Mesotherapy Strategies and Techniques

Mesotherapy Strategies and TechniquesMESOTHERAPYINTRODUCTIONMesotherapy is an art of injecting small quantities of mingled medicinal preparations such as vitamins, minerals and other conventional drugs directly into the mesoderm to sh ar pathological conditions local anestheticly. It involves the judicial system of intradermal or subcutaneous shooters of compounds to consider a variety of medical conditions and avoiding systemic adverse effects due to drugs. It appears to be a novel technique to administer medicines local to the pathology while the flake off serves as a indwelling time- release system.BACKGROUND OF MESOTHERAPYThe term mesotherapy (derived from Greek mesos. Middle and therapeia to shargon medically) denotes dig of substances into middle layer of skin ( mesoderm) for medical purposes.Historical aspects1Mesotherapy was originally employ to treat annoyanceful conditions victimisation local procaine injectants. Michael Pistor who coined the term mesotherapy i s considered the drive of mesotherapy. In his original article,he draw treating deafness, tinnitus, vertigo and headaches using local injections of procaine. Earlier to this in 1884, Koller an ophthalmologist utilise local cocaine to relieve pain. In 1925 Lerich used 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 used 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 delimit mesotherapyas a techniquethat was used to treat mesoderm,(primary germ layer that develops into connective tissue, muscle and the circulatory system). In 1953, Dr.Mario Lebel invented a 3mm length needle that could be used on the dot for injection of substances into the dermis. In 1964, the French s ociety of Mesotherapy was founded by Michel Pistor and use of mesotherapy was extended to treat decorative conditions.The American influence was evident aft(prenominal) Dr. Lionel Bissoon popularized the technique in North America. Despite the fact that mesotherapy is gaining popularity in aesthetic medicine especially for localized cellulite reduction, it continues to be a contr oversial topic and therefore requires cautious approach. The guard duty and efficacy of these mesotherapy remain ambiguous to forbearings and physicians alike. 2Applied basic science 1, 3The concept that led to discovery of mesotherapy is quite interesting. Pistor saw recovery of chronic hearing privation 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 depth of injection was considered important. This led the researchers to the fact that at a depth of 1.5 to 2mm th e local activity of the product would last longer due to a persistent reservoir with wan local diffusion in the dermis whereas products injected into dermis would dissipate to greater distances.A product when injected intradermally acts in two ways. Firstly, by stimulating dermal receptors in situ and secondly, over long distances by r all(prenominal)ing other organs via circulation. A concept of meso-interface exists which is the surface of contact established between the injected products and the tissue injected. The more the quintuple punctures atomic number 18 made and the more fragmented products atomic number 18 delivered in small quantities, the greater the meso-interface and proportionately greater numbers of dermal receptors get activated.Pistor has always described this technique as follows. A little volume, a few 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 microci rculation to activate dermal receptors.A general chemical mechanism of execution (based on the target site, 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 occur by correction of these altered functions. Individual drugs or agents target the specific index of mesotherapy.EQUIPMENTSThe various equipments used in mesotherapy areMesogun (Fig 1)Mircromesotherapy device harryless MesotherapyMesogunMesogun is a syringe infusion spunk that is capable of injecting the desired substance at a required amount, speed and depth using the injector and needle. Syringes varying from 2cc-10cc and needle lengthsvarying in size from 4mm to 13mm can be used based on the indication, and desired depth of injection. A device known as guide is used to keep the needle at a constant depth. Once the parameters are chosen, the product can be injected by one of the following modes.Continuous Min 3cc/min Max 10cc/min.Mircro process 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 painlessAccurate delivery systemVersatality readiness 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 commonly 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 mesoneedles plop and cellulite 6mm 30G mesoneedles, inch 30G needles.Multi-injectors and plates (Fig2 b) These accessories help to cover l arger sports stadiums in a short time facilitating faster and easier procedure for the injector. There are sterilized circular and linear multi-injectors with needles ready 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 superficial layer of dermis therebyminimizing incidence of bruising, pain and scarring.Needle-Less 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.Probably around 20% efficiency compared to traditional mesotherapy as there is no neocollagenesis or neo angiogenesis reactions that occur with needle micro injury.This whitethorn 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 regard 3Products used for mesotherapy involves combination of products some of which are main ingredients known as principals as they have high grade 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 given indication. because the ingredients in mesosolutions are broadly classified into main categoriesPrincipal (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/MAJORCOMPLEMENTARY/MINORSKIN REJUVENATIONMesoliftHyaluronic Acid5DMAE complete silicumFibronectin + VegetalProteinsVitamin CGlycolic AcidXadenalVitamin A step-up FactorsStem CellsMesoglowHyaluronic AcidSiloagVitamin CXadenalTaurineMeso lighteningKojic AcidAzalaic AcidVitamin CGlutathioneTretinoinGlycolic AcidStriae or stretch marksStretch MarksOrganic silicumCentella AsiaticaVegetal Proteins +FibronectinDMAEVitamin CIdebenoneHair LossAndrogenetic AlopeciaMinoxidilFinasterideDutasterideDexenolBiotinAmino acidsPeptidesZincAzelaic AcidStem CellsTelogen effluviumBiotinDexapanthenolPyridoxineMulti VitaminsTrace ElementsCellulite and fatnessMeso CelluliteCaffeineCarnitineAminophyllineDMAERutinArtichokeYohimbineProcaineVitam in 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 injectionsTechnique wisdomIntraepidermal1mmPapular2mmNappage2-4mmPoint by point4mmMesoperfusion 4mmThe salient features of various techniques are outlined belowIntra-epidermalThis is one of the most superficial of the techniques described by Perrin.Depth 1mm inside the epidermisPainless, no exhaustSimple and large surface covered warning for patients with low pain thresholdIdeal for facial rejuvenation, mesoglowPapularDepth2mm dermoepidermal conjunctivePainfulUseful in mesobotoxIdeal treatment of wrinklesNappage(French for covering) Also known as picotage is the classic injection technique in mesotherapy. (Illustration 11.2) It is the most astray used technique in aesthetic dermatology. The syringe is held obliquely and the physician applies constant pressure on the plunger flicks the wrist to infuse a confuse 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 4mmPerpendicular 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 box 11.1 and box11.2.Box 11.1 Indications for mesotherapyBox 11.2 Contraindications for mesotherapyRelated to patientUnrealistic expectationsBody mass index greater than 30Pregnancy / Lac tationH/O strokes, recent cancer.H/o multiple meds for warmheartedness 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 key to success. Care should be taken to avoid patients with active skin diseases, too elderly and patients with history of sensitive skin. For androgenetic alopecia better results are seen in patient with Grades 1 3.Counseling and preparing the patientA proper counseling is essential before starting mesotherapy. Patients with body dysmorphic disorder s and those with unrealistic expectations should not be treated. assemble procedures should be discussed sufficiently as mesotherapy is s gutter in the controversial stage. A written informed consentis mandatory in the present medical scenario. A replete(p) before and after clinical photograph is needed to evaluate 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 utilize or ice-anesthesia can be used to numb the treatment area. Patients are preferably injected in a lying down opinion. The required quantity of ingredients is drawn into the syringe using an 18Gx11/2needle. The injection is given 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 normal saline and a mositurising cream can be applied to the treated area and massaged gently. 9. The pro cedure takes about 20 30 minutes depending 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 immediately.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. Mild swelling at site of injection may require anti-inflammatory agents for few days.The patients need to be counseled on the following aspectsAvoid sun exposure and smoking for next 48 hours slack fitting 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 1-2we eks for 6 sessions, 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 few 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 10 fell necrosis, Ulcers 11Abscess 12Hyper pigmentationAtypical mycobacterial infection 13Rare granulomatous panniculitis 14,15, koebnerisation, granuloma annulare, Oleoma 16SystemicAnaphylaxisNauseaVasovagal shockHepatic toxicityNerve demyelinationAllergy to specific ingredientsThyrotoxicosisIschaemic colitis 17Management of ComplicationsBruisingIt is a common but preventable complication. Always advice patient to stop aspirin or NSAIDs at least 2 weeks antecedent to the day of procedure. While injecting be slow and gentle. It is advisable to avoid mesotherapy during menstruation.Burning/ItchingBurning can be overcome 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 cold compresses with ice. Other methods that help to minimize pain are by pinching the skin for point by point injections or by stretching it when natural endowment a nappage. Change needles after every few pricks to reduce the pain caused by blunt injecting needlesUrticariaUrticaria can be avoided by a careful 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 protection 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 enhance 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 after th e 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 conduct 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 and efficacy of mesotherapy but many about its complications, hence it only natural to distrust 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 Level C, whereas cellulite treatment has been assigned Evidence Level D 18.Few recent studies have shown lustrous 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 new?. 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 mod 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 include original intention versus intention in mesotherapy e.g. aminophylline was originally used for brochodilation. In mesotherapy it is used for vasodilatation etcEvidence grade ( wherever available)