Carbon dioxide therapy, also known as carboxytherapy, involves injecting medical grade carbon dioxide into the skin using small needles. It is used cosmetically to treat conditions like stretch marks, cellulite, and under-eye circles. The carbon dioxide stimulates collagen production, improves blood flow, and releases more oxygen in tissues through the Bohr effect. It has been used in Europe since the 1930s and is common in South America. Treatment protocols and techniques vary depending on the condition but typically involve 15-20 injections spaced over the treatment area, with 1-2 sessions per month. Potential side effects include pain and localized inflammation at the injection sites.

1. Carbon Dioxide Therapy: ‘Magic Gas or Hot Air?’
An overview with Dr. Patrick Treacy RSM March 2014

2. RioBlush

5. So where are we?
‘Magic Gas or Hot Air?’

6. What is Carboxytherapy?
Carbon dioxide therapy (Carboxytherapy) is a
procedure 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.

7. 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.

8. 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.

10. Where does the CO2 story start?

13. Lavoisier was brought to trial on 8 May 1794.
According to a (probably apocryphal) story,
the appeal to spare his life so that he could
continue his experiments was cut short by the
judge: "La République n'a pas besoin de
savants ni de chimistes ; le cours de la justice
ne peut être suspendu."
"The Republic needs neither scientists nor
chemists; the course of justice cannot be
delayed."

14. Lalouette (1777 )
• Joseph Black isolated carbon dioxide in 1757
• Henry Cavendish isolated hydrogen in 1766
• Daniel Rutherford isolated nitrogen in 1772
• Joseph Priestly isolated oxygen in 1772
• Lalouette showed in 1777 that carbon dioxide improved
chronic and inveterate skin problems, especially in foot ulcers
not response to convention treatments such as daily
dressings and debridement.
• Carbon dioxide water bath therapy (carbothera) ... springs” or
(artificial) therapeutic CO2 officially recognized in France as
medications
•

16. Scientific Publications
Carbotherapy continued to be used in France and
publications begin to appear in the early
1930s.Doctors in the medical spa of Royat 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.

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

30. 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

32. 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

34. Stimulation of collagen synthesis
• A 2008 Brazilian study* showed a reorganization of
collagen fibres 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.

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

49. 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

50. 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

53. 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.

55. 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

58. 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.

59. 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

60. 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

61. 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)

62. 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

63. 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

64. Thank You