Celluqol® - a quality of life measurement for patients with cellulite

Abstract

Introduction: After puberty, most women develop some amount of cellulite.With the increasing number of dermatological consultations about treating cellulite, a broader understanding of the characteristics, wishes and expectations of these patients regarding their quality of life has become necessary. Objective: To develop and validate an instrument to evaluate the quality of life of patients with cellulite. Methods: The study consisted of two stages: in the first, instruments for assessing patients' quality of life were developed and validated; in the second, two questionnaires were administered to 100 females with cellulite, aged 18 to 45. Results: The reliability of the results was assessed using factorial analysis and Cronbach's alpha test. With the use of exploratory factorial analysis, it was possible to test (1) the hypothesis that all questions in the shortened questionnaire measured a single factor (cellulite) and (2) the hypothesis that each block of questions in the full version of the questionnaire measured a single domain or factor among the parameters being assessed (dressing style, physical activity, partner, feelings and change in daily habits). Conclusion: The validation analysis showed that both questionnaires effectively measure cellulite patients' quality of life.

Full text

Author:
Doris Hexsel1
Magda Blessmann Weber2
Maria Laura Taborda1
Taciana Dal'Forno3
Débora Zechmeister-Prado4
1Dermatologist Physician – Porto Alegre
(RS), Brazil
2Associate Professor of Dermatology,
Medical Clinic Department, Universidade
Federal de Ciências da Saúde de Porto
Alegre (UFCSPA) – Porto Alegre
3Cosmetic Dermatology Preceptor, Der ma-
tology Department, Pontificia Univer-
sidade Católica do Rio Grande do Sul,
(PUCRS) – Porto Alegre
4Pharmacist – Porto Alegre
Correspondence:
Doris Hexsel
Dr. Timoteo, 782 – Moinhos do Vento
90570 040 - Porto Alegre – RS, Brazil
Tel.: (55 51) 3264 1234 /3026 2633
E-mail: doris@hexsel.com.br
Received on: 03/01/2011
Approved on: 09/03/2011
This study was carried out at the Centro
Brasileiro de Estudos em Dermatologia
(CBED) – Porto Alegre (RS), Brazil.
Conflicts of interests: none
Financial support: none
Surg Cosmet Dermatol 2011;3(2):96-101.
Original
Article A quality of life measurement for patients
with cellulite
Celluqol® - instrumento de avaliação de qualidade de vida em
pacientes com celulite
ABS TRACT
Introduction: After puberty, most women develop some amount of cellulite. With the increasing
number of dermatological consultations about treating cellulite, a broader understanding of the charac-
teristics, wishes and expectations of these patients regarding their quality of life has become necessary.
Objective: To develop and validate an instrument to evaluate the quality of life of patients with
cellulite.
Methods: The study consisted of two stages: in the first, instruments for assessing patients’ quality
of life were developed and validated; in the second, two questionnaires were administered to 100
females with cellulite, aged 18 to 45.
Results:The reliability of the results was assessed using factorial analysis and Cronbach's alpha test.
With the use of exploratory factorial analysis, it was possible to test (1) the hypothesis that all ques-
tions in the shortened questionnaire measured a single factor (cellulite) and (2) the hypothesis that
each block of questions in the full version of the questionnaire measured a single domain or factor
among the parameters being assessed (dressing style, physical activity, partner, feelings and change in
daily habits).
Conclusion: The validation analysis showed that both questionnaires effectively measure cellulite
patients’ quality of life.
Keywords: quality of life; questionnaires; cellulitis.
RESU MO
Introdução: Após a puberdade, a maioria das mulheres desenvolve algum grau de celulite.
O aumento do número de consultas dermatológicas relacionadas ao tratamento da celulite
demandou compreensão mais ampla de características, desejos e expectativas desses pacientes
com relação à qualidade de vida.
Objetivo: Elaborar e validar instrumento de avaliação da qualidade de vida para pacientes
com celulite.
Métodos: O estudo teve duas etapas: a elaboração e a validação dos instrumentos de avali-
ação da qualidade de vida. Na segunda etapa, dois questionários foram elaborados e aplica-
dos a 100 voluntárias com idade entre 18 e 45 anos, que apresentavam celulite.
Resultados: A confiabilidade dos resultados foi verificada por meio de análise fatorial e Teste α
de Cronbach para avaliação estatística. Uma análise fatorial exploratória possibilitou testar a
hipótese de que todas as questões do questionário resumido mediam um único domínio ou
fator (no caso, celulite) e a hipótese de que cada bloco de questões do questionário comple-
to media um único domínio ou fator entre os parâmetros avaliados (modo de vestir, lazer,
atividade física, parceiro, sentimentos e mudança de hábitos cotidianos).
Conclusões: A análise de validação mostrou que ambos os questionários podem ser usados,
com grau similar de eficácia.
Palavras-chave: qualidade de vida; questionários; celulite.
96

Surg Cosmet Dermatol 2011;3(2):96-101.
Cellulite and quality of life 97
INTRODUCTION
The World Health Organization supports an inclusive view
of health, according to which the state of
b eing healthy does not refer merely to a lack of a disorder or
illness, but also an individual’s ability to lead a productive and
pleasant life.1Although important, evaluating quality of life is
neither an easy nor a simple task. As a result, several measure-
ments that apply to several disorders or groups of patients have
been de veloped and validated.2,3
Dermatology and other medical specialties – such as
plastic surgery – involve caring for patients with
aes thetic complaints. However, there is comparatively little
discussion in the literature of quality of life in this area.
Cellulite is a condition that occurs mostly in women,
affecting especially the thighs and buttocks, and constitutes an
extremely frequent complaint. The term, which originated in
the French medical literature more than 150 years ago, is glob-
ally known and used to characterize alterations on the skin’s sur-
face that resemble the appearance of an orange peel, cottage
cheese or a quilt. Synonyms include: edematous adi posity and
gynoid lipodystrophy.
Although its prevalence has not been established, most
women develop some degree of cellulite following puberty. It is
prevalent in women of all races, but is more common in
Caucasians. 4There are three hy potheses that try to explain
cellulite’s physiology: inflammatory factors and vascular or con-
junctive tissue’s septae alterations; 4there is also a relevant hor-
monal component, since it affects almost all women and is rare
in men. The first classification of cellulite was described by
Nurnberger and Muller in 1978 and was based on the lesions’
clinical aspect. 5A new classification developed by Dal’Forno
and Hexsel – the Cellulite Severity Scale – adds further clinical
parameters,, evaluating cellulite qualitatively and quantitatively.6
There is an increasing search for a perfect physical appear-
ance, and a lack of clinical studies in this field.
In Brazil, the rates of plastic surgeries and cosmetic con-
sultations are among the highest in the world. Understanding
the reasons that lead patients to undergo such a great number of
procedures – including surgeries – to improve their physical
appearance could lead to a decrease in the current number of
unnecessary procedures.7,8 The accelerated growth of dermato-
logic consultations about aesthetic complaints suggests there is a
need for a more inclusive understanding of the characteristics,
desires and expectations of patients that seek cosmetic proce-
dures.
Noting the lack of a method to evaluate the quality of life
in patients with cellulite, the authors were motivated to devel-
op such an instrument to make it possible to verify, both quan-
titatively and qualitatively, the reasons why aesthetic imperfec-
tions are considered an inconvenience that disturb and interfere
with people’s daily life, apparently more intensively today than
in previous times.
OBJECTIVE
This study is aimed at the elaboration and validation of an
instrument for evaluating of the quality of life of patients with
cellulite.
METHODS
A transversal study was developed to analyze female
patients aged 18 or older who sought treatment for cellulite at
the research unit of the Centro Brasileiro de Estudos em
Dermatologia – Brazilian Center of Studies in Dermatology
(CBED in Porto Alegre, RS, Brazil. Patients with a history of
psychiatric disorders or decompensated systemic disorders such
as systemic arterial hypertension and diabetes mellitus, were
excluded.
The study was conducted according to Good Clinical
Practices and the Declaration of Helsinki. The research study
was approved by the ethics committee of the Universidade
Federal de Ciências da Saúde de Porto Alegre (UFCSPA) and
was assigned the number 281/06.
The study comprised two stages, each of which had two
phases: the preparation and validation of a Portuguese-language
assessment tool and the evaluation of patients’ quality of life.
Stage I: Preparation of the quality of life evaluation tool
Based on information contained in the CBED’s research
unit database, patients who had already sought care relating to
cellulite were identified and invited to participate in the study
as a convenience sample. The sample used in that stage of the
study was based on convenience, having been considered ideal
when there was enough coincidence of answers, without the
presence of new significant complaints. The patients were eval-
uated in light of the inclusion and exclusion criteria before the
interview. Those who were eligible for participation were
instructed about the objectives of the analysis and offered a
Term of Free and Informed Consent to be signed in case of
agreement. The patients took part in the study by answering a
single open-ended question about which aspects of their lives
are impaired by their cellulite: “We are trying to find out how
much cellulite affects the patients’ life. We would be grateful to
have your help, though you are not obliged to do so. Please
describe below how cellulite affects your life. You can take into
consideration any aspect of your professional and social life, per-
sonal relationships, leisure activities, or any other situation.
Although it would be important to know your age, you don’t
need to disclose it.”
In the second phase of Stage I, patients’ answers were qual-
itatively assessed and a database with the main complaints,
grouped in wider domains, was created as described below:
Manner of dressing: choices of colors and fabrics, choice of
tighter cuts and use of very short clothes.
Leisure: participation in group activities that involve expos-
ing the body to a large number of people (beach, swimming
pool) or a more restricted number of people (massage).
Physical activities: participation in sports activities that
require exposing the body (swimming, water aerobics).

Surg Cosmet Dermatol 2011;3(2):96-101.
98 Hexsel D, Weber MB, Taborda ML, Dal’Forno T, Prado-Zechmeister D
Table 1: Celluqol (full version)
How having cellulite makes Not bothered Not bothered Indifferent Bothered Bothered all
you feel about: at all most of the time most of the time the time
MANNER OF DRESSING
1. choice of clothes’ colors 1 2 3 4 5
2. choice of clothes’ fabric 1 2 3 4 5
3. choice of tight cuts 1 2 3 4 5
4. wearing of very short clothes 1 2 3 4 5
LEISURE
5. participation in activities that 1 2 3 4 5
involve exposing the body to a
large number of people (beach,
swimming pool)
6. participation in group activities 1 2 3 4 5
that require exposing the body
to a restricted number of people
(massage)
PHYSICAL ACTIVITIES
7. HAVING CELLULITE 1 2 3 4 5
8. participation in sports 1 2 3 4 5
activities that involve
exposing the body
(swimming, water aerobics)
PARTNER
9. exposing the body to a partner 1 2 3 4 5
10. fear of losing partner 1 2 3 4 5
11. sexual life 1 2 3 4 5
12. the fact that a partner notices 1 2 3 4 5
the cellulite
FEELINGS
13. embarrassment 1 2 3 4 5
14. difficulties and doubts about 1 2 3 4 5
the result of treatments, disbelief
15. guilt 1 2 3 4 5
16. frustration 1 2 3 4 5
17. discouragement 1 2 3 4 5
18. self-esteem 1 2 3 4 5
19. rebelliousness 1 2 3 4 5
CHANGES IN DAILY HABITS
20. 20. changes in eating habits 1 2 3 4 5
21. 21. spending more than able 1 2 3 4 5
to afford on treatments
22. restricting other expenses 1 2 3 4 5
to treat cellulite

Partner: exposing the body to a partner, fear of losing the
partner, restrictions in sexual life, bothered by the fact that a
partner notices the cellulite.
Feelings: embarrassment, difficulties and doubts about the
result of treatments, disbelief, guilt, frustration, discouragement,
decrease in self-esteem, rebelliousness.
Changes in daily habits: changes in eating habits, spending
more than able to afford on medications and creams, restricting
other expenses to treat cellulite.
The results of this analysis also allowed the preparation of
an initial questionnaire to assess the quality of life of patients
who complained about cellulite.
Stage II: Questionnaire preparation and validation
With the identification of the domains and main points
referred to in each of them, the initial version of Celluqol®was
developed. The initial phase of Stage II included all questions
(22 in total, Table 1) in order to validate those that would con-
stitute the final questionnaire. A shortened 8-item version was
developed (Table 2) and compared with the full version, to
explore its use in daily medical practice.
The scores obtained from the full questionnaire ranged
from 22 to 110 points, with the measured changes in quality of
life assessed as follows:
From 22 to 44 points – cellulite does not affect quality of life
From 44 to 66 points – cellulite slightly affects quality of life
From 66 to 88 points – cellulite reasonably affects quality of life
From 88 to 110 points – cellulite intensely affects quality of life
Surg Cosmet Dermatol 2011;3(2):96-101.
Cellulite and quality of life 99
The shortened questionnaire’s scores ranged from 8 to 40
points, with changes in quality of life interpreted as follows:
From 8 to 16 points – cellulite does not affect quality of life
From 16 to 24 points – cellulite slightly affects quality of life
From 24 to 32 points – cellulite reasonably affects quality of life
From 32 to 40 points – cellulite intensely affects quality of life
RESULTS
After administering the full and shortened versions of the
questionnaires to 100 volunteers, their validity and reliability
were assessed using Cronbach’s factorial and Alpha analyses for
statistical evaluations.
FACTORIAL ANALYSIS
An exploratory factorial analysis allowed testing of the
hypotheses that all eight questions of the shortened question-
naire measured a single domain or factor (cellulite) and that
each block of questions in the full questionnaire measured a sin-
gle domain or factor of the appraised parameters (manner of
dressing, leisure, physical activity, partner, feelings and change of
daily habits). A factor was considered dominant if its measured
eigenvalues were greater than 1. A component of the matrix of
a domain was considered to belong in the factor or domain
when its weight was greater than 0.4.
In the evaluation of the shortened questionnaire, it was
observed that only one could be deemed the main component,
when the greater than 1 eigenvalues criterion was considered.
The explained variance was 48.77%, and Cronbach’s Alpha,
0.842 (Table 3). The factorial analysis of the full version of the
Table 2: Celluqol (shortened version)
How having cellulite makes Not bothered Not bothered Indifferent Bothered most Bothered
you feel about: at all most of the time of the time all the time
1. your body’s appearance 1 2 3 4 5
2. manner of dressing 1 2 3 4 5
3. your eating habits 1 2 3 4 5
4. leisure or physical activities that 1 2 3 4 5
involve exposing the body publicly
(beach, gym, etc)
5. leisure or physical activities that 1 2 3 4 5
require exposing the body in a
limited way (massage, medical
consultations etc)
6. your sexual life 1 2 3 4 5
7. 7. your negative feelings (guilt, 1 2 3 4 5
embarrassment, frustration,
low self-esteem, shame, fear,
rebelliousness)
8. difficulties and doubts about the 1 2 3 4 5
result of treatments, disbelief

Surg Cosmet Dermatol 2011;3(2):96-101.
100 Hexsel D, Weber MB, Taborda ML, Dal’Forno T, Prado-Zechmeister D
questionnaire presented five main components when the greater
than 1 eigenvalues criterion was considered. The explained vari-
ance was 70.72%, and Cronbach’s Alpha was 0.935 (Table 4).
DISCUSSION
Since no information was found about previous studies
that have validated a specific questionnaire assessing the quality
of life for patients with cellulite, it was unfeasible to forecast the
variability of answers in the present study. A sample calculation
to estimate a proportion was therefore carried out, maximizing
the variance and considering a 95% confidence interval. This
sample calculation supplied the estimate of 385 patients.
Nevertheless the study was conducted with 100 patients. A pre-
liminary analysis was subsequently performed to analyze the
behavior of the data and the necessity of including a greater
number of patients. As the data showed considerable consisten-
cy, it was not necessary to increase the sample size.
The factorial analysis of the shortened questionnaire found
that each question measured a single factor or domain: cellulite.
This single domain explains 48.77% of the variance, indicating
that all questions in the shortened questionnaire effectively refer
to cellulite. Since each matrix component presented expressive
values, it was not necessary to exclude any questions. In addi-
tion, the Cronbach’s Alpha (0.842) indicated good internal con-
sistency for the shortened questionnaire (Table 2).
The factorial analysis of the full version of the question-
naire indicated that those questions measured five main factors
or domains. Observing the matrix components, it was verified
Table 3: Exploratory factorial analysis and internal consistency
(Shortened version)
Question (Q) Evaluated parameter Factor’s weight
in the only
domain found
1
Q1 Body’s appearance 0,677
Q2 Manner of dressing 0,701
Q3 Eating habits 0,559
Q4 Physical activities with public 0,786
exposure of the body
Q5 Physical activities with limited 0,718
exposure of the body
Q6 Sexual life 0,839
Q7 Negative feelings 0,764
Q8 Doubts, disbelief regarding 0,467
treatments 48,77%
Applied % of the
variance
Cronbach’s Alpha 0,842
Q = question
Table 4: Exploratory factorial analysis and internal consistency
(full version)
Question Evaluated Factor’s weight in the 5 domains
(Q) parameter found
12345
MANNER OF DRESSING
QB1a choice of clothes’ colors 0,659
QB1b choice of clothes’ fabric 0,884
QB1c choice of tight cuts 0,836
QB1d wearing of very 0,709
short clothes
LEISURE
QB2a activities with public 0,549
exposure of the body
QB2b activities with limited 0,675
exposure of the body
PHYSICAL ACTIVITIES
QB3a physical activity in general 0,621
QB3b physical activities with 0,814
exposure of the body
PARTNER
QB4a Exposure of the body 0,667
to a partner
QB4b Fear of losing partner 0,837
QB4c sexual life 0,860
QB4d partner notices cellulite 0,725
NEGATIVE FEELINGS
QB5a embarrassment 0,505
QB5b doubts and disbelief about the 0,467
result of treatments
QB5c guilt 0,669
QB5d frustration 0,715
QB5e discouragement 0,812
QB5f self-esteem 0,695
QB5g rebelliousness 0,697
CHANGES IN DAILY HABITS
QB6a eating habits 0,606
QB6b restricting expenses to treat cellulite 0,797
QB6c Restrição gastos 0,802
Applied % 70,7
of the variance
Cronbach’s 0,935
Alpha
Q = questão

Surg Cosmet Dermatol 2011;3(2):96-101.
Cellulite and quality of life 101
that all questions corresponding to the “manner of dressing”
appeared together in the same domain with expressive values
(Table 3). The questions regarding “leisure” and “physical activ-
ity” appeared together in the same domain, suggesting that they
measure the same parameters. Of the questions considered, it
was found that QB3a and QB4b could probably be combined
into a single question due to their similarity, with the variables
being grouped in a single domain (i.e., without differentiating
between leisure and physical activity). All questions regarding
the “partner” appeared in the same domain, indicating that they
are in accordance with the questionnaire – as well as all ques-
tions regarding “changes in daily habits.” The variables relating
to “feelings” were generally consistent, appearing in different
domains, except for QB5a and QB5b, which were the least
expressive and did not appear in the same domain as the others,
suggesting they could be modified or excluded. The 0.935
Cronbach’s Alpha indicated good internal consistency in the full
version of the questionnaire.
The questionnaire was easy to administer, and the patients
did not have difficulty in understanding the questions. The aver-
age time of application was five minutes – rather reasonable for
clinical use and research.
Comparisons of Celluqol with other quality of life ques-
tionnaires should be carried out in the future to assess the cor-
relation of quality of life changes in patients with cellulite with
that of patients in general.
CONCLUSION
The authors developed two questionnaires to evaluate the
quality of life in female patients with cellulite. Administration of
the measurement was straightforward, and the validation analy-
ses demonstrated that both questionnaires could be used with
similar efficacy. In daily clinic practice, the shortened version is
recommended to evaluate cellulite as the main component of
changes in patients’ quality of life. The full version of the ques-
tionnaire presented five main components for evaluating patient
quality of life; its use is recommended for clinical research. ●
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