Reprinted by permission of Blackwell from Nurnberger F, Muller G 1978 So-called cellulite: An invented disease. Journal of Dermatologic Surgery and Oncology 4:221.

Figure 8.2 Structured patterns of the fibrous septae network according to sex and presence of cellulite. Our quantitative findings give more evidence about the heterogeneity in the directions of the septae, and highly suggest that modeling the 3D architecture of fibrous septae as a perpendicular pattern in women but tilted at 45 degrees in men would be an oversimplification.

Reprinted by permission of Blackwell from Querleux B, Cornillon C, Jolivet O, Bittoun J 2002 Anatomy and physiology of subcutaneous adipose tissue by in vivo magnetic resonance imaging and spectroscopy: relationships with sex and presence of cellulite. Skin Research and Technology 8:118-124.

Figure 8.3 Visualization of the 3D architecture of fibrous septae in subcutaneous adipose tissue: (A) woman with cellulite, (B) normal woman, and (C) man.

Figure 8.4 Color sonographs of the thigh of an affected woman, an unaffected woman, and an unaffected man. Note the extrusion of adipose tissue into the dermis of the affected individual.

Reprinted by permission of Pierard-Franchiemont C, Pierand GE, Henry F, et al 2000 A randomized, placebo controlled trial of topical retinal in the treatment of cellulite. American Journal of Clinical Dermatology 1:369-374.

It is less well established whether excess adipose tissue contributes to the appearance of cellulite. There are many thin females who have the appearance of cellulite on their bodies, whereas some heavier females may display only a subtle appearance of any cellulite. It is likely that excess adipose tissue may predispose or exacerbate the cellulite, but it is less likely that excess adipose tissue alone is a driving factor. We believe that excess fatty tissue and cellulite should be considered as two distinct entities, and that they should be evaluated and treated as such.

Evaluation of fatty tissue and cellulite

Body mass index (BMI = person’s weight in kilograms divided by the square of their height in meters), remains the classic method for determining obesity. However, this may be an over-simplification, as it does not necessarily take into account the patient’s mixture of muscle and adipose tissue or their overall body type. Furthermore, many patients presenting for non-invasive body sculpting may be in very good shape overall with only a few small problem areas such as the thighs or flanks. Although BMI may be a useful tool for defining obesity in large populations, we do not find it particularly useful in our practice. More commonly, we utilize measurements such as thigh circumference, waist circumference, skinfold thickness, visual assessment, and photographic comparisons pre- and post-procedure in our practice, as these more typically reflect the patient’s ultimate clinical presentation and outcome.

Pearl 2

BMI is a simple tool to assess overall body habitus. However, BMI is often not the best method to assess localized areas of fat excess and is not often used in our clinical assessments. Furthermore, obese patients (BMI > 30) are often not good candidates for non-invasive body contouring and may require diet, bariatric, or other surgical interventions.

Cellulite can similarly be assessed with various measurements and definitions. Typically, direct observation with side lighting is the simplest and most effective assessment. Based upon these observations, a relatively simple scoring system for the appearance of cellulite has been described (Table 8.1).

Table 8.1 Cellulite classification

Grade I	No or minimal skin irregularity upon standing, pinch test, or muscle contraction
Grade II	No or minimal skin irregularity upon standing. Dimpling becomes apparent by pinching or muscle contraction
Grade III	Classic skin dimpling at rest with palpable, small subcutaneous nodularities
Grade IV	More severe puckering and nodularity