Cellulite - Is There Hope?

Frederick R. Jelovsek MD

Very frequently, women (and men) make requests to doctors to prescribe a medication or treatment that will smooth out the contours of the body - eliminate cellulite. It presents a problem for the doctors who are not dermatologists, plastic surgeons or obesity experts because they are somewhat removed from the latest concepts regarding adipose tissue distribution and problems. Medical literature is fairly thin on this subject while the lay literature describes numerous questionable treatments that promise to rid the body of irregular appearing fat deposits. It is apparent that this topic - cellulite - has not been studied by medical science very much. It is perhaps time to look at what evidence does exist is on this subject.

Dimpling of the skin of the buttocks and thighs, especially in women, is known as cellulite. Many people have heard stories about the existence of two types of fat - brown and white - in which the brown is the type in cellulite, but medical studies have failed to confirm that there are any different types of adipose tissue. One study, Rosenbaum M, Prieto V, Hellmer J, Boschmann M, Krueger J, Leibel RL, Ship AG :An exploratory investigation of the morphology and biochemistry of cellulite. Plast Reconstr Surg 1998 Jun;101(7):1934-9 looked at both the anatomical structure of cellulite as well as its physiologic function.

Ultrasound examination of the thigh showed a diffuse pattern of extrusion of underlying fat (adipose) tissue into the reticular dermis in individuals with cellulite, but not not in unaffected, individuals. Studies also demonstrated that women had a generalized pattern of irregular and discontinuous connective tissue immediately below the skin (dermis), but this same layer of connective tissue was smooth and continuous in men. They also found no significant differences in they way the fat tissue looked under the microscope, how it responded to fat deposition and resorption, or even regional blood flow between affected and unaffected sites within individuals. They did find there were structural characteristics of connective tissue below the skin that predispose women to develop the irregular extrusion of adipose tissue into the dermis, which characterizes cellulite. In other words, cellulite represents areas of a "break in the fence" where fat cells come into the skin area and the dimpling represents where the support structure of the skin (the original "fence") is still intact.

In spite of the above paper, most scientists really do not know what causes cellulite. They have studied fat metabolism and deposition and had many and varied findings. Most areas of fat deposits are the result of two factors

• the number of fat cells - adipocytes
• the amount of fat inside the adipocytes

Occasionally there are reports that cellulite fat has more proteoglycans that lead to more water retention or that there are more or less receptors for various physiologic hormones or proteins, but it does not appear that these are the causative factors. Cellulite fat will respond to calorie restriction just as any other fat cell, but it is the stored fat that goes away; the cell is still present and can refill if calorie excess resumes. That is why most treatments of cellulite are directed at removal of the cells surgically.

Yes, women are more predisposed to cellulite than men. The Rosenbaum study found that women have a much more irregular, discontinuous supporting skin matrix than men do so there is more opportunity for fat cells to extrude into the dermis area. To some extent this must be hormonally controlled through estrogens because most men are not as prone as women to cellulite but men who are given estrogens as treatment for medical problems are known to develop new areas of cellulite.

Fat distribution is different also in women and men. Women have more fat deposits under the skin but tend not to accumulate it inside the abdominal cavity; men seem to have less room for fat over their muscles and under the skin but they will accumulate much more excess fat inside the abdominal cavity. Regionally, women have a tendency for more fat deposition in the buttocks and thighs (gluteal/femoral areas) but that tendency only starts after a women's ovaries become hormonally active.

The medical literature does not support evidence that I could find of any topical creams or ingested medicines or substances that get rid of cellulite unless those treatments result in significant loss of total body fat. In those cases, the dimpling from cellulite becomes less apparent but does not actually go away. This observation must be tempered by the realization that medical science does not seem to have studied this subject very rigorously, thus the room for many "claims of cure" that cannot be refuted as well as they should be.

Most physician-based treatments are surgical. Either fat cells are removed by various excision or suction techniques or/and the cells are redeposited in areas of dimpling so the contour looks more even. None of the surgical treatments are directed at fixing the underlying cause but merely fixing the result. Cellulite areas will recur as long as there is any excess fat deposition over the natural metabolic rate.