Lecture by Dr. Patrick Treacy on Carboxytherapy to the Royal Society of Medicine in London Advanced Cosmetic Interventional Group 2013
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Carbon Dioxide Therapy: Magic Gas or Hot Air? An overview with
Dr. Patrick Treacy RSM March 2014
Carboxytherapy in the Media
So where are we? Magic Gas or Hot Air?
What is Carboxytherapy? Carbon dioxide therapy (Carboxytherapy)
is a procedure similar to mesotherapy. It consists of intradermal
or subcutaneous injections of medical grade CO2 using 30G
needles.
What is Carboxytherapy? The gas in injected either into the
subcutaneous layers to improve fat, either into the dermis layers
to improve wrinkles, stretch marks and under-eye circle.
Carboxytherapy has been widely used in the last 10 years in
South America in Brazil for cosmetic purposes: stretch marks,
cellulite, localized adiposities and under-eye dark circles, in
combination with other minimally invasive procedures.
Carboxytherapy can be performed at the office with no down
time. It requires the physician to get a CO2 insufflator equipment,
tubing, bacterial filters and small needles.
Where did the CO2 story start?
Antoine Lavoisier Lavoisier spent a great deal of his time
studying the physiology of respiration. He showed that respiration
was a process of combustion, with the utilisation of oxygen and the
production of carbon dioxide. He used his findings to push for
better public health in French cities and towns. He based his
arguments around his belief that people who lived in a crowded
conurbation needed a certain amount of good clean air to live a
decent life.
French revolution brought Lavoisier to trial on 8 May 1794.
There was an appeal by hjis legal team to spare his life so that he
could continue his experiments The judge replied: "La Rpublique n'a
pas besoin de savants ni de chimistes ; le cours de la justice ne
peut tre suspendu." "The Republic needs neither scientists nor
chemists; the course of justice cannot be delayed." Joseph Black
isolated carbon dioxide in 1757 Henry Cavendish isolated hydrogen
in 1766 Daniel Rutherford isolated nitrogen in 1772 Joseph Priestly
isolated oxygen in 1772
Lalouette (1777 ) Lalouette showed in 1777 that carbon dioxide
improved chronic and inveterate skin problems, especially in foot
ulcers not response to convention treatments such as daily
dressings and debridement. Carbon dioxide water bath therapy
(carbothera) ... springs or (artificial) therapeutic CO2 officially
recognized in France as medications
Scientific Publications Carbotherapy continued to be used in
France and publications begin to appear in the early 1930s. Doctors
in the medical spa of Royat found that transdermal use of CO2 in
enriched warm baths improved vascular ischemia symptoms because of
a strong direct vasodilator effect, a neo-angiogenesis effect and
better oxygen release in superficial tissues.
Neo-angiogenesis effect Experiments started in Italy in the
1930s. These consisted of injecting CO2 into the leg of frogs
showing a strong vasodilatation, associated with the creation of
new capillaries.
Mechanism of action: Effects of CO2 Vasodilatation The first
effects following CO2 injection is a strong vasodilatation, a blood
flow increase and a higher pO2 in the treated area. The Bohr effect
Local oxygen release is improved because of the Bohr effect. The
Bohr effect describes the tendency of haemoglobin to have less
affinity for oxygen when the blood concentration of CO2 is
increased. This lower affinity leads the haemoglobin to release the
oxygen better in superficial tissues and muscles. CO2 is quickly
converted to bicarbonates and H+ acid in presence of the carbonic
anhydrase enzyme. CO2 + H2O H+ + HCO3
Bohr Effect
Bohr Effect This reaction causes the tissues pH to become
acidic with even more dissociation of O2 from haemoglobin, allowing
the tissue to become even more oxygenated
Stimulation of collagen synthesis A 2008 Brazilian study*
showed a reorganization of collagen fibres following intradermal
injections of carbon dioxide and demonstrated that the CO2 is
capable of increasing the collagen turnover: a trauma to the dermis
launches a healing process with collagen synthesis. CO2 improves
the process by first, increasing neovascularization with more
healing substances and factors to be on site. In second, it
releases more oxygen around and in the healing area, improving the
recovery phase.
Stretch marks Indications Old white stretch marks, deep
depressed stretch marks, irregular old stretch marks are the main
indications. Young pink/red stretch marks should preferably have
laser treatment (KTP or pulsed dye laser). Principle Improve
neovascularization and blood flow, improve melanocyte pigment
production to darken white stretch marks. Improve collagen
synthesis to reduce the wave appearance of old stretch marks.
Protocol Combined intradermal and subcutaneous injections One
session per month Flow: 80150 cc/min Puncture inside the mark,
Number of sessions: four to ten
Technique of Carboxytherapy to Stretch Marks
Technique Start injecting the dermis and when done push the
needle further to inject the subcutaneous layers. Endpoints Popcorn
appearance (inflated stretch marks) for 1 or 2 minutes then
erythema. Injection points Follow each stretch mark and inject each
12 cm. Post-treatment care No post injection care is required. Pain
management Injecting stretch marks is often painful. Patients
describe a burning sensation. Although flow greater than 100 cc/min
is recommended, it is sometimes impossible to maintain these values
because of the pain. Lowering flows to 7080 cc/min may make the
patient more comfortable
Periorbital Area Principle Increase blood flow, stimulate
collagen production, reduce fatty prolapse in some cases.
Indications Fatty prolapse, eye wrinkles, under-eye dark circles.
Smoker female with dark circle are good indications Protocols Eye
wrinkles Combined intradermal and subcutaneous injections One
session per month, Flow: 2040 cc/min Four to five punctures around
the lower orbit bones Number of sessions: three to six
Under-eye dark circles Intradermal injections One session per
month. Flow: 2040 cc/min Four to five punctures around the lower
orbit bones Number of sessions: three to six Fatty prolapse
Subcutaneous and intradermal injections One session per month.
Flow: 2040 cc/min Puncture in the fatty area. Number of sessions:
three to six Periorbital Area
Technique Injection points Fatty prolapse will receive two to
four quick punctures in the area where the fat resides. Eye
wrinkles and dark circles require from 2 to 3 punctures, 1 or 2 cm
spaced, 1 or 2 seconds each, made all along the external inferior
border of the eye orbit, next to the orbit bones (zygomatic bone).
Endpoints Eye lid becomes distended and inflated. Upper eye lid
distension may be important. Fatty prolapses are inflated and red.
The eye returns to normal appearance within 2 or 3 minutes.
Post-treatment care No post-treatment care is required. Sun
protection may be used in the next 2 weeks. Pain management Emla if
treatment is too painful (This cream lowers the Bohr effect:
vasoconstriction reduces blood flow); To reduce pain, lower the
flow and increase the number of punctures.
Caution One of the major CO2 side effects and complication is
pertinent to the eyelid procedure. It is important to purge and
remove any trace of oxygen/air in the tubes and needle. O2
injection into the eye lid leads to a strong inflammatory reaction
which lasts 4 or 5 days, with redness, edema, closed eye and
pain
Cellulite/orange peel skin Principle Stimulate blood flow and
activate receptors involved in the natural lipolysis of the body.
Improve skin tightening to reduce orange peel skin. Fibrous
cellulite treatments will require mechanical disruption of fibrous
septae with higher CO2 flows. Indication: All types of cellulite
from grade III to grade IIIIV. Subcutaneous irregularities after
liposuction. Complementary treatment to liposuction, which does not
have any efficacy on cellulite.
Protocol Cellulite grade I or II Combination of subcutaneous
and intradermal injections. One session per day to one per week
Flow: 12 cc/kg/min approximately 2 minutes per injection Punctures:
1520 cm spaced, no overlapping - Number of sessions: 1020
Progressive flow (automatic mode) available with some machines
Cellulite grade III or IV Combination of subcutaneous and
intradermal injection. One session per day to one per week Flow:
>2 cc/kg/min Punctures: 1520 cm spaced, no overlapping. Number
of sessions: 1020 Progressive flow (automatic mode) available with
some machines
Technique The operators hand movement should target both the
subcutaneous layer and the intradermal layer as both lipolysis and
collagen synthesis need to be activated. Injection points
Injections points should be made in the area where cellulite
resides: hips and thighs. Endpoint Subcutaneous injection will let
the gas diffuse and create a 1520 cm diameter granite-like
appearance disk. After several sessions, the skin offers less
resistance to the gas diffusion, so a few injections point may then
be enough to treat the all cellulite area. Post-treatment care: No
post-injection care is necessary. Pain management Pain is more
frequent in the first sessions: CO2 can be reduced in the first
sessions and progressively increased from session to session. If
too much pain is reported, change the injection point and reduce
the treatment time, giving more, shorter injections. Maximizing
results CDT may benefit from combination with such treatments as
RF, Cellu-M6, Velasmooth and manual lymphatic massage. Dietetic
advice should be given to help the patient maintain a stable
weight. Reinforcement sessions Patients are usually advised to
renew the treatment at least once a year in order to maintain
the
Localized fat Indication: Any kind of localized fat or skin
irregularity after liposuction. Can also be a complementary
treatment to liposuction to treat the remaining fat. Protocol :
Subcutaneous layer, 1 session per day to 1 per week Flow: 12
cc/kg/min (5080 cc/min), approximately 2 minutes per injection
point Punctures spaced 1520 cm apart Number of sessions: 1020 First
results usually seen after session #4~6 Progressive flow (automatic
mode) available with some machines Submentonian area: deep dermis
(and/or subcutaneous) Flow: 12 cc/kg/min (5080 cc/min),
Approximately 3060 seconds per area injected (until onset of
erythema or pain) - Usually three punctures (one in the center, one
left side, one right side). May trigger a tempo-mandibular
articulation pain (lasts 1 or 2 minutes)
General CO2 contraindications needle phobia stress, with
history of vagal unconsciousness event severe heart failure,
congestive heart disease recent heart infarction or instable angina
pectoris restrictive pulmonary disease, chronic obstructive lung
diseases sleep apnea renal failure, dialysis recent cerebrovascular
accident uncontrolled blood pressure epilepsy recent phlebitis or
pulmonary embolism uncontrolled diabetes immunosupression or
deficiency chemotherapy, cancer (healing disorders) patients with
impaired healing connective tissue disorders or diseases bleeding
diseases: Willebrands disorder, hemophilia
Local contraindications bacterial infection: dermatitis,
cellulites foreign body in the area to be treated herpes simplex in
acute phase and other acute skin viral infection skin disease with
abnormally increased local circulation facial rosacea poikiloderma
of Civatte red necks and red dcolletage. Temporary
contraindications pregnancy (precautionary principle) lactation
(precautionary principle) anticoagulation, recent aspirin or
antiinflammatory drugs intake acute skin infection (wait until it
is cured) other aesthetic procedure or skin traumatism less than 15
days prior to CDT