CELLULITE

SCN: We commonly use the term "cellulite," but what does it really mean?

Doctor: The term "cellulite" refers to unsightly, puckered or dimpled skin on the backs and sides of the thighs and buttocks. The appearance has been likened to that of cottage cheese or to a "peau dèorange" (an orange peel).

Cellulite is largely seen in women, and current estimates suggest that more than 85 percent of women suffer from it. For this reason, perhaps, it should be viewed as a normal female developmental characteristic.

SCN: How does one develop cellulite?

Doctor: The exact causes of cellulite are still unknown. Under the microscope we find fat deposits and tissue swelling within the subcutaneous (fat layer) of the skin bound between tight, horizontal fibrous tissue bands. The upward swelling of the fatty tissue is responsible for the puckered appearance, and the downward pull of the fibers is responsible for the pitted look of the overlying skin.

Contrary to popular misconception, cellulite isn’t a matter of being excessively overweight, since it can be found in individuals of all body shapes and sizes. However, being overweight may worsen the appearance.

A predisposition for the development of cellulite does run in families, and it’s also more common in Caucasians. While it can manifest as early as adolescence, the condition clearly worsens with advancing age as the overlying skin thins.

SCN: Is there a cure for cellulite?

Doctor: At present, unfortunately there is no cure. Many therapies have been proposed for dealing with it, but rigorous scientific substantiation is lacking for any of them. These include the use of topical agents to decrease tissue swelling and promote lymphatic drainage; massage therapy (manual or mechanical) to break up fatty deposits and fibrous bands; and even liposuction or liposculpture to remove excess fat and disrupt fibrous tissue.

The benefits of any of these tend to be temporary, and maintenance treatment is generally required. More recently, laser and focused ultrasound therapies have been introduced to promote fat breakdown, resorption and recontouring, but these, too, await further intensive investigation to validate their long-term efficacy.

SCN: The market is saturated with cellulite creams; do any of them work?

Doctor: Many lotions and creams intended for cellulite (as well as some oral medications) contain a variety of vitamins, minerals, herbal ingredients and theophyllines (caffeine-related chemicals). The latter in particular may have some mild benefit for promoting fat breakdown and fluid drainage.

However, unfortunately, none of these products has been subjected to intensive medical investigation, and even in the very small studies that some proprietary preparations have undergone, the results were far from impressive and continued maintenance was certainly required.

SCN: How do you typically treat cellulite?

Doctor: In my experience, deep dermaspacing — a minimally invasive office procedure — followed by the injection of a volumizing agents, such as Radiesse and Evolence, have proven quite helpful for individuals with multiple, discrete areas of pronounced puckering.

Since it stimulates natural collagen production, dermaspacing alone may be helpful for raising a site the way it does when treating depressed chicken pox or acne scars. I’ve found, however, that the supplemental use of volumizing agents, such as Radiesse and Evolence, is essential for achieving optimal results.

The additional use of microchanneling (microneedling) may also prove useful, particularly for smoothing surface irregularities.

SCN: How do dermaspacing and microneedling work exactly?

Doctor: Dermaspacing is quite simple. First, approximately 10 of the most prominent or deepest?dimples and craters are outlined with a surgical marker on each side of the thighs and buttocks. Next, a small amount of local anesthetic containing epinephrine (for constricting blood vessels and diminishing bruising) is instilled directly underneath each of the spots.

A needle-like cutting instrument, or trochar, is then inserted immediately below the dimple and fanned about in all directions to break up the tight fibrous connections encircling the fat bundles and to create a small pocket into which newly synthesized collagen will be deposited.

Next, the volumizer is injected directly into the newly created pocket. This serves to directly plump up the overlying skin. It also enhances native collagen synthesis. And lastly, it acts as spacer material to prevent the pocket from closing before there's sufficient natural collagen produced to fill it up and raise the pucker above.

Finally, after applying a topical anesthetic, the entire surface of the skin is rolled with a microneedling roller, which looks very much like a dough roller from which numerous spokes (extremely fine needles) project. The microchannels created in the skin by this process stimulate new, more youthful collagen to be produced, further smoothing the surface, a process called collagen induction therapy or CIT.

Each site requires a few minutes to complete each procedure, and the entire treatment session may take about 30 minutes.

SCN: What kind of side effects, recovery and cost can we expect?

Doctor: Bruising, slight swelling and discomfort are common and may last for several days. Since the resulting wounds all lie entirely below the skin’s surface, they’re allowed to heal by themselves and require no special wound care.

Cosmetic improvement is usually seen in about two to four weeks — the time it takes for new collagen to be laid down. The procedure may need to be repeated one or more times to achieve maximal correction. Fees typically range from $1,500-$3,000.

I've also found the supplemental regular use of a home rolling device for microneedling (devices for home rolling generally contain a much smaller number of penetrating needles) along with an appropriate topical regimen to be very helpful for promoting further improvement and maintenance.

STRETCH MARKS

SCN: What’s the precise definition of stretch marks?

Doctor: Stretch marks, or striae distensae, are another common cosmetically-troubling problem for which ideal treatment is still unavailable. Like the American flag, stretch marks come in red, white and blue.

Early on, they may be reddish and slightly elevated; later, dusky purple or bluish; and finally, ivory-colored or whitish flattened bands with a wrinkly, crinkly surface.

Typically, they appear on the breasts, abdomen, thighs and arms after the skin is excessively stretched as a result of adolescent growth spurts, pregnancy, weight gain and weight lifting. They affect about 70 percent of adult women and 40 percent of young men.

SCN: What causes stretch marks?

Doctor: Much remains to be learned about what causes them, but current wisdom suggests that stretch marks result from an overproduction of adrenal glucocorticoid, which accompanies the above circumstances, including growth spurts, pregnancy, weight gain and weight lifting. They can also appear following prolonged use of high potency glucocorticoid creams and ointments.

Whichever the case, the high level of steroids interferes with the production of collagen and elastin fibers, resulting in a loss of dermal support that leads to tearing when the skin is stretched. The term "stretch marks" is actually a misnomer. Although stretching can determine where striae may appear and even in which the direction they run, it doesn’t cause them. In fact, no matter how much you stretch or overstretch, they won’t appear unless glucocorticoid steroid levels are increased.

SCN: How do you approach treatment?

Doctor: To be effective, treatments must be geared to the particular phase of stretch mark development. Early on, during the reddish-purple phase, therapy must deal with dilation of blood vessels and damage to collagen in the dermis.

Later, during the white crinkly "mature stretch mark" phase, the approach must address thinning of the epidermis (the topmost layer of the skin) and the inflammation and remodeling of collagen that leads to the loss of pigment cells or obscuring of normal skin pigmentation.

Unfortunately, we currently don’t have any gold standard method for entirely eliminating stretch marks. We do, however, have a number of very effective techniques for improving them.

In general, the earlier the mark is treated, the greater the anticipated improvement. Certain lasers and intense pulsed light therapies (IPL) have proven useful for diminishing the vascular dilation of the early phase and for promoting the production of healthy collagen. Light-emitting diodes (LEDs) in the ultraviolet range have stimulated pigment production. Each of these methods usually requires anywhere from six to 10 or more treatments.

SCN: How do you treat stretch marks at your practice?

Doctor: I’ve found that at all stages, daily topical application of high potency retinoids (vitamin A derivatives), such as Avage, along with alpha hydroxy acids, such as Amlactin, has been helpful for promoting new collagen and elastic fiber production and stimulating the turnover of epidermal cells. Here, too, the earlier treatment is begun, the better.

Microchanneling (microneedling), as described above, is my treatment of choice for stretch marks of all types, ages and locations on the body. I have seen 60-80 percent improvement in appearance following a series of three to four treatments spaced at six week intervals and coupled with the daily use of a home roller and suitable topical therapies for maintenance.

I've also found that a series of microdermabrasion treatments can be helpful for smoothing the surface of some stretch marks. And in selected cases, I add dermaspacing for breaking up distorted collagen bands and stimulating new collagen production.

SCN: Many women are concerned about getting stretch marks during pregnancy, especially if their moms had them. Is there any way to prevent stretch marks?

Doctor: Unfortunately, there’s little practical advice for preventing pregnancy-related stretch marks. There’s also currently no way to know for sure that you will develop them.

However, if you do, I would suggest that you seek treatment as soon as possible after you give birth or finish nursing. The earlier you begin treating stretch marks, the better the outcome. Since they pose no risk to either the fetus or newborn, microdermabrasion and dermaspacing, if deemed appropriate, can be performed at any time.

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To learn more about cosmetic dermatologist Nelson Lee Novick, M.D., F.A.A.C.S., F.A.A.D., please visit his bio.

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