Validated Assessment Scales for Cellulite Dimples on the

Buttocks and Thighs in Female Patients

Doris Hexsel, MD* Sabrina Guillen Fabi, MD,† Gerhard Sattler, MD,‡ Rolf Bartsch, MD,x
Kimberly Butterwick, MD,† Gabriela Casabona, MD,║ Yates Yen-Yu Chao, MD,¶
Joana Costa, MD,** Joseph Eviatar, MD,†† Thorin L. Geister, PhD,‡‡ Kate Goldie, MD,xx
Jenny Grice, BSc,║║ Martina Kerscher, MD,¶¶ Paul Lorenc, MD,*** Mary Lupo, MD,†††
Wouter Peeters, MD,‡‡‡ Rainer Pooth, MD, PhD,†† Heidi A. Waldorf, MD,xxx
Yana Yutskovskaya, MD,║║║ and Michael S. Kaminer, MD¶¶¶

BACKGROUND New treatment methods for cellulite require globally accepted scales for aesthetic research
and patient evaluation.

OBJECTIVE To develop a set of grading scales for objective assessment of cellulite dimples on female but-
tocks and thighs and assess their reliability and validity.

MATERIALS AND METHODS Two photonumeric grading scales were created and validated for dimples in the
buttocks in female patients: Cellulite Dimples—At Rest, and Cellulite Dimples—Dynamic. Sixteen aesthetic
experts rated photographs of 50 women in 2 validation sessions. Responses were analyzed to assess inter-rater
and intra-rater reliability.

RESULTS Overall inter-rater reliability and intra-rater reliability were both “almost perfect” ($0.81, intraclass
correlation efficient and weighted kappa) for the At Rest scale. For the Dynamic scale, inter-rater reliability and
intra-rater reliability were “substantial” (0.61–0.80). There was a high correlation between the cellulite scales
and body mass index, age, weight, and skin laxity assessments.

CONCLUSION Consistent outcomes between raters and by individual raters at 2 time points confirm the
reliability of the cellulite dimple grading scales for buttocks and thighs in female patients and suggest they will
be a valuable tool for use in research and clinical practice.

Supported by Merz Pharmaceuticals GmbH, Frankfurt, Germany. The authors received an honorarium for
participating in the scale rating meeting. The authors have indicated no significant interest with commercial
supporters.

C ellulite is the term used to describe the uneven,

dimpled skin that typically appears on the surface
of the thighs and buttocks and which is estimated to
affect between 80% and 90% of women at some point
during their lives.1 While not a pathologic condition, it
is an issue of cosmetic concern for many women.2
Women are believed to be particularly susceptible to
the condition because the fibrous septae in the
subcutaneous adipose tissue are oriented
perpendicularly in relation to the skin surface.3,4

*Brazilian Center for Studies in Dermatology, Porto Alegre, Brazil; †Cosmetic Laser Dermatology, San Diego,
California; ‡Rosenparkklinik, Darmstadt, Germany; xThe Aesthetics, Vienna, Austria; ║Clı́nica Vida, São Paulo,
Brazil; ¶CHAO Institute of Aesthetic Medicine, Taipei, Taiwan; **Clı́nica Dermatológica Joana Costa, Brası́lia,
Brazil; ††Omni Aesthetic, New York, New York; ‡‡Merz Pharmaceuticals GmbH, Frankfurt, Germany; xxEuropean
Medical Aesthetics Ltd, London, United Kingdom; ║║Le Prioldy, Bieuzy les Eaux, France; ¶¶Division of Cosmetic Sciences,
University of Hamburg, Hamburg, Germany; ***Z. Paul Lorenc Aesthetic Plastic Surgery, New York, New
York; †††Lupo Center for Aesthetic and General Dermatology, New Orleans, Louisiana; ‡‡‡AZ Klina, Brasschaat,
Belgium; xxxWaldorf Dermatology Aesthetics, Nanuet, New York; ║║║Department of Cosmetology, Pacific State Medical
University of Health Ministry of Russia, Moscow, Russia; ¶¶¶SkinCare Physicians, Chestnut Hill, Massachusetts

© 2019 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. All rights reserved.
· ·
ISSN: 1076-0512 Dermatol Surg 2019;45:S2–S11 DOI: 10.1097/DSS.0000000000001993

S2

© 2019 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.

Between these fibrous strands, fat is stored in large
globular adipocytes. It is believed that increased
tension in the fibrous septae as a result of either
expansion of the fat cells or shortening of the septae
due to connective tissue changes, such as trauma, leads
to retraction at their cutaneous insertion points
causing the typical cellulite dimples.5,6 The raised
areas between the dimples represent the projection of
underlying adipocytes.7 In men, altered fat
distribution and a crisscross rather than perpendicular
organization of the septae make the development of
cellulite much less likely.3 The likelihood of cellulite
developing is increased by a number of factors
including a predisposing genetic background,
hormonal changes or imbalances, impaired
microcirculation, medications that cause water
retention, a sedentary lifestyle, unhealthy eating
habits, and Caucasian ethnic background.8–10
Cellulite appearance is also worsened by age-
associated skin laxity.11–13
In recent years, a better understanding of the etiology
of cellulite has led to the development of new treat-
ment approaches that target the underlying cause of
the condition.6,14,15 As new pharmacological and
technological medical advances reach the market,
reliable and specific methods of cellulite assessment
become necessary to identify subjects appropriate for
therapy and to measure treatment outcomes. Cur-
rently available scales do not meet this need16,17
because they are not specific for cellulite dimples and
because they are time-consuming for use in daily
clinical practice. In this article, the authors present
the cellulite dimple grading scales for the objective
quantification of the severity of cellulite dimples in
both static (relaxed or “at rest”) and dynamic states,
as well as the validity and reliability of these photo-
numeric scales.
Methods
Subject Selection and Photographic Imaging
A photographic database of the buttocks and thighs of
120 female subjects was established to provide repre-
sentative images across the complete spectrum of cel-
lulite dimple severity. The women were aged 18 to 65
© 2019 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
HEXSEL ET AL
years with a body mass index (BMI) in the range 18 to
42 kg/m2, Fitzpatrick skin Types I to VI, and even
cellulite contour irregularities on both sides. Individ-
uals were excluded if they had any dermatosis, scar-
ring, or tattoos on the buttock or thigh area or if they
had received any previous aesthetic treatments or
procedures in these areas. Subject demographic data
were collected including age, ethnicity, body mass
index (BMI) class, smoking status, Fitzpatrick skin
phototypes, and self-reported exposure to sunlight
(based on a 5-point rating scale where 0 = never and 4 =
very often). All subjects were informed of the objec-
tives and targets of the study and gave consent to their
photographs being rated, analyzed, and used in pub-
lications for scientific purposes.
All subjects were photographed by a professional
photographer using a Nikon D800 camera/70- to
200-mm lens (Nikon Corporation, Tokyo, Japan).
Photographs were standardized as to framing, light-
ing, and subject orientation. The angle of the lights
and distances between the platform, lights, and
camera were all standardized and confirmed for each
photography session. The area to be captured cov-
ered the buttocks and the upper thighs up to about 8
to 10 cm below the gluteal crease (infragluteal sul-
cus). Images included both posterior and oblique (45

angle) views of both sides and were taken at rest and
with maximum contraction of the musculus gluteus
maximus (dynamic state). A microrelief image was
also obtained.
Creation of the Cellulite Dimple Scales
The process of scale creation followed the method-
ology used for the creation of the other Merz Aes-
thetic Scales.18–21 In brief, the subjects’ images were
screened, and one subject’s image was chosen as the
base image for scale creation. Additional images were
then selected from the photographic database to
superimpose varying degrees of cellulite dimple
severity onto the base image to create composite
computer-generated images for the cellulite dimple
scale. The software used to produce the super-
imposed images was Adobe Photoshop. Several ver-
sions were reviewed with aesthetic experts/physicians
and improved stepwise until a final version was
45:8S:AUGUST SPECIAL ISSUE 2019 S3
 ASSESSMENT SCALES FOR CELLULITE DIMPLES

acknowledged and agreed upon for validation. Pho- Statistical Analyses

tographs used for creation of the assessment scales
All rating data from the validation booklets
could not be used for the validation process. The final
underwent a double-data entry by independent and
rating scale was a 5-point cellulite severity scale
qualified professionals followed by data entry verifi-
with a score ranging from 0 to 4 (Figure 1). The cel-
cation. Rating results from the first and second vali-
lulite dimple scales differ slightly from other Merz
dation sessions were summarized by descriptive
Aesthetic scales in that 2 additional reference images
statistics including number of ratings (n), arithmetic
were included for each severity grade. These were
mean, SD, median, range, and number of missing
designed to act as a photo guide to be used alongside
values.
the photonumeric scale to aid physicians with the
grading process. The reference images covered all
Inter-rater and Intra-rater Reliability
Fitzpatrick skin types.
For both scales, the reliability between the aesthetic
Validation of the Cellulite Dimple Scales experts (inter-rater reliability) and the reliability
between the first and second validation sessions for
After the creation of the scales, a psychometric vali-
each aesthetic expert (intra-rater reliability) were
dation was conducted to determine their validity and
assessed by the intraclass correlation coefficient (ICC)
reliability for assessment of photos of cellulite
2.1 of Shrout and Fleiss.22 To account for the fact that
severity and to determine whether they would be
the validated scales are ordinal scales and the ICC
appropriate measurement tools for use in clinical
derivation assumes a quantitative scale, weighted
practice. The validation was performed by 16 inter-
kappa values (Fleiss-Cohen weights) were also
national experts in the field of aesthetics. The experts
derived.23,24 Intraclass correlation coefficient 2.1
each rated a validation booklet containing images of
assumes that all subjects are rated by the same aes-
50 subjects displaying all cellulite dimple severity
thetic experts, who are assumed to be a random subset
grades presented alongside the 2 cellulite dimple
of all possible aesthetic experts. The following ICC
grading scales: Cellulite Dimples—At Rest, and
ranges were used for interpretation of both inter-rater
Cellulite Dimples—Dynamic. The booklets con-
and intra-rater results25,26: 0.00 to 0.20 slight, 0.21 to
tained different sets of 50 images, so that those used in
0.40 fair, 0.41 to 0.60 moderate, 0.61 to 0.80 sub-
the “At Rest” booklet could not also be used in the
stantial, and $0.81 almost perfect. Lower ICC values
“Dynamic” booklet. The booklets were designed in
indicate variability in the assessment of subjects (e.g.,
an A4 landscape, double-page, spiral-bound
different ratings for the same subject by the raters).
format, and each had unique identifiers (raters
Based on the above classifications, ICC values of >0.60
name and randomization number). Experts were
were considered to demonstrate a high consistency of
given a general introduction on the procedure and
scale ratings.
methods for validation, but no specific training. Two
sets of validation booklets were produced for each
Bivariate scatter plots (bubble plots) for validation
expert, so that ratings could be performed in 2 vali-
session 1 versus validation session 2 were also gener-
dation cycles at least 2 weeks apart.
ated for representation of intra-rater reliability.

Subjects’ images were presented in a randomized

sequence in the booklets for each of the 2 sessions by
assigning a page number to the respective subject’s
image. Raters were blinded with respect to the chosen
subjects, subject identifiers, subject characteristics,
and subject randomization sequences in the booklets.
The ratings of each aesthetic expert were entered
directly into the booklet for each scale.
Correlation
Validity of the scales was explored by means of
Spearman correlation coefficients with bias adjust-
ment of at rest and dynamic scale ratings against
subject demographic variables including age, height,
weight, BMI, smoking status, Fitzpatrick skin classi-
fication, and self-rated level of sun exposure.

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 HEXSEL ET AL

Figure 1. (A) Final set of Cellulite Dimple—At Rest and (B) Cellulite Dimple—Dynamic scales.

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 ASSESSMENT SCALES FOR CELLULITE DIMPLES
Correlation of the cellulite dimple scales with the skin
laxity severity scales27 was also determined. The cor-
relation coefficients were calculated by validation
session for each aesthetic expert and over all aesthetic
experts. In addition, the Spearman correlation coef-
ficients with bias adjustment between the at rest and
dynamic outcome measures were calculated by vali-
dation session over all aesthetic experts.
All analyses were written, validated, and performed
using SAS version 9.3.
Results
For each validation session and each cellulite scale,
there were 800 planned ratings (16 aesthetic experts ·
50 subjects rated). For most experts, there was a
duration of 3 to 4 weeks between the 2 validation
sessions. A few aesthetic experts did not provide a
rating for each subject, but missing data were few
(<1%) in both validation sessions.
Subject Characteristics
All the subjects were women with a mean age of 33.2 6
12.3 years in the Cellulite Dimples—At Rest pop-
ulation and 34.0 6 13.9 years in the Cellulite Dim-
ples—Dynamic population. Mean BMI values were
23.5 6 4.6 kg/m2 and 23.1 6 4.4 kg/m2, respectively.
All Fitzpatrick skin Types (I–VI) were represented, but
the most frequent was Fitzpatrick skin Type III.
Exposure to sunlight “seldom,” “seldom to some-
times,” or “sometimes” was reported by 78% and
84% of women, respectively, and 22% and 24%,
respectively, were current smokers.
Expert Characteristics
Of the 16 aesthetic experts (9 women and 7 men), 12
were dermatologists, 3 were plastic surgeons, and 1
was an ophthalmologist.
Descriptive Statistics
For the “Cellulite Dimples—At Rest” scale, the grad-
ing of aesthetic experts at validation session 1 covered
all severity scores from Grade 4 “very severe” (12.3%
of women) to Grade 1 “mild” (34.4% of women);
15% had no dimples. For validation session 2, grading
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ranged between Grade 4 (9.0%) and Grade 1 (38.6%);
11.6% had no dimples. Mean ratings were compara-
ble between validation sessions 1 and 2 at 1.8 (SD:
1.26) and 1.7 (SD: 1.15), respectively, indicating mild-
to-moderate cellulite dimples.
For the “Cellulite Dimples—Dynamic” scale, the
grading of experts at validation session 1 ranged from
Grade 4 “moderate” (11.5% of women) to Grade 1
“mild” (20.4% of women); 5.8% had no dimples. For
validation session 2, grading ranged between Grade 4
(12.5%) and Grade 1 (20.8%); 7.1% had no dimples.
Mean ratings were again comparable for validation
sessions 1 and 2 at 2.2 (SD: 1.07) and 2.2 (SD: 1.11),
respectively, indicating moderate cellulite dimples.
Inter-rater Reliability
The ICC and weighted kappa values for overall inter-
rater reliability of the 2 cellulite dimple scales are
presented by validation session in Table 1. Weighted
kappa and ICC values for inter-rater reliability were
very similar and showed qualitatively the same results.
Overall inter-rater reliability was determined to be
almost perfect ($0.81) at both validation sessions for
the Cellulite Dimples—At Rest scale and substantial
(0.61–0.80) at both validation sessions for the Cellu-
lite Dimples—Dynamic scale. For both scales, inter-
rater reliabilities were slightly higher in validation
session 1 compared with session 2.
Intra-rater Reliability
The ICC and weighted kappa values for intra-rater
reliability of the 2 cellulite dimple scales are presented
in Table 2. Overall intra-rater reliability was deter-
mined to be almost perfect ($0.81) for the Cellulite
Dimples—At Rest scale and substantial (0.61–0.80)
for the Cellulite Dimples—Dynamic scale. Intra-rater
reliability of individual aesthetic experts for the At
Rest and Dynamic scales ranged from 0.69 to 0.93 and
0.57 to 0.89, respectively. For Cellulite Dimples—At
Rest, intra-rater reliability was $0.70 for all experts.
For Cellulite Dimples—Dynamic, intra-rater reliabil-
ity was $0.70 in 87.5% of experts and $0.60 in
93.8% of experts. With such large numbers of experts,
individual reliability comparisons are expected to
sometimes vary by chance, but the majority of the
 HEXSEL ET AL

TABLE 1. Inter-rater Reliability Estimates by Validation Session for Cellulite Dimple At Rest and Dynamic
Rating Scales

ICC 2.1 Mean Weighted Kappa*

Scale (Asymptotic 95% CI) (Fleiss-Cohen) (SD)
Cellulite Dimples—At Rest
Validation session 1 0.85 (almost perfect†) (0.79; 0.90) 0.85 (almost perfect†) (0.051)
Validation session 2 0.81 (almost perfect†) (0.73; 0.87) 0.81 (almost perfect†) (0.083)
Cellulite Dimples—Dynamic
Validation session 1 0.72 (substantial†) (0.63; 0.81) 0.72 (substantial†) (0.101)
Validation session 2 0.67 (substantial†) (0.56; 0.78) 0.68 (substantial†) (0.136)

*Mean of all rater combinations.

†Substantial: 0.61 to 0.80, almost perfect: $0.81.
CI, confidence interval; ICC, intraclass correlation coefficient.

reliability estimates indicated at least substantial
reliability.
A bubble plot for all experts pooled, illustrating the
frequency of rating combinations between the first and
second validation session for the Cellulite Dimples—
At Rest scale, is shown in Figure 2. There were 477 of
793 ratings with perfect agreement and 24 of 793
ratings with a difference of more than 1 grade. The
location of the high-frequency ratings on the diagonal
line of the bubble plot demonstrates the high intra-
rater reliability. The bubble plot for ratings of “Cel-
lulite Dimples—Dynamic” shows 425 of 794 ratings
with perfect agreement and 16 of 794 ratings with a
difference of more than 1 grade (Figure 3).
high correlation between the 2 cellulite dimple scales
and the recently released skin laxity scales for the
buttock, thigh, and knee area, which are being pub-
lished in an accompanying article in this issue27
(Table 4).
Discussion
The results of this validation study demonstrate that
the newly developed Merz Aesthetics cellulite dimple
grading scales are a reliable and reproducible scoring
system for aesthetic evaluation of cellulite dimples on
the buttocks and thighs. The scales provide 5-point
photonumeric assessments with photo guides of cel-
lulite severity at rest and in a dynamic state.

Validity of the Scales
Relevant Spearman correlations between the cellulite
dimple scale ratings and subject demographic char-
acteristics are shown in Table 3. For both scales,
positive Spearman correlation coefficients were
observed for BMI, age, and weight, and a negative
correlation was observed for height. There was also a
For evaluation scales to be accurate, they must reflect
the target population assessed. The subjects included
in this study represented the whole spectrum of cellu-
lite severity grades and covered a large age range, BMI
levels, as well as all Fitzpatrick skin types. The scales
were therefore evaluated across all cellulite severity
grades in a heterogeneous population similar to what a
physician might encounter in clinical practice. To

TABLE 2. Intra-rater Reliability Estimates for the Cellulite Dimples Grading Scales

ICC 2.1 Mean Weighted Kappa*

Scale (Asymptotic 95% CI) (Fleiss-Cohen) (SD)
Cellulite Dimples—At Rest 0.83 (almost perfect†) (0.81; 0.85) 0.83 (almost perfect†) (0.072)
Cellulite Dimples—Dynamic 0.78 (substantial†) (0.75; 0.81) 0.77 (substantial†) (0.087)

*Mean of all aesthetic experts.

†Substantial: 0.61 to 0.80, almost perfect: $0.81.
CI, confidence interval; ICC, intraclass correlation coefficient.

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 ASSESSMENT SCALES FOR CELLULITE DIMPLES
Figure 2. Intra-rater reliability: bubble plot for Cellulite
Dimples—At Rest.
further reflect clinical practice, no specific detailed
training in advance of the validations was performed
to gauge whether the newly created scales are robust
assessment tools for general use.
The reproducibility of the scales for the assessment of
cellulite dimple severity was based on the evaluation of
50 sets of photographs by 16 aesthetic experts on 2
Figure 3. Intra-rater reliability: bubble plot for Cellulite
Dimples—Dynamic.
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separate occasions separated by at least 2 weeks. The
2-week interval between validation sessions was
implemented to eliminate recall bias by the raters. For
most raters, the second validation session took place 3
to 4 weeks after the first, further reducing the potential
of any memory effects between sessions.
Data recorded on a rating scale are the subjective
judgment of the rater, and the generality of a set of
ratings is therefore a concern. For the scales to be of
use, it is important to demonstrate that the obtained
ratings are not peculiar to one rater’s subjective
judgment, but representative of a group of raters as a
whole. Knowledge of inter-rater reliability is there-
fore crucial when evaluating the generality of a set of
ratings as it represents the extent to which the dif-
ferent aesthetic experts tend to make exactly the
same judgments about the rated subject. For repre-
sentation of cellulite dimples at rest, there was
almost perfect inter-rater reliability (ICC $0.81) in
both validation sessions. The weighted kappa coef-
ficients were approximately equivalent to the ICC
2.1 values, confirming the high inter-rater reliabil-
ity. For most aesthetic scales, dynamic representa-
tion is the most consistent and reliable method of
assessing the severity of an aesthetic trait. In contrast
to the “at rest” scale, inter-rater reliability for cel-
lulite severity in the dynamic state did not reach
perfect agreement, but it was still substantial (ICC
0.61–0.80). This may suggest that cellulite severity
is more difficult to rate in a dynamic state and that
both scales should be used when evaluating a patient
to ensure accurate grading. For both scales, inter-
rater reliabilities were slightly higher in validation
session 1 compared with session 2, but in both ses-
sions, reliability was nevertheless almost perfect for
cellulite dimples at rest and substantial for cellulite
dimples dynamic. Similar small variations in inter-
rater reliability between validation sessions are not
unusual and have also been observed with other
aesthetic scales.18,28,29 It is likely that had the raters
been trained in the use of the scales before valida-
tion, even higher consistency between raters in the 2
validation sessions would have been observed.
Reliability between the first and second validation
sessions for the same aesthetic expert (intra-rater
 HEXSEL ET AL

TABLE 3. Correlation of Cellulite Dimple Scale Ratings With Subject Demographic Data by Validation
Session (Spearman Correlation Coefficient With Bias Adjustment and 95% Confidence Interval)

Validation Session 1 Validation Session 2

Cellulite Dimples—At Rest
Age (yr) 0.46 (0.41 to 0.52) 0.45 (0.39 to 0.50)
Height (cm) 20.29 (20.35 to 20.22) 20.27 (20.34 to 20.21)
Weight (kg) 0.42 (0.36 to 0.48) 0.43 (0.37 to 0.49)
BMI (kg/m2) 0.62 (0.57 to 0.66) 0.62 (0.57 to 0.66)
Smoker status (yes/no) 0.07 (0.00 to 0.14) 0.05 (20.02 to 0.12)
Fitzpatrick skin Types (I–VI) 20.07 (20.14 to 0.00) 20.07 (20.14 to 0.00)
Sun exposure (0 = never to 4 = very frequent) 0.12 (0.05 to 0.18) 0.15 (0.08 to 0.22)
Cellulite Dimples—Dynamic
Age (yr) 0.39 (0.33 to 0.45) 0.34 (0.28 to 0.40)
Height (cm) 20.28 (20.35 to 20.22) 20.30 (20.36 to 20.23)
Weight (kg) 0.31 (0.25 to 0.37) 0.27 (0.20 to 0.33)
BMI (kg/m2) 0.48 (0.43 to 0.54) 0.44 (0.38 to 0.50)
Smoker status (yes/no) 0.20 (0.14 to 0.27) 0.20 (0.13 to 0.26)
Fitzpatrick skin Types (I–VI) 0.03 (20.04 to 0.10) 0.04 (20.03 to 0.10)
Sun exposure (0 = never to 4 = very frequent) 0.12 (0.05 to 0.19) 0.07 (0.00 to 0.14)

BMI, body mass index.

reliability) also showed almost perfect intra-rater
ICC values ($0.81) for the Cellulite Dimples—At
Rest scale. For the Cellulite Dimples—Dynamic scale,
intra-rater reliability was substantial (0.61–0.80)
overall. With such large numbers of experts, indi-
vidual reliability comparisons are expected to some-
times vary by chance, but the majority of the
reliability estimates indicated at least substantial
reliability.
Validity of the cellulite dimple scale scores was also
explored by means of correlations with the scales
themselves and other variables that might be expected
to influence cellulite severity. There was a high corre-
lation between the 2 cellulite scales themselves, and
with a separate scale assessing skin laxity in the but-
tock and thigh region.27 Other factors with a high
correlation with cellulite dimples were BMI, followed
by age and weight, supporting the concept that while
not causal, cellulite may be worsened by aging and
weight gain. Fitzpatrick skin type, sun exposure, and
smoking status were found to have no influence on
cellulite severity.
The cellulite dimple scales have been specifically
developed as a tool to assist physicians offering
treatments that target cellulite dimples. While they can
also be used to give an overall impression of cellulite
severity, they cannot be generalized to all cellulite-
related deformities. Cellulite can also be influenced by
skin laxity, particularly in older individuals,11,12 and a
separate publication in this issue details the develop-
ment of a new skin laxity scale for the buttock and
thigh area that can be used in conjunction with the
dimple scale when assessing cellulite severity and
deciding on the best treatment options.27 The cellulite
dimple scales differ from other cellulite severity
scales16,17 available in the literature in their specificity
for cellulite dimples and in their simplicity. The
Nürnberger and Müller16 classification was developed
in 1978 and has 4 severity grades. It is based on
observations both at rest and in a dynamic state.
Hexsel and colleagues17 included the Nürnberger and
Müller classification in the Cellulite Severity Scale,
which also comprises the 4 most important clinical
features of cellulite (number of evident depressions,
depth of depressions, morphological appearance of
skin surface alterations, and grade of skin laxity). The
severity of each of the 5 scale items is graded from 0 to
3, allowing a final sum of scores that range numerically
from 1 to 15. Based on the final numeric score, cellulite
is classified as mild, moderate, or severe.17 The Hexsel

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 ASSESSMENT SCALES FOR CELLULITE DIMPLES
TABLE 4. Correlation Between Cellulite Dimple and Skin Laxity Scales by Validation Session (Spearman
Correlation Coefficient With Bias Adjustment and 95% Confidence Interval)
Cellulite
Dimples—
At Rest
Validation session 1
Cellulite Dimples—At Rest 1 0.76 (0.72–0.79)
Cellulite Dimples—Dynamic
Skin Laxity—At Rest/posterior
thighs and buttocks
Skin Laxity—At Rest/anterior
thighs and knees
Validation session 2
Cellulite Dimples—At Rest 1 0.76 (0.72–0.80)
Cellulite Dimples—Dynamic
Skin Laxity—At Rest/posterior
thighs and buttocks
Skin Laxity—At Rest/anterior
thighs and knees
and colleagues’ scale was created to provide an
objective method of measuring cellulite severity based
on their main characteristics and to guide the choice of
different treatment modalities, but the 5 different scale
items can be time-consuming to assess. Although it
lacks some sensitivity,30 this was the first attempt to a
better clinical evaluation of skin laxity.
The cellulite dimple scale was developed on the
premise that treatments that target cellulite dimples act
in a separate manner to those that target skin laxity.
While both improve cellulite severity, their differing
mechanisms of action necessitate separate validation
scales. The current study validates the cellulite severity
scale for photographic assessment of cellulite and
confirms the validity of the scales to objectively rate
cellulite severity regarding its depressed lesions. Fur-
ther studies are now warranted that investigate the
accuracy of the scales for measuring the efficacy of
treatments that target cellulite dimples such as the US
FDA-cleared Cellfina System, a minimally invasive
procedure that involves subcision of the fibrous septae
and results in improvements in the appearance of cel-
lulite on the buttocks and thighs with no loss of benefit
for up to 3 years,15,31 the Cellulaze laser-based treat-
ment for the release of fibrous septae,32 and the manual
subcision for cellulite, which is the basis of the above
cited technologies.33,34
S10 DERMATOLOGIC SURGERY
© 2019 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Cellulite Skin Laxity—At Rest/ Skin Laxity—At Rest/
Dimples— Posterior Thighs and Anterior Thighs and
Dynamic Buttocks Knees
0.72 (0.67–0.76) 0.84 (0.82–0.87)
1 0.68 (0.61–0.73) 0.72 (0.67–0.76)
1 0.71 (0.66–0.75)
1
0.74 (0.69–0.78) 0.84 (0.82–0.86)
1 0.64 (0.57–0.70) 0.69 (0.64–0.74)
1 0.74 (0.70–0.78)
1
Conclusion
An accurate classification of cellulite is important
when planning a therapeutic strategy, both in deciding
which patients are suitable for treatment and in
assessing treatment outcomes. The cellulite dimple
scales provide physicians and researchers with a sim-
ple, accurate, and reliable assessment tool for both
clinical and research purposes.
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Address correspondence and reprint requests to: Doris
Hexsel, Brazilian Center for Studies in Dermatology, 1592
Dom Pedro II Street, Porto Alegre 90550-141, Rio Grande
do Sul, Brazil, or e-mail: doris@hexsel.com.br
45:8S:AUGUST SPECIAL ISSUE 2019 S11