Cellulite Skin. What Should You Know?

The term cellulite refers to the 'orange peel,’ 'mattress,' or 'dimpling' appearance on the thighs, buttocks, and sometimes lower abdomen and upper parts of the arms of otherwise healthy women. Approximately 85% of post-pubertal woman has a form of cellulite. This appearance is much more common in women than in men because of differences in how fat, muscle, and connective tissue are distributed in men's and women's skin. Although rarely observed in men, those men presenting with cellulite are commonly deficient in male hormones. The lumpiness of cellulite is caused by fat deposits that push and distort the connective tissues beneath the skin, leading to characteristic changes in the appearance of the skin. The causes of cellulite are not well understood. Theories include genetics, circulatory problems, inflammation, hormonal disturbances, tight clothing, and lifestyle factors. Although being overweight is not a prerequisite for cellulite, excess body fat makes cellulite more visible. The aging process can worsen the appearance of cellulite, as skin loses elasticity and is less able to resist irregular tension created by the fibrous bands. Despite many treatments available—all of which claim to work somehow—few do work, and many works with unpredictable results. The new minimally invasive techniques of power liposuction (without suction) and fat transfer are rewarding to achieve acceptable results.

What is Cellulite (dimpled skin)?

The causes of cellulite are not well understood. Theories include genetics, circulatory problems, inflammation, hormonal disturbances, tight clothing, and lifestyle factors. Although being overweight is not a prerequisite for cellulite, excess body fat makes cellulite more visible.

Cellulite forms when fibrous bands called “septae,” which connect the skin to the underlying muscle fascia, tighten irregularly, pull down on the skin, and break down, allowing the standard layer of fat beneath the skin to push up. This results in the puckering or “cottage cheese” appearance.

An estimated 85 to 90% of adult women have cellulite, typically on the abdomen, buttocks, and thighs. While overweight people tend to have more pronounced cellulite, it is common even in very lean women, and losing weight rarely gets rid of cellulite altogether. The aging process can worsen the appearance of cellulite, as skin loses elasticity and is less able to resist irregular tension created by the fibrous bands.

What Are the Causes of Cellulite?

The causes are not well understood. Theories include genetics, circulatory problems, inflammation, hormonal disturbances, tight clothing, and lifestyle factors. Although being overweight is not a prerequisite for cellulite, excess body fat makes cellulite more visible. It forms when fibrous bands called “septae,” which connect the skin to the underlying muscle fascia, tighten irregularly, pull down on the skin, and break down, allowing the standard layer of fat beneath the skin to push up

.This results in the puckering or “cottage cheese” appearance. An estimated 85 to 90% of adult women have cellulite, typically on the abdomen, buttocks, and thighs. The aging process can worsen the appearance of cellulite, as skin loses elasticity and is less able to resist irregular tension created by the fibrous bands. While overweight people tend to have more pronounced cellulite, it is common even in very lean women, and losing weight rarely gets rid of cellulite altogether.

How Is Cellulite Happens?

A skin microanatomy review is needed to understand better how cellulite is formed. The outermost layer of skin is referred to as the epidermis. Immediately under this is the dermis (also called the corium), which is richly filled with hair follicles, sweat glands, blood vessels, nerve receptors, and connective tissue.


The next layer of tissue is the first of two subcutaneous layers (beneath the skin) of fat in this first region of subcutaneous fat (called the areolar layer with fat cell chambers (or lobules).  Fat cells in the subcutaneous layer are arranged in chambers surrounded by bands of connective tissue called septae. As the volume of fat cells increases, the surrounding septae contract and harden, unable to hold the cells within the existing limits.

This causes the fat cells to push against the skin surface, resulting in a dimpled skin appearance called the lumpy, ‘cottage-cheese’ effect. This structural alteration of subcutaneous fat protruding (or herniating) into the dermis gives skin the ‘bumpy’ appearance called cellulite. A second similar theory adds that cellulite results from a laxity (or weakening) in the dermis’s connective tissue bands that allow fat protrusions to occur.

Why is Cellulite Rarely Observed in Males?

Men and women have different connective tissue organizational structures in the first layer of subcutaneous fat. In women, the adipose tissue is contained in chamber-like structures that favor the expansion of fatty tissue into the dermis. Contrariwise, men have a network of crisscrossing connective tissue architecture, forming smaller polygonal units that allow subcutaneous fat deposits to expand laterally and internally, but with slight protrusion (if any) into the dermis.

Men also have thicker epidermis and dermis tissue layers in the thighs and buttocks than women. Variations in hormones between genders explain this skin structure deviation. It has been shown that men born deficient in male hormones will often have a subcutaneous fat cell appearance like women. Although cellulite can affect both sexes, it is much more common in women, mainly because they are more likely to have fat and connective tissue types.

Grading or Severity

  • Grade 1 sees no clinical symptoms, but a microscopic examination of cells from the area detects underlying anatomical changes.
  • Grade 2 requires the skin to show pallor (pastiness), be at a lower temperature, have decreased elasticity, and microscopic examinations to note anatomical changes.
  • Grade cellulite has visible skin roughness (like an orange peel) and all grade 2 signs.
  • Grade IV cellulite has the features of grade III plus more visible, palpable, dimpled, painful nodules with a wavy appearance at rest.

Am I a Good Candidate for Dimpled Skin Treatment?

If you are unhappy with dimpled skin and irregular appearance is bothersome treatment will be most effective if:

  • You are bothered by the effect cellulite has on your appearance and wish to reduce it
  • You are happy with your current body weight and not significantly overweight
  • You are in good overall health
  • You have realistic expectations—cellulite reduction treatments can cut dimpling but not end it.

What is Nonsurgical Treatment?

Cosmetic surgeons use a variety of treatments to help patients reduce skin dimples. While none are permanent, many can achieve results that last a year or longer. Below, we’ve outlined the most used treatment types and brand name applications—availability of these or any other treatment will vary depending on what cosmetic surgeons in your area offer.

Weight loss

Dimpled skin occurs in lean women and obese women and men. Weight gain, however, can accentuate the appearance of cellulite. Weight losses can have variable effects on cellulite grade.

It can improve or worsen the condition for some. On average, cellulite severity decreases following weight loss. This is especially true for affected individuals with a higher body mass index (BMI) and greater severity of cellulite grading. These individuals experienced an improvement in cellulite severity with significant weight loss.

Topical Treatment

The role of topical treatments in skin dimpling is troublesome. Although numerous topically applied creams are advertised as a treatment minimal data substantiates any of them. The initial challenge of any topical cream is that it must penetrate the skin and dermis to reach the target fat tissue before being absorbed by the tissue.

Most of these creams function to promote lipolysis of fat. Methylxanthines (e.g., caffeine, aminophylline, and theophylline) are agents that stimulate lipolysis. Methylxanthines show a modest decrease in thigh circumference and subcutaneous fat thickness but no cellulite reduction. Some topical cellulite creams use retinoids.

His hypothesis of retinoid treatment in cellulite site areas promotes dermis thickness. Retinoids are similar in chemical structure to Vitamin A, a well-known anti-aging ingredient in many facial creams. Some research suggests modest improvements in cellulite appearance with retinoid creams over a treatment period of 6 months.

The downside of topical treatments is their inability to appreciably penetrate the skin to render more than a superficial tissue effect. At the same time, others show no responsiveness to cellulite’s appearance. The good news is the usage of electroporation or iontophoresis as methods of advanced transdermal drug delivery system to enhance the transportation of active ingredients across the skin, enhancing its efficacy in treating cellulite.

Dietary Supplements

These products contain various ingredients such as ginkgo Biloba, sweet clover, grape-seed bioflavonoids, bladderwrack extract, evening primrose oil, fish oil, and soy lecithin. The claims positively affect the body by boosting metabolism, improving circulation, protecting against cell damage, and breaking down fats. Many claims are challenging to evaluate, as with similar assertions made on behalf of many supplements and alternative therapies.

Concepts such as “metabolism,” “circulation,” or “cell damage” cannot be easily measured on an objective basis to determine whether any improvement has been achieved. Additionally, because these products are sold as dietary supplements and not as drugs, they are not subject to the U.S. Food and Drug Administration (FDA) authority. They are exempt from meeting the scientific standards for safety and effectiveness applied to drugs. Furthermore, no valid clinical studies support using these dietary supplements to treat cellulite.

Massage and Tissue Manipulation

Massage and tissue manipulation techniques are employed to enhance the removal of accumulated fluid in the dermis area. It offers only a short-term minor reduction in the amount of dimpling. This is more related to the removal of excess fluid. Endermologie has been used for skin dimpling since the mid-1990s. This technique uses an electrically powered device that suctions, pulls, and squeezes affected areas. Treatments are expensive and typically last for 30-45 minutes, and 10-12 treatments are typically required before results are noticeable.

fat reduction-non-surgical-vacuum
fat reduction-non-surgical-vacuum

The basis for various massage/suction techniques used for skin dimpling rests on the premise that the condition is caused by impaired circulation. The U.S. FDA has approved Endermologie for the temporary reduction in the appearance of cellulite. While a temporary decrease in the appearance of cellulite may occur, the technique appears to redistribute fat rather than permanently alter its configuration under the skin. Regular maintenance treatments are required after the initial effect has been achieved or the appearance of cellulite will return.


Mesotherapy is also employed as a cosmetic treatment for fat reduction and cellulite treatment using injectable medications and homeopathic substances (such as vitamins, minerals, amino acids, and enzymes) into a cellulite site in the body. The ingredient most consistently used in mesotherapy is phosphatidylcholine. Although data does exist that mesotherapy does induce lipolysis and slightly improves the appearance of cellulite.

However, this therapy is discouraged due to the lack of a precise treatment protocol and the risk of adverse effects (including swelling, infection, and irregular contours). The Brazilian National Agency of Health banned mesotherapy in 2003 due to its undesirable effects.

2005 report in the Journal of Cosmetic and Laser Therapy stated that: “Patients considering mesotherapy for cellulite must be aware that the substances currently being injected to treat this cosmetically disturbing, but medically benign, condition have not been thoroughly evaluated for safety or efficacy.


Collagenase is a naturally occurring enzyme in the body that breaks down collagen, a component of connective tissue (the tissues that bind our cells together). The treatment is considered experimental and is not yet routinely available, but research is underway to determine if collagenase injections may become an option for cellulite treatment.

Cellulite diets

Special “cellulite diets” have a claimed to be effective in treating cellulite. Arguments for these diets claim that combining foods can reduce inflammation, improve circulation in affected areas, and diminish cellulite. However, no studies published in the medical literature have supported these claims. Experts note that eating a healthy diet can decrease fluid retention and improve the overall health and appearance of the skin, but specific diets designed to target cellulite are unnecessary.

Body Wraps

Many salons offer herbal or other types of body wraps as treatments for cellulite. Like cellulite diets, their effects have not been proven or reported in controlled studies in the medical literature. While wraps may decrease fluid retention and improve the skin’s overall appearance, these effects are temporary. It is also impossible to “detoxify” the body using herbal or other wraps.


Themotherapy is a heat application technique that promotes blood flow and vasodilation. No studies demonstrate any effectiveness with this treatment, and it may aggravate cellulite appearance.

Selective Cryolysis

Cryolysis is an exciting concept that might have future applications in reducing cellulite and localized adiposities. here is evidence that adipose tissue is selectively sensitive to cold injuries, such as “popsicle panniculitis.’ Theoretically, reducing the volume of herniated fatty tissue in the hypodermis in a selective, predictable, controlled, and safe manner might clinically improve cellulite.

In addition, increasing the dermal thickness can also potentially strengthen the dermo-hypodermal junction, thereby reducing fatty tissue herniation. Recently introduced non-invasive cryolysis might have promising results in reducing subcutaneous fat, at least temporarily. Its role in the treatment of cellulite adipose tissue remains to be explored.


Carboxytherapy was initially used for aesthetic purposes by Brazilians to sculpt residual post-liposuction fatty deposits above the knees. Histological studies showed that the fat cells were ruptured by CO2 gas while leaving the remaining skin structures and nerves unharmed. It also showed collagen remodeling and thickening and smoothing of the overlying skin.

Carboxytherapy is a treatment in which carbon dioxide is injected into the subcutaneous tissue. This treatment is purported to affect fat cells and circulation. The proposed mechanism may be related to a hypercapnia-induced rise in capillary blood flow, a drop in cutaneous oxygen consumption, or a right shift of the oxygen dissociation curve (Bohr effect).

Laser or light therapy

The FDA has approved two light-therapy devices that temporarily combine suction or massage with light therapy to reduce cellulite’s appearance. Reactive is a treatment that combines a low-level laser treatment with suction and manipulation of the skin, while VelaSmooth is a treatment combining laser and massage therapy.

fat reduction-non-surgical-laser
fat reduction-non-surgical-laser

The use of low-energy lasers has wound healing properties, affecting endothelial cells, erythrocytes, and collagen, which potentially aids in healing localized chronic inflammation, which is still believed to be one of the factors in the etiology of cellulite. A combination of RF and laser light may occur in enhanced localized fat metabolism, like in mesotherapy. Like Endermologie, both treatments require multiple treatment sessions and maintenance treatments to keep up the improved appearance.

The StarLux® IR delivers fractionated energy through the device’s handpiece, emitting light from 850 to 1350nm to the deep dermis, targeting water as the primary chromophore and its mechanism action and infrared absorption depth. The SkinTyte™ also utilizes light energy at 800 to 1400nm. Several treatments are required with this device for successful collagen remodeling to be achieved.

Radiofrequency (RF)

Radiofrequency current can be low or high frequency, depending on the emission settings of the RF generator. Radiofrequency is usually applied in a mono or bipolar manner. Both methods employ two electrodes: a delivery and a return electrode. In most “monopolar” RF systems, the delivery electrode is located over the target tissue, and the return electrode is attached at some distance.

The therapeutic effects of RF are electrothermal, created by the impedance or resistance of the tissue to the electricity flow through it. In “bipolar” RF, the two electrodes are incorporated in a single handpiece, with the current passing into and through the local tissue between electrodes. The depth of penetration of RF into the tissue is recognized as approximately one-half of the distance between the electrodes.

fat reduction-non-surgical-radiofrequency
fat reduction-non-surgical-radiofrequency

Electrothermal damage induces the wound healing process, leading to therapeutic effects—transparent coupling gel facilitates good electrical contact between the skin and the electrodes. Integrating RF into cellulite treatment affects the connective tissue septae and fat, which contribute to cellulite.

The current heating process causes the collagen proteins in connective tissue to denaturalize (changes occurring in the structure of proteins) and then ‘tighten’ as they regain their structural integrity as if it were like a wound healing.

Radiofrequency energy is used to treat tissue in both the fatty layer of skin near the surface and deeper layers. Radiofrequency energy heats the tissue in a controlled fashion, targeting fat cells while promoting the production of new collagen and increasing local circulation to aid in the drainage of fatty deposits. It reduced cellulite in 89.286% of the women who underwent RF treatment.

The treatment resulted in visually (and with ultrasound imagery) noticeable decreases in cellulite appearance six months following the treatment. It is also theorized that this treatment increases local blood flow and fat metabolism at the site. This pioneering technology looks promising for the treatment of cellulite.


Ultrasound used for body shaping can be divided into two broad categories: low-frequency non-thermal ultrasound and high-intensity focused ultrasound (HIFU). Ultrasound cellulite treatments use high-frequency and low-frequency sound waves to heat and melt away fat cells. On-thermal devices use low-frequency ultrasound to produce cavitation (with some minor heat generation through absorption).

Cavitation creates bubbles inside the cell, which swells and ruptures, creating mechanical stress that disrupts the fatty cell membrane and releases the stored triglyceride contents. The treatment is performed by applying a transducer to the skin surface above the target fat pocket and applying ultrasound in pulses to create repeated compressions and rarefactions in the tissue.

fat reduction-non-surgical-ultrasound-focus
fat reduction-non-surgical-ultrasound-focus

These rarefactions generate cavitation events, causing cell death through mechanical disruption. Ma sage typically accompanies these treatments, which might increase blood flow for faster elimination.

Ultra-Shape emits focused ultrasound waves to deliver concentrated energy into a focal volume at a precise depth in the subcutaneous tissue. This system used mechanical (non-thermal) energy to disrupt fat cells without damaging neighboring structures (skin, blood, lymph vessels, muscles, and nerves) due to their differential susceptibility to mechanical stresses induced by the ultrasound.

Ultrasound cellulite treatments typically require repeating every month or two because the human body continually stores fat. These treatments address cellulite that remains after diet and exercise in isolated spots on the body. Adhering to a low-fat diet and incorporating exercise into the daily routine after ultrasound cellulite treatments might stimulate collagen to keep skintight.

Therapists typically recommend plenty of fluids after treatments to help flush fatty deposits from the bloodstream. Although ultrasound can be a valuable adjunct to other treatments used for cellulite, its efficacy as the sole treatment lacks substantial evidence.

The LipoSonix system is achieved using the thermo-mechanical ablation of subcutaneous adipose tissue (SAT). Molecular vibrations and shear forces generated using HIFU raise local tissue temperature and produce rapid focal cell death by coagulative necrosis. With HIFU, heat intensity and depth of penetration are precisely controlled by adjusting wavelength and energy level. HIF can penetrate the skin and superficial tissue to reach precise levels within the deeper SAT without damaging the dermis or other collateral tissues.

The focused point protects the skin, nerves, blood vessels, or organs encountered before or beyond the focal point, as the ultrasound waves will not have enough energy here to create too much thermal damage. Heat sufficient to create the ablative effect on adipose tissue is only generated when the focused beams converge to ensure tissue lysis is confined to the treatment zone.   The cell debris of both methods of ultrasound treatment is then expected to be safely ingested by tissue macrophages initiated by the local inflammatory response.

A further clinical study must confirm no significant changes to serum lipid levels or undue stress to the liver and kidneys. The intensely focused ultrasound technology delivers profound dermal energy at tissue planes in the subdermal connective tissue and the superficial dermis to effect collagen contraction and remodeling. Howe er, it is not known whether ultrasound treatment effectively changes the architectural component of cellulite to cause lasting effects.

Shock Waves

Shock wave therapy is an energy pressure pulse of large amplitude followed by some small wave components. High energy shock waves are used therapeutically to treat kidney and urethral stones. The application of low-energy shock wave therapy on biological tissue is very recent. It is non-invasive, side effect free, and delivered in brief treatments.

Howe er, more research is needed to determine the appropriate regimes and equipment parameters that work most effectively for cellulite reduction. It has been hypothesized that shock wave therapy promotes a ‘remodeling’ of the collagen proteins in the connective tissue in the dermis. There is a loud audible sound with this treatment that may irritate some.

What are My Surgical Cellulite Treatment Options?

Liposuction is an argumentative intervention for the treatment of cellulite. Although there are subjective reports that it has improved the appearance, others have noted that it worsens the dimpled skin appearance. While liposuction can diminish fat deposits deep in the subcutaneous fat, its effect on the external components of fat, as seen in cellulite, is often disappointing. Skin necrosis from devascularization after extensive undermining is one of the major limiting factors.

Ultrasonic liposculpture may be a superior, potentially safer, and less destructive technique for cellulite reduction than traditional liposuction. At M I, ultrasound-power-assisted liposculpture may be offered for selected cases when patients undergo body contouring with cellulite in limited areas. Power liposuction cannulas produce much faster recovery times for patients who undergo tumescent liposuction.


It allows faster procedure times and cuts surgeon fatigue, resulting in safer and more precise surgery. The short-powered strokes can be used more precisely than the longer “to and fro” motion of manual liposuction. The device can also be used while holding the hand still to remove fat in difficult areas such as the periumbilical region.

Why do we treat cellulite from above the skin when the real problem lies beneath it? Ask Prof Moawad. After tumescent anesthesia is injected into the awakened patient’s target areas, Prof Moawad uses a unique power cannula that helps him to subcise the fibrous septa that dimple the skin’s surface precisely without suctioning fat.

The powered stroke precisely cuts these fibrous septa (subcise) underneath the skin. This ensures more remarkable fat survival and successful fat transfer afterward. At M I, the result is excellent in treating cellulite and smoothing out the skin by combining these two procedures. It is worth mentioning that this approach is offered to our patients as a standalone treatment or combined with liposuction or with monopolar radiofrequency skin tightening sessions afterward.


Subcision is a method in which a needle or, better, a special cannula is inserted into the cellulite site’s dermis (after injection of local anesthesia). The needle alters the connective tissue structure to improve the cellulite appearance. Subcision can temporarily improve the skin dimpling seen in cellulite-prone areas. It might seem reasonable that if the septae are responsible for the clinical appearance of cellulite, their sectioning should result in improvement in all affected people.

On the other hand, these fibrous strands’ sectioning might destabilize the dermo-hypodermal junction, thereby facilitating the adipose tissue herniation. The long-term efficacy of subcision remains controversial.

Cellfina is an FDA-cleared automated mechanical cellulite reduction treatment. It works by releasing tightened septae using a skinny blade inserted through a tiny incision. Unfortunately, no objective scientific assessment data is available with this technique.

Cellfina is indicated as the longest-lasting cellulite treatment, with results lasting up to 3 years. The s in is gently suctioned up into the Cellfina device, which allows the cosmetic surgeon to insert the blade only a few millimeters beneath the skin, minimizing the impact on surrounding tissues.

Local anesthesia is used. Minim l downtime is needed, and results are noticeable within a few days after treatment. Side effects include temporary soreness and mild bruising, with serious side effects rare when a qualified physician performs the treatment.

Subdermal Laser and Fat Transfer

I can use laser light in the range of far infrared to target fat selectively. Fat can be selectively coagulated or destroyed using ultrashort, high-peak-power laser pulses to generate a photoacoustic effect that disintegrates adipocyte membranes, discharging the cellular contents with minimal risk of tissue charging. The l ser also coagulates tissue to promote collagen tightening and hemostasis. The thermolysis of the laser will ablate fat tissue, which either syringe suction or peristaltic pump can then aspirate.

Although laser-assisted liposuction has gained tremendous interest among surgeons and dermatologists, its efficacy and superiority over traditional liposuction have been questioned. Of concern is the fact that thermal energy, when used for therapeutic purposes, always has the potential for and risk of scarring. Laser-assisted lipoplasty may be best suited for smaller surface areas.

Cellulaze’s Nd: YAG 1440 nm pulsed laser wavelength is applied sub-dermally via Cynosure’s proprietary fiber optic SideLaze3D™ to side-firing laser energy. The combination of pulsed subdermal Nd: YAG  1064nm laser energy and autologous fat transplantation was reported to treat cellulite. However, this technique was not compared with autologous fat transplantation alone or tumescent liposuction with autologous fat transplantation, which questions the validity of laser lipolysis for cellulite.

After injecting you with local anesthesia (read: you’re fully awake), the doctor threads a laser fiber through a pencil-lead-thin cannula and “snips” the septae, melts your fat pockets, and heats the skin from the inside out, which encourages collagen and elastin growth. The doctor turns it 90 degrees down to vaporize the fat. Finally, we turn it toward the surface, where the heat can thicken the skin.” (This is a good thing. However, there is no scientific evidence that collagen tightening will lead to the clinical elimination of cellulite.

Cellulite Treatment. Five Take Away Messages 

  • Improving diet and exercise is an excellent way to improve cellulite appearance. It has been shown that females who lose weight have a minor cellulite appearance. So, it would be best if you implemented a caloric-restricted diet plan combined with a comprehensive exercise (aerobic exercise and resistance training) program to reduce some of the underlying body fat.
  • Subcutaneous fat is layered on top of the muscle. Therefore, if the muscles in the hips, thighs, and buttocks are weak and flaccid, it will contribute to the ‘uneven’ view of the skin surface. Therefore, educate clients that a meaningful benefit of resistance training is minimizing the appearance of cellulite.
  • Prof Moawad advises his patients NOT to invest their hopes and monies in mesotherapy, skin kneading, manipulation techniques, thermotherapy, topical ointments, and herbals to improve their cellulite management.
  • Despite many treatments available—all of which claim to work somehow—few do work, and many works with unpredictable results.
  • Given cellulite’s complex and multifactorial etiology, devices that combine radiofrequency, infrared lasers, and suction with massage have recently gained popularity. Future treatment options for cellulite depend upon our understanding of the molecular basis and hormonal influences of cellulite adipose tissue.
  • The new minimally invasive techniques of power liposuction (without suction) and fat transfer are rewarding to achieve acceptable results, says Prof. Moawad.


Radiofrequency Skin Tightening & Fat Reduction Results (before and after)