Cellulite: general principles of correction

Cellulite, or lipodystrophy, is a special condition of subcutaneous fat tissue that leads to a whole range of cosmetic defects.

The term "cellulite" is not generally accepted, it was first used in the 20s of the last century. Only since the 80s serious scientific research has been conducted and publications have appeared in the media.

By now, the clinical picture and factors leading to the development of cellulite have been studied in sufficient detail, and methods for its correction are constantly being proposed and improved.

Pathogenesis of cellulite. Lipodystrophy is based on both exogenous and endogenous predisposing factors. Exogenous factors include physical inactivity, unbalanced diet (unlimited consumption of fats and carbohydrates), smoking, stress, alcohol consumption and other factors. It is emphasized that wearing high-heeled shoes is a significant negative factor. Among endogenous factors, the importance of endocrine changes (leading primarily to hyperestrogenism and hypoandrogenism) and circulatory disorders (for example, varicose symptom complex), as well as hereditary predisposition, biotype, concomitant diseases (for example, gastrointestinal tract) are especially emphasized. It is believed that women, especially Caucasians, are more susceptible to cellulite. The prevalence of cellulite among women is explained by a number of anatomical and physiological features. Thus, hyperestrogenism and hypoandrogenism are more typical for women, and hypotonia of the blood vessels of the skin and underlying muscles is more characteristic for them. Among the morphological characteristics of the subcutaneous fat tissue, the larger fat lobules in women compared to men are noteworthy. In addition, it is known that the interlobular connective tissue septa in women are located parallel to each other and perpendicular to the skin surface, and in men - at an angle of 45° to the skin surface.

A complex of endo- and exogenous predisposing factors leads to an increase in the size of adipocytes and an increase in the mass of adipose tissue. An increase in the size of adipocytes is associated with an imbalance between the processes of lipogenesis (synthesis of triglycerides from glycerol-3-phosphate and fatty acids) and lipolysis (splitting of triglycerides into glycerol and free fatty acids). It is believed that it is the enlarged adipocytes that exert mechanical pressure on fibroblasts, which is the cause of excessive collagen formation, i.e. fibrosis. On the other hand, an increase in adipose tissue predisposes to a disruption of circulation in various layers of the skin, which leads to tissue edema, venous and lymphatic stasis. Local hypoxia also contributes to the proliferation and change in the qualitative composition of collagen fibers of connective tissue. In this case, the formation of fibrous structures located perpendicular to the skin surface occurs. The specified complex of morphological changes further aggravates the disruption of trophism and neurotrophism in all layers of the skin.

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Symptoms of cellulite

The complex of morphological changes leads to thickening of the subcutaneous fat tissue and the formation of so-called "cellulite dimples". The following stages of cellulite development are usually distinguished:

• Stage I - there are no external manifestations. But there is a slight swelling, due to vascular disorders there is a tendency to form hematomas, skin healing is impaired.
• Stage II - the swelling is more pronounced. Micronodules are formed. When taking a skin fold, the so-called "orange peel" is revealed.
• Stage III - "orange peel" visible to the eye. Skin temperature decreases.
• Stage IV - large nodes are formed, skin retractions in areas of pronounced fibrosis. Due to compression of nerve endings, areas with impaired sensitivity appear, cold spots are detected on the thermogram. Some nodes are painful to the touch. Large telangiectasias may occur at any stage. They may be a consequence of impaired blood circulation in adipose tissue due to developing fibrosis, as well as varicose symptom complex. Such patients should be consulted by a phlebologist.

Principles of cellulite correction

It is necessary to emphasize that a successful solution to this problem is possible only with a comprehensive and individual approach. That is why in recent years specialists in the field of body cosmetology have given the greatest preference to the development of comprehensive and individual programs. Thanks to such programs, a professional has the opportunity to stage and scientifically substantiate the impact of various links in the pathogenesis of cellulite, taking into account the individual characteristics of each client.

The development of a comprehensive individual program includes several stages:

1. Conducting an initial consultation.
2. Evaluation of the clinical picture and determination of the stage of cellulite.
3. Completing a standardized questionnaire.
4. Selection of key methods, their combined or sequential use

Initial consultation

A full initial consultation is 80% of the success in achieving a stable result. It is during the initial consultation that adequate psycho-emotional contact and trusting relationships can be established between the client and the doctor. The cosmetologist's task is to clarify the purpose of the visit, determine the motives for losing weight. If necessary, the specialist should help the client clearly formulate the motivation for visiting the salon, which often helps the client subconsciously tune in to a positive result. Let us cite just a few statements from clients as an example: "I have a chic pantsuit, but I can't wear it because the trousers are too tight on my hips and emphasize the "breeches" area, I want to get rid of this problem", or: "After pregnancy and childbirth, I gained weight sharply, pronounced signs of cellulite appeared, I would like to return to my previous shape." As can be seen from the above statements, clients can have a variety of motivations and, therefore, the approach to solving their problems should be strictly individual. For complete mutual understanding, the doctor needs to find out the client's opinion about his body: what he likes, what he doesn't like, what he would like to change, how he sees his body, what he is ready to do to achieve the goal and maintain the result. It is important to lead the client to the idea of cooperation, since the next stage of the consultation is a discussion of the diet. Most people mistakenly believe that if they attend cosmetic procedures, then nothing else should be done. The doctor is responsible for conducting a competent introductory consultation on dietary low-calorie nutrition, explaining that the process of cellulite treatment is not only long-term, but also complex, and it is impossible to do without following basic rules for diet, replenishing fluids and salt balance. It is necessary to remind the client that dietary restrictions should concern only carbohydrates and fats, and proteins, vitamins, minerals and water should be consumed in full quantities, otherwise the body will break down not fats, but muscle protein (the volume of muscle mass will decrease, and fat deposits will remain "in reserve"). In addition, the client needs to be reminded about increasing physical activity. It is quite clear that in our fast-paced life it is almost impossible to find time to visit both a beauty salon and a gym, so it is important to focus the client's attention on increasing the time spent walking ("to the store not by car, but on foot to the apartment not by elevator, but by stairs," etc.).

During the initial consultation, it is necessary to tune the patient to two extremely important aspects of his work on himself - self-esteem and self-control. They are the factors that allow the client to fully engage in the work: on the one hand, it is perceived as an interesting and easy game, on the other - by doing a certain job, recording the results on paper, the client subconsciously tunes in to a stable, positive result. Self-esteem consists of measuring the body once a week in the morning and weighing once every 10 days (it is not worth doing these operations more often, since cellulite treatment is a long process and the absence of positive dynamics at first negatively affects the emotional state). Self-control implies, first of all, keeping a food diary, counting the kilocalories consumed and spent (the difference between consumption and expenditure should be at least 1200 kcal per day, otherwise the fat burning processes will not be activated).

Evaluation of the clinical picture and determination of the stage of cellulite

Before the examination, a thorough anamnesis must be collected. The specialist pays special attention to endocrine and gynecological diseases, gastrointestinal tract pathology, studies heredity and family history in detail (whether the mother, grandmother, other female relatives have a tendency to be overweight, whether there was a large weight gain in childhood, adolescence, etc.). When questioning, it is necessary to find out whether oral contraception is used and find out about its duration. If necessary, specialist consultations may be recommended before prescribing a course of treatment.

An objective examination reflects the general condition at the time of examination, the condition of the skin, body type, the condition of regional lymph nodes, body measurements (in cm), body weight measurement (kg), calculation of the body mass index, the coefficient of excess weight (percentage of fat tissue). All of the listed indicators should be entered into a specially developed questionnaire (see below)

Determining the stage of cellulite is crucial when choosing methods for a course of treatment. It is known that cellulite is a complex disease that affects all the constituent elements of tissues (vascular system, nerve endings and nerve fibers, fibrous structures of connective tissue, adipocytes, etc.). A factor that somewhat facilitates the doctor's task is the gradual inclusion of tissue structures in the processes of cellulite development, because it is not for nothing that there is a figurative expression that "cellulite creeps up unnoticed." Knowing what pathomorphological links are involved in the development of cellulite, specialists can, with the help of a number of physical factors, break the "vicious circle."

Morphological changes depending on the stage of cellulite and the “target” for hardware techniques

Stage of cellulite	Description of morphological changes in tissues	Targets for "hardware techniques"
I	A slight increase in the volume of adipocytes, compression of vessels (arterioles, venules, capillaries, lymphatic vessels), the release of mucopolysaccharides into the intercellular substance, their polymerization by water, fluid retention	Tissue edema, enlarged adipocytes, hypoxia
II	Further increase in the volume of adipocytes, overstretching of the cell membrane, decrease in the sensitivity of beta receptors and, as a consequence, inhibition of lipolysis processes. Increased intercellular edema and hypoxia affect connective tissue fibers (elastic and collagen), the formation of incorrect, so-called "perpendicular" collagen is stimulated, "cross-links" are formed	Tissue edema, enlarged adipocytes, hypoxia
III	Significant disruption of lymph flow, accumulation of metabolic products, formation of clusters of tightly fused adipocytes covered with a fibrous capsule (“micronodules”)	Tissue edema, increase in adipocyte size, microcirculation disorders, fibrous structures, "adhesions"
IV	Formation of macrowells, rigid fibrous structures, compression of nerve endings, impaired tissue sensitivity, pain, increased disturbances of microcirculation and lymph flow	Tissue edema, increase in adipocyte size, microcirculation disorders, rigid fibrous structures, lymphostasis

The next stage of work is filling out a standardized questionnaire. The questionnaire should include basic demographic information about the client (last name, first name, middle name, year of birth, address, contact phone number, etc.), anamnesis data, concomitant diseases and the results of an objective examination at the time of the initial examination with all anthropometric data (pulse, body weight, body mass index, excess weight coefficient, etc.). The questionnaire should also indicate the stage of cellulite. The specialist indicates the selected treatment methods, data on dynamic monitoring of the client during the therapy. Filling out the questionnaire helps the cosmetologist to comprehensively assess the problem, creates the prerequisites for objective monitoring of the dynamics of changes in his condition against the background of the treatment. It is also important that the questionnaire drawn up in the presence of the client is medical documentation that reflects the objective condition of the client at the time of the first visit and against the background of the procedures. The presence of such a document, constantly stored in the salon, provides objective information and ensures the safety of the doctor, which is extremely important in the conditions of the dawn of insurance medicine.

The selection of key methods, their combination or sequential appointment for cellulite correction use: skin care, appointment of external preparations that affect the main pathogenetic links and clinical manifestations of cellulite, diet therapy, oral administration of drugs that improve trophism and appearance of the skin, injection techniques, hardware cosmetology techniques.

It should be remembered that against the background of any methods of physical impact, adequate skin care is necessary, including gentle cleansing and exfoliation, as well as constant moisturizing. For washing the skin, it is recommended to use gels and mousses that do not change the acidity of the skin surface. Periodic prescription of exfoliating products for the body is also acceptable (once every 7-14 days). For the purpose of moisturizing, emulsions and body creams are recommended. Normalization of skin care is an important component of a comprehensive cellulite treatment program, as it leads to a significant reduction in dryness - skin turgor is restored, its texture and color are improved. In recent years, external products have become popular, including not only moisturizing components, but also substances that improve microcirculation, lymph flow (usually caffeine compounds), activating lipolysis, etc. (anti-cellulite ranges of the Vichy, Lierac, RoC laboratories, etc.).

Scientific developments in recent years have shown that nutrition can play a decisive role in preventing a decrease in skin turgor and the severity of cellulite. It is known that supplementing the standard diet with microelements (for example, calcium derivatives), green tea polyphenones, glucosamine sulfate, procyanidins and other agents can positively affect the condition of the skin and subcutaneous fat. Thus, in experimental animals, the intake of large amounts of calcium with food significantly suppressed fat accumulation by inhibiting the enzyme fatty acid synthetase and increased lipolysis. In addition, calcium has the ability to bind fatty acids in the intestine and form insoluble soaps that are easily excreted from the body. The intake of large amounts of calcium also promotes the formation of calcipotriol and the expression of a specific agouti gene in human adipocytes. This, in turn, leads to a decrease in the calcium content in adipocytes and a subsequent decrease in body weight. In this regard, various biologically active food supplements are very popular. In particular, the product "Inneov Cellustrech" ("Laboratoires Inneov", France) was developed by scientists to restore skin structures and prevent signs of cellulite development.

For the treatment of cellulite, various methods of paralytic cosmetology are widely used: using electric current, some mechanical factors, temperature effects, etc. Combined effects methods are currently gaining great popularity.

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List of methods for treating cellulite, their purpose and methods of combination

Methods using electric current

1. Electrophoresis is a combined effect of galvanic current and medicinal substances on the affected tissue, which makes it possible to create a “depot” of medicinal substances in the tissue.

The focus of the method: enhancing microcirculation, resorptive and lipolytic action, as well as other properties, depending on the mechanism of action of the drug used.

Method of administration: every other day, 10-12 procedures per course, duration - 15-20 minutes.

2. Lymphatic drainage is a low-frequency pulsed current effect on muscles to stimulate lymphatic drainage. Lymphatic drainage is performed using bipolar pulses coordinated with heart contractions, sequentially from the periphery to the center.

The focus of the method: lymphatic drainage.

Method of administration: 2-3 times a week, 10-15 procedures, duration - 40 min.

3. Myostimulation is the effect of alternating pulsed current on neuromuscular structures to obtain spike responses and conduct passive muscle contractions.

The focus of the method: muscle toning, strengthening the muscular frame.

Method of administration: 2-3 times a week, 15-20 procedures, duration - 20-40 min.

4. Electrolipolysis is a direct lipolytic action of electric current on the fat droplet of adipocytes with its breakdown into final decay products and the release of a large amount of energy.

Direction of the method: lipolysis

Method of administration: once every 4-5 days, 10-15 procedures, duration - 60 min.

5. Microcurrent therapy is the use of low-power currents (up to 600 μA) and interference phenomena to normalize the bioelectric potential of cell membranes, activate metabolism and enhance ATP synthesis.

The focus of the method: lymphatic drainage, lifting, restoration of skin turgor, anti-cellulite programs.

Method of administration: every other day, 15-20 procedures, time - 40 minutes.

Methods using mechanical factors, vacuum and temperature effects

• Ultrasound therapy - the use of such properties of ultrasound waves as: destruction of fat droplets, improvement of membrane transport, acceleration of metabolic processes, defibrosing effect on connective tissue structures, dividing fat cells into micro- and macronodules.

The focus of the method: mediated lipolysis, restoration of elasticity and firmness of connective tissue structures.

Method of administration: 2-3 times a week, 10-15 procedures, duration - 20-30 min.

• Vibrotherapy is a low-frequency transcutaneous effect that accelerates microcirculation and metabolic processes.

Direction of the method: lymphatic drainage, anti-cellulite programs. Method of administration: 2-3 times a week, 10-15 procedures, duration - 20-30 min.

• Vacuum action - negative pressure created in a vacuum chamber leads to a change in oncotic and hydrostatic pressure and promotes local reduction of edema and acceleration of metabolic processes. Cyclic vacuum has the ability to destructure the fat droplet.

Direction of the method: lymphatic drainage, mediated lipolysis. Method of administration: daily or every other day, 15-20 procedures, time - 15 min.

• Pressotherapy is an alternating change in air pressure.

Direction of the method: sequential lymphatic drainage. Method of administration: 2-3 times a week, 10-15 procedures, time - 15 min.

• Thermotherapy: heat therapy and cryotherapy are used to improve microcirculation and increase the permeability of the epidermis for cosmetics.

The method focuses on: opening pores, removing toxins, improving skin turgor and elasticity. Method of administration: 1-2 times a week, 10-15 procedures, time - 50 min.

Combined methods:

• The Endermologie method, which includes 3 mechanical factors of influence on all structural units of tissues (vacuum, mechanical and roller massage, vibration).

The focus of the method: lymphatic drainage, body shaping (redistribution of fat deposits), indirect lipolytic action, restoration of skin turgor and elasticity.

Method of administration: 1-2 times a week, 15-20 procedures, time - 35-60 min.

• Mud therapy - the use of warm mud wraps to enhance metabolic processes. The focus of the method: restoring skin tone and turgor, activating metabolic processes.

Method of administration: 1-2 times a week, 10-15 procedures, time - 30-60 min.

• Mesotherapy is the introduction of microdoses of drugs into the upper layers of the epidermis to improve microcirculation and accelerate oxidation-reduction reactions.

The focus of the method: depending on the composition of the cocktail of medicinal products - lipolysis, restoration of skin tone and turgor, etc.

The range of cellulite treatment methods is quite large, so it is important to remember the priority in prescribing procedures and the program stages. It is recommended to designate stages to determine the time period during which a particular method has time to deploy its activity (for example, for electrolipolysis, it is necessary to carry out 3-5 procedures over 2-3 weeks to obtain the initial result). On average, the calculation of the course stages is for 2 weeks - 4-6 procedures per stage. In particular, lymphatic drainage is carried out 2-3 times a week, thus, 4-6 procedures are performed at the first stage. This is already a significant unloading of the body from excess fluid and a good basis for prescribing such procedures as myostimulation and "deep heat" at the next stage.

At the first stage, based on the pathogenesis of cellulite, the following procedures are recommended:

• Lymphatic drainage procedures to reduce interstitial edema. For this purpose, pressoprocedures, microcurrent lymphatic drainage, sequential electrolymphatic drainage, and the endermology method are used. The effect of the procedure is immediately visible, expressed in a decrease in pastosity and increased work of the urinary system
• Lipolytic procedures (reduction of adipocyte size, destruction of fat droplet) - electrolipolysis, mesotherapy, electrophoresis, vacuum techniques, ultrasound therapy, endermology. At the first stage, it is not recommended to carry out thermal procedures, since heat has the physical property of expanding blood vessels and increasing blood flow, provoking aggravation of vascular stasis.
• When treating advanced stages of cellulite (III-IV st.), it is necessary to act on connective tissue and fibrous structures. For this, ultrasound therapy and endermology are prescribed.

At the second stage of the course, all methods enter the phase of expanded action, preserving the lymphatic drainage, lipolytic, ultrasound and endermological procedures in the appointment, it is recommended to add for cellite (I-II st.) methods that strengthen the muscle frame, and thermal procedures with mud wraps. Moreover, the temperature during the warm procedures should not be high, so that the processes of diffusion of cosmetics prevail over the processes of removing toxins (sweating). At this stage, the number of lymphatic drainage procedures can be halved.

For cellulite stages III-IV, myostimulation and "deep heat" procedures are introduced at the third stage (from the 4th-6th week). In addition, it is necessary to carefully monitor the skin tone and, if it decreases, add endermology, microcurrent therapy, and "cold wrap" procedures to the prescriptions.

The course of procedures for the treatment of cellulite stages I-II should last at least 6-8 weeks + maintenance stage, for the treatment of cellulite stages III-IV - this is 14-15 weeks + maintenance stage. At the maintenance stage, endermology, myostimulation, wraps (once every 1-2 weeks) are not used.

As the analysis of the cosmetology services market shows, not all salons dealing with cellulite problems have a full list of devices and methods. Therefore, it is very important, knowing the main pathomorphological changes in cellulite, to choose other methods that are similar in action.