BOLAND CELL CELLULITE
Basic sciences and biotechnology of cellulite and obesity
Knowledge of the basic sciences relevant to human adipocytes is important for a better understanding of cellulite. It is know well established that obesity and overweight persons with an increase in abdominal circumference are destined to premature degenerative disease, especially coronary artery disease. This has been fully alluded to in Time Magazine. For these reasons it is valuable to have background basic science knowledge when treating cellulite and obesity. Because ultrasound, compression, massage and radiofrequency are used to treat cellulite, it is important to have a background of developmental embryology and biochemistry. BOLAND CELL has extensive experience with the biotechnological background regarding the ex-vivo, and laboratory proliferation of adult mesenchymal stem cells from adipose tissue. Central to the discussion is that the mesenchymal cell can differentiate into either fibroblasts and adipocytes. Both these concepts are important to understand, because the treatment of cellulite is directed at neocollagenesis ( fibroblasts interaction) and adipocyte alteration or destruction ( adipocyte). For the moment we are not sure which of the two, or a combination of the two are important in the modification or amelioration of cellulite. Mesenchymal cells form both white and brown adipose tissue. Brown adipose tissue is very important for the development and growth of children from babies. Brown fat is multilocular, and plays a critical role in heat dissipation. White fat on the other hand has a lot to do with the storing of fat in adipocytes and insulation against cold. White adipose tissue , is typically histologically, unilocular in appearance. Regarding secondary fat formation, the mesenchymal cell differentiates into a preadipocyte ( see Kierszenbaum 2002). With time, fat inclusion occurs in the cytosol. Insulin, catecholamines, cortisol, and prostaglandins are important in fat metabolism. Insulin, and Insulin-like growth factor and receptors are central to this aspect. With time, the intracellular fat droplets coalesce and form a unilocular adipocyte with an eccentrically placed nucleus when viewed at histology. It is sometimes referred to as a signet-ring. Fat deposits are innervated by the sympathetic nervous system, and this is important to know. Because obesity is a disorder of energy balance, it is imperative that dietary aspects are addressed when treating cellulite. Failure to address diet will obviously result in a poor result regarding the cellulite. Knowledge of the protein, leptin, is also important because it is a substance that is secreted by adipocytes.
The term “cellulite” is not accepted in the anatomical or histological nomenclature at the present time. Nor does it appear in NOMA ANATOMICA OR HISTOLOGICA. The physiological condition related to derangement of adipose tissue deposition is not “cellulitis”. The latter condition is an infective pathologic, invasive, bacterial process affecting the skin and sometimes the deep fat. Clinically, cellulite manifests as irregular skin contours or dimpling of the skin. The condition is most prominent in the thigh and buttock region. Histologically, it is typified by excess adipose retention within fibrous septa (Alster and Tanzi et al 2005). The aetiology of cellulite is unknown but related to dietary, postmenopausal and genetic factors.
Novel treatments directed at cellulite include:
1. Radiofrequency, infrared light and mechanical tissue manipulation. (See Cosmetic and Laser therapy: 2005; 7: 81-85).
2. Subcision (complicated and invasive procedure).
3. Liposuction (or ultrasonic liposculpuring)
5. Endermologie, mechanical massage
6. Dieting, topical anti-cellulite creams
7. Pharmacotherapy and phosphatidylcholine injections
8. Laser treatment
9. Air pressure, balloon devices.
The definite treatment for cellulite is still in a state of evolution. Liposuction is associated with a small statistical mortality rate of about 19.1 per 100,000 procedures (Grazer et al, Plast Reconst Surg 105: 436-446, 2000. In the hands of experts, the results are good, but recurrence has been documented. The public want non-invasive technology for the treatment of cellulite. Apart from lasers, two technologies are available and in competition with each other.
1. Non-invasive destruction of fat cells by ultrasound (Ultrashape®).
2. Radiofrequency, infrared light and mechanical tissue manipulation (VelaSmooth®).
The mechanism of action differs for the two modalities. No doubt, with time, other new innovations or modifications will be introduced. Lipolysis by ultrasound results in destruction and emulsification of fat. Released lipids have to be absorbed, and presumably this is via the systemic venous circulation and liver extraction. The process of fat-clearance may take several hours after treatment and as yet is not known to cause side effects. Fat lipid-overload, obviously, will be a problem when large surfaces of fat are lysed by ultrasound. Excessive fat emulsification with release of free-fatty acids and triglycerides into the venous systemic circulation may be detrimental. If prolonged, ultrasound exposure may effect cellular DNA, and this possibility remains to be determined. Radiofrequency methodology, induces thermal changes in the dermis. In some patients, it is painful and sedation, including local anaesthesia is needed. Other workers have shown that radiofrequency devices can also be used for the treatment of facial skin-tightening (see Alster et al, Dermatol Surg 2004; 30: 503-507). Early results show that younger persons respond better than those older than 55-years. So older skin may be less amenable to heat-induced tissue tightening. Also, in the early phase, skin tightening may be only due to oedema formation. This will not produce a permanent result.
For the moment, multiple treatments are needed from both devices, to affect modest changes to cellulite.
Hair removal is an important component of aesthetic medicine, and typically has been in the domain of lasers. For years, laser-based hair removal, has been the gold standard for hair removal, albeit painful, in patients with low pain thresh holds. This involves applying laser pulses to the skin surface. The principle is based on thermal destruction of the hair shaft and follicle using optical energy. Basically, laser light is monochromatic light. Intense Pulse Light technology (IPL) makes use of a broader spectrum. Earlier generation models have given way to new updates. The problem of the earlier devices was overheating of the epidermis. Sophisticated new devices allow for cooling of the skin during treatment. Dark skin races have been a huge challenge and limitation of photo-depilation. The light energy applied to the skin by these devices is measured in fluence units J/cm2.
BOLAND CELL: SCIENTIFIC AND ACADEMIC DISCUSSION (CELLULITE)
Only time will tell which of the two non-invasive modalities, ultrasound or radiofrequency-heating will be the better for cellulite. For the moment, both are investigational, and modestly effective. The mechanism of action of the two modalities differs, and need to be clarified. Both modalities seem safe in efficacy, but lipid and triglyceride rushes and plasma overload need addressing especially in patients with dyslipidaemia. Long-term and comparative studies are needed to facilitate usage of the technology.
Conclusion: New novel and exciting technologies may have an impact on cellulite. Drawbacks include costs, need for multiple treatments and maintenance therapy. Possibly, radiofrequency treatment can be combined with liposuction. Food supplements have not all been passed by FDA for the treatment of cellulite. Accent and VelaSmooth appear to be promising technologies.
Boland Cell Literature Cellulite Resources:
1. Plast Reconstr Surg 1999; 104: 1110-4.
2. Int J Dermatol 2000; 39: 539-44.
3. J Eur Acad Dermatol Venereol 2000; 14: 251-62.
4. J Cosmet Laser Ther 2004; 6: 181-5.
5. J Cosmet Laser Ther 2005; 7: 7-10.
6. J Cosmet Laser Ther 2005; 7: 81-5.
7. Lasers Surg Med 2006; 38: 727-30.
8. J Drugs Dermatol 2006; 5: 714-22.