Introduction

Mesotherapy is a nonsurgical cosmetic treatment invented by Michael Pistor in France in 1952 after he completed research in intradermal therapy and research in treating disorders in the mesoderm layer.¹ By choosing mesotherapy, the patient is not subjected to oral or intravenous medication, as it treats the problem at its source by local action. The French Academy of Medicine recognized mesotherapy as a specialty of medicine in 1987. The International Society of Mesotherapy has members in 14 countries throughout Europe and South America. Over the past 50 years, in excess of 18 000 physicians worldwide have used mesotherapy on a daily basis for a variety of purposes, including treatment of cellulite, spot weight reduction, overall weight loss, hair loss, facial rejuvenation, correction of liposuction errors, pain management, and sports injuries. This chapter will only deal with the cosmetic applications of mesotherapy for body contouring and cellulite.²

Mesotherapy employs multiple injections of a combination of homeopathic and pharmaceutical medication, plant extracts and vitamins that are injected into the mesoderm layer targeting the adipose fat cells, dermal vasculature, and connective tissue septae. The medications selected for use are based on the intent of the treatment. Injection lipolysis (Fig. 52.1) using a single substance like Lipodissolve™ should not be confused with mesotherapy that uses combinations of medications.³ The injections are performed with a special needle that varies from 0.4 to 0.6 cm, spaced approximately 1.5–2.5 cm apart. Sometimes the technique of Nappage is used; this is a series of injections of small amounts of substance into superficial concentrated areas of the skin with a longer needle up to 13 mm used occasionally to target deeper fat.³

FIG. 52.1 Lipolysis.

β-AR stimulates lipolysis; α-AR inhibition of lipolysis; the α2-AR/β-AR ratio is higher in the thigh/gluteal region leading to increased adipocity.

(Courtesy Dr. Marion Shapiro.)

Mesotherapy has spurred some controversy in the American medical community even though it has been very well accepted in Europe and South America.⁴ Unlike recognized FDA-approved cosmetic procedures, the medications used are off-label and no double-blind studies have been completed to support mesotherapy as an effective nonsurgical alternative to liposuction. Success rates vary on the formulas used, and most users keep their formula proprietary. It is safe to say that mesotherapy should only be utilized by practitioners that are licensed to use injectable medications, and have studied the techniques and complications of the procedure.⁵

Selection of Patients for Mesotherapy

Proper selection of patients for mesotherapy is paramount for the treatment. Both men and women respond equally to mesotherapy, as do patients of all skin color. Patients who have a BMI > 30 should not be treated, as their results will not be adequate. Patients with very loose skin will not have significant results, nor will patients with extremely hard fibrous fat. The fat must be in the mesoderm layer, and not beyond the reach of the mesotherapy needle. Breast, ankles and lower legs (except the calves) should never be treated. The face must be treated with caution as facial fat is generally cosmetically desired. The areas that respond the best are areas of soft pinchable fat with tighter skin, such as the abdomen, “love handles”, and legs, submental fat, and asymmetrical areas following liposuction or fat grafting.

Cellulite can also be treated with mesotherapy. Cellulite refers to the appearance of dimpled skin referred to as “orange peel”, on the thighs, buttocks, and sometimes lower abdomen of otherwise healthy patients; 90% of cellulite cases occur in women.⁶ Cellulite is most common in areas of fat deposits and is the result of the unevenness of this fatty tissue beneath the skin surface. Since cellulite is largely due to a structural aberration below the skin, people who have more fat deposits have more pronounced cellulite. Most structural changes include vertical orientation of the septae with increased septal thickness, while those with less fat and more muscular definition tend to have less visible cellulite. There is still much controversy over the etiology and pathology of cellulite. Most theories postulate this condition with abnormal connective tissue organization, alterations in fat metabolism, microcirculatory/lymphatic derangements, and venous insufficiency.⁷

According to studies conducted using magnetic resonance imaging and sonography,⁸ female fat lobules are larger than males’ and compartmentalized by fibrous septae that form radial and archlike structures. The uppermost layer of subcutaneous fat has been described as “standing fat-cell chambers” separated by connective tissue. From these fat-cell chambers, small projections of fat cells protrude into the dermis. This unevenness and irregularity of the subcutaneous fat give the skin the appearance we call cellulite.

Mesotherapy treatments for cellulite attempt to improve these four pathological aspects. Medications are selected to improve lymphatic and venous drainage, improve the connective tissue characteristics, and reduce adipose deposits that result in the dimpled look of the skin.⁹ Although fat reduction is important in the treatment, usually the appearance is of most concern to the patient, rather than a size change of the area.

Cellulite is also graded as follows: Grade 1 is cellulite that is only perceptible on pinching of the skin; Grade 2 is cellulite that is visibly apparent but disappears on lying flat; Grade 3 is cellulite that is apparent in any position.

Patients should be given full counseling on adding exercise and nutritionally sound diets to their daily routines if they are not already adhering to them. Alcohol consumption should be at a minimum, as should UV exposure for suntanning. Sun burn, concurrent skin treatments in the area, or skin infection will contraindicate treatments. Patients should not expose their skin to tanning, jacuzzis or steam following their treatments. Hot showers or baths should also be avoided for 48 hours. Exercise also should be avoided for 8 hours if excessive sweating occurs (Table 52.1).¹⁰

TABLE 52.1 Liposuction Versus Mesotherapy

Formulations

The selection of medications, herbal extracts and vitamins is generally at the discretion of the practitioner, and is learned in a course on mesotherapy. It is important to choose medication based on the reason for the treatment (Fig. 52.2). The formula for each patient will differ and medications and volume of each “cocktail” will vary from one body region to another and may change each time. Treatment for fat alone will utilize medication for lipolysis, vasodilation and perfusion, while treatments for cellulite will also include dissolution of septae and banding. Sometimes multiple medications will be used together that cause lipolysis, because they have different physiological actions. All mesotherapy mixtures must adhere to ensure patient safety. The medications used must be isotonic, biocompatible and sterile, with pH between 5 and 7. In Europe, theophylline tends to be the drug of choice for lipolysis, whereas in the Americas it is usually phosphotidylcholine.¹¹ Usually 20–30 ml of formula are injected in each session, with the formula varying in each syringe if necessary.

FIG. 52.2 Treatment protocol.

Disinfect skin with alcohol, mark areas to treat, complete markings on skin (A, B, C). Prepare syringes (D, E) – needle depth 6–13 mm (F).

(Courtesy Dr. Marion Shapiro.)

PrepAration for Mesotherapy

Consultation with the patient should include a thorough medical history and physical exam of the areas to be treated. Note should be made of any prior surgical procedures, stretch marks, or unusual pigmentation in those areas. The patient’s cellulite should be evaluated and classified as to the grade of severity. Photographs of the patient should be made against a neutral background, without utilizing flash. The patient’s areas of treatment should be measured with a measuring tape and recorded. BMI should be recorded and a starting weight if possible. Consent for the procedure should be signed by both the patient and practitioner. A progress sheet should be placed on the patient’s chart, where the patient’s information can be recorded on a weekly basis. Drawings of the areas treated should be placed on this sheet. A weekly progress note should notate each visit, medication used, and any adverse side effects or comments the patient has made regarding their progress.

Injections

Once the formula is selected, the frequency of treatments, needle selection, and technique of injections must be determined. The use of a mechanical injector such as a Pistor, or injection by hand is determined by the training of the mesotherapist. The use of a mechanical injector is more precise as it can deliver an exact amount of medication and to the desired depth each and every time an injection is given. There are many types of mechanical injectors available, and the type that use single needles have the fewest side effects.

The number of treatments and frequency is determined by the severity of the patient’s symptoms and how they respond to the therapy. In general, treatments are usually given at least 1 week apart, but this can be longer if the patient has lingering swelling or reactions to the medications used. To be most effective, the time between treatments should not usually be longer than 4 weeks. Most patients will begin to see results after the third treatment, but this can be longer if they are slow responders to the medications. The number of treatments is based on the response of the patient to the medication and the goals set by the patient.

Needle selection is based on the treatment of fat and cellulite in relation to the depth of fat in the mesoderm layer. Traditionally, a size 0.4 cm needle is used for cellulite and scar reduction, a size 0.6 cm needle for superficial fat loss, and a 13 cm needle for deeper fat deposits. As with the variation of medication, needle sizes can be changed each time the patient has mesotherapy. For lipolysis, a minimum of 0.6 cm needle is used. Mesotherapy needles are also created for multiple sticks, and must be discarded after 50 injections are made.

Techniques of mesotherapy injections include proper spacing with a grid-like pattern between injections 1.5 cm apart. When the face is injected, the spacing falls to 1 cm between injections. A 0.6 cm needle is used to create skin retractions and care must be taken to avoid injecting into the musculature. The area is first cleaned with alcohol, and the area to be treated is marked in a grid-like pattern. With mesotherapy “cocktails”, approximately 0.1 ml is injected into every site, so that the medication can spread evenly in the treated area. This differs significantly from fat lipolysis using only mixtures of phosphatidylcholine/deoxycholate, where up to 0.5 ml are injected into individual areas treated.¹²

Nappage technique can also be used for scarring, especially when it is a result of surgery or liposuction. Usually a 0.4 cm needle is used and the scar is pricked, 0.1 cm apart along the entire length of the scar tissue, to break the fibrous bands both in the dermis and mesoderm layer. Because this can be painful, lidocaine is always added to the formula for pain relief. Also, collagenase and hyluronidase are both essential additives. A very small amount of medication (one drop) is administered with each injection in a linear fashion. Nappage can also be used for very superficial cellulite and divots.

Side Effects and Treatment

Most side effects of mesotherapy occur from the trauma of injection. After treatment, the patient usually develops transient redness at the injection sites. They may complain of site tenderness or pruritus, which usually dissipates within 10 minutes of the treatment. Some patients may develop transient urticaria that also resolves on its own. These issues can also be avoided by placing arnica gel on the skin after treatment.

By far the greatest side effect of mesotherapy is bruising. This occurs because small blood vessels are inadvertently pierced by the needle, causing small subdermal hematomas. Unfortunately, those vessels that are non-visible cannot be avoided; however, although that general area can be treated, the visible blood vessels should not be injected. Patients will complain about the bruising. However, the actual bruises are not tender, as are those created by trauma. The bruising will usually last for several days and resolves on its own. When the bruises are persistent, proper care needs to be given. For larger bruises, ice can be placed on the area for 10 minutes on, 10 minutes off following treatment. After 48 hours, warm compresses may be applied. Compounds such as arnica montana and bromelain can be taken before and after treatments as a preventative treatment. For bruising that persists for more than 2 weeks, a strong hydrocortisone cream like Pandel may be prescribed and used twice daily on the affected area. Hyperpigmentation may be treated with a bleaching cream. Although this complication is rare, it must be addressed or the patient can have long-lasting problems.

After several treatments, there may be clusters of small blood vessels originating from the needle injection site. This neovascular response usually occurs distal to the knee. If this side effect is seen, mesotherapy should be discontinued indefinitely, as this change may not resolve. Using the vascular laser, or IPL, may help eliminate the neovascular response.

Patients may develop an allergic reaction, such as wheal and flare in response to one of the components of the medication. Patch testing should be done 1 week after the reaction has occurred. Usually this will respond to Benadryl and topical cortisone cream; however, if the reaction persists or becomes painful, a Medrol Dosepack should be prescribed.¹³

Other adverse reactions reported are cutaneous granulomas, atypical mycobacterial infections, lichenoid eruptions, ulcerations and exacerbation of psoriasis. To avoid these complications, patients need to choose physicians who have been trained in mesotherapy and perform it under sterile conditions with properly formulated sterile components¹⁴ (Fig. 52.3A–D).

FIG. 52.3 Mesotherapy for liposuction before (A, C) and after (B, D).

(Courtesy Dr. Marion Shapiro.)

Conclusion

Although mesotherapy has attracted wide acceptance in the medical community in Europe and South America, the absence of double-blind studies has caused the United States medical community to be slow in its acceptance of mesotherapy. Nonetheless, those practitioners of it who have been properly trained have consistently observed highly successful results in their patients (Fig. 52.4A–J). As a result, various pharmaceutical companies have recently conducted trials using mesotherapy medications with an expectation that FDA approval will be obtained and the medical community will be more likely to perform research on and practice mesotherapy.

FIG. 52.4 Mesotherapy for liposuction complications before (A, C, E, G, I) and after (B, D, F, H, J).

(Courtesy Dr. Marion Shapiro.)