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Lecture to Los Angeles Cosmetic Conference 2011 by Dr. Patrick Treacy about the new RioBlush treatment for stretch marks.
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Carbon Dioxide Therapy Face and body rejuvenationAn overview with Patrick Treacy
RioBlush
Introduction
Carbon dioxide therapy (CDT Carboxytherapy)is a procedure which is very similar to mesotherapy It consists of intradermal or subcutaneous injections of medical grade CO2 using 30G needles 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
History of use
CDT (known as carboxitherapy carboxytherapy or carbotherapy) was first described in France in the early 1930s in the medical spa of Royat Doctors 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
Publications
CO2 was first used as a treatment of ischemic lower legs arterial diseases before medical treatments evolved to grafts stents by-passes Raynaudrsquos phenomenon skin ulcers with arterial or venous cause as well as several vascular erection disorders were also CDT indications Since 1930 hundreds of thousands patients undergone these procedures
The technique is still used in developing countries in vascular treatments
The use of CO2 in aesthetic procedure is new There are only two studies published by the Italian University of Siena in the 2000s concerning the improvement of localized adiposities after liposuction for one or with CDT performed alone in the second
There is also a 2008 Brazilian study available to indicate that collagen turnover is improved with CO2 Although only one team made the study on a limited number of patients the technique has been commonly used since in cellulite and fat indications whereas in other aesthetic indications
Mechanism of action Effects of CO2
bull Vasodilatation
bull The first effects following CO2 injection is a strong vasodilatation a blood flow increase and a higher pO2 in the treated area
bull The Bohr effect bull 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
bull CO2 + H2O 1048774 H+ + HCO3
Bohr Effect
bull This reaction causes the tissuersquos pH to become acidic with even more dissociation of O2 from haemoglobin allowing the tissue to become even more oxygenated
Stimulation of collagen synthesis
bull A 2008 Brazilian study showed a reorganization of collagen fibers 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
bull 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
Neo-angiogenesis effect
bull The first experiments in the 1930s consisted of injecting CO2 into the leg of a frog They have shown a strong vasodilatation associated with the creation of new capillaries
Suspected melanocyte pigment synthesis stimulation Further studies needs to be done but we feel CO2 injections have an important role in the stimulation of melanocytes capabilities as they tend to re-pigment white stretch marks The mechanism of this improvement needs to be worked out
Receptor activation and lipolysis cascading improvement
The pressure receptors are stimulated by CO2 injections There is a release of bradykinin histamine serotonin and catecholamine These mediators have a role on the activation of beta-adrenergic receptors and tissue cyclic AMP leading to stimulation of lipase enzymes Some companies or factories are claiming that CO2 pressure directly destroys fat cells by fragilization which does not seem to be the case
Cosmetic Indications
Aesthetic indications can be divided in two main groups Group 1 is dealing with fatcellulite Group 2 is targeting collagen blood flow and skin oxygenation
Schematically fat indications require deeper injections subdermal
Stretch marksPrinciple
Improve neovascularization and blood flow (red color seen via skin transparency will appear pink close to the natural skin color) improve melanocyte pigment production to darken white stretch marks Improve collagen synthesis to reduce the wave appearance of old stretch marks
Indications
Old white stretch marks deep depressed stretch marks irregular old stretch marks are the main indications Young pinkred stretch marks should preferably have laser treatment (KTP or pulsed dye laser)
Protocol Combined intradermal and subcutaneous injections One session per month Flow 80ndash150 ccmin Puncture inside the mark Number of sessions four to ten
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 1ndash2 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 ccmin is recommended it is sometimes impossible to maintain these values because of the pain Lowering flows to 70ndash80 ccmin may make the patient more comfortable
Periorbital AreaPrinciple
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 20ndash40 ccmin 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 20ndash40 ccmin 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 20ndash40 ccmin Puncture in the fatty area Number of sessions three to six
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 Emlareg 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 oxygenair 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
Celluliteorange 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 IndashII to grade IIIndashIV 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 1ndash2 cckgmin ndash approximately 2 minutes per injection Punctures 15ndash20 cm spaced no overlapping - Number of sessions 10ndash20 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 gt2 cckgmin Punctures 15ndash20 cm spaced no overlapping Number of sessions 10ndash20 Progressive flow (automatic mode) available with some machines
Technique The operatorrsquos 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 15ndash20 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 1ndash2 cckgmin (50ndash80 ccmin) approximately 2 minutes per injection point Punctures spaced 15ndash20 cm apart Number of sessions 10ndash20 ndash First results usually seen after session 4~6 Progressive flow (automatic mode) available with some machines Submentonian area deep dermis (andor subcutaneous) Flow 1ndash2 cckgmin (50ndash80 ccmin) Approximately 30ndash60 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 contraindicationsbull
bull needle phobia bull stress with history of vagal unconsciousness event bull severe heart failure congestive heart disease bull recent heart infarction or instable angina pectoris bull restrictive pulmonary disease chronic obstructive lung diseases bull sleep apnea bull renal failure dialysis bull recent cerebrovascular accident bull uncontrolled blood pressure bull epilepsy bull recent phlebitis or pulmonary embolism bull uncontrolled diabetes bull immunosupression or deficiency bull chemotherapy cancer (healing disorders) bull patients with impaired healing bull connective tissue disorders or diseases bull bleeding diseases Willebrandrsquos disorder hemophilia
Local contraindicationsbull bacterial infection dermatitis cellulites bull foreign body in the area to be treated bull herpes simplex in acute phase and other acute skin viral infection bull skin disease with abnormally increased local circulation bull facial rosacea bull poikiloderma of Civatte bull red necks and red deacutecolletage
bull Temporary contraindications bull pregnancy (precautionary principle) bull lactation (precautionary principle) bull anticoagulation recent aspirin or antiinflammatory drugs intake bull acute skin infection (wait until it is cured) bull other aesthetic procedure or skin traumatism less than 15 days prior to CDT
RioBlush
Introduction
Carbon dioxide therapy (CDT Carboxytherapy)is a procedure which is very similar to mesotherapy It consists of intradermal or subcutaneous injections of medical grade CO2 using 30G needles 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
History of use
CDT (known as carboxitherapy carboxytherapy or carbotherapy) was first described in France in the early 1930s in the medical spa of Royat Doctors 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
Publications
CO2 was first used as a treatment of ischemic lower legs arterial diseases before medical treatments evolved to grafts stents by-passes Raynaudrsquos phenomenon skin ulcers with arterial or venous cause as well as several vascular erection disorders were also CDT indications Since 1930 hundreds of thousands patients undergone these procedures
The technique is still used in developing countries in vascular treatments
The use of CO2 in aesthetic procedure is new There are only two studies published by the Italian University of Siena in the 2000s concerning the improvement of localized adiposities after liposuction for one or with CDT performed alone in the second
There is also a 2008 Brazilian study available to indicate that collagen turnover is improved with CO2 Although only one team made the study on a limited number of patients the technique has been commonly used since in cellulite and fat indications whereas in other aesthetic indications
Mechanism of action Effects of CO2
bull Vasodilatation
bull The first effects following CO2 injection is a strong vasodilatation a blood flow increase and a higher pO2 in the treated area
bull The Bohr effect bull 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
bull CO2 + H2O 1048774 H+ + HCO3
Bohr Effect
bull This reaction causes the tissuersquos pH to become acidic with even more dissociation of O2 from haemoglobin allowing the tissue to become even more oxygenated
Stimulation of collagen synthesis
bull A 2008 Brazilian study showed a reorganization of collagen fibers 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
bull 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
Neo-angiogenesis effect
bull The first experiments in the 1930s consisted of injecting CO2 into the leg of a frog They have shown a strong vasodilatation associated with the creation of new capillaries
Suspected melanocyte pigment synthesis stimulation Further studies needs to be done but we feel CO2 injections have an important role in the stimulation of melanocytes capabilities as they tend to re-pigment white stretch marks The mechanism of this improvement needs to be worked out
Receptor activation and lipolysis cascading improvement
The pressure receptors are stimulated by CO2 injections There is a release of bradykinin histamine serotonin and catecholamine These mediators have a role on the activation of beta-adrenergic receptors and tissue cyclic AMP leading to stimulation of lipase enzymes Some companies or factories are claiming that CO2 pressure directly destroys fat cells by fragilization which does not seem to be the case
Cosmetic Indications
Aesthetic indications can be divided in two main groups Group 1 is dealing with fatcellulite Group 2 is targeting collagen blood flow and skin oxygenation
Schematically fat indications require deeper injections subdermal
Stretch marksPrinciple
Improve neovascularization and blood flow (red color seen via skin transparency will appear pink close to the natural skin color) improve melanocyte pigment production to darken white stretch marks Improve collagen synthesis to reduce the wave appearance of old stretch marks
Indications
Old white stretch marks deep depressed stretch marks irregular old stretch marks are the main indications Young pinkred stretch marks should preferably have laser treatment (KTP or pulsed dye laser)
Protocol Combined intradermal and subcutaneous injections One session per month Flow 80ndash150 ccmin Puncture inside the mark Number of sessions four to ten
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 1ndash2 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 ccmin is recommended it is sometimes impossible to maintain these values because of the pain Lowering flows to 70ndash80 ccmin may make the patient more comfortable
Periorbital AreaPrinciple
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 20ndash40 ccmin 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 20ndash40 ccmin 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 20ndash40 ccmin Puncture in the fatty area Number of sessions three to six
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 Emlareg 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 oxygenair 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
Celluliteorange 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 IndashII to grade IIIndashIV 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 1ndash2 cckgmin ndash approximately 2 minutes per injection Punctures 15ndash20 cm spaced no overlapping - Number of sessions 10ndash20 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 gt2 cckgmin Punctures 15ndash20 cm spaced no overlapping Number of sessions 10ndash20 Progressive flow (automatic mode) available with some machines
Technique The operatorrsquos 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 15ndash20 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 1ndash2 cckgmin (50ndash80 ccmin) approximately 2 minutes per injection point Punctures spaced 15ndash20 cm apart Number of sessions 10ndash20 ndash First results usually seen after session 4~6 Progressive flow (automatic mode) available with some machines Submentonian area deep dermis (andor subcutaneous) Flow 1ndash2 cckgmin (50ndash80 ccmin) Approximately 30ndash60 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 contraindicationsbull
bull needle phobia bull stress with history of vagal unconsciousness event bull severe heart failure congestive heart disease bull recent heart infarction or instable angina pectoris bull restrictive pulmonary disease chronic obstructive lung diseases bull sleep apnea bull renal failure dialysis bull recent cerebrovascular accident bull uncontrolled blood pressure bull epilepsy bull recent phlebitis or pulmonary embolism bull uncontrolled diabetes bull immunosupression or deficiency bull chemotherapy cancer (healing disorders) bull patients with impaired healing bull connective tissue disorders or diseases bull bleeding diseases Willebrandrsquos disorder hemophilia
Local contraindicationsbull bacterial infection dermatitis cellulites bull foreign body in the area to be treated bull herpes simplex in acute phase and other acute skin viral infection bull skin disease with abnormally increased local circulation bull facial rosacea bull poikiloderma of Civatte bull red necks and red deacutecolletage
bull Temporary contraindications bull pregnancy (precautionary principle) bull lactation (precautionary principle) bull anticoagulation recent aspirin or antiinflammatory drugs intake bull acute skin infection (wait until it is cured) bull other aesthetic procedure or skin traumatism less than 15 days prior to CDT
Introduction
Carbon dioxide therapy (CDT Carboxytherapy)is a procedure which is very similar to mesotherapy It consists of intradermal or subcutaneous injections of medical grade CO2 using 30G needles 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
History of use
CDT (known as carboxitherapy carboxytherapy or carbotherapy) was first described in France in the early 1930s in the medical spa of Royat Doctors 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
Publications
CO2 was first used as a treatment of ischemic lower legs arterial diseases before medical treatments evolved to grafts stents by-passes Raynaudrsquos phenomenon skin ulcers with arterial or venous cause as well as several vascular erection disorders were also CDT indications Since 1930 hundreds of thousands patients undergone these procedures
The technique is still used in developing countries in vascular treatments
The use of CO2 in aesthetic procedure is new There are only two studies published by the Italian University of Siena in the 2000s concerning the improvement of localized adiposities after liposuction for one or with CDT performed alone in the second
There is also a 2008 Brazilian study available to indicate that collagen turnover is improved with CO2 Although only one team made the study on a limited number of patients the technique has been commonly used since in cellulite and fat indications whereas in other aesthetic indications
Mechanism of action Effects of CO2
bull Vasodilatation
bull The first effects following CO2 injection is a strong vasodilatation a blood flow increase and a higher pO2 in the treated area
bull The Bohr effect bull 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
bull CO2 + H2O 1048774 H+ + HCO3
Bohr Effect
bull This reaction causes the tissuersquos pH to become acidic with even more dissociation of O2 from haemoglobin allowing the tissue to become even more oxygenated
Stimulation of collagen synthesis
bull A 2008 Brazilian study showed a reorganization of collagen fibers 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
bull 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
Neo-angiogenesis effect
bull The first experiments in the 1930s consisted of injecting CO2 into the leg of a frog They have shown a strong vasodilatation associated with the creation of new capillaries
Suspected melanocyte pigment synthesis stimulation Further studies needs to be done but we feel CO2 injections have an important role in the stimulation of melanocytes capabilities as they tend to re-pigment white stretch marks The mechanism of this improvement needs to be worked out
Receptor activation and lipolysis cascading improvement
The pressure receptors are stimulated by CO2 injections There is a release of bradykinin histamine serotonin and catecholamine These mediators have a role on the activation of beta-adrenergic receptors and tissue cyclic AMP leading to stimulation of lipase enzymes Some companies or factories are claiming that CO2 pressure directly destroys fat cells by fragilization which does not seem to be the case
Cosmetic Indications
Aesthetic indications can be divided in two main groups Group 1 is dealing with fatcellulite Group 2 is targeting collagen blood flow and skin oxygenation
Schematically fat indications require deeper injections subdermal
Stretch marksPrinciple
Improve neovascularization and blood flow (red color seen via skin transparency will appear pink close to the natural skin color) improve melanocyte pigment production to darken white stretch marks Improve collagen synthesis to reduce the wave appearance of old stretch marks
Indications
Old white stretch marks deep depressed stretch marks irregular old stretch marks are the main indications Young pinkred stretch marks should preferably have laser treatment (KTP or pulsed dye laser)
Protocol Combined intradermal and subcutaneous injections One session per month Flow 80ndash150 ccmin Puncture inside the mark Number of sessions four to ten
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 1ndash2 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 ccmin is recommended it is sometimes impossible to maintain these values because of the pain Lowering flows to 70ndash80 ccmin may make the patient more comfortable
Periorbital AreaPrinciple
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 20ndash40 ccmin 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 20ndash40 ccmin 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 20ndash40 ccmin Puncture in the fatty area Number of sessions three to six
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 Emlareg 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 oxygenair 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
Celluliteorange 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 IndashII to grade IIIndashIV 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 1ndash2 cckgmin ndash approximately 2 minutes per injection Punctures 15ndash20 cm spaced no overlapping - Number of sessions 10ndash20 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 gt2 cckgmin Punctures 15ndash20 cm spaced no overlapping Number of sessions 10ndash20 Progressive flow (automatic mode) available with some machines
Technique The operatorrsquos 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 15ndash20 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 1ndash2 cckgmin (50ndash80 ccmin) approximately 2 minutes per injection point Punctures spaced 15ndash20 cm apart Number of sessions 10ndash20 ndash First results usually seen after session 4~6 Progressive flow (automatic mode) available with some machines Submentonian area deep dermis (andor subcutaneous) Flow 1ndash2 cckgmin (50ndash80 ccmin) Approximately 30ndash60 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 contraindicationsbull
bull needle phobia bull stress with history of vagal unconsciousness event bull severe heart failure congestive heart disease bull recent heart infarction or instable angina pectoris bull restrictive pulmonary disease chronic obstructive lung diseases bull sleep apnea bull renal failure dialysis bull recent cerebrovascular accident bull uncontrolled blood pressure bull epilepsy bull recent phlebitis or pulmonary embolism bull uncontrolled diabetes bull immunosupression or deficiency bull chemotherapy cancer (healing disorders) bull patients with impaired healing bull connective tissue disorders or diseases bull bleeding diseases Willebrandrsquos disorder hemophilia
Local contraindicationsbull bacterial infection dermatitis cellulites bull foreign body in the area to be treated bull herpes simplex in acute phase and other acute skin viral infection bull skin disease with abnormally increased local circulation bull facial rosacea bull poikiloderma of Civatte bull red necks and red deacutecolletage
bull Temporary contraindications bull pregnancy (precautionary principle) bull lactation (precautionary principle) bull anticoagulation recent aspirin or antiinflammatory drugs intake bull acute skin infection (wait until it is cured) bull other aesthetic procedure or skin traumatism less than 15 days prior to CDT
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
History of use
CDT (known as carboxitherapy carboxytherapy or carbotherapy) was first described in France in the early 1930s in the medical spa of Royat Doctors 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
Publications
CO2 was first used as a treatment of ischemic lower legs arterial diseases before medical treatments evolved to grafts stents by-passes Raynaudrsquos phenomenon skin ulcers with arterial or venous cause as well as several vascular erection disorders were also CDT indications Since 1930 hundreds of thousands patients undergone these procedures
The technique is still used in developing countries in vascular treatments
The use of CO2 in aesthetic procedure is new There are only two studies published by the Italian University of Siena in the 2000s concerning the improvement of localized adiposities after liposuction for one or with CDT performed alone in the second
There is also a 2008 Brazilian study available to indicate that collagen turnover is improved with CO2 Although only one team made the study on a limited number of patients the technique has been commonly used since in cellulite and fat indications whereas in other aesthetic indications
Mechanism of action Effects of CO2
bull Vasodilatation
bull The first effects following CO2 injection is a strong vasodilatation a blood flow increase and a higher pO2 in the treated area
bull The Bohr effect bull 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
bull CO2 + H2O 1048774 H+ + HCO3
Bohr Effect
bull This reaction causes the tissuersquos pH to become acidic with even more dissociation of O2 from haemoglobin allowing the tissue to become even more oxygenated
Stimulation of collagen synthesis
bull A 2008 Brazilian study showed a reorganization of collagen fibers 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
bull 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
Neo-angiogenesis effect
bull The first experiments in the 1930s consisted of injecting CO2 into the leg of a frog They have shown a strong vasodilatation associated with the creation of new capillaries
Suspected melanocyte pigment synthesis stimulation Further studies needs to be done but we feel CO2 injections have an important role in the stimulation of melanocytes capabilities as they tend to re-pigment white stretch marks The mechanism of this improvement needs to be worked out
Receptor activation and lipolysis cascading improvement
The pressure receptors are stimulated by CO2 injections There is a release of bradykinin histamine serotonin and catecholamine These mediators have a role on the activation of beta-adrenergic receptors and tissue cyclic AMP leading to stimulation of lipase enzymes Some companies or factories are claiming that CO2 pressure directly destroys fat cells by fragilization which does not seem to be the case
Cosmetic Indications
Aesthetic indications can be divided in two main groups Group 1 is dealing with fatcellulite Group 2 is targeting collagen blood flow and skin oxygenation
Schematically fat indications require deeper injections subdermal
Stretch marksPrinciple
Improve neovascularization and blood flow (red color seen via skin transparency will appear pink close to the natural skin color) improve melanocyte pigment production to darken white stretch marks Improve collagen synthesis to reduce the wave appearance of old stretch marks
Indications
Old white stretch marks deep depressed stretch marks irregular old stretch marks are the main indications Young pinkred stretch marks should preferably have laser treatment (KTP or pulsed dye laser)
Protocol Combined intradermal and subcutaneous injections One session per month Flow 80ndash150 ccmin Puncture inside the mark Number of sessions four to ten
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 1ndash2 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 ccmin is recommended it is sometimes impossible to maintain these values because of the pain Lowering flows to 70ndash80 ccmin may make the patient more comfortable
Periorbital AreaPrinciple
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 20ndash40 ccmin 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 20ndash40 ccmin 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 20ndash40 ccmin Puncture in the fatty area Number of sessions three to six
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 Emlareg 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 oxygenair 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
Celluliteorange 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 IndashII to grade IIIndashIV 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 1ndash2 cckgmin ndash approximately 2 minutes per injection Punctures 15ndash20 cm spaced no overlapping - Number of sessions 10ndash20 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 gt2 cckgmin Punctures 15ndash20 cm spaced no overlapping Number of sessions 10ndash20 Progressive flow (automatic mode) available with some machines
Technique The operatorrsquos 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 15ndash20 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 1ndash2 cckgmin (50ndash80 ccmin) approximately 2 minutes per injection point Punctures spaced 15ndash20 cm apart Number of sessions 10ndash20 ndash First results usually seen after session 4~6 Progressive flow (automatic mode) available with some machines Submentonian area deep dermis (andor subcutaneous) Flow 1ndash2 cckgmin (50ndash80 ccmin) Approximately 30ndash60 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 contraindicationsbull
bull needle phobia bull stress with history of vagal unconsciousness event bull severe heart failure congestive heart disease bull recent heart infarction or instable angina pectoris bull restrictive pulmonary disease chronic obstructive lung diseases bull sleep apnea bull renal failure dialysis bull recent cerebrovascular accident bull uncontrolled blood pressure bull epilepsy bull recent phlebitis or pulmonary embolism bull uncontrolled diabetes bull immunosupression or deficiency bull chemotherapy cancer (healing disorders) bull patients with impaired healing bull connective tissue disorders or diseases bull bleeding diseases Willebrandrsquos disorder hemophilia
Local contraindicationsbull bacterial infection dermatitis cellulites bull foreign body in the area to be treated bull herpes simplex in acute phase and other acute skin viral infection bull skin disease with abnormally increased local circulation bull facial rosacea bull poikiloderma of Civatte bull red necks and red deacutecolletage
bull Temporary contraindications bull pregnancy (precautionary principle) bull lactation (precautionary principle) bull anticoagulation recent aspirin or antiinflammatory drugs intake bull acute skin infection (wait until it is cured) bull other aesthetic procedure or skin traumatism less than 15 days prior to CDT
History of use
CDT (known as carboxitherapy carboxytherapy or carbotherapy) was first described in France in the early 1930s in the medical spa of Royat Doctors 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
Publications
CO2 was first used as a treatment of ischemic lower legs arterial diseases before medical treatments evolved to grafts stents by-passes Raynaudrsquos phenomenon skin ulcers with arterial or venous cause as well as several vascular erection disorders were also CDT indications Since 1930 hundreds of thousands patients undergone these procedures
The technique is still used in developing countries in vascular treatments
The use of CO2 in aesthetic procedure is new There are only two studies published by the Italian University of Siena in the 2000s concerning the improvement of localized adiposities after liposuction for one or with CDT performed alone in the second
There is also a 2008 Brazilian study available to indicate that collagen turnover is improved with CO2 Although only one team made the study on a limited number of patients the technique has been commonly used since in cellulite and fat indications whereas in other aesthetic indications
Mechanism of action Effects of CO2
bull Vasodilatation
bull The first effects following CO2 injection is a strong vasodilatation a blood flow increase and a higher pO2 in the treated area
bull The Bohr effect bull 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
bull CO2 + H2O 1048774 H+ + HCO3
Bohr Effect
bull This reaction causes the tissuersquos pH to become acidic with even more dissociation of O2 from haemoglobin allowing the tissue to become even more oxygenated
Stimulation of collagen synthesis
bull A 2008 Brazilian study showed a reorganization of collagen fibers 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
bull 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
Neo-angiogenesis effect
bull The first experiments in the 1930s consisted of injecting CO2 into the leg of a frog They have shown a strong vasodilatation associated with the creation of new capillaries
Suspected melanocyte pigment synthesis stimulation Further studies needs to be done but we feel CO2 injections have an important role in the stimulation of melanocytes capabilities as they tend to re-pigment white stretch marks The mechanism of this improvement needs to be worked out
Receptor activation and lipolysis cascading improvement
The pressure receptors are stimulated by CO2 injections There is a release of bradykinin histamine serotonin and catecholamine These mediators have a role on the activation of beta-adrenergic receptors and tissue cyclic AMP leading to stimulation of lipase enzymes Some companies or factories are claiming that CO2 pressure directly destroys fat cells by fragilization which does not seem to be the case
Cosmetic Indications
Aesthetic indications can be divided in two main groups Group 1 is dealing with fatcellulite Group 2 is targeting collagen blood flow and skin oxygenation
Schematically fat indications require deeper injections subdermal
Stretch marksPrinciple
Improve neovascularization and blood flow (red color seen via skin transparency will appear pink close to the natural skin color) improve melanocyte pigment production to darken white stretch marks Improve collagen synthesis to reduce the wave appearance of old stretch marks
Indications
Old white stretch marks deep depressed stretch marks irregular old stretch marks are the main indications Young pinkred stretch marks should preferably have laser treatment (KTP or pulsed dye laser)
Protocol Combined intradermal and subcutaneous injections One session per month Flow 80ndash150 ccmin Puncture inside the mark Number of sessions four to ten
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 1ndash2 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 ccmin is recommended it is sometimes impossible to maintain these values because of the pain Lowering flows to 70ndash80 ccmin may make the patient more comfortable
Periorbital AreaPrinciple
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 20ndash40 ccmin 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 20ndash40 ccmin 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 20ndash40 ccmin Puncture in the fatty area Number of sessions three to six
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 Emlareg 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 oxygenair 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
Celluliteorange 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 IndashII to grade IIIndashIV 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 1ndash2 cckgmin ndash approximately 2 minutes per injection Punctures 15ndash20 cm spaced no overlapping - Number of sessions 10ndash20 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 gt2 cckgmin Punctures 15ndash20 cm spaced no overlapping Number of sessions 10ndash20 Progressive flow (automatic mode) available with some machines
Technique The operatorrsquos 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 15ndash20 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 1ndash2 cckgmin (50ndash80 ccmin) approximately 2 minutes per injection point Punctures spaced 15ndash20 cm apart Number of sessions 10ndash20 ndash First results usually seen after session 4~6 Progressive flow (automatic mode) available with some machines Submentonian area deep dermis (andor subcutaneous) Flow 1ndash2 cckgmin (50ndash80 ccmin) Approximately 30ndash60 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 contraindicationsbull
bull needle phobia bull stress with history of vagal unconsciousness event bull severe heart failure congestive heart disease bull recent heart infarction or instable angina pectoris bull restrictive pulmonary disease chronic obstructive lung diseases bull sleep apnea bull renal failure dialysis bull recent cerebrovascular accident bull uncontrolled blood pressure bull epilepsy bull recent phlebitis or pulmonary embolism bull uncontrolled diabetes bull immunosupression or deficiency bull chemotherapy cancer (healing disorders) bull patients with impaired healing bull connective tissue disorders or diseases bull bleeding diseases Willebrandrsquos disorder hemophilia
Local contraindicationsbull bacterial infection dermatitis cellulites bull foreign body in the area to be treated bull herpes simplex in acute phase and other acute skin viral infection bull skin disease with abnormally increased local circulation bull facial rosacea bull poikiloderma of Civatte bull red necks and red deacutecolletage
bull Temporary contraindications bull pregnancy (precautionary principle) bull lactation (precautionary principle) bull anticoagulation recent aspirin or antiinflammatory drugs intake bull acute skin infection (wait until it is cured) bull other aesthetic procedure or skin traumatism less than 15 days prior to CDT
Publications
CO2 was first used as a treatment of ischemic lower legs arterial diseases before medical treatments evolved to grafts stents by-passes Raynaudrsquos phenomenon skin ulcers with arterial or venous cause as well as several vascular erection disorders were also CDT indications Since 1930 hundreds of thousands patients undergone these procedures
The technique is still used in developing countries in vascular treatments
The use of CO2 in aesthetic procedure is new There are only two studies published by the Italian University of Siena in the 2000s concerning the improvement of localized adiposities after liposuction for one or with CDT performed alone in the second
There is also a 2008 Brazilian study available to indicate that collagen turnover is improved with CO2 Although only one team made the study on a limited number of patients the technique has been commonly used since in cellulite and fat indications whereas in other aesthetic indications
Mechanism of action Effects of CO2
bull Vasodilatation
bull The first effects following CO2 injection is a strong vasodilatation a blood flow increase and a higher pO2 in the treated area
bull The Bohr effect bull 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
bull CO2 + H2O 1048774 H+ + HCO3
Bohr Effect
bull This reaction causes the tissuersquos pH to become acidic with even more dissociation of O2 from haemoglobin allowing the tissue to become even more oxygenated
Stimulation of collagen synthesis
bull A 2008 Brazilian study showed a reorganization of collagen fibers 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
bull 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
Neo-angiogenesis effect
bull The first experiments in the 1930s consisted of injecting CO2 into the leg of a frog They have shown a strong vasodilatation associated with the creation of new capillaries
Suspected melanocyte pigment synthesis stimulation Further studies needs to be done but we feel CO2 injections have an important role in the stimulation of melanocytes capabilities as they tend to re-pigment white stretch marks The mechanism of this improvement needs to be worked out
Receptor activation and lipolysis cascading improvement
The pressure receptors are stimulated by CO2 injections There is a release of bradykinin histamine serotonin and catecholamine These mediators have a role on the activation of beta-adrenergic receptors and tissue cyclic AMP leading to stimulation of lipase enzymes Some companies or factories are claiming that CO2 pressure directly destroys fat cells by fragilization which does not seem to be the case
Cosmetic Indications
Aesthetic indications can be divided in two main groups Group 1 is dealing with fatcellulite Group 2 is targeting collagen blood flow and skin oxygenation
Schematically fat indications require deeper injections subdermal
Stretch marksPrinciple
Improve neovascularization and blood flow (red color seen via skin transparency will appear pink close to the natural skin color) improve melanocyte pigment production to darken white stretch marks Improve collagen synthesis to reduce the wave appearance of old stretch marks
Indications
Old white stretch marks deep depressed stretch marks irregular old stretch marks are the main indications Young pinkred stretch marks should preferably have laser treatment (KTP or pulsed dye laser)
Protocol Combined intradermal and subcutaneous injections One session per month Flow 80ndash150 ccmin Puncture inside the mark Number of sessions four to ten
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 1ndash2 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 ccmin is recommended it is sometimes impossible to maintain these values because of the pain Lowering flows to 70ndash80 ccmin may make the patient more comfortable
Periorbital AreaPrinciple
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 20ndash40 ccmin 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 20ndash40 ccmin 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 20ndash40 ccmin Puncture in the fatty area Number of sessions three to six
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 Emlareg 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 oxygenair 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
Celluliteorange 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 IndashII to grade IIIndashIV 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 1ndash2 cckgmin ndash approximately 2 minutes per injection Punctures 15ndash20 cm spaced no overlapping - Number of sessions 10ndash20 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 gt2 cckgmin Punctures 15ndash20 cm spaced no overlapping Number of sessions 10ndash20 Progressive flow (automatic mode) available with some machines
Technique The operatorrsquos 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 15ndash20 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 1ndash2 cckgmin (50ndash80 ccmin) approximately 2 minutes per injection point Punctures spaced 15ndash20 cm apart Number of sessions 10ndash20 ndash First results usually seen after session 4~6 Progressive flow (automatic mode) available with some machines Submentonian area deep dermis (andor subcutaneous) Flow 1ndash2 cckgmin (50ndash80 ccmin) Approximately 30ndash60 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 contraindicationsbull
bull needle phobia bull stress with history of vagal unconsciousness event bull severe heart failure congestive heart disease bull recent heart infarction or instable angina pectoris bull restrictive pulmonary disease chronic obstructive lung diseases bull sleep apnea bull renal failure dialysis bull recent cerebrovascular accident bull uncontrolled blood pressure bull epilepsy bull recent phlebitis or pulmonary embolism bull uncontrolled diabetes bull immunosupression or deficiency bull chemotherapy cancer (healing disorders) bull patients with impaired healing bull connective tissue disorders or diseases bull bleeding diseases Willebrandrsquos disorder hemophilia
Local contraindicationsbull bacterial infection dermatitis cellulites bull foreign body in the area to be treated bull herpes simplex in acute phase and other acute skin viral infection bull skin disease with abnormally increased local circulation bull facial rosacea bull poikiloderma of Civatte bull red necks and red deacutecolletage
bull Temporary contraindications bull pregnancy (precautionary principle) bull lactation (precautionary principle) bull anticoagulation recent aspirin or antiinflammatory drugs intake bull acute skin infection (wait until it is cured) bull other aesthetic procedure or skin traumatism less than 15 days prior to CDT
The use of CO2 in aesthetic procedure is new There are only two studies published by the Italian University of Siena in the 2000s concerning the improvement of localized adiposities after liposuction for one or with CDT performed alone in the second
There is also a 2008 Brazilian study available to indicate that collagen turnover is improved with CO2 Although only one team made the study on a limited number of patients the technique has been commonly used since in cellulite and fat indications whereas in other aesthetic indications
Mechanism of action Effects of CO2
bull Vasodilatation
bull The first effects following CO2 injection is a strong vasodilatation a blood flow increase and a higher pO2 in the treated area
bull The Bohr effect bull 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
bull CO2 + H2O 1048774 H+ + HCO3
Bohr Effect
bull This reaction causes the tissuersquos pH to become acidic with even more dissociation of O2 from haemoglobin allowing the tissue to become even more oxygenated
Stimulation of collagen synthesis
bull A 2008 Brazilian study showed a reorganization of collagen fibers 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
bull 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
Neo-angiogenesis effect
bull The first experiments in the 1930s consisted of injecting CO2 into the leg of a frog They have shown a strong vasodilatation associated with the creation of new capillaries
Suspected melanocyte pigment synthesis stimulation Further studies needs to be done but we feel CO2 injections have an important role in the stimulation of melanocytes capabilities as they tend to re-pigment white stretch marks The mechanism of this improvement needs to be worked out
Receptor activation and lipolysis cascading improvement
The pressure receptors are stimulated by CO2 injections There is a release of bradykinin histamine serotonin and catecholamine These mediators have a role on the activation of beta-adrenergic receptors and tissue cyclic AMP leading to stimulation of lipase enzymes Some companies or factories are claiming that CO2 pressure directly destroys fat cells by fragilization which does not seem to be the case
Cosmetic Indications
Aesthetic indications can be divided in two main groups Group 1 is dealing with fatcellulite Group 2 is targeting collagen blood flow and skin oxygenation
Schematically fat indications require deeper injections subdermal
Stretch marksPrinciple
Improve neovascularization and blood flow (red color seen via skin transparency will appear pink close to the natural skin color) improve melanocyte pigment production to darken white stretch marks Improve collagen synthesis to reduce the wave appearance of old stretch marks
Indications
Old white stretch marks deep depressed stretch marks irregular old stretch marks are the main indications Young pinkred stretch marks should preferably have laser treatment (KTP or pulsed dye laser)
Protocol Combined intradermal and subcutaneous injections One session per month Flow 80ndash150 ccmin Puncture inside the mark Number of sessions four to ten
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 1ndash2 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 ccmin is recommended it is sometimes impossible to maintain these values because of the pain Lowering flows to 70ndash80 ccmin may make the patient more comfortable
Periorbital AreaPrinciple
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 20ndash40 ccmin 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 20ndash40 ccmin 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 20ndash40 ccmin Puncture in the fatty area Number of sessions three to six
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 Emlareg 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 oxygenair 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
Celluliteorange 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 IndashII to grade IIIndashIV 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 1ndash2 cckgmin ndash approximately 2 minutes per injection Punctures 15ndash20 cm spaced no overlapping - Number of sessions 10ndash20 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 gt2 cckgmin Punctures 15ndash20 cm spaced no overlapping Number of sessions 10ndash20 Progressive flow (automatic mode) available with some machines
Technique The operatorrsquos 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 15ndash20 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 1ndash2 cckgmin (50ndash80 ccmin) approximately 2 minutes per injection point Punctures spaced 15ndash20 cm apart Number of sessions 10ndash20 ndash First results usually seen after session 4~6 Progressive flow (automatic mode) available with some machines Submentonian area deep dermis (andor subcutaneous) Flow 1ndash2 cckgmin (50ndash80 ccmin) Approximately 30ndash60 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 contraindicationsbull
bull needle phobia bull stress with history of vagal unconsciousness event bull severe heart failure congestive heart disease bull recent heart infarction or instable angina pectoris bull restrictive pulmonary disease chronic obstructive lung diseases bull sleep apnea bull renal failure dialysis bull recent cerebrovascular accident bull uncontrolled blood pressure bull epilepsy bull recent phlebitis or pulmonary embolism bull uncontrolled diabetes bull immunosupression or deficiency bull chemotherapy cancer (healing disorders) bull patients with impaired healing bull connective tissue disorders or diseases bull bleeding diseases Willebrandrsquos disorder hemophilia
Local contraindicationsbull bacterial infection dermatitis cellulites bull foreign body in the area to be treated bull herpes simplex in acute phase and other acute skin viral infection bull skin disease with abnormally increased local circulation bull facial rosacea bull poikiloderma of Civatte bull red necks and red deacutecolletage
bull Temporary contraindications bull pregnancy (precautionary principle) bull lactation (precautionary principle) bull anticoagulation recent aspirin or antiinflammatory drugs intake bull acute skin infection (wait until it is cured) bull other aesthetic procedure or skin traumatism less than 15 days prior to CDT
Mechanism of action Effects of CO2
bull Vasodilatation
bull The first effects following CO2 injection is a strong vasodilatation a blood flow increase and a higher pO2 in the treated area
bull The Bohr effect bull 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
bull CO2 + H2O 1048774 H+ + HCO3
Bohr Effect
bull This reaction causes the tissuersquos pH to become acidic with even more dissociation of O2 from haemoglobin allowing the tissue to become even more oxygenated
Stimulation of collagen synthesis
bull A 2008 Brazilian study showed a reorganization of collagen fibers 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
bull 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
Neo-angiogenesis effect
bull The first experiments in the 1930s consisted of injecting CO2 into the leg of a frog They have shown a strong vasodilatation associated with the creation of new capillaries
Suspected melanocyte pigment synthesis stimulation Further studies needs to be done but we feel CO2 injections have an important role in the stimulation of melanocytes capabilities as they tend to re-pigment white stretch marks The mechanism of this improvement needs to be worked out
Receptor activation and lipolysis cascading improvement
The pressure receptors are stimulated by CO2 injections There is a release of bradykinin histamine serotonin and catecholamine These mediators have a role on the activation of beta-adrenergic receptors and tissue cyclic AMP leading to stimulation of lipase enzymes Some companies or factories are claiming that CO2 pressure directly destroys fat cells by fragilization which does not seem to be the case
Cosmetic Indications
Aesthetic indications can be divided in two main groups Group 1 is dealing with fatcellulite Group 2 is targeting collagen blood flow and skin oxygenation
Schematically fat indications require deeper injections subdermal
Stretch marksPrinciple
Improve neovascularization and blood flow (red color seen via skin transparency will appear pink close to the natural skin color) improve melanocyte pigment production to darken white stretch marks Improve collagen synthesis to reduce the wave appearance of old stretch marks
Indications
Old white stretch marks deep depressed stretch marks irregular old stretch marks are the main indications Young pinkred stretch marks should preferably have laser treatment (KTP or pulsed dye laser)
Protocol Combined intradermal and subcutaneous injections One session per month Flow 80ndash150 ccmin Puncture inside the mark Number of sessions four to ten
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 1ndash2 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 ccmin is recommended it is sometimes impossible to maintain these values because of the pain Lowering flows to 70ndash80 ccmin may make the patient more comfortable
Periorbital AreaPrinciple
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 20ndash40 ccmin 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 20ndash40 ccmin 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 20ndash40 ccmin Puncture in the fatty area Number of sessions three to six
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 Emlareg 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 oxygenair 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
Celluliteorange 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 IndashII to grade IIIndashIV 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 1ndash2 cckgmin ndash approximately 2 minutes per injection Punctures 15ndash20 cm spaced no overlapping - Number of sessions 10ndash20 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 gt2 cckgmin Punctures 15ndash20 cm spaced no overlapping Number of sessions 10ndash20 Progressive flow (automatic mode) available with some machines
Technique The operatorrsquos 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 15ndash20 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 1ndash2 cckgmin (50ndash80 ccmin) approximately 2 minutes per injection point Punctures spaced 15ndash20 cm apart Number of sessions 10ndash20 ndash First results usually seen after session 4~6 Progressive flow (automatic mode) available with some machines Submentonian area deep dermis (andor subcutaneous) Flow 1ndash2 cckgmin (50ndash80 ccmin) Approximately 30ndash60 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 contraindicationsbull
bull needle phobia bull stress with history of vagal unconsciousness event bull severe heart failure congestive heart disease bull recent heart infarction or instable angina pectoris bull restrictive pulmonary disease chronic obstructive lung diseases bull sleep apnea bull renal failure dialysis bull recent cerebrovascular accident bull uncontrolled blood pressure bull epilepsy bull recent phlebitis or pulmonary embolism bull uncontrolled diabetes bull immunosupression or deficiency bull chemotherapy cancer (healing disorders) bull patients with impaired healing bull connective tissue disorders or diseases bull bleeding diseases Willebrandrsquos disorder hemophilia
Local contraindicationsbull bacterial infection dermatitis cellulites bull foreign body in the area to be treated bull herpes simplex in acute phase and other acute skin viral infection bull skin disease with abnormally increased local circulation bull facial rosacea bull poikiloderma of Civatte bull red necks and red deacutecolletage
bull Temporary contraindications bull pregnancy (precautionary principle) bull lactation (precautionary principle) bull anticoagulation recent aspirin or antiinflammatory drugs intake bull acute skin infection (wait until it is cured) bull other aesthetic procedure or skin traumatism less than 15 days prior to CDT
Bohr Effect
bull This reaction causes the tissuersquos pH to become acidic with even more dissociation of O2 from haemoglobin allowing the tissue to become even more oxygenated
Stimulation of collagen synthesis
bull A 2008 Brazilian study showed a reorganization of collagen fibers 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
bull 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
Neo-angiogenesis effect
bull The first experiments in the 1930s consisted of injecting CO2 into the leg of a frog They have shown a strong vasodilatation associated with the creation of new capillaries
Suspected melanocyte pigment synthesis stimulation Further studies needs to be done but we feel CO2 injections have an important role in the stimulation of melanocytes capabilities as they tend to re-pigment white stretch marks The mechanism of this improvement needs to be worked out
Receptor activation and lipolysis cascading improvement
The pressure receptors are stimulated by CO2 injections There is a release of bradykinin histamine serotonin and catecholamine These mediators have a role on the activation of beta-adrenergic receptors and tissue cyclic AMP leading to stimulation of lipase enzymes Some companies or factories are claiming that CO2 pressure directly destroys fat cells by fragilization which does not seem to be the case
Cosmetic Indications
Aesthetic indications can be divided in two main groups Group 1 is dealing with fatcellulite Group 2 is targeting collagen blood flow and skin oxygenation
Schematically fat indications require deeper injections subdermal
Stretch marksPrinciple
Improve neovascularization and blood flow (red color seen via skin transparency will appear pink close to the natural skin color) improve melanocyte pigment production to darken white stretch marks Improve collagen synthesis to reduce the wave appearance of old stretch marks
Indications
Old white stretch marks deep depressed stretch marks irregular old stretch marks are the main indications Young pinkred stretch marks should preferably have laser treatment (KTP or pulsed dye laser)
Protocol Combined intradermal and subcutaneous injections One session per month Flow 80ndash150 ccmin Puncture inside the mark Number of sessions four to ten
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 1ndash2 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 ccmin is recommended it is sometimes impossible to maintain these values because of the pain Lowering flows to 70ndash80 ccmin may make the patient more comfortable
Periorbital AreaPrinciple
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 20ndash40 ccmin 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 20ndash40 ccmin 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 20ndash40 ccmin Puncture in the fatty area Number of sessions three to six
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 Emlareg 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 oxygenair 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
Celluliteorange 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 IndashII to grade IIIndashIV 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 1ndash2 cckgmin ndash approximately 2 minutes per injection Punctures 15ndash20 cm spaced no overlapping - Number of sessions 10ndash20 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 gt2 cckgmin Punctures 15ndash20 cm spaced no overlapping Number of sessions 10ndash20 Progressive flow (automatic mode) available with some machines
Technique The operatorrsquos 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 15ndash20 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 1ndash2 cckgmin (50ndash80 ccmin) approximately 2 minutes per injection point Punctures spaced 15ndash20 cm apart Number of sessions 10ndash20 ndash First results usually seen after session 4~6 Progressive flow (automatic mode) available with some machines Submentonian area deep dermis (andor subcutaneous) Flow 1ndash2 cckgmin (50ndash80 ccmin) Approximately 30ndash60 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 contraindicationsbull
bull needle phobia bull stress with history of vagal unconsciousness event bull severe heart failure congestive heart disease bull recent heart infarction or instable angina pectoris bull restrictive pulmonary disease chronic obstructive lung diseases bull sleep apnea bull renal failure dialysis bull recent cerebrovascular accident bull uncontrolled blood pressure bull epilepsy bull recent phlebitis or pulmonary embolism bull uncontrolled diabetes bull immunosupression or deficiency bull chemotherapy cancer (healing disorders) bull patients with impaired healing bull connective tissue disorders or diseases bull bleeding diseases Willebrandrsquos disorder hemophilia
Local contraindicationsbull bacterial infection dermatitis cellulites bull foreign body in the area to be treated bull herpes simplex in acute phase and other acute skin viral infection bull skin disease with abnormally increased local circulation bull facial rosacea bull poikiloderma of Civatte bull red necks and red deacutecolletage
bull Temporary contraindications bull pregnancy (precautionary principle) bull lactation (precautionary principle) bull anticoagulation recent aspirin or antiinflammatory drugs intake bull acute skin infection (wait until it is cured) bull other aesthetic procedure or skin traumatism less than 15 days prior to CDT
Stimulation of collagen synthesis
bull A 2008 Brazilian study showed a reorganization of collagen fibers 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
bull 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
Neo-angiogenesis effect
bull The first experiments in the 1930s consisted of injecting CO2 into the leg of a frog They have shown a strong vasodilatation associated with the creation of new capillaries
Suspected melanocyte pigment synthesis stimulation Further studies needs to be done but we feel CO2 injections have an important role in the stimulation of melanocytes capabilities as they tend to re-pigment white stretch marks The mechanism of this improvement needs to be worked out
Receptor activation and lipolysis cascading improvement
The pressure receptors are stimulated by CO2 injections There is a release of bradykinin histamine serotonin and catecholamine These mediators have a role on the activation of beta-adrenergic receptors and tissue cyclic AMP leading to stimulation of lipase enzymes Some companies or factories are claiming that CO2 pressure directly destroys fat cells by fragilization which does not seem to be the case
Cosmetic Indications
Aesthetic indications can be divided in two main groups Group 1 is dealing with fatcellulite Group 2 is targeting collagen blood flow and skin oxygenation
Schematically fat indications require deeper injections subdermal
Stretch marksPrinciple
Improve neovascularization and blood flow (red color seen via skin transparency will appear pink close to the natural skin color) improve melanocyte pigment production to darken white stretch marks Improve collagen synthesis to reduce the wave appearance of old stretch marks
Indications
Old white stretch marks deep depressed stretch marks irregular old stretch marks are the main indications Young pinkred stretch marks should preferably have laser treatment (KTP or pulsed dye laser)
Protocol Combined intradermal and subcutaneous injections One session per month Flow 80ndash150 ccmin Puncture inside the mark Number of sessions four to ten
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 1ndash2 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 ccmin is recommended it is sometimes impossible to maintain these values because of the pain Lowering flows to 70ndash80 ccmin may make the patient more comfortable
Periorbital AreaPrinciple
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 20ndash40 ccmin 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 20ndash40 ccmin 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 20ndash40 ccmin Puncture in the fatty area Number of sessions three to six
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 Emlareg 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 oxygenair 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
Celluliteorange 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 IndashII to grade IIIndashIV 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 1ndash2 cckgmin ndash approximately 2 minutes per injection Punctures 15ndash20 cm spaced no overlapping - Number of sessions 10ndash20 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 gt2 cckgmin Punctures 15ndash20 cm spaced no overlapping Number of sessions 10ndash20 Progressive flow (automatic mode) available with some machines
Technique The operatorrsquos 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 15ndash20 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 1ndash2 cckgmin (50ndash80 ccmin) approximately 2 minutes per injection point Punctures spaced 15ndash20 cm apart Number of sessions 10ndash20 ndash First results usually seen after session 4~6 Progressive flow (automatic mode) available with some machines Submentonian area deep dermis (andor subcutaneous) Flow 1ndash2 cckgmin (50ndash80 ccmin) Approximately 30ndash60 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 contraindicationsbull
bull needle phobia bull stress with history of vagal unconsciousness event bull severe heart failure congestive heart disease bull recent heart infarction or instable angina pectoris bull restrictive pulmonary disease chronic obstructive lung diseases bull sleep apnea bull renal failure dialysis bull recent cerebrovascular accident bull uncontrolled blood pressure bull epilepsy bull recent phlebitis or pulmonary embolism bull uncontrolled diabetes bull immunosupression or deficiency bull chemotherapy cancer (healing disorders) bull patients with impaired healing bull connective tissue disorders or diseases bull bleeding diseases Willebrandrsquos disorder hemophilia
Local contraindicationsbull bacterial infection dermatitis cellulites bull foreign body in the area to be treated bull herpes simplex in acute phase and other acute skin viral infection bull skin disease with abnormally increased local circulation bull facial rosacea bull poikiloderma of Civatte bull red necks and red deacutecolletage
bull Temporary contraindications bull pregnancy (precautionary principle) bull lactation (precautionary principle) bull anticoagulation recent aspirin or antiinflammatory drugs intake bull acute skin infection (wait until it is cured) bull other aesthetic procedure or skin traumatism less than 15 days prior to CDT
Neo-angiogenesis effect
bull The first experiments in the 1930s consisted of injecting CO2 into the leg of a frog They have shown a strong vasodilatation associated with the creation of new capillaries
Suspected melanocyte pigment synthesis stimulation Further studies needs to be done but we feel CO2 injections have an important role in the stimulation of melanocytes capabilities as they tend to re-pigment white stretch marks The mechanism of this improvement needs to be worked out
Receptor activation and lipolysis cascading improvement
The pressure receptors are stimulated by CO2 injections There is a release of bradykinin histamine serotonin and catecholamine These mediators have a role on the activation of beta-adrenergic receptors and tissue cyclic AMP leading to stimulation of lipase enzymes Some companies or factories are claiming that CO2 pressure directly destroys fat cells by fragilization which does not seem to be the case
Cosmetic Indications
Aesthetic indications can be divided in two main groups Group 1 is dealing with fatcellulite Group 2 is targeting collagen blood flow and skin oxygenation
Schematically fat indications require deeper injections subdermal
Stretch marksPrinciple
Improve neovascularization and blood flow (red color seen via skin transparency will appear pink close to the natural skin color) improve melanocyte pigment production to darken white stretch marks Improve collagen synthesis to reduce the wave appearance of old stretch marks
Indications
Old white stretch marks deep depressed stretch marks irregular old stretch marks are the main indications Young pinkred stretch marks should preferably have laser treatment (KTP or pulsed dye laser)
Protocol Combined intradermal and subcutaneous injections One session per month Flow 80ndash150 ccmin Puncture inside the mark Number of sessions four to ten
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 1ndash2 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 ccmin is recommended it is sometimes impossible to maintain these values because of the pain Lowering flows to 70ndash80 ccmin may make the patient more comfortable
Periorbital AreaPrinciple
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 20ndash40 ccmin 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 20ndash40 ccmin 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 20ndash40 ccmin Puncture in the fatty area Number of sessions three to six
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 Emlareg 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 oxygenair 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
Celluliteorange 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 IndashII to grade IIIndashIV 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 1ndash2 cckgmin ndash approximately 2 minutes per injection Punctures 15ndash20 cm spaced no overlapping - Number of sessions 10ndash20 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 gt2 cckgmin Punctures 15ndash20 cm spaced no overlapping Number of sessions 10ndash20 Progressive flow (automatic mode) available with some machines
Technique The operatorrsquos 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 15ndash20 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 1ndash2 cckgmin (50ndash80 ccmin) approximately 2 minutes per injection point Punctures spaced 15ndash20 cm apart Number of sessions 10ndash20 ndash First results usually seen after session 4~6 Progressive flow (automatic mode) available with some machines Submentonian area deep dermis (andor subcutaneous) Flow 1ndash2 cckgmin (50ndash80 ccmin) Approximately 30ndash60 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 contraindicationsbull
bull needle phobia bull stress with history of vagal unconsciousness event bull severe heart failure congestive heart disease bull recent heart infarction or instable angina pectoris bull restrictive pulmonary disease chronic obstructive lung diseases bull sleep apnea bull renal failure dialysis bull recent cerebrovascular accident bull uncontrolled blood pressure bull epilepsy bull recent phlebitis or pulmonary embolism bull uncontrolled diabetes bull immunosupression or deficiency bull chemotherapy cancer (healing disorders) bull patients with impaired healing bull connective tissue disorders or diseases bull bleeding diseases Willebrandrsquos disorder hemophilia
Local contraindicationsbull bacterial infection dermatitis cellulites bull foreign body in the area to be treated bull herpes simplex in acute phase and other acute skin viral infection bull skin disease with abnormally increased local circulation bull facial rosacea bull poikiloderma of Civatte bull red necks and red deacutecolletage
bull Temporary contraindications bull pregnancy (precautionary principle) bull lactation (precautionary principle) bull anticoagulation recent aspirin or antiinflammatory drugs intake bull acute skin infection (wait until it is cured) bull other aesthetic procedure or skin traumatism less than 15 days prior to CDT
Suspected melanocyte pigment synthesis stimulation Further studies needs to be done but we feel CO2 injections have an important role in the stimulation of melanocytes capabilities as they tend to re-pigment white stretch marks The mechanism of this improvement needs to be worked out
Receptor activation and lipolysis cascading improvement
The pressure receptors are stimulated by CO2 injections There is a release of bradykinin histamine serotonin and catecholamine These mediators have a role on the activation of beta-adrenergic receptors and tissue cyclic AMP leading to stimulation of lipase enzymes Some companies or factories are claiming that CO2 pressure directly destroys fat cells by fragilization which does not seem to be the case
Cosmetic Indications
Aesthetic indications can be divided in two main groups Group 1 is dealing with fatcellulite Group 2 is targeting collagen blood flow and skin oxygenation
Schematically fat indications require deeper injections subdermal
Stretch marksPrinciple
Improve neovascularization and blood flow (red color seen via skin transparency will appear pink close to the natural skin color) improve melanocyte pigment production to darken white stretch marks Improve collagen synthesis to reduce the wave appearance of old stretch marks
Indications
Old white stretch marks deep depressed stretch marks irregular old stretch marks are the main indications Young pinkred stretch marks should preferably have laser treatment (KTP or pulsed dye laser)
Protocol Combined intradermal and subcutaneous injections One session per month Flow 80ndash150 ccmin Puncture inside the mark Number of sessions four to ten
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 1ndash2 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 ccmin is recommended it is sometimes impossible to maintain these values because of the pain Lowering flows to 70ndash80 ccmin may make the patient more comfortable
Periorbital AreaPrinciple
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 20ndash40 ccmin 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 20ndash40 ccmin 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 20ndash40 ccmin Puncture in the fatty area Number of sessions three to six
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 Emlareg 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 oxygenair 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
Celluliteorange 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 IndashII to grade IIIndashIV 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 1ndash2 cckgmin ndash approximately 2 minutes per injection Punctures 15ndash20 cm spaced no overlapping - Number of sessions 10ndash20 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 gt2 cckgmin Punctures 15ndash20 cm spaced no overlapping Number of sessions 10ndash20 Progressive flow (automatic mode) available with some machines
Technique The operatorrsquos 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 15ndash20 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 1ndash2 cckgmin (50ndash80 ccmin) approximately 2 minutes per injection point Punctures spaced 15ndash20 cm apart Number of sessions 10ndash20 ndash First results usually seen after session 4~6 Progressive flow (automatic mode) available with some machines Submentonian area deep dermis (andor subcutaneous) Flow 1ndash2 cckgmin (50ndash80 ccmin) Approximately 30ndash60 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 contraindicationsbull
bull needle phobia bull stress with history of vagal unconsciousness event bull severe heart failure congestive heart disease bull recent heart infarction or instable angina pectoris bull restrictive pulmonary disease chronic obstructive lung diseases bull sleep apnea bull renal failure dialysis bull recent cerebrovascular accident bull uncontrolled blood pressure bull epilepsy bull recent phlebitis or pulmonary embolism bull uncontrolled diabetes bull immunosupression or deficiency bull chemotherapy cancer (healing disorders) bull patients with impaired healing bull connective tissue disorders or diseases bull bleeding diseases Willebrandrsquos disorder hemophilia
Local contraindicationsbull bacterial infection dermatitis cellulites bull foreign body in the area to be treated bull herpes simplex in acute phase and other acute skin viral infection bull skin disease with abnormally increased local circulation bull facial rosacea bull poikiloderma of Civatte bull red necks and red deacutecolletage
bull Temporary contraindications bull pregnancy (precautionary principle) bull lactation (precautionary principle) bull anticoagulation recent aspirin or antiinflammatory drugs intake bull acute skin infection (wait until it is cured) bull other aesthetic procedure or skin traumatism less than 15 days prior to CDT
Cosmetic Indications
Aesthetic indications can be divided in two main groups Group 1 is dealing with fatcellulite Group 2 is targeting collagen blood flow and skin oxygenation
Schematically fat indications require deeper injections subdermal
Stretch marksPrinciple
Improve neovascularization and blood flow (red color seen via skin transparency will appear pink close to the natural skin color) improve melanocyte pigment production to darken white stretch marks Improve collagen synthesis to reduce the wave appearance of old stretch marks
Indications
Old white stretch marks deep depressed stretch marks irregular old stretch marks are the main indications Young pinkred stretch marks should preferably have laser treatment (KTP or pulsed dye laser)
Protocol Combined intradermal and subcutaneous injections One session per month Flow 80ndash150 ccmin Puncture inside the mark Number of sessions four to ten
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 1ndash2 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 ccmin is recommended it is sometimes impossible to maintain these values because of the pain Lowering flows to 70ndash80 ccmin may make the patient more comfortable
Periorbital AreaPrinciple
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 20ndash40 ccmin 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 20ndash40 ccmin 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 20ndash40 ccmin Puncture in the fatty area Number of sessions three to six
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 Emlareg 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 oxygenair 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
Celluliteorange 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 IndashII to grade IIIndashIV 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 1ndash2 cckgmin ndash approximately 2 minutes per injection Punctures 15ndash20 cm spaced no overlapping - Number of sessions 10ndash20 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 gt2 cckgmin Punctures 15ndash20 cm spaced no overlapping Number of sessions 10ndash20 Progressive flow (automatic mode) available with some machines
Technique The operatorrsquos 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 15ndash20 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 1ndash2 cckgmin (50ndash80 ccmin) approximately 2 minutes per injection point Punctures spaced 15ndash20 cm apart Number of sessions 10ndash20 ndash First results usually seen after session 4~6 Progressive flow (automatic mode) available with some machines Submentonian area deep dermis (andor subcutaneous) Flow 1ndash2 cckgmin (50ndash80 ccmin) Approximately 30ndash60 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 contraindicationsbull
bull needle phobia bull stress with history of vagal unconsciousness event bull severe heart failure congestive heart disease bull recent heart infarction or instable angina pectoris bull restrictive pulmonary disease chronic obstructive lung diseases bull sleep apnea bull renal failure dialysis bull recent cerebrovascular accident bull uncontrolled blood pressure bull epilepsy bull recent phlebitis or pulmonary embolism bull uncontrolled diabetes bull immunosupression or deficiency bull chemotherapy cancer (healing disorders) bull patients with impaired healing bull connective tissue disorders or diseases bull bleeding diseases Willebrandrsquos disorder hemophilia
Local contraindicationsbull bacterial infection dermatitis cellulites bull foreign body in the area to be treated bull herpes simplex in acute phase and other acute skin viral infection bull skin disease with abnormally increased local circulation bull facial rosacea bull poikiloderma of Civatte bull red necks and red deacutecolletage
bull Temporary contraindications bull pregnancy (precautionary principle) bull lactation (precautionary principle) bull anticoagulation recent aspirin or antiinflammatory drugs intake bull acute skin infection (wait until it is cured) bull other aesthetic procedure or skin traumatism less than 15 days prior to CDT
Stretch marksPrinciple
Improve neovascularization and blood flow (red color seen via skin transparency will appear pink close to the natural skin color) improve melanocyte pigment production to darken white stretch marks Improve collagen synthesis to reduce the wave appearance of old stretch marks
Indications
Old white stretch marks deep depressed stretch marks irregular old stretch marks are the main indications Young pinkred stretch marks should preferably have laser treatment (KTP or pulsed dye laser)
Protocol Combined intradermal and subcutaneous injections One session per month Flow 80ndash150 ccmin Puncture inside the mark Number of sessions four to ten
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 1ndash2 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 ccmin is recommended it is sometimes impossible to maintain these values because of the pain Lowering flows to 70ndash80 ccmin may make the patient more comfortable
Periorbital AreaPrinciple
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 20ndash40 ccmin 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 20ndash40 ccmin 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 20ndash40 ccmin Puncture in the fatty area Number of sessions three to six
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 Emlareg 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 oxygenair 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
Celluliteorange 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 IndashII to grade IIIndashIV 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 1ndash2 cckgmin ndash approximately 2 minutes per injection Punctures 15ndash20 cm spaced no overlapping - Number of sessions 10ndash20 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 gt2 cckgmin Punctures 15ndash20 cm spaced no overlapping Number of sessions 10ndash20 Progressive flow (automatic mode) available with some machines
Technique The operatorrsquos 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 15ndash20 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 1ndash2 cckgmin (50ndash80 ccmin) approximately 2 minutes per injection point Punctures spaced 15ndash20 cm apart Number of sessions 10ndash20 ndash First results usually seen after session 4~6 Progressive flow (automatic mode) available with some machines Submentonian area deep dermis (andor subcutaneous) Flow 1ndash2 cckgmin (50ndash80 ccmin) Approximately 30ndash60 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 contraindicationsbull
bull needle phobia bull stress with history of vagal unconsciousness event bull severe heart failure congestive heart disease bull recent heart infarction or instable angina pectoris bull restrictive pulmonary disease chronic obstructive lung diseases bull sleep apnea bull renal failure dialysis bull recent cerebrovascular accident bull uncontrolled blood pressure bull epilepsy bull recent phlebitis or pulmonary embolism bull uncontrolled diabetes bull immunosupression or deficiency bull chemotherapy cancer (healing disorders) bull patients with impaired healing bull connective tissue disorders or diseases bull bleeding diseases Willebrandrsquos disorder hemophilia
Local contraindicationsbull bacterial infection dermatitis cellulites bull foreign body in the area to be treated bull herpes simplex in acute phase and other acute skin viral infection bull skin disease with abnormally increased local circulation bull facial rosacea bull poikiloderma of Civatte bull red necks and red deacutecolletage
bull Temporary contraindications bull pregnancy (precautionary principle) bull lactation (precautionary principle) bull anticoagulation recent aspirin or antiinflammatory drugs intake bull acute skin infection (wait until it is cured) bull other aesthetic procedure or skin traumatism less than 15 days prior to CDT
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 1ndash2 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 ccmin is recommended it is sometimes impossible to maintain these values because of the pain Lowering flows to 70ndash80 ccmin may make the patient more comfortable
Periorbital AreaPrinciple
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 20ndash40 ccmin 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 20ndash40 ccmin 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 20ndash40 ccmin Puncture in the fatty area Number of sessions three to six
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 Emlareg 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 oxygenair 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
Celluliteorange 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 IndashII to grade IIIndashIV 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 1ndash2 cckgmin ndash approximately 2 minutes per injection Punctures 15ndash20 cm spaced no overlapping - Number of sessions 10ndash20 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 gt2 cckgmin Punctures 15ndash20 cm spaced no overlapping Number of sessions 10ndash20 Progressive flow (automatic mode) available with some machines
Technique The operatorrsquos 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 15ndash20 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 1ndash2 cckgmin (50ndash80 ccmin) approximately 2 minutes per injection point Punctures spaced 15ndash20 cm apart Number of sessions 10ndash20 ndash First results usually seen after session 4~6 Progressive flow (automatic mode) available with some machines Submentonian area deep dermis (andor subcutaneous) Flow 1ndash2 cckgmin (50ndash80 ccmin) Approximately 30ndash60 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 contraindicationsbull
bull needle phobia bull stress with history of vagal unconsciousness event bull severe heart failure congestive heart disease bull recent heart infarction or instable angina pectoris bull restrictive pulmonary disease chronic obstructive lung diseases bull sleep apnea bull renal failure dialysis bull recent cerebrovascular accident bull uncontrolled blood pressure bull epilepsy bull recent phlebitis or pulmonary embolism bull uncontrolled diabetes bull immunosupression or deficiency bull chemotherapy cancer (healing disorders) bull patients with impaired healing bull connective tissue disorders or diseases bull bleeding diseases Willebrandrsquos disorder hemophilia
Local contraindicationsbull bacterial infection dermatitis cellulites bull foreign body in the area to be treated bull herpes simplex in acute phase and other acute skin viral infection bull skin disease with abnormally increased local circulation bull facial rosacea bull poikiloderma of Civatte bull red necks and red deacutecolletage
bull Temporary contraindications bull pregnancy (precautionary principle) bull lactation (precautionary principle) bull anticoagulation recent aspirin or antiinflammatory drugs intake bull acute skin infection (wait until it is cured) bull other aesthetic procedure or skin traumatism less than 15 days prior to CDT
Periorbital AreaPrinciple
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 20ndash40 ccmin 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 20ndash40 ccmin 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 20ndash40 ccmin Puncture in the fatty area Number of sessions three to six
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 Emlareg 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 oxygenair 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
Celluliteorange 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 IndashII to grade IIIndashIV 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 1ndash2 cckgmin ndash approximately 2 minutes per injection Punctures 15ndash20 cm spaced no overlapping - Number of sessions 10ndash20 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 gt2 cckgmin Punctures 15ndash20 cm spaced no overlapping Number of sessions 10ndash20 Progressive flow (automatic mode) available with some machines
Technique The operatorrsquos 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 15ndash20 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 1ndash2 cckgmin (50ndash80 ccmin) approximately 2 minutes per injection point Punctures spaced 15ndash20 cm apart Number of sessions 10ndash20 ndash First results usually seen after session 4~6 Progressive flow (automatic mode) available with some machines Submentonian area deep dermis (andor subcutaneous) Flow 1ndash2 cckgmin (50ndash80 ccmin) Approximately 30ndash60 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 contraindicationsbull
bull needle phobia bull stress with history of vagal unconsciousness event bull severe heart failure congestive heart disease bull recent heart infarction or instable angina pectoris bull restrictive pulmonary disease chronic obstructive lung diseases bull sleep apnea bull renal failure dialysis bull recent cerebrovascular accident bull uncontrolled blood pressure bull epilepsy bull recent phlebitis or pulmonary embolism bull uncontrolled diabetes bull immunosupression or deficiency bull chemotherapy cancer (healing disorders) bull patients with impaired healing bull connective tissue disorders or diseases bull bleeding diseases Willebrandrsquos disorder hemophilia
Local contraindicationsbull bacterial infection dermatitis cellulites bull foreign body in the area to be treated bull herpes simplex in acute phase and other acute skin viral infection bull skin disease with abnormally increased local circulation bull facial rosacea bull poikiloderma of Civatte bull red necks and red deacutecolletage
bull Temporary contraindications bull pregnancy (precautionary principle) bull lactation (precautionary principle) bull anticoagulation recent aspirin or antiinflammatory drugs intake bull acute skin infection (wait until it is cured) bull other aesthetic procedure or skin traumatism less than 15 days prior to CDT
Under-eye dark circles Intradermal injections One session per month Flow 20ndash40 ccmin 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 20ndash40 ccmin Puncture in the fatty area Number of sessions three to six
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 Emlareg 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 oxygenair 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
Celluliteorange 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 IndashII to grade IIIndashIV 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 1ndash2 cckgmin ndash approximately 2 minutes per injection Punctures 15ndash20 cm spaced no overlapping - Number of sessions 10ndash20 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 gt2 cckgmin Punctures 15ndash20 cm spaced no overlapping Number of sessions 10ndash20 Progressive flow (automatic mode) available with some machines
Technique The operatorrsquos 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 15ndash20 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 1ndash2 cckgmin (50ndash80 ccmin) approximately 2 minutes per injection point Punctures spaced 15ndash20 cm apart Number of sessions 10ndash20 ndash First results usually seen after session 4~6 Progressive flow (automatic mode) available with some machines Submentonian area deep dermis (andor subcutaneous) Flow 1ndash2 cckgmin (50ndash80 ccmin) Approximately 30ndash60 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 contraindicationsbull
bull needle phobia bull stress with history of vagal unconsciousness event bull severe heart failure congestive heart disease bull recent heart infarction or instable angina pectoris bull restrictive pulmonary disease chronic obstructive lung diseases bull sleep apnea bull renal failure dialysis bull recent cerebrovascular accident bull uncontrolled blood pressure bull epilepsy bull recent phlebitis or pulmonary embolism bull uncontrolled diabetes bull immunosupression or deficiency bull chemotherapy cancer (healing disorders) bull patients with impaired healing bull connective tissue disorders or diseases bull bleeding diseases Willebrandrsquos disorder hemophilia
Local contraindicationsbull bacterial infection dermatitis cellulites bull foreign body in the area to be treated bull herpes simplex in acute phase and other acute skin viral infection bull skin disease with abnormally increased local circulation bull facial rosacea bull poikiloderma of Civatte bull red necks and red deacutecolletage
bull Temporary contraindications bull pregnancy (precautionary principle) bull lactation (precautionary principle) bull anticoagulation recent aspirin or antiinflammatory drugs intake bull acute skin infection (wait until it is cured) bull other aesthetic procedure or skin traumatism less than 15 days prior to CDT
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 Emlareg 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 oxygenair 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
Celluliteorange 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 IndashII to grade IIIndashIV 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 1ndash2 cckgmin ndash approximately 2 minutes per injection Punctures 15ndash20 cm spaced no overlapping - Number of sessions 10ndash20 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 gt2 cckgmin Punctures 15ndash20 cm spaced no overlapping Number of sessions 10ndash20 Progressive flow (automatic mode) available with some machines
Technique The operatorrsquos 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 15ndash20 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 1ndash2 cckgmin (50ndash80 ccmin) approximately 2 minutes per injection point Punctures spaced 15ndash20 cm apart Number of sessions 10ndash20 ndash First results usually seen after session 4~6 Progressive flow (automatic mode) available with some machines Submentonian area deep dermis (andor subcutaneous) Flow 1ndash2 cckgmin (50ndash80 ccmin) Approximately 30ndash60 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 contraindicationsbull
bull needle phobia bull stress with history of vagal unconsciousness event bull severe heart failure congestive heart disease bull recent heart infarction or instable angina pectoris bull restrictive pulmonary disease chronic obstructive lung diseases bull sleep apnea bull renal failure dialysis bull recent cerebrovascular accident bull uncontrolled blood pressure bull epilepsy bull recent phlebitis or pulmonary embolism bull uncontrolled diabetes bull immunosupression or deficiency bull chemotherapy cancer (healing disorders) bull patients with impaired healing bull connective tissue disorders or diseases bull bleeding diseases Willebrandrsquos disorder hemophilia
Local contraindicationsbull bacterial infection dermatitis cellulites bull foreign body in the area to be treated bull herpes simplex in acute phase and other acute skin viral infection bull skin disease with abnormally increased local circulation bull facial rosacea bull poikiloderma of Civatte bull red necks and red deacutecolletage
bull Temporary contraindications bull pregnancy (precautionary principle) bull lactation (precautionary principle) bull anticoagulation recent aspirin or antiinflammatory drugs intake bull acute skin infection (wait until it is cured) bull other aesthetic procedure or skin traumatism less than 15 days prior to CDT
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 oxygenair 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
Celluliteorange 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 IndashII to grade IIIndashIV 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 1ndash2 cckgmin ndash approximately 2 minutes per injection Punctures 15ndash20 cm spaced no overlapping - Number of sessions 10ndash20 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 gt2 cckgmin Punctures 15ndash20 cm spaced no overlapping Number of sessions 10ndash20 Progressive flow (automatic mode) available with some machines
Technique The operatorrsquos 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 15ndash20 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 1ndash2 cckgmin (50ndash80 ccmin) approximately 2 minutes per injection point Punctures spaced 15ndash20 cm apart Number of sessions 10ndash20 ndash First results usually seen after session 4~6 Progressive flow (automatic mode) available with some machines Submentonian area deep dermis (andor subcutaneous) Flow 1ndash2 cckgmin (50ndash80 ccmin) Approximately 30ndash60 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 contraindicationsbull
bull needle phobia bull stress with history of vagal unconsciousness event bull severe heart failure congestive heart disease bull recent heart infarction or instable angina pectoris bull restrictive pulmonary disease chronic obstructive lung diseases bull sleep apnea bull renal failure dialysis bull recent cerebrovascular accident bull uncontrolled blood pressure bull epilepsy bull recent phlebitis or pulmonary embolism bull uncontrolled diabetes bull immunosupression or deficiency bull chemotherapy cancer (healing disorders) bull patients with impaired healing bull connective tissue disorders or diseases bull bleeding diseases Willebrandrsquos disorder hemophilia
Local contraindicationsbull bacterial infection dermatitis cellulites bull foreign body in the area to be treated bull herpes simplex in acute phase and other acute skin viral infection bull skin disease with abnormally increased local circulation bull facial rosacea bull poikiloderma of Civatte bull red necks and red deacutecolletage
bull Temporary contraindications bull pregnancy (precautionary principle) bull lactation (precautionary principle) bull anticoagulation recent aspirin or antiinflammatory drugs intake bull acute skin infection (wait until it is cured) bull other aesthetic procedure or skin traumatism less than 15 days prior to CDT
Celluliteorange 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 IndashII to grade IIIndashIV 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 1ndash2 cckgmin ndash approximately 2 minutes per injection Punctures 15ndash20 cm spaced no overlapping - Number of sessions 10ndash20 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 gt2 cckgmin Punctures 15ndash20 cm spaced no overlapping Number of sessions 10ndash20 Progressive flow (automatic mode) available with some machines
Technique The operatorrsquos 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 15ndash20 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 1ndash2 cckgmin (50ndash80 ccmin) approximately 2 minutes per injection point Punctures spaced 15ndash20 cm apart Number of sessions 10ndash20 ndash First results usually seen after session 4~6 Progressive flow (automatic mode) available with some machines Submentonian area deep dermis (andor subcutaneous) Flow 1ndash2 cckgmin (50ndash80 ccmin) Approximately 30ndash60 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 contraindicationsbull
bull needle phobia bull stress with history of vagal unconsciousness event bull severe heart failure congestive heart disease bull recent heart infarction or instable angina pectoris bull restrictive pulmonary disease chronic obstructive lung diseases bull sleep apnea bull renal failure dialysis bull recent cerebrovascular accident bull uncontrolled blood pressure bull epilepsy bull recent phlebitis or pulmonary embolism bull uncontrolled diabetes bull immunosupression or deficiency bull chemotherapy cancer (healing disorders) bull patients with impaired healing bull connective tissue disorders or diseases bull bleeding diseases Willebrandrsquos disorder hemophilia
Local contraindicationsbull bacterial infection dermatitis cellulites bull foreign body in the area to be treated bull herpes simplex in acute phase and other acute skin viral infection bull skin disease with abnormally increased local circulation bull facial rosacea bull poikiloderma of Civatte bull red necks and red deacutecolletage
bull Temporary contraindications bull pregnancy (precautionary principle) bull lactation (precautionary principle) bull anticoagulation recent aspirin or antiinflammatory drugs intake bull acute skin infection (wait until it is cured) bull other aesthetic procedure or skin traumatism less than 15 days prior to CDT
Protocol
Cellulite grade I or II
Combination of subcutaneous and intradermal injections One session per day to one per week Flow 1ndash2 cckgmin ndash approximately 2 minutes per injection Punctures 15ndash20 cm spaced no overlapping - Number of sessions 10ndash20 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 gt2 cckgmin Punctures 15ndash20 cm spaced no overlapping Number of sessions 10ndash20 Progressive flow (automatic mode) available with some machines
Technique The operatorrsquos 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 15ndash20 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 1ndash2 cckgmin (50ndash80 ccmin) approximately 2 minutes per injection point Punctures spaced 15ndash20 cm apart Number of sessions 10ndash20 ndash First results usually seen after session 4~6 Progressive flow (automatic mode) available with some machines Submentonian area deep dermis (andor subcutaneous) Flow 1ndash2 cckgmin (50ndash80 ccmin) Approximately 30ndash60 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 contraindicationsbull
bull needle phobia bull stress with history of vagal unconsciousness event bull severe heart failure congestive heart disease bull recent heart infarction or instable angina pectoris bull restrictive pulmonary disease chronic obstructive lung diseases bull sleep apnea bull renal failure dialysis bull recent cerebrovascular accident bull uncontrolled blood pressure bull epilepsy bull recent phlebitis or pulmonary embolism bull uncontrolled diabetes bull immunosupression or deficiency bull chemotherapy cancer (healing disorders) bull patients with impaired healing bull connective tissue disorders or diseases bull bleeding diseases Willebrandrsquos disorder hemophilia
Local contraindicationsbull bacterial infection dermatitis cellulites bull foreign body in the area to be treated bull herpes simplex in acute phase and other acute skin viral infection bull skin disease with abnormally increased local circulation bull facial rosacea bull poikiloderma of Civatte bull red necks and red deacutecolletage
bull Temporary contraindications bull pregnancy (precautionary principle) bull lactation (precautionary principle) bull anticoagulation recent aspirin or antiinflammatory drugs intake bull acute skin infection (wait until it is cured) bull other aesthetic procedure or skin traumatism less than 15 days prior to CDT
Technique The operatorrsquos 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 15ndash20 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 1ndash2 cckgmin (50ndash80 ccmin) approximately 2 minutes per injection point Punctures spaced 15ndash20 cm apart Number of sessions 10ndash20 ndash First results usually seen after session 4~6 Progressive flow (automatic mode) available with some machines Submentonian area deep dermis (andor subcutaneous) Flow 1ndash2 cckgmin (50ndash80 ccmin) Approximately 30ndash60 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 contraindicationsbull
bull needle phobia bull stress with history of vagal unconsciousness event bull severe heart failure congestive heart disease bull recent heart infarction or instable angina pectoris bull restrictive pulmonary disease chronic obstructive lung diseases bull sleep apnea bull renal failure dialysis bull recent cerebrovascular accident bull uncontrolled blood pressure bull epilepsy bull recent phlebitis or pulmonary embolism bull uncontrolled diabetes bull immunosupression or deficiency bull chemotherapy cancer (healing disorders) bull patients with impaired healing bull connective tissue disorders or diseases bull bleeding diseases Willebrandrsquos disorder hemophilia
Local contraindicationsbull bacterial infection dermatitis cellulites bull foreign body in the area to be treated bull herpes simplex in acute phase and other acute skin viral infection bull skin disease with abnormally increased local circulation bull facial rosacea bull poikiloderma of Civatte bull red necks and red deacutecolletage
bull Temporary contraindications bull pregnancy (precautionary principle) bull lactation (precautionary principle) bull anticoagulation recent aspirin or antiinflammatory drugs intake bull acute skin infection (wait until it is cured) bull other aesthetic procedure or skin traumatism less than 15 days prior to CDT
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 1ndash2 cckgmin (50ndash80 ccmin) approximately 2 minutes per injection point Punctures spaced 15ndash20 cm apart Number of sessions 10ndash20 ndash First results usually seen after session 4~6 Progressive flow (automatic mode) available with some machines Submentonian area deep dermis (andor subcutaneous) Flow 1ndash2 cckgmin (50ndash80 ccmin) Approximately 30ndash60 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 contraindicationsbull
bull needle phobia bull stress with history of vagal unconsciousness event bull severe heart failure congestive heart disease bull recent heart infarction or instable angina pectoris bull restrictive pulmonary disease chronic obstructive lung diseases bull sleep apnea bull renal failure dialysis bull recent cerebrovascular accident bull uncontrolled blood pressure bull epilepsy bull recent phlebitis or pulmonary embolism bull uncontrolled diabetes bull immunosupression or deficiency bull chemotherapy cancer (healing disorders) bull patients with impaired healing bull connective tissue disorders or diseases bull bleeding diseases Willebrandrsquos disorder hemophilia
Local contraindicationsbull bacterial infection dermatitis cellulites bull foreign body in the area to be treated bull herpes simplex in acute phase and other acute skin viral infection bull skin disease with abnormally increased local circulation bull facial rosacea bull poikiloderma of Civatte bull red necks and red deacutecolletage
bull Temporary contraindications bull pregnancy (precautionary principle) bull lactation (precautionary principle) bull anticoagulation recent aspirin or antiinflammatory drugs intake bull acute skin infection (wait until it is cured) bull other aesthetic procedure or skin traumatism less than 15 days prior to CDT
General CO2 contraindicationsbull
bull needle phobia bull stress with history of vagal unconsciousness event bull severe heart failure congestive heart disease bull recent heart infarction or instable angina pectoris bull restrictive pulmonary disease chronic obstructive lung diseases bull sleep apnea bull renal failure dialysis bull recent cerebrovascular accident bull uncontrolled blood pressure bull epilepsy bull recent phlebitis or pulmonary embolism bull uncontrolled diabetes bull immunosupression or deficiency bull chemotherapy cancer (healing disorders) bull patients with impaired healing bull connective tissue disorders or diseases bull bleeding diseases Willebrandrsquos disorder hemophilia
Local contraindicationsbull bacterial infection dermatitis cellulites bull foreign body in the area to be treated bull herpes simplex in acute phase and other acute skin viral infection bull skin disease with abnormally increased local circulation bull facial rosacea bull poikiloderma of Civatte bull red necks and red deacutecolletage
bull Temporary contraindications bull pregnancy (precautionary principle) bull lactation (precautionary principle) bull anticoagulation recent aspirin or antiinflammatory drugs intake bull acute skin infection (wait until it is cured) bull other aesthetic procedure or skin traumatism less than 15 days prior to CDT
Local contraindicationsbull bacterial infection dermatitis cellulites bull foreign body in the area to be treated bull herpes simplex in acute phase and other acute skin viral infection bull skin disease with abnormally increased local circulation bull facial rosacea bull poikiloderma of Civatte bull red necks and red deacutecolletage
bull Temporary contraindications bull pregnancy (precautionary principle) bull lactation (precautionary principle) bull anticoagulation recent aspirin or antiinflammatory drugs intake bull acute skin infection (wait until it is cured) bull other aesthetic procedure or skin traumatism less than 15 days prior to CDT
