used to characterize cellulite severity and the impact of treatment, but only 2-dimensional and 3-dimensional digital photography have been adequately validated. However, in many cases, imaging findings do not correlate with subjective measures of cellulite severity. A number of cellulite rating scales have been developed; some provide only a qualitative measure, while others do not fully capture all clinically relevant aspects of cellulite, including the perspective of the patient. There remains an unmet need for global adoption of a validated scale that can be used easily by clinicians and patients in clinical and research settings. We propose features that should be included in an ideal rating scale for assessment of cellulite severity.
... Although many authors cite postural changes as a predisposing factor of cellulitis, no studies in the literature have identified and demonstrated such a relationship, thus the need to investigate it. The muscle fascia are different according to the region of the human body, presenting more slender in the abdomen and thicker and with greater amount of dense connective tissue in the glutei and hips 22 . ...
... Photographic records of the gluteal region were performed without and with gluteal contraction (Figure 2), with the machine positioned 100 cm high and 3 m away from the volunteer. Evaluation of the cellulitis has been carried out according to the photonumeric scale proposed by Hexsel, Dal'Forno and Hexsel 22 , which evaluates the severity of cellulitis, on a scale of 1 to 15. It is considered mild from 1 to 5, moderate from 6 to 10 and severe from 11 to 15. ...
... The photonumeric scale of Hexsel, Dal'Forno and Hexsel 22 offers a practical way to assess the severity of cellulitis to distinguish and facilitate its diagnosis and direct the treatment according to the grade of involvement. It is important to note that the graduation shows important aspects, which are not considered in other forms of classification such as the number and depth of depressions, the morphological aspects of skin and flaccidity degree. ...
... Although many authors cite postural changes as a predisposing factor of cellulitis, no studies in the literature have identified and demonstrated such a relationship, thus the need to investigate it. The muscle fascia are different according to the region of the human body, presenting more slender in the abdomen and thicker and with greater amount of dense connective tissue in the glutei and hips 22 . ...
... Photographic records of the gluteal region were performed without and with gluteal contraction (Figure 2), with the machine positioned 100 cm high and 3 m away from the volunteer. Evaluation of the cellulitis has been carried out according to the photonumeric scale proposed by Hexsel, Dal'Forno and Hexsel 22 , which evaluates the severity of cellulitis, on a scale of 1 to 15. It is considered mild from 1 to 5, moderate from 6 to 10 and severe from 11 to 15. ...
... The photonumeric scale of Hexsel, Dal'Forno and Hexsel 22 offers a practical way to assess the severity of cellulitis to distinguish and facilitate its diagnosis and direct the treatment according to the grade of involvement. It is important to note that the graduation shows important aspects, which are not considered in other forms of classification such as the number and depth of depressions, the morphological aspects of skin and flaccidity degree. ...
Article
Full-text available
RESUMO O fibroedema geloide (FEG) é uma desordem dos tecidos dérmico e subcutâneo. Acomete 90% das mulheres após a puberdade. Vários fatores predisponentes interferem na sua ocorrência, entre os quais as alterações posturais. Para avaliação da postura e do FEG, a fotogrametria tem se mostrado um recurso confiável, de fácil aplicação, reprodução e de baixo custo. Avaliou-se se há correlação entre alinhamento pélvico e FEG na região glútea por meio da fotogrametria. Estudo do tipo transversal observacional, com 46 mulheres de 18-29 anos (média 23 anos±4,2 anos). Foi realizada avaliação postural pelo software de avaliação postural (SAPO) e calculado o ângulo entre as espinhas ilíacas anteros superiores direita e esquerda. O FEG foi classificado de acordo com a escala fotonumérica de Hexsel. As análises foram realizadas por dois avaliadores independentes e cegos, e foi utilizado o teste de correlação de Pearson. Obteve-se como resultado o valor médio do ângulo de desalinhamento pélvico de 1,70 (±1,46), o valor médio do FEG no glúteo direito de 6,30 (±4,01) e no esquerdo de 6,76 (±3,61). Não foi observada correlação entre o alinhamento pélvico e o grau de FEG na região glútea (p=0,38).
... Among the injectables widely consumed in the realm of esthetics, carboxytherapy consists of the therapeutic subcutaneous injection of CO 2 [26] and has been widely used for the treatment of esthetic problems [27][28][29] due to its ability to improve irregularities in the skin, as occurs in cases of cellulite [28,[30][31][32][33][34]. Cellulite is a localized metabolic disorder of the dermis and subcutaneous tissue involving changes in microcirculation and can lead to the formation of fibrosis and macronodules, and it can be aggravated by the presence of flaccidity at the site [35][36][37][38]. ...
... Women between 18 and 49 years of age with a body mass index (BMI) between 18.5 and 39.9 kg/m 2 , moderate to severe cellulite in the gluteal region and no prior experience with carboxytherapy will be included in the study. The degree of cellulite will be determined using the cellulite severity scale proposed by Hexsel, Dal'Forno and Hexsel [37]. Women with the following conditions will not participate in the study: pregnancy, currently breastfeeding, postmenopause period, amenorrhea, metabolic or autoimmune disorder, history of epilepsy, malignant or benign tumors, use of diuretics, heart disease, use of pacemaker, hypoesthesia, regional anesthesia, skin lesions, surgical procedure in the gluteal region and the use of alcoholic beverages, analgesics, muscle relaxants or anti-inflammatories in the 24 h prior to the session. ...
... A physical examination will be performed for the determination of anthropometric measures (body mass and height), demarcation of visible dimples, determination of the degree of cellulite and demarcation of the gluteal region. The volunteers will be instructed to remain standing in a dark swimsuit and maintain the area of the buttocks exposed to enable the assessment of the degree of cellulite using the cellulite severity scale [37]: moderate (score of 5-9 points); severe (score of [11][12][13][14][15]. Cellulite will then be marked on the skin using a white pencil. Next, the gluteal region will be marked bilaterally with the aid of a flexible metric tape: a vertical line will be drawn from the iliac crest to the lateral extremity of the infragluteal fold, with the greater trochanter as the midpoint defining the lateral limit; a horizontal line perpendicular to the vertical line will be drawn 4 cm below the superior-posterior iliac spine defining the upper limit of the gluteus maximus; another horizontal line perpendicular to the vertical line will be drawn at the infra-gluteal fold defining the lower limit; a medial line will then marked anatomically by the intergluteal cleft defining the medial limit, as shown in Figure 2A. ...
Article
Background: To date, there has been no investigation addressing the effects of vibration anesthesia during carboxytherapy. Aim: Investigate the analgesic effect of different vibratory devices during carboxytherapy for the treatment of cellulite. Materials & methods: A total of 78 women between 18 and 49 years of age with cellulite in the gluteal region will be randomly allocated to three groups: Group A (carboxytherapy and vibratory device A), Group B (carboxytherapy and vibratory device B) and control group. Pain intensity will be assessed using a numerical rating scale after each puncture. Expected outcome: Vibration anesthesia is expected to be effective at diminishing the pain intensity caused by carboxytherapy comparison with the control group, with no differences between the vibratory devices. Trial registry: Brazilian Registry of Clinical Trials- ReBEC (RBR-8jcqy7c)
... Cellulite Severity Scale (CSS) was used for assessment of the degree of cellulite, a scale for the target investigation of cellulite grades. This scale morphologically measures the parts of cellulite, comparable to the quantity of obviously depressed lesions, the extent of the depressed lesions, the appearance of accelerated lesions, buckling, also with the previous traditional classification [5]. ...
... This made the total count of scores ranging from 0 to 15. According to the total numeric score, cellulite is classified as mild (1)(2)(3)(4)(5), moderate (6-10), or severe (11)(12)(13)(14)(15). All measurements of each patient were taken before, after 8 weeks and at the end of treatment. ...
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Introduction: Cellulite is one of the complications post liposuction. Cellulite causes changes in the lymphatic system. Manual lymphatic drainage is utilized as an effective treatment for enhancing cellulite. Aim: To compare between Vodder Manual Lymphatic Drainage (MLD) Technique and Casley-Smith MLD Technique for cellulite after liposuction. Material and methods: Thirty female patients with cellulite grade 3 after thigh liposuction participated in the study, and they were randomly divided into two equal groups: Group (A) that received Vodder MLD Technique and Bandage and Group (B) that received Casley-Smith MLD Technique and Bandage. The duration of the intervention was 8 weeks per participant, and each participant received 3 sessions per week. Results: The results revealed that there was a significant improvement in both groups by using two different methods of treatment (p < 0.001), but there was no significant difference between the two study groups (p > 0.05). Conclusions: Both Vodder technique and Casley-Smith technique are effective in treatment of cellulite after thigh liposuction but there is no difference between them, hence any technique of MLD is recommended to achieve better improvement in this case.
... Soft cellulite is usually found in mature women with low physical activity. Loss of muscle mass, strength, and tone (hypotonia) and an increase in the fat volume lead to soft cellulite, which is characterized by a progressive loss of elasticity, pliability, and flaccidity of skin [14,15]. In this stage, irregular beads and nodules can appear. ...
... This fully automatic image processing and decision-making protocol allows much faster repeat testing and analysis, thus increasing the objectivity, reliability, and reproducibility of diagnosis. We employ this automatic, computer-based image processing protocol on clinical IR thermographic images obtained from 212 female volunteers of age ranging between 19 and 22 years and possessing cellulite of different stages which has been diagnosed a priori with use of the Nürnberger-Müller scale [2,10,15]. We then compare the accuracy of the automatic diagnosis with respect to the accuracy of the diagnosis as per current clinical protocol. ...
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Background Cellulite is a common physiological condition of dermis, epidermis, and subcutaneous tissues experienced by 85 to 98% of the post-pubertal females in developed countries. Infrared (IR) thermography combined with artificial intelligence (AI)-based automated image processing can detect both early and advanced cellulite stages and open up the possibility of reliable diagnosis. Although the cellulite lesions may have various levels of severity, the quality of life of every woman, both in the physical and emotional sphere, is always an individual concern and therefore requires patient-oriented approach.Objectives The purpose of this work was to elaborate an objective, fast, and cost-effective method for automatic identification of different stages of cellulite based on IR imaging that may be used for prescreening and personalization of the therapy.Materials and methodsIn this study, we use custom-developed image preprocessing algorithms to automatically select cellulite regions and combine a total of 9 feature extraction methods with 9 different classification algorithms to determine the efficacy of cellulite stage recognition based on thermographic images taken from 212 female volunteers aged between 19 and 22.ResultsA combination of histogram of oriented gradients (HOG) and artificial neural network (ANN) enables determination of all stages of cellulite with an average accuracy higher than 80%. For primary stages of cellulite, the average accuracy achieved was more than 90%.Conclusions The implementation of computer-aided, automatic identification of cellulite severity using infrared imaging is feasible for reliable diagnosis. Such a combination can be used for early diagnosis, as well as monitoring of cellulite progress or therapeutic outcomes in an objective way. IR thermography coupled to AI sets the vision towards their use as an effective tool for complex assessment of cellulite pathogenesis and stratification, which are critical in the implementation of IR thermographic imaging in predictive, preventive, and personalized medicine (PPPM).
... 3,4 Treating skin laxity by improving dermal strength and elasticity are potentially important elements for treatments targeting the appearance of cellulite dimples. [4][5][6] The acoustic subcision device (Soliton, Inc.) uses rapid acoustic pulses designed to improve the appearance of cellulite. The authors hypothesize that rapid acoustic pulses noninvasively disrupt the fibrous septae (i.e., subcision) in the subcutaneous extracellular matrix space, leading to tissue release that results in the improvement in the appearance of cellulite. ...
... This scale was based on the LS component of Hexsel's validated photonumeric CSS. 6 Reviewers also provided a GAIS score for change in skin laxity from baseline to 12-weeks. Finally, after reviewing their own baseline and 12-week posttreatment photographs participants were given a satisfaction questionnaire using a 5-point scale (Strongly agree = 2; Agree = 1; Neutral = 0; Disagree = −1; Strongly disagree = −2) see Table 4. ...
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Introduction and Objectives Surface depressions and skin laxity together play a role in the appearance of cellulite. Cellulite depressions can be improved through disruption of the subcutaneous fibrous structures. Some currently utilized approaches accomplish this through invasive techniques requiring local anesthesia and potential down time. Skin laxity can exacerbate the appearance of cellulite, however current invasive approaches do little to improve skin laxity. The objective of this study was to evaluate a noninvasive approach to improving both cellulite depressions and skin laxity through the use of rapid acoustic pulses (acoustic subcision). Safety, efficacy, tolerability, and participant satisfaction results were measured. Methods Women (n = 56) with moderate to severe cellulite were treated in a single acoustic subcision treatment session without anesthesia. Posttreatment adverse events (AEs) and tolerability were recorded. At 12-weeks cellulite outcomes were assessed using a 6-point simplified Cellulite Severity Scale (CSS), Global Aesthetic Improvement Scale (GAIS), and a participant satisfaction questionnaire. Additionally, laxity improvement was measured using a 4-point Laxity Score (LS) and GAIS. Results Improvement in cellulite appearance measured at 12-weeks showed that participants (n = 56) had a mean CSS reduction of 1.01 (a 29.5% reduction from baseline). The posttreatment photograph was correctly identified by blinded independent reviewers from randomized pairs of pre/posttreatment photographs for 96.4% of participants. Cellulite was graded as improved, much improved or very much improved using the GAIS at 90.9% of treated locations. Finally, 92.9% of participants reported positive satisfaction responses. Scoring for improvement in skin laxity appearance at 12-weeks showed a mean LS reduction of 0.57 (a 27.9% reduction from baseline). GAIS for laxity was graded as improved, much improved or very much improved in 67.3% of treated areas. No unexpected or serious AEs were noted at treatment or follow-up. Overall average pain score during treatment was 2.4 (0–10 pain scale) and 0.3 immediately posttreatment. Conclusion A single noninvasive acoustic subcision session can safely provide meaningful improvement in the appearance of cellulite in terms of depressions, as well as skin laxity, with minimal treatment pain and no posttreatment down time. Further improvement in appearance is expected with multiple treatments over time. Additional trials to verify this are planned.
... Cellulite grading scale: A simple gradingscore of cellulite was used by inspection. It consists of 4 grades for assessment of cellulite [8,9] . ...
... • Cellulite grading scale: It is used to assess the grade of cellulite, it consists of 4 grades [8,9] . • Mattress-phenomenon spontaneously while standing 3 ...
... [1][2][3][4][5] The Hexsel's and Dalfornos' photonumeric classification, known as the Cellulite Severity Scale, is the most commonly utilized clinical tool to assess the severity of cellulite based on 5 aspects of cellulite: the number of evident depressions, depth of depressions, morphological appearance of the skin surface, grade of flaccidity, and the cellulite grade. 6,7 Each of these categories is rated on a scale of 0 to 3, and the sum of all the items is utilized to determine the severity of the cellulite (mild, moderate, or severe). Although the occurrence of cellulite is not linked to mortality or morbidity, the aesthetically undesirable effect can negatively impact various aspects of health-related quality of life (HRQOL) of individuals with cellulite, including body image and physical, psychosocial, and sexual well-being. ...
... Branching logic in the survey was employed to determine if survey respondents met the following eligibility criteria: female, resides in the United States, aged 18 to 49 years, body mass index (BMI) of 18.5 to 32.0, "somewhat open" to receiving aesthetic treatments in a doctor's office, and self-identified as having "almost none" to "severe" cellulite in the buttocks utilizing the validated Patient-Reported Photo-numeric Cellulite Severity Scale (PR-PCSS). 7,22 This instrument includes 5 photos that show examples of none, almost none, mild, moderate, and severe cellulite on the buttocks. Participants were asked to choose the picture that most closely resembled the appearance of cellulite on their buttocks. ...
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Background Cellulite is a localized metabolic disorder of the subcutaneous tissue. To measure the impact of cellulite and its treatment(s) on patients’ health-related quality of life a psychometrically sound patient-reported outcome measure (PROM) is needed. Objective To develop and field-test a new BODY-Q Cellulite scale to measure the appearance of cellulite. Methods Appearance-related codes from the original BODY-Q qualitative interviews were reexamined, and a set of cellulite-specific items was developed and refined through cognitive patient interviews (n=10) and expert input (n=17). This scale was field-tested in adults with cellulite through 2 crowdworking platforms. Rasch Measurement Theory (RMT) analysis was used to refine the scale and examine its psychometric properties. Results The field-test sample included 2129 participants. The 15-item scale was reduced in length to 11 items. Data from the sample fit the Rasch model (X2 (99) = 21.32, p=0.06). All items had ordered thresholds and mapped out a targeted clinical hierarchy. The reliability statistics for the person separation index was 0.94, and for Cronbach’s alpha was 0.97. In terms of validity, worse scores on the Cellulite scale were associated with being more bothered by how the cellulite looked overall, having more severe cellulite on the Patient-Reported Photo-numeric Cellulite Severity Scale, and having more self-reported cellulite and more areas of the body with cellulite. Conclusion The BODY-Q Cellulite scale can be used to measure appearance of cellulite and provides a solid basis for future studies evaluating the impact of cellulite and its treatment.
... 1 The Hexsel Cellulite Severity Scale (CSS) was validated in women aged 18 to 45 years with Grade I to III cellulite and a mean body mass index of 25 but may be cumbersome because it incorporates multiple pathologic ratings and does not assess cellulite severity from the patient perspective. 19 The modified Investigator Global Aesthetic Improvement Scale (I-GAIS) and Subject Global Aesthetic Improvement Scale (S-GAIS) ask clinicians and patients, respectively, to rate changes in cellulite appearance, based on before and after digital images, which are dynamic assessments by design. To overcome the limitations of these assessments, the buttockand thigh-specific Clinician Reported Photonumeric Cellulite Severity Scale (CR-PCSS) and Patient Reported Photonumeric Cellulite Severity Scale (PR-PCSS) were developed to assess cellulite severity from both clinician and patient viewpoints using a photonumeric reference, cellulite severity labels (e.g., "mild" or "moderate"), and corresponding descriptors. ...
... Clinicians rated cellulite severity using the CR-PCSS and the Hexsel CSS; they evaluated cellulite appearance in the same 4 possible treatment areas in real time, while viewing each patient in a relaxed, standing position ( Figure 1A,B). 19 Patients who had $1 treatment area with PR-PCSS and CR-PCSS scores of 3 or 4 (i.e., moderate or severe cellulite) and a Hexsel CSS score of #13 were included. One buttock or thigh with moderate or severe cellulite per patient received treatment randomly assigned using an interactive web-response system. ...
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Background: Edematous fibrosclerotic panniculopathy (EFP; cellulite) is associated with thickening and contraction of collagen-rich subdermal septae. Collagenase clostridium histolyticum (CCH) may disrupt collagen-rich septae. Objective: To evaluate the safety and efficacy of CCH for treatment of EFP. Materials and methods: In a randomized, double-blind study, women with moderate or severe EFP of the buttocks or posterolateral thighs (i.e., Clinician Reported Photonumeric Cellulite Severity Scale [CR-PCSS] and Patient Reported Photonumeric Cellulite Severity Scale [PR-PCSS] ratings of 3 to 4, and Hexsel Cellulite Severity Scale score ≤13) received up to 3 treatment sessions (Days 1, 22, and 43) of subcutaneous CCH 0.84 mg or placebo injections. End points included the percentage of 2-level and 1-level composite responders (i.e., had ≥2-level or ≥1-level improvement in CR-PCSS and PR-PCSS) at Day 71. Results: Three hundred seventy-five women (mean age, 46.5 years; 86.4% white) were randomly assigned to CCH (n = 189) or placebo (n = 186). At Day 71, the percentages of 2-level and 1-level composite responders were greater with CCH (10.6% and 44.6%, respectively) versus placebo (1.6% and 17.9%; p < .001 for both). The most common adverse events were injection-site related. Conclusion: CCH significantly improved EFP appearance versus placebo; further evaluation of CCH for EFP (cellulite) is warranted.
... The main eligibility criteria were: women between 18 and 55 years of age; body mass index (BMI) of up to 29.9; non-smokers; without previous conditions; with light, moderate and severe degrees of cellulite severity according to the Cellulite Severity Scale (CSS) [5] in the gluteus and posterior thigh areas and localized fat in the abdomen and flanks areas. The main criteria of ineligibility were that the participants had received other treatment for cellulite less than 30 days before the study, male gender, suffering from dermatitis and dermatosis, fragility of the blood capillary, history of deep venous thrombosis (DVT) neoplasia, having implanted cardiac pacemakers or other implanted electronic devices. ...
... For the evaluation of cellulite, the Cellulite Severity Scale (CSS) was used, which covers and classifies with punctuations from 0 to 3 the different aspects of cellulite, such as: number of depressions, depth, morphological aspect, degree of flaccidity, and the cellulite gradation according to Nürnberger & Müller. The sum of the punctuations of each of these aspects generates the classification, which can be light (1 to 5), moderate (6 to 10) or severe (11)(12)(13)(14)(15) [5]. ...
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Introduction: Several technologies have been developed and optimized for the treatment of unaesthetic disorders. Among them is the oscillatory vibration therapy, a novel form of treatment based on the mechanical and physiological fundamentals of the vibration platform. Objective: The present study evaluated the efficacy of the oscillatory vibration therapy in the improvement of body contour remodeling and in the aspect of cellulite in women. Methods: This is a prospective longitudinal comparative study, in which the following evaluation tools are used: anthropometry, perimetry, adipometry, evaluation of skin viscoelasticity with Cutometer®, evaluation of the thickness of the hypodermis with diagnostic ultrasound and analysis of severity of cellulite (CSS). The evaluations occurred at the start and 1 week after the end of ten oscillatory vibration therapy. The results were analyzing using a paired student’s t-test with interval confidence of 95% (P-Value <0.05). Results: Thirty women took part in the research, with age of 33 ± 9 years, weight of 62 ± 11 kg, height of 1.66 ± 0.06 m, BMI of 22 ± 2 kg/m2. The measurements of perimetry, adipometry, analysis of subcutaneous tissue thickness by means of diagnostic ultrasound and analysis of skin viscoelasticity did not present significant alterations. However, the CSS variable of the right gluteus (7.3 ± 1.8 to 5.8 ± 1.6 ≤ 0.0001), left gluteus (7.2 ± 1.9 to 5.8 ± 1.6= 0.0001), right thigh (6.9 ± 1.9 to 5.6 ± 1.4 = 0.0004), left thigh (6.9 ± 1.9 to 5.6 ± 1.3 = 0.0004) and Celluquol® (59 ± 16 to 49 ± 16 = 0.022) presented significant difference. Conclusion: The multi-directional oscillatory vibration therapy is an effective and efficient therapy for the treatment of cellulite; however, for the treatment of body remodeling, it must be further evaluated and studied.Keywords: vibration platform, vibration, cellulite, body contour, aesthetic medicine.
... A total of 84 women aged between 18 and 44 years, with body mass indexes (BMIs) <18.5-29.9 kg/m², with regular menstrual cycles, with no prior experience with carboxytherapy and TENS and with the presence of Grade II or moderate cellulite in the gluteal region according to the Cellulite Severity Scale (CSS) proposed by Hexsel Dal'Forno & Hexsel 19 were recruited for this study. ...
... The gluteal region was inspected bilaterally by the assessor to classify the degree of cellulite severity through application of the CSS. 19 The sum of the points should total ≥6-10, characterizing the degree II or moderate of cellulite. Next, skin depressions with cellulite were marked with a dermographic pencil, and the gluteal area was defined with measuring tape from one electrode in the superior-lateral limit (SLL), one in the superiormedial limit (SML), one in the infra-lateral limit (ILL), and one in the infra-medial limit (IML), according to the regions defined by the horizontal lines ( Figure 2). ...
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Background: Carboxytherapy may generate local pain that is considered the main limiting factor in clinical practice. Transcutaneous electric nerve stimulation (TENS) is widely used in the control of acute pain; however, the effect of TENS on pain relief during carboxytherapy has not been studied to date. Aims: To assess the effect of TENS on pain intensity during carboxytherapy in patients with cellulite in the gluteal region. Patients/methods: This randomized clinical trial was conducted with 84 patients, 18-44 years of age, who had moderate cellulite in the gluteal region, according to Cellulite Severity Scale, but never received carboxytherapy. Patients were randomized into 3 groups: active TENS, placebo TENS, and control group. For the intervention, skin depressions with cellulite were outlined, and the gluteal area to be treated was defined. The subcutaneous injection of CO2 was performed using 0.30 × 13 mm-needles at a 45° angle, with a controlled flow rate of 100 mL/min maintained for 1 minute at each puncture site. The parameters for TENS were as follows: frequency of 100 Hz and pulse duration of 200 μs; TENS intensity was adjusted until the patient reported strong paresthesia. The visual numeric pain rating scale was used to assess pain intensity after each puncture. Results: The active TENS group reported lower pain intensity compared to the placebo TENS (P < .0001) and control (P < .0001) groups. Conclusions: Transcutaneous electric nerve stimulation (TENS) was effective in reducing pain intensity during carboxytherapy in patients with cellulite in the gluteal region.
... Scales commonly used to assess cellulite severity include the Nürnberger-Müller scale (1978) and the Hexsel Cellulite Severity Scale (CSS; 2009). 4,5 The photonumeric scale (Hexsel CSS) was the first standardized and objective method of grading cellulite severity 3,5 ; it added additional morphologic features to the Nürnberger-Müller scale (i.e., number and depth of depressions; aspect of raised areas; and degree of laxity, flaccidity, or sagging skin). 5 The Hexsel CSS is reproducible but has been complex and cumbersome to administer 6 and does not have a patient selfassessment component. ...
... 4,5 The photonumeric scale (Hexsel CSS) was the first standardized and objective method of grading cellulite severity 3,5 ; it added additional morphologic features to the Nürnberger-Müller scale (i.e., number and depth of depressions; aspect of raised areas; and degree of laxity, flaccidity, or sagging skin). 5 The Hexsel CSS is reproducible but has been complex and cumbersome to administer 6 and does not have a patient selfassessment component. Additional scales, such as the Global Aesthetic Improvement Scale (GAIS), 7 although not designed specifically to assess cellulite, 7 have been adapted for use in assessing changes in cellulite severity in clinical trials, 8,9 by both clinicians (Investigator-GAIS [I-GAIS]) and patients (Subject-GAIS [S-GAIS]). ...
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Background: The Clinician Reported Photonumeric Cellulite Severity Scale (CR-PCSS) and Patient Reported PCSS (PR-PCSS) are newly developed tools for assessing cellulite severity. Objective: To report on the reliability, validity, and ability to detect a change in cellulite severity on the buttocks of adult women with the CR-PCSS and PR-PCSS. Materials and methods: Content validity of both scales was established through concept elicitation and cognitive interviews. Test-retest reliability was evaluated, and intra-rater (both scales) and inter-rater (CR-PCSS only) reliability were estimated using intraclass correlation coefficients (ICCs) for agreement and consistency. Ability to detect a change was determined using the Subject-Global Aesthetic Improvement Scale (GAIS) or Investigator-GAIS as anchors. Results: For the CR-PCSS (n = 6) at baseline and Day 2, the mean interrater ICCs were ≥0.70 and mean intrarater ICCs (95% confidence interval [CI]) were ≥0.81 (0.72-0.90) for both buttocks. For the PR-PCSS (n = 99) at baseline and Day 14, the mean test-retest reliability ICCs (95% CI) were ≥0.86 (0.79-0.91) for both buttocks. A clinically meaningful change was 1.0 point on the PR-PCSS and 1.0 on the CR-PCSS. Conclusion: The CR-PCSS and PR-PCSS reliably assess cellulite severity of the buttocks and can detect a clinically meaningful change after treatment for cellulite.
... The study included healthy women aged 18-55 years with a BMI less than 25 kg/m 2 and moderate-to-severe cellulite on the buttocks and thighs as assessed using the Hexsel, Dal'Forno and Hexsel Cellulite Severity Scale (CSS). 36 Women were also required to have mild-to-severe skin laxity on the thighs and a desire for improvement in the appearance of their cellulite. Subjects were not eligible for treatment if they had undergone any treatment for skin laxity or cellulite in the last 3 months, had received liposuction in the treatment area, or had experienced an increase or decrease in body weight of more than 10% in the past 6 months. ...
... Two independent, blinded evaluators assessed cellulite severity from photographs taken at baseline and 90 days after treatment using the CSS. 36 The scale identifies 5 key clinical morphologic features of cellulite: (1) number of evident depressions, (2) depth of depressions, (3) morphologic appearance of skin surface alterations, (4) grade of laxity, flaccidity or sagging skin, and (5) the classification scale originally described by Nürnberger and Müller. 3 The severity of each item was graded from 0 to 3, where 0 represented the absence of cellulite and 3 represented the most severe cellulite changes. ...
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Background:. Age-associated skin laxity contributes to worsening of cellulite appearance. This study evaluated the effects of microfocused ultrasound with visualization (MFU-V; Ultherapy) in combination with diluted calcium hydroxylapatite (CaHA; Radiesse) on cellulite appearance and on neocollagenesis. Methods:. Twenty women (18–55 years old) with skin laxity and moderate-to-severe cellulite on the buttocks and thighs were retrospectively enrolled. MFU-V was applied using 4 and 7 MHz transducers (25 lines/transducer/site) and immediately followed by subdermal CaHA injection (1 ml/buttock or thigh). Photographs at baseline and 90 days were assessed by 2 independent, blinded evaluators using a 5-item cellulite severity scale. One subject scheduled for thighplasty received treatment with 6 different CaHA dilutions (0.3 ml/5 cm2) followed by MFU-V. Tissue specimens from each dilution site were examined under polarized light microscopy to assess neocollagenesis. Results:. Both evaluators reported statistically significant improvements compared with baseline for each item on the cellulite severity scale (P < 0.001) with a 4.5-point improvement in mean overall score (P < 0.001) after a single MFU-V/CaHA treatment. At 90 days, histologic analysis showed peak neocollagenesis in samples treated with the 1:1 dilution, whether with CaHA alone or in combination with MFU-V. The highest conversion of collagen type III into collagen type I at month 3 occurred in samples injected with 1:1 and 1:0.6 CaHA dilutions without subsequent MFU-V treatment. Both procedures were well tolerated, and subject satisfaction was high. Conclusions:. Combination treatment with MFU-V and diluted CaHA is effective for improving skin laxity and the appearance of cellulite on the buttocks and upper thighs.
... Three blinded, paid, independent master's-level evaluators were trained by NN in grading and each tested 3 times for consistency of 20 graded monochrome cellulite photographs that we had validated using the Cellulite Severity Scale 12 based on 5 key morphologies: (1) depression numbers; (2) depression depths; (3) clinical appearance of evident raised lesions; (4) grade of laxity, flaccidity, or sagging skin; and (5) cellulite grade according to Nü rnberger-Mü ller 9 classification. Each aspect was graded 0 to 3 yielding summed scores (0-15) and 3 classifications: mild (1-5), moderate (6-10), and severe (11)(12)(13)(14)(15). Photographs were presented to evaluators in random order after trial completion (Figure 2b indicates concordance between evaluators). ...
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Cellulite remains an obstinate clinical and cosmetic problem. In this study, we adapted the Thai traditional noninvasive treatment formulated with 5 additional herbals to improve blood flow, edema, and lipolysis, thereby augmenting cellulite treatment. This was a double-blind, randomized placebo-controlled paired trial. Twenty-one women (20-55 years) having cellulite (grade ≥2) were treated with steamed placebo or herbal compresses randomly assigned to one or other thigh twice weekly for 8 weeks with 2 weeks washout. Cellulite reduction was assessed from standardized photographs by 3 blinded evaluators at baseline and every 2 weeks; also assessed were thigh circumferences and cutaneous skin-fold thicknesses, trial diaries, and participant feedback. After 8 weeks, herbal compress treatment reduced Nürnberger-Müller cellulite scores from 12.6 ± 2.0 to 9.9 ± 2.4 compared with 12.5 ± 2.1 to 12.1 ± 2.0 (means ± SEM) for contralateral placebo-treated thighs (P < .0001; effect size [ES] = 1.16, confidence interval [CI] = 0.48-1.83). Thigh circumferences diminished by 2.2 ± 0.9 cm (herbal) and 1.4 ± 0.7 cm (placebo) (ES = 0.96, CI = 0.30-1.61) and correspondingly skin-folds by 5.6 ± 2.2 and 2.4 ± 1.3 mm (ES = 1.72, CI = 0.99-2.45). No adverse actions were reported, and there were no dropouts, no missing data, and 100% adherence. Herbal compresses were efficacious against cellulite and thigh sizes. The herbal formula might be adapted to other delivery options, and rationally added herbals may increase effectiveness of traditional therapies and more sustainable actions.
... 12 To the authors' knowledge, there are currently no other aesthetic scales that have been specifically designed to evaluate skin laxity in the knee, upper thigh, and buttock areas. The cellulite severity scale developed by Hexsel and colleagues 24 included a skin laxity component, but only as part of the overall cellulite scale. When used in combination with standardized photographic equipment and parameters, the current skin laxity scales will prove of value in clinical practice as well as for ongoing research. ...
Article
Background: The demand for noninvasive skin-tightening body procedures is increasing. Objective: To develop a set of grading scales for the objective assessment of skin laxity and assess their reliability and validity. Materials and methods: Two photonumeric grading scales were created and validated for skin laxity in female patients: Skin Laxity-Posterior Thighs/Buttocks, and Anterior Thighs/Knees. Fifteen aesthetic experts rated photographs of 50 women in 2 validation sessions. Responses were analyzed to assess inter-rater and intra-rater reliability. Results: Overall inter-rater reliability according to intraclass correlation efficient (ICC) 2.1 and weighted kappa was at least "substantial" for both scales in both sessions, and "almost perfect" (≥0.81) for the Anterior Thighs and Knees scale in session 2. Intra-rater reliability was "almost perfect" for both scales (ICC 2.1) and "substantial" to "almost perfect" by weighted kappa. A correlation between the skin laxity scales and body mass index, age, weight, sun exposure, and cellulite severity was observed. Conclusion: The skin laxity photonumeric grading scales are valid and reliable instruments for assessing laxity on the posterior thighs and buttocks, and anterior thighs and knees. The scales will be of value for standardizing clinical evaluations and quantifying outcome measurements in research and clinical practice.
... The patient was assessed using the Hexsel and Dal'Forno Severity Scale of Cellulite and the Nürnberger-Müller Classii cation Scale. 5,6 Although the Nürnberger-Müller classii cation is considered the current standard in classii cation of cellulite, it is less detailed than the newer Hexsel and Dal'Forno Severity Scale of Cellulite. The Hexsel and Dal'Forno Severity Scale of Cellulite uses a 0-to-3 numerical score (0=none, 1=mild, 2=moderate, 3=severe) to rate ve categories: number of evident depressions (0 to ≥10 or more); depth of depressions (0=no depressions, 3=deep depressions); morphological appearance of skin surface alterations (0=no raised areas, 3="orange peel, " "cottage cheese, " or "mattress" appearance); and grade of laxity// accidity (0=slight, 3= severe draped appearance). ...
Article
Radiofrequency (RF) microneedling has been used to reduce skin laxity, due to aging, on the face and neck. Our objective for this case study was to evaluate the use of RF in combination with microneedling to nonsurgically improve skin laxity, a result of significant weight loss, on the thighs of a 39-year-old woman. Two sessions of subcutaneous RF microneedling were performed five months apart on the patient's bilateral medial thighs. Laxity was graded before the first session and two months following the second session using the Hexsel and Dal'Forno Severity Scale of Cellulite. Upon visual evaluation, the appearance of cellulite and skin laxity was improved, with a five-point improvement on the Hexsel and Dal'Forno scale at two months after the second treatment. Laxity and depth of depressions showed the most improvement. Our patient reported satisfaction with the results. RF microneedling might offer an effective alternative to surgical correction of skin laxity. Further research is needed to explore the expanding applications of RF microneedling in aesthetic medicine.
... Die ärztlichen Bewertungen beinhalteten: Zufriedenheit mit der TS-GS-Behandlung mittels Global Aesthetic Improvement Score (GAIS; [12]), Vorher-nachher-Fotodokumentation, Cellulite-Schweregrad mittels Fotodokumentation und Cellulite Severity Scale (CSS). Die CSS dient der Eingruppierung der Cellulite in 4 Stadien: keine, milde, moderate oder schwere Form der Cellulite [7]. Mittels GAIS wird eine Veränderung nach der Behandlung in sehr stark verbessert, stark verbessert, verbessert, keine Veränderung und Verschlechterung dokumentiert. ...
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Background The tissue stabilized-guided subcision system (TS-GS) focuses on releasing fibrous septae associated with cellulite dimples. The aim was to investigate the effectiveness of the new medical device for the treatment of cellulite in aesthetic practice in Germany. Methods Prospective, structured evaluation of a single TS-GS treatment of cellulite dimples according to treatment guidelines for buttocks and thighs. Assessments were carried out before and 6 months after TS-GS including the physician global aesthetic improvement scale (GAIS), pre-post treatment photography, severity of cellulite using the Cellulite Severity Scale (CSS), patient satisfaction as well as tolerability. Results Female outpatients, 30–51 years old (mean 38.9 years; n = 15), were treated in routine aesthetic practice. Patient satisfaction 6 months after single session TS-GS was 93.3% demonstrating a very satisfying (40%) and satisfying (53.3%) improvement of appearance of cellulite. Aesthetic appearance according to the physician GAIS assessment was rated as 100% improvement. Severity of cellulite decreased after the single session TS-GS from a mean score of 2.33 to 0.26. No unexpected side effects were reported. All patients reported bruising for 12–21 days and 11 patients reported mild to moderate pain after treatment. All side effects resolved without sequelae. Conclusion Data from the use of TS-GS in routine aesthetic practice in Germany are in accordance with results from studies and practice in the USA. The minimally invasive outpatient treatment was well tolerated and effective with only one treatment session. The precise tissue release results in lasting improvement of cellulite appearance with a high level of satisfaction for patient and physician..
... Evaluation of the severity of cellulite can be performed through anthropometric measurements, photography, bio- electric impedance, thermography, Doppler flowmetry, high-resolution 2-dimensional ultrasonography, magnetic resonance imaging (MRI), and skin biopsy with histo- pathological examination. [34][35][36][37][38] The subcutaneous adipose tissue is composed of two layers: the first, which is more superficial, contains com- pacted globules of fat and a large quantity of fibrous septa; the second is the deeper fat layer, which contains irregular amorphous fat pads. Cellulite presents itself at the inter- face of the dermis with the superficial subcutaneous fat and possesses a complex anatomical structure. ...
Article
Background Cellulite is one of the most common skin and subcutaneous tissue conditions, affecting predominantly the thighs and hips in post-adolescent women. Its etiology is not well defined, and multiple available treatments show variable efficacy. Objective To describe a technique for treatment of cellulite of the gluteal region, thighs, and hips through superficial liposuction utilizing a special cannula, combined with subcutaneous autologous fat grafting. Methods A retrospective review was performed of patients treated over 26 years at the Hospital São Lucas, Pontifical Catholic University of Rio Grande do Sul, Porto Alegre, Brazil. Patients underwent pretreatment evaluation as to the extent of their cellulite, and pretreatment and posttreatment photographs were obtained for visual evaluation of the results. Results Procedures were performed on 126 patients: 121 (96%) women and 5 (4%) men. The majority considered their results good or excellent. The complication rate was low, with the most common complications being ecchymosis, contour irregularities, partial recurrence of cellulite, seroma, and numbness. Conclusions We describe an effective method for the treatment of cellulite. Whereas subcision techniques utilize a needle or microblade to cut fibrous septa, we utilize a special cannula; larger areas can be treated than with subcision. Fat grafting is utilized to correct depressions and improve skin quality, which are added benefits compared to traditional subcision. Considering the multiple available cellulite treatments and their limitations, and the high patient satisfaction rate we achieved, with a low recurrence and complication rate, this technique can be a safe and effective option for patients with cellulite.
... 5,[22][23][24][25]27,28 This may be further exacerbated by septal fibrosis secondary to various hormonal and inflammatory factors 6,17,26,29 and has been postulated to cause the dimpled skin appearance in cellulite. 25,28,30 Although several studies have sought to provide conclusive evidence on gender differences in the anatomical structural arrangement, these investigations should be interpreted with caution. These studies were limited because of small sample size, 22,27,28 including female subjects without having a representative comparison group, 5,22,23,25,28 or failure to correlate anatomical subcutaneous architecture to its underlying biomechanical properties. ...
Article
Objective: To investigate gender differences in gluteal subcutaneous architecture and biomechanics to better understand the pathophysiology underlying the mattress-like appearance of cellulite. Materials and methods: 10 males and 10 female body donors (mean age: 76 ± 16.47 years; range: 36-92 years; mean BMI: 25.27 ± 6.24 kg/m; range: 16.69-40.76) were used to generate full-thickness longitudinal and transverse gluteal slices. In the superficial and deep fatty layers, fat lobule number, height, and width were investigated. The force needed to cause septal breakage between the dermis and superficial fascia was measured using biomechanical testing. Results: Increased age was significantly related to decreased dermal thickness, independent of gender (OR 0.997, 95% CI [0.996 - 0.998], p < 0.0001). The mean number of subdermal fat lobules was significantly higher in males (10.05 ± 2.3) than in females (7.51 ± 2.7; p = 0.003), indicating more septal connections between the superficial fascia and dermis in males. Female gender and increased BMI were associated with increased height of superficial fat lobules. The force needed to cause septal breakage in males (38.46 ± 26.3 N) was significantly greater than in females: (23.26 ± 10.2 N; p= 0.021). Conclusions: The interplay of dermal support, septal morphology, and underlying fat architecture contribute to the biomechanical properties of the subdermal junction. This is influenced by gender, age and BMI. Cellulite can be understood as dis-balance between containment and extrusion forces at the subdermal junction; aged females with high BMI have the greatest risk of developing or worsening cellulite.
... Se o FEG somar de 1 a 5 pontos é do tipo leve, de 6 a 10 é moderado e de 11 a 15 é grave. Portanto, a Escala Fotonumérica consiste em um exame criado para classificar o FEG de forma objetiva e internacionalmente (Hexsel et al., 2009 Muitos tratamentos têm sido propostos para o FEG, desde conduta de dieta balanceada, prática de exercícios e tratamentos estéticos específicos, tais como: uso de cosméticos associados ou não a condutas termoterapêuticas, fototerapêuticas, eletroterapêuticas e massoterapia. Dentre os procedimentos eletroterapêuticos, há destaque para a carboxiterapia, radiofrequência, ultrassom, terapia extracorpórea por ondas de choque e terapias combinadas. ...
... Această scală are 5 puncte de referinţă morfologice: 1. Numărul depresiilor cutanate; 2. Adâncimea depresiilor; 3. Morfologia clinică; 4. Întinderea laxităţii pielii; 5. Clasificarea Nürnberger şi Müller. Fiecărui punct i se dau note între 0 şi 3. Interpretarea finală fiind: 1-5 = celulită uşoară, 6-10 = celulită moderată, 11-15 = celulită severă (29). ...
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Cellulite mainly affects the female sex, being an aesthetic burden. Although initially it was considered a problem only from an aesthetic point of view, it is now considered the predisposition to develop systemic diseases depending on the cellulite fence. Cellulite develops rapidly during adolescence, during pregnancy or during menopause. The treatment can be cumbersome and raises problems, including from the point of view of the final results, making visible the lack of thorough studies in the field.
... 5-39.9 kg/m 2 , no previous experience with carboxytherapy and presence of moderate or severe cellulite in the gluteal region will be selected for the study. The degree of cellulite will be graded according to the Hexsel Dal'Forno & Hexsel cellulite severity scale [37]. ...
Article
The aim of the present study is to describe a study protocol to compare different types of analgesic electrical currents on pain intensity and sensory comfort during the application of carboxytherapy for the treatment of cellulite. Seventy five women with the presence of moderate and/or severe gluteal cellulite will be randomly allocated into three groups: carboxytherapy plus transcutaneous electrical nerve stimulation, carboxytherapy plus interferential current or carboxytherapy plus Aussie current. Pain intensity, which is the primary outcome, will be measured by a numeric rating scale (0–10). The secondary outcome is sensory comfort, which will be measured using the visual analogue scale (0–10). Trial registration: Brazilian Clinical Trials Registry: ReBEC (RBR-6z82zb) www.ensaiosclinicos.gov.br/rg/RBR-6z82zb/
... For this reason, the hormonal function in women and the dysfunction in men have been proposed in the etiology of this condition. 4,7 Other theories about the etiology of cellulite are based on the different subcutaneous structures between males and females. 3 The studies of Querleux et al. with magnetic resonance imaging (MRI) showed that the percentage of connective tissue septae, perpendicular to the skin, that run from the derma to subcutis are present in a higher percentage in women with cellulite, respect men and females without this condition. ...
Article
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Background Cellulite is a topographic alteration of the skin with unknown etiology and is characterized by the presence of a dimpled or puckered aspect, as resembling an orange peel and cottage cheese or as having mattress-like appearance. Aim The aim of this research was to find the different histological aspect of cellulite in sixty patients. Materials and Methods A total of 60 women, mean age 48.8 ( ± 11.08) were included in the study. Among these, 11 women were in menopause (18.33%). All patients after physical examination, aesthetic, and dermatological evaluation were subjected to five cellulite biopsies with a 2.0 mm diameter and 1.5 mm in length in the trochanteric region affected by cellulite. The descriptive statistics were performed for each study predictors demographic age, height, bmi, waist, belly, hip thigh, and knee. Results The histological analysis of the stained slides showed five different histological features were present in the most of patient. Conclusion In conclusion, the outcome of this study shows that the histological evidence does not characterize the different states of cellulite, but several different histological aspects were present in the same patient, which effectively eliminates staging and could consider cellulite as a degenerative disease.
... 1,2,4 One type of skin irregularity, laxity, is characterized by the skin that is permanently distended and sags. 22 In a study of the reliability of the Hexsel Cellulite Severity Scale, skin laxity did not contribute to the internal consistency of the scale, and therefore, contour alterations because of skin laxity should not be mischaracterized as cellulite. 23,24 Collagenase clostridium histolyticum-aaes was safe and generally well tolerated in both studies. ...
Article
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Background: Fibrous septae play a role in contour alterations associated with cellulite. Objective: To assess collagenase clostridium histolyticum-aaes (CCH) for the treatment of cellulite. Materials and methods: Two identically designed phase 3, double-blind, randomized studies (RELEASE-1 and RELEASE-2) were conducted. Adult women with moderate/severe cellulite (rating 3-4 on the Patient Reported Photonumeric Cellulite Severity Scale [PR-PCSS] and Clinician Reported PCSS [CR-PCSS]) on the buttocks received up to 3 treatment sessions of subcutaneous CCH 0.84 mg or placebo per treatment area. Composite response (≥2-level or ≥1-level improvement from baseline in both PR-PCSS and CR-PCSS) was determined at Day 71. Results: Eight hundred forty-three women received ≥1 injection (CCH vs placebo: RELEASE-1, n = 210 vs n = 213; RELEASE-2, n = 214 vs n = 206). Greater percentages of CCH-treated women were ≥2-level composite responders versus placebo in RELEASE-1 (7.6% vs 1.9%; p = .006) and RELEASE-2 (5.6% vs 0.5%; p = .002) and ≥1-level composite responders in RELEASE-1 (37.1% vs 17.8%; p < .001) and RELEASE-2 (41.6% vs 11.2%; p < .001). Most adverse events (AEs) in the CCH group were injection site related; few CCH-treated women discontinued because of an AE (≤4.3%). Conclusion: Collagenase clostridium histolyticum-aaes significantly improved cellulite appearance and was generally well tolerated.
... A grade of zero to three is given to each of these classes. The sum of these scores that ranges from 1 to 15 will lead to the classification of the degree of cellulite as mild if scores lay between 1 and 5, moderate (score between 6 and 10), or severe (score between 11 and 15) [34]. ...
Article
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Cellulite is a multifactorial condition induced by topographic alteration of skin giving rise to ‘orange peel’ appearance. It is a universal aesthetic problem affecting 85% of post pubertal females. The present article provides an exclusive overview of all aspects related to cellulite,including its clinical manifestation, etiology, pathophysiology, evaluation and classification. Approaches for reducing cellulite appearance are innumerable. Conventional therapeutic strategies and modern practices such as physical, mechanical methods - including subcision and mesotherapy- and pharmacological agents, oral and topical routes, are reviewed. Novel delivery systems based on nanocarriers incorporating anti-cellulite agents developed in the past decade have been enumerated and analyzed for their efficacy in delivering drugs to target sites. Two main carrier based systems have been reviewed; lipid and polymer based carriers. Methylxanthines, specifically caffeine, has been critically evaluated due to its lipolytic effect of fat cells through inhibition of phosphodiesterase enzymes. The main challenge of this active moiety is its inability to penetrate the closely packed lipophilic stratum corneum. Its incorporation in such delivery systems have shown promising results in its bioavailability and efficacy. However, despite the utilization of nanocarriers in achieving targeted drug delivery has been demonstrated, yet its application in this indication has emerged recently and is limited. It is anticipated that this is a golden opportunistic research area to be exploited and developed.
... A grade of zero to three is given to each of these classes. The sum of these scores that ranges from 1 to 15 will lead to the classification of the degree of cellulite as mild if scores lay between 1 and 5, moderate (score between 6 and 10), or severe (score between 11 and 15) [34]. ...
Article
Cellulite is a multifactorial condition induced by topographic alteration of skin giving rise to ‘orange peel’ appearance. It is a universal aesthetic problem affecting 85% of post pubertal females. The present article provides an exclusive overview of all aspects related to cellulite, including its clinical manifestation, etiology, pathophysiology, evaluation and classification. Approaches for reducing cellulite appearance are innumerable. Conventional therapeutic strategies and modern practices such as physical, mechanical methods - including subcision and mesotherapy- and pharmacological agents, oral and topical routes, are reviewed. Novel delivery systems based on nanocarriers incorporating anti-cellulite agents developed in the past decade have been enumerated and analyzed for their efficacy in delivering drugs to target sites. Two main carrier based systems have been reviewed; lipid and polymer based carriers. Methylxanthines, specifically caffeine, has been critically evaluated due to its lipolytic effect of fat cells through inhibition of phosphodiesterase enzymes. The main challenge of this active moiety is its inability to penetrate the closely packed lipophilic stratum corneum. Its incorporation in such delivery systems have shown promising results in its bioavailability and efficacy. However, despite the utilization of nanocarriers in achieving targeted drug delivery has been demonstrated, yet its application in this indication has emerged recently and is limited. It is anticipated that this is a golden opportunistic research area to be exploited and developed.
... The validated CR-PCSS was conducted by the study investigators using live assessments (ie, not digital images). Women receiving CCH treatment were also assessed at baseline and at days 71 (+ 5 days) and 360 (± 7 days) using the validated photonumeric Hexsel CSS (live assessment), 13 the Investigator Global Aesthetic Improvement Scale (I-GAIS), and the Subject Global Aesthetic Improvement Scale (S-GAIS). ...
Article
Background:. Collagenase clostridium histolyticum-aaes (CCH) enzymatically releases fibrous septa that contribute to the skin dimpling characteristic of cellulite. Long-term safety/duration of efficacy (durability) results from an open-label extension (OLE) of a randomized, double-blind, placebo-controlled trial (RCT) evaluating CCH efficacy/safety for moderate-to-severe cellulite of the buttocks or posterolateral thighs in women was assessed. Efficacy/safety of CCH treatment/retreatment during OLE was also evaluated. Methods:. After RCT unblinding, women could enroll in OLE for assessment of long-term CCH durability (observation only, up to day 720) or CCH treatment/retreatment, the latter in women with moderate-to-severe buttock/posterolateral thigh cellulite [Clinician Reported Photonumeric Cellulite Severity Scale (CR-PCSS) and Patient Reported PCSS (PR-PCSS) scores of 3/4; Hexsel Cellulite Severity Scale score ≤13]. A treatment/retreatment course comprised 1 or 2 courses of 3 sessions (0.84-mg CCH injected at days 1, 22, and 43). CCH efficacy/safety was assessed at baseline, days 22, 43, 71, and quarterly at day 360. Results:. Of the 259 OLE participants, 53 were observed for long-term CCH durability. For those who were ≥2-level composite responders during RCT (≥2-point CR-PCSS/PR-PCSS score improvements), CCH effect was durable (scores did not reach RCT baseline levels) in all women on days 180 (19/19), 360 (16/16), and 720 (7/7). Of the 200 women receiving CCH treatment/retreatment, more than 75% had ≥1-level improvement in patient and clinical assessments at day 71. The most common adverse events were injection-site bruising and pain. Conclusions:. CCH treatment provided durable improvement in moderate-to-severe buttock/thigh cellulite and was generally well tolerated. Repeated CCH exposure did not increase adverse event risk or reduce efficacy.
... 22 The final score ranges from 1 to 15, from 1 to 5 corresponding to mild severity, 6 to 10 moderate, and 11 to 15 severe. 18 For the evaluation we used photographic records of the gluteal region and posterior proximal thigh. A CANON ® brand EOS 600D camera with 18 megapixel resolution and ISO sensitivity from 100 ...
Article
Background Cellulite is a multifactor and controversial condition. Several methods have been explored to reduce it, not always with favorable results. Shock Wave Therapy has been shown to be effective, but the results of its association with an Aerobic Exercise Program are unknown. Aims To verify whether Shock Wave Therapy in association with an Aerobic Exercise Program reduces the degree of severity of Cellulite in the gluteal region and in the ⅓ of the proximal posterior of the thigh. Methods Forty‐five healthy women, aged from 18 to 32, randomly assigned, considering the severity degree in the Cellulite Severity Scale and the level of physical activity, in three groups: two experimental and one control group. The control group performed the evaluations. The experimental group 1 performed an Aerobic Exercise Program, and the experimental group 2 associated this program with a Radial Shock Wave Therapy protocol. The experimental groups completed six interventions within 3 weeks. In addition, the degree of severity in the Cellulite Severity Scale, height, body composition, skin temperature, and subcutaneous adipose tissue thickness were assessed. One‐way ANOVA test and Kruskal‐Wallis were used to obtain the results, with level of significance of 0.05. Results Forty‐two women completed the study. There was a significant reduction in the severity of Cellulite between experimental group 2 and group 1 (P = 0.032), and from group 2 to the control group (P = 0.042). Conclusion The association of Shock Wave Therapy and Aerobic Exercise was shown to be effective in reducing the severity of cellulite.
Article
Background: There is a growing demand for procedures to treat cellulite. Subcision™ is widely used for cellulite correction, and injectable poly-L-lactic acid (PLLA) has been shown to be an effective option for various body conditions. Aims: Present the results of combining Subcision™ plus PLLA, in the same session, in patients with cellulite and flaccidity. Patients/methods: Twenty-four women underwent Subcision™ followed by PLLA injections. An expert panel of dermatologists evaluated before and after photographs according to Global Aesthetic Improvement Scale (GAIS). Patients also answered a satisfaction questionnaire. Results: The author describes the results, as well as number of sessions and dose used. The most frequent GAIS score was "great improvement." No nodules or granulomas appeared in the treated areas. Conclusion: The combination of Subcision™ plus PLLA, in the same treatment session, promotes safe and desirable results for cellulite associated with flaccidity.
Article
Background: Given differences in buttock versus thigh cellulite, collagenase clostridium histolyticum-aaes (CCH-aaes) injection technique may impact treatment effects at these sites. Aim: To evaluate efficacy and safety of 5 CCH-aaes injection techniques. Methods: A phase 2A, open-label trial enrolled women with mild-to-severe cellulite (Clinician Reported Photonumeric Cellulite Severity Scale) on both buttocks or thighs. CCH-aaes 0.84 mg was administered as 12 injections in each of 2 buttock or 2 thigh treatment areas (total dose, 1.68 mg) during 3 treatment sessions (Days 1, 22, 43). On Day 1, women were sequentially assigned to: Technique A = shallow injection/3 aliquots; Technique B = shallow injection/1 aliquot; Technique C = deep injection/1 aliquot; Technique D = deep and shallow injections/5 aliquots; or Technique E = shallow injection/4 aliquots. Change from baseline in Hexsel Cellulite Severity Scale (CSS) depression depth (range, 0 [no depressions] to 3 [deep depressions]) was assessed at Day 71. Safety was evaluated via adverse events. Results: Sixty-three women with buttock (n = 31) or thigh (n = 32) cellulite received ≥ 1 CCH-aaes dose. For buttock cellulite, CCH-aaes injection Technique A resulted in the greatest baseline-adjusted improvement in CSS score on Day 71 (least-squares mean, 1.17-point improvement). For thigh cellulite, CSS score improvement was greatest with Technique D (least-squares mean, 1.40-point improvement). CCH injection Techniques A, D, and E were associated with more favorable safety profiles than Techniques B and C. Conclusion: Different CCH-aaes injection techniques are required with buttock (Technique A) versus thigh (Technique D) cellulite to optimize treatment outcomes.
Article
Background: Magnetic resonance Imaging (MRI) is a recognized method to assess the morphological characteristics of subcutaneous adipose tissue (SAT). This study aimed to assess objectively different characteristics of SAT of women with different ages and body mass index (BMI) using MRI. Materials and methods: Retrospective, observational study. Pelvic-MRI exams of 133 women aged between 15 and 80 years, with BMI 16 to 30 kg/m2 were assessed. Results: There was a moderate positive correlation between the total fat thickness and the BMI (r = 0.64; p<0.0001) considering the entire sample. Within the different age groups, strong positive correlation was observed for age groups 15 to 30 years (r=0.76; p<0.0001) and 46 to 60 years (r=0.75; p<0.0001), and moderate positive correlation in the others (r=0.61; p<0.0001 [31-45 years] and r=0.53; p<0.0001 [>61 years-old]). There was no correlation between age and fat layer thickness. Correlation between deep fat layer thickness and BMI showed similar pattern to that of the total fat layer. Within the different BMI groups, SAT thickness tends to decrease with aging in patients with low BMI. Conclusion: Inside each age group, the average thickness of the total fat layer increases according to BMI. The results suggest that BMI influences the thickness of SAT throughout life and how SAT changes with age in patients with different BMI. In patients with moderate BMI, the thickness of SAT remains stable.
Chapter
Cellulite is characterized by cutaneous relief alterations that result from a combination of depressed and elevated lesions on the surface of the skin. It is an expression of normal structures of the skin and the subcutaneous tissue in the affected areas, such as the projection of the fat lobules and the retraction of fibrous septa to the skin surface. Subcision® is a surgical technique originally described for the treatment of cutaneous depressed lesions including scars and wrinkles, which was later developed for the treatment of cellulite depressed lesions and other cutaneous relief alterations caused by surgical traumas or liposuction sequelae. Subcision® can be performed manually with a specific needle, or with a device called tissue stabilized-guided subcision or percutaneous subdermal delivery of laser energy. Complications are rare and easily managed, if a proper technique is used by an experienced professional, and if the recommendations are followed by the patients. The technique is effective and the results are persistent.
Article
Objective: Evaluate the effects of the whole body vibration in improving of cellulite in the women's gluteal region. Methods: Controlled clinical trial performed with 42 women, with cellulite in the gluteal region, detected by means of clinical examination. After evaluation, the women were divided into two groups: Whole-Body Vibration (WBV_G) and control (C_G). The evaluations were performed at the beginning and the end of 10 sessions and superficial skin temperature, perimetry in the gluteal region, analysis of body contouring, analysis of improvement by blind reviewers and instrument of satisfaction, by numeric scale were investigated. Results: In the thermographic analysis, the WBV_G obtained significant increase of superficial skin temperature on the right (p = 0.02) and left (p = 0.02) gluteal region. There was no difference in intra- and intergroups in perimetry and the analysis of body contour. The WBV_G obtained a higher percentage of improvement by assessment of the blind reviewers (p = 0.003) and greater aesthetics satisfaction (p = 0.006), when compared to C_G. Conclusion: WBV provided an improvement in the aspect of the cellulite when assessed by blind reviewers and greater participants' satisfaction, providing a significant increase in the superficial skin temperature in the gluteal region.
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Gynoid lipodystrophy (GLD) is a structural, inflammatory, and biochemical disorder of the subcutaneous tissue causing alterations in the topography of the skin. Commonly known as "cellulite," GLD affects up to 90% of women, practically in all stages of the life cycle, beginning in puberty. It is a clinical condition that considerably affects the patients' quality of life. It is a frequent reason for consultation, although the patients resort to empirical, improvised, nonevidence-based treatments which discourage and can be a source of frustration not only because of the lack of results but also due to the complications derived from those treatments. In this article, a panel of experts from different specialties involved in the management of this clinical skin disorder presents the results of a systematic literature search and of the consensus discussion of the evidence obtained from different treatments currently available. The analysis was divided into topical, systemic, noninvasive, and minimally invasive treatments.
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Background: Cellulite can be significantly improved using vacuum-assisted tissue stabilized-guided subcision (TS-GS). However, the treatment of shallow and linear cellulite has remained problematic. Objective: In this retrospective study, we describe a modified technique of vacuum-assisted TS-GS. The aim is to demonstrate that this new limited-release technique is an effective treatment for long ripples and interconnected shallow dimples, which are characteristic of mild-to-moderate cellulite. Methods: Patients with mild-to-moderate cellulite were treated with limited-release vacuum-assisted TS-GS. All subcisions were performed at the 6-mm depth and a minimum of 3 mm between each dimple. Using a 4-point scale, 2 raters graded cellulite improvement on evaluation of prephotographs and postphotographs. Results: A total of 23 female patients were included in this study. The pre- and post-treatment photographs were correctly identified in 22 of the 23 patients (95.6%). The average cellulite improvement was 2.9 of 4 for the buttocks and 2.8 of 4 for the posterior thighs. Global cellulite improvement was reported at 3.1 of 4. Conclusion: The results demonstrate that modified, limited-release, vacuum-assisted TS-GS can be an effective and safe method for the treatment of long ripples and shallow dimples that are characteristics of mild-to-moderate cellulite.
Article
Background: Clinical scales are useful to assess skin laxity in different areas of the body. Objective: To elaborate and validate a photonumeric scale to assess buttocks skin laxity. Materials and methods: The Buttocks' Skin Laxity Severity Scale (SLSS) was developed based on a sample of 120 patients. The SLSS validity and reliability were assessed in 2 validation cycles, performed by 8 dermatologists assessing 50 clinical cases. Both criteria and construct validity were tested. Results: The Buttocks' SLSS is composed by 5 clinical aspects of skin laxity graded from absent (0) to severe (3): buttocks ptosis, skin scalloped appearance, infragluteal fold, localized fat on the lower third of the buttocks, and linear depressed lesions. Final skin laxity classification results from the sum of each item grade multiplied by its weight and varies from 0 to 24. Overall, Kendall, weighted kappa, and intraclass correlation coefficients indicated very good reliability and consistent interrater and intrarater agreement (p < .001). Cronbach alpha of 0.82 indicates high scale reliability. The scale validity was confirmed by criteria validity tests (rs: 0.72, p < .05). Conclusion: Buttocks' SLSS is a reliable and valid scale to identify skin laxity severity and its different features, and it is an accurate tool for clinical research.
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Background: More than 90% of women have reported concerns of cellulite on their skin. Both commercially advertised creams and topical pharmacological agents have shown limited improvement. Thus far, there has been a paucity of thorough review articles on how to address and treat this condition. Objective: To investigate how the etiology and pathogenesis of cellulite can help guide treatment combinations and provide a more algorithmic approach to comprehensively address a condition that affects so many women. Materials and methods: A review of the literature surrounding treatment options for cellulite and the authors' experience in this area are provided. Conclusion: This review summarizes available treatment options for cellulite, including topical agents, controlled subcision, energy-based devices, dermal fillers, and new injectable medications. Furthermore, the various ways that these treatments can be combined in an algorithmic and sequential approach based on the degree of volume loss, skin laxity, and excess adiposity associated with cellulite are addressed. These combination therapies for cellulite are supported both in the published literature and the authors' experience to help clinicians tailor a comprehensive treatment plan for the multiple factors that contribute to cellulite. Further clinical trials are needed to compare various devices and techniques for cellulite as well as combination treatments.
Article
Background: Gynoid lipodystrophy (GLD), or female cellulitis, is a chronic multifactorial disorder characterized by the irregular appearance of the skin surface on the thighs and gluteal regions, which affects 80-90% of women after puberty. No curative treatments are available, and there is a paucity of epidemiological studies related to its prevalence, quality of life impact, and risk factors. We aimed to identify the prevalence and factors associated with the development of GLD in Brazilian adolescent girls. Methods: A cross-sectional study examined adolescent girls from São Paulo, Brazil. The explored factors were grouped: familial history, gynecological and hormonal characteristics, exercise practice, nutrition and diet, anthropometric measures, body mass index, and body composition, according to GLD severity assessed through multivariate hierarchic statistics. Results: In total, 184 girls, aged from 12 to 18 years, were included in the study. The overall prevalence of GLD was 77.7% (CI 95% 71.7-82.1%); moderate and severe categories of GLD occurred in 56.5% (CI 95% 48.9-62.5%) of the sample. An impact on the quality of life was identified in 39.7% of the girls. GLD was independently associated with higher body mass index, early menarche, higher carbohydrate intake, lower water consumption, menstrual irregularity, familial report of GLD, and less exercise practice. Conclusion: Gynoid lipodystrophy is a multifactorial disorder; its onset in adolescent girls is associated with familial occurrence, body composition, diet habits, exercise, and hormonal factors. These results support further interventions for GLD prevention and treatment.
Article
Cellulite affects almost all women, and it is characterized by surface relief alterations, mainly located on the thighs and buttocks, and other areas. Whereas depressed lesions occur due to the presence of thick subcutaneous fibrous septa that pull the skin surface down, raised areas result from the projection of underlying fat to the skin surface. We support that the absence of cellulite can be defined as the ideal balance between the mechanical forces that act between the subcutaneous structures, such as fat and fibrous septa and muscles, and the overlying skin.
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Background: Cellulite represents a common cosmetic problem that affects nearly all women. This study aimed to evaluate microwave therapy's effectiveness for cellulite treatment. Methods: In this study, 26 women showing severe or moderate cellulite underwent four sessions of microwave therapy on the buttocks and posterior thighs. The following assessments were performed at baseline and the three-month follow-up after the last treatment: the Cellulite Severity Scale (CSS), Nürnberger-Müller classification scale, photographic evaluation, and buttocks/posterior thighs circumference measurements. A Likert scale questionnaire was used to assess patient satisfaction at the 3-month follow-up. Results: The treatment positively affected the cellulite severity as confirmed by the Cellulite Severity Scale (CSS) and Nürnberger-Müller classification scale results. CSS showed a significant amelioration in cellulite severity between the initial assessment and the 3-month follow-up for the buttocks and posterior thighs, with total average scores that ranged from 10.7 ± 3.1 to 4.5 ± 1.8 (p < 0.01). The treatment also resulted in a remarkable improvement in comfort/satisfaction and a buttocks and posterior thighs circumference reduction. No serious adverse events were observed. Conclusions: Microwave therapy has proven to be a safe treatment for improving cellulite appearance and reducing body circumferences.
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Gynoid lipodystrophy (cellulite) is an extremely controversial topic. A lack of knowledge regarding specific aetiopathogenic factors, as well as the opportunism of some professionals and the media, has fuelled debate regarding the scientific basis of this condition. This article reviews the clinical, epidemiological, histopathological and therapeutic aspects of cellulite.
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The anatomic basis of so-called cellulite, the hormonal basis for the clinical condition, the prevalence of it, the essential normality and inevitability of it in women, the supervention of it in hormonally feminized men, and the near futility of treating the non-disease are explored in this paper.
Article
Author's Note: This article represents a combination of knowledge from the skin care industry (Dr. Marenus) and the dermatologic community (Dr. Draelos). The first of the two-part article discusses current understanding of the etiology of cellulite while the second part presents purported treatments. Cellulite is a condition affecting 85% of postadolescent women characterized by dimpled tissue on the upper outer thighs, posterior upper thighs, and lower buttocks. A better understanding of the etiology of cellulite has been obtained through ultrasonic analysis of the upper thigh and buttock tissue demonstrating herniation of the subcutaneous fat into the dermis. The initial changes leading to cellulite formation appear to be deterioration of the dermal matrix and vasculature, particularly loss of the capillary networks, leading to excess fluid retention within the dermal and subcutaneous tissues. This loss of the capillary network is thought to be due to engorged fat cells clumping together and inhibiting venous return. A variety of treatments, to include xanthines, herbal derivatives, heating, massage, and skin kneading, have been put forth as possibly reducing the dimpled skin appearance.
Article
Cellulite is a common clinical condition, with few proven effective therapeutic options. Subcision is a surgical technique that is useful in treating advanced degree cellulite. This study was designed to determine the usefulness of the treatment of cellulite by subcision. From January 1995 to January 1998, 232 female patients, aged 18-52 years, with cellulite on the thighs and buttocks were treated on an outpatient basis by the subcision technique. In the postoperative period, all the patients had pain, bruises, and hemosiderosis. An improvement in the surface depressions was observed and the patients reported a high degree of satisfaction. This outpatient procedure is effective in the correction of surface depressions on the thighs and buttocks, clinically classified as cellulite.
Article
Agreement measures are used frequently in reliability studies that involve categorical data. Simple measures like observed agreement and specific agreement can reveal a good deal about the sample. Chance-corrected agreement in the form of the kappa statistic is used frequently based on its correspondence to an intraclass correlation coefficient and the ease of calculating it, but its magnitude depends on the tasks and categories in the experiment. It is helpful to separate the components of disagreement when the goal is to improve the reliability of an instrument or of the raters. Approaches based on modeling the decision making process can be helpful here, including tetrachoric correlation, polychoric correlation, latent trait models, and latent class models. Decision making models can also be used to better understand the behavior of different agreement metrics. For example, if the observed prevalence of responses in one of two available categories is low, then there is insufficient information in the sample to judge raters' ability to discriminate cases, and kappa may underestimate the true agreement and observed agreement may overestimate it.
Article
Cellulite is a common condition in women for which treatment is frequently requested. Its etiology is unknown, but a myriad of factors including genetics, hormones, and inflammation appear to contribute to its formation. Despite the popularity of therapies touting their effectiveness for this pervasive condition, few have proven long-lasting benefits. Lasers and light sources are the latest devices to have entered the cellulite therapeutic market. This paper describes these optical devices and provides an overview of their published effectiveness.
Women's Dermatology-from Infancy to Maturity
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Women's Dermatology -from Infancy to Maturity
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Hexsel DM. Body repair. In: Parish LC, Brenner S, Ramos-e-Silva M, eds. Women's Dermatology -from Infancy to Maturity. Parthenon Publishing, New York (NY), 2001: 586-595.
Definition, clinical aspects, associated conditions, and differential diagnosis
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Hexsel D. Dal'Forno TO, Cignachi S. Definition, clinical aspects, associated conditions, and differential diagnosis. In: Goldman MP, Bacci PA, Leibaschoff G, Hexsel D, Angelini F, eds. Cellulite -Pathophysiology and Treatment. Taylor&Francis, New York (NY), 2006: 7-28.