BASIC AND CLINICAL DERMATOLOGY - PART 9 ppt

the septum. The septa are cut on the backstroke of the needle, while maintaining the blade traction against the septa, thus releasing the tension exerted on the skin. This cutting technique allows a precise cut with a minimum of tissue damage, which ensures better postoperative results. A slight pin ch test on the treated lesion is useful because it reveals any areas that remain retracted by septa (3,5). 5. Compression: Following cutting the septa, vigorous compression is required in the treated area for 5 to 10 minutes, suffici ent time for the process of coagulation to begin, permitting hemostasis and control of the size of the hematomas. The use of sand bags is recommended; they should weigh approximately 5 kg, be made from a washable mate- rial, and be wrapped in sterile fabric (3). Such bags produce a more uniform and efficacious compression than that achieved manually. 6. Dressings: The treated areas are covered with sterile adhesive bandages and given addi- tional compres sion with dressings and compressive clothing (elastic pants or shorts) that should be worn for 30 days. The patient receives the following postoperative instructions: & Use analgesics for the first 48 hours; this period can be extended if pain persists. Acetaminophen at a dose of 750 mg every six hours is recomm ended. & Continue use of the antibiotic until the third day. Figure 6 After antisepsis of the surgical area, local anesthesia is performed in the surgical room. Sterile sheets are used to protect the surgical area. 256 & HEXSEL AND MAZZUCO & Perform physical exercises only after the third week. & Use compressive clothing for 30 days. & THE POSTOPERATIVE PERIOD The first postoperative evaluation should be made after 72 hours, when the dressings are changed and the use of the antibiotic discontinued (3). Hematomas and hemosiderosis are expected in all patients during this period. The hematomas should follow a normal evolu- tion of spontaneous reabsorption over a period varying from 10 to 20 days. Hemosiderosis may persist for several months and is directly proportional to the absorption of iron present in the extravasated red blood cells. Other complications may arise as a result of this procedure and they are listed below. & COMPLICATIONS According to Orentreich and Orentreich (1), the following complications may arise; they are rare and easily dealt with: 1. Hematomas and ecchymosis (Fig. 8) 2. Erythema, edema, and localized sensitivity 3. Infection Figure 7 A gentle pinch test is performed to find residual septa pulling the skin surface. SUBCISION â & 257 4. Alterations to the consistency of the treated area 5. Alterations to the color of the skin in the treated area 6. Suboptimal response 7. Excessive response 8. Keloid scars In fact, complications arising from the use of Subcision 1 (5) for the treatment of cellulite are rare, owing to the safety of the method and the fact that regions of the anat- omy commonly treated are free of vital structures and large blood vessels. Other complications include: 1. Hemosiderosis: This occurs due to the extravasation of the red blood cells and the deposit of hemosiderin, a pigment that contains iron, and the resulting degradation of the hemo- globin, (12) giving the skin a chestnut pigmentation (Fig. 9). It occurs in all treated patients to varying degrees and resolution occurs spontaneously within 2 to 12 months. 2. Organized hematomas: This may occur in some treated areas, but usually clear up spon- taneously in a period from one to three months, although they can be treated with intralesional corticosteroids. They are usually painful and hard to the touch. 3. False ex cess response: This is characterized by a raised area of skin at the treated area, appearing as a herniation of the skin and fat (Fig. 10). This does not respond well to corticoid injections and may be due to bad technique (e.g., Subcision 1 in extensive areas or excessively superficial) or a lack of postoperative care such as not using com- pressive clothing for 30 days following the procedure. Favorable results can be obtained with the use of liposuction in the affected area. Figure 8 Hematomas in the third postoperative day in well-compressed areas. 258 & HEXSEL AND MAZZUCO Figure 9 Hemosiderosis one month after Subcision 1 . Figure 10 False excess response after Subcision 1 . SUBCISION â & 259 & CONCLUSIONS Subcision 1 is a simple, effective (Figs. 11 and 12), low-cost surgical method for the treat- ment of advanced cellulite. Figure 11 Cellulite on the buttocks before treatment. Figure 12 Same patient as in Figure 11, after two Subcision 1 treatments. 260 & HEXSEL AND MAZZUCO It is a precise surgical procedure, in which the septa that retain the skin are cut, and the resulting traction and tension forces are redistributed among the fat lobules in the treated area, giving an immediate improvement to the skin surface. Complications are rare and easily treated. The production of new connective tissue from the hemotomas occurs in two to five weeks and normally persists for a considerable time in the correction of the treated defect. The results are technique dependent and are usually long lasting (3). SUBCISION â & 261 & REFERENCES 1. Orentreich DS, Orentreich N. Subcutaneous incisionless (Subcision) surgery for the correction of depressed scars and wrinkles. Dermatol Surg 1995; 21:543–549. 2. Hexsel DM, Mazzuco R. Subcision: Uma alternativa cirurgica para a lipodistrofia ginoide (‘‘celulite’’) e outras alteracoes do relevo corporal. An Bras Dermatol 1997; 72:27–32. 3. Hexsel DM, Mazzuco R. Subcision: a treatment for cellulite. Int J Dermatol 2000; 39:539–544. 4. Hexsel DM, Mazzuco R, Dal’Forno T, Hexsel CL. Simple technique provides option for treat- ing scars and other skin depressions. J Cosmet Dermatol 2004; 17(1):35–41. 5. Hexsel D, Mazzuco R, Gobbato D, Hexsel CL. Subcision. In: Kede MP, Sabatovitch O. Tratado de Medicina Estetica. 1st ed. Rio de Janeiro: Atheneu, 2003:350–359. 6. Vieira GL, Rocha PRS. Anestesia local. In: Fonseca FP, Rocha PRS, eds. Cirurgia Ambulator- ial. Rio de Janeiro: Guanabara Koogan, 1987:49–71. 7. Namias A, Kaplan B. Tumescent anesthesia for dermatologic surgery. Cosmetic and noncos- metic procedures. Dermatol Surg 1998; 24(7):755–758. 8. Robinson JK. Management of hematomas. In: Robinson JK, Ardnt KA, LeBoit PE, Wintroub BU, eds. Atlas of Cutaneous Surgery. Philadelphia: WB Saunders, 1996:73–77. 9. McCalmont TH,Leshin B.Preoperative evaluation of the cutaneous surgery patient. In: LaskGP, Moy RL, eds. Principles and Techniques of Cutaneous Surgery. New York: McGraw-Hill, 1996: 101–112. 10. Hoffman BB, Lefkowitz RJ. Catecholamines, sympathomimetic drugs and adrenergic receptor antagonists. In: Hardman JG, Limbird LE, Mollinoff PB, et al., eds. Goodman & Gilman’s Pharmacological Basis of Therapeutics. New York: McGraw-Hill, 1996:199–248. 11. Fewkes JL. Antisepsis, anesthesia, hemostasis, and suture placement. In: Ardnt KA, Le Boit PE, Robinson JK, Wintroub BU, eds. Cutaneous Medicine and Surgery. Philadelphia: WB Saunders, 1996:128–138. 12. Villac¸a CM Neto. Anestesia—Parte 1. An Bras Dermatol 1999; 74(3):213–219. 262 & HEXSEL AND MAZZUCO 16 Mesotherapy in the Treatment of Cellulite Gustavo Leibaschoff University of Buenos Aires School of Medicine, and International Union of Lipoplasty, Buenos Aires, Argentina Denise Steiner Mogi das Cruzes University, Mogi das Cruzes, Sao Paulo, Brazil & A BRIEF HISTORY The idea of treating a pathology using the intradermal (ID) or subcutaneous route is not new. This method has also been used with great effect in the treatment of visceral pain, with the injection of an anesthetic with lidocaine and distilled water into painful areas. In dermatology, ID injection has traditionally been used for the treatment of alopecia, keloids, scars, and other conditions for many years. The French physician Pistor brought together these experiments with his own pio- neering work, expanded them, and began to work with this technique on a regular basis with a large number of patients. It all began in his country surgery in the village of Bray-lu (France), where the favorable response of a deaf patient to procaine injection led Dr. Pistor to inquire further into the properties of this drug, when injected intradermically in the vici- nity of the affected auditory organ. He broadened his pathologic investiga tions, moved to Paris, and in 1958, presented the first publication on the subject, wherein he proposed the name ‘‘mesotherapy’’ for this procedure. In 1964, his professor and frien d, the medical sur- geon Lebel, invented the small needle that carries his name and recommended the creation of The French Society of Mesotherapy, which Pistor started that same year (1). & THE CONCEPT Mesotherapy is a simple therapeutic concept in which the principle is to approximate the medicine to the location of the disease using minimal doses applied intradermically into the region. The word mesotherapy derives from the Greek meso (medium or middle) and therapy (treatment). In this case, the word meso refers to the mesoderm, which is the embryonic middle layer located between the ectoderm and endoderm. This middle layer 263 originates all the connective tissue that forms the dermis and it is into this layer that the medicine is injected when mesotherapy is used. According to Dr. Pistor, mesotherapy is an allopathic, light, parenteral, polyvalent, and regionalized medicine. & Allopathic: because the medicines used form part of the official pharmacological range. & Light: because the doses used are always low compared to those habitually used in tra- ditional medicine. & Parenteral: because intradermic or subcutaneous injections are performed with active drugs while using procaine as a vehicle. & Polyvalent: because of its efficacy in multiple diseases involving distinct specialties. & Regionalized: because mesotherapy is performed in the vicinity of the lesion. & ACTION MECHANISM OF MESOTHERAPY PISTORIAN REFLEX THEORY While the action mechanism of this therapeutic technique is not totally explained, there are a number of theories. Dr. Pistor alleges that the direct pharmacological action of the drugs administered locally or regionally is not sufficient to explain the results obtaine d in pathologies in which the ethiopathogenic base is located in deep organs. He advances the possibility that the skin might be a projection of different internal locations of deep organs, over/on which an authentic map or plan can be designed as in acupuncture. His observations suggest the exis- tence of a correlation between a pathology and its cutaneous representation. According to this reflex theory, mesotherapy interrupts the visceral–medullar–cerebral path at the lateral- medullar level (where the vegetative system is connected to the cerebral–spinal system) by means of inhibitory stimuli originating at the dermal level. These dermal inhibitory stimuli are both mechanical (provoked by the needle) and phy siochemical–pharmacological (due to the medicines administered through the needle). Definitively, this represents a localized ‘‘shock’’ that has repercussions on the lateral-medullar sympathetic center. Studies ana- lyzed by Lichwitz in his 1929 thesis showed that depending on the substance injected at the dermal level , vegetative, medullar, and cerebral reactions are produced that may be accompanied by an action at the visceral level. According to this concept, mesotherapy, with few chemical products and small doses, is capable of producing significant results (2). BICHERON’S MICROCIRCULATORY THEORY The drugs administered locally or regionally produce a stimulating effect on the local microcirculation that is altered by the lesion. A diseased organ, tendon, or articulation leads to microcirculatory vascular damage that further worsens the problem in question. This theory on the role of microcirculation has been confirmed by thermographic studies that reveal alterations before and after the treatment. This explains how mesotherapy acts in such diverse pathologies as cephalgias, rachialgia, degenerative osteoarticular disease, vascular acrosyndromes, or cellulite. However, the ID use of vasodilators represents a risk factor for cutaneous, iatrogenic harm related to the appearance of hematomas and lesions caused by microbacteria. 264 & LEIBASCHOFF AND STEINER MESODERMIC THEORY According to its creator, mesotherapy is the treatment of the connective tissue that has its origin in the mesoderm. The mesoderm gives origin to various tissues: skin, bone, and car- tilage among others. The mesodermic theory can be explained by the actions of three units: 1. The microcirculatory unit: It consists of small capillary and venous spaces that ensure blood interchange as well as the transport of the secretions from the connective tissue cells and the medications introduced via the mesoderm. 2. The neural-vegetative unit: Owing to the elements of the sympathetic system that exist in the dermis, it is possible to achieve the regulation of the nervous system. 3. The immunological aspect unit: The connective tissue generates defined defense zones with specialized cells (plasmocytes and mastocytes) to react to the penetra tion of a product through the skin. This explains the influence of mesotherapy on the immuno- logical system. THIRD CIRCULATION THEORY The interstitial compartment is known as the third circulation, the first being the blood circulation and the second, the lymphatic system. The interstitial compartment or third cir- culation is the chosen area for mesotherapy. There may be a process, perhaps mediated by procaine with its membrane-stabilizing action, which in some way retards the passage of medicines to the lymphatic and venous capillaries. These would dissolve through the inter- stitial space to the deepest tissues, reaching the target site in high concentrations, without loss due to absorption by vessels. In this way, mesotherapeutic infiltration would have a therapeutic effect even with minimal medicinal doses. It can be seen how, with distinct perspectives, the authorities on mesotherapy have tried to explain this phenomenon. & BENEFITS AND ADVANTAGES OF THE METHOD 1. Elevation of the therapeutic rate: However great the impact and therapeutic efficiency may be on the local or regional (in situ) affections, this therapeutic method treats the disease locally. 2. Reduction of the required doses: Owing to the pharmacokineti c film that permits the potentization of the active agents, it is possible to administer efficient allopathic micro- doses. The quantity of medicine administered is greatly inferior to that habitually used in conventional medicine. 3. Reduction of iatrogenic and side effects: This is achieved as a result of the global reduc- tion in the doses of drugs and also by the suppression of the unwanted plasma peaks that occur with other methods or routes. 4. Fewer therapeutic sessions: Because of the basic principles of this method, the difference in the number of therapeutic interventions and, consequently, the shortening of the treatment period is very accentuated (3). MESOTHERAPY FOR CELLULITE & 265 [...]... Diagnostico Clınico e Instrumental Maio, 199 1 ´ 2 Pinto R, Saenger Ruiz F, Govantes Lopez P Celulitis Paniculopatia Edemato Fibro-Esclerotica Marco, 199 5 ¸ 3 Corbel D Mesoterapia (ID Terapia) y Celulitis In: Masson ed Novembro, 199 2 4 Garcia O Tratado de mesoterapia Outubro, 199 3 5 Sanchez C, Altmann-Canesti E Ques es la mesoterapia? Buenos Aires: Celsius, 198 9 ´ 6 Steiner D Beleza levada a serio Celebris... studies on the lipolytic response of human subcutaneous and omental adipose tissue to noradrenaline and theophylline Acta Med Scand 196 9; 185:465–4 69 39 Berlan M, et Lafontan M Cathecolamines et tissue adipeux blanc MDN Le quotidian du Medecin Num 19 13, janvier, 198 3 40 Legrand JJ Traitement local du tissu adipeux par mesoterapie Gaz Med France 197 4; 81 (9) :1115 41 Ravilly G, Thierree RA, Sauval P Interet... Medi 6 Ed., 195 8 47 Pistor M Un defi therapeutique 3rd ed Maloine, 197 9 48 Pistor M Les micro-injections de la mesotherapie Paris: Maloine, 197 0:254 49 Bicheron M La Microcirculation Tempo medical, mars 198 1, Num 76 et Num 77 50 Dalloz-Bourguignon A Theorie du mesoderme, La mesotherapie Maloine, 198 3 51 Pistor M La mesotherapie Une conception nouvelle de la therapeutique Paris: Maloine, 196 7 :96 pp 52 Ravilly... edematofibrosclerosis and localised adiposity Folder of the Italian Society of Mesotherapy 199 6 34 Ravily G Mesotherapy L’essentiel France: Modiasoft, 199 1 35 Multedo JP, et al Mesoterapia farmacologica Solal Francia, 198 8 36 Bartoletti CA La mesoterapia nei il trattamento de la cellulite e delle adiposita localizzate, La Medicicina Estetica, 1, 1, 22, 197 7 37 Ordiz Garcia I Tratado de Mesoterapia Asturias, Spain, 199 3... Mech Ageing Dev 198 4; 26:277–282 30 Baker R, Powards D, Haywood LJ Restoration of the deformability of irreversibly stickled cells by procaine hydrochloride Biochem Res Commun 197 4; 59: 548–556 31 Berger A Action de la procaine sur la deformabilite erythrocytaire These Doct Pharm, Tours 198 6, num 91 , 97 pp 32 Lopez Barri A Mesoterapia en dermatologia y estetica Spain, France: Masson, 199 4 33 Maggiori... subcutaneous tissue and dermis and eventually changes fat cell metabolism Mesotherapy treatment is targeted to improve microcirculation, strengthen connective tissues, and dissolve excess fat (41–43) FACE AND NECK REJUVENATION WITH MESOLIFT Aging, sagging, and wrinkling of the skin occur from accumulation of fat, loss of skin elasticity, and excessive free-radical damage Using antioxidants and amino acids,... CA, Maggioris S, Tomaselli F Mesoterapia 198 2, Salus Ed 14 Dalloz-Bourguignon A Vademecum de mesotherapie, Maloine, 198 7 15 Pistor M Expose sommaire des proprietes nouvelles de la procaine locale en pathologie humaine Presse Med 195 8; 66(44) :99 9–1000 16 Binaglia, Marconi, Pitzurra The diffusion of intradermally administered procaine Giornale di Mesoterapia, 198 1, I Salus Ed 17 Parienti IJ, Serres P... treated with mesotherapy Giornale di Mesoterapia, 198 2, II, 2, Salus Ed MESOTHERAPY FOR CELLULITE & 285 28 Boulanger Y, Schreier S, Leitch LC, Smith ICP Multiple binding sites for local anesthetics in membranes: characterization of the sites and their equilibria by deuterium NMR of specifically deuterated procaine and tetracaine Can J Biochem 198 0; 58 :98 6 99 5 29 Bai F, Michel R, Rossignol P Effects of procaine... (linear multi-injector), or from 7 to 18 needles (small or large circular multi-injectors) The necessity to change all the needles once they have been used, together with the difficulty in cleaning the multi-injector and the problem caused by the formation of oxide particles on the body of the device following sterilization, led to the abandonment of the use of such devices (4) Equipment Needles and syringes... fat is translated exteriorly as orange skin presentation and cellulite The more L-carnitine individuals have, the more their fat cells burn and, consequently, this makes the individuals thin and creates more energy along with an improved resistance to cold and exhaustion PHENTOLAMINE It blocks alpha-2 adrenergic receptors It is used for lipolysis and vasodilatation (34) GINKGO BILOBA It is used in mesotherapy . and Surgery. Philadelphia: WB Saunders, 199 6:128–138. 12. Villac¸a CM Neto. Anestesia—Parte 1. An Bras Dermatol 199 9; 74(3):213–2 19. 262 & HEXSEL AND MAZZUCO 16 Mesotherapy in the Treatment. York: McGraw-Hill, 199 6: 199 –248. 11. Fewkes JL. Antisepsis, anesthesia, hemostasis, and suture placement. In: Ardnt KA, Le Boit PE, Robinson JK, Wintroub BU, eds. Cutaneous Medicine and Surgery MESOLIFT Aging, sagging, and wrinkling of the skin occur from accumulation of fat, loss of skin elas- ticity, and excessive free-radical damage. Using antioxidants and amino acids, mesother- apy can reduce