Besides, it involves hardly controllable changes in the locomotor, digestive, and endocrine systems.

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1 CELLULITE WHY CELLULITE IS A CONCERN FOR US? The disorders characteristic of cellulite involve endocrine-metabolic alterations that affect the microcirculatory system. They also draw our attention to the functionality and the cleansing process of the whole organism Besides, it involves hardly controllable changes in the locomotor, digestive, and endocrine systems. Last, but not least, it is a cause of discomfort and an ill-tolerated lack of aesthetics that drives the patient to accept any type of so-called therapeutic treatments in order to solve the problem. Too frequently such "treatments" have no scientific basis. Our efforts should be focused on the recovery of trophism and tissue tone, as well as on the control of endocrine-metabolic alterations that may entail irrevocabletissue damage, not only from an aesthetic point of view. However, aesthetic considerations are not unbecoming for the physician and should not be deemed as such. If it comes to that, we may say they are a kind of sublimated medical attitude and therefore require still greater professionalism. We should always bear in mind that ineffective or hardly effective aesthetic treatments have three inescapable consequences: clinical damage, aesthetic injury and, more frequently, serious psychological damage. HOW CELLULITE DEVELOPS As a consequence of physiopathological facts, cellulite goes through different phases but the starting point is almost always associated with alterations in the interstitial matrix. 1 Cellulite

2 1) Alterations in metabolic reactions at the interstitial matrix level, such as increase in tissue acidity, changes in the oxy-reduction mechanisms, progressive slowing down of arteriole flow, detriment of collagen fibers, and impairment of the fibroblast-adipose cellnervous axon-lymphocyte system. 2) Free water increase and reduced hyaluronic acid, proteoglycan, and (?do you mean glycosaminoglycan) functionality 3) Alterations in connective structures and the collagen system 4) Development of pathological lipedema 5) Development of lipolymphoedema 6) Disorders in the lipogenesis-lipolysis system 7) Venous-lymphatic microcirculation alterations 8) Surface hypoxia 9) Lipodystrophy 10)Tissue fibrosis 11)Sclerotic connective evolution CLINICAL CLASSIFICATION Cellulite might be divided into the following types: 1) Adipose cellulite 2) Edematous cellulite 3) Adipoedematous cellulite 4) Edematoadipose cellulite 5) Fibrous cellulite 6) Sclerotic cellulite 7) Mixed cellulite 2 Cellulite

3 It may also be characterized by the presence of: 1) Soft tissue 2) Soft tissue with skin excess 3) Hard tissue 4) Mixed tissue To this general classification, an accurate physiopathological and etiological diagnosis should be added. MANIFESTATIONS OF CELLULITE Besides its characteristic "peau d orange" appearance and alterations in arms, abdomen, knees, and trochanters, subjective symptoms may appear characterized by alterations in the trophism of subcutaneous tissues. The following alterations may be found: Altered sensitivity Pain Cramps Heaviness Nocturnal restlessness Cold feet Changes in skin coloration Livedo reticularis Dry skin Ecchymosis Edema Tiredness 3 Cellulite

4 EVOLUTION When does cellulite become evident? Nearly always the process starts in puberty, affecting particularly the lower limbs. Other triggering periods are pregnancy, periods of sexual dissatisfaction, lack of human or family understanding in combination with an altered lifestyle, wrong diet and intestine dysfunctions. Very few women above 18 years of age are totally free from some form of cellulite. Which is the relationship between cellulite and obesity? A clear distinction between cellulite and obesity should be done, even though confusion is frequent. Though they may coexist, the two processes are definitely different. Adiposity is the simple accumulation of adipose tissue in the available space. When fatty tissues exceed the normal value of 30%, there is obesity. Cellulite, instead, involves a transformation and alteration of subcutaneous interstitial tissues and is certainly not a mere accumulation of fat. The widespread confusion between these two conditions leads women to attempt, at the first manifestation of cellulite, all the methods available to lose weight. A diet, which is poor in nutrients and aimed at reducing localized volume, has a first harmful consequence: tissues lose their structure and different areas slim down. After such therapeutic attempts, muscular tone and tissue structure are often irrecoverable. In this regard, the damage caused by needless chondroitrin sulfatase infiltrations should be recalled: glycosaminoglycans release free water and tissues give way causing or resulting in"permanent unevenness". The same is true for ozone infiltrations and therapies that apply heat and ozone simultaneously. Predisposing factors Among predisposing factors the following should be highlighted: Ethnic origin. White women show the highest predisposition. 4 Cellulite

5 Family background, especially hereditary endocrine-metabolic syndromes, but also common nutritional deficiencies. Body structure, especially postural and spinal column alterations. Hormone imbalances in patients suffering from hormone functional alterations and patients consuming progestagen or hormone-supplemented food. Dietary disorders, particularly an excess of sugar, fat, and hormones. Digestive disorders, especially those associated with intestinal flora alterations. Disorders of the intestinal flora, which is the initial pathology in all degenerative tissue alterations such as arthrosis, myalgia, angiopathies, and cellulite pathologies. Postural problems associated with foot orthopaedic pathologies or with an ill-functioning sound foot (e.g., inadequate footwear). Psychosomatic disorders, especially depressive anxiety or languid, apathetic, and faltering character frequently associated with cultural deficiencies. Sexuality. Sexual activity is one of the basic activities of life, as essential as feeding oneself, sleeping, and breathing. Every human being requires sexual satisfaction and may achieve it in different ways, but such satisfaction should always exist in order that the remaining normal metabolic functions work properly. Sexuality has a "physiological" manifestation characterized by the urge to elicit "organic functions and reactions", and a "spiritual" manifestation characterized by the need to arouse "emotions". Both should be fulfilled since they are the chemical catalyst of many other functions. Lifestyle. A proper balance is needed among diet, evacuation, work, sleep, and exercise. External compression. Tight dresses, jeans, unnecessary elastic hoses do not help the intestinal lymph adipose system in its functions or the cutaneous microcirculatory system, thus favoring cellulite pathologies of the metabolic hypoxic type. Infections may cause tissue damage, which, in turn, results in alterations and fibrosclerosis. Smoking. It certainly slows down microcirculation in the cutaneous arterioles and is thus lipogenetic, generating the cutaneous hypoxia traditionally known as peau d'orange. On the other hand, hormone and thyroid stimulation induced by smoke itself activates noradrenaline and speeds up tissue catabolic processes thus favoring lipolysis at the subcutaneous level. Finally, in order to balance cutaneous peau d'orange, subcutaneous 5 Cellulite

6 lipolysis occurs. However, permanent and deceitful damages in the interstitium due to an excess of free radicals when defense mechanisms such as SOD fail should also be assessed. The intake of estro-progestagens such as those included in birth-control pills and food conservatives favor interstitial liquid retention generating endothelial edema and activating Fenton reactions (Fe-Ca). The process inevitably generates some form or other of lipedema and lipolymphoedema, which in their turn result in lipodystrophy. Besides, women who are administered hormones show a high level of free radicals as may be easily seen in ROM s tests Triggering factors Three factors should be highlighted: Obesity and overweight: All forms of being overweight are characterized by an increase of fat in subcutaneous tissue. In normal interstitial and microcirculatory exchanges, adipose cells interfere with water, oxygen and protein ions unleashing processes that alter the interstitium due to hyperinsulinemia. Hormone intake: Estro-progestagens in particular, but all hormones present in food, generate typical alterations, either at the endocrine-hypophyseal feedback level, or at the peripheral receptor level, giving rise to various phenomena such as lipogenesis, lipedema, and calcium loss in venous and lymphatic walls, with a concomitant increase in capillary permeability, and alterations in tissue oxy-reduction reactions. Anatomic alterations: Postural alterations and gait disorders interfere with normal metabolic and microcirculatory processes. Dietary deficiencies: Diets poor in protein, vitamins and fibers often associated with intestinal flora alterations result in stagnation of feces and dilatation of the ampulla recti, as well as in compression of iliac veins and subsequent hampering of the venous and lymphatic flow in the lower limbs. Metabolic alterations. However, metabolic alterations at the interstitial matrix level are still more important than others 6 Cellulite