Mesotherapy in Practice:

Article published in leading aesthetic journals.

Dr Sotirios Foutsizoglou

Lead trainer for the mesotherapy training courses

Mesotherapy, from the Greek word mesos, meaning “middle” and therapy from Greek word therapeia, meaning “to treat medically” is the practice of using a combination of micro-injections into the mesoderm to deliver healing or corrective treatment to conditions ranging from arthritis and sports injuries to improvement of blood circulation and lymphatic drainage. The mesoderm is the middle layer of the three primary germ cell layers in the very early embryo—the other two are the ectoderm and endoderm. It differentiates to give rise to a number of tissues and structures including bone, muscle, connective tissue, and the middle layer of the skin.

Mesotherapy was founded by Dr Michel Pistor in the early 1950s. Since then, an increasing number of physicians have been performing treatments based on the mesotherapy principles and techniques.

The lack of gold standard clinical trials demonstrating the efficacy of mesotherapy has led to criticism by the medical community. Yet, allopathic and homeopathic remedies—mainly as intradermal infusions—have gained popularity throughout Europe and South America. The French Academy of Medicine recognised mesotherapy as a “specialty of medicine” in 1987. In the UK and US, mesotherapy has been used widely—mainly for aesthetic purposes as an alternative to traditional non-surgical cosmetic procedures.

For the record, fat reduction by injection lipolysis—that is, phosphatidylcholine ± deoxycholate—is not mesotherapy. Mesotherapy is distinct from treating adipose tissue with subcutaneous injections, which usually require a depth of 6–12mm into the subcutaneous fatty tissue as opposed to intracutaneously administered injections at a depth of 1–4mm for mesotherapy.

One of the fundamental principles of mesotherapy:

Always inject superficially, that is, preferably at the level of dermal-epidermal junction. There are hundreds of substances that form the mesotherapy armamentarium and their use is dependent on practitioners’ preferences and experience and the area of the body being treated. My main focus is to suggest some protocols for face and neck treatments based on my experience and provide the scientific background and evidence for the most commonly used products in mesotherapy that every practitioner aesthetic medicine should be familiar with.

Injection techniques:

There are three main injection techniques used in mesotherapy: papule, nappage and point by point—usually deeper injections used in rheumatology or sports-related pathology.

Nowadays, assisted injection systems—namely mesotherapy guns—have been used increasingly as they provide a standardised injection depth, reduce treatment time, are easy to work with and most importantly make the whole procedure better tolerated by the patient.

Cutaneous ageing is due to a cumulative effect of intrinsic and extrinsic ageing factors leading to skin atrophy and cell apoptosis. Intrinsic and extrinsic ageing are two processes but seem to share common biochemical and molecular mechanisms. With increasing age, a progressive deterioration of the response of the keratinocytes and fibroblasts to growth factors is detected along with a decline of their proliferative capacity. Photo ageing, the main extrinsic ageing factor, induces cellular changes and alterations of the protein matrix in the papillary dermis, probably through repeated exposure to proteolytic enzymes released by inflammatory cells, causing fragility, loss of elasticity and poor healing. The interaction of UV with the skin causes, among other reactions, the formation of free radicals of the reactive oxygen species type responsible for oxidative stress leading to a large decrease in the reducing capacity of the cellular redox couples, such as glutathione.

UV radiation gives rise to melanin pigment alterations, and exposure to UVA induces the activation of metaloproteases, which subsequently break down collagen and inhibit procollagen biosynthesis. In the ageing skin, reactive carbonyl species are responsible for the cross-linking of collagen fibres that, coupled with an increase in production of advanced glycosylation end products, leads to formation of wrinkles, prominent in ageing. There has not been any drug, substance or treatment that can reverse or stop intrinsic ageing. Cosmetic treatments have been successful in correcting or reducing symptomatic cutaneous ageing of either extrinsic or intrinsic causes.

The aim of cosmetic mesotherapy is to break the chain of events leading to the manifestations of ageing either by cellular replenishment of the skin (through stimulation of synthesis of collagen and proteoglycans increasing the thickness of the epidermis and dermis) or by rendering skin capable of fighting off damaging exogenous and endogenous mechanisms such as free radical action and increasing the speed of cutaneous regeneration. Mesotherapy is an excellent way of providing:

• Photo protection by inhibiting immunosuppression and ROS production along with protection of cellular DNA and mitochondria

• Anti-free radical action such as anti-oxidant vitamins C and E; co-enzymes such as Q-10; trace elements such as copper, zinc, magnesium and selenium

• Increase in the production of skin matrix proteins. For example, by administering amino acids or certain synthetic peptides there is stimulation of dermal proteins such as collagen, elastin and glycoproteins which, to a great extent, are responsible for the biomechanical properties of the skin

• Whitening action; for example, glycolic acid, glutathione

• increase of firmness and cutaneous elasticity—for example, organic silica, centella asiatica

• Cellular proliferation, differentiation and keratinisation along with regulation of fat production (retinoids)

• Anti-inflammatory and immunomodulatory properties (vitamin A)

• Inhibition of metaloproteases (time.1, Timp2, Timp3 and TIMP4)

• Hydration (hyaluronic acid)

• Cytokines (synthetic oligopeptides)

Dimethylaminoethanol, also known as DMAE, is related to choline and is a biochemical precursor to the neurotransmitter acetylcholine which is involved in muscle tone counteracting flaccidity. DMAE produces a cholinergic stimulation of fibroblasts, by acting on their membrane receptors, which coupled by its anti-radical and anti-lipofuscine properties along with its repairing ability on the proteinic cross linking—that is, collagen and elastin— results in a firming and lifting effect of the skin. The indications are lifting, flaccidity and sagging skin. Hyaluronic acid (HA) is an anionic, non-sulfated glycosaminoglycan distributed widely throughout connective, epithelial, and neural tissues. HA fills in the space between collagen and elastin fibres taking part in cutaneous mechanical support.

Hyaluronic acid’s interaction with CD44 drives collagen synthesis and normal skin function. Present in the extracellular matrix of basal keratinocytes, hyaluronic acid is critical to the structural integrity of the dermal collagen matrix.

Barrier:

Skin provides a barrier to the external environment and acts to prevent the ingress of infectious agents. Once injured, the tissues beneath are exposed to infection; therefore, rapid and effective healing is of crucial significance to reconstruct a barrier function. Skin wound-healing is complex and includes many interacting processes initiated by haemostasis and the release of platelet-derived factors. The following stages are inflammation, granulation tissue formation, re-epithelisation and remodelling. HA is likely to play a multifaceted role in mediation of these cellular and matrix events.

HA provides a mechanism of transport of essential nutrients from the bloodstream to skin cells and is a powerful hydrating endogenous agent for the skin. The presence of HA in epithelial tissue has been shown to promote keratinocyte proliferation and increase the presence of retinoic acid, effecting skin hydration.

Owing to its free-radical scavenging function, HA protects the skin against UV irradiation.

It plays a role in angiogenesis by supporting the proliferation of endothelial cells and thus allowing better cutaneous vascularisation. The indications are skin hydration, correction of superficial wrinkles, skin tone and radiance, and anti-ageing.

Organic silica is a water soluble and biologically active metalloid that is present in macromolecules such as elastin, collagen, proteoglycans and structural glycoproteins. It is used widely in mesotherapy because of its diverse properties.

Organic silica acts as an anti-oxidant to prevent premature ageing; it binds moisture in the epidermis, thus firming and strengthening the skin’ it increases the concentration of cyclic adenosine monophosphate within adipose tissue, making possible the lipolysis and hydrolysis of the triglycerides without disturbing the cellular metabolism; it stimulates fibroblast mitosis, therefore increasing the biosynthesis of elastic and collagenous fibres; and it enhances venous capillary and lymphatic permeability to improve microcirculation. The indications are skin rejuvenation, cellulite, lipolysis, hair loss, stretch marks and wound healing.

Vitamin C (or L-ascorbic acid or L-ascorbate) forms part of the group of anti-oxidant vitamins along with vitamins A and E. It is the main non-enzymatic water soluble antioxidant of the skin being capable of rapidly scavenging reactive oxygen species. L-ascorbate is a weak sugar acid structurally related to glucose that naturally occurs attached either to a hydrogen ion, forming ascorbic acid, or to a metal ion, forming a mineral ascorbate. Ascorbic acid performs numerous physiological functions in the human body. These functions include the synthesis of collagen (vitamin C is the co-factor in the hydroxylation process of procollagen), carnitine and neurotransmitters, the synthesis and catabolism of tyrosine and the metabolism of microsome. Treatments include photo ageing, skin rejuvenation, melasma, wound healing, and hair loss.

Centella asiatica has been documented to stimulate type I collagen production. The triterpenes (Asiatic acid, madecassic acid and asiaticoside) of Asian centella stimulate collagen and elastin biosynthesis by enhancing dermal fibroblast activity and help to improve wound repair with a better re-epithelialisation and normalisation of perivascular connective tissue, allowing an improvement of the venous wall tone and elasticity. Centella has the potential to enhance connective tissue integrity, elevate anti-oxidant levels in wound healing, and improve capillary permeability. Treatments include anti-ageing, cellulite, scars, wound healing, venous disorders, dermatitis, skin ulcers and hair loss Sodium pyruvate is a stable salt of the pyruvic acid. Pyruvate increases energy through the production of glycerol from adipocytes resulting thus in enhanced lipolytic action. It has been demonstrated that pyruvate stimulated the synthesis of collagen in the skin. It is considered an excellentenergy substrate with applications in cutaneous ageing, striae, and alopecia.

Sodium pyruvate can be used for anti-ageing, lipolysis, alopecia (in combination with centella asiatica, and organic silica).

If you would like to learn mesotherapy visit the KT Training for more information.

Dr Sotirios Foutsizoglou is medical director SF Medica and lead trainer for KT Training (master classes and mesotherapy)