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Intro:

During the past 25 years, there has been a vast explosion in new information relating to
the art and science of dermatology as well as fundamental cutaneous biology. Furthermore, this information is no longer of interest only to the small but growing specialty
of dermatology. Clinicians and scientists from a wide variety of disciplines have come
to recognize both the importance of skin in fundamental biological processes and the
broad implications of understanding the pathogenesis of skin disease. As a result, there
is now a multidisciplinary and worldwide interest in the progress of dermatology.
With these factors in mind, we have undertaken this series of books speciﬁcally
oriented to dermatology. The scope of the series is purposely broad, with books ranging
from pure basic science to practical, applied clinical dermatology. Thus, while there is
something for everyone, all volumes in the series will ultimately prove to be valuable additions to the dermatologist’s library.
The latest addition to the series, volume 37, edited by Drs. Goldman, Bacci,
Leibaschoff, Hexsel, and Angelini is both timely and pertinent. The editors are well known
authorities in the ﬁeld of dermatological surgery and cosmetic dermatology. We trust that
this volume will be of broad interest to scientists and clinicians alike.

Foreword
What exactly is cellulite? Is it a disease or a normal ﬁnding in postpubcrtal women? Should it
be treated or ignored? Is it nothing more than a convenient marketing opportunity for cosmetic manufacturers or something worthy of medical attention? These are but a few of the
controversies surrounding the condition commonly known as ‘‘cellulite.’’ Perhaps the only
point of agreement is that cellulite is unattractive and undesirable. It appears shortly after
the initiation of menstruation in young girls on the upper outer thighs and buttocks and continues to worsen with the passage of time. Cellulite seems to affect tall and short, fat and
thin, asthenic and curvy females. For many women, cellulite marks the end of the idyllic
youthful body and the onset of the aging, declining female shape. Certainly, there must be
something that technologic medical science can offer. Even in the 1960s, cellulite treatments
abounded with the vibrating belt machines designed to ﬁrm the buttock and thighs while
minimizing cellulite. At the time of this writing, there are many creams, devices, and procedures that attempt to deal with the ubiquitous problem of cellulite, but an organized scientiﬁc
treatise is lacking.
This text is the ﬁrst serious evaluation of the etiology and treatment of cellulite. The
editors have assembled an international panel of cellulite researchers and clinicians to share
their combined knowledge on the subject. The book is nicely organized with an introduction
into the social impact of cellulite, followed by a characterization of the problem through
visual and noninvasive techniques, with a major focus on the various treatment modalities.
Cellulite improvement through the use of topical agents, Endermologie1, surgery, lymphatic drainage, electroporation, and mesotherapy are investigated by practitioners of each of
the arts. The editors thus provide a full critical evaluation of how each of these treatments
impacts the appearance of cellulite.
Most dermatologists would agree that not a day goes by in clinical practice without a
patient asking about cellulite treatments. To date, it has been difﬁcult to ﬁnd any reputable
reference source on the subject. This text is a large step forward in characterizing the etiology of cellulite and evaluating worthwhile treatment approaches. The editors and their
vauthors should be congratulated for tackling a complex subject and organizing a text to
highlight and discuss the controversies. This book is an illuminating treatise on the cloudy
topic of cellulite.

Preface
Beauty has been extolled and made a cult object in all cultures and civilizations, whatever their
geographic distribution, ethnic origin, or religion. In ancient Egypt, beauty was associated
with a sacred nature and personiﬁed by Queen Nefertiti, a woman who had high brows, wide
and well-delineated eyes, rich lips, a digniﬁed countenance, and an upright bearing, the very
image of subtle energy; the ancient Egyptians regarded beauty closely akin to ‘‘holiness.’’
The Greek aesthetic ideal was characterized by ‘‘perfect proportions’’ in the sense of
the geometric relationships deﬁning body harmony. Aphrodite, the goddess of beauty, was
also worshipped as the goddess of love. Among the Etruscans, the Venus of Melos represented beauty and harmony; this has remained intact and unpolluted throughout subsequent civilizations.

During the Renaissance, the tall ﬁgures of Aphrodite and Venus, slim but muscular at the
same time although somewhat androgynous, became impressive and important, as is evident
in the works of Rembrandt and Rubens. The beauty of women was embodied in ﬁgures with
abundant localized adiposity, though not obese: the faces were round and blissful and expressed
a superb femininity and kindness that conveyed the idea of motherhood and protection.
After the French Revolution, the standard representation of the woman took a new
turn. The feminine body started to express activity, labor, functionality, precision, and harmony, losing some traits of Renaissance femininity. In the new society established after the
Revolution, women slowly acquired new roles, carried out new activities, and achieved an
unprecedented independence. As time went by, women even started to smoke cigarettes
and practice sports. There were no objections to this new role as long as the exaggeration
and myths of a sculptured body—such as those characteristic of the 1960s—are avoided.

Contents
Series Introduction Alan R. Shalita . . . . iii
Foreword Zoe Diana Draelos .... v
Preface . . . . vii
Contributors . . . . xix
1. Social Impact of Cellulite and Its Impact on Quality of Life . . . . . . . 1
Doris Hexsel and Camile Luisa Hexsel
Introduction . . . . 1
Aspects of Cellulite Related to QOL . . . . 2
Conclusions . . . . 4
References . . . . 5
PART I: DIAGNOSIS OF CELLULITE
2. Deﬁnition, Clinical Aspects, Associated Conditions, and Differential
Diagnosis . ......................................... 7
Doris Hexsel, Taciana de Oliveira Dal’Forno, and Stela Cignachi
Deﬁnition . . . . 7
Nomenclature . . . . 9
Clinical Aspects . . . . 9
Differential Diagnosis . . . . 21
References . . . . 24
Appendix . . . . 27
3. Anatomy of Cellulite and the Interstitial Matrix . . . . . ......... 29
Pier Antonio Bacci
Introduction . . . . 29
Cellulite . . . . 29
Interstitial Matrix . . . . 32
References . . . . 38
4. Pathophysiology of Cellulite . . . . . ....................... 41
Pier Antonio Bacci and Gustavo Leibaschoff
What Is Cellulite? . . . . 41
Deﬁnition . . . . 41
xiiiClassiﬁcation . . . . 43
Evolution . . . . 47
Lipedema and Lipolymphedema: Patholophysiologic
Hypotheses . . . . 50
Lipodystrophy . . . . 57
The Lymphoadipose System . . . . 58
Venous–Lymphatic Stasis . . . . 61
How Cellulite Develops . . . . 62
Manifestations of Cellulite . . . . 62
Clinical Classiﬁcation . . . . 63
Why Cellulite Is a Concern . . . . 63
Liposclerosis and Localized Adiposity . . . . 63
Etiopathogenic Factors . . . . 68
The Term ‘‘Cellulite’’ . . . . 70
References . . . . 72
5. Diagnosis . . . . ..................................... 75
Gustavo Leibaschoff
Patient History . . . . 75
Clinical Examination . . . . 75
Laboratory Investigations . . . . 80
ROM Test . . . . 81
Primary Instrument Examinations . . . . 82
Secondary Instrument Examinations . . . . 86
Photography . . . . 88
Diagnosis . . . . 88
Therapeutic Strategy . . . . 95
Medical History . . . . 95
References . . . . 97
Appendix A . . . . 98
Appendix B . . . . 101
6. Cellulite Characterization by High-Frequency Ultrasound and
High-Resolution Magnetic Resonance Imaging . . . . . . ........ 105
Bernard Querleux
Introduction . . . . 105
Materials and Methods . . . . 105
Results . . . . 108
Discussion . . . . 112
References . . . . 114
7. Clinical–Therapeutic Classiﬁcation: BIMED–TCD . . . ........ 115
Pier Antonio Bacci and Gustavo Leibaschoff
Introduction . . . . 115
Binazzi’s Classiﬁcation . . . . 115
Curri’s Classiﬁcation . . . . 116
xiv & CONTENTSBartoletti’s Classiﬁcation . . . . 116
BIMED Classiﬁcation . . . . 117
BIMED–TCD Classiﬁcation . . . . 127
Pathophysiological Classiﬁcation and Protocols of
BIMED–TCD . . . . 130
Edematous Cellulite . . . . 131
Adipose Cellulite . . . . 134
Interstitial Cellulite (Lipedema) . . . . 135
Fibrous Cellulite . . . . 137
Summary . . . . 139
References . . . . 140
8. Medical Treatment of Cellulite . . . ...................... 143
Gustavo Leibaschoff
Introduction . . . . 143
Abstracts of Studies in Cellasene1 . . . . 146
New Research About the Use of Cellasene1
or Cellulase Gold1 . . . . 147
References . . . . 153
9. Theory and Working Principles of Beautytek
in Cosmetic Medicine ................................ 155
Valerio Genitoni
10. Topical Management of Cellulite . . ...................... 159
Doris Hexsel, Debora Zechmeister do Prado, Jaggi Rao,
and Mitchel P. Goldman
Introduction . . . . 159
Deﬁnition and Nature of Cellulite . . . . 160
Pathophysiologic Mechanisms of Cellulite Formation . . . . 160
Topical Management . . . . 161
Conclusion . . . . 168
References . . . . 169
11. The Role of Endermologie in Treatment of Cellulite . ........ 171
Pier Antonio Bacci
Introduction . . . . 171
Anatomy and Physiology . . . . 173
Adipose Tissue and Lipoderma . . . . 176
The Superﬁcial Fascia . . . . 177
Massage . . . . 178
Manual Lymphatic Drainage . . . . 178
The Technique ‘‘Endermologie1’’ . . . . 178
Indications . . . . 181
Method . . . . 182
Conclusions . . . . 185
References . . . . 186
CONTENTS & xv12. The Use of TriActiveTM in the Treatment of Cellulite . ........ 189
Anju Pabby and Mitchel P. Goldman
Mechanism . . . . 189
Review of Cellulite . . . . 189
Parameters . . . . 189
Initial Studies . . . . 190
Other Uses . . . . 191
Contraindications . . . . 191
Protocol . . . . 191
13. Carboxytherapy . . . . . . ............................. 197
Gustavo Leibaschoff
Introduction . . . . 197
Indications . . . . 198
Treatment Method . . . . 201
Conclusions . . . . 207
References . . . . 209
14. Surgical Treatment
A: Lipoplasty, Vibro-Assisted Liposuction, Lipoﬁlling,
and Ultrasonic Hydroliposuction . . ...................... 211
Gustavo Leibaschoff
Lipoplasty . . . . 211
Historical Background . . . . 212
B: VASER ...................................... 220
Alberto Di Giuseppe
Deﬁnition . . . . 222
Fat Tissue Vascularization . . . . 223
Patient Selection . . . . 223
Prescriptions . . . . 228
Postoperative Scheme . . . . 229
Conclusion . . . . 230
C: Vibro-Assisted Liposuction . . . . ...................... 231
Pier Antonio Bacci, M. Scatolini, P. Belardi, S. Leonardi, and
S. Mancini
Introduction . . . . 231
Lipoplasty . . . . 232
Lipolymphosuction . . . . 232
The Vibro-Assisted Method . . . . 232
D: Lipoﬁlling . .................................... 234
S. V. Savchenko, Marlen A. Sulamanidze, and George M. Sulamanidze
Lifting . . . . 236
Liposhifting . . . . 237
xvi & CONTENTSE: Ultrasonic Hydrolipoclasis (External Ultrasound) . . ........ 239
Maurizio Ceccarelli
Cavitation . . . . 242
Biological Effects . . . . 242
Technique . . . . 244
References . . . . 248
15. Subcision ....................................... 251
Doris Hexsel and Rosemari Mazzuco
Introduction . . . . 251
Indications and Mechanisms of Action . . . . 251
Contraindications for Subcision1 . . . . 254
Preoperative Consultation . . . . 254
Surgical Technique . . . . 254
The Postoperative Period . . . . 257
Complications . . . . 257
Conclusions . . . . 260
References . . . . 262
16. Mesotherapy in the Treatment of Cellulite . . ............... 263
Gustavo Leibaschoff and Denise Steiner
A Brief History . . . . 263
The Concept . . . . 263
Action Mechanism of Mesotherapy . . . . 264
Beneﬁts and Advantages of the Method . . . . 265
Materials and Techniques . . . . 266
General Indications for Mesotherapy . . . . 267
Mesotherapy in Cellulite . . . . 267
Uses for Mesotherapy . . . . 270
What Is Mesotherapy? . . . . 271
Why Are Drugs Injected into the Skin? . . . . 271
What Drugs Are Used? . . . . 271
Which Drugs Should Be Used and How Should They Be
Administered? . . . . 272
Drugs and Products Used in Mesotherapy . . . . 277
No-Needle MesotherapyTM . . . . 282
Conclusion . . . . 283
References . . . . 284
17. Manual Lymphatic Drainage . . . . ...................... 287
Gustavo Leibaschoff
References . . . . 290
CONTENTS & xvii18. The Role of Dermoelectroporation . ...................... 291
Pier Antonio Bacci
Introduction . . . . 291
Transderm1 Method . . . . 292
Characteristic Features . . . . 292
Possible Uses . . . . 293
Dermoelectroporation Treatment . . . . 293
Clinical Study . . . . 294
Conclusions . . . . 297
References . . . . 298
19. Lipodissolve for Body Sculpting . . ...................... 301
Martin Braun
Introduction . . . . 301
Phosphatidylcholine (PC) . . . . 302
Deoxycholate (Deoxycholic Acid) . . . . 305
Availability of Lipostabil1 in the United States and Canada . . . . 306
Contraindications for Lipodissolve Injections . . . . 307
Side Effects of Lipodissolve Injections . . . . 307
Dosages and Techniques for Lipodissolve Injections . . . . 309
General Considerations for Lipodissolve Injections . . . . 309
Lipodissolve Formulae for Fat Pad Dissolution . . . . 310
Procedure for Injecting Lipodissolve into Fatty Pads . . . . 312
Clinical Examples of Lipodissolve Therapy . . . . 313
Lipodissolve Summary: Simple Injections for Fat Reduction . . . . 313
References . . . . 322
Index . . . . 323

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