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A validated photonumeric cellulite severity scale
Journal of The European Academy of Dermatology and Venereology
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.
... This categorises skin appearance into 4 grades (0-III): I-visible changes with skin clamping or muscle contraction; II-visible changes without manipulation; and III-visible changes associated with nodules. 4,6,8,9 The Cellulite Severity Scale by Hexsel et al. has become the new standard classification system for clinical evaluation and treatment response. 9,10 This scale adds four additional clinical morphologic features to the NM scale: the number of evident depressions, the depth of the depressions, the morphological appearance of skin surface alterations and the grade of laxity. ...
... The severity of each item is graded from 0 to 3. The sum could be 0 in case of complete absence. 9 The clinical assessment of cellulite remains subjective despite the clear qualitative and quantitative measures taken to make evaluation more effective. There are many different treatments which are all designed to minimise the cellulite appearance and to achieve a smoother skin surface. ...
... There are many different treatments which are all designed to minimise the cellulite appearance and to achieve a smoother skin surface. 4,6,8,9,11 5 | TREATMENTS ...
Gynoid lipodystrophy, also called cellulite, is defined as a metabolic disorder of the subcutaneous tissue that alters body contour. It is rare in men but affects 80%–90% of adult women.The authors describe a technique for the treatment of cellulite with non‐traumatic subcision TM of septa by cannula associated with large‐gel‐particle hyaluronic acid (HA). It uses a special marking, a safe plan and a specific product. The product being used is Subskin Aeskins, in a subcutaneous plan as no major blood vessels were found.The authors report good aesthetic results with the proposed technique. The patients reported a high degree of satisfaction.The product chosen has high G prime and large particles, which accounts for resistance to deformation and a high lifting power. Moreover, HA is a biocompatible, absorbable product and considered a safe filler. This technique allows the treatment of an area with various surface irregularities.The Square Technique proved to be a minimally invasive technique, with fast results, no major risks and little downtime, bringing satisfaction to patients and improving their self‐confidence and quality of life.
... In previous studies, Byun et al. 6 and de Godoy et al. 9 assessed cellulite treatment with different techniques but they did not include detailed descriptions of their assessment methods or provide information on the reliability of their measurement processes. Several assessment systems, for example, the Hexsel cellulite severity scale (CSS) 10 and the Nurnberger-Muller scale, 11 to measure cellulite have been developed. Although some of these standardized scales were reproducible, the methods have often been relatively complex, had relatively low sensitivity or required direct clinical assessment of the participant, which would make it more difficult to ensure blinded assessment in a clinical trial. ...
... Although some of these standardized scales were reproducible, the methods have often been relatively complex, had relatively low sensitivity or required direct clinical assessment of the participant, which would make it more difficult to ensure blinded assessment in a clinical trial. [10][11][12][13] Hexsel et al. 10 assessed the reliability of the CSS in evaluating cellulite of the buttock and thigh regions. ...
... Although some of these standardized scales were reproducible, the methods have often been relatively complex, had relatively low sensitivity or required direct clinical assessment of the participant, which would make it more difficult to ensure blinded assessment in a clinical trial. [10][11][12][13] Hexsel et al. 10 assessed the reliability of the CSS in evaluating cellulite of the buttock and thigh regions. ...
Unlabelled:
Numerous products and minimally-invasive procedures are available to reduce cellulite. However, there are a limited number of tools to evaluate the effects of these interventions and some are relatively complex to implement.
Objective:
This study evaluated the reliability of a standardized grading system for scoring the overall severity of cellulite on the posterior thigh. The study evaluated inter-rater and intra-rater (test/re-test) reliability of the method and engaged in an iterative process to develop a reliable method to evaluate changes in the appearance of cellulite.
Methods:
There were two stages in the validation process. The first stage was an open process without evaluator training. The second stage was a more controlled process with training given and moderator involvement to review grade selections. In the first stage, inter-rater reliability was examined across five evaluators who were asked to evaluate 24 photographs (right thighs) based on a cellulite graded severity chart. During the second stage, the same photographs were examined by paired evaluators who had received additional training. Scores were independently moderated by a third person. The inter-rater reliability and intra-rater reliability over a 4-week interval were evaluated using intraclass correlation coefficients (ICCs).
Results:
Twenty-four female participants (18-51 years, mean 31.68 ± 9.03 years) with a mean BMI of 29.04 ± 6.52 participated in the trial. Five female evaluators completed the initial evaluations. In stage 1, the inter-rater reliability (ICC2,5 ) was 0.838 (95%CI:0.700-0.922) and test/retest ICC3,1 values ranged from 0.360-0.990. In stage 2, the inter-rater reliability for 2 evaluators improved to 0.978 (95%CI:0.948-0.991), and the test/retest reliability of the moderated scoring method improved to 0.993 (95%CI:0.983-0.997).
Conclusion:
The iterative process developed a simple and reliable method of rating cellulite severity, with excellent inter-and intra-rater reliability, based on evaluating images of cellulite against a standard set of graded severity images. A reliable method of assessing cellulite severity is essential for undertaking future clinical trials to evaluate cellulite treatments.
... 4,5 Several factors contribute to the development of cellulite in women, such as age, thickened fibrous septa, enlarged fat lobules, stress, hormonal imbalance, decreased dermal collagen, and a sedentary lifestyle. 6,7 Successfully addressing cellulite has proven challenging. Anatomical studies of the structure of cellulite have increased the understanding of its pathophysiology, leading to the development of additional treatment options. ...
... 10,11 Radiological studies have demonstrated that thickened fibrous septa connect the dermis to the underlying superficial fascia with superficial fat located in the space between. 7,11,12 The septa between the superficial fascia and the dermal undersurface are not simplistic, 2-dimensional structures similar to a single pillar or string; rather, they are 3-dimensional structures with densely grouped, thickened fibrous lattices and structural configurations similar to the hexagonal cells in a honeycomb. [13][14][15] With changes in the fat lobules, the fibrous septa restrain portions of the dermis to the superficial fascia, resulting in depressions and dimpled appearance of the skin. ...
... The validated Cellulite Severity Scale (CSS) was developed by Hexsel et al and is based on 5 key morphologic aspects of cellulite. 7 For the purposes of this study based on FDA precedent, only the first 2 components were utilized: number of depressions (Part A) and depth of depressions (Part B). The primary efficacy endpoint for the study was considered reached with a mean ≥1 point reduction in the total CSS score (Part A + Part B-1) at day 90 (Table 1). ...
Background:
Cellulite is an aesthetic condition affecting the appearance of skin in certain body regions and is associated with body dissatisfaction, psychosocial stress, and decreased quality of life. Previous studies have established the safety and feasibility of a novel, minimally-invasive device utilized for precisely identifying and verifiably releasing septa responsible for cellulite depressions. The single procedure is known as Targeted Verifiable Subcision (TVS).
Objectives:
The objective of this single-arm, open-label, multicenter study was to evaluate the safety and efficacy of TVS for reducing the appearance of moderate to severe cellulite in the buttock and thighs of adult women.
Methods:
Adult women 21-55 years of age and a BMI <30 kg/m2 with moderate or severe cellulite on the buttocks and/or thighs were eligible to be enrolled at 9 sites. Endpoint data includes results from 4 of the postprocedural follow-up visits at 24 hours, 7 days, 30 days, and 90 days (3 months). The primary endpoints were a mean ≥ 1 point reduction in the Cellulite Severity Scale (CSS) at 90 days and no related serious adverse events (SAEs) at 30 days.
Results:
Seventy-four female participants with a mean BMI of 24.8 ± 2.7 and age of 41.4 ± 7.4 years received this single procedure. The mean improvement in CSS (N=68) was 1.5 ± 0.9 (p < 0.0001). There were no device-related SAEs at 30 days.
Conclusions:
Targeted Verifiable Subcision for selectively identifying and verifiably releasing septa responsible for cellulite depressions is an effective and safe means for improving the appearance of moderate to severe cellulite in adult women.
... 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. ...
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.
... 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. ...
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)
... Foram selecionadas 16 participantes, mulheres, sedentárias, com idade de 30 a 55 anos, recrutadas através de divulgação veículos de comunicação (rádio, jornais, entre outros). Os critérios de inclusão foram: ter celulite de grau 1 a 4, de acordo com o critério padronizado por Hexsel (2009) e ser sedentária. ...
... Na avaliação qualitativa das possíveis mudanças na aparência das alterações superficiais, na textura da pele, na profundidade das depressões da região glútea optou-se por utilizar os critérios de avaliação visual por imagem descritos por Hexsel (2009) Research, Society and Development, v. 13, n. 9, e5113946847, 2024 (CC BY 4.0) | ISSN 2525-3409 | DOI: http://dx.doi.org/10.33448/rsd-v13i9.46847 ...
A celulite possui uma etiologia multifatorial e causa alterações significativas na camada subcutânea, incluindo edema, lipodistrofia e desvio fibroso do tecido conjuntivo. Essas mudanças estão relacionadas a fatores hormonais e à presença de mediadores inflamatórios. Neste contexto, o infravermelho longo (IVL) tem apresentado efeitos benéficos sobre o metabolismo e função celular, aumentando a biodisponibilidade de óxido nítrico (NO) e Ca2+, melhorando a circulação sanguínea. Este estudo objetivou avaliar os efeitos do uso de uma calça confeccionada com tecido emissor de IVL em mulheres com celulite. Esta pesquisa foi submetida e aprovada por Comitê de Ética em Pesquisa. Foram selecionadas 16 mulheres, sedentárias, de 30 a 55 anos, com grau 1 a 4 de celulite. As participantes receberam duas calças confeccionada com tecido emissor de IVL, tecnologia INFUSION (BEAUTYTECH®, Guariba, SP, Brasil). O uso da calça foi por um período de 6 horas diárias (8:00 as 18:00h), 5 vezes na semana, durante um mês. Avaliações antes e após tratamento foram realizadas (fotografia, ultrassom e termografia). Os dados quantitativos foram tabulados para realização da análise estatística. As imagens foram analisadas qualitativamente. O uso de uma calça confeccionada com tecido emissor de infravermelho longo (IVL), nas condições experimentais apresentadas, demonstrou promover uma discreta redução do edema e uma significativa diminuição da temperatura superficial. Esses efeitos resultaram em uma melhoria qualitativa na aparência das alterações cutâneas, incluindo a textura da pele e a profundidade das depressões. Os resultados preliminares indicam que essa tecnologia pode ser uma estratégia terapêutica promissora no tratamento da celulite.
... Eligible participants were females ($18-50 years; BMI #30 kg/m 2 ) who had severe cellulite ($4.0) as assessed by the clinical investigators on a validated 6-point Cellulite Severity Scale (CSS; See Supplemental Digital Content 1, Figure 1, http://links.lww.com/DSS/B334) 26 at baseline, on at least 1 thigh and/or buttock (scale of 0-5; 0 5 none, 1-2 5 mild, 3 5 moderate, 4-5 5 severe). Additional inclusion criteria included: weight (65% of body weight) stable for at least 6 months before the study; no invasive or energy-based cellulite treatments (e.g., liposuction, subcision, laser) for the previous 12 months; and no use of topical-based cellulite treatments for the previous 6 months. ...
... photographs, then graded the baseline and post-treatment images using a simplified 6-point CSS (scale of 0-5, with 5 being the most severe). 26 The percentage of participants with a $1point change in CSS score at the 12-and .52-week follow-up visit was also calculated. ...
BACKGROUND
Cellulite is an aesthetically displeasing rippling or dimpling of the skin, primarily on the buttocks/thighs. A recent study showed a novel acoustic subcision device produced significant short-term (12-week) improvement in the appearance of cellulite after a single rapid acoustic pulse (RAP) treatment.
OBJECTIVE
To evaluate the long-term (>52-weeks) efficacy and safety of RAP treatment for improvement in the appearance of cellulite.
MATERIALS AND METHODS
In this prospective, multicenter trial, female participants ( n = 42) with severe cellulite were treated with the acoustic subcision device in a single visit. At >52 weeks, blinded board-certified dermatologists assessed efficacy by correctly identifying post-treatment photographs and using a 6-point simplified Cellulite Severity Scale (CSS). Participant satisfaction was also collected. Safety was assessed throughout.
RESULTS
The blinded panel correctly identified post-treatment photographs at a rate of 95.2%; 70.4% of participants had a >1-point reduction in the CSS score from baseline (mean reduction of 1.09). All participants (100%) reported improved cellulite appearance. Overall pain during treatment was rated as 2.4 and 0.3 post-treatment (pain scale 0–10). No device or treatment-related adverse events were reported at the >52-week follow-up.
CONCLUSION
Rapid acoustic pulse treatment significantly improved the long-term appearance of cellulite and was well-tolerated.
... in the literature [1,14] that could be associated with the anatomical, genetic, and hormonal predisposition for developing alterations in the adipose tissue when comparing them with men [6], as well as the greater propensity for aesthetics in females. Te average age was 47 years, and most patients had a university education (91.34%), which could indicate that a higher educational level has a greater tendency for self-care and a better economic income, allowing access to this service and a greater disposition to improve their quality of life. ...
... Tese diferences could be related to the ethnic characteristics of body constitution in the Latin population, where a major fat distribution is observed in these areas that could explain the lesser loss. With regard to the cellulite appearance, diferent scales are found, as reported by Di Pietro et al. [1], and in this study, they described a series of 20 women, with a BMI <30, who underwent four sessions of microwave treatment with a 30-day interval; they later compared results before the frst session, four and eight weeks after treatment using the cellulite severity scale-CSS [14]. An initial moderate to severe CSS was found in 95% of patients with posterior signifcant improvement in cellulite degree, and 80% of patients were reclassifed as mild (p < 0.05), with no loose skin in 65% of patients. ...
Background:
The microwave body remodeling system is indicated for people who want to improve their physical appearance as it can penetrate deep tissues, causing thermic stress on adipocytes to produce adipolysis while in superficial tissues, it dissolves fibrous tracts and stimulates new collagen.
Objectives:
The aim of this study was to assess the localized adiposity reduction in Latin American patients using a microwave system.
Methods:
A total of 35 patients with a mean age of 47.5 (±9.0) years received body remodeling treatment, using the microwave system between the years 2019-2022 in a Bogota, Colombia reference center. Data descriptive analysis was made as well as single-factor repeated measures ANOVA to show pre- and post-treatment difference, and mixed ANOVA for body mass index (BMI) subgroup analysis was performed.
Results:
In all patients examined, statistical significant differences were found in pre- and post-treatment skinfold test for each body area: superior abdomen (F(1,27) = 63.13; p=0.001), iliac crest (F(1, 23) = 114.33; p < 0.001), posterior waist (F(1, 20) = 27.36; p < 0.001), trochanter (F(1, 17) = 26.94; p < 0.001), among others.
Conclusions:
According to the study's findings, this microwave system is an innovative and effective technique for body remodeling and cellulite and localized fat reduction.
... 7 The CSS, on the other hand, is a validated qualitative and quantitative scale that uses 5 items: number of depressions, depth of depressions, morphology of skin surface alterations, skin laxity, and the Nürnberger-Müller Scale (Table 3). 16 Each of the items is rated on a scale of 0 to 3. Total scores of 1 to 5 indicate mild cellulite, 6 to 10 indicate moderate cellulite, and 11 to 15 indicate severe cellulite. Although a comprehensive scale, the CSS does not capture the patient perspective. ...
... Cellulite Severity Scale16 ...
Cellulite is an aesthetically distressing skin condition that manifests as dimples and depressions, producing an uneven surface to the skin. Occurring in 80% to 90% of females, mostly on the thighs, buttocks, and hips, it is associated with profound negative psychosocial and quality of life issues. Its ethiopathogenesis and pathophysiology are likely to be multifactorial and complex and not fully understood. There is no effective treatment for cellulite, although a number of different treatment modalities are available, from noninvasive to minimally invasive. The efficacy of most treatments is unpredictable and improvements in cellulite appearance are short lived, although significant progress has been made with newer treatments. This review provides an update on the current state of knowledge about cellulite, with an emphasis on patient assessment and an individualized treatment approach for optimal results.
Level of Evidence: 5
... Lotti et al 27 described the existence of an anomalous connective response that can result in an increased collagen deposition in the subcutaneous tissue due to the retention of liquids in the interstitial matrix 27 . Some years later, in 2009, Hexsel et al 28 established a new photonumeric method to grade cellulite, the so-called cellulite severity scale (CSS) 28 . This grade scale was divided into five clinical and morphological aspects taken from 55 patients previously photographed (Table V). ...
... Classification of cellulite severity by Hexsel et al28 . ...
Cellulite is a common topographic condition of the skin manifested as lumpy, dimpled flesh resembling an orange peel on some zones such as the thighs, hips, buttocks and abdomen.
The aetiology of this cosmetic issue is multifactorial, with hormonal, anatomical, environmental and genetic factors influencing its origin, although the exact mechanisms which cause this condition are still unknown. In the present work, a bibliographic analysis of the cellulite etiology has been updated and exposed, as well as the multiple classification grade scales established over the decades. In addition, a new method to classify cellulite severity, in which the clinical manifestations are correlated to the histological aspects more frequently found in the patients, has been presented.
Several theories regarding its appearance, structure and clinical aspects have arisen with the aim of developing and establishing a valuable therapeutic approach. However, the lack of a consensus regarding the classification of cellulite severity has complicated the developments within this field.
... Cellulite severity was evaluated according to the cellulite severity scale (CSS) of Hexsel Dal'Forno & Hexsel. 36 The exclusion criteria were described in the previously published protocol. 35 Women undergoing esthetic treatment who had drunk alcohol or taken analgesics, muscle relaxants or anti-inflammatories in the 24 h before the session were excluded from the study. ...
... Participants were instructed to remain standing, wear dark colored swimsuits, and keep their gluteus exposed to enable the evaluation of cellulite severity using the CSS, with scores of five to nine indicating moderate severity and 11-15 severe ( Figure 1A). 36 Next, cellulite was marked with a dermatograph pencil for carboxytherapy. It should be noted that, for cellulite severity assessment (performed by the responsible researcher), intra-rater reliability for the CSS was tested in 17 women not involved in the study, who were recruited and evaluated at 48-h intervals. ...
Background:
Pain is considered the main limiting factor in carboxytherapy. Electroanalgesia has gained recognition in the field of dermatology and to date, only transcutaneous electrical nerve stimulation (TENS) has proved to be effective at reducing pain associated with carboxytherapy; however, the effect of medium frequency currents has yet to be investigated.
Aims:
Compare the effects of TENS, interferential current (IFC), and Aussie current on pain intensity associated with carboxytherapy and sensory comfort in the treatment of cellulite.
Patients/methods:
Seventy-five women aged 18-49 years with moderate and/or severe gluteal cellulite were randomized into three groups: TENS (n = 25), IFC (n = 25), and Aussie current (n = 25), which underwent three sessions of carboxytherapy associated with an electrical current. Current amplitude was adjusted after each puncture, according to the maximum tolerance reported by participants, below the motor threshold. Pain intensity was measured using a numeric rating scale (0-10) and sensory comfort with the visual analogue scale (0-10).
Results:
There was no significant intergroup difference in pain intensity (p > 0.05) and sensory comfort (p = 0.502) during the application of carboxytherapy throughout the three treatment sessions.
Conclusion:
TENS, IFC, and Aussie currents showed no difference in pain intensity reduction and no current was found to be more comfortable.
... Photonumeric Cellulite Severity Scale[34] ...
... Scoring system of the Cellulite Severity Scale and Cellulite Classification[34] Some devices available in the market with their proposed modes of action and advantages ...
Cellulite remains one of the most common dissatisfactions among women after puberty. Many studies have tried to clarify the origin of cellulite; however, its precise etiology is still unclear, and most authors consider it a multifactorial entity with skin architecture and connective tissue, inflammatory, vascular, endocrine, and genetic factors playing a major role. Cellulite is known to worsen during high estrogen states, including pregnancy, nursing, and chronic use of oral contraceptives. Recently, two polymorphisms have been associated with cellulite: 11549465 HIF1A is protective, whereas ACE rs1799752 increases the risk of cellulite development. Clinical examination with a focus on a palpable medical examination and a visual evaluation is at the center of cellulite diagnosis, but the use of complementary clinical and image tools can be useful. Although no cure for cellulite exists, multiple treatments have been developed over the years to try to improve its appearance. These include noninvasive treatments such as topical and oral treatments, manual or device-based mechanical stimulation, or the increasingly popular noninvasive body contouring devices. Other techniques include liposuction, with laser-assisted liposuction as a preferred option, and subcision, which has recently been combined with autologous fat grafting with promising results.
... Some authors suggest that this may make such a severity assessment less reliable [11]. This is also why the Nürnberger-Müller scale has been gradually replaced by the photonumeric cellulite severity scale in recent years [28]. The latter scale was also used by Whipple et al. [27], who demonstrated a positive correlation between cellulite severity, "depth" of cellulite dimples, and body weight. ...
Background: Cellulite is a cosmetic defect of multifactorial etiology that affects over 90% of women worldwide. Cellulite-induced skin changes are undesirable and negatively affect self-esteem. Despite a plethora of cellulite-reducing treatments, we still lack objective tools to enable accurate diagnosis and treatment efficacy assessment. The aim of this study was to determine whether high-frequency ultrasound can be helpful in assessing cellulite and whether there is an association between ultrasound-derived measurements, parameters ascertained clinically, and cellulite assessment scale scores. Methods: The study group consisted of 114 women with cellulite in their posterior thighs, assessed using the Nürnberger–Müller scale. Two types of ultrasound devices were used in this study: a conventional scanner with a linear transducer and a skin-dedicated scanner equipped with a mechanical transducer. We used high-frequency ultrasonography to determine epidermal thickness, dermal thickness, the surface area of fat protrusions at the dermal subcutaneous junction, and the thickness and stiffness of the subcutaneous tissue (ultrasound elastography). Results: There was a correlation between cellulite severity and subcutaneous tissue thickness (r = 0.63), the surface area of fat protrusions at the dermal subcutaneous junction (r = 0.64), and the elastographic strain ratio (r = 0.51). An association was also demonstrated between thigh circumference and subcutaneous tissue thickness (r = 0.48). There was a significant difference in the assessed parameters between the subgroups identified by cellulite severity scores. Conclusions: Ultrasound-determined surface area of fat protrusions at the dermal subcutaneous junction as well as the thickness and stiffness of the subcutaneous tissue seem useful in cellulite assessment. Thus, ultrasonography has the potential to become a common tool in aesthetic medicine and cosmetology.
... Physical inactivity exacerbates the condition by promoting weight gain and reducing muscle tone, making cellulite more visible. Smoking and excessive alcohol consumption also impair blood circulation and skin health, further contributing to cellulite formation [8]. ...
Metabolic syndrome (MetS) encompasses a cluster of metabolic abnormalities, including insulin resistance,
hypertension, abdominal obesity, and dyslipidemia, increasing cardiovascular disease and type 2 diabetes
risks. Cellulite, a cosmetic condition marked by dimpled skin, predominantly affects women and shares risk
factors with MetS, such as obesity and hormonal imbalances. This review examines the potential link
between MetS and cellulite, focusing on shared pathophysiological pathways and implications for clinical
practice and future research. Common factors such as inflammation, hormonal changes, and adipose tissue
dysfunction are explored. The review highlights the importance of longitudinal studies to track cellulite
progression in MetS patients, biomarker identification for early detection, intervention trials to assess
therapeutic efficacy, mechanistic studies to elucidate underlying pathways and the impact of comorbidities
on cellulite development. Understanding these relationships can enhance prevention, diagnosis, and
treatment strategies for both MetS and cellulite, addressing significant public health and cosmetic concerns.
... A imagem corporal foi examinada por meio do Teste para Avaliação de Imagem Corporal (Matsuo et al., 2007), enquanto a satisfação corporal foi mensurada através do Questionário sobre a Imagem Corporal (Legnani et al., 2012). A severidade da celulite foi determinada utilizando a Cellulite Severity Scale (CSS) (Hexsel et al., 2009), e a qualidade de vida relacionada ao FEG foi avaliada pelo Celluqol® (Hexsel et al., 2011). Além disso, a presença de gordura localizada foi avaliada por meio do Teste de Quadril, enquanto as dobras cutâneas foram medidas com um adipômetro científico e a perimetria foi realizada utilizando uma fita métrica (Schneiberg, Franciscon, 2016). ...
... In this study, all efficacy assessments were based on non-invasive methods, and the validity of these methodologies is supported by many previous studies [39][40][41][42][43][44][45]. Non-invasive methods, in general, are considered relevant and useful tools in studies assessing the efficacy of SD treatment options because the findings from these methods have been reported to be consistent with histological findings [25]. ...
Striae distensae (SD), or stretch marks, are a common skin problem having a psychological impact and cosmetic concern, especially for women, in whom the prevalence is higher than in men. This study assessed the efficacy and safety of a single autologous micrografting treatment (AMT®) using Rigenera® technology for the management of SD.
This single-centre study included 10 healthy women between 24 and 65 years of age, with Fitzpatrick–Goldman skin types I–IV, who had visible SD in glutes/thighs. Each subject acted as their own control. The treatment procedure (microneedling + AMT) and the control procedure (no treatment) were performed on contralateral sides of the glutes/thighs, targeting matched and paired SD. Microneedling was carried out using Dermapen®, equipped with 32 needle heads set at 1.5 mm needle length. The AMT procedure involved extracting biopsies from the mastoid hair zone with a 2.5-mm dermal punch, followed by disaggregation of the biopsies in a physiological saline solution using the Rigeneracons. The disaggregated micrografts were then intradermally injected using 30G 4-mm needles, maintaining a distance of 1 cm between injection points, covering the entire marked treatment region.
In the treated area, at 3 months post-procedure compared to pre-procedure, the following changes were observed, all with statistical significance (P ≤ 0.05): (a) significant reductions in skin roughness (Ra, − 15.9%; Rz, − 22.6%), skin luminance (− 2.0%), and blue-green color distribution (− 10.6%); (b) significant increases in skin microcirculation maximum value (+ 240.1%), skin hydration (+ 71.2%), skin elasticity (+ 216.5%), skin density (+ 34.3%), skin thickness (+ 26.0%), and hypodermis thickness (+ 29.9%). Furthermore, for each of the aforementioned parameters, there was a significantly greater improvement observed with the AMT procedure compared with microneedling at 3 months (all P ≤ 0.05).
The AMT procedure using Rigenera technology resulted in an noticeable improvement in the SD appearance after 3 months in healthy women.
... The noticeable changes consist of protrusions, caused by fat and subcutaneous structures protruding into the dermis, and depressions, caused by skin retraction due to subcutaneous fibrous septa. 1,2,3,4 Author σ: MD, PhD The primary factor for the development of gynoid lipodystrophy is the presence of estrogen; therefore, it occurs almost exclusively in women. Its onset is common after puberty and can be exacerbated in periods of increased hormone levels such as during pregnancy, breastfeeding, menstruation, and the use of oral hormonal contraceptives. ...
Background: Gynoid lipodystrophy(GLD), popularly known as cellulite, is the result of fat deposits under the skin. It is characterized by structural, inflammatory, and biochemical disorders of the subcutaneous tissue that cause irregular dimpling of the epidermis. Among many treatments used for GLD, Goldincision® has proved to be effective, showing more significant and satisfactory results. Therefore, this work aimed to describe this technique. Methodology: This is a multicenter observational study which analyzed the cases of 47 patients who were submitted to the Goldincision® technique in 2021, using the team’s protocol for assessment, treatment, and follow-up.
... También se ha informado del empleo del APPL para tratar la celulitis con buenos resultados. La mejoría de la zona afectada se produce a través de la inducción y remodelación de nuevo colágeno, cambiando la calidad de la piel en cualquiera de los estadios de la clasificación de la celulitis [19][20][21]. Cuando se emplea el APLL para tratar la celulitis en los muslos y glúteos se infiltra en un plano más superficial, aunque siempre en el tejido graso subcutáneo y se usa en este caso el Lanluma V ® en alta dilución; con 30 ml de agua bidestilada y 2 ml de lidocaína al 2% y cánula de 22G y 90 mm, infiltrando el producto por toda la zona afectada de forma lineal retrógrada en abanico [6]. ...
Introducción. La remodelación estética por medio de la bioplastia permite restaurar, modelar o modificar el cuerpo humano. Entre los materiales que pueden emplearse figura el ácido poli‑L-láctico (APPL) por su capacidad de estimular al fibroblasto para producir nuevo colágeno a través de un proceso inflamatorio controlado. El nuevo colágeno revierte la laxitud de la piel con aumento del volumen cutáneo en cualquier parte de la anatomía. El objetivo de este trabajo es conocer el tratamiento con APLL en distintas aplicaciones como la atrofia del tejido graso que acontece después de inyecciones repetidas en una zona, la modelación de la zona glútea y de otras áreas anatómicas del contorno corporal. Material y método. Se recomienda añadir 40 ml a Lanluma X® y 15 ml a Lanluma V®. Con las proporciones mencionadas Lanluma X® contendrá 15,75 mg/ml de principio activo y Lanluma V® 14 mg/ml. La infiltración debe hacerse en el tejido subcutáneo o sobre el plano supraperióstico; siempre en grasa y nunca intradérmico. El APPL puede aplicarse en la cara, excepto en mucosas, labios y ojeras, y en otras zonas corporales, con o sin atrofia, como glúteos, cara interna de brazos y piernas, manos y abdomen. En el trabajo que se presenta se han tratado 143 pacientes en diversas localizaciones con alguno de los productos reseñados. Resultados. Los resultados del tratamiento con APLL han alcanzado un alto grado de satisfacción; 75% en las pacientes tratadas de flacidez en la zona rotuliana, hasta un 85% en las tratadas de glúteos y brazos. Conclusiones. El APPL se ha mostrado muy eficaz para tratar la atrofia de los compartimentos grasos, dando firmeza y mayor volumen a la piel en diferentes zonas del cuerpo. Los buenos resultados son muy dependientes del médico que lo aplica, requiriéndose un entrenamiento adecuado para evitar la aparición de efectos indeseables.
... We assessed the cellulite of each buttock of the patients using the CSS, 8 a photonumeric scale that rates the five main cellulite morphological features (depressions number, depressions depth, clinical appearance of evidently raised lesions, flaccidity, and the Nurnberger-Muller cellulite classification scale). Each criterion is rated from 0 to 3, and their total sum classifies the cellulite as mild, moderate, or severe. ...
Introduction: High-intensity focused electromagnetic field treatment (HIFEM) uses low-frequency electromagnetic waves to induce supramaximal muscle contractions, causing muscle hypertrophy and reducing fat.
Objective: To evaluate the effects of a HIFEM treatment for the improvement of cellulite on the buttocks.
Methods: Thirty patients were divided into two groups that received eight or 12 HIFEM sessions on the buttocks for six weeks. We assessed the improvement in cellulite and the buttocks' global appearance through the Cellulite Severity Scale (CSS), the Global Aesthetic Improvement Scale (GAIS), and a satisfaction questionnaire. Changes in body composition were evaluated through bioimpedance and hip circumference measurements.
Results: Patients from both groups improved the global appearance of their buttocks. Cellulite lesions of some patients improved, but for most patients, the improvement wasn’t great enough to change the grade on the Cellulite Severity Scale. Patient satisfaction was high and adverse events were few, minor, and transitory.
Conclusion: The effects of HIFEM on cellulite are subtle, as this treatment modality cannot address the fibrous septa that cause the depressed lesions of cellulite. Nevertheless, HIFEM procedures can improve the buttocks’ global appearance, enhancing the patients’ subjective perception of their cellulite.
... Cellulite (gynoid lipodystrophy), commonly referred to as the "orange peel effect", is a typical problem for women, affecting about 80-98% of post-pubertal women [1]. It is characterized by the presence of dimples and irregular texture of the skin and is most prevalent mainly on the hips, thighs, and buttocks; it can also be seen on the breasts, lower abdomen, arms and back of the neck [1,2]. Many factors can influence the formation of cellulite, such as genetic predisposition, along with hormonal influences, structural differences in adipose tissue, and inflammation can also contribute to triggering this aesthetic problem [3]. ...
Objective:
The objective of this work was to develop a self-emulsifying drug delivery system (SEDDS) containing caffeine for the treatment of cellulite.
Methods:
SEDDS were prepared by the solution method. 0.5% (w/v) caffeine was added to previously selected excipients. The system was characterized by droplet size, zeta potential, emulsification time, and long-term stability. In vitro release and skin permeation were investigated in Franz-type diffusion cells. The cytotoxicity was evaluated on normal human keratinocytes.
Results:
Caffeine SEDDS were thermodynamically stable, with Zeta Potential less than - 22mV and droplet size around 30 nm, and long-term stable. The permeation study showed that the formulation promotes caffeine accumulation in the skin layers, suggesting an increase in local circulation. Cytotoxicity studies on HaCaT cells were not conclusive since the surfactant used indicates false positive results due to high molar mass.
Conclusion:
It was possible to obtain a stable SEDDS that can cause an increase in blood flow in the applied area, resulting in cellulite reduction.
... The REAL study was a multicenter, open-label, phase 3 trial. Women eligible to be included in the trial were those aged 18 to 60 years with mild-to-moderate cellulite (CR-PCSS score of 2 or 3); a Hexsel Cellulite Severity Scale 16 ...
Background:
Collagenase clostridium histolyticum-aaes (CCH-aaes) is approved in the US for moderate-to-severe cellulite in the buttocks of adult women.
Aim:
Interim analysis to evaluate efficacy/safety of CCH-aaes in the treatment of thigh cellulite.
Methods:
Data were analyzed from a phase 3, open-label study (REAL). Women with mild-to-moderate cellulite on both thighs (Clinician Reported Photonumeric Cellulite Severity Scale score, 2 or 3) received ≤0.84 mg (volume, 18 mL) of CCH-aaes subcutaneously, in up to 12 dimples per posterolateral thigh, in up to 3 treatment sessions (Days 1, 22, and 43). Follow-up was on Day 90 (interim cutoff). A subset of women participated in the concurrent study (PIXELS), which included high-definition photography and 3D-image scanning of treatment areas.
Results:
Twenty-two women (44 thighs) were included in the interim analysis (mean age, 42.3 years, thighs with mild cellulite, 68.2%). Investigators reported high percentages of responders (score of "improved" or better on Investigator Global Aesthetic Improvement Scale) at Day 90 for either thigh (86.4%, primary endpoint) or both thighs (72.7%). Patient-reported bother due to cellulite was reduced at Day 90, mean change was 15.3 points (85.5% reduction) in BODY-Q Appraisal of Cellulite scale total score (possible range, 11-44). In PIXELS analysis, Day 90 3D-image scans showed improvement from baseline in skin roughness in some of the treated thigh areas. The most commonly reported adverse events were injection-site bruising and pain (95.5% and 50.0% of patients, respectively).
Conclusions:
CCH-aaes treatment of mild-to-moderate thigh cellulite was effective and generally well tolerated, with markedly reduced cellulite-related bother.
... Buttocks have always been synonymous of femininity and especially nowadays, thanks to the internet, the magazines and the media, the care of our body has become one of the most important aspects of our lives (1). In fact, there has been a sudden increase in the number of patients demanding surgical and non-surgical procedures to improve and enhance the appearance of their buttocks (2)(3). For these reasons, several authors started to create evaluation scores for the gluteal region (4). ...
Introduction:
New treatment methods to improve and enhance buttocks appearance require globally accepted scales for aesthetic research and patient evaluation. The purpose of our study was to develop a set of grading scales for objective assessment of the gluteal region and assess their reliability and validity.
Materials and methods:
Twelve photonumeric grading scales were created. Eleven aesthetic experts rated photographs of 650 women in 2 validation sessions. Responses were analyzed to assess inter-rater and intra-rater reliability. The Rasch model was used as part of the validation process.
Results:
All the scales exceeded criteria for acceptability, reliability and validity. Overall inter-rater reliability and intra-rater reliability were both "almost perfect" (p=0.15 and p=0.16 respectively).
Conclusion:
Consistent outcomes between raters and by individual raters at 2 time points confirm the reliability of the Objective Buttocks Assessment Scale in female patients and suggest it will be a valuable tool for use in research and clinical practice.
... The CSS consists of 20 photographs, and by comparison with the volunteer, the morphological characteristics are and Müller Scale, classified as: 0: zero, 1: one degree, 2: two degrees, 3: three degrees. The final sum of the evaluation varies from 1 to 15 and classifies cellulite as: medium severity (1-5 points), moderate severity (6-10 points) and severe (11-15 points) (Hexsel, Dal'Forno & Hexsel, 2009). ...
Gynoid lipodystrophy (GL), popularly known as cellulite, affects 85% of women after puberty. The aim of the study was to develop, characterize and evaluate the effectiveness of a topical formulation based on Coffea canephora green extract (GCE) applied by phonophoresis in the treatment of GL in young women. Formulations with 1.0% (w/w) and 3.0% (w/w) of GCE were developed and characterized by organoleptic analysis, pH, centrifugation, caffeine content, rheology, spreadability, preliminary stability and cytotoxic analysis. And after the selection of the formulation, in a longitudinal, randomized and blind study, with volunteers in separate groups, the Control Group (CG, n=15) used the formulation based on a copolymer of sodium acrylates and lecithin (Lec) and the Test Group (TG, n=15) the copolymer formulation of sodium acrylates and lecithin containing 3.0% (w/w) of GCE (Lec/GCE3). Volunteers were assessed before and after treatment for cellulite severity using the Cellulite Severity Scale (CSS) and quality of life using the Dermatology Life Quality Index (DLQI-BRA). The groups were treated with 5 sessions, twice a week, 20 min/session. As a result, the GT achieved a significant reduction (p=0.002) in cellulite severity according to the CSS and both groups showed significant changes in the DLQI-BRA after treatment, CG (p=0.001) and TG (p=0.001). We conclude that the LEC/GCE3 formulation applied by phonophoresis was effective for cellulite in young women.
Inadequate eating habits negatively impact aesthetics, especially in women who experience dysfunctions such as Gynoid Lipodystrophy (GL). Many people still do not associate healthy eating with better aesthetic results, contributing to an increase in problems related to improper diets. This study conducted a bibliographic review, consulting databases such as Google Scholar, PubMed, and SciELO, with the objective of analyzing the influence of healthy diets on the aesthetic treatment of GL. The search used the following descriptors: Gynoid Lipodystrophy AND Nutrition, Gynoid Lipodystrophy AND Diet, Fibroedema Gelóide AND Nutrition, Fibroedema Gelóide AND Diet, Cellulite AND Nutrition, and Cellulite AND Diet. Five selected articles indicated that diets rich in vegetables can improve the condition, while protein-rich diets help with weight loss and improvement in the appearance of cellulite, especially on the thighs. Despite challenges in adherence, balanced diets and weight loss are fundamental for cellulite treatment.
Cellulite treatments vary in their mechanisms, invasiveness, and durability of outcomes. Non-invasive options, such as topical agents and oral supplements, provide moderate benefits but require prolonged use. Massage and energy-based therapies offer better cosmetic improvements but often require multiple sessions with results that may not be long-lasting. Invasive treatments, like subcision and injectable options, directly address structural issues underlying cellulite. The choice of treatment depends on individual patient needs, cellulite severity, and the desired balance between invasiveness and results. A tailored approach considering the underlying structural and aesthetic concerns often yields the best outcomes.
Cellulite is a common dermatologic condition affecting 80-90% of post-pubertal females, particularly on the thighs, buttocks, and hips. It is characterized by dimpling and a "mattress-like" skin appearance, significantly impacting body image and quality of life. More prevalent in Caucasian women, it results from multifactorial causes, including hormonal influences (e.g., estrogen), structural differences in subcutaneous tissues, vascular changes, and low-grade inflammation. Lifestyle and aging further contribute to its severity. Treatments range from topical applications and energy-based devices to minimally invasive procedures, though results are often temporary. Due to its complex etiopathogenesis and structural changes, cellulite remains challenging to treat, necessitating realistic patient expectations and further research for improved and lasting solutions.
Background: Gynoid lipodystrophy (GL) is a complex condition that mainly affects women, who often face challenges such as body dissatisfaction, difficulty finding clothes, and pain due to the appearance of an "orange peel" texture. These issues have a significant impact on their quality of life, sometimes leading to social exclusion. Objective: This study aimed to correlate the Cellulite Severity Scale (CSS) with Thermography when used to classify GL. Patients/Methods: Cross-sectional study, where 40 women underwent evaluation through the photonumerical scale of cellulite severity and thermography. After analyzing the inclusion criteria, the buttocks were classified as right (HG) and left (LG) and underwent Pearson's correlation test and linear regression. Results: The results showed that there is no correlation between the mean temperature of the left buttock (ºC) by thermography and the CSS score of the left buttock (r=0.15); and there is also no correlation between the mean temperature of the right buttock (ºC) by thermography and the CSS score of the right buttock (r=0,21). Conclusion: It was concluded that there is neither correlation nor association between thermography and the CSS when used to classify GL.
BACKGROUND
Ultrasound energy can successfully treat fine lines and wrinkles, as well as lift the eyebrow and submentum. Ultrasound waves of high intensity induce thermal injury in the dermis with subsequent tissue remodeling.
OBJECTIVE
To examine the utility of a novel ultrasound device that utilizes high-intensity, high-frequency, parallel ultrasound beams to improve the clinical appearance of cellulite on the thighs and buttocks.
MATERIALS AND METHODS
A prospective, multicenter, clinical study investigated this novel ultrasound device using 2 treatments.
RESULTS
Sixty-five subjects completed both treatments. The mean age was 46 years, and 100% were women. Fitzpatrick skin types I to VI were represented. Assessments compared 3-month follow-up with baseline. Two blinded reviewers agreed in identifying pretreatment and post-treatment photographs for 89.2%. For Cellulite Severity Scale rating, there was significant improvement of 1.61 units ( p < .001). For cellulite Global Aesthetic Improvement Scale (GAIS), 89.2% had improvement, with a mean of 0.87 units ( p < .001). For Laxity Scale rating, there was significant improvement of 0.70 units ( p < .001). For skin laxity GAIS, 89.2% had improvement, with a mean of 0.76 units ( p < .001). No device-related adverse events occurred.
CONCLUSION
A novel ultrasound device that utilizes high-intensity, high-frequency, parallel ultrasound beams can safely and effectively improve the clinical appearance of cellulite on the thighs and buttocks.
Cellulite is a condition characterized by dimpling and contour irregularities in the gluteal and thigh regions, affecting an estimated 80–98% of postpubertal women. Innovative treatments for cellulite dimpling in the buttocks have gained popularity in recent years, seeking new solutions for a historically challenging condition. In this open-label, investigator-initiated, single-center, prospective clinical study, the authors sought to evaluate the safety and efficacy of diluted calcium hydroxylapatite (CaHA; Radiesse®, Merz Aesthetics, Raleigh, NC) for the treatment of cellulite dimpling in the buttocks of adult women.
Subjects underwent three treatment sessions, receiving a total of 12 syringes of 1:1 diluted CaHA administered using a cannula-based subcision technique. Endpoints included the cellulite severity scale (CSS), the global aesthetic improvement scale (GAIS), subject satisfaction measured on a 5-point scale, and three-dimensional imaging analysis via the Quantificare 3D Track®.
Twenty-four subjects completed the study (mean age, 35 years; mean BMI, 26.88 kg/m2; mean body fat percentage, 31.29%), and no serious complications were reported. Quantitative analysis at week 14 revealed a mean reduction of 54.0% in the number of visible dimples and 50.09% in dimple depth compared to baseline. The mean CSS score decreased by 4.29 points, representing a 43.92% improvement in cellulite severity from baseline (p < 0.0001). Both physician-assessed and subject-assessed GAIS ratings also demonstrated significant improvement, with 91.6% of subjects rating their cellulite appearance as “improved” or greater.
The results of this study support the safety and efficacy of diluted CaHA for treating cellulite dimpling in adult women.
This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.
Clinical trials registration: This study is registered with clinicaltrials.gov (ID: NCT05885035) and can be found at this link: https://clinicaltrials.gov/study/NCT05885035.
Background
The demand for body procedures is increasing, and buttocks beautification is one of the most sought-after procedures in dermatological and plastic surgery clinics. Several aspects affect the beauty of this area, including sagging, cellulite, contour irregularity, and volume reduction. This makes treatment of the area more challenging. Calcium hydroxylapatite (CaHA), which may be injected into the buttocks, stimulates local neocollagenesis, provides volume replacement, increases the strength and elasticity of the dermis, and thickens the underlying superficial fascia. However, no protocol for buttocks beautification tailors the dilution and deep application of CaHA filler simultaneously according to clinical assessments and personal priorities regarding contour, sagging, and cellulite.
Purpose
To report the results of a minimally invasive protocol using different dilutions of CaHA (Buttocks Beautification 3D) in the buttocks with application in different planes. The treatment was performed according to a previous individualized evaluation to improve the area aesthetically.
Patients and methods
Six women and one man were submitted to the protocol. An assessment was performed to determine the shape, sagging, cellulite (in women), and patients’ preferences for buttocks beautification. The dilution, volume, depth, and injection technique for CaHA were based on these assessments. The results of the treatment were then assessed using standardized photographs and patient satisfaction.
Results
We reported favorable results in six women and one man with different grades of sagging, female cellulite, and shapes of the gluteal region who were treated with CaHA injections according to a tailored protocol. All participants reported high satisfaction with the procedure.
Conclusion
Highly satisfactory results were achieved in seven adult patients who were assessed and treated for the buttocks with CaHA using an individualized protocol. Prospective studies should be performed to corroborate our findings and optimize the use of Buttocks Beautification 3D as a reliable modality of treatment for this body area.
Background:
With many treatments available for managing cellulite, non-invasive procedures are increasingly sought after. Radiofrequency (RF) and targeted pressure energy (TPE) are new techniques developed to counter aesthetic signs of aging. The combination of RF and TPE for cellulite thus requires a more robust investigation.
Objective:
We sought to determine the effectiveness and safety of combined/simultaneous RF and TPE for skin tightening and reducing the appearance of cellulite.
Methods:
Thirty subjects aged 46.5±9.0 (31-74) years, BMI 19.8-36kg/m2 were enrolled and treated for cellulite on the hips, thighs, abdomen and arms. Each subject received four treatments, over 2 to 4 consecutive weeks. The circumference of the treated areas was measured at baseline, after the final treatment session, and at follow-up visits one month, three months and six months following treatment. The efficacy of the therapy was evaluated based on the Cellulite Severity Scale, Global Aesthetic Index Scale, and the Subject Satisfaction Questionnaire. Occurrence of side effects and adverse events was monitored, therapy comfort was analyzed.
Results:
Cellulite severity improved from moderate to mild cellulite (p<0.001) in 95 percent of patients. Blinded, independent, evaluators reported aesthetic improvement in 90 percent of subjects. Significant circumference decrease in the abdomen, hips, and thighs was observed six months after treatment (p<0.01). Eighty-six percent of subjects were satisfied with improved cellulite appearance, and 82 percent of patients reported improved skin laxity. No severe side effects or adverse events occurred.
Conclusion:
The simultaneous TPE+RF procedure was able to non-invasively improve cellulite appearance in the majority of subjects and may be recommended for skin tightening on various body parts.
Cellulite in the proximal lower extremities is a reported concern among many adult females. The unsightly appearance of cellulite leads many affected individuals to seek treatment by trained specialists. The objective of this review is to provide the reader with an update on new and innovative therapies for cellulite including various treatment combinations to maximize therapeutic outcomes, and strategies for minimizing adverse events. The availability of new technologies and the results from recent clinical trials provide additional tools and data to consider when creating treatment plans for cellulite patients. This update to previous treatment recommendations is based on the most recent developments in cellulite management including the personal experiences of the authors with an emphasis on injectable enzymes, acoustic subcision, targeted verifiable subcision, and biostimulators. Formal clinical studies are warranted to compare various treatment modalities and further investigate combination regimens.
Level of Evidence: 5
Background:
Cellulite is a highly prevalent aesthetic condition in postpubertal women.
Objective:
The objective of this article was to describe the latest data on the pathophysiology of cellulite and to highlight the psychosocial aspects that should be considered when treating cellulite.
Methods:
A roundtable meeting was convened to discuss and share views on the latest data on the pathophysiology and psychosocial aspects of cellulite. The participants' experience helped guide a narrative review on this topic.
Results:
The pathophysiology of cellulite primarily involves fibrous septal changes. Strategies targeting the fibrous septa have shown the most consistent efficacy, while showing inconsistent or short-term results when targeting the other components of cellulite, such as decreased dermal thickness, vascular alterations, and inflammation. Female sex, increased age, and high body mass index contribute to cellulite pathophysiology.
Conclusion:
Patients seeking treatment for cellulite are willing to endure numerous treatments, high cost, temporary and/or delayed results, and invasive procedures with potential adverse effects. Psychological discomfort has been reported among patients with cellulite, and understanding their behaviors and psychological characteristics can help clinicians provide better care to these patients seeking treatment.
Cellulite is characterized by dimpled or puckered skin of the buttocks and posterior and lateral thighs. This condition has also been described as resembling an orange peel and cottage cheese or as having mattress-like appearance. The evaluation of a patient with cellulite may be done most of the times on clinical examination and sometimes using image exams, such as ultrasound, magnetic resonance imaging (MRI), laser Doppler flowmetry (LDF) and thermography. The degree of cellulite is important to determine the more appropriate treatment and to monitor treatment improvement.
The prevalence of metabolic syndrome is increasing day by day, owing to the sedentary lifestyle, unhealthy food habits, genetic factors, environmental influences and many other conspicuous variables. Skin, aptly considered to be a mirror of internal organs, often manifests with certain signs and symptoms, suggestive of a diagnosis of metabolic syndrome. In this chapter, we have attempted to touch upon the dermatological manifestations (both common and uncommon) of metabolic syndrome.KeywordsMetabolic syndromeDiagnosisSkin manifestations
Cellulite affects more than 80% females and is an aesthetically troublesome issue. The clinical manifestation is nodules and fibrosis in subcutaneous areas of the pelvic region, predominantly on the buttocks and thighs. The etiology is multifactorial consisting of genetic tendency, hormonal disorders, and endothelial disruption. There is no satisfactorily proven theory for the clinical presentation and the treatment modalities of cellulite. There are limited number of peer-reviewed studies outlining the effective cellulite treatment protocols. The chapter summarizes the probable pathophysiology, classification, and various treatment options that are documented in literature. Newer, emerging treatment options for cellulite are also mentioned that can lead to future successful outcomes in cellulite removal.
Background:
Cellulite is a common condition and laxity in the superficial fascial system (SFS) contributes significantly to its appearance in the thigh and buttock areas. Components of the SFS such as the fibrous septae and adipose tissue are targets for an effective treatment to improve the appearance of cellulite. This preliminary report demonstrates the use of radiofrequency-assisted lipolysis (RFAL) as a novel treatment approach to improve the appearance of cellulite by tightening the SFS.
Methods:
Ten female patients with Grade II and Grade III cellulite of the thighs or buttocks were included in this study. Minimally invasive application of bipolar radiofrequency energy to the affected areas was performed. Predetermined internal thermal endpoints at multiple tissue levels and different directions were reached in the treated tissues. Aspiration of the coagulated adipose tissue was performed using a small diameter cannula to minimize damage to the connective tissues. Pre-treatment and 6 months post-operative photos of 70 different body areas were randomized and scored by five blinded evaluators.
Results:
Using the Photonumeric Cellulite Severity Scale (CSS), scoring of preoperative and postoperative photographs revealed statistically significant differences in all body area comparisons. The magnitude of the differences in all scored body areas were considered large and mean differences were all positive indicating an improvement across time.
Conclusions:
Grade 2 and Grade 3 cellulite of the thighs and buttocks can be effectively treated using RFAL technology to decrease the laxity of the SFS.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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
- Dm Hexsel
- Body
- Lc Parish
- S Brenner
- Ramos
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.
- Jf Hair
- Re Anderson
- Rl Tatham
- Wc Black
10 Hair JF, Anderson RE, Tatham RL, Black WC, eds. Multivariate Data
Analysis. Prentice Hall, Upper Saddle River (NJ), 1998.
Women's Dermatology -from Infancy to Maturity
- D M Hexsel
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
- D Hexsel
- T O Dal'forno
- S Cignachi
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.