Dr Philippe Hamida-Pisal details the aetiology of cellulite and advises on treatments using mesotherapy
Cellulite is a concern that many of our aesthetic patients are likely to present with. While there are a variety of treatment options available, including skincare, laser or LED treatments, electrotherapy, lymphatic drainage and injection lipolysis, this article will focus on the use of mesotherapy, examining its efficacy as a successful method of managing cellulite.
While most people will be familiar with the term ‘cellulite’, it is important that practitioners thoroughly understand its meaning before offering treatment. ‘Cellulite’ or ‘superficial lipodystrophy’ is a cluster of hypodermic fat. Its scientific name is panniculopathy oedematous-fibro-sclerosis (PEFS), which corresponds to different states of the advancement of cellulite.1 PEFS is an increase in thickness of the hypodermis combined with an increase in thickness of the dermo-hypodermic panniculus, and an excessive local thickening of the superficial adipose tissue. Cellulite is characterised by a padded cutaneous appearance, commonly known as ‘orange peel’.1
The more excess fat is stored as triglycerides, the greater the swelling of adipocytes filled with fat will be, as adipocytes can grow up to 50 times their original volume.1 As such, cellulite becomes more visible making it a greater aesthetic concern for our patients.
Three indications characterise cellulite: adipose, water retention and fibrosis. To target these issues using mesotherapy, we have to choose the appropriate medicines.
Stage 0: smooth appearance of the skin when standing and when pinched
Stage 1: smooth appearance of the skin but ‘orange peel’ effect evident when standing and lying
Stage 2: smooth appearance of the skin when lying, however padded appearance when standing
Stage 3: padded appearance in all positions
In 1978, Nurnberger and Muller proposed a classification based on the appearance of the skin (Figure 1).3 Through biopsies, they demonstrated the existence of cellulite adipose lobules. In the case of female patients, the adipose tissue is contained in chamber-like structures that favour the expansion of adipose tissue into the dermis. Conversely, men have a network of criss-crossing, connective tissue architecture, forming smaller polygonal units that allow for subcutaneous fat deposits to expand laterally and internally, but with little protrusion into the dermis.3 This explains the ‘orange peel effect’, which is often present in women.
In 1979, Curri and Merlen were the first to explain the physiopathology of cellulite using video capillaroscopy, allowing direct observation of the blood flow between the adipocytes and highlighting the essential role of microcirculatory failure. They proposed a classification split into four phases:6
Phase 1: Decrease and loss of mucopolysaccharides with increased permeability and plasma exudation, which leads to water retention.
Phase 2: Formation of collagenous fibres that encapsulate clusters of adipocytes.
Phase 3: Formation of a capsule of connective fibres enclosing adipocytes.
Phase 4: Formation of micro-cellulite nodules (30 to 50 adipocytes) surrounded by collagen fibres evolving towards macro-nodules causing micro-diffuse sclerosis.
Since the early 1980s, researchers and practitioners have jointly agreed on the multi-factorial origin and pathophysiological mechanisms of cellulite:7
In 2000, Dr Philippe Blanchemaison, repeating this classification, proposed a new type of cellulite called R-FAT: water retention, fibrosis and adipose tissue.1,6 This classification is based on the development of an index of water retention (IRE) quantified by the use of high-frequency ultrasound. According to Blanchemaison, each of the three factors of cellulite (R-FAT) can therefore be defined in terms of the physiopathology. Mesotherapy treatment is based on this triple notion:
Adipose cellulite: lipodystrophy
Cellulite water retention: hydrolipodystrophy
Fibrous cellulite: fibrolipodystrophy
When considering using mesotherapy as a cellulite treatment, the practitioner should consider the following questions:
This is the most important question to answer, as the practitioner will have to recall the previous notions of physiopathology. They should look at the properties of each drug and choose the most appropriate:
Pentoxifylline (Trental): peripheral vasodilator with arterial vasodilator effect demonstrated. Greater use of pentoxifylline causes a slight decrease in fibrinogen and changes in erythrocyte deformability.1,3
Papaverine: a musculotropic spasmolytic. In mesotherapy it acts on the microcirculation by promoting capillary vasodilation.1,6
Etamsylate (Dicynone): used in functional manifestations of veno-lymphatic insufficiency, impaired capillary fragility. Mesotherapy using etamsylate promotes drainage of the connective tissues and improves the state of the capillaries.1,6
Organic Silica (Conjonctyl): a 1% solution of sodium monomethyl trisilanol orthohydroxybenzoate. The active ingredient is conjonctyl salicylate monomethyltrisilanol, a digestible and bioavailable organic silica. This rebuilds the inner lining of the blood vessels and improves blood circulation. Silica used in mesotherapy implements the reorganisation of the architecture of the dermis. Conjonctyl will boost the synthesis of elastic tissue and thereby improve circulation.1,6
Synthetic salmon calcitonin (Miacalcin): widely used in mesotherapy. It has a stimulating effect on the microcirculation within the cellulite. However, practitioners need to be aware of potential side effects such as nausea and hot flushes, if the dosage is too high or if the vascular passage is fast.1
Nutritional cocktail (NCTF 135): made-up of vitamins, minerals, amino acids and nucleic acids.
Magnesium: for its nutritional and antioxidant properties.
Xanthine bases (Aminophylline): inhibitors of phosphodiesterase and thus act on lipolysis.7
Caffeine: the use is dependent on each individual. During consultation the practitioner should find out if the patient has a known reaction to caffeine and advise accordingly. When using caffeine, always start with a low dose and only increase this if the patient does not have an adverse reaction.
In most cases, the same quantity of each drug has to be mixed when the rules of pharmacology permit. Calcitonin, the only hormone used in mesotherapy, is used with caution (50 international units in general) so as not to cause side effects associated with the molecule.6 The amount must be carefully calculated according to the surface area to be treated, usually 10ml.1
Injections should occur in the areas that are normally affected by cellulite which are the stomach, upper thighs, inner areas of the upper thighs, inner knees and buttocks. Practitioners should be aware that some areas where the skin is very thin may be sensitive and should be treated with caution.
The injection is always intradermal and hypo i.e. between 3-6mm. The intradermal technique is most often used. In case of severe pain at the point of injection, the ‘point-by-point’ technique may be an alternative. Point-by-point is the technique to inject 0.05 to 0.1ml, meaning that there are less points of injection, less pain for the patient and generally produces good diffusion. The use of an injector (for example, the mesogun) may aid the technique as it can offer more direct placement.
The patient should be treated weekly for 10 to 12 weeks. The results are patient dependent, but usually seen at approximately the fifth week, with optimum results visible at the tenth or twelfth session. We advise our patients to undergo a maintenance treatment every six months. Mesotherapy is not only a therapeutic treatment, but also a preventative technique for cellulite. Don’t hesitate to involve other means of mesotherapy because, as mentioned earlier, no effective technique is used in isolation.
Firstly, it is important to remember that any cellulite treatment must have a treatment for general circulation, which needs to be performed every two weeks. On some occasions, it is also useful to treat the patient for stress, as an aggravating factor such as this often prevents us from achieving a good result. It is now widely acknowledged that stress can be a cause of cellulite and inhibit a good response to a treatment.1,3,6
The information below details various mixture recommendations for the treatments of adipose, water retention and fibrosis. This is by no means a comprehensive list of the options available, however it should serve as a helpful tool when considering adopting mesotherapy as a treatment option for your cellulite patients.
Primary medicine: Base xanthan: theophylline aminophylline, euphylline
Secondary medicines: vasodilator: papaverine, silica: conjonctyl, magnesium
Main medicine: Etamsylate: dicynone
Secondary medicine: papaverine, vitamin C, conjonctyl, magnesium
NCTF 135 1ml
Main medicine: Calcitonin
Secondary medicine: Vasodilator: papaverine, silica, vitamin C
NCTF 135 1ml
Cellulite is not a disease but a chronic dysfunction and the reasons for its existence are multi-factorial. Mesotherapy is an effective treatment for cellulite and has been used for more than 50 years. The results are pleasing, however it is necessary to combine it with other treatments to achieve the best results. These are selected based on the specific case of cellulite in each patient and the doctor’s knowledge and resources at their disposal. Performing mesotherapy requires precise technique and the practitioner needs to fully understand the procedure. As far as I am aware, all accidents referenced to date (including infection) are commonly due to negligence or malpractice of the practitioners and the methods they adopt. Finally, it is essential that the patient maintains a healthy lifestyle, participates in regular physical activity and eats a balanced diet in order to achieve optimal results each time.