Mesotherapy For Cellulite Treatment

Cellulite is a common topographical alteration popularly described as an “orange peel” or “cottage cheese” appearance of the thighs, breasts, and buttocks, which affects millions of aesthetic patients worldwide. The condition mainly affects women and rarely occurs in men. It has been reported that approximately 85% of post-adolescent women have some degree of cellulite. The debate surrounding the etiology of the disease and the efficacy of available treatments remains unsolved, confined by the limited data in the literature devoted to addressing the topic. Current proposed treatments for cellulite include topical agents, light-emitting diodes (LED), electrotherapy, injection lipolysis, lymphatic drainage, and liposuction. This article will focus on mesotherapy injection, exploring its mechanism of action, as well as its efficacy in managing cellulite.

Patient Analysis

Patients between the ages of 18 and 75 years are generally the best candidates for mesotherapy, provided they are in good physical and medical health and with realistic expectations. A detailed medical history and physical examination are crucial in mesotherapy administration. Laboratory tests may not be necessary unless the patient has a comorbid medical condition during the initial consultation. The treatment is not recommended for patients who are pregnant, breastfeeding, or those of childbearing potential who are not using any forms of contraception. Ideally, patients should have a normal blood count, lipid levels, and renal and liver function. Patients with darkly pigmented skin (Fitzpatrick IV-VI) may be at risk for post-inflammatory hyperpigmentation.

The patient must be counselled that swelling, tenderness, and nodule formation may occur. Additionally, they should be informed that the results are slow but long lasting. Repeat treatments are normally required to achieve favorable outcome. Pre-treatment and post-treatment photographs are helpful to assess results, though photographs alone may not reflect subtle changes, such as firmer or tighter sensation, which most patients experience after treatment.

Definition and Physiopathology

From a histomorphological point of view, cellulite is defined as panniculopatia edemato-fibro-sclerotica (PEFS), which corresponds to the stages of advancement of cellulite. Therefore, cellulite may be considered, not as one disease entity, but a series of events characterized by interstitial edema, connective tissue fibrosis, and concomitant sclerotic evolution. Hence, the three indications that potential treatments should target are the presence of excess adipose, water retention, and fibrosis, as proposed by Dr. Philippe Blanchemaison in 2000. Cellulite is caused by many complex events that involve the epidermis, dermis, and subcutaneous tissue. While it’s not specific to overweight women, increased adipose formation will exacerbate the condition. There are three forms of edema that can be associated with cellulite disorder:

1. Venous edema – associated with inflammation of the tissues and deposition of hemosiderin
2. Lipedema – characterized by fat and water deposits in the subcutaneous tissue
3. Lymphedema – related to accumulation of lymph with high protein content due to stasis in the interstitial space and characterized by tumescent state of soft tissues

The occurrence of cellulite seems to be attributable to morphologic, inflammatory, and biochemical alterations in the subcutaneous tissue, with localized adipose deposits and edema being the main precipitating factors. If there is an increase in excess fat stored as triglycerides, the swelling of adipocytes will be greater, as adipocytes can expand up to 50 times their original volume.

History and Classification

Goldman described cellulite as a “normal physiological state in women, which maximizes adipose tissue retention to ensure adequate caloric availability for pregnancy and lactation.” In 1922, French doctors Alquier and Pavot described cellulite as characterized by interstitial fluid retention and dystrophy of the mesenchymal tissues, without inflammatory elements. Pierard-Franchimont was the first to recognize the “mattress” phenomenon in cellulite upon pinching of the skin. He also observed that women who are not overweight or obese rarely develop full-blown cellulite.

Nurnberger and Muller (1978) and Rosenbaum et al. (1998) stated that there is a gender-based difference between the layer of connective tissue immediately below the dermis. In women, subcutaneous tissue in cellulite-prone areas are separated by voluminous lobules that favor the expansion of adipose tissue into the dermis. Men, on the other hand, have crisscrossing bands in the connective tissues that form smaller polygonal lobules, which do not tend to protrude into the dermis despite hyper-accumulation of lipids. Nurnberger and Muller classified cellulite in four stages based on the appearance of the skin.

1. Stage 0 – no alterations to the skin surface
2. Stage I – skin is smooth while the patient is standing or lying down but pinching the skin shows folds and furrows
3. Stage II – skin surface is smooth while lying down but mattress phenomenon is seen when standing
4. Stage III– mattress phenomenon is observed in both standing and lying positions

Cellulite Treatment

Weight loss has been the most frequently suggested treatment for cellulite since decreasing the subcutaneous fat may reduce the puckered or dimpled appearance of the skin. Weight reduction, physical activity, massage, and liposuction have shown favorable results in clinical practice. Other cosmetic, pharmacological, herbaceutical, and homeopathic remedies, despite fleeting commercial success, fail to ameliorate the condition completely. Topical treatments are often employed for mild to moderate cellulite. The active substances in these topical creams, gels, and lotions act by increasing microcirculation, promoting lipolysis, and scavenging and preventing free radical formation, as well as restoring the normal structure of the dermis and subcutaneous tissue.

Mesotherapy

The French physician, Michel Pistor, was the first to conceptualize the practice in the 1950s, particularly for the management of pain and vascular disorders. He described it as an “allopathic, mild, polyvalent, and regional therapeutic procedure.” While the impact of mesotherapy is primarily anecdotal, it is starting to gain popularity in different countries worldwide, including Brazil, Singapore, South Korea, Canada, Belgium, and Germany to name a few. Experts in the field regard mesotherapy, also known as intradermal therapy, as a “philosophy” and not just a simple technique. Some authors describe the procedure as something in between acupuncture and reflexogenic techniques.

Common Applications

Mesotherapy involves a diverse array of intradermal or subcutaneous injection techniques that conveys micro doses of medications and other compounds known to have a therapeutic effect on medical and cosmetic conditions. Mesotherapy is a popular treatment for cellulite. Other common applications of mesotherapy include body sculpting, lipoma, alopecia, facial rejuvenation, hyperpigmentation, and a variety of dermatologic conditions such as acne, melasma, eczema, psoriasis, telangiectasia, and vitiligo.

Products

here is no standardized formulation for mesotherapy injection. The products selected for treatment depends on the condition being treated. In some cases, a combination of different agents called “cocktails” is utilized to achieve desired results. A cocktail mixture must contain at least two to three active agents for it to be effective. In treating cellulite with mesotherapy, the injector will have to go back to the physiopathology of the condition and examine the properties of each compound. The ideal product must be isotonic, hydrosoluble, biocompatible, physically and chemically stable, have an adequate pH, and well tolerated after dermal administration; more importantly, have low allergenic potential. One should keep in mind the four stages in treating cellulite with mesotherapy (1) Reducing lipedema, (2) restoring efficient microcirculation, (3) lipolysis, and (4) restructuring the connective tissue.

Circulatory enhancers

1. Pentoxifylline – improves microcirculatory perfusion because of its effect on erythrocyte shape, platelet aggregation, and plasma fibrinogen concentration
2. Papaverine – a vasodilator that promotes microcirculation
3. Etamsylate (Dicynone) – promotes drainage of connective tissues and improves the integrity of capillaries

Connective tissue breakdown

1. Hyaluronidase – may break down hyaluronic acid, and eventually, the connective tissue bands that produces the orange peel appearance of cellulite
2. Organic silica (Conjonctyl) – reorganizes the architecture of the dermis and improves blood circulation by rebuilding the inner lining of blood vessels.
3. Synthetic salmon calcitonin (Miacalcin) – stimulates microcirculation within the cellulite
4. Nutritional cocktail (NCTF 135) – contains hyaluronic acid, vitamins, minerals, amino acids, nucleotides, coenzymes, and antioxidants to resist the effects of oxidative stress and help in fibroblast functioning
5. Magnesium – essential in maintaining large numbers of normal enzymatic reactions and needed for its antioxidant properties

Lipolytic

1. L-carnitine – helps deliver fatty acids into cells, which can be burned as a source of fuel
2. Caffeine – stimulates the release of fat to the blood stream, which can be metabolized
3. Aminophylline – has a localized lipolytic effect
4. Isoproterenol – a b-receptor stimulator, which increases rate of lipolysis
5. Yohimbine – an alkaloid extracted from the inner bark of the tree Corymanthe yohimbe, which is excellent for targeting localized fat.

Techniques

Superficial intradermic or multi-pricking method is commonly used for treating cellulite. Meso-therapeutic agents are introduced into the dermis thorough multiple rapid injections using a 4mm to 6mm needle. It is also called “nappage bouncing,” described by Dr Pistor as a slight bouncing action of the wrist. It is performed by making quick needle pricks on the skin at a rate of 10 punctures/second without dragging the needle on the skin. Many practitioners choose to use mesotherapy gun (mesogun) for injections. The benefits of using a mechanical delivery gun are as follows:

1. More comfortable for injectors and patients
2. Faster than manual injection
3. Delivers precise doses of medication
4. Achieves consistent depth of penetration on each injection

Treatment course

Mesotherapy is suggested to have little effect on obese patients without proper diet and exercise. Combining different active ingredients yields better results. Treatment can be administered weekly for 10-12 weeks. The results differ from patient to patient, but usually are seen at the fifth week, with optimum results observed at the tenth or twelfth session.

Various treatment cocktails

Below are suggested medication mixtures for treating adipose, water retention, and fibrosis in cellulite. Designing the best treatment plan depends on the practitioner’s careful evaluation of each patient’s condition. This is by no means a comprehensive list and should only serve as a guide when considering mesotherapy for patients with cellulite.

For adipose

Active ingredients: Base xanthan, theophylline aminophylline, and Euphylline

Secondary ingredients: Vasodilator, Papaverine

Silica: Conjonctyl, magnesium

Mixture:

1. Lidocaine 2ml
2. Euphylline 2ml
3. Papaverine 2ml
4. Conjonctyl 2ml

For water retention

Active ingredients: Ethamsylate (Dicynone)

Secondary ingredients: Papaverine

Vitamin C, Conjonctyl, magnesium

Mixture:

1. Lidocaine 2ml
2. Dicynone 2ml
3. Papaverine 2ml
4. Conjonctyl 1ml
5. NCTF 135 1ml

For fibrosis

Active ingredients: Calcitonin

Secondary ingredients: Vasodilator, Papaverine

Silica, Vitamin C

Mixture:

1. Lidocaine 2ml
2. Calcitonin 50 U.I.
3. Papaverine 2ml
4. Conjonctyl 1ml
5. NCTF 135 1ml

Conclusion

The pathophysiology of cellulite remains enigmatic for clinicians. Perhaps if the exact origin of the condition is revealed, better treatment options could be developed. While mesotherapy sounds like a novel technique, physicians have been using it for decades to treat medical and aesthetic indications. Clinicians practicing mesotherapy should possess a good knowledge of medications and compounds used to ensure patient’s safety. It is recommended to choose products whose mechanism of action is well understood and whose adverse effects are well studied. It is quite possible; however, that a combination of several treatment modalities may be the best intervention to ameliorate the signs and symptoms of cellulite.