Cellulite is the only word we have to describe the uneven pitted surface or dimpling of the skin commonly seen on the thighs of women. I am not sure who first coined the term but doubt it was first used by cosmetics manufacturers to describe this condition. It is common in women, rarely seen in men and begins at various ages depending on body type, genetic makeup, and other factors.

The outer skin is separated from the underlying muscle by a layer of fat. The fat has little strength therefore lying parallel to the skin throughout the fat layer is a sheet of connective tissue called superficial fascia. This fascia in turn is connected via finger like septal extensions through the fat to the overlying skin and underlying muscle. This architecture helps hold the fat together and keep the skin from falling down like a loose sock. In men the superficial fascia is much thicker than it is in women and the septal extensions are crosshatched lying oblique to the plane of the skin. In women the septal extensions are fewer and lie perpendicular to the skin surface. In some areas the distance between skin, superficial fascia and muscle is very small. Aging, smoking, dramatic weight changes (gain and loss) and the presence of an inherently weaker superficial fascia in women increase the possibility of the thigh and buttock skin sagging. The muscle layer can be toned up and the fat layer diminished by exercise and dieting but the fascial system once damaged cannot be rejuvenated. The skin also usually is incapable of shrinking once the fascial system is damaged. If cellulite were solely due to the amount of fat present under the skin then men and women with the equal amounts of thigh fat would show similar degrees of cellulite. This is clearly not the case. Even very obese men rarely have cellulite but cellulite can even be seen in slender women with good muscle tone who exercise regularly. Conversely dieting and/or exercise cannot completely erase any signs cellulite.

My feeling, although I can't prove it scientifically is that there are 3 possible causes for cellulite:

1. edema or swelling of the skin and fat due to increased water content
2. contraction of the muscle pulling the septal extensions or shortening of these septa resulting in pitting of the overlying skin
3. descent of the skin and fat envelope that normally occurs with aging resulting in skin pitting due to the pull of septa whose length is unchanged. This is more common in women who have an inherently weaker fascial support system to hold the skin up. This problem is aggravated by smoking and dramatic changes in weight (gain and loss).

There are also 3 levels of cellulite severity:

1. the skin has to be pinched in order to see surface dimpling
2. cellulite is only visible when standing
3. cellulite is visible when standing or sitting

Treatment of the first cause is straightforward - get rid of the water. The second cause is treated by surgical transection of the responsible septa. The third cause is most common and requires lifting of the skin and fat envelope i.e. a thigh buttock lift in severe cases. There is no difference in fat metabolism in areas of cellulite vs. areas without cellulite. Thus, aminophylline and other creams have no effect. Exercise will have little or no effect because it works on the underlying muscle, not the fascial support system. Fat removal by liposuction or weight loss can diminish the severity of cellulite skin dimpling but will not ameliorate the underlying fascial structural problem that creates it. It will not cure the problem. Unless there is very severe sagging I usually do not recommend a thigh buttock lift in younger women.

Endermologie whereby external suction and motorized massage are applied has been ok'd by the FDA for the temporary reduction in the appearance of cellulite. This may be due to the swelling induced by twice weekly treatments and then the requirement of maintenance treatments. There has been no evidence to date whether or not after a certain number of treatments you can stop and will have permanent reduction of cellulite.

Aaron Stone, MD is a board certified plastic surgeon and a graduate of Yale Medical School Dr. Stone has had a number of medical articles published in various scientific journals. He is in private practice in Los Angeles, CA. His office can be reached at (310)843-9021.