Ask An Expert | Cellulite Myth Busting

The following is an excerpt from the Glow Journal podcast. To listen to the full interview, subscribe now on iTunes or Spotify

In this instalment of our Ask An Expert series with our friends at Candela Medical, we’re taking YOUR questions to Dr Andreas Fox. Qualified from Oxford University, Dr Fox worked as a consultant plastic and aesthetic surgeon for some of London’s largest and most prestigious hospitals before moving to Sydney to pursue a career in non-invasive medical aesthetics. With over 20 years of experience, Dr Fox was who I felt was the ideal doctor to objectively answer YOUR questions and bust some myths around on cellulite, skin firming and skin tightening.

Away from our regular brand founder conversations, I am frequently asked so many highly specific questions about the skin. Given that I am an educated consumer and by no means an expert, it would be extremely unethical for me to even attempt to address your skin concerns- which is why I have long insisted on taking those questions to a medical doctor. That’s why I truly love producing this Ask An Expert series with Candela. Although the series itself is sponsored, doctors legally and ethically have to remain completely objective in interviews like this. For this reason, this series is the single most authentic way for me to integrate branded content into the podcast because it’s giving you, the listeners, completely unbiased expert answers to your most specific skin questions.

GLOW JOUNAL: Before we start talking treatments, I think it’s really important to actually know what we’re treating. So, to start, what is cellulite?

DR ANDREAS FOX: Cellulite is essentially a condition of the skin and of the underlying fatty tissues. It results in a sort of cobblestone appearance with lumpiness and dimples, primarily affecting the buttocks and the outer thigh area- although it can be seen also in the upper arms and lower tummy as well. It’s variable in its severity and variable in its distribution.

Now, essentially there are two components to cellulite- there is a skin component and there’s a fatty tissue component. The skin component, which is often the most troublesome, essentially consists of “cords.” If you imagine a piece of string that is stuck to the underside of your skin, pulls downwards and is attached to the deep tissues, commonly muscle or the connective tissue just about the muscle that surrounds the muscle and pulls down, and that gives you the sort of dimpling. And then, on either side, the specific architecture of the fatty tissue results in that sort of bouncy appearance upward. So you get this sort of lumpy, bumpy, dimply, cobblestone-y appearance, but there are two components to that. There’s the skin bit, and there’s a fatty tissue component. So it makes it much more challenging to sort of get your head around.

Do we actually know what causes cellulite and if there’s anything that we can do to minimise our chances of getting it down the track?

The causes are unclear. The underlying pathophysiology is not anywhere really in the literature, very clearly understood or explained. But we do know that there are risk factors and, therefore, certain things that we can do in order to reduce the chances or minimise the extent of the cellulite.

Women, for a start- why do women get cellulite? It’s so much more common in women than it is in men! A few reasons. Really, this most commonly relates to the distribution of fatty tissue. It’s much more common to have pockets of fatty tissue around the thighs and buttocks in ladies than in gents. Also, the actual architecture of the fat cells just underneath the surface of the skin is different, so therefore sex is the biggest risk factor in development of cellulite.

Weight can also be an issue and we can talk about that a bit later on. Things like lack of exercise, therefore not having such firm, toned muscles to support those strings and therefore, as the muscle flops downwards a little bit more, it will pull a little bit more downwards giving the dimpling a worse appearance. Whereas if you’ve got a more toned, say lateral, thigh muscle, that will provide a far more stable base. and therefore that cord isn’t as tightly pulling downwards.

Hormonal factors can also affect that, and that also relates to why it is potentially worse in or after pregnancy. There are also genetic reasons- it just runs in some families. And the fact that, especially the more severe types of cellulite, are seen in families, it tells me that this multifactorial. It’s not one thing. It’s a lot of different things. There are genetic and environmental components to it. Age is another thing, because lack of a elastin and collagen in older age results in less elastic skin, which can’t resist the pulling down motion.

So, in summary, no, we don’t know what causes it. There are many different factors that contribute to its development and some people get it worse than others.

I’m so glad that you’ve touched on so many different reasons there, because I feel like one of the biggest myths is that it’s just weight-related. We think “Oh, I’ve put on a bit of weight so my cellulite’s so bad now,” but can you talk to me a bit about that? Obviously you’ve mentioned that it’s to do with these fatty pockets, but it’s not just weight-related.

No, it’s not, and in fact a lot of my clients who are not particularly overweight and have cellulite seem really  frustrated. I think the reason for that and how I explain it to my, say, “slimmer” clients, is that distribution and architecture of fatty tissue, that is the key to the development of cellulite. And therefore you don’t need a lot of fatty tissue in order to get the appearance of cellulite. Now, those sorts of body types, ie. a reasonable BMI with a good exercise and diet regime, will have slightly less extensive cellulite, but they will have it. And that really comes down to the fact that the fatty cells just underneath the skin have a particular distribution and a particular organisation that is independent of the amount of fatty cells. And so it really comes down to the fact that, at the end of the day, it’s the arrangement of fatty cells on the underside of the skin that gives you that appearance. Some will have it worse than others. No doubt, if you’re overweight, you’re carrying a little bit more weight, especially in the more vulnerable areas, that will make the distribution more extensive and the severity greater.

I had a number of listeners ask about post-pregnancy cellulite. I’ve had one listener ask “Does cellulite actually get worse with pregnancy or is that a myth?”

That’s a really good question because it’s something that I very commonly get asked. I think there is certainly a worsening of cellulite with pregnancy, it is possible to get worsening of cellulite especially towards the end of pregnancy and also after pregnancy. “I’ve never had it before and now I have it- what’s going on? Why do I have cellulite suddenly after I’ve already given birth?”

Again, it’s a multifactorial thing,  but because it’s a common question I just want to spend a little bit of time on that. During pregnancy, there is a change in lifestyle. There will be, perhaps, a reduction in the amount of exercise. There may be some changes in diet based around cravings, based around not being so conscientious about controlling junk food. Things change as a result of pregnancy. So a lifestyle component that results in an alteration in your vulnerability, if you like or for want of a better word.

Also, during pregnancy, some women suffer more than others with a degree of water retention, and this affects various regions of the body and indirectly exacerbates the pockets of cellulite and makes it more obvious. So it’s there, but it becomes much more obvious. There are also hormonal changes, and there is some evidence to suggest that various hormones whose levels are vulnerable and changing during pregnancy, such as oestrogen or prolactin and also insulin and thyroxin, have an effect on various metabolic processes that increase vulnerability and also the physical increase of weight. As you sit down, if you’re heavier, there’s greater pressure of the side of the buttocks or the lateral thighs, for example. And that can create a few more of indentations that results in cellulite. So there are lots of different reasons why you may get worsening of existing cellulite or the beginning of cellulite when you didn’t have it before. The likelihood is that you did have it, it was really mild and it just wasn’t on your radar. You didn’t see it particularly in any noticeable way, but there are lots of different things that changed during pregnancy that make you a little bit more vulnerable.

I’ve had another listener tell me that she has never really had issues with cellulite before, so perhaps this is what you’ve just mentioned- that she did have it and just didn’t notice it. But since giving birth, she said she has really, really obvious cellulite on her legs. What would be her best treatment options?

So look, the first thing to do is accept that there will be some fine tuning of your physiology back to status quo. So lactation, which happens after pregnancy, also comes about through changes in hormone levels. So all I would say to somebody who would come and see me, for example, I would say, just give it enough time after you’ve stopped breastfeeding and see what degree of correction you have once you feel you’re getting towards your pre-pregnancy shape and just your way of feeling, which tells me that your physiology is becoming a little bit more steady state and a little bit more back to normal. Then if there is still a persistent problem, then we can assess it at that point. It’s foolhardy to try to intervene at a point where there may still be some natural improvement and resolution of the problem. So I think it’s really important to not rush into trying to deal with an issue, whatever that post-pregnancy issue is, until you’re way past the breastfeeding stage and you’re you feel that you’re getting back to normal again.

Can you talk to me a bit about laser and cellulite? I received a number of questions about VelaShape– what is this? And is it a viable option for cellulite reduction?

Sure. So there are lots of different devices on the market doing a variety of jobs in an effort to try and get to the bottom of this. Velashape is a device that uses a combination of treatments. There is vacuum technology that brings us in much closer to the device. And then there is a combination of infrared and radio frequency. Equally, there are devices that use laser. Fundamentally, the aim of this is to create a degree of damage to the fat cells and a degree of remodelling to the cords.

It’s really difficult to get a device that does these things together. Personally, I use Profound. I think for me, when it comes to cellulite, that is by far the most effective device on the market from the point of view that it deals with, very effectively, the skin and the cord and the fatty tissue.

But as far as some of the other devices are concerned, say VelaShape, you would expect the results in about eight to 10 weeks. It’s probably better for reduction in fatty tissue. So for a heavier client that has a little bit of cellulite, but also quite a large diameter of, say, the upper thigh, then that would be a more effective choice. It’s particularly good at fat reduction, not so effective at dealing with the cords that pull downwards.

It’s not always a permanent thing. That’s the issue. Because not all the fat cells are permanently destroyed. So they are able to extend themselves again. We’re all born with a certain number of fat cells. They don’t increase in number. They increase in size. And so if you effectively eliminate them, they won’t come back. Surrounding fat cells will come back. If you haven’t effectively eliminated them, then they may survive and then begin to grow again.

Multiple treatments, that’s a common aspect of some of these devices, VelaShape included. I think the third generation of VelaShape has improved the number of treatments. I think it’s now down to about three. And, of course, response varies. That is the commonality to any of these devices.

You mentioned the Profound in there, which is great because I did receive some questions on that as well. Could you talk a bit more about that and how it works?

Profound uses tiny needles to direct radio frequency to the target tissue of interest. So the radio frequency is essentially a form of energy that creates very specific and very accurate thermal injury. The body responds very effectively to a thermal injury and heals where the components that were there already. Wwhat I really like about Profound is that it deals with the skin. So the skin part of Profound will return collagen and elastin and hyaluronic acid to the deep layer of the skin that gives us that elasticity, that bounce, that firmness. The literature also shows us very clearly that the cords that I mentioned at the beginning are remodelled to become much more elastic and therefore less likely to pull downwards. And, at the same time, the fatty tissue component of Profound eliminates effectively the fatty cells, because you’re inserting the needles and therefore the source of radio-frequency that results in the heating at the point of contact. It’s far more effective at eliminating those fat cells, and heat is probably one of the best types of “injury” that the body will respond to. So that’s why I’ve really seen some great results with Profound, simply because I feel that it really deals with both the issues that we spoke about skin and the cords that I put together as the skin problem, and also the fatty tissue pockets on either side of the cords.

And does that one require repeat treatments as well?

No! My American colleagues call it “one and done.” The reason why it’s a very long-term result is that the body will heal, as I said earlier, with what was there before. So it very naturally replaces collagen, elastin and hyaluronic acid. And once it responds to the thermal injury and replaces the constituent proteins and hyaluronic acid, they will stay there once you injure effectively and specifically the fat cells, they will be absorbed by the body and treat it as dead cells effectively.

Now, if you change your habits and you put on a lot of weight, you’re obviously much more vulnerable to that recurring. But in principle, this is not something that we will do again and again, and again. The rate limiting factor is the amount of volume of local anaesthetic. So if a client has extensive cellulite, I will tend to treat the area that is particularly troublesome first and then come back and treat another area. It is possible, of course, to have Profound without general anaesthetic, in which case you can deal with the whole area as one session. But in a clinic scenario where you walk in and walk out, usually what I will do is treat the most severe areas first and then come back and deal with others if they’re extensive. To be honest, a lot of my clients have the distribution that I can deal with in one session so it’s not too much of a problem.

You have touched on a few of them, but what would you say are the big key differences between Profound and Velashape?

I think the ability to deal with the skin component is more effective in Profound. The ability to deal with the fatty tissue is probably more effective with VelaShape. I think that the easiest thing to deal with is the fatty tissue, so the reason why I’ve sort of steered towards Profound is that it’s far more effective, in my eyes at least, in dealing with the skin component and that is the most challenging and most difficult part. I’m not so concerned about the fatty tissue. I’m happy with the degree of minimalisation, if you like, of the fatty tissue with profound. But as I said at the beginning, Velashape is good if you’ve got lots and lots of fatty tissue and not so much of a an issue with the skin.

When treating cellulite, do different areas of the body need to be treated differently?

Again, it depends if it’s more of a skin thing or more of a fatty component. So the key is the accurate and appropriate assessment. So, like anything, choose your clinician. If you’re happy and confident with your clinician and their expertise, then they will make the right decision for you.

But it’s a smart question, because when I assessed the cellulite, if I feel that there is a more significant skin component, rather than fatty tissue components, I will really focus on that. If I feel that there is more fatty tissue component than skin issues, I will spend more time trying to deal with the fatty tissue. So it really varies. And the most important thing is to, really, get an expert opinion and be happy that they, the clinician who is looking at you and treating you, has a degree of expertise in dealing with this.

A listener writes in saying “I have deep dimples on my backside. Is this cellulite?”

It may be! It’s the most likely cause. In the absence of an injury, trauma, surgery, things like that, it is most likely to be this. Deep dimples, that’s going to be primarily a skin and cord issue. So that’s actually a good example of the degree of contribution of the two components. Not everybody has the same degree of issue. Some people may have very, very light dimples, but quite a sort of cottage cheese or orange peel appearance throughout. That tells me that the skin component is not too bad, but it’s more of a fatty tissue component. I will focus on that. But somebody who says I’ve got really deep dimples, and then when I look at them I’m like “That is a much more of a skin issue rather than a fatty tissue issue.” So again, diagnosis and careful consideration of the cause is important in trying to decide the best way to treat it.

Something that I was asked a lot about was topical treatments. Can topical skincare products like creams and scrubs actually reduce cellulite?

Oh my goodness, Gemma. Where do I start with that?! Look, there are certain facts about this. Anything that you put on the skin, anything that is topical, will remain at the very superficial levels of the skin. That is what it’s designed to do. That is where it works. So, at no point can we say that topical skincare products will treat the underlying cause. Therefore, if you’re not treating the underlying cause, the only thing that you can achieve is camouflage, which is fine if you’re happy to accept the fact that there will be a recurrence and recurrence and recurrence. The degree of camouflage is very variable. So all I say is use it in conjunction with something that will treat the underlying cause.

There are very few studies that have been well controlled and conducted to show that any of the various topical treatments are particularly effective. There will be proponents of one versus the other for various reasons, but there is such variability in the response because we are all different. You and I may have slightly different collagen and elastin, we might have slightly different fatty tissue distribution, slightly different degrees of cords pulling downwards. We are all different, and therefore it’s highly unlikely that one thing will be good for all of us, because we know this is a very multi-factorial thing.

So, by all means, if you want to try a topical treatment, try it, see if it works for you. Moderate your expectations, and accept that this is camouflage but not dealing with the underlying cause. And that may be enough. It may be fine. But at the end of the same, if it’s something that really troubles you and you’re not getting the sort of improvement that you want with a topical application, then look at dealing with the underlying cause and then also use a topical application to camouflage.

What about something like dry body brushing? I had a few listeners ask if this can help at all.

It’s designed to stimulate blood flow, and really anything that does that, in principle, could promote more collagen, more elastin production, faster turnover of cells and so on and so forth. It’s that, again, there aren’t any decent studies that would say yes or no either way. It’s a very simplistic way of looking at it. Again, it doesn’t treat the underlying cause particularly effectively, or specifically, or accurately. But I can understand the rationale behind using it. And it goes a little bit like my advice with topical treatments- by all means try it, moderate your expectations, accept that the outcome and improvement may not be dramatic. But if for some reason it works for you, great!

I was also asked a lot about diet. Is there any truth to claims that certain foods can reduce our chances of getting cellulite or reduce the appearance of existing cellulite?

My goodness, every week there is something that is either good for you, bad for you, this causes cellulite, this treats cellulite!

Again, these are only observational studies. They’re not particularly well controlled. It’s very hard to prove because there’s so many confounding factors [that are] very hard to correlate, again, because we’re all different. If I give you a tablet, and I give it also to somebody else and you get a really good improvement and they don’t, is it because of the tablet or is it because of something else intrinsic within each of you? So it’s very difficult to prove that anything works. A lot of this data and a lot of these reports are anecdotal and observational.

My fundamental advice to clients is that you are defined by your habits, not your indiscretions. No matter what you do in life, if you have a balanced diet and a reasonable amount of exercise, you will be defined by that. Whether or not there are a few indiscretions on the weekend or at some point in the week, that’s fine. But get into a good, healthy routine of exercise and a decent diet in the majority of the time. I wouldn’t really try particularly hard to eliminate this or the other, but again, if in doubt, try it, and if it works for you great.

It’s the same with a lot of alternative medicine. I would never say that I’m against it, I would just say keep hold of the conventional that has a good science-base, and by all means add to that something different that is perhaps less scientific. And sometimes things work, even though we don’t have good science behind it. And so by all means try it! But I wouldn’t focus on eliminating or adding certain things, but I do appreciate there’s plenty of reports that suggest this is good for you. This is more likely to give you better or less cellulite than this is definitely a bad thing for cellulite. And there are good reasons for some of those. But it probably wouldn’t be my priority in trying to treat cellulite.

Moving on a bit from cellulite- what about skin that we want to firm or tighten? What causes skin that isn’t quite as firm as we would like?

Several things, and I think of them in two categories- intrinsic to the skin, and issues either above or below the skin.

So, intrinsic to the skin first. The degree of collagen, elastin and hyaluronic acid are essential in determining the firmness of skin. As we age, for example, from our late twenties onwards, we begin to lose and metabolise collagen, elastin and hyaluronic acid. And so, we lose intrinsically the bounce and firmness that we would have had in our teens and twenties. So that is the most common thing, or factor, that results in lack of firmness and loose skin.

And then there are other considerations. For example, if you consider the skin around the face, there are certain points along the face whereby the skin is connected to the underlying skeleton by ligaments. So when these also lose their firmness and elasticity, they are not as effective at propping up and keeping up the skin. Similarly, underlying muscle tone- if there isn’t that sort of firmness to support the skin, then there is a far easier platform for skin to become loose.

Very similarly, factors from above the skin. So if we don’t use SPF, if we allow the effects UVA and UVB and various other environmental pollutants to have their effects on the top layer, that will also have effects on the degree of collagen and elastin, cellular turnover and so on and so forth. So I think there are, in summary, components within the skin, principally collagen, elastin, and hyaluronic acid, and components or factors above and below the skin, which could be anything from muscle tone, ligaments and environmental pollutions.

You’ve mentioned how there are a couple of different “categories” of loose skin. Is there a difference between just quite general skin firming and tightening compared to treating something like loose skin from the stomach post-pregnancy, or other areas after quite extreme weight loss?

Yeah, absolutely.  And I think when treating anything, you need to think “What is the underlying cause and how can I address that?” So lack of firmness around, say, the lower part of the face. Then that [requires] a different way of treating things than, say, the looseness and lack of firmness in the lower part of the tummy post significant weight loss and pregnancy. And so you need to really look at what is the underlying cause, and then how can I address that course?

So for example, the excess skin that results in the lower part of the tummy post pregnancy or after significant weight loss, that may actually require a surgical solution. Whereas a lack of firmness to the lower third of the facial skin may simply require some skin booster technology or some dermal filler or some topical treatments. So there are different treatments for different conditions, and the most important thing, and I go back to this, is that you’re comfortable that your clinician has the level of experience and expertise that is necessary to really understand the fundamentals of what is the cause of this problem and what are my options in treating the problem. But you’re right to ask the question, because there are many different causes and therefore many different treatments.

A listener asks “What is the best thing that I can do to firm the bottom half of my stomach after a C-section?”

That’s a fair question. Again, there are lots of causes for that and therefore we need to address those in turn. If there is any excess tissue, then we need to consider whether or not there is a need to surgically remove that or at least revise the abdominal closure at the point of the C-section, and this usually declares itself once everything has healed and you’re post breastfeeding and you’re feeling as if you’re kind of back to your post-pregnancy physiology and feeling and body habitus. If you then think this is excess skin, I didn’t really have this beforehand, it may well require surgical attention.

Other, more subtle, ways of improving things is improving core stability and tone of the lower abdominal muscles. So yes, going to pilates or specifically addressing the abs once you’re up and around and getting back into the gym again, would help to an extent to maintain a degree of firmness in the skin if the problem is subtle.

Another listener asks “Are there any laser treatments that would work for the ridges made by stretch marks and the loose skin from weight loss?”

Yes, you can use laser to treat stretch marks of any cause. Like any treatment for stretch marks, if they’re relatively new and thin, they will respond better to treatment. Again, variable response, and it may well help. My approach to stretch marks is treat early rather than sitting on it and leaving it. Topical treatments can help to camouflage again, but fundamentally, yes, we need to get a little bit of more collagen and elastin in the underlying tissue and surrounding tissue to try and improve that- again, moderating expectations. We don’t have an eraser to rub over a stretch mark and make it go away. But if it’s something that bothers you, it’s worth getting an expert opinion about it. There are lots of different ways of treating it.

I received a number of questions around micro-current technology for skin firming. What is micro-current and how does it work?

Microcurrent, essentially, is the use of low voltage currents in order to stimulate some underlying muscles, ie. giving them a bit of a workout and also to increase the amount of blood supply and collagen turnover. It also decreases the degree or amount of protein degradation. The best evidence in the literature is really based on facial muscles. Translating that to a bigger surface area and bigger muscles, I’m not quite sure that there’s the evidence base to justify doing that. And again, their response is variable. You need a lot of sessions. And one of the biggest criticisms is that you’ll be in and out of that clinic at infinitum. And in fact, one of the better scientific papers conceded that the biggest disadvantage is that they needed up to 30 sessions in order to get the best results. And the best evidence is for muscles of the forehead. But I really think I can achieve a very similar outcome, very natural and very authentic, with a little bit of Botox. So it’s not something that I particularly advocate, just because I think the evidence-based is not that great for areas outside the face, and we have better ways of dealing with facial skin issues.

Much like the questions I received from listeners around cellulite, I was sent many, many, many queries around topical skincare. Once again, is there anything at all that topical skincare can do to firm and tighten the skin?

Again, there are a lots of advocates for various different types of skin products. We must accept, as I touched on before, that this is a camouflage of the problem and not a particularly effective way of treating the problem, which is fine. Really, the essence is to improve skin hydration and promote collagen and elastin. The effectiveness of any of these products is variable. So before undertaking in a bulk buy of any product, try it for a little bit in a small area and see if it responds particularly well for you, but there is no one single thing out there that has been shown to effectively, for everyone, deal with the symptoms, even the camouflaging aspects of it. So because it’s so multifactorial, it’s a pathology that has lots of different components to it. I think if in doubt, take a small amount, put it over a small area, see how it responds for you.

Perhaps a nice, all encompassing note to wrap up on. One listener asks “What is the definitive, very best way to firm and tighten the skin and get rid of cellulite?”

That’s a Nobel prize right there isn’t it! Whoever identifies the one golden bullet, that’s it! You’ll be off to Stockholm to collect your Nobel prize!

Look, there’s no such thing as one thing. The reason for that is that the causes are multifactorial, the underlying physiology of each individual is different, and so it’s asking a lot of one thing to work really effectively for everyone. And so it goes back to what I mentioned earlier- choose your clinician with care. See somebody who’s an expert in the field, make sure that you get assessed appropriately and that your questions are answered. There’s never such thing as a silly question. Ask whatever you need to ask, make sure that you’re in safe, capable, competent hands, and follow the advice of your clinician. Any clinician worth their salt will always tell you that this is not something that we can just magically get rid of, but we can improve significantly. And so it’s a matter of doing the right thing for the right person using the right tool.