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Assessment of psychological, psychiatric, and behavioral aspects of patients with cellulite: A pilot study

Authors:
  • Hexsel Dermatologic Clinics

Abstract

Introduction: About 50% of the population reports some kind of dissatisfaction related to their physical appearance. Patients' motivations for seeking cosmetic treatment are not yet fully understood. Objectives: To evaluate the behavioral, psychological, and psychiatric characteristics of patients with cellulite. Methods: In the first phase of this cross-sectional, descriptive and observational study, forty-six volunteers answered a self-administered questionnaire. In the second phase, a psychiatrist administered the M.I.N.I. questionnaire. Results: Most interviewees described the forthcoming of cellulite during puberty. Discomfort caused by cellulite was mainly felt at the beach (87%) and pool (67,4%). Almost half of patients reported having been subject to an embarrassing comment related to their cellulite, while 78.3% felt pressure to seek treatment. The eating disorders described included the use of drugs, compulsive ingestion of food, feeling guilty after eating, and self-induced vomiting. The most frequently found specific emotional disorder was generalized anxiety. Conclusions: Patients with cellulite can experience emotional distress and negative feelings in everyday situations. Changes in specific behaviors and the presence of psychological and psychiatric comorbidities can be present in some patients.
Assessment of psychological, psychiatric,
and behavioral aspects of patients with
cellulite: a pilot study
Avaliação dos aspectos psicológicos, psiquiátricos e
comportamentais de pacientes com celulite: estudo-piloto
Original
Article
Authors:
Doris Hexsel1
Carolina Siega2
Juliana Schilling-Souza3
Amanda Stapenhorst4
Ticiana Costa Rodrigues5
Cristiano Brum6
1Dermatologist Physician; Dermatology
Specialist (accredited by the Brazilian
Society of Dermatology); Preceptor,
Dermatology Clinic, Pontifícia
Universidade Católica do Rio Grande do
Sul (PUCRS) – Porto Alegre (RS), Brazil;
Technical Director, Centro Brasileiro de
Estudos em Dermatologia (CBED) – Porto
Alegre
2BSc in Biological Sciences; Researcher,
CBED
3Pharmacist; Researcher, CBED
4Biomedical Academician; Researcher, CBED
5 Endocrinologist Physician; PhD in
Endocrinology from Universidade Federal
do Rio Grande do Sul (UFRGS) – Porto
Alegre (RS), Brazil; Physician at the
Endocrinology Department of the Hospital
de Clínicas de Porto Alegre – Porto Alegre
(RS), Brazil; Post-graduate Instructor,
Endocrinology, UFRGS; Researcher, CBED
6Psychiatrist; MSc in Psychiatry from the
Universidade Federal de Ciências da Saúde
de Porto Alegre (UFCSPA) – Porto Alegre
(RS), Brazil; Researcher, CBED .
Correspondence:
Dra. Doris Hexsel
Dr. Timóteo, 782 - Moinhos de Vento
90570-040 - Porto Alegre - RS
E-mail: doris@hexsel.com.br
Received on: 16 April 2012
Accepted on: 29 May 2012
This study was carried out at the Centro
Brasileiro de Estudos em Dermatologia
(CBED) – Porto Alegre (RS), Brazil.
Financial support: This study was funded by
the Centro Brasileiro de Estudos em
Dermatologia (CBED).
Conflict of interest: None
ABS TRACT
Introduction: About 50% of the population reports some kind of dissatisfaction related to
their physical appearance. Patients’ motivations for seeking cosmetic treatment are not yet
fully understood.
Objectives: To evaluate the behavioral, psychological, and psychiatric characteristics of
patients with cellulite.
Methods: In the first phase of this cross-sectional, descriptive and observational study,
forty-six volunteers answered a self-administered questionnaire. In the second phase, a
psychiatrist administered the M.I.N.I. questionnaire.
Results: Most interviewees described the forthcoming of cellulite during puberty.
Discomfort caused by cellulite was mainly felt at the beach (87%) and pool (67,4%).
Almost half of patients reported having been subject to an embarrassing comment relat-
ed to their cellulite, while 78.3% felt pressure to seek treatment. The eating disorders
described included the use of drugs, compulsive ingestion of food, feeling guilty after eat-
ing, and self-induced vomiting. The most frequently found specific emotional disorder
was generalized anxiety.
Conclusions: Patients with cellulite can experience emotional distress and negative feel-
ings in everyday situations. Changes in specific behaviors and the presence of psycholog-
ical and psychiatric co-morbidities can be present in some patients.
Keywords: celullitis; skin; behavior; questionnaires.
RESU MO
Introdução: Cerca de 50% da população refere algum tipo de insatisfação com a aparência. Os
hábitos comportamentais que motivam os pacientes a procurar tratamentos cosméticos ainda não estão
completamente entendidos.
Objetivos: Avaliar os aspectos comportamentais, psicológicos e psiquiátricos de pacientes com celuli-
te.
Métodos: Estudo transversal observacional descritivo. Na primeira etapa, 46 voluntárias responde-
ram a questionário autoaplicável e, na segunda etapa, um psiquiatra aplicou o questionário Mini.
Resultados: A maioria das entrevistadas referiu o início das lesões de celulite após o início da puber-
dade. Os ambientes que mais causaram desconforto quanto à celulite foram praia (87%) e piscina
(67,4%). Quase metade das pacientes referiu já ter recebido algum tipo de comentário constrange-
dor em razão da sua celulite e 78,3% delas sentem-se pressionadas a procurar tratamentos.
Distúrbios de alimentação apresentados incluíram uso de drogas, ingestão compulsiva de alimentos,
culpa após as refeições e indução de vômitos. O transtorno emocional específico mais encontrado foi
ansiedade generalizada.
Conclusões: Pacientes com celulite podem apresentar desconforto emocional e sentimentos negativos
em situações comuns do dia a dia. Alterações em hábitos comportamentais específicos e presença de
comorbidades psicológicas ou psiquiátricas podem estar presentes em algumas pacientes.
Palavras-chave: celulite; pele; comportamento; questionários.
131
Surg Cosmet Dermatol 2012;4(2):131-6.
Surg Cosmet Dermatol 2012;4(2):131-6.
132 Hexsel D, SIega C, Schilling-Souza J, Stapenhorst A, Rodrigues TC, Brum C
INTRODUCTION
Approximately 50% of the population has reported some
degree of dissatisfaction with his or her appearance. Part of this
group seeks cosmetic procedures to correct features that are
considered undesirable in order to improve their self-esteem and
confidence and, consequently, their quality of life.1
The demand for minimally invasive cosmetic treatments
has been expanding every year; there was a 77% increase in cos-
metic procedures in the United States between 2000 and 2010.
2In Brazil, the demand for cosmetic treatments has always been
high, and has grown considerably in recent years. Therefore, it is
necessary to understand the psychological factors that underpin
people’s motivations for these treatments, as well as their expec-
tations and anticipated psychological benefits. 3
The term cellulite is used to describe the skin’s surface
when it resembles an orange peel or padding. The condition is
prevalent in women of all races, especially in Caucasians. 4 There
seems to be an important hormonal component in cellulite,
given that it is rarely found in male patients, mostly affects
women after menarche, and reportedly worsens with the use of
contraceptives. There are three etiological hypotheses for cellu-
lite: inflammatory factors, vascular alterations, and changes in the
conjunctive tissue’s septa. 4
Since there is greater exposure of the body in tropical
regions, cellulite has become a concern among women living
countries such as Brazil. As a result, cellulite can have a signifi-
cant social impact and drive the search for specific treatments.5
Making the distinction between emotionally healthy peo-
ple seeking to improve their appearance and those with self-
image perception disorders can be difficult in a physician’s daily
practice, and dermatologists may be the first professional to have
contact with such patients. Ishigooka and colleagues reported
that more than 47.7% of patients who seek cosmetic procedu-
res meet some of the criteria for the diagnosis of mental disor-
ders, 6the most common of which are body dysmorphic disor-
der and narcissistic and histrionic personality disorders. 7A
recent study conducted in Brazil found that cosmetic patients
had a higher prevalence of body dysmorphic disorder (14%)
compared to patients from the general dermatology outpatient
clinic (6.7%) and to controls without skin conditions or com-
plaints (2%). 8
Few studies in the literature address the psychological
aspects of patients seeking treatment for cellulite. Based on the
hypothesis that understanding the emotional context of each
patient will help the dermatologist’s assessment, this study’s
objective was to investigate the psychological and behavioral
characteristics, and the presence of psychiatric symptoms, of
women who sought medical care for cellulite.
METHODS
A descriptive cross-sectional observational study was car-
ried out involving patients who sought care for cellulite at the
Brazilian Center for Studies in Dermatology (Centro Brasileiro
de Estudos em Dermatologia – CBED) between 2008 and
2011. All participants signed a term of free and informed con-
sent, and the study protocol was approved by the Ethics
Committee of the Hospital Moinhos de Vento de Porto Alegre
(Approval Opinion number 2008/115).
The inclusion criteria were: women aged 18-45 with cel-
lulite (regardless of the degree of severity), who had completed
primary education and had the ability to understand the ques-
tionnaire, and the absence of serious systemic and/or serious
skin conditions that could cause psychological distress.
Volunteers who presented significant hearing or visual pro-
blems, or difficulty understanding the study’s language, were
excluded.
The volunteers initially answered a self-administered ques-
tionnaire with 50 questions on demographic, anthropometric,
and lifestyle aspects and their use of medications. Issues linked
to the psychological aspects of cellulite, symptoms related to
eating disorders, and time and money spent on cosmetic proce-
dures were also assessed.
The women who consented to participate in the second
stage of the study were then interviewed by a psychiatrist (CB),
who administered the key questions related to each of the psy-
chiatric disorders contained in the Mini International
Neuropsychiatric Interview (MINI). If this initial assessment
was positive for any psychiatric disorder, the volunteer would be
reassessed with the MINI, using questions relevant to the diag-
nostic criteria of the suspected disorder, in order to confirm or
deny the psychiatric diagnosis.
The MINI is a short (15-30 minutes) standardized ques-
tionnaire that is consistent with the DSM-III-R/IV and CID-10
criteria. It is intended for use in clinical practice, research, prima-
ry care, and psychiatry, and can be used by clinicians after a short
training session (1-3 hours). 9It was developed by researchers at
the Pitié-Salpêtrière Hospital in Paris and the University of
Florida 10, and is widely used to select patients in multicenter
psychopharmacological trials, in other clinical protocols, in psy-
chiatry, and in primary care in Europe, the USA, and Brazil. The
Brazilian translation of the updated version of the MINI DSM-
IV (version 5.0) has been previously validated. 10
The results regarding the reliability and validity of the
MINI are broadly satisfactory. Compared to the CIDI
(Composite International Diagnostic Interview) and the SCID-
P (Structured Clinical Interview for DSM-III-R), the MINI
proved to be broadly adequate for diagnosing disorders. Given
that it cuts the evaluation time in half (or more) compared to
long questionnaires, the sensitivity and specificity of the MINI
are considered to be very satisfactory. 10
The data were described using mean values and standard
deviations for the continuous variables, and percentages for the
category related information. The statistical analyses were per-
formed using SPSS 16.0 (Chicago, IL, USA).
RESULTS
The study included 46 volunteers. The majority of patients
were Caucasian, with higher education and permanent employ-
ment, and used oral contraceptive (Table 1). Most volunteers
Surg Cosmet Dermatol 2012;4(2):131-6.
Psychological aspects of cellulite patients 133
described the onset of cellulite during puberty. The group’s
body mass index (BMI) was 23.5 ± 3.4 kg/m2(range: 16-39
kg/m2); only 23.9% (n = 11) of patients presented with excess
body weight (BMI > 24.9 kg/m2) and only two patients were
considered obese (BMI > 29.9 kg/m2).
The environments described by the patients as causing the
most discomfort regarding their cellulite were the beach
(87,0%), swimming pool (67.4%), gym (19.6%), and bath
(8.7%), with 4.3% reporting no discomfort. Situations and envi-
ronments involving leisure (beach, swimming pool, and parties),
everyday life, and media (magazines and television) were cited
as responsible for stressful and uncomfortable situations by
76.1%, 39.1%, and 8.7% of the patients, respectively.
Of the volunteers evaluated, 84.8% regularly observed the
presence of cellulite in other women, 28.3% reported compa-
ring themselves to others regarding cellulite, 69.6% believed
Variable
Ethnicity
Education
Permanent employment
Moment when noticed presence of cellulite
Family history of cellulite
Sought information about treatment for cellulite
Other aesthetic treatments
Menstrual cycle
Use of contraceptive method
Caucasian
Black
Other
Did not complete
Secondary complete
Higher incomplete
Higher complete
Post-graduate
Yes
No
After puberty
> 30 years old
After pregnancy
After losing weight
After gaining weight
Other
Yes
No
Did not know
Yes
No
Yes
No
Did not complete
Regular
Irregular
Menopause
Interrupted
Did not complete
Oral
Other
Does not use
Did not complete
Frequency
36 (78,3%)
3 (6,5%)
2 (4,5%)
5 (10,9%)
10 (4,7%)
13 (28,8%)
21 (45,7%)
2 (4,3%)
42 (91,3%)
4 (8,7%)
263 (56,6%)
2 (4,3%)
2 (4,3%)
2 (4,3%)
2 (4,3%)
9 (19,6%)
41 (89,1%)
2 (4,3%)
3 (6,5%)
27 (58,7%)
19 (41,3%)
20 (43,5%)
25 (54,3%)
1 (2,2%)
33 (71,7%)
6 (13%)
1 (2,2%)
2 (4,3%)
4 (8,7%)
27 (58,7%)
7 (15,2%)
8 (17,4%)
4 (8,7%)
Tabela 1 – Characteristics of the 46 patients studied
Surg Cosmet Dermatol 2012;4(2):131-6.
134 Hexsel D, SIega C, Schilling-Souza J, Stapenhorst A, Rodrigues TC, Brum C
that men note and observe the presence of cellulite, and 41.3%
reported having received at least one embarrassing comment
about their cellulite. Most volunteers (78.3%) were embarrassed
about their cellulite and felt compelled to seek treatment. Table
2 describes the frequency of feelings reported by patients when
they look in the mirror and observe their cellulite.
The compulsive ingestion of food at least once was repor-
ted by 84.8% of the volunteers, and more than half (58.7%) felt
guilty after meals about the quantity and quality of the food
they had eaten. Some volunteers mentioned the habit of indu-
cing vomiting (10.9%) and counting calories (17.4%), with
67.4% reporting the use of weight loss medications – with or
without medical advice. The volunteers also reported great con-
cern about the presence of body fat (89.1%). Table 3 describes
the drugs used by the patients for losing weight; sibutramine was
the most frequently used drug. Table 4 shows the time (in hours
per week) and spending (in monthly monetary units) on cellu-
lite, the severity assessed by the volunteer, and the expectations
when seeking treatment. Table 5 shows the frequency of use of
different types of treatments for cellulite.
Of the patients evaluated in the study, 43.5% had already
had some type of cosmetic treatment for diverse conditions.
About 9,0% had undergone botulinum toxin injections, 15.2%
some type of facial peel, 4.3% some type of laser, 6.5% some
type of plastic surgery, and 21.7% reported other procedures.
Regarding the psychiatric diagnoses found, five patients
presented with generalized anxiety disorder, one presented a
specific phobia, two presented compulsive eating, and one pre-
sented attention deficit disorder with hyperactivity. The other
patients did not present criteria for recognized psychiatric disor-
ders.
DISCUSSION
This pilot study assessed the behavioral and psychological
issues of women with cellulite who seek cosmetic treatments
that mitigate the condition, and researched comorbid psychia-
tric diagnoses. The data obtained can be of great help in future
studies aimed at establishing the psychological profile of patients
who seek treatment for cellulite and understanding the feelings
associated with the condition, to contribute to a strong and
empathetic doctor/patient relationship.
Most women who seek treatment for cellulite feel uncom-
fortable about the condition and can develop morbid behaviors
linked to the condition or become preoccupied with their
appearance. The study data related to eating habits stand out.
The majority of volunteers (84.8%) had eaten compulsively at
Variable
Disappointment
Embarrassment
Frustration
Sadness
Guilt or anger
Tries to hide the condition
Impotence
Absence of feelings
Frequency (%)
49
28,3
21,7
21,7
13
10,9
8,7
6,5
Table 2 – Description of feelings related to cellulite
Variable
Use of weight loss
medications
Sibutramine
Laxatives
Prescribed formulations
Phytotherapics
Amphetamines
Diuretic
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Frequency
31 (67,4%)
15 (32,6%)
13 (28,3%)
33 (71,7%)
12 (26,1%)
34 (73,9%)
8 (17,4%)
38 (82,6%)
6 (13%)
40 (87%)
5 (10,9%)
41 (89,1%)
5 (10,9%)
41 (89,1%)
Table 3 – Medications used to lose weight
Cellulite
Hours per week spent treating
cellulite
Monthly expenditure on
cellulite
Self-assessed cellulite severity
Expectations when seeking
treatment
<3h
3h-6h
>6h
> R$ 100,00
< R$ 100,00
Zero
Mild
Moderate
Severe
Improve
Totally eliminate
Total
Other
Frequency
12 (26,1%)
10 (21,7%)
4 (8,7%)
8 (17,4%)
8 (17,4%)
27 (58,7%)
6 (13%)
28 (60,9%)
12 (26,1%)
20 (43,5%)
16 (34,8%)
6 (13,0%)
Table 4 – Time, monthly expenditure, cellulite severity perceived by
the patient, and expectations when seeking treatment
Surg Cosmet Dermatol 2012;4(2):131-6.
Psychological aspects of cellulite patients 135
some point. Negative feelings such as guilt after eating (mentio-
ned by more than half of the volunteers, 58.7%) and great con-
cern about the amount of body fat were observed, and are fac-
tors that can be related to the indiscriminate use of anorectic
and laxative medications.
In the present study 78.3% of volunteers reported feeling
embarrassed by their cellulite and compelled to seek treatment.
A small percentage of patients (6.5%) felt influenced by their
partners to seek treatment, while 28.3% were influenced by the
media.
The concern with physical appearance is directly related to
leisure and daily activities, causing attitudes of isolation and low
self-esteem, and others that negatively affect the quality of life.
A previous study by Hexsel and others showed that treat-
ment of cellulite improves patients’ quality of life and self-
esteem. 11
The authors acknowledge some limitations of the present
study; its results must be interpreted with these in mind. The
number of volunteers was small, the sample individuals were
chosen by convenience, and all study participants sought medi-
cal care for treating cellulite, which can be considered a selec-
tion bias and a factor responsible for the high degree of discom-
fort found among volunteers. The absence of a control group,
which has another aesthetic complaint or even no complaints
about cellulite and/or other cosmetic issues, can be considered
limiting. Those factors, however, do not invalidate the study’s
results, since this is an initial pilot study that has found a high
degree of psychological discomfort in patients with cellulite.
These factors can be controlled in future studies in order to
obtain new data.
CONCLUSIONS
Disruptions and emotional distress are frequently reported
by patients with cellulite, who also describe negative feelings in
everyday situations. Knowledge and understanding of patients
with cosmetic complaints, and their feelings, habits, and beha-
vioral and psychological characteristics – in addition to their
expectations regarding the treatments – are very important for
dermatologists and can lead to better results. l
Variable
Diet and physical exercise
Creams
Lymphatic drainage
Lasers
Carboxytherapy
Mesotherapy
Endermotherapy
Subcision®
Liposuction
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Frequency
9 (19,6%)
35 (76,1%)
23 (50%)
22 (47,8%)
18 (39,1%)
27 (58,7%)
3 (6,5%)
42 (91,3%)
4 (8,7%)
41 (89,1%)
4 (8,7%)
41 (89,1%)
3 (6,5%)
42 (91,3%)
4 (8,7)
41 (89,1%)
2 (4,3%)
43 (93,5%)
Table 5 – Types of treatment for cellulite used by the studied
patients
Surg Cosmet Dermatol 2012;4(2):131-6.
136 Hexsel D, SIega C, Schilling-Souza J, Stapenhorst A, Rodrigues TC, Brum C
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... 11 Studies and surveys have demonstrated that cellulite can negatively affect self-esteem, body image, and quality of life. 12,13 Current treatment options for cellulite include vacuumassisted manual subcision of septa via microblade, thermal lipolysis of adipocytes and thermal subcision of septa by lasers, or chemical subcision via collagenase clostridium histolyticum injections. [14][15][16] Recently, Kaminer and colleagues 17 showed lasting improvement in the appearance of cellulite via mechanical subcision of fibrous septa. ...
... Previous studies have indicated that women with cellulite often experience psychological distress and low self-esteem, particularly in social settings. 12,13 Future studies that elucidate the potential impact of RAP treatment on psychological distress and quality of life are warranted. Treatment with the acoustic subcision device was also well-tolerated, as evidenced by the lack of device or treatment-related UAEs or SAEs in participants. ...
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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.
... Despite being painless, cellulite has significant negative impacts on individuals' psychosocial well-being due to its aesthetic implications. Females affected by cellulite commonly experience body dissatisfaction, psychological distress, anxiety, and a diminished quality of life [5]. ...
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Background and Objectives: Cellulite, or edemato-fibro-sclerotic panniculopathy (EFP), is characterized by dermal and hypodermal changes leading to adipose tissue accumulation and compromised venous circulation. This study investigates the efficacy of a hypertonic cream containing concentrated sodium chloride (Jovita Osmocell®) in addressing water retention and structural alterations in adipose tissue, aiming to interrupt the cellulite formation process. Materials and Methods: A 12-week, prospective, monocentric, double-blind, placebo-controlled study enrolled 30 female subjects with grade II or III cellulite. Patients were randomized to receive hypertonic cream or a placebo. Thigh circumference, ultrasound evaluations, and standardized photographs were collected at baseline, intermediate, and endpoint visits. Adverse events were monitored. Results: After 84 days, the hypertonic cream group exhibited a significant reduction in thigh circumference compared to the placebo group (p = 0.0037). B-mode ultrasound examinations revealed significant changes in the parameters studied, such as the thickness of the subcutaneous tissue. No statistically significant changes were noticed in the placebo group. Volunteers reported the investigational product’s pleasantness and good anti-cellulite activity, with no reported adverse events. Conclusions: The hypertonic cream demonstrated efficacy in reducing thigh circumference, addressing water retention and structural alterations in adipose tissue. The proposed mechanism involves osmosis, releasing accumulated fluids between fat cells, supporting drainage, and reducing inflammation. This study supports the efficacy and safety of hypertonic sodium chloride emulsions in cellulite treatment and confirms safety and user satisfaction.
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Cellulite is a highly prevalent and aesthetically distressing skin condition. Whilst there are a variety of treatment modalities, none are definitively established. This systematic review aims to assess invasive and noninvasive treatment modalities for cellulite management. The review protocol was published and registered a priori (PROSPERO CRD42022359334). A comprehensive electronic search for relevant randomised controlled trials, (RCTs) was performed in CENTRAL, MEDLINE, Embase and Web of Science databases. Study quality and risk of bias were assessed using Cochrane’s risk of bias tool, respectively. Overall, 753 studies were initially identified, of which 24 randomised controlled trials (RCTs) satisfied the eligibility criteria with a total of 2084 patients with a mean follow-up of 3.33 ± 13.4 weeks. Evaluated interventions included mechanical stimulation, topical therapy, shock wave therapy (SWT), laser and light-based devices, radiofrequency therapy, subcutaneous injectables, and ultrasound. SWT emerged as a standout intervention, demonstrating a consistent cellulite reduction score of 2.07 ± 0.39 across four studies. Radiofrequency therapy exhibited a statistically significant reduction of thigh circumference (− 2.09 cm, p < 0.001) and subcutaneous tissue thickness (− 2.23 cm, p < 0.001). Subcutaneous injectables, specifically collagenase Clostridium histolyticum-aaes, demonstrated a statistically significant improvement in the clinician-reported photonumeric cellulite severity scale (17.0%) and patient-reported photonumeric cellulite severity scale (25.7%) (p < 0.001). The overall quality of the studies using the grading of recommendations, assessment, development and evaluation approach was moderate. This is the first methodologically robust systematic review evaluating interventions for cellulite. SWT, radiofrequency therapy, and subcutaneous injectables have shown promising findings in cellulite treatment. The journal asks authors to assign a level of evidence to each article. For a complete description of Evidence-Based Medicine ratings, see the Table of Contents or the online Instructions for Authors at www.springer.com/00266.
Article
Background In the buttocks and thighs, skin quality, focal adiposity and/or volume deficiency, skin laxity, and textural issues each contribute to overall appearance. For patients undergoing rejuvenation/beautification procedures, global improvement is desired, making multimodal treatment to address these mechanistically distinct concerns the standard of care. Resolution of cellulite depressions is central to patient satisfaction and aesthetic outcomes: Without management, the overall aesthetic suffers, and patients are left partially unsatisfied with treatment results. With minimally invasive Targeted Verifiable Subcision™ (TVS; Avéli® [Revelle Aesthetics, Inc, Mountain View, CA]), septa with a confirmed role in dimple formation can be released via mechanical verified subcision, permitting consistent outcomes. Objectives Discuss application of TVS as part of a multimodal approach to buttock and thigh rejuvenation and share best practices for obtaining optimal improvement. Methods A group of 6 experts in aesthetic plastic surgery and dermatology convened for a 2-hour roundtable discussion of select case studies, best practices, and their approaches for obtaining optimal outcomes in clinical practice. Results Clinical cases from 6 patients who presented for buttock and/or thigh rejuvenation/beautification are presented where TVS was applied as part of a multimodal approach. Before-and-after images, details of patient cases, and a discussion of best practices for patient education and evaluation, treatment planning, technique, safety, postprocedure care, and open research questions are included. Conclusions TVS is emerging as a valuable tool for the treatment of cellulite in the buttocks and thighs that may potentially be used alongside surgical and nonsurgical approaches, often on the same day.
Article
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.
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Article
Full-text available
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
Article
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.
Article
Background: Collagenase clostridium histolyticum-aaes (CCH) is approved for the treatment of moderate-to-severe cellulite. Objective: This is a retrospective image review of subjects previously enrolled in Cohort 2 of the EN3835-305 trial to determine the effects of CCH on volumetric changes of cellulite dimples and overall gluteal contouring. Methods: In this retrospective analysis, photographs from Day 90 and Day 180 were superimposed on baseline images and the volumetric change of each treated cellulite dimple was quantified. Side-by-side photographs of the buttocks were also evaluated for change in gluteal contour using the Physician Global Aesthetic Improvement Scale (PGAIS). Results: Fifty-eight female subjects and 403 cellulite dimples were evaluated. Three-dimensional imaging analysis revealed a significant improvement in total negative dimple volume at both Day 90 and Day 180 of 27% and 26%, respectively (p < .001 and p = .002, respectively). At Day 90, the overall gluteal contour, as signified by the mean PGAIS among the 3 blinded dermatologists, was rated as +1 (improved) in 27% (n = 17) of the subjects. At Day 180, the mean PGAIS was +1 (improved) or +2 (very much improved) in 39% (n = 26) of the subjects. Conclusion: CHH is an effective tool for treating cellulite dimples and improving gluteal contour.
Article
Full-text available
Cellulite has a complex and multifactorial etiology. Synergistic action on treating cellulite has gained support in the treatment of cellulite. This study evaluated safety and efficacy of a bipolar radiofrequency, infrared, vacuum and mechanical massage device for cellulite treatment and reduction of body measures. This was a pilot study, which assessed 9 subjects who presented body mass index from 18 to 25 Kg/Kg and at least grade 6 in the Cellulite Severity Scale (CSS). All subjects underwent a 12-session treatment of posterior thighs and buttocks. There was a significant reduction of the hip circumference (p = 0.001), however, no changes in thigh circumferences were observed (p = 0.4). CSS has improved specifically on both buttocks [p = 0.002 (left side) and p = 0.038 (right side)], and no changes were observed on thighs. The studied device demonstrated efficacy in the reduction of cellulite severity and body circumference measures in the buttocks.
Article
This article discusses the psychiatric assessment of patients referred for a cosmetic procedure. Putative factors associated with poor outcome include being male; young; suffering from psychosis, severe depression or mania, an eating disorder, body dysmorphic disorder or significant personality disorder; having a ‘type-change’ procedure (e.g. rhinoplasty) rather than ‘restorative’ procedure (e.g. rhytidectomy); experiencing significant interference in their social and occupational functioning; having unrealistic expectations of outcome (for example, believing that they will obtain a new partner or job); or being dissatisfied by multiple areas of their body.It should be emphasized that a single factor by itself is unlikely to be relevant and that there have been no prospective studies to evaluate the putative factors properly. The article focuses on body dysmorphic disorder and some suggestions are provided on engagement in therapy.
Article
An impairing preoccupation with a nonexistent or slight defect in appearance is the core symptom of body dysmorphic disorder (BDD), a psychiatric condition common in dermatology settings. We sought to determine the prevalence of BDD in dermatologic patients, comparing general and cosmetic settings, and describing some demographic and clinical characteristics. In all, 300 patients were consecutively assessed. Screening and diagnoses were performed with validated instruments plus a best estimate diagnosis procedure. The final sample comprised 150 patients in the cosmetic group, 150 patients in the general dermatology group, and 50 control subjects. Standard statistical analyses were performed (chi(2), nonparametric tests, logistic regression). The current prevalence was higher in the cosmetic group (14.0%) compared with general (6.7%) and control (2.0%) groups. No patient had a previous diagnosis. Frequently the reason for seeking dermatologic treatment was not the main BDD preoccupation. Patients with BDD from the cosmetic group were in general unsatisfied with the results of dermatologic treatments. Cross-sectional study conducted in a university hospital is a limitation. It is uncertain if the findings can be generalized. Retrospective data regarding previous treatments are not free from bias. BDD is relatively common in a dermatologic setting, especially among patients seeking cosmetic treatments. These patients have some different features compared with general dermatology patients. Dermatologists should be aware of the clinical characteristics of BDD to identify and refer these patients to mental health professionals.
Article
The demographic features of 415 patients seeking cosmetic surgery were investigated from a psychiatric point of view. Of the 415 patients, 198 (47.7%) were found to have mental disorders according to ICD-10 including: 17 with schizophrenia, 20 with other persistent delusional disorders, 33 with depressive episode, 47 with neurotic disorders, 42 with hypochondriacal disorder, five with paranoid personality disorder and 14 with histrionic personality disorder. The rate of subjects with poor social adjustment was 56.0%. It was noteworthy that such a considerable number of patients with mental disorders or with poor social adjustment had sought cosmetic surgery. Distinct gender differences were found: male subjects were characterized to have a greater number of mental disorders, especially dysmorphophobia (other persistent delusional disorders plus hypochondriacal disorder) and showed the narrow age range between teenage and young adult age when they were preoccupied with their 'deformity', and poor social function. A history of frequent operations was not considered to be an indicator for mental abnormality. The diagnostic issue in dysmorphophobia is briefly described.
Article
The Mini-International Neuropsychiatric Interview (M.I.N.I.) is a short structured diagnostic interview, developed jointly by psychiatrists and clinicians in the United States and Europe, for DSM-IV and ICD-10 psychiatric disorders. With an administration time of approximately 15 minutes, it was designed to meet the need for a short but accurate structured psychiatric interview for multicenter clinical trials and epidemiology studies and to be used as a first step in outcome tracking in nonresearch clinical settings. The authors describe the development of the M.I.N.I. and its family of interviews: the M.I.N.I.-Screen, the M.I.N.I.-Plus, and the M.I.N.I.-Kid. They report on validation of the M.I.N.I. in relation to the Structured Clinical Interview for DSM-III-R, Patient Version, the Composite International Diagnostic Interview, and expert professional opinion, and they comment on potential applications for this interview.
Article
What determines patients' goals for cosmetic surgery and their satisfaction with the outcome? Historical trends, body image theory, evolutionary biology, and clinical and experimental psychology each contribute answers. The physical changes that patients seek are typically a means to psychosocial goals. Individual objectives vary, but often share an origin in recurrent painful feelings, thoughts, or experiences. Surgical goals include: (1) changes in emotional states or cognitions; (2) improvement in interpersonal relationships; and (3) an altering of reactions of the larger society. Psychological studies of cosmetic surgery patients have been designed primarily to address two fundamental questions: (1) is there a preoperative psychological profile of cosmetic surgery patients; and (2) does cosmetic surgery produce enduring, beneficial psychological change? The use of specialized screening interview questions, and effective collaboration with mental health providers, help a wider range of patients achieve successful surgical outcomes.
Article
Beauty is important. As psychiatrists, we see the interface of beauty with mental health, self-esteem, and mental illness. As physicians who enhance cosmetic appearance, you encounter a broad spectrum of patients ranging from those with a healthy pursuit of enhanced appearance to those whose behavior is extremely maladaptive. This article provides some examples of unhealthy pursuit and how to recognize patients who may be inappropriate for cosmetic procedures. Patients with body dysmorphic disorder and narcissistic and histrionic personality disorders are suffering from psychiatric illnesses that interfere with their judgment and can lead them to make poor choices when considering cosmetic procedures. Clinicians who acquire a basic understanding of these psychiatric conditions can properly screen their patients and enhance their understanding of their patients' goals, both realistic and unrealistic, thus saving them from performing inappropriate procedures that cause frustration to both the clinician and the patient.
2010 Cosmetic Plastic 2 Available from:www.plasticsurgery.org2010-cosmetic-plastic-surger y-minimally-invasivestatistics.pdf Grossbart TA, Sarwer DB.Cosmetic Surgery: Surgical Tools - 3. Psychological Goals Seminars in Cutaneous Medicine and Surgery
American Society of Plastic Surgens. [Internet]. 2010 Cosmetic Plastic 2. Surgery Statistics. [cited 2012 mar. 5]. Available from:www.plasticsurgery.org/Documents/newsresources/statistics/2010/statistics/Overall- Trends/2010-cosmetic-plastic-surger y-minimally-invasivestatistics.pdf Grossbart TA, Sarwer DB.Cosmetic Surgery: Surgical Tools - 3. Psychological Goals Seminars in Cutaneous Medicine and Surgery. Semin Cutan Med Surg. 1999; 18(2):101-11.
Social Impact of Cellulite and its impact 5. ons quality of life
  • D Hexsel
  • C L Hexsel
  • M B Weber
Hexsel D, Hexsel CL, Weber MB. Social Impact of Cellulite and its impact 5. ons quality of life. In: Goldman MP, Hexsel D, eds. Cellulite pathophysiology and Treatment. Informa Healthcare 201. p. 1-4.