One more way to classify and criticize ourselves? No, not today. Cellulite affects 90% of women and 10% of men, some people are bothered by it, some aren't. What causes cellulite is debatable, but most scientists agree that it results from some combination of reduced microcirculation, interstitial edema, localized hypertrophy of fat cells, oxidative stress, persistent low grade inflammation, and extracellular matrix alterations from collagen degradation. Huh? Don't worry, I'm going to break that down for you...
I don't know about you, but I am overwhelmed by the non-science (nonsense) when I look for help from the beauty industry. I am also too old to beat myself up over a few lumps and bumps on my thighs. On the other hand, if cellulite reflects the health of my body (my skin, connective tissue, adipose, microcirculation, estrogen levels, collagen production, diet, habits), perhaps it is worth understanding the pathology so I can make some informed decisions regarding my lifestyle. According to Pavicic et al, up to 98% of women are concerned about their skin changes due to cellulite and the changes decrease their self-esteem. Whoa, that's upsetting. So, if it is bothering you, it is bothering me.
Let's begin by classifying cellulite, the Nurnberger and Muller scale is the most commonly used classification for cellulite. This is a simplified version:
STAGE 0 No visible cellulite while standing
STAGE 1 The skin is smooth while standing or lying down, but the Pinch Test produces an orange peel appearance
STAGE 2 Cottage cheese appearance to the skin is visible while standing. It disappears when laying down.
STAGE 3 Dimpling appearance is visible regardless of whether the woman is standing or lying down.
STAGE 1: Smooth skin while standing, bumps and dimples appear while sitting.
STAGE 2: Orange peel or cottage cheese appearance sitting or standing.
STAGE 3: Orange peel appearance present while sitting or standing with deep raised and depressed areas.
• What causes cellulite?
Cellulite is a condition where fat cells push through the connective tissue beneath the skin. The image below depicts the normal architecture of the layers under the skin. The subcutaneous layer of fat lies below the skin on top of a layer of fascia (fascia is a collagen-based sheet of connective tissue). There are vertical, fibrous cords connecting the fascia to the skin. There are also arteries and veins running through this superficial fat layer. When the structure of this superficial layer becomes disturbed (via inflammation, estrogen, aging, trauma, edema, oxidative stress, decreased blood flow, fat cell enlargement) the fascia, fibrous cords, skin, and fat cells lose this organized structure.
As mentioned, cellulite formation is multifactorial, this image depicts the enlargement of adipose cells; as they get bigger they protrude through the skin while the fibrous cords tether the skin the the underlying fascia resulting in the visible skin dimple.
This might explain cellulite as it relates to increased body fat, but other factors are at play. The dermis is held together by a protein called collagen, made by fibroblasts. Fibroblasts are skin cells that give the skin its strength and resilience. As we age, our fibroblasts produce less and less collagen and the existing collagen becomes weaker. As the collagen in the skin decreases these protruding fat cells become more visible (the orange peel appearance). So now we have 2 issues, enlarged fat cells and weakened skin. Imagine now that there is injury to the vertical cords of connective tissue from trauma, decreased circulation (smoking or aging), UV damage, and/or free radical accumulation. Injury results in inflammation, this causes the fibrous cords to contract and thicken and potentially shorten, which tethers the fascia to the skin at each cord. And the result? The overlying skin becomes dimpled as the cords pulls down and fat cells protrude up.
• What can we do about it?
We have to address the pathology, notice I said "healing" cellulite.
1. Improve circulation
2. Reduce inflammation
3. Increase collagen regeneration; reduce breakdown and increase formation
4. Release the tethering of the fibrous cords
5. Reduce the size and number of fat cells
1. Improve circulation
While the actual cause of cellulite is the result of a breakdown in the connective fibers, one must remember that the reason for this breakdown is most likely a decline in the circulatory system. Loss of circulation to an area – whether caused by lack of exercise, too much sitting, clogged arteries, tight clothing or nutrient deficiency – can have a serious impact and accelerate cellulite formation.
One theory is that as estrogen in women decreases in the approach to menopause, blood flow to the connective tissue under the skin also decreases. The vessels then become more fibrotic, hardened, and narrowed, which results in leaking and edema. Reduced blood flow results in a build up of toxins in the tissue as well, these cause free radical damage and increased inflammation. All of this results in poor blood flow and nutrition to the fibroblasts, which means they aren't able to regenerate collagen and repair damaged cells.
So what can we do to increase circulation? First, stop the offending agents.
Cigarette smoke has been shown to reduce blood vessel flow and to weaken and disrupt the formation of collagen, allowing for the connective tissue to become stretched and damaged more easily and for underlying fat to show through. Avoid tight underwear or elastic bands from your clothing which restrict blood flow. Avoid prolonged sitting, get up and move at least once per hour for 5 minutes.
Exercise can improve circulation, and it doesn't have to be intense. Yoga, stretching, and walking are all effective methods to improve circulation. Massage treat cellulite by increasing blood flow (especially if the tissue is heated first), decreasing tissue edema and effecting the cellular level by stimulating fibroblast activity and decreasing adipocyte activity. Try massaging the ares while in the shower when the tissue is warm. Regularly brushing your skin will increase the flow of blood to the skin's surface. This ensures that nutrients reach the surface area for healthy skin renewal. Brush dry or damp skin using a body brush with firm, but not overly coarse, bristles.
Topically, the essential oil from geranium, fennel, cypress, cedarwood, rosemary, patchouli, tangerine, and lemongrass when applied topically can increase blood flow to the microcirculation and reduce edema and blockage of flow. Products with greater than 3% caffeine and/or retinol have also been shown to increase microcirculation in the skin when applied topically.
2. Reduce inflammation
Clearly when we improve circulation there will be less tissue damage and the inflammation will improve. But there are things we can do to reduce low grade inflammation like ingesting an anti-inflammatory diet and a daily dose of omega-3 oils. Whereas eating oxidized or rancid fats and sugar will increase inflammation in your body, eating healthy fats such as animal-based omega-3 fats or the essential fatty acid gamma linolenic acid (GLA) will help to reduce them. Ongoing oxidative damage drives chronic inflammation. Reducing oxidative damage can help control inflammation. Antioxidants like vitamin C, vitamin E and selenium all help to control oxidative damage by neutralizing “free radicals.” In fact, all of the following can increase your risk of chronic inflammation: being overweight, eating a poor diet, an existing heart condition, a family history of heart disease, diabetes that's poorly controlled, a sedentary lifestyle, smoking, gum disease, and stress. Research shows bromelain, an enzyme found in the core of a pineapple, exerts its anti-inflammatory effect by altering leukocyte migration and activation. Turmeric is an ingredient found in curry powder. Curcumin is an antioxidant compound in turmeric, which gives curry and mustard their yellow color and offers anti-inflammatory benefits. Certain constituents of ginger, called gingerols, have a strong anti-inflammatory effect. They inhibit a number of biochemicals that promote inflammation.
3. Increase collagen regeneration
First, reduce premature collagen breakdown
Researchers seem to agree that the integrity of connective tissue is governed by the presence of collagen, it is now understood that cellulite formation is a biological function of collagen breakdown. Much of what try to do to improve the appearance of the skin involves creating a controlled injury to collagen in order to encourage remodeling. Preventing unnecessary, premature collagen breakdown (uncontrolled injury) is the first step however. Recall, cigarette smoke has been shown to reduce blood vessel flow and to weaken and disrupt the formation of collagen. Exposure to ultraviolet radiation causes collagen to break down. Exposure to natural sunlight is healthy and important for maintaining vitamin D levels; however, wear sunscreen to protect the delicate matrix of proteins supporting the skin. Avoid tanning booths as they damage skin rapidly with intense UVA light, which penetrates the skin even more deeply than natural sunlight. Tomato paste contains high doses of lycopene, more than what you would get by eating a fresh tomato. Studies have shown that this antioxidant may help reduce UV-induced sun damage, as well as help prevent collagen breakdown. The most important source of antioxidants is provided by nutrition. To the most known systemic antioxidants belong vitamin C, vitamin E, carotenoids, and from the trace elements copper and selenium. There are two main groups of agents that can be used as anti-aging cream components, the antioxidants and the cell regulators. The antioxidants, such as vitamins, polyphenols (green tea) and flavonoids, reduce collagen degradation by reducing the concentration of free radicals in the tissues. By preserving collagen in your skin, you are keeping a healthy thick top layer of skin overlying your fat layer, which reduces the out-pouching of underlying fat cells, making cellulite less visible
Second, increase collagen formation
The cell regulators, such as retinols, peptides and growth factors, have direct effects on collagen metabolism and influence collagen production when applied topically. We commonly induce controlled injury to the existing collagen to induce turnover and remodeling. Exfoliation helps kick start collagen production because creating mild irritation to your skin triggers a healing response. Part of that response is fibroblast cells that begin to synthesize collagen fibers. Exfoliation also increases cell turnover in your skin, which slows with aging. If you help remove the dead cells, you make it easier for newer cells to come to the surface. Radiofrequency (RF; like BodyFX) provides a selective, heat-induced denaturalization of dermal collagen that leads to reactive synthesis. The RF technology produces electric current, which generates heat through resistance in the dermis and as deep as the subcutaneous fat and results in skin tightening and immediate collagen contraction. Light-based laser treatments (YAG 1064 Aerolase) also injury the tissue in a controlled fashion, prompting regeneration. Manipulation of the tissue through massage, fascial blasting, vacuuming and cupping stimulates collagen regeneration as well. For optimal regeneration we need collagen building blocks: collagen peptide (>2.5gms per day); Vitamin C; Threonine is an essential amino acid for collagen production. An essential amino acid is one your body cannot make, so you have to get it from food or dietary supplements. You can get threonine from foods such as lentils, peanuts, eggs, milk, pork, beef and chicken. If you prefer a vegetarian diet, you can also get threonine from soybeans, chickpeas, hummus, snap beans and asparagus.
4. Release the tethering of the fibrous cords
Myofascial release is a simple and effective technique used to release tissue restrictions in the connective tissue beneath the skin. A low-load, gentle pressure applied slowly over an area helps to elongate the fascia and connective tissue. Ashley Black from the Fascia Blaster says, "Imagine your hair is messy and matted, and you're just trying to smooth it over with your palms," she says. "Now imagine you have a hairbrush that actually combs out the knots. Which will leave your hair smooth and knot-free?" Similar to endermologie, deep massage may induce alterations in dermis connective tissue. These techniques do not remove the cellulite, but may have a temporary effect in reducing the amount of 'dimpling' appearance.
5. Reduce the size and number of fat cells
Let's compare a fat cell to a balloon; it starts out under-inflated and very small, but it can be inflated to 10 times its original size. When we consume more energy than we expend, the same thing happens to our fat cells, they enlarge (hypertrophy). Scientists used to believe you couldn't grow more fat cells after infancy, but we now know that fat cells can split and increase in number at any point in life when stimulated by the right conditions.
There is significant clinical evidence that caffeine acts directly on adipocytes, promoting lipolysis through the inhibition of phosphodiesterase by augmentation of cAMP. We can conclusive say that creams and oils with >2% caffeine help to shrink fat cells thereby improve the look of cellulite. This is not permanent and requires ongoing treatment.
We discussed above how radiofrequency waves heat the tissue and promote collagen regeneration, this alone improves the appearance of cellulite as research indicates a direct correlation between new collagen synthesis and skin tightening. BodyFX is a multimodal RF device that helps temporarily reduce the appearance of cellulite via vacuum suction, radio frequency energy, and high-efficiency pulses. According to clinical trials, there is a 100% response rate, and the average patient showed a 68% improvement in cellulite and an average circumferential reduction of 3.58 cm. The technology can be used to treat the buttocks, abdomen, flanks, and thighs. Clinical studies show 30% fat cell apoptosis at a 2.5 cm depth and new collagen synthesis of 13.7%. Results are achieved approximately 3 months after the treatments (the time it takes for collagen regeneration). Fractional cell death is seen; that means not all of the fat cells in a given region die, but a significant number do. Fibrous support is restored, and fat layer thickness is reduced by an average of 40% as measured by high-resolution ultrasound. In looking at before and after images from the BodyFX below, you can see some definite tissue lift as well as fat reduction.
In conclusion, cellulite is more than an accumulation of fat. Cellulite results from a complex relationship between fascia, connective tissue, collagen, inflammation, free radicals, the microcirculation, and the fat cells. We finally have evidence-based methods for reducing the appearance of cellulite, albeit temporarily. Which brings me full circle, this isn't about self-criticism or body-shaming. We are learning that cellulite is a reflection of health, understanding this pathophysiology arms you with the information you need to improve your health and potentially show yourself a little more love.
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Lupi O, Semenovitch IJ, Treu C, Bottino D, Bouskela E. Evaluation of the effects of caffeine in the microcirculation and edema on thighs and buttocks using the orthogonal polarization spectral imaging and clinical parameters. J Cosmet Dermatol. 2007;6(2):102–107
Dupont E, Journet M, Oula M-L, et al. An integral topical gel for cellulite reduction: results from a double-blind, randomized, placebo-controlled evaluation of efficacy. Clinical, Cosmetic and Investigational Dermatology. 2014;7:73-88. doi:10.2147/CCID.S53580.
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