Therapeutic procedures

Aesthetic mesotherapy: a vast under-utilized potential

Jean Marc CHARDONNEAU

Introductory summary

Key words mesotherapy - aesthetics - tissue induction.

Mesotherapy is a therapeutic concept that consists in bringing the distance between the place of therapy and the place of the area to be treated closer. It is an injection of allopathic products in small quantities at the epidermal, dermal and subcutaneous level. This was the motto of Doctor Michel Pistor, French pioneer of this treatment: "Few, rarely and in the right place".

In 1987, mesotherapy was recognized by the Academy of Medicine as an integral part of traditional medicine. The first university degree in mesotherapy was granted in 1989.

This therapeutic approach focused on pathology (sports and rheumatic pathologies, etc.) at first, has been extended for more than twenty years to the aesthetic and anti-aging sphere. It is a simple treatment to use, without social eviction, effective and with an excellent safety of the products used (1).

Since the description of the technique, the use of mesotherapy increased slowly during the first 20 years (1971-1991) but exponentially during the last 30 years.

The increase in the number of these therapeutic procedures today seems to be largely related to the objective of skin rejuvenation. This French procedure (2) is practiced worldwide. Approximately 20,000 American physicians use mesotherapy in their daily medical practice (American Journal of Mesotherapy).

HISTORY

  • In 1844, RYND advocated intradermal injection (ID) in England,
  • Then in 1855, BEHIER introduced the method in France. 
  • In 1905 he synthesized procaine and gave great hope to the treatment of pain.
  • In 1928 LERICHE uses for the first time procaine in ID in trigeminal neuralgia with results that exceed all his expectations.
  • In 1937 ARON publishes the first preliminary study on the interest of introducing drug substances intradermally and in 1947 ASLAN publishes his work on the use of procaine in geriatrics.
  • In 1952 Michel PISTOR, in his village of Bray et Lu, treated a cobbler for an asthma attack with procaine IV. This treatment had little effect on the original pathology, but this patient, who had been deaf for many years, was able to hear the village bells ringing throughout the day and night.
  • Michel PISTOR then had the idea of continuing the treatment with procaine, but with regard to the ear and the results were conclusive. It is from this observation that he will tirelessly seek to treat the pathology as closely as possible.
  • From 1952 to 1958, PISTOR and LEBEL experimented with the locoregional use of medicinal mixtures in numerous indications. In order to facilitate local injections, their work led to the creation of the LEBEL needle.
  • In 1958, Michel PISTOR's work was published for the first time in the "Presse Médicale" with the first appearance of the word "mesotherapy".
  • The French Society of Mesotherapy was created in 1964.
  • In 2003, there are 5 university teaching centers for the IUD of mesotherapy.
  • The same year, the National Council of the Order of Physicians validated the diploma, thus allowing only the holders of the IUD to mention their diploma on their nameplates and prescriptions.

PRINCIPLE 

The term "meso" in mesotherapy comes from the Greek word "mesos" referring to the mesoderm (or middle germ cell layer) in the early embryo. The cells of the mesoderm form the somites (which will give the vertebrae, the muscles of the trunk and limbs and the dermis).

2 mechanisms would explain its action: a pharmacological effect and a mechanical effect.

  • Action of substances micro-injected in situ:  The active ingredient is placed near the target organ. A drug injected in small doses into the superficial layer of the skin spreads slowly to the underlying tissues and remains longer than systemic administration, as confirmed by studies. Higher concentrations of intradermally injected drug were detected in the skin, muscle, and joints underlying the infiltration site compared to intramuscular administration. In addition, a higher immune response, both primary and secondary, was reported after intradermal injection compared to intramuscular administration.
  • Stimulation of mechanoreceptors by micro-punctures of needles: This is tissue induction. Tissue induction (3 ,4 ,5 , 6) is a new therapeutic approach.
  • This complex but scientifically proven phenomenon is based on cellular stimulation with the fibroblast as the target (in the skin) and the production of collagen as the end result.
  • Collagen plays a crucial role in the signs of aging and in the restoration of the skin's functions. That's why it is the preferred choice for strategies to correct the effects of time.
  • The principle consists in exploiting the properties of the permanent epidermal-dermal dialogue (keratonocytes and fibroblasts) and between collagen and the other elements of the extra-cellular matrix (2), in particular elastin, with the result of reinforcing skin cohesiveness.
  • Different procedures are used: luminous, biological, thermal and mechanical.
  • Mesotherapy, by its mechanical (7) and biological action, becomes a very interesting actor in this phenomenon of tissue induction. Therefore, we can think that mesotherapy mainly uses the interstitial pathway to achieve its therapeutic effects in the context of facial rejuvenation.

 

TECHNICAL

2 processes are used: manual techniques and injectors.

5 techniques are used manually: 

  1. Intra-epidermal:

Technique, using a 13 mm needle, difficult to master. The needle is placed on the skin at an angle of 15°, with the bevel pointing upwards. It requires a rapid and light movement which will crack the epidermis from top to bottom. The intra-epidermal injection is between 0.05 and 0.1 mm.

  2. Intra-dermal superficial by papule:

Injection of product at the level of the basal layer which creates a sort of separation between the epidermis and the superficial dermis. It is the point by point. The injections are done perpendicular to the skin.

  • Intra-dermal superficial by topping:

Rapid penetration of the needle does not allow for the injection of product, but deposits a drop at each impact opposite the skin break. About ten punctures are made per second, spaced 2 to 4 mm apart. The superficial intra-dermal injection is between 0.1 and 0.2 mm.

  • Deep Intra-dermo

A 4 mm needle is used. The deep intradermal injection is between 1 and 2 mm.

  • Intra hypodermic

Injection between 2 and 13 mm deep. A 6 or 13 mm needle is used

Certain factors influence the thickness of the skin:

- age responsible for a decrease in the thickness of the dermis but not of the epidermis.

- hormonal variations in women with water retention increase the thickness of the dermis.

- Corticoids are responsible for thinning dermis and epidermis.

- phototypes have little influence on dermal-epidermal thickness.

The injectors

The gun

It is an automated injector that allows micro-injections to be performed at a high rate. 

The gun allows to respect precisely all the predefined parameters: doses, depth and speed which are controlled with the precision of the electronics. It is especially used for large treatment areas.

It is also perfectly adapted to the topping technique. The asepsis of this tool must be rigorous.

Injector pen

It is an electronic pen with a single-use tip equipped with about 30 micro-needles.

It creates more than 1000 micro-channels per second and allows the physician to adjust the speed and depth of needle penetration.

The treatment, which is not very painful, is especially interesting for the eye and lip contour. It is very interesting for the micropapular techniques.

Multi-injectors

Circular plastic multi-injectors are composed of seven needles or linear five-needle disposables.

PHARMACOPÉE

Many substances are used in aesthetic medicine.

- Non-crosslinked hyaluronic acid which stimulates the production of fibroblast via receptor 44. It promotes elasticity and firmness of the skin, in addition to moisturizing it

-Organic silicon which protects the cell membranes and helps in the synthesis of collagen and skin hydration.

- Vitamins for their antioxidant effect.

The procainused as a vasodilator

Dimethylaminoethanol (DMAE) participates in the hydration and realizes a tensor effect on the skin.

- Glycerol helps moisturize the skin

Phosphatidylcholine and deoxalate (forbidden in France) by their action of emptying of the fat cells.

-Lipolytics are used in the treatment of cellulite and localized fat, they promote the movement of fat nodules to facilitate their natural elimination. The most common lipolytics are L-Carnitine, caffeine.

- Flavonoids Lymphatic decongestants and venotonics, which limit the dilation of the veins and the inflammatory phenomenon.

- Etamsylate has an anti-edematous action.

Calcitonin improves microcirculatory flow.

- Zinc, selenium and iron are used for their anti-inflammatory and anti-oxidant action.

- Platelet-rich plasma (authorized in France only in pathology) stimulates healing and microcirculation.

Dutasteride and minoxyl are prescribed to combat moderate alopecia.

Cellular regeneratorsas the centella asiatica, are widely used to improve healing and prevent the appearance of stretch marks.

Some associations are CE marked:

  • Revitacare biorevitalization: for dull, tired, mature skin or skin lacking radiance. Suitable for young skin for an anti-aging effect.
  • NCFT135HA High concentration hyaluronic acid + polyrevitalizing solution. Indicated for the hydration of tired skin or skin lacking radiance and the treatment of superficial wrinkles.
  • Reparestimated:indicates biorevitalization, hydration of tired skin or skin lacking radiance and the treatment of superficial wrinkles.

INDICATIONS IN AESTHETIC MEDICINE

  • Skin aging (improvement of the skin's appearance through a skin tightening effect, by modifying the radiance): the Mesolift (which consists of injecting a solution based on non-crosslinked hyaluronic acid and vitamins into the skin of the face to moisturize and tone it. In a few sessions, the skin is plumped up and the complexion is unified.
  • Hands
  • Acne
  • Scars
  • Jowls
  • Double chin
  • Stretch marks (8)
  • Alopecia
  • Deep hyperlipodystrophy or steatomery
  • Cellulite
  • Venous insufficiency
  • Skin sagging

TREATMENT PROTOCOLS

In the 3 main areas:

Mesolift of the face

Mixture:

  • with non-crosslinked hyaluronic acid 70 %
  • + depending on the case :
    • dmae (sagging skin)
    • vitamins (dull face)
    • organic silicon (very fine dermis)

Type of injection: Intra-epidermal and intradermal by topping.

Rhythm:  1 session every 15 days - 3 to 4 sessions.

Cellulite: the mesocellulite protocol

  • Based on the work carried out on the physiology and metabolism of adipose tissue by different teams and in particular that of INSERM in Toulouse, lead to believe that the local injection of an ortho-osmolar mixture with essentially vaso-active aim would lead to a reduction of clusters greasy and more particularly cellulite
  • Mixture used:

Procaine 1%: 2 cc - Thiocolchicoside: 3 cc - Etamsylate: 2 cc - Magnesium Pidolate: 2 cc - PPI Water: 1 cc

  • The products selected in the mixture were chosen for the following properties:

Procaine as a vector.

Thiocolchicoside for its defibosant action and on the elastin production system. - Etamsylate for its rheological and lymphatic action.

Magnesium Pidolate for its effect of muscular relaxation on the muscular fibers of arterioles and venules, and also for its involvement in numerous enzymatic systems at the origin of the physiological boost of lipolysis.

  • The treatment scheme is as follows:

Rhythm:  a mesotherapy session with the mixture indicated above at a rate of one session every week for a maximum of ten days. The time between two sessions can be exceptionally modified according to the constraints of the doctor and the patient without exceeding 21 days. Total 6 to 8 sessions.

Injection technique One point is placed approximately every cm². Half of the injection points are made at a depth of 1 to 2 mm (IED or IDS) and the other half at a depth of 4 to 6 mm (IDP).

The two depths are evenly distributed over the treated area.

- the volume of each injection site is 0.1 to 0.2 cc.

- the total volume injected is a maximum of 10 cc per area to be treated.

Stretch marks

Blend with centella asiatica 30 % and organic silicon 70 %

Type of injection Superficial Intra-dermo and Deep Intra-dermo.

Pace: 1 session every week - 8 sessions

SIDE EFFECTS

Side effects are rare and generally ephemeral and benign:

  • Allergic reaction to one of the injected components
  • Edema
  • Erythema
  • Ecchymosis
  • Pruritus
  • Infection
  • Nodules
  • Pigmentation

CONTRAINDICATIONS

They are very rare:

  • known hypersensitivity to any of the components
  • pregnancy
  • lactation period
  • patients on anticoagulants (relative contraindication)
  • skin infections

THE STUDIES

Aesthetic mesotherapy (9) has often been criticized as suffering from a lack of study compared to traditional mesotherapy.

However, numerous scientific studies have confirmed its place and interest in aesthetic treatments in various fields.

  • Massimo Mammucari et al. Mesotherapy and phosphatidylcholine injections: historical clarification and review 2020.
  • Comparison of efficacy of Tranexamic Acid Mesotherapy versus 0.9% normal Saline for Melasma; A split face study in a Tertiary Care Hospital of Karachi 2020. Sana Kaleem1Rabia Ghafoor 2Sidra Khan 
  • Polycomponent mesotherapy formulations for the treatment of skin aging and improvement of skin quality 2015. Sergey Prikhnenko1.

CONCLUSION

Mesotherapy is a scientifically recognized therapy and has a place of choice in the aesthetic sphere. It can be used alone or combined with other procedures: LED - radiofrequency - laser - tensor threads. It is a low-cost treatment that saves on medication. It is not very traumatic, safe and effective.

The phenomenon of tissue induction and its restoration of the extra-cellular matrix, particularly through mesotherapy, in the face of an exponential demand for facial rejuvenation, will become part of our therapeutic strategy.

Not only is this tissue induction of interest in the aesthetic sphere but also, according to many biologists, in chronic diseases.

Covering many fields of application, mesotherapy is today an integral part of the aesthetic therapeutic arsenal available to the practitioner, either in isolation or in conjunction with other therapies.

BIBLIOGRAPHY

  1. Evaluation of the effectiveness of the practice of therapeutic mesotherapy -2010.                        G Sivagnanam . Mesotherapy - The French connection. J. Pharmacol Pharmacotherapy 2010 ;1(1):4-8
  2. Rodrigo ArroyoEvgeniya Ranneva Philippe Deprez. In vitro study of RRS HA injectable mesotherapy/biorevitalization product on human skin fibroblasts and its clinical utilization Clin Cosmet Investig Dermatol 2016. 23; 9:41-53.
  3. Adam Wahlsten, Dominic Rütsche, Monica Nanni, Costanza Giampietro, Thomas Biederman. Mechanical stimulation induces rapid fibroblast proliferation and accelerates the early maturation of human skin substitutes. Biomaterials 2021.120779
  4. B Mole. Tissue induction: understanding and using a promising phenomenon. J Med Esth Chir Dermato 179 , 2018 147-154.
  1. Grimaud JA. Photobiomodulation, bioconduction, mechano-transduction: exploration of the dermal-epidermal dialogue induced by dynamic videomicroscopy using conditioned media. Reality in Plastic Surgery. 14, 2016: 7-9.
  1. Zeitter S, Sikora Z, Jahn S, et all. Microneedling: matching the results of medical needling and repetitive treatments to maximize potentials for skin regeneration. Burns 2014; 40 (5): 966-73.
  1. JM Chardonneau. Stretch marks and hyaluronic acid:a couple to discover. J Med Esth Chir Dermato 176 , 2017 213-219.
  1. J Le Coz. The point on aesthetic mesotherapy. J.de Med.Esth.et de Chir. Dermato 2011,149: 35-39