Mesotherapy Strategies and Techniques

Mesotherapy Strategies and TechniquesMESOTHERAPYINTRODUCTIONMesotherapy is an art of injecting menial quantities of various medicinal preparations such as vitamins, minerals and other conventional drugs directly into the mesoderm to wield affectiond conditions topical anestheticly. It involves the administration of intracutaneous or subcutaneous nips of compounds to treat a variety of medical conditions and baring systemic adverse exertions due to drugs. It appears to be a novel technique to administer medicines local anesthetic anesthetic to the pathology bit the jumble serves as a natural time- release system.BACKGROUND OF MESOTHERAPYThe term mesotherapy (derived from Greek mesos. Middle and therapeia to treat medicall(a)y) denotes stab of substances into middle layer of kowtow ( mesoderm) for medical purposes.Historical aspects1Mesotherapy was originally engaged to treat painful conditions exploitation local procaine nips. Michael Pistor who coined the term mesoth erapy is considered the padher of mesotherapy. In his original name,he described treating deafness, tinnitus, vertigo and headaches using local injections of procaine. Earlier to this in 1884, Koller an ophthalmologist employ local cocaine to relieve pain. In 1925 Lerich employ intradermal injections in the intercostal spaces. In 1937 Aron studied the use of intradermal injections to have an analgesic effect. Albert Lemaire, a Belgian physician use procaine injections to treat trigeminal neuralgia. In 1952, Michel Pistor a French physician popularized mesotherapy to treat various conditions in dermatology,sports,traumatology and vascular disease chiefly as a pain-relieving therapy. He defined mesotherapyas a techniquethat was use to treat mesoderm,(primary germ layer that develops into connective tissue, muscle and the circulatory system). In 1953, Dr.Mario Lebel invented a 3mm duration needle that could be used precisely for injection of substances into the dermis. In 1964, the French society of Mesotherapy was founded by Michel Pistor and use of mesotherapy was extended to treat cosmetic conditions.The Ameri good deal influence was evident aft(prenominal) Dr. Lionel Bissoon popularized the technique in northeast America. Despite the fact that mesotherapy is gaining popularity in aesthetic medicine especially for localized cellulite reduction, it continues to be a polemical topic and thitherfore requires cautious approach. The safety and efficacy of these mesotherapy remain ambiguous to patients and physicians alike. 2Applied basic intelligence 1, 3The concept that led to discovery of mesotherapy is quite interesting. Pistor saw recovery of chronic hearing loss while treating a patient with procaineinjections for an asthma attack. Subsequent intradermal injections of this product into the mastoid region proved this effect to be true. However the prescience of injection was considered important. This led the researchers to the fact that at a depth of 1.5 to 2mm the local activity of the product would last longer due to a persistent reservoir with weak local dispersal in the dermis whereas products injected into dermis would dissipate to greater distances.A product when injected intradermally acts in 2 ways. Firstly, by stimulating dermal receptors in situ and secondly, over long distances by reaching other variety meat via circulation. A concept of meso-interface exists which is the climb of contact established between the injected products and the tissue injected. The more the multiple punctures argon made and the more fragmented products be takeed in small quantities, the greater the meso-interface and proportionately greater add up of dermal receptors get activated.Pistor has always described this technique as discovers. A little volume, a some times and in the right place. The idea was that by placing these products in the dermis, the skin acts as a reservoir for drugs to diffuse slowly via microcirculation to activ ate dermal receptors.A general mechanism of action (based on the target place, dermis) and a specific mechanism of action (based on the ingredients used) has been proposed to explain the concept of mesotherapy. The dermis is considered to be common denominator for circulatory, neurological and immunological functions and the general mode of action is believed to keep by correction of these adapted functions. Individual drugs or agents target the specific indication of mesotherapy.EQUIPMENTSThe various equipments used in mesotherapy beMesogun (Fig 1)Mircromesotherapy widgetNeedleless MesotherapyMesogunMesogun is a syringe infusion pump that is capable of injecting the desired substance at a necessary amount, speed and depth using the injector and needle. Syringes varying from 2cc-10cc and needle lengthsvarying in size from 4mm to 13mm canful be used based on the indication, and desired depth of injection. A stratagem known as guide is used to keep the needle at a constant dept h. Once the parameters are chosen, the product can be injected by one of the following modes.Continuous Min 3cc/min gook 10cc/min.Mircrodose Max0.1cc/trigger.Standard dose Max 0.3cc/trigger.Mesoperfusion Max 0.3cc/trigger.Nappage 0.1cc/trigger.Advantages of MesogunGood comfort level for patient and physicianProcedure is faster and relatively easyAccurate delivery systemVersatality Ability to perform various modes such as nappage, continuous, mesoperfusion in dosimetry.Syringes used in Mesogun Generally 1ml, 5ml, 10ml and 20ml syringes with luer lock system is used based on the indication.MesoNeedles (Fig2 a) Mesoneedles or Lebel needles are usually used in mesotherapy.The John Screw needles have an adjustable length.The recommended parameters for needles are based on the site of injectionFace and neck 4mm 30G mesoneedlesFat and cellulite 6mm 30G mesoneedles, inch 30G needles.Multi-injectors and plates (Fig2 b) These accessories help to cover larger stadiums in a short t ime facilitating faster and easier procedure for the injector. There are sterile circular and linear multi-injectors with needles dynamic to be used for any body part.Micromesotherapy DeviceMicromesotherapy is an evolution of conventional mesotherapy. Usually mesotherapy uses needles to deliver drugs in deep dermal layer. Here a reverse cone shaped device has ultrafine needle 32Gx2mm by which drugs are injected into the sciolistic layer of dermis therebyminimizing incidence of bruising, pain and scarring.Needle- little Mesotherapy or No Needle MesotherapyThis is a needle free device that pushes mesotherapy products painlessly through the skin using electrical waves known as isophoresis. The main features of needle less mesotherapy areLess painful and less traumaticUses ultrasound/electroporation technology.credibly around 20% efficiency compared to traditional mesotherapy as there is no neocollagenesis or neo angiogenesis reactions that occur with needle micro injury.This may be an option if mesotherapy is not allowed in the country.It has been discussed in details in Chapter 12.MESO SOLUTIONS (Fig6VG1The basic requirements of meso products is that it should be approved and skin-compatible.Systemic administration (intravenous, intramuscular, subcutaneous or intradermal) should be safe and known pharmacological actions to be effective. The ingredients used in mesotherapy products should be water soluble, isotonic and non-allergenic.The mesoproducts vary with the indications chosen for treatment. 4 Figure 3Products used for mesotherapy involves combination of products some of which are main ingredients known as principals as they have high strain of evidence in the treatment of each indications and complementary agents that have been approved for treatment of each indications. For a mixture to be effective it should contain 2 3 principals for any prone indication. Therefore the ingredients in mesosolutions are broadly classified into main categoriesPrinci pal (P) / MajorComplementary (C) / Minor.The main targets for mesotherapy are skin, hair, fat and cellulite. (Table 11.1).Table 11.1 Principal and Complementary ingredients in meso solutions in various indicationsINDICATIONPRINCIPAL/MAJOR completing/MINORSKIN REJUVENATIONMesoliftHyaluronic Acid5DMAEOrganic silicumFibronectin + VegetalProteinsVitamin CGlycolic AcidXadenalVitamin AGrowth Factors root word CellsMesoglowHyaluronic AcidSiloagVitamin CXadenalTaurineMeso lighteningKojic AcidAzalaic AcidVitamin CGlutathioneTretinoinGlycolic AcidStriae or exsert marksStretch MarksOrganic silicumCentella AsiaticaVegetal Proteins +FibronectinDMAEVitamin CIdebenoneHair LossAndrogenetic AlopeciaminoxidilFinasterideDutasterideDexenolBiotinAmino acidsPeptidesZincAzelaic AcidStem CellsTelogen effluviumBiotinDexapanthenolPyridoxineMulti VitaminsTrace ElementsCellulite and FatMeso Cellulite caffeinCarnitineAminophyllineDMAERutinArtichokeYohimbineProcaineVitamin CFat depositsBody Sculpting, localized fat, CellulitePPCDeoxy cholateL CarnitineAminophyllinePentoxifyllineDMAE -Dimethylaminoethanol PPC PhosphatidylcholineTECHNIQUES FOR MESOTHERAPY INJECTIONSThe mesoproducts can be injected into the skin by various injection techniques to reach desired depth.The commonly used techniques and the desired depth reached are summarized in Table 11.2and Illustration 11.1Table 11.2 Techniques and depth in mesotherapy injectionsTechniqueDepthIntraepidermal1mmPapular2mmNappage2-4mm channelise by dismantle4mmMesoperfusion 4mmThe salient features of various techniques are outlined belowIntra-epidermalThis is one of the most superficial of the techniques described by Perrin.Depth 1mm within the epidermisPainless, no bleedingSimple and large surface coveredIdeal for patients with low pain thresholdIdeal for facial rejuvenation, mesoglowPapularDepth2mm dermoepidermal junction frighteningUseful in mesobotoxIdeal treatment of wrinklesNappage(French for covering)Also known as picotage is the clas sic injection technique in mesotherapy. (Illustration 11.2) It is the most widely used technique in aesthetic dermatology. The syringe is held athwart and the physician applies constant pressure on the plunger flicks the wrist to infuse a drop of the solutioninto the dermis(Fig 4). The injections are 2-2.5mm deep and 1cm apart. This technique can also be used for injections using a mesogun. (Fig 5)Depth 2-4mmLess pain and less bleedingIdeal for rejuvenation and scalp treatmentsPoint by Point(Fig 6)Depth 4mm upright injectionIdeal for fat reductionMesoperfusionDepth 4 mmMesosolution is injected slowly over a priod of 10 minutesNot commonly used in dermatologyPRACTICAL ASPECTS OF MESOTHERAPYIndications and contraindications for mesotherapy are listed in rap 11.1 and box11.2.Box 11.1 Indications for mesotherapyBox 11.2 Contraindications for mesotherapyRelated to patientUnrealistic expectationsBody mass index greater than 30Pregnancy / LactationH/O strokes, recent cancer.H/o multipl e meds for heart diseaseH/o allergy to ingredients e.g. Soy proteins, lignocaine.Autoimmune disordersEpilepsyInsulin dependent diabetesRelated to productAminophylline Known hypersensitivity to drug, active peptic ulcer,Pentoxiphylline, aminophylline- recent cerebral retinal bleedL. carnitine history of seizure disorderPhosphatidyl choline relative contraindications with antiphospholipid antibody syndromecaffeine arrhythmias, anxiety, insomnia hypotensionMannitol pulmonary edema, renal disease.Patient selectionSelecting the patient with a valid indication for mesotherapy is the expose to success. Care should be taken to avoid patients with active skin diseases, too elderly and patients with history of exquisite skin. For androgenetic alopecia better results are seen in patient with Grades 1 3.Counseling and preparing the patientA worthy counseling is essential before starting mesotherapy. Patients with body dysmorphic disorders and those with unrealistic expectations should not be treat. Alternate procedures should be discussed sufficiently as mesotherapy is still in the controversial stage. A written informed consentis mandatory in the present medical scenario. A good before and after clinical photograph is needed to adjudicate results following the procedure.Procedural aspectsThe area to be treated is marked and thoroughly cleaned with an antiseptic solution. For anesthesia, a local anesthetic cream may be applied or ice-anesthesia can be used to desensitize the treatment area. Patients are preferably injected in a lying down position. The required quantity of ingredients is force into the syringe using an 18Gx11/2needle. The injection is effrontery either manually or using a device to deliver by the papular, nappage or point by point technique. A gentle massage is given after the treatments. Fresh principle saline and a mositurising cream can be applied to the treated area and massaged gently. 9. The procedure takes about 20 30 minutes depend ing on the indication and area to be treated. There is no downtime after the procedure and the patient will be able to return to normal activities at present.Good results are seen with mesotherapy done for skin rejuvenation, cellulite and double chin. Fig 7, 8, 9Post procedure care and counseling for follow upThere may be mild pain, pinpoint bleeding, itching, burning or erythema after the injection which will subside spontaneously. Bruising and hematoma can appear occasionally and can be managed symptomatically. lenient swelling at site of injection may require anti-inflammatory agents for a couple of(prenominal) days.The patients need to be counseled on the following aspectsAvoid sun exposure and smoking for next 48 hoursLoose allowance clothes to be worn especially after lipolytic injections.The area to be treated is generally massaged after 72 hours and continued daily till disappearance of nodules if any.Follow up Generally treatments are given once every 1-2weeks for 6 ses sions, then once a month for 5months. Maintenance sessions are to be done once or twice a year. This protocol may be altered depending on the indication, patients lifestyle, financial position and response toprevious treatments.ComplicationsThough there are a couple of(prenominal) evidence based studies on the efficacy of mesotherapy, there are documented reports on various complications. 10-17 The complications can be classified as local and systemic complications. (Box 11. 3)Box 11.3 ComplicationsLocalBruisingBurning or itchingPain, Tenderness, swellingUrticaria 10Skin gangrene, Ulcers 11Abscess 12Hyper pigmentationAtypical mycobacterial infection 13Rare granulomatous panniculitis 14,15, koebnerisation, granuloma annulare, Oleoma 16SystemicAnaphylaxis illnessVasovagal shockHepatic toxicityNerve demyelinationAllergy to specific ingredientsThyrotoxicosisIschaemic colitis 17 prudence of ComplicationsBruisingIt is a common but preventable complication. Always advice patient to stop aspirin or NSAIDs at least 2 weeks prior to the day of procedure. While injecting be slow and gentle. It is advisable to avoid mesotherapy during menstruation.Burning/ItchingBurning can be pommel by adding lignocaine to the products if compatible. A mesomask applied immediately following procedure can also minimize burning and itching as it has a soothing effect.Pain/Tenderness Procedural pain can be minimized by using adequate topical anaesthesia. Immediate post treatment pain can be alleviated by frosty compresses with ice. other(a) methods that help to minimize pain are by pinching the skin for point by point injections or by stretching it when giving a nappage. Change needles after every few pricks to squeeze the pain caused by blunt injecting needlesUrticariaUrticaria can be avoided by a metric history to avoid products that would provoke an allergic reaction. E.g. phosphatidyl choline in individuals with history of allergy to soy proteins.Skin necrosisSkin necrosis occ urs usually with phosphatidyl choline when the injections are given superficially UlcersUlcers can due to infection or irritant nature of the drugs. Irritant induced ulcers can be prevented by minimizing the number of drugs used in the cocktail to 4 or 5. Infective ulcers can be avoided by disinfecting the treatment area thoroughly and by wearing sterile gloves and using sterile equipment and materials.Hyper pigmentationThis can be avoided by advising the patient photo justification for 48 hours after the procedure and by addition of topical skin lightening agents in patients with a history of post inflammatory hyper pigmentation.COMBINING MESOTHERAPY WITH OTHER TECHNIQUESMesotherapy can be combined with other techniques to deepen results.Soon after injection of mesotherapy products, ultrasound, radiofrequency or electroporation may be applied to help in better diffusion of the injected products. The techniques are discussed in chapter 12. Mesomasks can be applied immediately afte r the injections to minimize bleeding points and to overcome the discomfort that follows injections.It is a 150 g of powder to be mixed with water to form a paste which is applied for 15minutes as a mask over gauze. This allows all products to penetrate deeper in the skin to give a better effect. These masks contain a mixture of calcium sulfate, talc and orange oil. Other procedures such as chemical peels, fillers and neurotoxins can be carried out between the mesotherapy sessions.In countries where mesotherapy is not practiced, mesotherapy products can be used following cosmetic skin needling. By using a dermaroller in the area to be treated, it is possible to create micro perforations that will be used as channels to deliver a product deeply into the skin.CLINICAL STUDIESMesotherapy has been in history for a long time and there are proponents who have been successfully using it in practice for the benefits of their patients. However there are few indexed studies about the safety a nd efficacy of mesotherapy but many about its complications, hence it only natural to suspiciousness proponents in relation to this technique Hence adequate controlled studies are needed to establish the value of mesotherapy in aesthetic dermatology. 18 Mesotherapy for skin rejuvenation, treatment of local fat deposits, body sculpting have been assigned Evidence aim C, whereas cellulite treatment has been assigned Evidence Level D 18.Few recent studies have shown promising results for mesotherapy in various aesthetic indications. A study by Larruba et al showed good results with hyaluronic acid mesotherapy on photoaging and assessed by ultrasound techniques. 5 A study by Savoia etal showed promisingVG1 An excellent compilation with evidence for few of them are given in these two articles from IJDVLSarkar R, Garg VK, Mysore V. Position paper on mesotherapy. Indian J Dermatol Venereol Leprol 201177232-7Konda D, Thappa DM. Mesotherapy What is modernistic?. Indian J Dermatol Venereol Leprol 201379127-34Another review of various indication s of mesotherapy is in this article by Dr. premlatha3.Latha P. and Vandana K.R. / International Journal of Advanced Pharmaceutics / 1 (1), 2011, 19-29( full text available of all three)The meso solutions can be tabulated in the format belowIndicationProductMechanism of action ( should implicate original intention versus intention in mesotherapy e.g. aminophylline was originally used for brochodilation. In mesotherapy it is used for vasodilatation etcEvidence strain ( wherever available)