Cellulite Pathophysiology and Treatment, 2nd Edition (Basic and Clinical Dermatology) by Mitchel

Cellulite Pathophysiology and Treatment, 2nd Edition (Basic and Clinical Dermatology) by Mitchel Edited by Mitchel P. Goldman Doris Hexsel Cellulite PATHOPHYSIOLOGY AND TREATMENT Second edition Cellulite PATHOPHYSIOLOGY AND TREATMENT Second edition edited by Mitchel P Goldman, MD Volunteer Clinical Professor of Medicine/Dermatology University of California San Diego, California USA Doris Hexsel, MD Preceptor and Coordinator, Cosmetic Dermatology Department of Dermatology Pontificia Universidade Católica do Rio Grande do Sul Porto Alegre, Rio Grande do Sul Brazil Series Editor Alan R. Shalita, M.D. Distinguished Teaching Professor and Chairman Department of Dermatology SUNY Downstate Medical Center Brooklyn, New York Most recent titles 1. Cutaneous Investigation in Health and Disease: Noninvasive Methods and Instrumentation, edited by Jean-Luc Lévêque 2. Irritant Contact Dermatitis, edited by Edward M. Jackson and Ronald Goldner 3. Fundamentals of Dermatology: A Study Guide, edited by Franklin S. Glickman and Alan R. Shalita 4. Aging Skin: Properties and Functional Changes, edited by Jean-Luc Lévêque and Pierre G. Agache 5. Retinoids: Progress in Research and Clinical Applications, edited by Maria A. Livrea and Lester Packer 6. Clinical Photomedicine, edited by Henry W. Lim and Nicholas A. Soter 7. Cutaneous Antifungal Agents: Selected Compounds in Clinical Practice and Development, edited by John W. Rippon and Robert A. Fromtling 8. Oxidative Stress in Dermatology, edited by Jürgen Fuchs and Lester Packer 9. Connective Tissue Diseases of the Skin, edited by Charles M. Lapière and Thomas Krieg 10. Epidermal Growth Factors and Cytokines, edited by Thomas A. Luger and Thomas Schwarz 11. Skin Changes and Diseases in Pregnancy, edited by Marwali Harahap and Robert C. Wallach 12. Fungal Disease: Biology, Immunology, and Diagnosis, edited by Paul H. Jacobs and Lexie Nall 13. Immunomodulatory and Cytotoxic Agents in Dermatology, edited by Charles J. McDonald 14. Cutaneous Infection and Therapy, edited by Raza Aly, Karl R. Beutner, and Howard I. Maibach 15. Tissue Augmentation in Clinical Practice: Procedures and Techniques, edited by Arnold William Klein 16. Psoriasis: Third Edition, Revised and Expanded, edited by Henry H. Roenigk, Jr., and Howard I. Maibach 17. Surgical Techniques for Cutaneous Scar Revision, edited by Marwali Harahap 18. Drug Therapy in Dermatology, edited by Larry E. Millikan 19. Scarless Wound Healing, edited by Hari G. Garg and Michael T. Longaker 20. Cosmetic Surgery: An Interdisciplinary Approach, edited by Rhoda S. Narins 21. Topical Absorption of Dermatological Products, edited by Robert L. Bronaugh and Howard I. Maibach 22. Glycolic Acid Peels, edited by Ronald Moy, Debra Luftman, and Lenore S. Kakita 23. Innovative Techniques in Skin Surgery, edited by Marwali Harahap 24. Safe Liposuction and Fat Transfer, edited by Rhoda S. Narins 25. Pyschocutaneous Medicine, edited by John Y. M. Koo and Chai Sue Lee 26. Skin, Hair, and Nails: Structure and Function, edited by Bo Forslind and Magnus Lindberg 27. Itch: Basic Mechanisms and Therapy, edited by Gil Yosipovitch, Malcolm W. Greaves, Alan B. Fleischer, and Francis McGlone 28. Photoaging, edited by Darrell S. Rigel, Robert A. Weiss, Henry W. Lim, and Jeffrey S. Dover 29. Vitiligo: Problems and Solutions, edited by Torello Lotti and Jana Hercogova 30. Photodamaged Skin, edited by David J. Goldberg 31. Ambulatory Phlebectomy, Second Edition, edited by Mitchel P. Goldman, Mihael Georgiev, and Stefano Ricci 32. Cutaneous Lymphomas, edited by Gunter Burg and Werner Kempf 33. Wound Healing, edited by Anna Falabella and Robert Kirsner 34. Phototherapy and Photochemotherapy for Skin Disease, Third Edition, edited by Warwick L. Morison 35. Advanced Techniques in Dermatologic Surgery, edited by Mitchel P. Goldman and Robert A. Weiss 36. Tissue Augmentation in Clinical Practice, Second Edition, edited by Arnold W. Klein 37. Cellulite: Pathophysiology and Treatment, edited by Mitchel P. Goldman, Pier Antonio Bacci, Gustavo Leibaschoff, Doris Hexsel, and Fabrizio Angelini 38. Photodermatology, edited by Henry W. Lim, Herbert Hönigsmann, and John L. M. Hawk 39. Retinoids and Carotenoids in Dermatology, edited by Anders Vahlquist and Madeleine Duvic 40. Acne and Its Therapy, edited by Guy F. Webster and Anthony V. Rawlings 41. Hair and Scalp Diseases: Medical, Surgical, and Cosmetic Treatments, edited by Amy J. McMichael and Maria K. Hordinsky 42. Anesthesia and Analgesia in Dermatologic Surgery, edited by Marwali Harahap and Adel R. Abadir 43. Clinical Guide to Sunscreens and Photoprotection, edited by Henry W. Lim and Zoe Diana Draelos 44. Skin Moisturization, Second Edition, edited by Anthony V. Rawlings and James J. Leyden 45. Cellulite, Second Edition, edited by Mitchel P. Goldman and Doris Hexsel Series introduction vi Preface vii List of contributors viii 1. Social Impact of Cellulite and Its Impact on Quality of Life 1 Doris Hexsel, Camile Luisa Hexsel, and Magda B Weber 2. Psychological Impact of Cellulite on the Affected Patients 5 Cristiano Brum 3. Anatomy of Cellulite and the Interstitial Matrix 8 Pier Antonio Bacci 4. Definition, Clinical Aspects, Classifications, and Diagnostic Techniques 13 Doris Hexsel, Taciana de Oliveira Dal’Forno, and Rosemarie Mazzuco 5. Cellulite Pathophysiology 24 Zoe Diana Draelos 6. Diagnostic Techniques 27 Molly Wanner and Mathew Avram 7. Cellulite-Associated Clinical Conditions of Aesthetic Interest 33 Rosemarie Mazzuco and Taciana de Oliveira Dal’Forno 8. Medical Therapy 43 Fabrizio Angelini, Carmine Orlandi, Pietro Di Fiore, Luca Gatteschi, Mirko Guerra, Fulvio Marzatico, Massimo Rapetti, and Attilio Speciani 9. Topical Management of Cellulite 62 Doris Hexsel, Débora Zechmeister do Prado, and Mitchel P Goldman 10. Golden Lift“ in the Management of Cellulite: A New Member from the Golden Peel“ Family 69 José Enrique Hernández-Pérez, Mauricio Hernández-Pérez, and Enrique Hernández-Pérez 11. Injection Lipolysis for Body Sculpting and Cellulite Reduction 74 Martin Braun 12. No-Needle Mesotherapy 86 Gustavo Leibaschoff 13. Endermologie–LPG Systems“ after 15 Years 91 Pier Antonio Bacci 14. The Use of the Tri-ActiveTM in the Treatment of Cellulite 99 Mitchel P Goldman 15. VelaSmooth and VelaShape 108 Neil S Sadick 16. Accent“ Unipolar Radiofrequency 115 Jane Unaeze and David J Goldberg 17. Scientific Bases for the Use of Low-Level Light Energy on the Treatment of Cellulite 120 Gordon H Sasaki 18. SmoothShapes“ Treatment of Cellulite and Thigh Circumference Reduction: When Less Is More 126 Michail M Pankratov and Serge Mordon 19. High Frequency Ultrasound Evaluation of Cellulite Treated with the 1064 nm Nd:YAG Laser 136 Régine Bousquet-Rouaud, Marie Bazan, Jean Chaintreuil, and Agustina Vila Echague 20. Dermoelectroporation and Biodermogenesi“ 145 Pier Antonio Bacci 21. Carboxitherapy 151 Gustavo Leibaschoff 22. TriPollarTM Radiofrequency 158 Woraphong Manuskiatti 23. CryolipolysisTM for Subcutaneous Fat Layer Reduction 168 Mathew Avram 24. Subcision“ 174 Doris Hexsel, Rosemarie Mazzuco, and Mariana Soirefmann 25. Surgical Treatment: Liposuction, Liposculpture, and Lipoplasty 180 Gustavo Leibaschoff 26. Study Protocols in Cellulite 191 Débora Zechmeister do Prado, Amanda Stapenhorst, and Marie-Laurence Abella 27. Digital Photography and Other Imaging Techniques in Cellulite 195 Ana Beatris Rossi, Alex Nkengne, and Christiane Bertin Index 203 Series introduction Over the past twenty-one years we have edited a series of forty-five volumes relating to the art and science of dermatology. The series has been purposefully broad in content to attract the interest of a large variety of readers, from clinicians to basic scientists, affiliated with universities, industry, and in private practice. The past decade has seen an explosion in interest in aesthetic dermatology. Significant advances have been made in cos- metic science and in new instrumentation for the treatment of aesthetic problems. Thus, a new focus has developed on the science of skin care both from the point of view of the practitioner as well as industry. The latest addition to this series, Cellulite: Pathophysiology and Treatment, is the second edition of this popular work and demonstrates that the need for new information is compelling. The authors, Drs Mitchel Goldman and Doris Hexsel, not only are distinguished authorities in the field in their own right, but also have assembled a coterie of other distinguished contribu- tors. We trust that this volume will again be of broad interest to scientists and clinicians alike. ALAN R. SHALITA, M.D., Sc.D(hon) Distinguished Teaching Professor and Chairman Department of Dermatology SUNY Downstate Medical Center Brooklyn, NY, U.S.A. Preface Artists in painting and sculpture over the last two millennia have perceived beauty in a woman’s figure as consisting in few muscles and a thick layer of subcutaneous fat. However, within the last four decades, there has been a radical change in per- ception, with today’s society defining the ideal female body as youthful and almost pre-pubertal; well-defined musculature with very little body fat is now the ideal. This recent definition of beauty has led to the development of a new medical “disease,” cellulite. Cellulite can best be described as a normal physiologic state in post-adolescent women whose purpose is to maximize adipose retention to ensure adequate caloric availability for pregnancy and lactation. Almost all women who are not cachectic have cellulite. The topic of cellulite appears every month on multiple televi- sion medical and talk shows, as well as in the lay public women’s health magazines (which often show the cellulite in various female celebrities caught wearing a bathing suit, without the benefit of the air brushing that their publicity photographs undergo). Demand for the treatment of cellulite has become extremely popular: “90% of women have cellulite and the other 10% think they do.” Sales of various topical therapies constitute a multimillion-dollar business; it is estimated that the sales of cellulite equipment is over 30 million dollars each year. It is therefore time for a comprehensive textbook on the pathophysiology and treatment of cellulite. This subject is not taught in medical schools nor in residency training programs and there are few medical publications in the English language on this subject. As patients go to their physicians (mostly cosmetic and plastic surgeons and dermatologists) to seek advice on the pathophysiology and treatment of cellulite, physicians will need to educate themselves on this subject. To this end, we have enlisted the enthusiastic support of some of the world's leaders in cellulite research. These respected profes- sors and clinicians from the USA, Brazil, France, Italy, Argentina, Canada, Thailand and El Salvador are recognized as leaders on this subject. They have published numerous scientific papers on this subject in both their native languages and English. Our role as editors of this work, in addition to contributing separate chapters on our own unique research, is to ensure that this second edi- tion of Cellulite is complete and up to date. We look forward to this textbook stimulating further research eventuating improved treatment of this cosmetically important condition. Mitchel P Goldman Doris Hexsel List of contributors Marie-Laurence Abella L’Oréal Recherche, Chevilly-Larue, France Fabrizio Angelini Department of Endocrinology, University of Parma, Parma, Italy Mathew Avram Department of Dermatology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachu- setts, USA Pier Antonio Bacci University of Siena, and Cosmetic Patholo- gies Center, Arezzo, Italy Marie Bazan Candela Corporation, Wayland, Massachusetts, USA Christiane Bertin Johnson & Johnson Group of Consumer Companies, Paris, France Régine Bousquet-Rouaud Dermatological Laser Unit, Millen- nium Clinic, Montpellier, France Martin Braun Vancouver Laser and Skin Care Centre, Van- couver, British Columbia, Canada Cristiano Brum Brazilian Center for Studies in Dermatology and Santa Casa Hospital Complex, Porto Alegre, Rio Grande do Sul, Brazil Jean Chaintreuil Candela Corporation, Wayland, Massachu- setts, USA Taciana de Oliveira Dal’Forno Brazilian Center for Studies in Dermatology, Porto Alegre, Rio Grande do Sul, Brazil Zoe Diana Draelos Department of Dermatology, Wake Forest University School of Medicine, Winston-Salem, North Caro- lina and Dermatology Consulting Services, High Point, North Carolina, USA Agustina Vila Echague Candela Corporation, Wayland, Massachusetts, USA Pietro Di Fiore Sports Medicine and Nutrition, Center for Pre- vention and Cure of Obesity, Palermo, Italy Luca Gatteschi Sports Medicine Clinic, Florence, Italy David J Goldberg Skin Laser Specialists of NY/NJ, and Mount Sinai School of Medicine, New York, New York, USA Mitchel P Goldman Department of Dermatology, University of California, San Diego, California, USA Mirko Guerra La Cittadella Socio Sanitaria di Cavarzere, Cavarzere, Italy Enrique Hernández-Pérez Center for Dermatology and Cosmetic Surgery, San Salvador, El Salvador José Enrique Hernández-Pérez Center for Dermatology and Cosmetic Surgery, San Salvador, El Salvador Mauricio Hernández-Pérez Center for Dermatology and Cosmetic Surgery, San Salvador, El Salvador Camile Luisa Hexsel Department of Dermatology, Henry Ford Hospital, Detroit, Michigan, USA Doris Hexsel Department of Dermatology, Pontificia Universi- dade Católica do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil Gustavo Leibaschoff University of Buenos Aires School of Medicine, and International Union of Lipolasty, Buenos Aires, Argentina Woraphong Manuskiatti Department of Dermatology, Siriraj Hospital, Mahidol University, Bangkok, Thailand Fulvio Marzatico Laboratory of Pharmacobiochemistry, Health Nutriceutical and Nutrition Research, University of Pavia, Pavia, Italy Rosemarie Mazzuco Brazilian Center for Studies in Dermato- logy, Porto Alegre, Rio Grande do Sul, Brazil Serge Mordon INSERM, Lille University Hospital, Lille, France Alex Nkengne Johnson & Johnson Group of Consumer Com- panies, Paris, France Carmine Orlandi Istituto di Ricerche Cliniche Ecomedica, Empoli, Italy Michail M Pankratov Eleme Medical, Inc., Merrimack, New Hampshire, USA Débora Zechmeister do Prado Brazilian Center for Studies in Dermatology, Porto Alegre, Rio Grande do Sul, Brazil Massimo Rapetti Istituto di Ricerche Cliniche Ecomedica, Empoli, Italy Ana Beatris Rossi Research and Development, Johnson & Johnson Group of Consumer Companies, Paris, France Neil S Sadick Department of Dermatology, Weill Medical College of Cornell University and Sadick Dermatology, New York, New York, USA Gordon H Sasaki Sasaki Advanced Aesthetic Medical Center, Pasadena, California and Linda Loma University Medical Center, Linda Loma, California, USA Mariana Soirefmann Brazilian Center for Studies in Derma- tology, Porto Alegre, Rio Grande do Sul, Brazil Attilio Speciani Eurosalus, Milan, Italy Amanda Stapenhorst Brazilian Center for Studies in Derma- tology, Porto Alegre, Rio Grande do Sul, Brazil Jane Unaeze Albert Einstein College of Medicine, New York, New York, USA Molly Wanner Department of Dermatology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachu- setts, USA Magda B Weber Department of Dermatology, Federal University of Health Science, Porto Alegre, Rio Grande do Sul, Brazil 1 Social Impact of Cellulite and Its Impact on Quality of Life Doris Hexsel, Camile Luisa Hexsel, and Magda B Weber Introduction Almost all women have or believe they have cellulite. As it is more common to expose the body in certain cultures and in sunny coun- tries such as Brazil, cellulite is of great concern to many women and also represents a problem of great social impact. In today’s globalized culture, physical well-being, including care taken with appearance, is highly valued. From this perspec- tive, it is very important to evaluate the impact on quality of life (QoL) of such cosmetic problems as cellulite, wrinkles and aging. The fact that these have an impact on the QoL is indirectly shown by the growing interest in the investigation and treatment of these problems, which until recently were considered to be of minor significance. New studies involving QoL will benefit all those who suffer to a greater or lesser degree from these problems, and will be of great value in assessing the need for new scientific research into the treatment of these problems. Medical treatments traditionally focused on quantitative fac- tors, such as the reduction of morbidity and mortality and the assessment of treatment safety and social markers of health. Qualitative factors, such as patients’ perceptions of well-being and capacity to perform activities of daily life were not a primary aim. In recent decades, however, the measurement of patient’s quality of life and the evaluation of different treatments have been the focus of growing attention. Sarwer et al. published a review of the literature that focused on psychological and social-cultural aspects, their relation to phys- ical appearance, and their influence on the decision to undergo cosmetic treatments [1]. Their study revealed that in the 37 dif- ferent cultures studied, men and women gave greater priority to sexual attraction in the choice of partners than to aspects of personality such as independence, emotional stability and maturity [1]. Dermatological diseases and cosmetic problems significantly affect self-esteem. As the symptoms are visible, the discomfort and psycho-emotional effects are frequently more serious than the physical alterations caused by the disease. Thus, it becomes very important to assess and quantify the emotional and social parameters in these patients, in order to understand the disruption that the problem causes in various daily activities. This will facilitate the follow-up and treatment evaluation, and consequently allow for improvements in the QoL of the patients. The great importance given to QoL evaluation in clinical inves- tigation and patient care has led to the development of ques- tionnaires designed for the collection of information from the patients on the impact of the disease on their everyday lives. This knowledge allows the medical professional to better observe how the disease affects the patients physically, psychologically, and socially, and facilitates the evaluation of the effects on the lives of the patients. In the case of cellulite, the reasons that lead the patient to seek treatment are generally social and, sometimes, also emotional. These may include the embarrassment caused by cellulite in social, affective, and sexual relations as well as the avoidance of normal everyday activities such as visiting a swimming pool or beach, practicing sports or exposing the body during intimacy. A number of studies have been published that deal with QoL and recognize the value of specific questionnaires for dermatolog- ical diseases such as psoriasis, acne, melasma, atopic dermatitis, hyperhidrosis, and alopecia among others [2–9]. These studies have revealed the existence of similar facets related to QoL in patients from various countries [10] and point to the discomfort and the psycho-emotional effect on the patients. However, in gen- eral, little research has been done on the psychological, environ- mental, and social aspects of dermatological diseases. Moreover, to date, no study on the QoL of those afflicted by cellulite has been published. Patients suffering from skin diseases should not be treated merely for the physical harm caused by the disease [10]. The skin is the most external and apparent organ, and skin contact contrib- utes to the formation and structure of the personality. Aspects of Cellulite Related to Qol Cellulite is a clinical and aesthetic condition affecting most women. It may appear in preadolescence, adolescence, or adult- hood. With cellulite, the connective tissue and adipose tissue undergo alterations, resulting in blood and lymphatic altera- tions [11]. Clinically, cellulite is characterized by alterations to the cutaneous surface, especially on the buttocks and thighs, giving the skin an orange peel or mattress appearance [12,13]. Clini- cally, cellulite is classified into degrees that range from 0 to III according to the clinical characteristics [14]. As well as classifying the cellulite, it is suggested that associated factors such as obesity [measured by the body mass index (BMI)] and degree of flaccidity (classified as light, moderate, or severe) be characterized. Our clinical experience has shown that cellulite is a problem that has an impact on the QoL of both younger and more mature women, though the impact is greater in younger women. It also seems that cellulite is more frequent nowadays than many years ago. We report here on a clinical study carried out in 62 female patients, aged between 18 and 45 years (average age 32) with BMIs between 18 and 25 (average 21.8), having various degrees of cellulite on the buttocks and thighs. Over a period of two months, these patients received mechanical treatment in both legs and topical treatment in only one randomly chosen leg. The degree of cellulite in each patient was evaluated before and at the end of the treatment and attributed a classifica- tion between 0 and III, according to the clinical appearance of the cellulite. No patients included in this study had a cellulite classification of 0. These patients also answered a non-validated questionnaire created by the authors at the beginning and end of the treatment. This questionnaire evaluated patients’ self-esteem and highlighted CELLULITE: PATHOPHYSIOLOGY AND TREATMENT, SECOND EDITION changes in the behavior of patients with cellulite such as avoiding wearing tight or small clothing; feeling embarrassed when frequenting swimming pools or at the beach, etc. The impact of cellulite in relation to age group was also evaluated, together with factors that patients believe may influence the cellulite, such as inheritance, diet, and physical activity, as well as the treatment performed and self-perception of the severity of their cellulite. A survey of the answers given to the questions permitted an assessment of: 1. patients’ impressions of the problem of cellulite; 2. the everyday situations that result in restrictions or embar- rassment for patients with cellulite; and 3. the impact of treatment on patients’ QoL. Some factors, in the opinion of the patient, may influence cellulite. When questioned regarding diet, 65% of patients believed that there is a relationship between cellulite and diet. For 60% of the patients interviewed, a specific diet can help with cellulite. Along the same lines, 90% of patients believed that practicing physical exercise is an efficient treatment for cellulite and may, in isolation, moderately reduce cellulite. Cellulite was perceived before 20 years of age by 65% of patients. With regard to family inheritance, 80% of patients reported having first- or second-degree relatives with cellulite. Because it is a clinically diagnosed and easily recognizable problem, this information is highly indicative of the presence of positive family cases, bearing in mind that the great majority of patients reported a family member of the first degree, mother or daughter, as having the same problem. Regarding the restrictions caused by cellulite, when ques- tioned in a generalized way about the degree to which cellulite hampered their lives with the options of “not at all (1),” “a little (2),” “moderately (3),” or “greatly (4),” it was found that 70% of the interviewed patients considered that cellulite hampered their lives greatly. Regarding specific daily situations, it was noted that those suffering from cellulite experience some day-to-day restric- tions. Each situation was evaluated by the patient and attributed a value from 1 to 5, in which “1” was given to situations in which having cellulite had no effect, “2” to little effect, “3” to a mod- erate effect, “4” to a significant effect, and “5” to a very significant effect. The situations included wearing a bikini and tight clothing, sexual activity, practicing sports, and crossing the legs and sitting, which indicate the great social impact caused by cellulite. Keep in mind that, in all the situations presented and even after treatment, having cellulite influences to a moderate or significant degree the daily lives of the patients. We notice that the treatment, even though it might not be 100% effective for the problem, may modify the behavior of cellulite patients. The results obtained from the studied sample reveal that the presence of cellulite after treat- ment interferes less in certain activities when the responses from before and after treatment are compared. This reduction is most evident in the item “sexual life” when the total sample is exam- ined: 21.9% of the patients mentioned that cellulite had great or very significant influence on their sexual life before treatment and, although the treatment may not have led to a marked improve- ment in the cellulite, only 8.3% of the patients gave the same response following treatment. The sitting position, a position that supposedly makes the cellulite more apparent, reveals that before treatment, 48.9% of the patients interviewed considered the influ- ence very significant, while after treatment this percentage fell to 15.1%. With regard to the embarrassment caused by the pres- ence of cellulite in the practice of sports, the answers both before and after treatment were very similar. The results suggest that, for women, exposing the body during sport is not as embarrassing as in other situations, as for example during sexual relations. According to Jorge [10], the psychological impact and in inter- personal relations, respectively, is more prejudicial for women than for men. Studies that evaluated patients with dermatosis, carried out in Sweden and Norway, suggest that those at risk of the greatest harm are females who are young and in whom that disease exists over an extended period of time [10]. As cellulite appears basically in women, this condition should be investigated in terms of its impact in QoL. A study by Harlow et al, that evaluated the impact on quality of life of dermatological diseases during primary attention, noted the differences between men and women in relation to the various forms of constraints caused by the diseases from which they suffered [15]. Ten (10) attributes were evaluated: physical symptoms, feelings, daily routine, clothing, social and leisure, sport and exercise, work and study, personal relations, sexual relations and treatment. Of these, only in the question related to the degree to which the condition affected the prac- tice of sports and exercise was the score given by males higher than that given by women [15]. This shows that the practice of sport may have greater significance in the male group than in the female. We also checked the impact of treatment on the QoL of patients with cellulite. Each patient attributed a value from 0 to 9, with 0 representing very low self-esteem in relation to the fact of having cellulite, and 9 representing very high self-esteem. The clinical evaluation considered the improvement on the left and right sides, which were treated differently. Even without any improve- ment in the degree of cellulite noted by the examiner, there was an increase in self-esteem (evaluated from 0 to 9) after treatment. This improvement can be seen in the difference in the percentage of scores found from before and after treatment. This shows that the treatment did have a positive effect on the self-esteem of the patients, indicating that the simple fact of treating the cellulite and caring for themselves, even in the absence of any clinical improve- ment, influenced the well-being of the patients, who described themselves as better and more confident following the treatment. It may suggest that treatments should be tried, even if there is no cure for this condition. In 2008, the authors conducted a new clinical trial with the aim to build a specific questionnaire on the QoL for cellulite patients. Fifty patients were included responding to a qualita- tive survey to evaluate the main spontaneous complaints of patients seen because of cellulite and the effect of cellulite on their quality of life. An open question was asked about the main complaint: “We are trying to find out how much the fact of having cellulite affects the life of female patients. We would appreciate your cooperation, but your participation is totally voluntary and not compulsory. Could you please describe in what ways having cellulite has affected your life? You may include aspects of your professional and social life, personal relationships, leisure activities, SOCIAL IMpACT OF CeLLULITe AND ITS IMpACT ON QUALITy OF LIFe Table 1.1 Summarized version of CelluQOL questionnaire Not bothered at all Bothered most of the time No feelings either way Bothered most of the time Bothered all the time Skin apperance 1 2 3 4 5 Clothing manners 1 2 3 4 5 Feeding habits 1 2 3 4 5 Physical and leisure activities involving exposure of the body in public 1 2 3 4 5 Physical or recreational activities involving the restricted exposure of the body 1 2 3 4 5 Sexual life 1 2 3 4 5 Negative feelings 1 2 3 4 5 Disbelief about results of treatments 1 2 3 4 5 or any other situation. Although we need to know how old you are, no further personal identification is necessary.” The preliminary analysis of the questions answered by the volunteers showed factors and situations which are influenced by the pres- ence of cellulite [16]. These patients mentioned that they usually avoid wearing white colored and beach clothing and prefer to wear black (90%); dislike walking on the beach without wearing beach jackets (56%), this is because they prefer to hide their cellulite; they also feel bothered and constrained by the presence of cellulite (38%); they are afraid about their partners noticing their condition (36%) and also have feelings of low self-esteem (20%). From the preliminary answers, it was possible to estab- lish the main domains that affect the QoL due to the presence of cellulite: clothing choices, leisure habits, physical activities, relationships with partners, personal feelings about themselves, and daily habits [16]. The second part of the same study mentioned above involved 100 patients and aimed to create and validate a new instrument of Quality of Life on Celluite, called CelluQOL. The authors created two versions of CelluQOL, based on the domains revealed in the first part of the study, one complete and the other summarized (Table 1.1). All patients responded to both questionnaires which were compared and validated. The complete data of this study are in process of statistical evaluation and will be published soon. However, the data collected and pre-analyzed from this study suggests that a QoL questionnaire for patients presenting cellulite may be useful in clinical practice [16]. Conclusion Thorough QoL evaluations will be necessary to evaluate not only the importance given to the problem of “cellulite”, but also the need to develop new treatments for cellulite [17]. It is interesting to note that, even without techniques that can guarantee significant improvement of cellulite in its different degrees, cosmetic patients want alternatives and their emotional improvement is not directly related to the clinical improvement. Care and attention to cosmetic problems can lead to improvement in the emotional state of the patients. Cellulite has a real impact on the QoL of patients, as it restricts those that suffer from the condition in everyday situations and activities. This causes damage in the psychological area in inter- personal relationships, as also occurs with other conditions that afflict the skin. Patient complaints should be evaluated objectively regardless of whether defects are visible and pertinent or just imaginary, or even if the patient’s concerns seem to be out of proportion with reality. As it is a very sensitive issue, techniques used for esthetic procedures should be improved, and their performance should lead to minimal side effects, faster recovery and greater safety. However, esthetic procedures may not be enough to deal with complaints that may in fact mask fears, anxiety and fantasies, and a full evaluation may be necessary to improve and preserve the doctor-patient relationship. Finding out what aspects in each domain concern patients and measuring their possible impact may help to make decisions about what type of treatment should be prescribed for any specific patient. Also, the development of instruments to measure the QoL of patients presenting aesthetic complaints is an innovative and challenging area to be studied. The measurement of the aspects in each domain that concern patients may help to make decisions about more effective ways to treat specific patients. REFERENCES 1. DB Sarwer, L Magge, V Clark. Physical appearance and cos- metic medical treatments: physiological and socio-cultural influences. Journal of Cosmetic Dermatology 2:29–39, 2003. 2. R Balkrishan, AJ McMichael, FT Camacho, F Saltzberg et al. Development and validation of a health-releated quality of life with for women with melasma. Br J Dermatol 149(3):572–7, 2003. 3. SP McKenna, AS Cook, D Whalley, LC Doward et al. Devel- opment of the PSORIQoL, a psoriasis-specific measure of quality of life designed for use in clinical practice and trials. Dr J Dermatol 149(2):323–31, 2003. 4. R Skoet, R Zachariae, T Agner. Contact dermatitis and quality of life: a structured review of the literature. Br J Dermatol 149:452–56, 2003. 5. LHF Arruda, S Ypiranga. Qualidade de vida em hiperidrose. In: AT Almeida, D Hexsel. Hiperidrose e Qualidade de Vida. Edição das autoras. São Paulo; 2003: 73–76. 6. AY Finalay, GK Khan. Dermatology life quality index (DLQI) – a simple pratical measure for routine clinical use. Clin Exp Dermatol 19:210–16, 1994. 7. S Shimidt, TW Fischer, MM Chren et al. Stratategies of coping and quality of life in women with alopecia. Br J Dermatol 144:1038–43, 2001. 3 CELLULITE: PATHOPHYSIOLOGY AND TREATMENT, SECOND EDITION 8. C Swartling, H Naver, M Lindberg. Botulinum A toxin improves life quality in severe primancy focal hiperhidrosis. European Journal of Neurology 8:247–52, 2001. 9. E Mallon, JN Newton, A Klassen et al. The quality of life in acne: a comparison with general medical conditions using generic questionnaires. Br J Dermatol 140:672–76, 1999. 10. HZ Jorge. Avaliação de Qualidade de Vida em Pacientes com Dermatoses: Estudo De Adaptação e Validação da Der- matology Life Quality Index: (DLQI) para uma amostra Sul-Brasileira. Tese de Mestrado, Faculdade de Psicologia, Pontifícia Universidade Católica do Rio Grande do Sul 2004. 11. GW Lucasse, WLM Van-der-Sluys et al. The effectiveness of massage treatment on cellulite as monitored by ultrasound imaging. Skin Re Technol 3:154–60, 1997. 12. AM Segers, J Abulafia et al. Celulitis. Estudo histopatológico e histoquímico de 100 casos. Med Cut ILA 12:167–72, 1984. 13. C Scherwitz, O Braun-Falco. So-called cellulite. J Dermatol Surg Oncol 4(3):230–34, 1978. 14. D Hexsel, R Mazzuco. Subcision: a treatment for cellulite. Int J Dermatol 39:539–44, 2000. 15. D Harlow, T Poyner, AY Finlay, PJ Dykes. Impaired quality of adults with skin disease in primary care. Br J Dermatol 143:979–82, 2000. 16. D Hexsel, M Weber, ML Taborda, JF Souza. Preliminary results of the elaboration of a new instrument to evaluate quality of life in patients with cellulite: CelluQOL. JAAD Poster Abstracts 3(60):P1192, 2009. 17. KG Bergstrom, K Arambula, AB Kimball. Medication formulation affects quality of life: a randomized single-blind study of clobetasol propionate foam 0.05% compared with a combined program of clobetasol cream 0.05% and solution 0.05% for the treatment of psoriasis. Cutis 72(5):407–11, 2003. 2 Psychological Impact of Cellulite on the Affected Patients Cristiano Brum New cellulite research is appearing in literature every day, including a new classification [1] system, new techniques and tools [2,3,4], with the aim of achieving better results and greater patient satisfaction. This process is a response to the explosion in popularity of other aesthetic treatments and it is mainly due to the safety of less-invasive procedures developed over the last two decades. As a result, these procedures received increased media attention and therefore more individuals were willing to undergo cosmetic treatments with the goal of enhancing their physical appearance [5] as well as increasing aspects of their quality of life, especially regarding body satisfaction and health [6]. Beauty is an attribute that has been desired by mankind since ancient times. Plato understood that beauty, good health and wealth acquired by honest means, are the most important wishes of every man [7]. Beauty inspired poets, painters, writers, and wars, as depicted in the Iliad, in which Homer describes the epic battles of the Trojan War caused by Paris’s abduction of Helen – said to be the most beautiful woman who ever lived – from her husband, King Menelaus. Beauty was also correlated to Darwin’s theory of evolution, in which physical signs of youth and health are the most reliable physical markers of fertility [8]. Beauty plays an important role in human relationships in a social setting. Koblenzer [9] mentions some studies that dem- onstrate real benefits from maintaining an appearance of youth- fulness and beauty during all stages of life. For example, “cute” babies receive more care-taking attention, nice-looking children are assumed by their teachers to be more intelligent, attractive adolescents are preferred as friends or dates, employers are more likely to hire applicants with nicer appearances, at higher salaries, whom they promote rapidly. Nowadays, one of the reasons for women’s dissatisfaction with their appearance is cellulite – a clinical condition that affects a significant number of women worldwide. It was noted that those suffering from cellulite, experience some day-to-day restrictions, including clothing choices, physical and sexual activity, among others. These problems suggest a great social impact of this con- dition on their lives [10]. There are no references in medical lit- erature about the psychological aspects of women that undergo cosmetic treatments for cellulite, except for the incipient studies regarding quality of life in this population [11]. To fill in this gap, the research group from the Brazilian Center for Studies in Dermatology (Porto Alegre, Brazil) collected new data from 30 healthy female volunteers, ranging in age from 20 to 45 years old. They answered a questionnaire focusing on the psychological aspects, symptoms of eating disorders, body image concerns, social functioning, previous psychotherapy and psychiatric problems, feelings related to their cellulite, social embarrassment, and cellulite treatment expectations [12]. Regarding the onset of cellulite, most of the patients (40%) mentioned the adolescent period, 33% their 20s, and the others varied situations, during weight loss and gain, after pregnancy, and after 40s were mentioned by 16.5%. It seems that early in life cellulite becomes a great concern for women [12]. Eighty-six percent of patients presenting cellulite stated that they notice cellulite in others. According to the patients’ opinions, they pay attention to the cellulite in other women to compare the severity (19%), to help them feel better about themselves because of the fact that they share the same condition with other women (15%), for both cited reasons (54%) and 12% for other reasons. When asked whether they thought men paid attention to their cellulite, 50% of women said yes, and the others said no [12]. When these patients stare in the mirror and see their cellulite, they experience diverse negative feelings, like anger, guilt, sadness, impotency, shame, discomfort and the desire to cover themselves. Among these feelings, the most frequently mentioned by this sample was frustration (26%). The volunteers also reported that they feel ashamed of their cellulite. For 67%, the feeling of shame is presented in only certain situations. In 30% of these patients, this feeling occurred more frequently, whereas only one woman denied feeling ashamed of her cellulite. Interestingly, the majority of patients (63.3%) mentioned that these negative feelings do not interfere in their daily activities. In 23.3%, these feelings have a positive impact on their self-care (health and appearance), and only 13.3% reported low self-esteem and isolation [12]. The leading cause for seeking cellulite treatments was personal motivation, reported by 63.3% of the patients. The second most common was media, responsible for 20%. Recommendations from partners, friends, or family also played an important role accounting for 13%. Overall, the volunteers believe that treating their cellulite will improve certain aspects of their lives, such as self-esteem and sociability [10]. Personal motivation is directly related to the inner world of each individual, their life story, parental support, self-esteem, for- mation process of their body image, and their personality traits. However, external influences are an important factor in the pur- suit of a perfect and attractive cellulite-free body. Some research shows that media significantly contributes to the creation of the thin body ideal, eating habits, altering moods, and satisfaction with their own body. Pinhas et al. [13] and colleagues examined changes in female university students’ mood states resulting from viewing pictures in fashion magazines of models who represent the thin ideal. The authors observed that viewing images of female fashion models had an immediate negative effect on women’s moods, represented by more depressed and angry states. Hawkins et al. [14] showed further aspects related to the exposure of women to thin-ideal magazine images, such as an increase in body dissatisfaction, negative mood states, eating disorder symptoms, and lowered self-esteem. In a recent study, participants were randomly divided in two groups, one of which watched a reality TV cosmetic surgery pro- gram, while the other watched a reality TV home improvement CELLULITE: PATHOPHYSIOLOGY AND TREATMENT, SECOND EDITION program. The authors concluded that among the participants, particularly those who had internalized the thin body-ideal and watched the cosmetic surgery program, reported greater percep- tions of media pressure to be thin [15]. Using functional neuroimaging in 18 healthy young women, Friederich et al. examined brain responses and levels of anxiety from images of slim-idealized bodies (active condition) and inte- rior designs (control condition) were measured. In active condi- tion, participants initiated their body shape processing network. The authors believe that brain networks associated with anxiety induced by self-comparison to slim images may be involved in the genesis of body dissatisfaction and hence with vulnerability to eating disorders [16]. In our study, bulimic symptoms were found in three patients, 10% of the sample. One volunteer reported she had a diagnosis of bulimia and was being treated by a psychiatrist [12]. The same pro- portion was described by Alagöz et al. [17] in research that investi- gated self-esteem, body imaging scale, and applied eating attitude scale tests in patients who had undergone cosmetic surgery. Another important finding from this study was the fact that twenty-one patients (70%) reported using weight-loss drugs, many volunteers taking more than one medication for this reason. Amphetamines were cited by four patients, eight volunteers took laxatives, three used diuretics, and eight received a prescription of sibutramine from their doctors [12]. This data suggests that many patients look for magic formulas to lose weight instead of adopting healthier lifestyles. Because these patients might be using such medications without knowing their possible side effects and the health threats, doctors should advise their patients about amphetamines’ adverse effects, such as paranoid delusions, hallucinations, anxiety disorders, mania, insomnia, irritability, chemical dependence and physical symptoms (hypertension, tachycardia, palpitation, mydrasis, bruxism, tremor and headache) [18]. The purchase and use of prescribed medications, without a prescription, is a very common practice in many countries world- wide, including Brazil. This is a major problem because the misuse of these medications can cause adverse effects, such as diuretics, resulting in hyponatremia, hyperkalemia, hypokalemia, increased levels of blood sugar and cholesterol, rash, joint disorders (gout), and menstrual irregularities. It is important to advise patients about misconceptions, as many women think diuretics help lose weight [19]. Laxatives are sometimes used by normal and bulimic women. This some improvement after the procedure, 16% have never done any treatment and 3% believe that there is no effective treatment for cellulite [12]. Crockett et al. [23] mentioned that patients who regularly watched one or more reality television show reported the fol- lowing: a greater influence from television and media to pursue cosmetic surgery; felt more knowledgeable about cosmetic sur- gery in general; and felt that plastic surgery reality television was more similar to real life than did non-frequent viewers. The results of this study suggest that many patients come to offices with unrealistic ideas and expectations regarding cosmetic pro- cedures. The evaluation of the psychological profile, expectations and knowledge about the technique may be helpful to improve the relationship between physicians and patients, especially when undergoing cosmetic procedures. Moreover, it is also important to manage their expectations, advise them about contraindications, possible side effects and complications, including limitations of each indicated procedure. Considering that patients usually do not inform doctors about their psychiatric problems if not asked, and that some psychiatric conditions do interfere with patient’s satisfaction, the psycho- logical history should be carefully evaluated. Certain psychiatric disorders, especially those interfering with the body image, seem to be more prevalent in cosmetic patients, and they may be con- sidered a contraindication to perform some cosmetic procedures [24]. Attention should be given to psychosis, eating disorders, body dimorphic disorder, depression, and anxiety [24,25]. In our research, 30% of the patients had a history of psychiatric disorders and previous psychotherapy. The main causes were depression, bulimia, anxiety, panic disorder, and psychological conflicts. None were diagnosed with body dimorphic disorder. It is important to mention that we learned that 77% of the patients would like to better evaluate their emotional symptoms and were open to this conversation. This emphasizes the impor- tance of the medical and psychological approach to cosmetic patients, especially those undergoing surgical procedures, to avoid patient and surgeon frustration and unexpected, negative outcomes. REFERENCES 1. D Hexsel, T Dal´Forno, CL Hexsel. A validated photo- numeric cellulite severity scale. J Eur Acad Dermatol Venereol (5):523–8, 2009. medication can cause fluid and electrolyte imbalances, steatorrhea, 2. K Altabas, V Altabas, MC Berković, VZ Rotkvić. From osteomalacia, diarrhea, and, cathartic colon. Although there is no evidence on the structural or functional impairment of enteric nerves or intestinal smooth muscle, nor colorectal cancer and other tumors, laxatives should be taken with caution [20]. When sibutramine is prescribed by doctors, patients should be aware of the side effects, which include drug intolerance, head- ache, insomnia, nausea, dry mouth, constipation, tachycardia, and hypertension-related events [21], as well as the case of patients with bipolar disorder, which could result in mania or mixed mood states [22]. Many patients want an “easy way” to lose weight. These patients also expect magic results from cellulite treatments. In our prelimi- nary research, 11 patients (37%) expect their cellulite to disappear with the treatment, another 37% are more realistic and expect Cellulite to smooth skin: Is Viagra the new dream cream? Med Hypotheses 73(1):118–9, 2009. 3. S Bielfeldt, P Buttgereit, M Brandt et al. Non-invasive evalua- tion techniques to quantify the efficacy of cosmetic anti-cellu- lite products. Skin Res Technol 14(3):336–46, Aug 2008. 4. A Goldman, RH Gotkin, DS Sarnoff et al. Cellulite: a new treatment approach combining subdermal Nd: YAG laser lipolysis and autologous fat transplantation. Aesthet Surg J 28(6):656–62, Nov-Dec 2008. 5. DB Sarwer, CE Crerand. Body image and cosmetic medical treatments. Body Image 1(1):99–111, 2004. 6. NA Papadopulos, L Kovacs, S Krammer et al. Quality of life following aesthetic plastic surgery: a prospective study. J Plast Reconstr Aesthet Surg 60(8):915–21, 2007. PsycHOLOgICAL IMpACT OF CeLLULITe oN THe AFFecTeD PATIeNTS