Lecture to Los Angeles Cosmetic Conference 2011 by Dr. Patrick Treacy about the new RioBlush treatment for stretch marks.

1. Carbon Dioxide Therapy: Face and body rejuvenation An overview with Patrick Treacy

2. RioBlush

5. Introduction Carbon dioxide therapy (CDT, Carboxytherapy) is a procedure which is very similar to mesotherapy. It consists of intradermal or subcutaneous injections of medical grade CO2 using 30G needles. 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.

6. 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.

8. History of use CDT (known as carboxitherapy, carboxytherapy, or carbotherapy) was first described in France in the early 1930s, in the medical spa of Royat. Doctors 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.

10. Publications CO2 was first used as a treatment of ischemic lower legs arterial diseases before medical treatments evolved to grafts, stents, by-passes. Raynaud’s phenomenon, skin ulcers with arterial or venous cause, as well as several vascular erection disorders were also CDT indications. Since 1930, hundreds of thousands patients undergone these procedures. The technique is still used in developing countries in vascular treatments.

13. The use of CO2 in aesthetic procedure is new. There are only two studies published by the Italian University of Siena* in the 2000s concerning the improvement of localized adiposities after liposuction for one, or with CDT performed alone in the second. There is also a 2008 Brazilian study available to indicate that collagen turnover is improved with CO2. Although only one team made the study on a limited number of patients, the technique has been commonly used since in cellulite and fat indications whereas in other aesthetic indications:

15. 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

17. Bohr Effect This reaction causes the tissue’s pH to become acidic with even more dissociation of O2 from haemoglobin, allowing the tissue to become even more oxygenated

19. Stimulation of collagen synthesis A 2008 Brazilian study* showed a reorganization of collagen fibers 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.

21. Neo-angiogenesis effect The first experiments in the 1930s consisted of injecting CO2 into the leg of a frog. They have shown a strong vasodilatation, associated with the creation of new capillaries.

23. Suspected melanocyte pigment synthesis stimulation Further studies needs to be done but we feel CO2 injections have an important role in the stimulation of melanocytes capabilities as they tend to re-pigment white stretch marks. The mechanism of this improvement needs to be worked out. Receptor activation and lipolysis cascading improvement The pressure receptors are stimulated by CO2 injections. There is a release of bradykinin, histamine, serotonin and catecholamine. These mediators have a role on the activation of beta-adrenergic receptors and tissue cyclic AMP, leading to stimulation of lipase enzymes. Some companies or factories are claiming that CO2 pressure directly destroys fat cells by fragilization, which does not seem to be the case

34. Cosmetic Indications Aesthetic indications can be divided in two main groups: Group 1 is dealing with fat/cellulite. Group 2 is targeting collagen, blood flow and skin oxygenation. Schematically fat indications require deeper injections: subdermal

37. Stretch marks Principle Improve neovascularization and blood flow (red color seen via skin transparency will appear pink, close to the natural skin color), improve melanocyte pigment production to darken white stretch marks. Improve collagen synthesis to reduce the wave appearance of old 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). Protocol Combined intradermal and subcutaneous injections One session per month Flow: 80–150 cc/min Puncture inside the mark, Number of sessions: four to ten

39. 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 1–2 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 70–80 cc/min may make the patient more comfortable

45. 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: 20–40 cc/min Four to five punctures around the lower orbit bones Number of sessions: three to six

46. Under-eye dark circles Intradermal injections One session per month. Flow: 20–40 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: 20–40 cc/min Puncture in the fatty area. Number of sessions: three to six

49. 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.

51. 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

54. 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 I–II to grade III–IV. Subcutaneous irregularities after liposuction. Complementary treatment to liposuction, which does not have any efficacy on cellulite.

55. Protocol Cellulite grade I or II Combination of subcutaneous and intradermal injections. One session per day to one per week Flow: 1–2 cc/kg/min – approximately 2 minutes per injection Punctures: 15–20 cm spaced, no overlapping - Number of sessions: 10–20 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: 15–20 cm spaced, no overlapping. Number of sessions: 10–20 Progressive flow (automatic mode) available with some machines

56. Technique The operator’s 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 15–20 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

58. 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: 1–2 cc/kg/min (50–80 cc/min), approximately 2 minutes per injection point Punctures spaced 15–20 cm apart Number of sessions: 10–20 – First results usually seen after session #4~6 Progressive flow (automatic mode) available with some machines Submentonian area: deep dermis (and/or subcutaneous) Flow: 1–2 cc/kg/min (50–80 cc/min), Approximately 30–60 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)

60. 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: Willebrand’s disorder, hemophilia

61. 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 décolletage. 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