Dr. Cibele Tamietti Durães
Dr. Manoela Fassina
Dr. Roberto Chacur

The online cellulite questionnaire was developed and implemented by the Clínicas Leger staff. It evaluates multiple physical and visual aspects of cellulite, in addition to analyzing how it affects the social and emotional lives of patients.

While there are several reputable classifications for this condition, the first one was described by Nürnberger and Müller in 1978, based on the clinical appearance of the lesions. Another classification was developed by Brazilian dermatologists Doris Hexsel, Camile Hexsel and Taciana Dal Forno, evaluating the degrees of cellulite using a scale called the Cellulite Severity Scale, which considers other clinical characteristics of cellulite, making a quantitative and qualitative assessment. More recently, an instrument was used to assess the quality of life in patients with cellulite (Celluqol®), also described by Doris Hexsel et al. I myself, together with the surgeon Roberto Chacur and his team, based on the Cellulite Severity Scale and the Celluqol quality of life assessment, both developed by Dr. Doris Hexsel, adapted a new classification for this condition and included some items in this questionnaire, such as the patient’s body mass index (BMI) and the presence or absence of post-trauma scarring (in addition to skin retractions caused by cellulite itself), which differs in the outcome and prognosis of the treatment, in addition to being aimed at the lay patient, who can then answer the questionnaire themselves, regardless of the medical evaluation, with the aim of being guided on the possible existing forms of treatment for each specific case of their complaint.

The questionnaire proposed by Roberto Chacur and collaborators is online (www.tratamentodacelulite.com.br) and can be answered at any time by patients from all over the world. It is based on ten questions about the type of cellulite that the person has and how it affects their life. For each of the ten questions, the patient will have a few response options; according to the chosen option, they will receive a targeted and personalized answer, indicating the best treatment for the flagged case. This individualized answer will be passed through the questionnaire link itself and will be directed to the patient’s email, so that they can understand the treatment options indicated for their type and degree of cellulite, and thus be able to seek appropriate medical treatment.

In the questions focused on the type of cellulite lesion, each answer option in the questionnaire is illustrated with photos of similar situations, so that the patient can identify their case in the best possible way and answer each question in the most accurate manner. All the photos presented in the questionnaire are from Roberto Chacur’s own patients, and their use was authorized by said patients.

In question one, the patient is asked about the number of cellulite foci they have, that is, the number of deep depressions they observe when looking in the mirror, with three answer options: from 1 to 3 foci; from 4 to 6; or over 6 cellulite foci. As an option to intervene in these foci, the patient is advised to seek a punctual treatment with the Goldincision® method.

In the area affected by cellulite, an injectable collagen biostimulator is applied, associated with the detachment of the fibrous septa in each depression (focus) of cellulite. This Goldincision® technique is described in detail in other chapters of this book.

In question two, the patient is asked about the depth of their cellulite, which can be superficial, moderate or deep. Since cellulite can be superficial to profound, regardless of the associated degree of flaccidity, we opted to separate these questions in the questionnaire. The depth of cellulite, in question two, refers to the depth of each depression presented by the patient, according to the photos shown in the online questionnaire, with the aim of helping them identify and select their answer. The patient is advised to use injectable collagen biostimulators to improve the appearance of the cellulite as well as its undulations and depressions in the affected region and, whenever necessary, on the importance of complementary procedures after a 45-day break, or, as the case may be, on the need for reapplication of injectable collagen biostimulators; this depends on the durability of the chosen product, in case the patient and/or their doctor has opted for absorbable products.

The indicated biostimulators can be absorbable ones, such as: Poly-L-Lactic Acid or Calcium Hydroxyapatite, both with a shelf life of 1.5 years; or Polycaprolactone, with a durability of 3 years. It is also possible to use non-absorbable ones, such as Polymethacrylate (PMMA); in this case, the implant is permanent.

At all times, the patient is warned in the questionnaire about the importance of seeking treatment from qualified medical professionals and paying attention to the importance of using products included in ANVISA regulations. These products must be opened in front of the patient with the product batch and expiration date checked; they must be of single-use, without being stored once opened.

In question three, the patient is asked about their degree of sagging, with four options for answers: absence of sagging, mild sagging, moderate sagging or severe sagging.

If the patient answers that there is absence of sagging, they are informed that there is no need to use devices, except for localized fat, if necessary, using cryolipolysis and applying enzymes. If the option is little sagging, it is suggested that they undergo manual drainage and use devices indicated for the treatment of flaccidity, such as Velashape III®, Freeze® (radiofrequency), carboxytherapy, Russian current, among others. The patient is informed that the choice of device varies according to individual assessment and that, for this degree of sagging, a minimum annual treatment protocol is recommended.

When the patient reports moderate sagging, in addition to the previously indicated procedures, the use of microfocused ultrasound devices (such as Ultraformer® and Uthera®) and a minimum of two annual treatment protocols is suggested. As for those who have severe sagging, in addition to all these devices, a minimum of three annual treatment protocols is indicated, suggesting that it may still be necessary to get an evaluation from a plastic surgeon regarding a possible dermolipectomy procedure.

Question four addresses the Body Mass Index (BMI), which the questionnaire system itself calculates according to the data provided by the patient regarding weight and height, which are filled out at the start of the questionnaire. According to this calculation, the online questionnaire guides the patient about their BMI: whether it is normal or whether the patient is overweight, obese or severely obese. According to this information, they are instructed on the best treatment for their case.

When the patient’s BMI is normal, they are congratulated. It is explained to the patient that their BMI is within the normal range, and thus they are in the ideal weight range for their height. However, the patient is reminded of the importance of maintaining healthy habits, such as regular physical activity and a balanced diet, in order to keep their BMI within normal limits.

For patients with a BMI that indicates overweight, it is proposed that a more expressive and lasting treatment effect can be observed if healthy habits are adopted, such as regular physical activity and a balanced diet. Furthermore, the questionnaire informs that guidance from a nutritionist collaborates with the gradual transition to a new routine, which helps to anticipate the definition of the best body shape.

Patients with a BMI indicating obesity, in addition to being suggested to adopt healthy habits, such as regular physical activity and a balanced diet, are suggested to consider the advice of a nutritionist or endocrinologist. Furthermore, this patient is advised to undergo laboratory tests in order to verify the existence of associated diseases and/or get their hormonal profile checked, since it may be associated with their obesity. In the case of patients with a BMI indicating severe obesity, they receive the same instructions as the previous group, but with the addition of the suggestion that they should also consider obtaining an evaluation from a bariatric surgeon.

In question four, it is also asked if the patient has any secondary irregularity, such as, for example, poor healing after injections, accidents, liposuctions or any other type of surgery. In this matter, although the way to perform the detachment of the fibrous septum during the Goldincision® procedure is a little different, since the fibrosis has greater rigidity and requires a different tool for its disruption, such as, for instance, the ultrafine needle used in ophthalmological surgeries (“ultra fine eye foreign body needle”), no different treatment is suggested for the patient; this is one more piece of data collected that can be used in future publications.

In questions six, seven and eight, the patient is asked about how cellulite affects their life and how it interferes with their routine. In each of these questions, the patient has two options to answer: yes or no. Question six, in particular, asks whether cellulite interferes with the way they dress; question seven, whether it interferes with their social wellbeing, such as, for instance, in intimate relationships or in gatherings with friends; and question eight asks whether they feel any discomfort on the cellulite site.

In question nine, the patient is asked about the emotional aspects of cellulite, that is, how cellulite affects their feelings when looking in the mirror. With “yes” or “no” answer options, they are asked whether they feel anger, guilt, sadness, frustration and/or shame in front of the mirror. Finally, in question ten, the patient has a space to write what motivated them to seek treatment for cellulite.

Therefore, after the person receives some guidance for the main complaints presented, they are informed that the treatment for cellulite is multidisciplinary. Thus, the respondent will have at their disposal several guidelines on possible treatments that they should seek to treat what bothers them, suitable for their degree of cellulite, even if they does not know how to classify it with medical terms.

Therefore, this is a questionnaire developed for patients to self-classify themselves, which is in contrast to other questionnaires proposed throughout the literature, which require a medical evaluation for the clinical classification of cellulite. This tool is intended to guide the patient and direct them to possible treatments according to the type and degree of cellulite they have.