Recent bulletin on Carboxytherapy and Mesotherapy

Here is a recent press release from the Physicians Coalition for Injectable Safety - a group of 7 American, Canadian and International Surgery groups, including plastic surgeons, facial plastic surgeons and ophthalmic surgeons - who review & study the latest and best methods regarding injectable cosmetic products. For the record, I agree with this bulletin, and do not currently recommend mesotherapy and carboxytherapy, based on lack of proven efficacy.

PHYSICIAN GROUP URGES CONSUMERS TO BE AWARE OF NON-APPROVED COSMETIC INJECTIONS

July 29, 2009 - The Physicians Coalition for Injectable Safety today issued a consumer warning about carboxytherapy and mesotherapy injections. These products, touting everything from cellulite treatment to weight loss are not FDA approved, and do not have clinical data that demonstrates results or safety.

Carboxytherapy uses carbon dioxide gas injected under the skin to reduce the look of cellulite, treatment of dark under-eye circles, and stretch marks and is also touted for fat sculpting on the face and the body. “Although many websites or providers claim carboxytherapy is safe and FDA approved, it has not been clinically tested or FDA approved for these purposes,” says Coalition leader Robert Weiss, MD of Baltimore, MD. “Carboxytherapy for use around the eyes is especially dangerous. It could potentially release gas bubbles into blood vessels causing blindness. In addition, the risks of putting carbon dioxide in your body are currently unknown.”

Mesotherapy, also known as injection lipolysis, is a mixture of vitamins, drugs and enzymes that are compounded (mixed together) to make the injected substance. “There is no conclusive, authoritative information that exists, such as unbiased, peer-reviewed clinical studies that meets the standards of an accepted medical journal, measuring both the efficacy and safety of mesotherapy,” says Coalition leader Mark Jewell, MD, Eugene, Oregon. “We don’t know the safety or efficacy of these compounds and, until there exists credible evidence, consumers are advised not to have these injections.”

The Coalition urges consumers to be very selective about cosmetic treatments, and the individuals who provide them. “Only accept treatment prescribed by a qualified physician and administered under that physician’s supervision. Whether an injection or treatment is to treat aging conditions, to treat cellulite or a similar body contouring condition, whether it sounds reasonable or too good to be true, you should always be aware of false claims,” says Coalition leader Jeffrey Kenkel, MD of Dallas, TX. “Verifying that the drug or device that is recommended for your injection is FDA approved is an important first step. It should be approved specifically for cosmetic use as prescribed or similarly to what is prescribed for you.”

Problems with laser-liposuction: who's the Smart one now?

Over the last few months, I have seen an alarming increase in the number of patients that come in for a second opinion about poorly-performed liposuction (done elsewhere, I might add.) All of these casse have been performed with new high-tech liposuction machines, either laser-assisted (like the SmartLipo) or ultrasonic (like the VASER).

I've seen major skin laxity, uneven liposuction, and obvious over-resection of fat leaving major divots and dents. Many of these problems are very difficult to fix, even with fat grafting techniques.

Here's a few observations:

1. All of these cases were performed by physicians and surgeons operating way outside of their specialty. They were not done by plastic surgeons or dermatologists, who are trained during residency in this technique.

2. In the majority of these patients, physical examination of the patient revealed crummy skin tone and poorly elasticized skin. In other words, since this skin won't contract like we want it to after liposuction, it's completely predictable that the post-op results will be poor, with floppy, deflated areas, and a worsened appearance. A surgeon with any significant training or experience in liposuction would have recognized this - and would have avoided performing liposuction in these patients. It's the wrong tool for the job!

3. All of these patients were preoperatively told by their physicians, "This new wonder lipo machine will tighten your skin".

4. All of these patients now say, "Skin tightening clearly did not happen...now I look worse."

5. None of these patients have an easy fix for their issues. All will require complex and expensive revisional surgery.

Lessons:

A fancy hammer does not a good carpenter make. Any doctor can buy (or rent) a fancy lipo machine.

There is, as yet, no reliable scientific evidence that laser-assisted liposuction:
a) tightens the skin, or
b) works better than standard liposuction.
Any claims to the contrary are "spin" or marketing hype; consider the source and what they're selling.

That being said, the problems seen here were not caused by the type of liposuction machine - but by the doofus using it! While the concept of liposuction is easy, getting excellent results with liposuction takes significant skill.

Please be careful about whom you choose to perform your liposuction. Even if it's performed in an office setting, with local anesthesia, liposuction surgery is still SURGERY. Training, experience and credentials matter.

DHEA: super supplement or snake oil?

DHEA supplements are widely claimed in the lay press to help with a huge number of diverse conditions: anti-aging, cardiovascular disease, chronic fatigue & fibromyalgia, body building, obesity, osteoporosis, sexual dysfunction, and lupus - just to name a few. Most of this excitement was based on positive results seen in early scientific studies done in mice, and from some anecdotal reports from enthusiastic users...and things took off from there.

These days, many people now take the widely available DHEA tablets, hoping to get a health benefit - are they wasting their money and effort? Or is DHEA a "fountain of youth" hormone in a bottle?

What is DHEA?
DHEA (dehydroepiandrosterone) is a hormone that is made by the adrenal glands, out of cholesterol. It is an intermediate product in the chain of biochemical events that convert cholesterol into active hormones like testosterone and estrogen. Production of DHEA seems to peak in the mid-20's, and starts to decline after the mid-30's. (Unlike testosterone and estrogen, we don't have any evidence that DHEA is particularly active by itself.)

So, the theory goes, that if we can boost the falling levels of this hormone back to the levels seen in healthy young adults, then various "good things" will happen, and we should feel young again. Sounds promising, but does it work in this case?

The evidence:

We can divide DHEA uses into 2 main groups: 1) deficiency states due to a specific disease, and 2) supplementation for otherwise normal, healthy people.

Scientific evidence supporting the use of DHEA is mostly positive when it is used as part of the treatment of specific problems, such as:
- adrenal insufficiency ("Addison's disease")
- systemic lupus erythematosus ("lupus")
- depression

So far, most of the other proposed indications for DHEA use in disease states (like cancer or heart disease prevention) have not been proven yet, based on the studies that have been completed to date.

In terms of using DHEA as an "anti-aging" supplement for normal, healthy people who just want to feel younger, the recent scientific trials that have been carefully conducted in people, rather than mice, are pretty disheartening:

- A double-blinded, placebo controlled study from France in 2003, looked at the effect of DHEA on muscle mass over a 12 month period in healthy 60-80 year olds. Although the DHEA supplements caused the blood levels of DHEA to go up to the range found in young adults, there was no significant difference in muscle strength, or muscle volume compared to the placebo group.

- A 2005 study from University of Pennsylvania looked at muscle mass, strength, endurance and quality of life measurements (feelings of well-being, sleep & sexual function) in postmenopausal women. Once again, while the levels of DHEA in the blood went up, there was no significant difference in the treated group on any of the parameters, compared to the people that had no hormone therapy at all.

- A 2001 study from Germany looked at DHEA supplementation in healthy men, aged 50-69, using a double-blinded cross-over study design with placebo controls. While the blood levels of the hormones again went up to youthful levels, there was no effect seen on serum lipids, bone markers, body composition & muscle mass or exercise capacity.

- In a study done in healthy men aged 35-65, the effect of 12 weeks of DHEA supplementation was examined in conjunction with a high-intensity fitness program. They found no enhancement above the results obtained by physical training alone, and worse, a 6.5% increase in cardiac risk, due to unfavorable changes in the cholesterol profile.

DHEA also has a number of common side effects: acne, unwanted hair growth, unfavorable changes in lipid (cholesterol) profiles.

The bottom line: DHEA supplementation remains controversial as a supplement for normal, healthy people.

Based on my own interpretation of these and other studies, I don't currently recommend DHEA to my patients as a general anti-aging supplement. It does not seem to have conclusively-proven effects on either the physical or mental aspects of aging. While there might be some sub-groups of people where DHEA therapy may have some benefit, these groups are still being defined, and more research is needed.

People that have known hormonally-sensitive cancers (breast, prostate, etc.) should especially avoid DHEA.

Does Vitamin E help the appearance of scars?

From time to time, people ask me about Vitamin E...and whether rubbing some of it on their incision will make it heal and look better.

It's an interesting "urban legend". The belief that Vitamin E helps scars seems pretty widespread.

First of all, what is Vitamin E? It's a fat-soluble vitamin that was discovered in 1922. It acts primarily as an antioxidant, helping to protect the membranes of cells from what is known as oxidative stress. It also seems to have anti-inflammatory effects, and adversely affects platelet aggregation (which is why we have our patients stop taking it prior to surgery, as it can cause more bleeding at surgery!)

As I always say, "Let's look at the science."

Although there have been a few animal studies where Vitamin E seems to have helped wound healing, the outcomes in human volunteers have been very disappointing.

There are two very good studies on the use of Vitamin E as a scar treatment.

In the first study, published in Dermatologic Surgery in 1999, researchers compared the use of twice-daily application of Vitamin E in Aquaphor ointment versus Aquaphor alone, applied for a twelve week period. They then had the patients and independent observers rate the appearance of the wounds. There was no difference and no improvement in the appearance of the Vitamin E treated incisions.

Unfortunately, 33% of patients developed a reaction to the Vitamin E, with a contact dermatitis rash - so the appearance was actually worse with Vitamin E treatment. Not only did the Vitamin E fail to help the scar look better, it actually had a side-effect problem.

In the second study, published in 1986, researchers from the well-known Shriner's Burn Institute in Cinncinati investigated whether the use of topical Vitamin E cream or steroid lotions would help the appearance of the skin grafts that are often necessary in the treatment of burns. Once again, there was no beneficial effect on the scar appearance with either Vitamin E or topical steroid. Side effects were again a problem - 16% of patients had reactions to the Vitamin E.

Despite the science, the myth persists. In a recent questionnaire of physicians, nurses, medical students and pharmacists, nearly 68% incorrectly thought that Vitamin E would improve scars, and 21% had tried it on themselves.

But now, you know better. Don't bother with putting Vitamin E on your scar. We have other products that work much better....and that actually been scientifically proven to work! We'll talk about these options in an upcoming blog.

Isn't myth-busting fun?!