Carbon Dioxide Therapy: ‘Magic Gas or Hot Air?’ An overview with Dr. Patrick Treacy RSM March 2014


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

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