BackgroundCarbon dioxide therapy, better known as carboxytherapy, relates to percutaneous infusion of medical carbon dioxide with therapeutic approaches, and its use in the treatment of localized fat has demonstrated good results. Gynoid lipodystrophy, also known as cellulite, affects 80%–90% of women after puberty, especially in the buttocks and thighs. Its etiology is complex and involves multifactorial aspects. Its treatment and evaluation require the use of new technologies (more effective and low-cost approaches). The objective was to investigate the effectiveness of carboxytherapy in the treatment of cellulite in the areas of buttocks and posterior thigh. IntroductionCellulite refers to a change that gives the skin a wavy and irregular appearance, and it affects 80%–90% of women after puberty.

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Numerous treatments have been proposed such as balanced diet, physical activity, massage, topical products, radiofrequency, therapeutic ultrasound, and light emitting diode therapy, among others. Carbon dioxide (CO 2) therapy, commonly known as carboxytherapy, refers to the administration of CO 2 with therapeutic proposals. The technique originated in France in 1932, and originally the treatment was carried out percutaneously (through the skin) by the so-called heated carbonated water baths or the application of water-saturated CO 2 directly to the skin of patients. The technique was used for arteriopathy and ulcer treatments., The results encouraged further studies, leading to the expansion of indications of new treatments. After the development of new technologies, the application was no longer topical and involved passing the CO 2 to be infused directly into the subcutaneous tissue, ensuring faster and better results. Sequential studies described the effectiveness of the carboxytherapy treatment of localized adiposities; demonstrated measurable reductions in circumference regions of the abdomen, thigh, and/or knee; and showed histological evidence of the effect of gas leakage, showing its possible lipolytic effects., Ferreira et al described the increase in collagen remodeling induced by intradermal injections of CO 2.

In another study, Abramo et al showed that after the controlled infusion of CO 2, vasodilation of the microcirculation skin was observed, accompanied by an increase of peripheral blood flow and an increase in skin temperature at the injection site (on average 3.48°C). Materials and methodsThis study began with a sample of 12 candidates and finished with ten of them with an average age of 29±6.1 years and body mass index (BMI) of 25.5±3.3 kg/m 2. Inclusion criteria were healthy women, aged 20–35 years, BMI. Volunteer N=10Weight (kg)BMI (kg/m 2)Body fat (%)Age (years)BaselineAfter treatmentBaselineAfter treatmentBaselineAfter treatment13274.876.727.127.813.525.423163.564.023.823.913.720.232973.574.027.727.927.127.643685.587.529.630.330.823.552360.063.020.321.318.018.362164.563.023.122.621.918.772765.567.026.627.224.721.583362.565.525.026.215.417.493864.565.728.127.728.7.053.821.220.517.116.0Mean ± SD29±5.967.0±8.168.0±9.325.3±2.925.5±3.321.1±0921.7±4.3P0.05P=0.10P=0.20P=0.73. Comparative photographic register of the aspect of cellulite. Notes: ( A, C) Rear view of gluteus and posterior right thigh at baseline; ( B, D) rear view of right gluteus 7 days after the last carboxytherapy session; ( E, G) right side view at baseline; and ( F, H) rear view of the right gluteus after the last session of carboxytherapy.In the panoramic image analysis performed by the ultrasound diagnosis, reduction of adipose tissue lodged between the skin and the muscles of the treated regions was verified, as seen in.

Qualitative analysis describes morphological improvement with respect to the subcutaneous tissue, fibrotic septa, and aspects of the dermis-related cellulite. The morphological improvement with respect to the subcutaneous tissue, fibrotic septa, and associated dermis aspect of the cellulite can also be seen.

DiscussionCellulite is a multifactorial disorder and has a high prevalence in young adult women and despite no morbidity causes great dissatisfaction and negative influence on quality of life. The pathophysiology of cellulite was described as an aesthetically unpleasant disorder for most women after adolescence. It is a complex problem that includes changes involving the microcirculation, lymphatic system, extracellular matrix, and adipocytes. It affects certain body areas with more emphasis, such as thighs and buttocks. Studies also describe the pathophysiology involving a hyperactivity of fibroblasts stimulated by estrogen, which increases the synthesis of glycosaminoglycans and collagen that increase interstitial osmotic pressure and water retention. A decrease in the capillary osmotic pressure in relation to the interstitial osmotic pressure generates edema and reduction in drainage with subsequent hyperpolymerization and formation of micronodules and fibrosclerotic collagen.

Symptoms include edematous adiposity, incipient cellulite, or changes in the skin relief measured by the clinical severity., Adipose tissue can be divided anatomically into two layers by a layer of fibrous tissue called Camper’s fascia. The areolar layer has fibrous septa arranged in a peculiar vertical architecture that connect the dermis filled by large globular adipocytes; below, the lamellar layer septa has more horizontal axis and the fat lobes are flattened. Adipocytes are specialized cells in the storage of fats.–,– In 2004, it was demonstrated for the first time that the hypodermic infiltration of CO 2 as an alternative measure to be associated with liposuction procedures was effective in treating localized adiposity or skin irregularities, resulting from the surgical procedure.

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Since then, the method has been used with increasing frequency in the treatment of different forms of lipodystrophies, as well as in aesthetic medicine. In this area, its main indications are in fighting cellulite in localized fat and sagging. Other studies show that controlled administration of medical CO 2 into the subcutaneous tissue induces hypercapnia and decreases local pH, which elicits a strong vasodilator response through the relaxation of the pre-arteriolar smooth muscle on the site., Histological features in the repair process showed the proliferation of newly formed small blood vessels and fibroblasts. The tissue stretching during infusion induces a subclinical inflammation, which triggers the repair and tissue regeneration processes that induce the activation of macrophages, fibroblasts, and endothelial cells that stimulate neovascularization and remodeling of the extracellular matrix. Among the diseases that may need carboxytherapy are peripheral artery disease and microangiopathy, psoriasis, varicose, and diabetic ulcers. This technique has also been frequently used for the treatment of cosmetic changes such as localized fat, cellulite, facial skin rejuvenation, alopecia, dark circles, and striae.,– In a study by Abramo et al, after the infusion of CO 2, there was an average temperature increase of 3.48°C in the skin of the treated site.

In addition, skin biopsies before and after treatment were evaluated by histology, and the authors observed that the diameter of the vessels increased by 3.24 times after treatment. Brandi et al described the effectiveness of carboxytherapy in the treatment of localized fat through measurable reductions in the circumference regions of the abdomen, thigh, and/or knee and showed histological findings of the effects of CO 2 gas infiltration on the subcutaneous adipose tissue and their possible lipolytic effects. Corroborating these findings, a standardized study involved 15 volunteers subjected to car-boxytherapy sessions on the anterior wall of the abdomen for 3 consecutive weeks.

Two sessions per week at intervals of 2–3 days between each session were made, with infused fixed volume of 250 mL of CO 2 per 100 cm 2 of treated surface. Tissue biopsies were collected before and after treatment and analyzed by flow cytometry, which showed a significant reduction in the number and change in the morphology of the adipocytes in the treated area.The objective of the study was to verify the effectiveness of carboxytherapy in the treatment of cellulite.

During the treatment period, there were no significant changes in the body weight or BMI, as shown in Table 2. Photographic images captured in a standardized manner were analyzed by three independent evaluators and were partially blind. The visual inspection of photographic records of the areas treated with carboxytherapy showed statistically significant ( P=0.0025) changes regarding the aspect of improvement of the degree of severity, as shown in. All volunteers showed improvement of skin appearance after carboxytherapy sessions, suggesting decreased tensile forces on the skin and possible redistribution of vertical forces (vector forces) in the septum.

With regard to the safety of the carboxytherapy treatment, important studies report that the use of CO 2 for contrast angiography attests to the safety of this gas and have shown that it is not likely to promote clots. CO 2 can be used with intravascular bolus injections of up to 100 mL and continuous flows between 20 and 30 mL/s without adverse reactions. In this study, 80 sessions with carboxytherapy were performed and no volunteer had any sort of significant adverse effects, but reported only mild transient discomfort, tolerable during treatment. One volunteer had two small bruises that resolved spontaneously, which suggests that carboxytherapy can be a safe technique. The treatment was tolerable for all the patients.Noninvasive assessment techniques have been used to evaluate the cellulite and its posttreatment results, among which stand out the magnetic resonance imaging (MRI) and diagnostic ultrasound. Researchers, using microimages of the MRI, correlate the anatomy of the subcutaneous tissue to the typical changes in the cellulite at different degrees of severity; other researchers also used MRI to study the cellulite and its treatment with lymphatic drainage. However, the development of software that allows the use of panoramic images captured by diagnostic ultrasound is more inexpensive.

Del Pino et al used this method to observe the results of the treatment of cellulite with nonablative radiofrequency. In this study, panoramic images taken by diagnostic ultrasound were used to evaluate the results of the treatment of cellulite with carboxytherapy.

These images allowed the registration of large anatomical areas and the access of the subdermal structures, especially fibrotic regions of septa. All images were collected and evaluated, and the comparative differences can be clearly seen in. The analysis of the structural aspect of cellulite allowed the observation of a significant improvement in the organization of fibrous lines observable by hyperechoic area (whitish structures of fibrotic septa) compared to pictures taken before treatment, also noting hypoechoic areas of adipose tissue. These results support the findings described by Lee in a compilation of clinical outcomes over 4 years (2004–2008) in 110 patients using carboxytherapy in the treatment of localized fat and cellulite; despite the methodological limitations of this study, the author concluded that carboxytherapy is a technique that demonstrates effectiveness for treating both localized fat and cellulite. The degrees of reduction of cellulite and possible reshaping of septa in this study likely occurred by the action of CO 2 on the microcirculation and tissue perfusion, described in the subcutaneous tissue. Studies showed that local application of CO 2 can promote improvement of peripheral circulation, increasing tissue perfusion and oxygen partial pressure by reflex vasodilation, and stimulate the neoangiogenesis.

In the study, after the treatment of carboxytherapy, there was a significant reduction ( P=0.0025) of the cellulite from degree III to degree II, and this improvement showed correlation with the improvement in the organization of fibrous lines and the disposal of adipose tissue lines of treated regions observed through the panoramic ultrasound image diagnosis. Another factor that may contribute to the effectiveness of carboxyther-apy in the treatment of cellulite is the decrease in the density and shape of adipocytes in the treated area as demonstrated in the study by Costa et al, since the accumulation of localized fat could contribute to increased local tissue compression, favoring the traction of fibrotic beams and herniation of adipocytes in the dermis causing the appearance of the orange peel skin depressions, a characteristic feature of cellulite disorder.

Your lymphatic system helps eliminate your body’s waste. A healthy, active lymphatic system uses the natural movements of smooth muscle tissue to do this.However, surgery, medical conditions, or other damage can cause fluids to build up in your lymph system and your lymph nodes, a condition known as.If you’ve ever had a surgery on or involving your lymph nodes, your doctor may have suggested lymphatic drainage massage performed by a certified massage or physical therapist. However,lymphatic massage is not recommended for people with the following conditions:. congestive heart failure. history of blood clots or stroke. current infection. liver problems.

kidney problems. Procedures that affect or remove your lymph nodes can cause lymphedema as a side effect.Lymphedema will only occur in the area near a surgical site.For example, if you have lymph nodes removed as a part of cancer surgery to your left breast, only your left arm, not your right, might be affected with lymphedema.Lymphedema can also occur as a result of an injury or medical conditions such as or in the body.To move waste fluids away from the damaged area, lymphatic massage, which uses a gentle pressure, can help. It’s one technique used to reduce lymphedema.Raakhee Patel, PT, DPT, CLT, is a physical therapist and certified lymphedema specialist who trains people to perform their own lymphatic massage after surgery.“We don’t talk enough about lymphedema,” says Patel. Fluid build-up is uncomfortable and causes pain and heaviness in the affected area. And, according to Patel, “Stage 3 lymphedema can be devastating,” causing significant depression and lack of mobility that could complicate healing.When performing a lymphatic massage, it’s important that the massage include more than just the affected area. The entire lymphatic system of the body, except the head, right side of the chest, and right arm, drains near the left shoulder. So, a massage should include all areas to drain properly.

Patel teaches two stages of lymphatic massage: clearing and reabsorption. The purpose of clearing is to create a vacuum with gentle pressure so that the area is prepared to bring in more fluid, creating a flushing effect.Clearing involves:.: located directly under the collarbone.: located under the arms. inside of the elbowsClearing motions can be repeated as many as 10 times a day. Patel advises, “Always massage both sides of your body, not just the side with the lymphedema.” A guide to clearingThere are three stages to clearing. Be sure to clear the supraclavicular area, axillary area, and inner-elbow area, in that order.To clear the supraclavicular area:. Begin by lying on a comfortable, flat surface. Cross your arms on your chest, with your hands resting just below the collarbones.

Then lift your elbows slowly. The muscle action is as much pressure required to prepare the area to flush lymphatic fluid.Next, clear the axillary area:. Lay one hand above your head.

Use your other hand to gently scoop the underarm area from top to bottom. The only pressure required is gentle enough to move the surface of the skin.Finally, clear the area inside the elbows:.

Lay your arm straight at your side. Use the fingers of your opposite hand to gently pull the skin inside the elbow an inch at a time.Only very gentle pressure is required. “In lymphatic massage, you’re only working the superficial skin structure,” says Patel. That’s where the fluid is trapped.

How to perform lymphatic massage on the legsThe goal of lymphatic massage on the legs is to open the lymphatic vessels to let excess fluid drain back up into the lymph nodes located in the groin.There are different techniques used to perform lymphatic massage on the legs, but all have the same end goal: to release the fluid to go back up through the lymph nodes.To perform a lymphatic massage on the legs, you can follow these steps:. Perform lymphatic massage of the upper body before beginning with the legs.

Follow the three stages of clearing in the supraclavicular area, the axillary area, and the inner-elbow area, in that order. This ensures that the system is clear to allow fluid to drain up. Use light pressure. If you can feel the muscles underneath your skin, you are pressing too hard.

Begin the leg massage at the furthest point away from the injury or affected area and work your way down. For example, if your ankle has swelling, start the massage on the upper part of the leg. Starting at the top of the leg, put one hand on the inside of the leg and the other on the back of your leg. With gentle pressure, stretch the skin from the inside of your leg up and out, toward your hip. Continue this motion down the leg until you reach the knee.

When you reach the knee, stretch the skin up, with alternating hands, toward your armpit. Repeat 10 to 15 times.You have now completed the clearing step of the lymphatic massage.

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A guide to reabsorptionThe second part of lymphatic massage is reabsorption. To perform this stage of massage:. Begin at the affected part of the body farthest from the core of the body.

For example, begin at the tips of the fingers if you have lymphedema in your hand, arm, and shoulder. Using a gentle, sweeping motion with just enough pressure to shift the surface of the skin, massage from fingertip to hand, from hand to elbow, and from elbow to shoulder.“Patient compliance is the hardest part of self-care, especially for women, who are so used to taking care of others,” says Patel.She advises people to set aside at least 20 minutes a day for lymphatic drainage massage.

How do you know if lymphatic drainage massage is effective? “This is a maintenance technique,” says Patel. “Your lymphedema should not get worse if you regularly practice lymphatic massage.”Also, drink water. Well-hydrated tissue helps moves out waste materials.Managing your lymphedema can also include:. using a compression sleeve to prevent fluid buildup.

seeing a qualified therapist for in-office drainage massageWhen choosing a therapist, learn as much about their education as possible. “Massage is very good for you, but deep tissue massage can be too heavy for someone with lymphedema, so don’t assume you can just go to a massage therapist.”Look for someone who is a certified lymphedema therapist (CLT) and preferably a physical or massage therapist with oncology and pathology training.