BASIC AND CLINICAL DERMATOLOGY - PART 2 docx

The lesions are essentially asymptomatic. Howe ver, in an advanced degree of cellu- lite, symptoms such as a sensation of weight and pain may occur in the affected areas (10,20,29). These probably occur as a result of compression of the nervous terminals or the presence of inflammatory reactions (16,19). The main manifestations of clinical cellulite are: 1. flaccid ‘‘mattress-like’’ skin, with multiple depressions and some elevations, caused by irregular retraction of the skin, form ing a surface where protuberances and depressed areas alternate (Fig. 1) (6,16,34); 2. ‘‘orange peel’’ skin due to the tumefact ion of the epidermis and dilation of follicular pores (6,16,34). The cutaneous surface alte rations that ch aracterize cellulite are predominantly depressed, when compared to cutaneous surface of the affected area (29). These depres- sions have the same color and consistency as normal skin, and the number of lesions mayvaryfromonetomany(29).Theshape of these lesions is varied (29): rounded, oval, or linear (Fig. 3). Most lesions are oval, as the longest axis of the lesions lies par- allel to the relaxed skin tension lines (Figs. 4A–E). It is interesting to note that those lesions that do not have the same disposit ion in relation to the relaxed skin tension lines in general originate from secondary fibrosis of the subcutaneous tissue, such as injec- tions, trauma, etc. They are usually found in the lower portion of the buttocks and the upper thigh (Fig. 4). In both the buttocks and the upper thigh, just below the gluteal fold, the longest axis is in the horizontal direction, with the lateral extremities slightly elevated. I n these locations, cellulite may be more evident due to flaccidity of the epider- mis, which tends to become a ggrava ted with age. This can be demonstrated by the diminishing or even the disappearance of the lesions when the buttocks are lifted to their original position. CLASSIFICATION Several authors have classified cellulite into four clinical stages or degrees (Table 2), based on the clinical alterations observed with the patient at rest and after the application of the pinch test or muscular contraction (6,29,34). Because cellulite is diagnosed by clinical alterations, without histopathological find- ings or anatomical or pathognomonic charact eristics, it can also be classified into primary and secondary cellulite. In primary cellulite, there are no aggravating factors involved. In secondary cellulite, the alterations are provoked by secondary factors such as localized fat, flaccidity, surgical or accident trauma mainly from lipos uction, after injections that cause lipoatrophy, or after subcutaneous fibrosis from any inflammatory or infectious process. These circumstances may aggravate or even bring about primary cellulite and should be detected through the medical history and physical examination. Treatment, in this case, implies the correction of the prim ary factor. CLINICAL APPROACH As with other pathologies, the medical history should be detailed in the evaluation of cel- lulite. The patient should be questioned regarding the age at which cellulite appeared, prior occurrence of trauma, liposuction or injections in the affected area, history of prior DEFINITION, CLINICAL ASPECTS, ASSOCIATED CONDITIONS, AND DIFFERENTIAL DIAGNOSIS & 11 disease or surgery, family history, presence of chronic vascular or associated hormonal diseases, the occasional or regular use of medications, and previous or current history of hormonal treatment or the use of any medicine that may contribute to the increase in the deposit of fat in the affected areas, such as corticosteroids and estrogens. Other aspects that should be researched are sedentarism, diet, psychosomatic factors, smoking, prior pr egnancy, and the behavior of cellulite during pregnancy. Although smoking and circulatory problems are frequently cited as causative agents of cellulite, in the experience of the present authors, in a sample of 1200 patients with advanced cellulite, the vast majority were neither smokers (more than 80%) nor those hav- ing varicose veins or other circulatory problems. Figure 3 Oval and linear lesions of cellulite. 12 & HEXSEL ET AL. Figure 4 (A) Relaxed skin tension lines mapped on a body scheme. The left half shows the frontal view and the right half, the back view. (B–E) Cellulite lesions follow the relaxed skin tension lines. DEFINITION, CLINICAL ASPECTS, ASSOCIATED CONDITIONS, AND DIFFERENTIAL DIAGNOSIS & 13 Physical Examination The physical examination should be performed with the patient in a standing position, with muscles relaxed (9,10,29). Cellulite can be better observed with the application of the pinch test, in which the skin in the area to be examined is pinched between the thumb and index finger to form a fold by skinfold plicometry or through the contraction of the muscles in the Table 2 Classification of Cellulite Classification Evaluation results Degree or stage 0 There is no alteration to the skin surface Degree or stage I The skin of the affected area is smooth while a subject is standing or lying down, but undulations on the skin surface can be seen on pinching the skin or during muscle contraction (Fig. 5) Degree or stage II The ‘‘orange peel’’ or ‘‘mattress’’ appearance is evident when standing, without the use of any manipulation (skin pinching or gluteus muscle contraction) (Fig. 6) Degree or stage III Presence of alterations described in second degree or stage II, plus presence of raised and depressed areas and nodules (Fig. 7) Figure 5 First degree cellulite, in which there are no alterations to the skin surface in a standing position and with relaxed gluteous muscles. Alterations are found under the pinch test applied to the skin of the affected area. 14 & HEXSEL ET AL. area (Figs. 8 and 9) (9). Overhe ad or tangential illumination of the patient facilit ates the visualization of cellulite (29). There are significant differences in the appearance of cellulite, depending on the position and the method used for its classification. For this reason, the standing position is recommended for the examination of a patient with cellulite. Palpation should always be performed to check the elasticity of the skin (6) and sub- cutaneous tissues. However, at present there are no exact parameters for the classification of skin elasticity. Venous or lymphatic insufficiency may, in theory, aggravate cellulite and should also be checked during the physical examination (35). One should make note of the presence of varicose and telangiectatic leg veins as well as any pitting edema or induration of the skin. A Doppler or duplex ultrasound examination of the superficial venous system will also he lp to classify the significance of venous insufficiency. Even if venous insuffi- ciency is not found to be an etiologic factor in the pathogenesis of cellulite, its presence or absence will help direct appropriate treatment regarding graduated compression. Figure 6 ‘‘Orange peel’’ or ‘‘mattress’’ appearance of second degree cellulite. DEFINITION, CLINICAL ASPECTS, ASSOCIATED CONDITIONS, AND DIFFERENTIAL DIAGNOSIS & 15 AGGRAVATING FACTORS A number of clinical conditions or circumstances frequently accompany or aggravate cel- lulite, especially obesity, localized fatty accumulations, and skin flaccidity. Obesity promotes a generalized increase in body weight (skeletal, muscular, intersti- tial 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 contribut- ing 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 ex amination and can be measured by specia l instruments or by the pinch test (Fig. 9) (36). Rosenbaum et al. described the exacerbation of cellulite with weight gain and its cor- relation with the body mass index (BMI). This study demonstrates the protrusion of adi- pose tissue into the dermis when the volume of subcutaneous fat is augmented, which explains the mattress-like appearance (31). Flaccidity is caused by physiological ptosi s of subcutaneous structures, making the skin permanently distended and loose. This condition frequently occurs in the buttocks, Figure 7 Third degree cellulite, showing raised and depressed areas and modules plus orange peel or mattress appearance. 16 & HEXSEL ET AL. thighs, the region above the knee, and the inner surface of the arms, regions where the skin probably has less retent ive capacity and suffers the mechanical action of weight exerted by the adipose tissue and by the other subcutaneous structures (29). The weight of these struc- tures 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 flaccidi ty. 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 8 Pinch test using a special device, the skinfold plicometry. DEFINITION, CLINICAL ASPECTS, ASSOCIATED CONDITIONS, AND DIFFERENTIAL DIAGNOSIS & 17 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. Figure 9 Patient with cellulite secondary to flaccidity or loose skin. Alterations to the skin surface became more evident on pinching the skin. 18 & HEXSEL ET AL. tension inside the lobes, and the cellulite becomes apparent as the lobes bulge and aggra- vate 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 ten- sion within them. This situation is respon sible 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 cellu lite or that aggravate cellulite are subcutaneous fibrosis caused by previous surgery, mainly liposuction, and the subcuta- neous 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 reflec- tion 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 classifica- tion in Table 2 is useful for generic diagnostic purposes, but is not appropriate for an accu- rate 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. COMPLEMENTARY EXAMINATIONS The BMI is widely used and cited by some authors as a simple, low-cost examination considered fundamental for the evaluation of the clinical cellulite (6,39). This is a quan- titative method that uses measures of weight and height to assess the degree of obesity (39). By using this index, it is not possible to distinguish the percentage of body fat in the muscular mass. BMI is an uncertain diagnostic index of obesity (40). Studies reveal that the estimated standard error of the percentage of body fat of BMI is approximately 5% to 6% (39). A clinical evaluation of a sample of 32 patients ranging from 18 to 45 years of age, performed by the present authors by means of physical examination, BMI calculation, and assessment of body fat percentage by skinfold plicometry (39), revealed that cellulite man- ifested even in patients with a low percentage of body fat and a normal BMI. DEFINITION, CLINICAL ASPECTS, ASSOCIATED CONDITIONS, AND DIFFERENTIAL DIAGNOSIS & 19 Two-dimensional ultrasound is a noninvasive method of evaluating variations (41,42) and alterations of the subcutaneous fatty tissue, and with the assistance of Doppler, it evaluates the local circulation (6). This examination has been used in some studies for the evaluation of cellulite, and has demonstrated a diffuse pattern of extrusion of underlying adipose tissue into the reticular dermis in affected individuals, but not in unaffected individuals (2,31). Computed tomography (43) and magnetic resonance imaging (44,45) are exami- nations used for measuring the thickness of adipose tissue, which do not allow evaluation of the dermis or microcirculation (6). In one study, the magnetic resonance imaging quan- tified deeper indentations of adipose tissue into the dermis and evidenced for the first time a great increase in the thickness of the inner fat layer in women with cellulite (46) . Although invasive, histological examination may be useful as a method for evaluat- ing cellulite (3,6,13). The stains used in this examination include hematoxylin–eosin for routine histological examination; Alcian blue for polysaccharides; periodic acid–Schiff for basement membranes; Weigert–Van Gieson (fuchsin–resorcin and acid fuchsin) for highlighting elastic, collagen, and flat muscle fibers; and Masson trichromic, which demonstrates contrast between collagen and muscle fibers (6). With this exami nation, it Figure 11 Pinch test, which makes the septa pulling the skin surface more evident. 20 & HEXSEL ET AL. [...]... Janeiro: Revinter, 20 00 :26 1 26 4 11 Nurnberger F, Muller G So-called cellulite: an invented disease J Dermatol Surg Oncol 1978; ¨ 4 :22 1 22 9 12 Burton JL, Cunliffe WJ Subcutaneous fat In: Champion RH, Burton JL, Ebling FJG, eds Textbook of Dermatology 6th ed Oxford: Blackwell Science, 19 92: 2140 13 Braun-Falco O, Buddecke E, et al Zellulitis Round-Table Gesprach Med Klin 1971; 66: 827 –8 32 14 Salache SJ,... Grilli-Cicioloni E A proposito della cosidetta cellulite e della dermato-paniculopa´ tia edemato fibrosclerotica Ann It Derm Clin Sper 1977; 31: 121 – 125 23 Binazzi M Cellulite Aspects cliniques et morpho-histologiques J Med Esth Et Chir Derm 1983; 10(40) :22 3 22 9 DEFINITION, CLINICAL ASPECTS, ASSOCIATED CONDITIONS, AND DIFFERENTIAL DIAGNOSIS & 25 ´ ˆ ˆ 24 Ciporkin H, Paschoal LHC Clınica da L.D.G In: Atualizacao... Textbook of Dermatology Vol 2 6th ed Oxford: Blackwell Science, 1998:11 12 1116 28 Sanches CF Celulitis 3rd ed Buenos Aires: Celsius, 19 92: 3 22 5 29 Hexsel DM Body repair In: Parish LC et al., eds Women’s Dermatology Nova Iorque: Parthenon Publishing, 20 01:586–595 30 Garder AS New insight on the etiology and treatment of cellulite according to Chinese medicine: more than skin deep Am J Acupunct 1995; 23 (4):339–346... Ginoide (LDG) ‘‘celulite’’ Sao Paulo: Santos, 19 92: 141–154 ˜ ´ 25 Francischelli RT, Francischelli MN Hidrolipodistrifia Avaliacao epidemiologica e uma pro¸˜ posta de classificacao SBME 20 01; 12: 27–36 ¸˜ 26 Pierard GE, Nizet JL, Pierard-Franchimont C Cellulite: from standing fat herniation to hypodermal stretch marks Am J Dermatopathol 20 00; 22 (1):34–37 27 Hay RJ, Adriaans BM Bacterial infections In: Champion... Este´ ´ tica Clınica e Cirurgica Rio de Janeiro: Revinter, 20 00 :25 7 26 0 35 Bertin C, Zunino H, Pittet JC, et al A double-blind evaluation of the activity of an anti-cellulite product containing retinol, caffeine, and ruscogenine by a combination of several non-invasive methods J Cosmet Sci 20 01; 52: 199 21 0 36 Coleman WP Liposuction In: Wheeland RG, ed Cutaneous Surgery Philadelphia: WB Saunders Company,... histopatologico e histoquımico de 100 casos Med Cutan Ibero Lat Am 1984; 12: 167–1 72 4 Scherwitz C, Braun-Falco O So-called cellulite J Dermatol Surg Oncol 1978; 4(3) :23 0 23 4 5 Ronald M, Di Salvo Controlling the appearance of cellulite Cosmet Toilet 1995; 110: 50–58 6 Rossi ABR, Vergnanini AL Cellulite: a review J Eur Acad Dermatol Vener 20 00; 14 :25 1 26 2 ´ 7 Hexsel DM, Gobbato D, Mazzuco R, Hexsel CL Lipodistrofia... injections (48) When unilateral, localized scleroderma or morphea should be part of the differential diagnosis (29 ) In these cases, the treatment of the primary condition is fundamental and mandatory 24 & HEXSEL ET AL & REFERENCES 1 Draelos ZD Cellulite Etiology and purported treatment Dermatol Surg 1997; 23 :1177–1181 2 Lucassen GW, Van-Der-Sluys WLN, et al The effectiveness of massage treatment on cellulite... 1994; 59: 127 7– 128 5 26 & HEXSEL ET AL 45 Thomas EL, Saeed N, Hajnal JV, et al Magnetic resonance imaging of total body fat J Appl Physiol 1998; 85:1778–1785 46 Querleux M, Cornillon C, Jolivet O, Bittoun J Anatomy and physiology of subcutaneous adipose tissue by in vivo magnetic resonance imaging and spectroscopy: relationships with sex and presence of cellulite Skin Res Technol 20 02; 8 (2) :118– 124 47 Gruber... Technol 20 02; 8 (2) :118– 124 47 Gruber PC, Fuller LC Lipoatrophy semicircularis induced by trauma Clin Exp Dermatol 20 01; 26 (3) :26 9 27 1 48 Perrot H Localized lipo-atrophies Ann Dermatol Venerol 1988; 115(4): 523 – 527 DEFINITION, CLINICAL ASPECTS, ASSOCIATED CONDITIONS, AND DIFFERENTIAL DIAGNOSIS & 27 & APPENDIX CELLULITE ASSESSMENT PROTOCOL Name: Age: ... Res 20 01; 21 (2) :79–84 9 Belcaro G, Caratelli M, Terranova R, et al A simple test to monitor oxidative stress Int Angiol 1999; 18 (2) : 127 –130 10 Bacci PA Le Celluliti Arezzo, Italy: Alberti Editori, 20 00:175–185 11 Campisi C Il linfedema In: Flebologia Oggi Torino, Italy: Minerva Medica, 1997 :23 29 12 Lucchi M, Bilancini S Il lipoedema In: Bacci PA, ed Le Celluliti Arezzo, Italy: Alberti Editori, 20 00:80–85 . dermato-paniculopa- tia edemato fibrosclero ´ tica. Ann It Derm Clin Sper 1977; 31: 121 – 125 . 23 . Binazzi M. Cellulite. Aspects cliniques et morpho-histologiques. J Med Esth Et Chir Derm 1983; 10(40) :22 3 22 9. 24 & HEXSEL. pro- posta de classificac¸a˜o. SBME 20 01; 12: 27–36. 26 . Pierard GE, Nizet JL, Pierard-Franchimont C. Cellulite: from standing fat herniation to hypo- dermal stretch marks. Am J Dermatopathol 20 00;. Science, 1998:11 12 1116. 28 . Sanches CF. Celulitis. 3rd ed. Buenos Aires: Celsius, 19 92: 3 22 5. 29 . Hexsel DM. Body repair. In: Parish LC et al., eds. Women’s Dermatology. Nova Iorque: Parthenon Publishing, 20 01:586–595. 30.