Aesthetics Journal / by Hermione Eyre
Medical practitioners discuss the practical difficulties associated with treating cellulite and examine its causes, diagnosis and grading, as well as the range of treatment options they have chosen to use in their clinics. David Jacobs reports.
The term 'cellulite' was first used in the 1920s to describe the alteration of the skin surface of the legs characterised by an 'orange peel' or dimpled effect'.
Dr Ayham Al-Ayoubi, a Facial Plastic and Laser Surgeon from the London Medical and Aesthetic Clinic, sees a similar profile among his patients: "80% of patients are ladies in their 40s and 50s with around 10%being ladies aged 25 to 30, and around 10%aged 60+." He adds, "I've seen patients in their 20s who have had bad cellulite and have had the problem from the age of 14or 15 when hormonal changes kick in.
Dr Ayham AI-Ayoubi sees 10-15 cellulite cases for Cellulaze laser treatment per month and about 100 cases for a course of Velashape; practitioners report that they see more patients as the summer months approach.
Cellulite it is a common cosmetic problem as Mr Hassan Shaaban, consultant plastic and laser surgeon, explains, "It is estimated that 80% of women above the age of 20 have it. In the majority of ladies, [it appears] in the outer thighs, the back of the legs, the buttocks and the front of the legs, and less on the inner the inner thighs.
Cellulite mainly affects women -in fact, some practitioners have never seen a man attend for treatment, however, that cellulite does not always mean excess fat and affects slim women in the same way that it does those who are overweight, My key patient group is Caucasian women between the ages of 30 and 55, although some do fall outside of this range. Both men and women suffer, although women are more predisposed due to their anatomy and hormonal differences.
THE PRINCIPAL CAUSES OF CELLULITE
The exact causes of cellulite are unclear and unlikely to be attributable to a single factor. "Abnormal vascular patterns, biochemical changes or cellular dystrophy have been suggested as causes. However, cellulite has a strong hereditary predisposition and this could be the main cause.
According to Dr Ayham AI-Ayoubi, "If cellulite is going to develop, then sadly it will develop." He explains that treatments and lifestyle changes will help to correct it and whilst these won't cure or prevent the problem, they will help to limit its spread. Asked to describe a particularly successful case.
Dr Ayham AI-Alyoubi highlights dramatic improvement, but not a cure. The case involved a female in her 40s who had initially been treated using Velashape but achieved only 'minimal improvements'. 18 months ago, after switching treatments to a combination of Velashape and Cellulaze laser, he noted, "The improvement was so dramatic that we converted her from Grade 3 to Grade 1,which usually I don't promise my patients,but the combination of therapies, plus good lifestyle, achieved significant improvement. The [differences in the] 'befores' and 'afters' were outstanding."
Causes may include poor diet, smoking, slow metabolism, lack of physical activity, hormonal changes, dehydration, the percentage of total body fat, and the thickness and colour of skin. With so many causes attributable to lifestyle. A range of controllable risk factors that patients should be made aware of as part of any effective treatment regimen. Along with other contributors, such as a healthy diet, increase hydration and exercise regularly.
The holistic approach, Legs are prone to cellulite owing to our sedentary lifestyle. They are dependent upon exercise and abdominal/pelvic muscle tone to ensure perfect lymphatic and venous drainage. New research has confirmed our suspicions that regular activity throughout the day ensures good cardiovascular health.
One hour in the gym will not counter the effects of a 12-hour-day spent on your bottom. Diet may also contribute via the stimulation of fat storage. The need to involve patients in their own treatment is important and they need to got to get involved actively as well. So there's a patient component to it.
Cellulite is one of the most difficult cosmetic problems to treat due to the complex nature of the condition. The core structure of cellulite is unique as it features three different problems in the same area, the expansion of fat cells within their tight compartments (causing fatty bulges); the shortening of skin septa (causing skin dimpling); and the loss of skin thickness and elasticity (giving the appearance of loose sagging skin). This clinical feature makes it difficult for women to rid themselves of, or even to hide, cellulite."
DIAGNOSING SEVERITY OF CELLULlTE PRIOR TO TREATMENT
The majority of practitioners consulted use a three-point graded scale. Grade 1 indicates that you need to pinch the skin to see cellulite and Grades 2 and 3 are split into mild, moderate and severe levels. Severe Grade 3 indicates large pockets of fat and very badly indented skin, where cellulite can be seen at any standing position or movement and under any lighting.
Dr Ayham AI-Ayoubi uses the three-point graded scale, however, he points out, "There is not an objective measure to look at cellulite -it's more subjective. We can do an ultrasound of the skin and fat tissue but from a practical point of view you're not going to perform an ultrasound on every patient and grade perform an ultrasound on every patient and grade the condition by the depth of the cellulite in the septum; so practically it's better to divide it into three based on appearance."
Dr Britta Knoll and others highlight the value of photo documentation and measurements, particularly when explaining to patients the status of the cellulite observed. Mr Shaaban explains that he organises treatment plans around the use of the Modified Muller Nuremberger Scale (ie, Grades 0-3) and examines patients when they are standing under good lighting conditions. However, even when using a standard scale, such as Muller Nuremberger, diagnosis of severity is principally achieved by examination.
TREATMENT OPTIONS AND THEIR OUTCOMES
Dr Ayham AI-Ayoubi combines Cellulaze with Velashape and says that, whilst other treatments may improve cellulite by one grade, by initially using Cellulaze and then four weeks later a course of Velashape, his clinic has achieved reductions from Grade 3 to 1.
He reports that 80% of his clients come to the clinic having already tried topical creams, massage and herbal medicines that have had no effect. "Massage and topical treatments will make the skin look temporarily better; they are a temporary fix and that includes caffeine-containing products." Dr Knoll recommends topicals, including those with high dose caffeine, but only for home treatment; and stresses that they must be combined with medical treatment to have the most effect.
Cellulaze is performed as a day-case procedure under a local anaesthesia, or IV sedation in an operating theatre under sterile conditions. Mild bruising, swelling and numbness is expected after surgery but it settles within a week. Dr Ayham AI-Ayoubi says that his 200 clients are even happier with the results two to three years later as the process continues to work.
Patients leave Dr Ayham AI-Ayoubi's clinic with MACOM Crystal Smooth Legwear compression garments, which help create a gentle heat and so improve blood circulation as well as fat and lymphatic drainage.
Dr Ayham AI-Ayoubi says that a patient will typically see a difference after four to six months with Cellulaze treatment alone, but by adding the Velashape and the MACOM garments, improvements are noticeable after just four to six weeks. Furthermore, he remains convinced that the future ofcellulite treatment is with lasers with a wavelength that targets the cellulite septum and fat tissue, and is of the opinion that with other technologies (eg, RF,ultrasound and infrared) the energy does not distinguish between cellulite and other tissue.
Mr Shaaban divides treatment for cellulite into three main groups: "creams and lotions (that have zero! minimal effect); external therapy, which includes ultrasound, radiofrequency, and external laser (which have limited success as they have no effect on fibrous bands); and Cellulaze.
The first treatment modality that addresses all components of cellulite. It dissolves fat bulges, divides fibrous bands to release skin dimples and also tightens the skin through the stimulation of collagen formation." The laser probe is inserted under the skin through two or three 'stab' like incisions", but Mr Shaaban describes it as "an effective, safe treatment, showing an immediate result that continues to improve with time."
Dr Knoll explains that she uses mainly mesotherapy as well as injection lipolysis. She deploys a range of products and adapts the selection and composition according to the individual needs of the patient However, she is interested in treating any diseases or constitutional problems underlying the cellulite, such as venous lymphatic insufficiency, and stresses that at the examination stage she determines what type of cellulite the patient presents since,
"There is a big variety of pathophysiologic types of cellulite and it's important we see what type it is -some are much harder to treat than others -and from the tissue quality determine, by examination and touch, the number and composition of treatments." she explains.
Also Cellulite treatment has shifted from mesotherapy to RF, the best outcomes are achieved by a combination of both.Best performed on a weekly basis for about 10 sessions,then adjusted to once per month. As mesotherapy, whilst not a difficult technique, does require practice to succeed. It also has two particular advantages: low cost and the fact that medications used in the injections, "complement the action of the RF device, so better results are achieved in a shorter time,
Lipotripsy is used as a stand-alone treatment and are advised to have two treatments per week and around eight to 12 sessions, It's non-invasive, pain-free, quick to administer and has no down time.
Coolsmooth, a new head for the Zeltiq CoolSculpting is used the Endymed 3DEEP quite a lot - a normal course would be six treatments, or more if the cellulite is really bad and sometime it can be used with Dermaroller in combination to help.
CHOOSING THE RIGHT TREATMENT
The key message is to select a technology that is,above all,safe and efficacious. Dr Ayham AI-Ayoubi affirms the need for FDA and MHRA approval.
Despite advances, cellulite remains impossible to 'cure', but it can be improved, maintained and prevented from worsening through a combination of treatments and good lifestyle choices, in terms of diet and exercise. In a challenging area of aesthetics, the market's new technologies and treatments may offer hope in the future for the many hundreds of women regularly seeking help to diminish this body concern.
To view Dr Ayoubi in the media click here.