Comparison of Cellulite Severity Scales and Imaging Methods

Abstract

Cellulite is characterized by dimpled contour alterations of the skin and is present in approximately 85% to 90% of postpubertal females. Although the pathophysiology of cellulite remains to be fully elucidated, experimental evidence indicates a multifactorial process involving the number and types of fibrous septae, microvascular dysfunction, subcutaneous inflammation, decreased dermal thickness with age, and fat deposition. Cellulite is a major cosmetic concern for many women, and a number of both noninvasive (eg, massage, cosmeceuticals, laser therapy) and minimally invasive techniques (eg, subcision, collagenase injection) have been evaluated to improve the appearance of the affected skin. However, evidence for many of these treatments is limited, largely due to the lack of a validated, convenient tool for the standardized evaluation of cellulite severity. Various imaging modalities have been employed to characterize cellulite severity and the impact of treatment, but only 2-dimensional and 3-dimensional digital photography have been adequately validated. However, in many cases, imaging findings do not correlate with subjective measures of cellulite severity. A number of cellulite rating scales have been developed; some provide only a qualitative measure, whereas others do not fully capture all clinically relevant aspects of cellulite, including the perspective of the patient. There remains an unmet need for global adoption of a validated scale that can be utilized easily by clinicians and patients in clinical and research settings. We propose features that should be included in an ideal rating scale for assessment of cellulite severity.

© 2020 The Aesthetic Society.

Figures

Figure 1.

Fascial architecture of females. Structure and arrangement of skin and subcutaneous tissue of individuals with low to normal BMI (upper panel) or high BMI (lower panel) are shown. The arrows demonstrate the interplay of biomechanical forces (blue arrows: outward force of fat lobules; red and grey arrows: inward tethering force of the septal network, with illustrated dimorphism between the numerous short and thin septae [grey arrows] vs the fewer long and thick septae, which have greater stability [red arrows]; orange arrows: inward containment force of the dermis). Reprinted with permission from Rudolph et al. BMI, body mass index.

Figure 2.

Fascial architecture of males. Structure and arrangement of skin and subcutaneous tissue of individuals with low to normal BMI (upper panel) or high BMI (lower panel) are shown. The arrows demonstrate the interplay of biomechanical forces (blue arrows: outward force of fat lobules; red and grey arrows: inward tethering force of the septal network, with illustrated dimorphism between the numerous short and thin septae [grey arrows] vs the fewer long and thick septae, which have greater stability [red arrows]; orange arrows: inward containment force of the dermis). Decreased probability of a mattress-like skin appearance at the skin surface in men may be due to the greater number of fibrous connections between the superficial fascia and the dermis, providing greater stability. Reprinted with permission from Rudolph et al. BMI, body mass index.

Figure 3.

The DiBernardo scoring system for evaluating cellulite dimples in women. The number of evidence dimples are rated on a 0 to 4 scale. Each photo is marked with 5 circles, which may or may not contain a dimple. This ensures that the evaluator is not confused by nondimpling irregularities and avoids bias by not being explicitly told where dimples are located. Photos show (A) score 0 (no dimples); (B) score 1 (1 dimple); (C) score 2 (2 dimples); (D) score 3 (3 dimples); (E) score 4 (4 or more dimples). Reprinted with permission from DiBernardo et al.

Figure 4.

The DiBernardo scoring system for evaluating cellulite contour irregularities in women. Contour irregularities are rated on a 0 to 4 scale. Photos show (A) score 0 (none: no depressions or raised areas); (B) score 1 (superficial irregularities: generalized, small depressions with no protuberances; (C) score 2 (mild irregularities: pattern of mild linear undulations with alternating areas of protuberances and depressions); (D) score 3 (moderate irregularities: pattern of moderate linear undulations with alternating areas of protuberances and depressions); (E) score 4 (severe irregularities: severe generalized linear undulations with alternating areas of protuberances and depressions). Reprinted with permission from DiBernardo et al.

Figure 5.

PR-PCSS and CR-PCSS for assessment of cellulite severity in women for the (A) buttocks and (B) thigh. CR-PCSS, Clinician Reported Photonumeric Cellulite Severity Scale; PR-PCSS, Patient Reported Photonumeric Cellulite Severity Scale. ©2017 Auxilium Pharmaceuticals, LLC. All rights reserved.

Figure 6.

Ultrasonography of the dermis of a woman presenting with cellulite. Images are of the dermis (green), hypodermis (black), and dermal–hypodermal interface showing fat herniations into the dermis at baseline (left) and 6 months after treatment with a 1440-nm pulsed laser (right). The vertical measured length is 12 mm in each image. Reprinted with permission from DiBernardo et al.

Figure 7.

Magnetic resonance imaging of cellulite from this 29-year-old woman at (A) baseline and (B) after subcision. Baseline image (A) shows a clear spot on the top of the depressed lesion with a perpendicular thick fibrous septum associated with this lesion and (B) the same area 7 months after subcision, showing the severed septum. Arrows 1 and 2 indicate anatomic structures utilized as a guide to obtain the same slices of bone and muscle layer, respectively. Arrow 3 points to the septum arising from the muscle. Reprinted with permission from Hexsel et al.