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Dr. Michael Lau

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New EPAT Treatment for Cellulite

About Cellulite - The Cellulite Institute and Clinic - Seattle

With so many treatment options being marketed for cellulite, it is important to understand the possible causes of cellulite and how they are addressed by the various treatment choices before committing to the time and expense of a particular treatment option.

Cellulite is a common skin condition, affecting more than 90% of post pubertal women, causing concern and even distress for many women. The skin appearance and texture of dimples, unevenness and bumps is often referred to as “cottage cheese,” “mattress,” or “orange peel” effect. Cellulite occurs mostly in the thighs, buttocks, abdomen and upper arms, and cellulite can occur in women of normal weight but seems to be exaggerated in women with excessive body fat.

The appearance of cellulite is caused by the bulging expansion of fat pockets under the skin while the fibrous septa, anchoring the skin to the underlying tissue, pull in at the dimple points in the skin, giving the mattress look, or even the cottage cheese look. The addition of skin edema (swelling) causes the orange peel look of cellulite. Thinner skin obviously exaggerates the cellulite appearance.

Causes of Cellulite

So why do post pubertal women have cellulite more than anybody else? The current theory is that there are four main causes of cellulite, and treatment decisions should be directed towards treating each of the causes:

Thinner Skin of Women

Women tend to have thinner skin than men, which makes the underlying subcutaneous fat pockets more obvious at the skin surface, causing the appearance of cellulite. One of the therapeutic objectives for cellulite is to stimulate the thickness of the skin to make cellulite less obvious.

Bulging of Subcutaneous Fat Pockets

Another reason for cellulite in women is due to the bulging of the fat pockets under the skin. In post pubertal women, the menstrual cycle change involves the increase of estrogen/progesterone, and also there can be an increase in estrogen caused by birth control pills or pregnancy. The increase in estrogen contributes to the enlargement of fat cells within the fat pockets under the skin, causing the appearance of cellulite. Estrogen related fat cell stimulation is most pronounced in the fat pockets of the thigh and buttock areas. Thus, these are the areas where most cellulite appears. It would be logical to treat cellulite by decreasing the size of the fat cells, and, in turn, the size of the subcutaneous fat pockets to decrease the bulge of these pockets through the skin in cellulite.

Fibrous Septa

Fibrous septa anchor the skin to the underlying tissue, and they play a role in causing the cellulite appearance by the “mattress” effect. Women tend to have more vertical fibrous septa perpendicular to the skin which effectively pull the skin downward at the anchor points, causing dimples. This is opposed to men where the subcutaneous fibrous septa tend to be less perpendicular to the skin. It would be logical to postulate that if one can release the fibrous septa from pulling the skin down, then the dimple look of cellulite should be less obvious.

Decrease in Local Circulation and Lymphatic Drainage

Another theory of cellulite causation is that in areas where cellulite appears, there is impaired circulation or lymphatic drainage under the skin. This decrease in circulation and lymphatic drainage causes a decrease in metabolic exchange between the fat cells and the circulation, causing the fat cells in the subcutaneous layer to be more engorged and expand the fat pockets, making the cellulite look worse. Furthermore, the lack of drainage and circulation causes local inflammation, building up undesirable protein deposits in the subcutaneous layer and exaggerating the cellulite look, especially the orange peel appearance. To make matters worse, the engorgement of fat cells, and the accumulation of the undesirable protein deposits further decrease the local circulation and lymphatic drainage, causing the vicious circle of making cellulite even worse. To counteract this cause of cellulite formation, treatment to improve local circulation and lymphatic drainage is effective in treating cellulite.

Rationale for Cellulite Treatment

The rationale for each treatment option for cellulite is usually based on the correction of some of the above mentioned causative factors.

Thinner Skin of Women

It is common for women to have thinner skin, especially with the aging process. For women with cellulite associated with obvious thin skin, it would be beneficial to encourage collagen and elastin production to thicken the skin and improve the skin tone, thus making the cellulite less obvious. There are several approaches to achieve the objective of improving the skin. Topical treatment using active ingredients such as Retinol, various vitamin derivatives, botanicals such as Bladderwrack, and growth factors can certainly help. Also, by using different energy platforms, such as ultrasound or shock wave, (e.g. EPAT technology), radiofrequency (e.g. Thermage), or various phototherapy, including laser, the skin thickness, tone, and appearance can be improved, making the cellulite less obvious. Since the underlying problem of fat pockets and fibrous septa are still present, it would be most logical to do combination treatments to also take care of those causative factors of cellulite. It would be even simpler to select a cellulite treatment modality that can address all of those causative factors at the same time, such as EPAT treatment or light treatment with topical chemicals.

Bulging of Subcutaneous Fat Pockets

It would be wonderful if by simply losing weight, one would decrease the appearance of cellulite. Unfortunately, while there will be some decrease in the cellulite appearance with weight loss, the majority of the loss of fat tissue is visceral fat, or deeper fat layers, and not in the subcutaneous fat pockets which cause cellulite. We know this because thin women can have cellulite. The attempt to decrease the subcutaneous fat pockets has to be mainly locally directed. Liposuction would seem to be a good treatment. However, it does not work that well since it is designed to contour deeper layers. To get rid of the superficial subcutaneous fat pockets, liposuction has to be done close to the skin, often causing more skin irregularities, making cellulite even worse.

Topical agents such as methylxanthines (e.g. caffeine, Theophylline), phosphotidylcholine, and certain botanicals (e.g. green tea, coffee) have some effectiveness in lipolysis, that is causing the fat cells to shrink and decrease the fat pocket bulges. Energy modalities such as pulse wave therapy (e.g. EPAT therapy) and ultrasound have shown a decrease in fat cell volume after treatment. So have some light and laser treatment treatments shown the effect of lipolysis, either by direct effect or photo-modulation (systemic effect of phototherapy). Mesotherapy, that is injecting the local subcutaneous tissue with chemicals to dissolve fat, remains somewhat controversial currently.

Fibrous Septa

The idea for this treatment is to divide or cut the fibrous septa, which are pulling down on the skin and causing the dimples of cellulite. The division of these fibrous septa can be done by subcision, an office procedure done under local anesthesia. Potentially, radiofrequency, shockwave, pulsewave therapy or focused ultrasound could also take care of the problem by causing the septa to rupture, but there has not been enough evidence on the effectiveness using these modalities. The Cellulite Institute and Clinic is undertaking research in this particular subject.

Decrease in Local Circulation and Lymphatic Drainage

A decrease in local circulation and lymphatic drainage causes fat cell swelling, protein deposits and local inflammation. Using mechanical means, such as massage and suction devices (e.g. Endermologie, VelaSmooth, Triactive), the local circulation and lymphatic drainage can potentially be improved, thus enhancing fat metabolism transport and causing a decrease in protein deposits and local inflammation. EPAT pulse wave treatment can also effectively stimulate circulation and lymphatic drainage. Alternatively, topical treatments such as retinol or botanicals, such as Centella Asiatic, have shown to improve circulation and thus decrease fat cell size. All these may contribute to improved circulation and thus decrease protein deposits and improve the appearance of cellulite.