A number of clinical conditions or circumstances frequently accompany or aggravate cellulite, especially obesity, localized fatty accumulations, and skin flaccidity.

Obesity promotes a generalized increase in body weight (skeletal, muscular, interstitial fluid, organ hypertrophy, etc.). After a return to the original baseline weight is achieved, an increased accumulation of fat is observable (36). The clinical manifestation of localized adiposity is an increase in the ill-defined symmetrical and bilateral diffuse volume, owing to an increase in the adipose tissue (29). The localized increase in adipose tissue in the subcutaneous tissue leads to the aggravation of cellulite lesions by contributing to a worsening of the irregular undulations of the skin. The increase in fat volume leads to an augmentation of tension forces within the fat lobules. This tension is projected to the skin surface and aggravates the depressions, causing an effect similar to that of a stuffed quilt (29). These alterations contribute to the appearance of the mechanical and circulatory alterations that occur in cellulite. Greater thickness of the subcutaneous fat in the affected areas may be seen by histopathological examination and can be measured by special instruments or by the pinch test (Fig. 9) (36).

Rosenbaum et al. described the exacerbation of cellulite with weight gain and its correlation with the body mass index (BMI). This study demonstrates the protrusion of adipose tissue into the dermis when the volume of subcutaneous fat is augmented, which explains the mattress-like appearance (31).

Flaccidity is caused by physiological ptosis of subcutaneous structures, making the skin permanently distended and loose. This condition frequently occurs in the buttocks,

Figure 8

Pinch test using a special device, the skinfold plicometry.

Thighs, the region above the knee, and the inner surface of the arms, regions where the skin probably has less retentive capacity and suffers the mechanical action of weight exerted by the adipose tissue and by the other subcutaneous structures (29). The weight of these structures increases the effect of gravity, causing alterations to the skin surface in these areas, which is seen as laxity and looseness (29). The reduced elasticity of the skin and sudden loss of weight (29) or subcutaneous fat due to liposuction (37) are conditions that can bring about or aggravate skin flaccidity.

Although it is of great importance, the presence of flaccidity or other aggravating conditions is usually not mentioned in present day classifications of cellulite. In the absence of flaccidity, a distension test in the antigravity direction tends not to diminish the lesions. In the presence of flaccidity, however, such a test can lead to a reduction or even disappearance of cellulite lesions (Fig. 10). The pinch test causes an increase in

Figure 9

Patient with cellulite secondary to flaccidity or loose skin. Alterations to the skin surface became more evident on pinching the skin.

Figure 10

The patient shown in Figure 9 showing improvement to the skin surface when stretching the skin in the direction opposite to forces of gravity.

Tension inside the lobes, and the cellulite becomes apparent as the lobes bulge and aggravate the traction of the septa in the pinched area (Fig. 11). Moreover, flaccidity has an effect similar to that of pinching by compressing the lobes and, thus, augmenting the tension within them. This situation is responsible for the emergence or worsening of cellulite lesions, especially after the fourth or fifth decade of life when the elastic properties of the skin diminish (38). This, together with the weight of the subcutaneous fat, determines the worsening of distension of the skin.

Other notable conditions that cause secondary cellulite or that aggravate cellulite are subcutaneous fibrosis caused by previous surgery, mainly liposuction, and the subcutaneous fibrosis and lipoatrophy originating from the trauma caused by injections in the affected areas. Alterations to the cutaneous surface resulting from liposuction usually appear late, from three months to one year after surgery. They may be slight, moderate, or severe, and always emerge in previously treated areas, such as the lateral and posterior thighs, buttocks, abdomen (Fig. 12), flanks, and the region above the knees. Like cellulite, the cutaneous sequelae from liposuction are predominantly depressed subcutaneous tissue, but raised and depressed areas may intercalate and vary in number and shape as a reflection of the number and variety of liposculpture cannula insertions, as well as the size and type of cannulas. Generally, they form larger depressions with bizarre shapes and do not necessarily follow the direction of the relaxed skin tension lines. Instead, they follow the direction of cannula insertion (Fig. 12).

The cutaneous surface alterations caused by previous injections (such as insulin injections in diabetics) occur in places where the injections are normally applied, that is, in the upper, outer quarter of the buttocks. They also vary in number and shape, and do not follow the force lines of the skin.

The presence of atrophic scars in the areas frequently affected by cellulite can also simulate or aggravate cellulite.

Many factors can cause cellulite, and other factors can make it worse. The classification in Table 2 is useful for generic diagnostic purposes, but is not appropriate for an accurate measure of the results of treatments, other than surgical treatment. To evaluate the results of other treatments, such as topical or systemic treatments, alternative objective and subjective measures are needed; these are presented in the appendix to this chapter in the form of a protocol used in our clinics.

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