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• Fibrosis is one of the most important aspects of cellulite…

• Fibrous septae or retinaculae cutis in cellulite?

• A visual representation of fibrosis in cellulite

• Without fibrosis there would be no cellulite

• Cellulite: a multi-faceted aesthetic condition

• WHat is fibrous cellulite then?

• What causes fibrosis in cellulite (and fibrous cellulite)?

• What can be done to break down the fibrosis and improve all other factors of cellulite?

• Fat: the elephant in the room

• Focus on fat or focus on fibrosis?

• Check our professional consultancy for a masterclass in radiofrequency, ultrasound cavitation, cellulite and skin tightening

Fibrosis is one of the 7 aspects of cellulite…

…together with fat accumulation, water retention, skin laxity. inflammation, free radical damage and glycation.

Fibrosis in cellulite refers to excess accumulation and contraction of collagen in the hypodermal skin ligaments that connect skin above with the fascia below.

(These skin ligaments are also called cutaneous retinaculae, fibrous “septae” or “collagen bands” by different people. Fibrosis occurs at the deepest skin layer, called the hypodermis.)

The contraction and thickening of these collagen fibre bundles means that skin is pulled down by the retinaculae cutis, while it is pushed up by fat adjacent to them.

The end result is the “orange peel skin” (also known as “cottage cheese skin”) appearance.

Fibrous septae or retinaculae cutis?

By the way, the term fibrous septae, although widely used is wrong. Research has shown that there are no septae in cellulite, i.e. there are not entire walls that separate fat compartments from each other. There are skin ligaments instead, that connect skin above to fascia underneath.

On ultrasound and MRI these things may deceivingly look like septae. Merriam-Webster defines a septum as “a dividing wall or membrane especially between bodily spaces or masses of soft tissue”.

However, microphotography reveals just retinaculae cutis. Merriam-Webster defines a retinaculae cutis as “One of the numerous small fibrous strands that extend through the superficial fascia attaching the deep surface of the dermis to the underlying deep fascia determining the mobility of the skin over the deep structures”.

Much more accurate.

So the term “fibrous septae” or “cellulite septae” is downright wrong and based on erroneous presumptions about the nature of cellulite, which have been debunked for more than 15 years now.

In fact fibrous septae are found on the subcutaneous adipose tissue (what people call ‘fat’) but not on the hypodermal adipose tissue (what people call ‘cellulite’). And this is probably the root of all the confusion about “septa” in cellulite.

Yet most cellulite “experts” still talk about “septae” in cellulite.

Oh well…

A visual representation of fibrosis in cellulite

The cellulite appearance is equivalent to a leather couch upholstery. In this representation:

• Leather equates to skin: the thinner leather/skin is, the saggier it looks

• The buttons attached to the bottom of the upholstery equate to the retinaculae: the tighter the buttons/retinaculae, the more pronounced the bumpy appearance

• The foam inside, which pushes the leather upwards, equates to fat: the more foam/fat, the more pronounced the bumpy appearance

Without fibrosis there would be no cellulite

As we see in the example above, the thicker and more shortened the retinaculae are, the worse cellulite looks. And of course the more fat accumulation there is, the worse cellulite also looks.

Without fibrosis, i.e. with the retinaculae being of normal thickness and not shortened, there would be no cellulite. And of course, without excessive fat accumulation, the primary cause of cellulite, there would be no cellulite either.

Cellulite: a multi-faceted aesthetic condition

This means that cellulite is not just a connective tissue (i.e. retinaculae) problem, as some simpletons claim.

Neither, of course it is “just fat”, as some other simpletons claim.

Nor is it just a water retention issue, so “all you need to do is have lymphatic massages” every week, forever, as some really simple simpletons believe.

The reason for simple minded options not doing much is because cellulite is a multi-faceted aesthetic condition: it is both a connective tissue and a fat accumulation problem, with skin laxity and water retention also being very important. Inflammation, free radical damage and glycation are also part of the problem.

WHat is “hard cellulite” / fibrous cellulite then?

Fibrous cellulite or “hard cellulite”, is cellulite with a high degree of fibrosis.

Fibrous cellulite usually occurs in people with stronger connective tissue.

Not always though. In severe cellulite we may observe both extremely fibrous cellulite AND skin laxity. This makes treating hard cellulite even more difficult, leading to a choice between breaking down the fibrosis or tightening up the skin.

In most cases of fibrous cellulite, fibrous cellulite is a worse visible issue than loose skin, so priority on breaking down cellulite fibrosis makes more sense than tightening up the skin.

What causes fibrosis in cellulite and fibrous cellulite?

So what causes fibrosis in the fibrous bands / skin retinaculae?

It is simple:

• As fat accumulation in the hypodermis pushes skin up, retinaculae are chronically stretched

• When these skin ligaments are stretched - especially in a chronic, low grade inflammation environment, such as the one which occurs in cellulite - they react by becoming shorter and more fibrous / thicker

• The result is shortened and thickened fibrous retinaculae, while at the same time the dermis itself is quite often too thin and lax, i.e. the opposite of fibrosis

The combination of fat accumulation, skin laxity, inflammation and water retention makes cellulite very complicated to treat.

Hence we always insist on a combination of treatments and creams plus healthy nutrition and exercise:

• just using “fascia blaster” tools (which actually not even “blast” the retinaculae at all, the mainly works deeper, in the subcutaneous fat)

• or just diet/exercise

• or just lymphatic massages

• or just…

…will not work.

A holistic, combined approach is needed.

What can be done to break down the fibrosis and improve all other factors of cellulite?

It is important to note here that:

• Unlike the example of the leather sofa above, the fibrous retinaculae are not equal / identical: some are very thick or very thin and some are very long or very short

• Once fibrosis gets established in the hypodermis, it cannot be totally broken down

These two things are the reason why cellulite cannot be totally eliminated or gotten “rid of” completely. So in 95% of the cases is is all about cellulite reduction, not cellulite elimination.

The best anti-fibrotic cellulite treatments are

• High-power ultrasound cavitation, primarily

• And strong, cellulite-specific massage, secondarily

The best anti-fibrotic natural molecules that can be included in cellulite creams are:

• centella asiatica triterpenes: asiatic acid, asiaticoside, madecassic acid, madecassoside

• curcumin

• EGCG

Fat: the elephant in the room

Breaking down fibrosis is all good, but that will achieve nothing unless we first reduce the fat accumulation, which is the primary cause of cellulite.

This can be done with healthy diet, exercise; deep-acting, high-power radiofrequency; and high-power ultrasound cavitation.

(We always insist on “deep acting” and/or “high-power” for RF/cavitation treatment, as the usual superficial or low-power versions achieve absolutely nothing.)

The following cellulite cream molecules, found in those rare real cellulite creams, can also be helpful: forskolin and caffeine (primarily) and centella asiatica triterpenes, curcumin and EGCG (secondarily).

So although breaking down the fibrosis is important, reducing hypodermal fat (cellulite fat) will act on the primary causes of cellulite and offer maximum benefits.

Focus on fat or focus on fibrosis?

Unfortunately today most people instead of focusing on removing cellulite fat, the elephant in the room, focus on removing the fibrosis, even by cutting out the retinaculae completely (subcision, cellfina etc), which is disastrous, or dissolving all collagen in the area with injections (collagenase injections, qwo), which is downright stupid.

The retinaculae and collagen are there for a reason: to keep skin in place. By breaking them down in order to reduce cellulite (which in most cases does not even happen, i.e. cellulite is not really reduced) you end by making skin jelly-like loose. Not smart…

Yes, it’s good to focus on fibrosis but not primarily. Cellulite fat reduction should be the primary aim, not reducing fibrosis at the cost of undermining skin firmness.

In fact, by creating firm skin and reducing fat, fibrosis immediately becomes irrelevant, as the firmer skin automatically hides the cellulite bumps. But that’s material for another article…

Check our professional consultancy for a masterclass in radiofrequency, ultrasound cavitation, cellulite and skin tightening

Do you want to deeply understand radiofrequency, ultrasound cavitation, cellulite and skin tightening? Attend a half-day, 1-day or 2-day or 3-day professional consultancy / one-to-one training and confidently offer your clients the safest, strongest and most effective treatment possible. Service available via Zoom or at our central London practice.