CarboxytherapyStretchmarks Protocol Technique Gesture Results

CADIC Philippe, MD, FRANCEpcadic@gmail.com

www.carboxyworld.com

Monaco June, 2012

CO2 Gas medical effectsMain carbon dioxide health effects and uses in the human body Vasodilation (expansion of arteries and arterioles). The Bohr effect The Bohr effect states that arterial hypocapnia will cause reduced oxygen release in tissue capillaries. Cells Oxygen Levels Oxygen Transport Free Radicals Generation Inflammatory Response CO2 is the key anti-inflammatory agent. Nerve Stabilization Muscle relaxation or relaxation of muscle cells is normal at high CO2 Brochodilation - dilation of airways: bronchi and bronchioles by carbon dioxide, and their constriction due to hypocapnia. Blood pH regulation and regulation of other bodily fluids. CO2: Lung Damage Healer: Elevated carbon dioxide prevents injury and promotes healing of lung tissues. CO2: Skin and Tissue Healer. Synthesis of Glutamine in the Brain, CO2 fixation, and other chemical reactions: there are many other regulatory and facilitating effects related to uses of carbon dioxide. Regularity and Smoothness of Breathing is controlled by CO2.

CO2 Gas medical effectsCarbon dioxide Dermatology effects Vasodilation (expansion of arteries and arterioles). Neo vascularization stimulation The Bohr effect The Bohr effect states that arterial hypocapnia will cause reduced oxygen release in tissue capillaries Collagen fibers organisation & turnover improvement Lipolytic effect

Vasodilation (expansion of arteries and arterioles).CO2: most potent vasodilator Studies related to CO2-induced vasodilation and vasoconstriction Dr. K. P. Buteyko and his colleagues found vasoconstrictive effects of hypocapnia (CO2 deficiency) on arteries and peripheral blood vessels (Buteyko et al, 1964a; Buteyko et al, 1964b; Buteyko et al, 1964c; Buteyko et al, 1965; Buteyko et al, 1967), while additional CO2 causes vasodilation, which is a normal state of arteries and arterioles.

Cell Oxygen Level The prime effect of overbreathing is reduced CO2 content in the lungs, blood and other body cells and tissues. Medical studies have found that hyperventilation reduces cell oxygen level in the following vital organs Reduced CO2 Reduced oxygen levels in cells

CO2+ H2O H+ + HCO3

Cell Oxygen LevelOxygen - Carbon Dioxide Transport & Hypocapnia (CO2 Deficiency) There are 3 independent mechanisms of hypocapnia or carbon dioxide deficiency that hampers efficiency of oxygen transport: chest breathing, vasoconstriction, and suppressed Bohr effect Since hypocapnia (carbon dioxide deficiency) causes constriction of arteries and arterioles and the suppressed Bohr effect, overbreathing (breathing more than the medical norm) reduces O2 tension in cells of the brain, heart, kidneys, liver, and other vital organs. Hence, the effects of chronic hyperventilation on oxygen transport are due to: constriction of blood vessels: arteries and arterioles (less blood and oxygen is delivered to cells and tissues) inefficient Bohr effect (less oxygen is released in cells and tissues).

Free Radicals Generation:Normal Effect of Low Body Oxygen Levels abnormal breathing is the most powerful source of free radicals and oxidative stress in modern, especially sick, people. "The role of carbon dioxide in free radical reactions of the organism" (Vesel & Wilhelm, 2002). They discovered several mechanisms to explain explain the protective antioxidant role of CO2 against free radical damage. Arterial hypocapnia (CO2 deficiency) causes tissue hypoxia Izv Akad Nauk Ser Biol. 1997 Mar-Apr;(2):204-17. [Carbon dioxide--a universal inhibitor of the generation of active oxygen forms [free radicals] by cells (deciphering one enigma of evolution)]

Chronic Inflammation and Anti-Inflammatory CO2 Effects: CO2 has powerful anti-inflammatory abilities Abnormally low arterial CO2 is a marker of chronic hyperventilation. Cell hypoxia is a fuel for systemic inflammation CO2 has powerful anti-inflammatory abilities

CO2: Natural Sedative and Tranquilizer:CO2 modifies Muscles and nerve sensitivity Studies designed to determine the effects produced by hyperventilation on nerve and muscle have been consistent in their finding on increased irritability (Brown, 1953). Muscles and nerve cells become abnormally sensitive or irritated. CO2 has a strong calming effect on excessive excitability of brain areas responsible for thinking (Krnjevic et al, 1965). CO2 is natural sedative and tranquilizer of nerve cells. Carbon Dioxide Natural Muscle Relaxant

CO2: BronchodilatorBest Bronchodilators: CO2 and NO relaxes smooth muscles or airways and causes dilation of bronchi and bronchioles. Carbon dioxide is probably the most powerful among all bronchodilators since it is the most potent relaxant of smooth muscles and vasodilator

CO2, Blood pH and Respiratory AlkalosisCarbonic Acid-Bicarbonate Buffer System Changes in carbon dioxide and breathing cause immediate and long-term effects of blood pH. higher CO2 content causes blood acidification and pH decrease, while reduced carbon dioxide levels increase blood pH CO2 also influences viscosity of blood. Acute hyperventilation and arterial hypocapnia makes blood more viscous

CO2: a healing gas Protective effect of carbon dioxide against bacterial contamination Hypocapnia worsens arterial blood oxygenation CO2 is a skin healer

CO2, Collagen stimulationCarbonic Acid-Bicarbonate Buffer System Histological analysis showed intense collagen turnover in the skin samples of the animals treated with CO2, especially in those with intradermal treatment. reductions in wrinkles consequent to CO2 therapy and also establish that intradermal injection is better than subcutaneous injection.

CO2, Fat reduction effectPhysiological oxidative lipolytic effect positive effect upon the physiological oxidative lipolytic process Better local oxygenation Better local blood flow Cascading lipolytic enzymes (after pressure stress) ?

Clinical StudiesCellulite and Localized Fat Cellulite and Localized fat Siena 1999 and 2000 - Italy.

In our study, the effectiveness of carbon dioxide therapy was confirmed both by histological data and by those regarding variations in the maximum circumference of the areas subjected to treatment. The statistically significant reduction observed in the areas treated (Table 1) was attributable to both a direct effect on adipose tissue, as revealed by the lysis of adipose cells, and to an indirect effect.

Clinical StudiesCellulite and Localized Fat Cellulite and Localized fat Siena 2004 - Italy.

Cnclusion: This study has shown that with CO2 therapy to obtain improvement of skin irregularity and cutaneous elasticity is possible. This has led us to consider the possibility of CO2 therapy as a complement to liposuction.

Clinical StudiesCellulite 2010

Cnclusion: The results of this audit agree with those reported in smaller prospective series, confirming that carboxytherapy is safe and effective.

Clinical StudiesCellulite and Localized Fat

Cnclusion: The percutaneous infiltration of CO2 reduces the population of adipocytes of the anterior abdominal wall and modifies their morphology.

Clinical StudiesMicrocirculation and Lymphedema - 2007

Cnclusion: Due to the vasomotor effects of CO2 and the absence of relevant major side-effects and toxicity, Carboxhytherapy has become increasingly diffused for the treatment of a variety of microcirculatory diseases. Specifically, the positive effect on lymphatic drainage in microcirculation let to use Carboxytherapy

Clinical StudiesChronic Wounds - 2011

Cnclusion: In the group that underwent subcutaneous treatment with CO2 therapy, the results highlighted a significant increase in tissue oxygenation values, which was confirmed by greater progress of the lesions in terms of both healing and reduction of the injured area.

Clinical StudiesAesthetic medicine - 2006

Clinical StudiesAesthetic medicine - Collagen - 2008

Clinical StudiesSCARS - 2010

Indications - CarboxytherapyCarbon Dioxide Therapy indicationsVascular indications Microvascularization diseases Raynaud phenomenon Lower limbs arterial diseases and ischemia Erectile dysfunction with microvascularization disorders

Dermatology Aesthetic indications

Cellulite Localized Fat Post liposuction Eye fatty prolapses Eye Dark circles Eye Wrinkles Naso genian folds

Stretchmarks Neck + decolletage rejuvenation Face Wrinkles Surgical scars / acne scars Psoriasis Healing process

Contra Indications - CarboxytherapyCarbon Dioxide Therapy contra indicationsGeneral contra indications 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:Willebrand disorder, hemophilia.

Contra Indications - CarboxytherapyCarbon Dioxide Therapy contra indicationsLocal contra indications bacterial infection: dermatitis, cellulitis foreign body in the area to be treated (jewellery implants and so on) 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 decolletage.

Contra Indications - CarboxytherapyCarbon Dioxide Therapy contra indicationsTemporary contra indications 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.

CarboxytherapyComplicationsClassical complications Same profile of risk than mesotherapy

Infection at the point of injection Inflammatory reaction at the point of injection (lack of purge) Eye oedema at the point of injection Hematoma at the point of injection

Gas embolism: never described since 1930. Very small amounts of CO2. Cannot compare to laparoscopic surgery. Blood virus transmission: never described. Single use disposable consumables.

CarboxytherapySide effectsClassical side effets / end points Pain at the point of injection because of an increase in pressure Erythema at the point of injection Temporary anesthesia lower than the infection point Emphysema sensation (temporary feeling) Heat sensation (vasodilatation) Vagal syndrome

CarboxytherapyPrevent the occurrence of side effects Pain at the point of injection because of an increase in pressure Use lower injection flows Take breaks during injections shorten the duration of the injection & make multiple injections points Practice local massage to help the gas diffuse. Stimulate (vibration) other part of the skin

Erythema at the point of injection This is a end point. Last around 15 minutes.

Temporary anesthesia lower than the infection point The sensation of anesthesia lasts about 1 to 3 minutes. Just wait

Emphysema sensation (temporary feeling) This is a end point, just wait a couple of minutes until the effect stops.

Heat sensation (vasodilatation) This is a end point. Wait 3 to 15 minutes until it stops

CarboxytherapyPrevent the occurrence of side effects Vagal syndrome Vagal syndrome might be severe (sensitive patients, lower legs treatements) Get sure the patient is not with empty stomach Get sure the patient has no needle phobia Get sure the patient has no hypoglycemia Install your patient in a comfortable position

In case of Vagal syndrome Stop the injection of CO2 elevate the legs of patients for more blood to the brain assess the interest of injecting atropine

CarboxytherapyCarboxytherapy managing pain levels

Pain levels and painful area Subcutaneous injections pain is related to an increase of pressure in the hypodermis and fat tissue. Lowering pain achieve a gradual increase in pressure Intradermal injections pain is related to dermis traumatism Lowering pain reduce the trauma = reduce flow valuenote that reduced flow value = reduced efficacy

Security considerations with CO2Necessary precautions with CO2 gas. Toxicity CO2 tanks and cartridges : 50 bars / 700 PSI Risk of explosion and injury Pressurized CO2 ~-78C : Risk of burn by freezing skin or cornea High pressure and grease: risk of explosion with pressure regulators Not Flammable Personal Precautions. Ventilate area or move cylinder to a well-ventilated area. Test for sufficient oxygen, especially in confined spaces, before allowing reentry. Protect cylinders from damage Never insert an object (e.g., wrench, screwdriver, pry bar) into cap openings Open valve slowly Never put cylinders of tank into the fire or expose to high temperatures Use CO2 detectors in rooms

Security (First Aid)Necessary precautions with CO2 gas. Toxicity INHALATION: Immediately remove to fresh air. If not breathing, give artificial respiration. If breathing is difficult, qualified personnel may give oxygen. SKIN CONTACT: For exposure to cold vapor or solid, immediately warm frostbite area with warm water not to exceed 105F (41C). In case of massive exposure, remove contaminated clothing while showering with warm water. SWALLOWING: An unlikely route of exposure. EYE CONTACT: For exposure to cold vapor or solid, immediately flush eyes thoroughly with warm water for at least 15 minutes. Hold the eyelids open and away from the eyeballs to ensure that all surfaces are flushed thoroughly. ophthalmologist

CO2 machines partsMain parts of a CDT machine CO2 tank connector Pressure regulator Pressure gauge (high , low) Flow regulator Low pressure sensor + modulator Heater (optional) Co2 exit port Bacterial filter 30 G needle

Schematic DiagramVarious types of options in a Carboxytherapy equipment

ConsumablesKey injections parts Mesotherapy needles: 30G (yellow) needle 0.22% filter (filters bacteria, fungus, dusts, viruses) Disposable, one use consumables (security) Plastic tubings (optional)

Injections layers / planesIntradermal or Sub cutaneous planes Fat Sub-cutaneous injections Stretchmarks, Eyes, Skin rejuvenation, Intradermal

Subcutaneous

Deep Dermis

Superficial dermis

Injections layers / planesIntradermal or Sub cutaneous planes

Sub cutaneous injections Subcutaneous CDT injections are administered to reach the localized fat area, activate lipolysis and improve blood flow. Subcutaneous CDT injections are also used for Raynaud phenomenon Lower limbs arterial diseases and ischemia Microvascularization disorders Psoriasis

Injections layers / planesSUB CUTANEOUS LAYERS INJECTION Needle angle ~ 40-45

Injections layers / planesSub cutaneous injection The subcutaneous injection is performed by 30G needle (mesotherapy needle). Angle > 45 The plan is injected subcutaneously surface so you can tracks & see the progression of the gas under the skin. Being too deep can complicate the visual tracking of the gas diffusion. The injection time is generally 60 to 90 sec per injection point It forms a disk of about 15 to 20 cm in diameter, Aspect of crepe paper with a slight erythema. The patient may report a heat sensation (vasodilation). When the disk is obtained, the operator moves the needle to cover the contiguous zone.

Injections layers / planesSub cutaneous injection Video on the DVD

Injections layers / planesIntradermal or Sub cutaneous planes

Intradermal injections Intradermal CDT injections are administered to improve collagen turnover and stimulate fibers orientation. Acne scars Surgical scars Traumatic scars Stretch marks Skin rejuvenation Eye wrinkles , Eye Dark circles

Injections layers / planesINTRADERMAL LAYERS INJECTION Needle angle Young red striaes (other modalities such as laser) Deep striaes > Thin striaes Corrugated striaes > White superficial striaes Internal side of thighs > external side Abdomen > Lower limbs > Upper limbs Dark skin > white phototypesIntradermal injection

End point & Results After injection Pop-corn effect, 1 to 2 minutes after injection Erythema, lasts from 5 to 10 minutes after injection Warmth sensation 5 to 10 minutes after injection Then back to normal appearance

Improvement may usually be seen after 1 to 2 sessions White color improves because red vessels below striaes, and pigment stimulation Stretch marks depth improves because of collagen synthesis stimulation Skin thightening may be seen also in treated areas

Protocol for Striae

Results

3 sessions , monthly spaced, 90 cc/min. 52 years old French Female. Dr CADIC May 2008

Results

10 sessions black skin french female Courtesy Dr Mole (Paris)

Results

Female: PhotoType 4 - 3 sessions on her legs at 80cc/min every 3 weeks Sept 2008

Results

Female ~ Age 23: Old SM after pregnancy PhotoType 3 - 4 sessions - 150cc/min every 4 weeks Nov 2009

Conclusion Advantages An opportunity to propose something where there are not many alternatives. A minimally invasive technique (similar to mesotherapy) with few side effects A quick technique in the realization of gesture No down time A technique that can be delegated to a nurse Visible improvements from the first or second session when it works An inexpensive equipment