Lecture by Dr. Patrick Treacy on Carboxytherapy to the Royal Society of Medicine in London Advanced Cosmetic Interventional Group 2013
Text of Carboxytherapy
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 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