Treating Gynoid Lipodystrophy

Dr Saleena Zimri discusses radiofrequency as a suitable treatment for cellulite

Gynoid lipodystrophy (GLD) is a prevalent skin concern, and although data isn’t completely conclusive, the condition reportedly affects between 80-98% of post-pubertal women.1 Men can also experience GLD, although they are far less likely. GLD is more commonly known as cellulite, so for the purposes of this article we will refer to it as such. Cellulite is a multifactorial disorder of the subcutaneous tissue resulting in alterations to skin topography and creating a distinctive wavy or dimpled appearance.1,2 Cellulite occurs due to the herniation of subcutaneous papillae adipose through the dermo-hypodermal junction and is commonly identified on the gluteal, femoral, abdominal and brachial areas of the skin.2 Despite its prevalence, and although it is not considered to be a dangerous condition, cellulite has the propensity to affect self-confidence and selfesteem, with one consumer survey of 2,006 women revealing that 64% felt self-conscious about their cellulite, with 49% bothered ‘a great deal’ or ‘a lot’ by their cellulite.3 Another small study of 46 volunteers showed 50% of the study population reporting dissatisfaction regarding their appearance and 78% reporting the need to seek treatment.4 Causes Several factors are known to contribute to the development of cellulite and the most common include, but are not limited to: age, weight, genetics and hormones.

Age Skin loses elasticity as we age, making cellulite more likely to occur as we get older. There is limited literature to support this, but a few studies have demonstrated a connection between the two, with skin laxity noted as one of the major aggravators of this condition.5,6,7

Weight Weight gain or a higher body fat percentage can increase visible cellulite due to the way in which adipose tissue is distributed. However, it’s also been widely reported that weight loss may actually worsen cellulite for some individuals.8 Research has shown that 31% of the 29 women, who were enrolled in medically supervised weight loss programmes, saw their cellulite worsen.9

Genetics Cellulite may run in families, since the distribution of adipose, metabolism, ethnicity and circulatory levels are influenced by genetics. Certain genes are required for cellulite development with one Italian study of 200 women identifying genetic variants in the ACE and the H1F1A gene are associated with cellulite in healthy women.11

Hormones Research has suggested that hormones including oestrogen, insulin and catecholamines also play a role in determining predisposition to developing cellulite.12,13 All of these hormones are connected to fat breakdown and storage and oestrogen deficiency in life events such as menopause, which impacts production of type I and III collagen and elastin fibres, which also contributes to cellulite formation.13

Assessment of cellulite Accurate assessment, classification and scoring of cases of cellulite is imperative to allow the practitioner to establish the best course of treatment to suit an individual’s need. There are several scales available to assist clinical assessment and grading of cellulite. However, Hexel’s photonumeric scale is recognised as the first standardised and objective method of grading cellulite severity and is widely used by practitioners.14 The scale identifies five key features of cellulite structure: the number of depressions, depth of depressions, clinical appearance of raised lesions, presence of flaccidity and the grade of cellulite. Each of these gets graded from 0 to three, helping to identify the final classification of cellulite as either mild,

Before After four treatments One month after six treatments

moderate, and severe.14 Although recognised as an effective method of assessing cellulite severity, Hexel’s model did not take into account patient assessment and so subsequent scales were developed such as the Clinician Reported Photonumeric Cellulite Severity Scale (CR-PCSS) and Patient Reported PCSS (PR-PCSS).15 So, although Hexel’s scale is the most used and still encouraged to use, it’s worth knowing that it has a limitation and practitioners should consider adding patient assessment in addition.

Treatment using radiofrequency There are numerous cellulite creams, clinic treatments, and supplements on the market which promise to eradicate an individual’s cellulite. However, it’s important to note that currently nothing has been scientifically proven to completely ‘cure’ cellulite, so caution should be taken against making unrealistic efficacy claims when consulting with patients to ensure that realistic outcome expectations and the highest standards of clinical ethics are maintained. I have personally found that an effective and popular intervention when treating patients presenting with cellulite is device-led using radiofrequency (RF) technology. RF is a type of non-invasive energy-based treatment that targets cellulite and delivers deep thermal heating via electrodes through the dermis to the subcutaneous adipose tissues.16 The depth and degree of thermal effects are directly related to the power, the wave frequency (the higher the frequency the greater the surface activity), the energy/tissue coupling mode (resistive or capacitive) and the conductivity characteristics of the treated tissue: in tissues with higher impedance, such as osseus, muscle and adipose tissue for instance, more heat is generated. The thermal action causes vasodilation, increased microcirculation and metabolism of adipose tissue improving topography.16

RF technology has a good safety and efficacy record that is supported by clinical data.17,18 It is effective and safe for use on all Fitzpatrick skin types, adverse events are rare and the treatment has the added benefit of zero downtime, making it a good option for treating cellulite for both patient and practitioner alike.17,18 As the treatment modality delivers thermal heating deep through the dermis to the subcutaneous tissues, it is suitable for treating all grades of cellulite.9 In my experience, I would expect on average to see the grade of cellulite decrease by one. One study of 10 women demonstrated the following mean grading scores for the treated leg versus the control leg: dimple density of 2.73 vs 3.18 and dimple distribution 2.89 vs 3.32, following three to six treatments.19 It should be noted that treatment success is also dictated by the level of commitment by the patient in terms of lifestyle factors that include water intake and regular exercise.

Procedure As with any procedure, it’s essential to perform an in-depth consultation and clinical examination of the area, along with careful skin analysis prior to treatment to ensure that the treatment modality is tolerable and suited to the needs of the individual. Performing a small spot test on a small, shaved area before carrying out the full treatment and waiting until the next day to assess the results is recommended by the manufacturers of my device of choice to assess for any possible unforeseen adverse event that is unique to the individual. This also allows the practitioner to select suitable fluence for the patient, ensuring not to exceed the maximum tolerable level for the individual. The treatment area should be clean and free of lotions or fragrant products. Conductive cream or gel suitable for use with RF devices should be spread over the area to be treated as well as partially over the electrode surface, as recommended by the device manufacturer. In my experience it is beneficial to work in a circular motion directed towards lymph nodes located in the popliteal fossa until the patient experiences an intense, but not uncomfortable, heat. The electrode should always be kept in motion in order to avoid causing erythema or burning.20 Practitioners should also take electrode size into consideration. When having to treat large areas (such as femoral or abdominal areas) choose an electrode with a larger diameter. For my chosen device, the desired temperature can be achieved by setting the electrode size to the area you are treating and also by placement of the grounding pads. Remember, practitioners should refer to specific instructions from their device manufacturer for the most effective settings for that device. The duration of each treatment can run from a minimum of 30-60 minutes according to the number and extent of areas to be treated. Treatment duration and length differs between individuals and will depend on factors that include age, lifestyle, location and severity of their cellulite. However, on average, patients could expect one treatment every one to three weeks, for four to six treatments in total. In my experience, it is possible that some improvement could be visible up to six months after the last treatment in the course. My patients typically book a maintenance course of three treatments after 12-18 months.

Safety considerations Although RF treatments are considered to have a good safety record, and adverse events are rare, they can be further minimised by ensuring that manufacturer instructions for your chosen device are followed and proper techniques are used. The patient’s medical history should also be taken into consideration at the consultation stage, especially if they are taking any medicines that increase sensitivity to heat or change the skin’s metabolism (antidepressant medication is one such example). When it comes to aftercare, some patients require a cooling gel to calm localised swelling, but as RF is so well tolerated I have found that this is rare. A follow-up consultation should always form part of any treatment plan and should be discussed on an individual basis with the patient.

Consider RF for cellulite treatments Cellulite is a prevalent skin concern that has several potential causes. In my experience, RF technology is a good treatment approach to improve its appearance. It is well-tolerated, is safe and effective for use on all Fitzpatrick skin types, requires little to no downtime and carries minimal risk of adverse events making it a beneficial treatment modality for patients and practitioners alike.

Dr Saleena Zimri is a former GP with a special interest in cosmetic dermatology. She has been practising aesthetics for the last 13 years and is the co-founder of the Skin Doctor Clinics and set up her first aesthetic skin and laser clinic 12 years ago in Yorkshire. The company has four branches located in Manchester, London, Leeds and York. Qual: MBChB, MRCGP, PGDip

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