Carboxytherapy has proven to be an efficient treatment option with which to improve the appearance of the legs, both with regard to cellulite and sagging skin. It has also enjoyed a promising growth in popularity over the past few years. In this article, the author discusses the history of carboxytherapy, how to use it, and the treatment outcomes it can provide.

Carboxytherapy treatment involves the cutaneous and subcutaneous injection of carbon dioxide (CO₂) in its gaseous state, for the treatment of a number of conditions, including cellulite and sagging skin, as well as killing fat cells. Originating at the Spa Royat near Clermont-Ferrand in 1932, a group of cardiologists began to treat peripheral arterial disease using CO2 insufflation, shortly followed by the first publication on this method in a professional journal in Argentina in 1934. In 1953, cardiologist Jean Baptiste Romuef published his 20‑year experience of subcutaneous injection of CO₂ treatment1. From this time until 1983, more than 400000 patients were treated in Clermont‑Ferrand. Currently, an average of 20000 patients are treated using this method every year1,2.

A 2009 study showed the interesting effect of carboxytherapy for 18 consecutive days on average intermittent claudication, and thus the walking distance of 62 patients3. This was accompanied by an increase in peripheral systolic partial pressure of oxygen (pO2). The study demonstrated that percutaneous CO₂ treatment significantly increased walking distance in patients with moderate intermittent claudication.

Jerome Berthier also started to use the application of the technique on cellulite successfully, which grew throughout Brazil in the 2000s, and with good results. In 2010, carboxytherapy in aesthetic medicine made a big leap in Europe. Many articles have now been published and conference communications are increasing with regard to the therapy as a treatment for cellulite, dark circles, stretch marks, and sagging skin4.

Principles

The injection of CO₂ creates a subcutaneous emphysema owing to the rapid diffusion of the gas, which lasts only a few minutes. However, CO₂ injection improves the oxygenation of tissues in situ by increasing the release of oxygen from the oxyhaemoglobin in which charge exchange and CO₂ is subsequently released by the lungs. This is referred to as the Bohr effect. In the presence of CO₂, there is a decline in pH by the release of H+ ions (CO₂ + H₂O ↔ H+ + HCO-3), all of which creates the oxyhaemoglobin dissociation curve and the release of oxygen into the tissues. The CO₂ is absorbed by the blood system at the level of 210 ml/min and by litre of blood. The CO₂ causes a decrease in blood pH, an increase in local blood flow (muscle and skin), an opening of the capillaries, dilation of pre-capillary segments, increased release of oxygen from the haemoglobin, and an increase in erythrocyte deformability5. In turn, these actions cause vasodilation and stimulate neoangiogenesis, through which metabolic exchanges will be accelerated. The vascular effect of CO₂ was the prime mover of treatment for arterial disease in Clermont‑Ferrand.

In 1995, Savin et al carried out a double-blind study of 10 patients suffering from peripheral arterial disease Class II and objective members increased transcutaneous oxygen tension (TcPO2) in the femoral and tibial arteries after 20 minutes of transcutaneous CO2 insufflation6. Femoral blood flow, tibial pressure, and foot TcPO2 were significantly increased after exposure of the skin to CO2‑rich spa gas. These results suggest that transfer of CO₂ across the skin can have beneficial local vasomotor effects in patients with stage II lower-limb arteriopathy.

Cellulite and sagging skin in female patients

Cellulite

In 2000, Leibaschoff first applied carboxytherapy to the treatment of cellulite7, then Brandi et al published a study on the effect of transcutaneous CO₂ injection on adipocyte lysis8, as well as a reduction in volume, which was both clinically and statistically positive. The author used pre- and post-treatment biopsies of tissues in order to study the exchange induced by the use of CO₂ on both adipose and connective tissue. The study revealed a positive result with regard to microcirculation and reduction of adipose accumulation associated with CO₂ therapy. A further study by Brandi et al examined the tightening effect of carboxytherapy on pre- and post‑liposuction sagging skin9. This study showed that obtaining improvement of skin irregularity and cutaneous elasticity through CO₂ therapy is possible. This has led many to consider the possibility of CO₂ therapy as a complement to liposuction.

Michel shared his experience on carboxytherapy and recommended a lighter flux in the first session, and increasing it thereafter9. Leibaschoff later recommended his protocol of 400 ml per session, and that 12 treatments sessions showed very good results10.

In 2010, Balik et al published a comparison between the biochemical effects with CO₂ injection and breathable air on 28 female rats11. A statistical difference in the number and diameters of adipocytes was found in the group with CO₂, and also that the bulging of CO₂ injection disappears very quickly (30 min). In the same year, Lee published his 4-year experience using carboxytherapy for fat reduction in 101 women, comprising abdominal therapy with only five treatment sessions12. He showed a significant reduction (P < 0.05) in mean upper, mid, and lower abdomen circumference, and concluded that carboxytherapy is a safe and effective treatment option.

Micheels shared his experience of treating seven patients with 15 sessions, plus three sessions 3 months later, then control at 6 months13. With control using echography after 6 months, the results were a decrease in fat of 10–40%, with an average of 25%, and a notable improvement in skin laxity and decrease in the ‘orange-peel’ appearance of the skin.

Mode of action on cellulite

CO₂ stimulates a mechanical effect in the hypodermis, a lipolysis of adipocytes, and a reduction in fibrosis. As the treatment sessions continue, it is evident that the gas is able to diffuse more evenly. Metabolic changes will be stimulated in lipid vesicles that are released from the lysed adipocytes, which will be better absorbed and oxidised by macrophages.

Carboxytherapy seems to reorganise the subcutaneous tissue with the succession of treatment sessions. In fact, during the first sessions the gas will diffuse in certain directions and totally omit to go in others, but progressively, dissemination is more even, as if the adhesions have dissolved and that tissue support has become homogenised.

Indications

The best indications for carboxytherapy remain the treatment of small volumes with a certain degree of orange peel (destruction of bridges between collagen chains, inducing fibrosis). In France, the decree of 2011 prohibits the use of carboxytherapy for the treatment of cellulite.

The author’s experience

The effect of carboxytherapy is certainly interesting, but the author’s experience is still somewhat limited with regard to volume of treatments. However, the results show an improved appearance of the skin, a reduced appearance of ‘orange peel’, and a tightening and firming of the skin. The author has treated some patients who are satisfied after only four sessions (around 25%), but most patients will notice a good skin-tightening effect after six sessions (50%), and some will only see results after 3 months (time for the fibroblasts to be reactivated) or have no improvement at all.

Sagging skin

In 2008, Ferreira et al carried out a study on 10 male rats, with two young rats as controls, four old rats with saline injection as controls also, and four olds rats which were injected with intradermal CO₂14. The authors found that collagen turnover increased in the CO₂-treated animals, which corroborates clinical observations of aesthetic improvements in human facial skin with CO₂ injections.

In 2012, the author of the present article also published on the treatment of cleavage with carboxytherapy, with very interesting results15.

Indications

While the treatment of cellulite with carboxytherapy has been much published and studied, curiously there is little literature on carboxytherapy in the treatment of sagging skin, while for the author this is a key part of her daily practice. The best indications are treatment to the oval of the face, neck, and chest, and inner thighs.

The author’s experience

The effect is slow but impressive on the inner thighs: the first results are usually seen around the sixth treatment session, and a total of at least 15 sessions are usually performed. Combination treatments are interesting with radiofrequency, which can reduce the number of sessions (between four and six on the face, and eight on the body).