Therefore, now that we know half the world are talking about cellulite, what is it, what causes it, how do you grade it and is there any treatment out there for the condition. For a start, many may be surprised to learn that the term cellulite is not actually a medical term and there is some dispute about the etiology of the condition. Some people claim that French and Italian doctors used the term cellulitis over one hundred years ago to describe a condition of fat deposits located under women's skin, which give a dimpled or peau d'orange appearance. The condition was extremely common and most physicians of the period considered it to be normal and were more interested in the fact that Felix Hoffman had just invented Aspirin. The decades passed, the world went to war twice and conventional medicine was not interested in treating a condition, which did not reflect an underlying illness.
Even in the early seventies, when Martin Luther King cleared his throat and addressed a quarter of a million people by the Lincoln Memorial, the condition was still largely unheard of. However, all that was about to change in 1973, when New York beauty salon owner Nicole Ronsard wrote her book 'Cellulite, Those Lumps, Bumps and Bulges you couldn't lose before'. In that year, fat must have began to bug the conscience of coastal America because the New York Times best seller non-fiction list best seller for that month was Dr. Atkins' Diet Revolution.
In that year, Ireland joined the Common Market and the comely maidens at the crossroads danced to David Cassidy, but in America the game was up....the condition cellulite was now out in the open and the world would never be the same again! Worse still, as more and more women found out that they too had these lumpy deposits all over their bodies, many charlatan doctors and fly by night companies started offering all kinds of dubious cures and preyed them upon their insecurities. One Italian chemist called Gianfranco Merizzi invented a new tablet that contained ginko, soya, fish oil, evening primrose oil, bioflavins, and many of the other normal suspects with a promise that it would cure the dreaded condition. The CEO of the company, Rexall even went on CNBC in March 1999 claiming 90% success rate for their product. Of course, they could not provide any scientific evidence to validate their results when challenged.
Another company, Relax-Cizor, then appeared on the market with a type of new cellulite machine, using iontophoresis paddles and Faraday current to remove the offending dimples. It wasn't long before they ran foul of the FDA who charged them with fraudulent advertising. They forgot to mention that the machine also was responsible for inducing hernias, creating abnormal cardiac rhythms, and inducing miscarriages. The machine was apparently repackaged and later sold in Europe where laws are considered not as stringent. It never ceases to amaze me how these companies can flourish on this side of the big pond and nobody seems to question them whenever they use eighteenth century terminology like Faraday current or iontophoresis to describe a simple thing like electromagnetism or electricity. Imagine trying to sell the latest personal computer to someone using Pascal or Babbage terminology. It is fair to say most people would immediately recognise the spoof!
However, this was not the case with cellulite because nobody had bothered to scientifically evaluate what exactly the problem was. Believe it nor not, it took until 1996, for Dr. Neil Solomon from the Johns Hopkins University to look more closely at the phenomena of cellulite. In a paper of this period, this doctor concluded that under the microscope cellulite looked no different from ordinary fat. In 1998, some researchers at the Rockefeller Institute examined the situation more closely and they concluded that there was no significant difference between the appearance or function of fatty tissue or the regional blood flow between people who had cellulite and those who did not. They also stated that there was some characteristic within female skin that made them more prone to developing the condition.
Meanwhile, as the new wonder pill Viagra hit the world market, the sale of miracle creams containing caffeine, green tea, theophylline and theobromine from cocoa continued and one company even produced a tablet that promised to take away cellulite while the patient slept. Things went from the sublime to the surreal as another company promised to remove the cellulitic condition by wrapping their clients in a type of snap wrap that caused water loss by perspiration and compression of the swollen tissues. The product was marketed through television and it caused the U.S. Federal Food and Drug Administration (FDA) and the Federal Trade Commission (FTC) to take notice and produce regulations and guidelines for the advertising of cellulitic products. The industry quickly realised that they needed to be more scientific in their approach and they quickly produced literature stating that caffeine used topically could actually reduce fat content in cells by blocking an enzyme that inhibits fat breakdown. As the pace quickened, others claimed that an alkaloid in cocoa called theobromine could penetrate to the subcutaneous fat layer and help stimulate the release of stored fat. Into this new age of scientific enlightenment came other prophets who claimed that horse chestnut contained a chemical called aescin, which could reinforce the strength of veins, support circulation and prevent swelling. Despite the rash of scientific opportunism, there was little on the market that could really reduce the cellulitic condition. It did not take a genius to realise that it would require more than tablets to remove those stubborn fibrous bands of tissue.
Around this time, another technology entered the market. It had started its earlier life in France as a deep tissue massage for horses until a company called LPG systems decided to try its effect on cellulite. The company called the procedure, Endermologie(r) and claimed it could increase circulation by 200%, by expelling toxins and water build up while the underlying connective fibres were stretched. The product was again heavily marketed in magazines and on the TC networks. Despite many clinical trials, the clinical evidence of the procedural effect remains ambiguous. One study performed in 1998, showed a mean index reduction in body circumference of between 1.34 and 1.83cms. It was the same year that President Bill Clinton risked impeachment over his affair with Monica Lewinsky. Despite this evidence, another clinically controlled trial by Collins and others, Cellulite Treatment, A Myth Or Reality. A controlled trial of two therapies Endomologie and Aminophylline cream' was published in Plastic and Reconstructive Surgery 104:1110-1114, 1999. This study found no objective difference in the thigh girth or thigh fat depth of 52 women who were measured by ultrasound. It further showed that only 3 of 35 patients with aminophylline-treated legs and 10 of 35 patients with Endermologie-treated legs actually felt that their cellulite appearance had actually improved. The authors concluded that neither of the two treatments was effective in improving the appearance of cellulite. Despite these findings, the Endomologie (r) procedure continues to be widely marketed and the process has gained popularity in some quarters. My own impression from the experience of many colleagues is that the procedure usually takes 10 to 20 treatments to see any results and the patient has to do one or two maintenance treatments per month to maintain any beneficial effect.
Therefore, where does that leave us regarding the scientific evaluation of cellulite? There is no doubt; most doctors now agree that cellulite is more often seen in women due to hormonal reasons. The scientific rationale behind this has not been fully evaluated and a cynic would state that this conclusion is not particularly difficult to make. We also know that cellulitic fat is arranged in large chambers of macromolecules that are separated by columns of collagen fibres. It does not take a University qualification to figure out that whenever excess fat is stuffed into these fibrotic compartments, it will cause them to bulge out, giving the surface dimply appearance of cellulite. Scientists also know that the 'dimpling' is made worse because of underlying water retention and fibrosis caused by impaired circulation and destruction of the tissues in this area. This is the main reason that many treatments can give a temporary solution to the problem. The effect is only temporary because in effect, cellulite is localised fat 'caught in a jail' of surrounding scar tissue and these fibrotic walls must be broken down before we can see a more long-term solution to the problem.
Recently, there have been two substantial changes in the continuing war against those offending dimples. In 2003, the Lipodissolve (r) procedure was introduced to the Irish market. During this procedure, phosphotidyl choline is injected directly into subcutaneous fat in an effort to dissolve it. It is not surprising that this method would be evaluated in an effort to see its effect on cellulite. In 2004, Network Lipolysis invited me to become European Group Leader for the evaluation of this pharmaceutical in the treatment of cellulite. The injections are quite painful and in my experience not always successful in treating the resilient condition. It takes multiple treatments to see any reduction in size and the dimpling effect often remains. We have treated nearly 500 patients with this compound in differing areas to date and our results will soon undergo scientific evaluation as part of a European trial.
This year, a new medical device arrived, which promises to be the most interesting development to date in the battle against cellulite. This product is called the VelaSmooth (r) and the machine has already undergone rigorous medical testing in the United States. The products works by using a combination of bipolar Radio Frequency, Infrared light, and suction in an effort to safely and effectively re-contour the skin surface. In clinical trials in both Israel and the United States, it appears to be the most effective treatment available to date. The device apparently works by allowing radiofrequency to heat fat tissue to a depth of 10mm and the makers claim this process increases oxygen intracellular diffusion. The infrared light part of the product heats subcutaneous fat to a level of 3mm and increases skin elasticity.
The suction device is similar to Endomologie (r), in that it can manipulate and smooth out the skin. The procedure requires two treatments a week for five to six weeks and the effects last about six months before requiring a top up treatment. The overall cost is about e750 for the complete package. Our clinic was selected to trial the new technology for the European market and we shall start evaluating our results in a few months.
So where does that leave us? I feel it will take a combination of the above treatments to eventually solve the problem of cellulite. Like the old spaghetti westerns, we will need technology like Velasmooth (r) to break down the walls of the jail and a compound like Phosphotidyl Choline to dissolve the baddies contained within. The trials surrounding this combination therapy have already begun in Canada and Italy and slowly but surely patients are beginning to see medicine and doctors at last becoming interesting in dealing with this tenacious condition.
