A Noninvasive Mechanical Treatment to Reduce the Visible Appearance of Cellulite

Cellulite is a cosmetic problem, not a disease process. It affects 85% to 90% of all women worldwide and was described nearly 100 years ago.¹ Causes may be genetic, hormonal, or vascular in nature and may be related to the septa configuration in the subdermal tissue. Fibrosis at the dermal-subcutaneous junction as well as decreased vascular and lymphatic circulation also may be causative factors.

Cellulite has a multifactorial etiology. Khan et al² noted that there are specific classic patterns of cellulite that affect women exclusively. White women tend to have somewhat higher rates of cellulite than Asian women. The authors also stated that lifestyle factors such as high carbohydrate diets may lead to an increase in total body fat content, which enhances the appearance of cellulite.²

The subdermal anatomy affects the appearance of cellulite. Utilizing in vivo magnetic resonance imaging, Querleux et al³ showed that women with visible cellulite have dermal septa that are thinner and generally more perpendicular to the skin’s surface than women without cellulite. In women without cellulite, the orientation of the septa is more angled into a crisscross pattern. In women with a high percentage of perpendicular septa, the perpendicular septa allow for fat herniation with dimpling of the skin compared to the crisscross septa pattern.² Other investigators have discussed the reduction of blood flow in specific areas of the body in women, particularly in cellulite-prone areas such as the buttocks and thighs, as another causative factor.^2,4,5 Rossi and Vergnanini⁶ showed that the blood flow was 35% lower in affected cellulite regions than in nonaffected regions without cellulite, which can cause congestion of blood and lymphatic flow and increased subdermal pressure, thus increasing the appearance of cellulite.

Although there is some controversy regarding the effects of weight loss on the appearance of cellulite,^2,7 it appears that the subdermal septa and morphology have more of an effect on the appearance of cellulite.^2,3,8

Rossi and Vergnanini⁶ proposed a 4-grade system for evaluating the appearance of cellulite (grade I, no cellulite; grade II, skin that is smooth and without any pronounced dimpling upon standing or lying down but may show some dimpling upon pinching and strong muscle contraction; grade III, cellulite is present in upright positions but not when the patient is in a supine position; grade IV, cellulite can be seen when the patient is standing and in a supine position). Both grades III and IV can be exacerbated by maximal voluntary contraction and strong pinching of the skin because these actions cause the subcutaneous fat to move toward the surface of the skin between the septa. This grading system aligns with categories I through III described by Mirrashed et al.⁹

There are many cellulite treatments available but few actually create a reduction in the visible appearance of cellulite. A number of these treatments were reviewed by Khan et al,¹⁰ including massage; a noninvasive suction-assisted massage technique; and topical agents such as xanthine, retinols, and other botanicals.^4,11-14 Liposuction has not been shown to be effective in the treatment of cellulite and in fact may increase the appearance of cellulite.^9,15 Mesotherapy, a modality that entails injecting substances into the subcutaneous fat layer, is another treatment of cellulite. Two of the most common agents purported to dissolve fat include phosphatidylcholine and sodium deoxycholate. The efficacy and safety of mesotherapy remains controversial and unproven. A July 2008 position statement from the American Society of Plastic Surgeons stated that “low levels of validity and quality of the literature does not allow [American Society of Plastic Surgeons] to support a recommendation for the use of mesotherapy/injection lipolysis for fat reduction.”¹⁶ Other modalities such as noninvasive dual-wavelength laser/suction devices; low-energy diode laser, contact cooling, suction, and massage devices; and infrared, bipolar radiofrequency, and suction with mechanical massage devices are available and show some small improvements in the visible appearance of cellulite, but no rating scales were used in any of these studies.^17,18 DiBernardo¹⁹ utilized a 1440-nm pulsed laser to treat cellulite. It is an invasive treatment that works by breaking down some of the connective tissue septa responsible for the majority and greater severity of the dermal dimpling seen in cellulite, increasing the thickness of the dermis as well as its elasticity, reducing subcutaneous fat, and improving circulation and reducing general lymphatic congestion.¹⁹ The system showed promise but was an invasive treatment, and one session could cost $5000 to $7000 for bilateral areas and another $2500 for each additional area.²⁰ Burns²¹ expressed that the short-term results showed promise in reducing the appearance of cellulite. Noninvasive ultrasound^22,23 as well as extracorporeal shock wave therapy^24,25 also has shown some improvement in the firmness of collagen but generally not in the appearance of cellulite.

We sought to evaluate the efficacy and safety of a noninvasive mechanical treatment of cellulite.