An Anatomical Approach to Evaluating and Treating Cellulite

January 2017 | Volume 16 | Issue 1 | Original Article | 58 | Copyright © January 2017

Mitalee P. Christman MD,a Daniel Belkin MD,b Roy G. Geronemus MD, a,band Jeremy A. Brauer MDa,b

aRonald O. Perelman Department of Dermatology, NYU Langone Medical Center, NewYork, NY bLaser & Skin Surgery Center of New York, New York, NY

Cellulite is the common rippling or dimpling of skin of the thighs and buttocks of women, formed from a confluence of skin laxity, tethering fibrous septa, and fat herniation. We describe an anatomical approach to evaluating the cellulite patient and selecting the best treatment from among available non-invasive, minimally invasive, and invasive therapies. It is crucial to consider the anatomy of the patient and the morphology of cellulite while choosing a treatment. Diffuse rippling represents increased adiposity and/or increased skin laxity which may stand to benefit from lipolytic and skin tightening modalities. Dimpling represents tethering by fibrous septa which may stand to improve from subcision by minimally invasive devices such as Cell na. Patients with both morphologies may be treated with a combination of treatments or Cellulaze. Careful evaluation of the patient can help identify the best therapeutic strategy. J Drugs Dermatol. 2017;16(1):58-61.


Cellulite is the often aesthetically displeasing rippling or dimpling of the skin most commonly located on the thighs and buttocks of women. Its appearance and texture is often likened by laypeople to that of “cottage cheese” or an orange peel. Cellulite is very common, affecting about 80-90% of postpubertal women.1 Gender, anatomy, genetic susceptibility, hormones, deficiencies in lymphatic drainage, and microvasculature are all thought to play a role in the condition’s pathogenesis. In normal skin, there is a support network of fibrous septa running through the subcutis, separating the adipose cells into chambers resembling a quilt. Magnetic resonance imaging demonstrates that in cellulite, these fibrous septa are contracted and sclerosed, ultimately tethering the skin at a fixed length.2 Concurrently, the adipose cells expand with weight gain or water absorption, promoting herniation, or outpouching of fat into the dermis. This results in skin dimpling creating the characteristic cellulite appearance. Two distinct morphologies of cellulite may be identified, sometimes coexisting in the same patient: 1) diffuse rippling in patients with increased adiposity and/or increased skin laxity and 2) dimpling, with discrete ellipsoid or linear depressions, in patients with good skin tone (Figure 1).

Clinical Assessment of the Patient

A thorough history including past medical and surgical histories, as well as physical examination of the patient, is essential in identifying the appropriate candidate for intervention. The history should assess the time of onset of the cellulite and any previous procedures or treatments in the area of concern (including oral or topical agents, non-invasive, minimally-invasive, or invasive procedures). One should also elicit any history of trauma, infection, swelling due to lymphatic or venous insufficiency, or bleeding problems in the area. The physical examination should be performed with adequate lighting while the patient is standing upright, as lying down may obscure some of the topographic changes. Tangential illumination may further help visualize the anatomy. The patient may slightly alter their stance or tense the muscles to highlight areas of concern, or the physician may pinch the area between the thumb and forefinger to further elicit surface changes. The skin tone should be assessed, as should the primary morphology of cellulite. The degree of cellulite may be quanti ed using one of multiple published grading or staging scales, none of which is uniformly preferred in the clinical or research setting.3-5 The patient’s weight and body mass index should be noted, and circumferential measurements obtained. Total body and close up clinical photographs, as well as three dimensional imaging if available, should be taken with the patient standing in a relaxed posture.6 Prior to treatment, consent for the procedure should be obtained after a thorough discussion of goals, expectations, tolerance for downtime, and an explanation of risks, bene ts, and alternatives with an opportunity to ask and answer any questions the patient may have.

Topical Treatment Options

Topical therapies for cellulite may transiently camouflage the rippled morphology by temporarily tightening the skin. The evidence is limited to small trials and case series with clinically unimpressive results.The primary topical therapies include retinoids and methylxanthines. Retinoids are known to increase neocollagenesis and are thought to decrease fat herniation by creating a thicker dermis.