Effectiveness of carboxytherapy in the treatment of cellulite in healt

Introduction

Cellulite refers to a change that provides the pores and skin a wavy and irregular look, and it impacts 80%–90% of ladies after puberty. Quite a few therapies have been proposed resembling balanced weight loss plan, bodily exercise, therapeutic massage, topical merchandise, radiofrequency, therapeutic ultrasound, and light-weight emitting diode remedy, amongst others.¹ Carbon dioxide (CO₂) remedy, generally often called carboxytherapy, refers back to the administration of CO₂ with therapeutic proposals. The approach originated in France in 1932, and initially the therapy was carried out percutaneously (by the pores and skin) by the so-called heated carbonated water baths or the applying of water-saturated CO₂ on to the pores and skin of sufferers. The approach was used for arteriopathy and ulcer therapies.^2,3 The outcomes inspired additional research, resulting in the growth of indications of recent therapies. After the event of recent applied sciences, the applying was not topical and concerned passing the CO₂ to be infused immediately into the subcutaneous tissue, making certain sooner and higher outcomes. Sequential research described the effectiveness of the carboxytherapy therapy of localized adiposities; demonstrated measurable reductions in circumference areas of the stomach, thigh, and/or knee; and confirmed histological proof of the impact of gasoline leakage, exhibiting its attainable lipolytic results.^3,4 Ferreira et al⁵ described the rise in collagen transforming induced by intradermal injections of CO₂. In one other research, Abramo et al⁶ confirmed that after the managed infusion of CO₂, vasodilation of the microcirculation pores and skin was noticed, accompanied by a rise of peripheral blood move and a rise in pores and skin temperature on the injection web site (on common 3.48°C). Cellulite impacts, particularly, the buttocks and thighs; its etiology is multifactorial and includes advanced points, and its therapy and analysis require the usage of new methodologies.^7–11 The lipolysis attributable to carboxytherapy appears to be attributable to temperature improve and native blood move and have been demonstrated in earlier research; nonetheless, medical research are nonetheless required, with good evaluation strategies that prioritize their results on cellulite.^2–6

This research aimed to confirm the effectiveness of managed infusion of CO₂ within the therapy of cellulite in gluteal and posterior thigh bilaterally.

Supplies and strategies

This research started with a pattern of 12 candidates and completed with ten of them with a mean age of 29±6.1 years and physique mass index (BMI) of 25.5±3.3 kg/m². Inclusion standards have been wholesome girls, aged 20–35 years, BMI <29.9 kg/m², with common menstrual cycle, and presence of cellulite of gluteal and posterior thigh bilaterally as labeled in levels of severity II and III as within the present classification of cellulite¹².

This research was authorized by the Analysis Ethics Committee: União das Instituições de Serviço, Ensino e Pesquisa – UNISEPE (CAAE: 02242112.9.0000.5490) and all topics signed knowledgeable consent kinds. The therapy was carried out within the Medical Laboratory of the Middle for Training and Superior Coaching CEFAI (Amparo, SP, Brazil). Volunteers have been excluded in the event that they have been in aesthetic therapy; had had some sort of therapy within the gluteal area and thighs for a interval main as much as 6 months earlier than the beginning of this research; in the event that they have been pregnant or had had a latest being pregnant (<6 months); if that they had cardiovascular issues, metabolic issues, respiratory issues, immunosuppression, kidney and liver failure, and pores and skin lesions on the therapy web site; or if that they had diabetes mellitus. In assessing weight and top, the volunteers wore solely underwear with out footwear.

A classical mechanical stadiometer (mannequin 110 CH; Welmy, SP, Brazil) was used. The BMI was evaluated by making use of the components BMI = weight in kilograms divided by the sq. of the peak in meters (kg/m²).^13–15 Physique fats share of every volunteer was measured with Biodynamics (Mannequin 310E; TBW, SP, Brazil).

All volunteers acquired instructions concerning the therapy steps and procedures to be carried out. The therapy protocol consisted of eight periods with an interval of seven days. The evaluations have been carried out earlier than the primary therapy (baseline) and seven days after the final therapy session. The overall time between the baseline and the posttreatment reevaluation was ~2.5 months. After evaluation of the realm, ten factors have been chosen for the infusion of CO₂ (4 within the gluteal space and 6 within the posterior thigh) as proven in Figure 1A. The handled areas have been inspected and consistently monitored throughout all periods. With a correct pen, factors equidistant from one another have been marked, 12 cm other than one another, in locations the place the infiltration of CO₂ was held. The antisepsis was carried out with alcoholic chlorhexidine at 0.5%. At every chosen factors, 80 mL of gasoline with a move price of 80 mL/min was infused. The needle was positioned at 45° (inferior angle), and a subcutaneous puncture was made with a depth of ~10 mm (Figure 1B).

Determine 1 (A) Factors of CO2 infusion; (B) place and angulation of needle placement for infusion, depth of ~10 mm (30 G × 1/2 inch measurement needle).

After the applying of the gasoline, the pores and skin of the handled space was inspected. The tools used on this research was ARES Carboxytherapy (IBRAMED, Indústria Brasileira de Equipamentos Médicos EIRELI, ANVISA 10360310032), and the medicinal CO₂ used was from White Martins Gases Industriais Ltda (São Paulo, Brazil). Cellulite grades have been decided by medical inspection of the affected person’s pores and skin, and standardized digital pictures with a digital digital camera (Canon EOS Insurgent T3i, Canon USA Inc., Melville, NY, USA) have been taken at baseline and seven days after the proposed therapy. All sufferers have been photographed in standing positions in three views: rear view, proper aspect, and left aspect. The main target of the picture was within the gluteal cleft with a focal size of 1 m, and the muscle tissue of the photographed areas have been relaxed. Seven days after the final CO₂ infiltration, new pictures have been taken. The photographs have been supplied to unbiased evaluators along with the factors for the verification side of the severity of cellulite. The stage of severity of cellulite in accordance to what’s usually accepted was used. Nürnberger and Müller describe completely different grades or phases of severity based mostly on medical presentation from 0 (zero) to III (three); 0= there is no such thing as a alteration of the pores and skin floor (seen with out modifications); I= the pores and skin of the affected space is clean whereas the topic is standing or mendacity, however the alterations to the pores and skin floor might be seen by pinching the pores and skin or with muscle contraction (seen modifications with pores and skin clamping or muscle contraction); II= the orange peel side of the pores and skin or mattress look is clear when standing, with out the usage of any manipulation of the pores and skin pinching or muscle contraction (seen with out manipulation); and III= the alterations described in grade or stage II, are current along with raised areas and nodules (seen modifications related to nodules).¹² To attenuate traits, evaluations of the pictures have been partially blind, ie, the evaluators acquired them in pairs with out figuring out which one represented the topics earlier than or after therapy. All of the volunteers collaborating within the research underwent diagnostic ultrasound that was carried out earlier than and after the proposed therapy. All of the volunteers underwent diagnostic ultrasound examination utilizing a linear transducer (frequency 6–18 MHz) (MyLab™25 Gold; Esaote, Italy), and VPan software program (Esaote, Italy) was used for the development of panoramic pictures. All panoramic pictures have been taken within the standing place. The probe was slipped at a sluggish and common velocity within the distal/proximal route alongside the areas. Panoramic pictures have been analyzed qualitatively contemplating the hyperechoic areas. Vivid echoes signify extremely reflective buildings (white = dermis and fibrotic septa) and hypoechoic areas signify sparse echoes, reflection, or intermediate transmission (grey = adipose tissue and skeletal muscle).

The paired Scholar’s t-test was used for statistical evaluation, with an alpha degree of 5% (P<0.05) being thought-about vital.

Outcomes

The volunteers have been numbered 1–10, and evaluations have been carried out at baseline and seven days after the final therapy session. Table 1 reveals the anthropometric values earlier than and after the infusion of CO₂. There have been no vital modifications in ­anthropometric measures of weight (P=0.10), BMI (P=0.20), and physique fats share (P=0.73), at baseline and after the therapy.

Desk 1 Imply and customary deviation of the typical of our affected person inhabitants (age, physique weight, BMI, and physique fats share) at baseline and after therapy (7 days after the final carboxytherapy session). Notes: Classification weight by BMI: <18.5 (underweight), 18.5–24.9 (regular vary), 25.0–29.9 (obese), 30.0–34.9 (weight problems class I), 35.0–39.9 (weight problems class II), and ≥40.0 (weight problems class III).13–15 Abbreviations: BMI, physique mass index; SD, customary deviation.

Figure 2 reveals a statistically vital discount (P=0.0025) within the side of cellulite; the pictures have been handed over to 3 unbiased evaluators, and assessments of the pictures have been partially blind in keeping with usually accepted classification of cellulite.

Determine 2 Cellulite diploma analysis in keeping with usually accepted classification of cellulite, baseline (earlier than) and seven days after the final carboxytherapy session. Observe: **P=0.0025.

Figure 3 reveals comparative photographic register of the side of cellulite at baseline and seven days after the final carboxytherapy session.

Determine 3 Comparative photographic register of the side of cellulite. Notes: (A, C) Rear view of gluteus and posterior proper thigh at baseline; (B, D) rear view of proper gluteus 7 days after the final carboxytherapy session; (E, G) proper aspect view at baseline; and (F, H) rear view of the proper gluteus after the final session of carboxytherapy.

Within the panoramic picture evaluation carried out by the ultrasound analysis, discount of adipose tissue lodged between the pores and skin and the muscle tissue of the handled areas was verified, as seen in Figures 4 and 5. Qualitative evaluation describes morphological enchancment with respect to the subcutaneous tissue, fibrotic septa, and features of the dermis-related cellulite. The morphological enchancment with respect to the subcutaneous tissue, fibrotic septa, and related dermis side of the cellulite can be seen.

Determine 4 Comparative panoramic pictures of gluteal area. Notes: (A, C) Earlier than therapy with carboxytherapy; (B, D) 7 days after the final session. Observe the hyperechoic areas: shiny echoes, extremely reflective buildings (white = dermis and fibrotic septa) and hypoechoic areas: sparse echoes, reflection, or intermediate transmission (grey = adipose tissue and skeletal muscle). The arrows point out the areas in contrast and the lower of the thickness of the fibrotic septa after therapy.

Determine 5 Comparative panoramic pictures of the posterior thigh. Notes: (A, C) Earlier than therapy with carboxytherapy; (B, D) 7 days after the final session. Observe the hyperechoic areas: shiny echoes, extremely reflective buildings (white = dermis and fibrotic septa) and hypoechoic areas: sparse echoes, reflection, or intermediate transmission (grey = adipose tissue and skeletal muscle). The arrows point out the areas in contrast and the lower of the thickness of the fibrotic septa after therapy.

Dialogue

Cellulite is a multifactorial dysfunction and has a excessive prevalence in younger grownup girls and regardless of no morbidity causes nice dissatisfaction and detrimental affect on high quality of life.¹ The pathophysiology of cellulite was described as an aesthetically disagreeable dysfunction for most ladies after adolescence. It’s a advanced drawback that features modifications involving the microcirculation, lymphatic system, ­extracellular matrix, and adipocytes. It impacts sure physique areas with extra emphasis, resembling thighs and buttocks.⁸ Research additionally describe the pathophysiology involving a hyperactivity of fibroblasts stimulated by estrogen, which will increase the synthesis of glycosaminoglycans and collagen that improve interstitial osmotic stress and water retention. A lower within the capillary osmotic stress in relation to the interstitial osmotic stress generates edema and discount in drainage with subsequent hyperpolymerization and formation of micronodules and fibrosclerotic collagen. Signs embrace edematous adiposity, incipient cellulite, or modifications within the pores and skin aid measured by the medical severity.^9,16,17 Adipose tissue might be divided anatomically into two layers by a layer of fibrous tissue referred to as Camper’s fascia.⁸ The areolar layer has fibrous septa organized in a peculiar vertical structure that join the dermis stuffed by giant globular adipocytes; beneath, the lamellar layer septa has extra horizontal axis and the fats lobes are flattened. Adipocytes are specialised cells within the storage of fat.^{8–11,16–19} In 2004, it was demonstrated for the primary time that the hypodermic infiltration of CO₂ in its place measure to be related to liposuction procedures was efficient in treating localized adiposity or pores and skin irregularities, ensuing from the surgical process. Since then, the strategy has been used with growing frequency within the therapy of various types of lipodystrophies, in addition to in aesthetic drugs. On this space, its fundamental indications are in combating cellulite in localized fats and sagging.²⁰ Different research present that managed administration of medical CO₂ into the subcutaneous tissue induces hypercapnia and reduces native pH, which elicits a robust vasodilator response by the relief of the pre-arteriolar clean muscle on the positioning.^2,6,25 Histological options within the restore course of confirmed the proliferation of newly fashioned small blood vessels and fibroblasts.²¹ The tissue stretching throughout infusion induces a subclinical irritation, which triggers the restore and tissue regeneration processes that induce the activation of macrophages, fibroblasts, and endothelial cells that stimulate neovascularization and transforming of the extracellular matrix. Among the many ailments which will want carboxytherapy are peripheral artery illness and microangiopathy, psoriasis, varicose, and diabetic ulcers. This method has additionally been steadily used for the therapy of beauty modifications resembling localized fats, cellulite, facial pores and skin rejuvenation, alopecia, darkish circles, and striae.^{2,4,20,22–26} In a research by Abramo et al,⁶ after the infusion of CO₂, there was a mean temperature improve of three.48°C within the pores and skin of the handled web site. As well as, pores and skin biopsies earlier than and after therapy have been evaluated by histology, and the authors noticed that the diameter of the vessels elevated by 3.24 occasions after therapy. Brandi et al⁴ described the effectiveness of carboxytherapy within the therapy of localized fats by measurable reductions within the circumference areas of the stomach, thigh, and/or knee and confirmed histological findings of the results of CO₂ gasoline infiltration on the subcutaneous adipose tissue and their attainable lipolytic results. Corroborating these findings, a standardized research concerned 15 volunteers subjected to carboxytherapy periods on the anterior wall of the stomach for 3 consecutive weeks. Two periods per week at intervals of two–3 days between every session have been made, with infused mounted quantity of 250 mL of CO₂ per 100 cm² of handled floor. Tissue biopsies have been collected earlier than and after therapy and analyzed by move cytometry, which confirmed a major discount within the quantity and alter within the morphology of the adipocytes within the handled space.

The target of the research was to confirm the effectiveness of carboxytherapy within the therapy of cellulite. Through the therapy interval, there have been no vital modifications within the physique weight or BMI, as proven in Desk 2. Photographic pictures captured in a standardized method have been analyzed by three unbiased evaluators and have been partially blind. The visible inspection of photographic information of the areas handled with carboxytherapy confirmed statistically vital (P=0.0025) modifications concerning the side of enchancment of the diploma of severity, as proven in Figure 2. All volunteers confirmed enchancment of pores and skin look after carboxytherapy periods, suggesting decreased tensile forces on the pores and skin and attainable redistribution of vertical forces (vector forces) within the septum (Figure 3). With regard to the protection of the carboxytherapy therapy, necessary research report that the usage of CO₂ for distinction angiography attests to the protection of this gasoline and have proven that it’s not more likely to promote clots. CO₂ can be utilized with intravascular bolus injections of as much as 100 mL and steady flows between 20 and 30 mL/s with out hostile reactions.²⁷ On this research, 80 periods with carboxytherapy have been carried out and no volunteer had any form of vital hostile results, however reported solely delicate transient discomfort, tolerable throughout therapy. One volunteer had two small bruises that resolved spontaneously, which means that carboxytherapy is usually a secure approach. The therapy was tolerable for all of the sufferers.

Noninvasive evaluation strategies have been used to judge the cellulite and its posttreatment outcomes, amongst which stand out the magnetic resonance imaging (MRI) and diagnostic ultrasound. Researchers, utilizing microimages of the MRI, correlate the anatomy of the subcutaneous tissue to the standard modifications within the cellulite at completely different levels of severity;²⁸ different researchers additionally used MRI to review the cellulite and its therapy with lymphatic drainage.²⁹ Nevertheless, the event of software program that permits the usage of panoramic pictures captured by diagnostic ultrasound is extra cheap. Del Pino et al¹⁹ used this methodology to look at the outcomes of the therapy of cellulite with nonablative radiofrequency. On this research, panoramic pictures taken by diagnostic ultrasound have been used to judge the outcomes of the therapy of cellulite with carboxytherapy. These pictures allowed the registration of enormous anatomical areas and the entry of the subdermal buildings, particularly fibrotic areas of septa. All pictures have been collected and evaluated, and the comparative variations might be clearly seen in Figures 4 and 5. The evaluation of the structural side of cellulite allowed the remark of a major enchancment within the group of fibrous traces observable by hyperechoic space (whitish buildings of fibrotic septa) in comparison with photos taken earlier than therapy, additionally noting hypoechoic areas of adipose tissue. These outcomes help the findings described by Lee²⁵ in a compilation of medical outcomes over 4 years (2004–2008) in 110 sufferers utilizing carboxytherapy within the therapy of localized fats and cellulite; regardless of the methodological limitations of this research, the creator concluded that carboxytherapy is a method that demonstrates effectiveness for treating each localized fats and cellulite. The levels of discount of cellulite and attainable reshaping of septa on this research seemingly occurred by the motion of CO₂ on the microcirculation and tissue perfusion, described within the subcutaneous tissue. Research confirmed that native utility of CO₂ can promote enchancment of peripheral circulation, growing tissue perfusion and oxygen partial stress by reflex vasodilation, and stimulate the neoangiogenesis.¹² Within the research, after the therapy of carboxytherapy, there was a major discount (P=0.0025) of the cellulite from diploma III to diploma II, and this enchancment confirmed correlation with the advance within the group of fibrous traces and the disposal of adipose tissue traces of handled areas noticed by the panoramic ultrasound picture analysis. One other issue which will contribute to the effectiveness of carboxytherapy within the therapy of cellulite is the lower within the density and form of adipocytes within the handled space as demonstrated within the research by Costa et al,²⁴ because the accumulation of localized fats may contribute to elevated native tissue compression, favoring the traction of fibrotic beams and herniation of adipocytes within the dermis inflicting the looks of the orange peel pores and skin depressions, a attribute function of cellulite dysfunction.

Conclusion

This pilot research confirmed that carboxytherapy could also be used to enhance the diploma of severity of cellulite within the subcutaneous tissue on the buttocks and posterior thighs of wholesome girls. Additional research with a bigger variety of sufferers will probably be wanted to extra totally characterize the total medical potential of carboxytherapy and its mechanism of motion.

Acknowledgment

The authors thank Ms Alexandra Paioli for English language and grammatical technical help.

Disclosure

Renata Michelini Guidi and Estela Sant’Ana are researchers at IBRAMED Indústria Brasileira de Equipamentos Médicos EIRELI. The opposite authors report no conflicts of curiosity on this work.

References