|Year : 2020 | Volume
| Issue : 3 | Page : 1045-1049
Evaluate the efficacy of carboxytherapy for localized lipolysis in a sample of Egyptian patients
Alaa H Maraee1, Azza G. A. Farag1, Ashraf A Zytoon2, Shahlaa A. E. R. Essa3
1 Department of Dermatology, Andrology and STDs, Faculty of Medicine, Menoufia University, Menoufia, Egypt
2 Department of Radiology, Faculty of Medicine, Menoufia University, Menoufia, Egypt
3 Department of Dermatology, Kafr Elshaikh Governate, Egypt
|Date of Submission||02-Mar-2019|
|Date of Decision||06-Apr-2019|
|Date of Acceptance||08-Apr-2019|
|Date of Web Publication||30-Sep-2020|
Shahlaa A. E. R. Essa
Kafr Elshikh, Kafr Elshikh
Source of Support: None, Conflict of Interest: None
To evaluate the efficacy of injection of carbon dioxide (CO2) in the treatment of localized fat deposits.
Obesity is a serious medical problem resulting in significant morbidity and mortality. CO2 therapy or carboxytherapy is the transcutaneous administration of CO2 for therapeutic purposes.
Patients and methods
A prospective, cross-sectional study was carried out on 15 men having localized fat deposits in the abdomen, who attended the Dermatology Outpatient Clinic, Faculty of Medicine, Menoufia University Hospitals, during the period from July 2017 to January 2018. Detailed history, clinical examination, digital photographic registration, and ultrasound measurements of the thickness of subcutaneous fat and therapeutic regimen were done.
Abdominal measurements by tape and ultrasound showed a statically significant reduction in abdominal circumference (P < 0.0001) and in fat thickness (P < 0.0001).
Carboxytherapy appeared to be effective in the treatment of localized obesity, without remarkable adverse effects, and can be used as a safe, complementary treatment option.
Keywords: carboxytherapy, injection, localized adiposity, obesity, ultrasound measurement
|How to cite this article:|
Maraee AH, Farag AG, Zytoon AA, Essa SA. Evaluate the efficacy of carboxytherapy for localized lipolysis in a sample of Egyptian patients. Menoufia Med J 2020;33:1045-9
|How to cite this URL:|
Maraee AH, Farag AG, Zytoon AA, Essa SA. Evaluate the efficacy of carboxytherapy for localized lipolysis in a sample of Egyptian patients. Menoufia Med J [serial online] 2020 [cited 2020 Oct 29];33:1045-9. Available from: http://www.mmj.eg.net/text.asp?2020/33/3/1045/296713
| Introduction|| |
Obesity is a medical problem resulting in morbidity and mortality. Many people are trying all kinds of diet regimens, but obesity remains in some areas. Surgical and nonsurgical procedures for improving appearance have increased in prevalence in the last few years . For patients requiring substantial fat reduction, surgical lipoplasty remains a popular method for body sculpting in the USA. However, the number of lipoplasty procedures performed annually has decreased dramatically as patients look for less invasive methods of body sculpting . Lipoplasty is associated with the highest potential for significant complications, morbidity, and mortality. Mortality is most often caused by embolism, complications of anesthesia, necrotizing fasciitis, and hypovolemic shock. Noninvasive alternatives to liposuction include cry lipolysis, radiofrequency ablation, laser therapies, injection lipolysis, high-intensity nonthermal (mechanical) focused ultrasound (US) and carboxytherapy .
Studies have demonstrated that Carbon dioxide therapy improves skin elasticity, circulation, and the appearance of fine lines and wrinkles, aids collagen repair and destroys localized fatty deposits. Essentially, carboxytherapy is the transcutaneous administration of carbon dioxide for therapeutic purposes. Brandi et al., showed that carboxytherapy positively affects the physiological oxidative lipolytic process. The treatment was found to be highly effective when administered subcutaneously for localized fat pads/cellulitis. During such treatment, it has been noted that adipose tissue fractures and lysis of adipocytes occur and triglycerides are released into the intracellular spaces; none of the vascular structures are adversely affected during this treatment . A similar study found a significant reduction in the mean upper, middle, and lower abdomen circumference in three different age groups who had been treated with carbon dioxide (CO2) therapy. No serious complications were reported and the author concluded that carboxytherapy is both safe and effective .
This study aimed to evaluate the efficacy and safety of subcutaneous injection of CO2 in the treatment of localized fat deposits.
| Patients and Methods|| |
A prospective, cross-sectional study was carried out on 15 men having localized fat deposits in the abdomen, who attended the Dermatology Outpatient Clinic, Faculty of Medicine, Menoufia University Hospitals, during the period from July 2017 to January 2018. Ethical consideration: All participants were volunteers. All of them signed written informed consent by explaining the aim of the study before the study initiation. Approval was obtained from the Ethics Committee in the Faculty of Medicine, Menoufia University. Inclusion criteria: Any patient more than 20 years old and having localized fat deposits in the abdomen and those having no history of previous treatment (at the last 6 months) for their localized fat deposition. Exclusion criteria: BMI more than 30, concomitant disease during the study (e.g., hepatic, renal, cardiac, autoimmune diseases, diabetes mellitus, and/or bleeding disorders), and subjects under treatment with carbonic anhydrase inhibitors (acetazolamide, clofenamide, etc.) .
All participants were instructed not to use any other methods of body weight reduction during the duration of the study. They were subjected to: full history taking and personal history including name, age, marital status, occupation; present history including the onset, course, and duration of localized fat deposits; and history of any medical illness and/or drug intake. Clinical examination: general examination to detect any excluding factor. BMI was performed by dividing the weight in kilogram (kg) by square of height in meters (m 2). Individuals having a BMI of below 18.5 were considered. Underweight and those having BMI of 18.5–24.9 were considered. Healthy weight and those having BMI (25.0–30.0) were considered Overweight and those having BMI (30.0–40.0) were considered obese. Local examination: For assessment of localized fat deposition by evaluation of circumferential measurements using tape measure. Abdominal circumference was taken in a line midway between the umbilicus and anterior superior iliac spine.
Photographing documentation: was performed using Canon digital camera (PowerShot A2200 HD, 14 mp, Shanghai, China), set at a fixed distance from the patient. Two photographs (frontal and lateral views) were taken on two occasions, one before treatment session (baseline) and the other one, 1 week after the last one. Ultrasound measurement: Ultrasound model Philips (HD11XE; Chagrin Falls, OH, USA) was used for the measurement of subcutaneous fat. All ultrasonic images were taken in the supine position. The probe was slipped at a slow and regular speed in the distal/proximal direction along the areas to be measured. The abdomen measurement was taken in a line midway between the umbilicus and the anterior superior iliac spine. Therapeutic regimen: Each patient in the study received carboxytherapy sessions, once per week for 8 weeks, or till improvement whichever is first. The instrument: A programmable Automatic Carbon Dioxide Therapy apparatus (Arab Medical Containers Co. Ltd., King Abdullah II Industrial Estate, Sahab, Amman, Jordan) and 30GA; 13 mm needle [Figure 1]. Injection method and anesthesia: The skin was first cleaned with ethyl alcohol and then a topical anesthetic cream (lignocaine cream) was applied to the skin under occlusion for 30 min.
Prepare the CO2 therapy apparatus: The device was automatically calibrated to adjust the flow rate, through regulation of infusion pressure, and the dosage of CO2 in ml. The infusion velocity consequently was adjusted to be 100 ml/min. The CO2 gas is 1.5 times heavier than air, so tends to go down with gravitation; depending on this fact the patient should receive the injection while they are in sitting or supine position to allow good lymphatic return to the lung ,. Total quantity of CO2 infused was 300–600 ml for the abdomen. However, subcutaneous administration of CO2 has not shown any toxic effect even at high doses (2–10 l) .
The session was performed as follows: Holding the 30 G needle at a 45° angle, pinch the fat, lifting it up away from any underlying muscle, insert the needle by all its length (13 mm), and holding it steady in place with the nondominant hand. Depress the foot pedal on the carboxy device to start the regulated flow of CO2. The carboxy machine will gradually dispense the present volume of gas, slowly into the tissues; the clinical endpoint of each injection is at the occurrence of erythema and distention. Postinjection care: The patients were advised to avoid any tight clothes on the treated area, and exhausting exercise in the same day of treatment, besides, to drink plenty of fluids to help get out of the injected CO2 .
Assessment of the efficacy of the therapeutic procedure: 1 week after the last session, the efficacy of therapeutic procedure was evaluated by clinical assessment: Circumference measurements at the pretreatment specific locations were recorded 1 week after the last session as mentioned in before treatment. US measurements: Thickness of subcutaneous fat was measured 1 week after the last session treatment as mentioned in before treatment. Patient's satisfaction: The degree of improvement according to patient's opinion was evaluated as follows: no improvement, 1–25% improvement (poor), 26–50% improvement (fair), 51–75% improvement (good), and 76–100% improvement (excellent). Safety assessment: All undesirable events, whether observed by the investigator or reported by the patients, are considered adverse events. The patients were informed to report any complications occurred such as pain, itching, and/or ecchymosis.
The results were analyzed and tabulated using Microsoft Excel version 7 (Microsoft Corporation, New York, New York, USA) and SPSS version 16. (SPSS Inc., Chicago, Illinois, USA). Two types of statistics were done: Descriptive, for example, percentage, mean, median, and SD. Analytical: paired numerical data were compared using the paired t-test. Independent numerical data were compared using one-way analysis of variance with the application of the Tukey–Kramer test for post-hoc comparison, if needed. Graphs were used to illustrate simple information. A value of P less than 0.05 was indicated as statistically significant.
| Results|| |
The studied cases were 15 men having localized obesity in the abdomen; their age ranged from 23 to 45 with a mean ± SD of 34.7 ± 6.9 years. Their BMI ranged from 27 to 30 with a mean ± SD of 30.0 ± 2.0 [Table 1].
|Table 1: Demographic characteristics of patients and the distribution of fat deposits in various body areas|
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Mean value of the abdominal circumference (tape measure) was 112 ± 4.5 cm, which became 105.5 ± 5.3 after treatment by carboxytherapy sessions. By the US the mean value of abdominal subcutaneous fat thickness before treatment was 3.5 ± 0.996 while after treatment it was 2.14 ± 0.75 [Table 2] and [Figure 2], [Figure 3].
|Table 2: Changes of the studied variables before and after carboxytherapy treatment|
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|Figure 2: (a) Before treatment: the abdominal circumference was 99 cm and (b) after treatment the abdominal circumference became 94 cm.|
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|Figure 3: (a) Before treatment: thickness of abdominal subcutaneous fat was 3.96 cm and (b) after treatment: thickness of abdominal subcutaneous fat became 2.76 cm.|
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Minimal side effects were recorded including ecchymosis and pain. Pain ranged from mild to moderate and occurred at the time of the session and subsided 2 h after injection without any analgesics.
| Discussion|| |
In this study, the age of the studied patients ranged from 23 to 45 with a mean ± SD of 34.7 ± 6.9 years. Likewise, El-Kamshoushy et al., in their study on 20 Egyptian female patients, reported that the age of their patients ranged from 23 to 53 with a mean ± SD of 38.4 ± 8.5 years. In the current study, the mean ± SD of the patients' BMI was 29.0 ± 1.0, indicating that lipodystrophy is not directly associated with obesity ,. Following this finding, Pianez et al., on their study on 10 women, observed that the mean BMI of their studied patients was 29.9 ± 1.0 kg/m 2. Regarding sites of localized fat deposits in our participants, 15 participants have localized fat deposits in the abdomen. Hasengschwandtner  on a study done on 441 patients found that 122 (28%) of the participants have localized fat deposits in the abdomen, 29 (6%) in the inner thigh, 20 (4%) in double chin and face, and the remaining in other areas. Localized adiposity is a result of the accumulation of adipose tissue present in small quantities in a specific area including the lower abdomen, thigh, arm, and chin . Management of localized fat adiposities is difficult and not satisfactory; many modalities were proposed to treat lipodystrophies such as liposuction, injection lipolysis, and electric stimulation. In 2001, 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 CO2 gas infiltration on the subcutaneous adipose tissue and their possible lipolytic effects. After sessions of carboxytherapy, we observed that abdominal circumference was reduced significantly (P < 0.0001). As well, the thickness of subcutaneous adipose tissues in the abdomen (assessed by the US) demonstrated a significant decrease (P < 0.001). In agreement of these results Lee  used carboxytherapy for targeting lipodystrophy on 110 female patients. They noticed a significant reduction in the upper, middle, and lower abdominal circumference. Recently, they treated 10 patients having localized fat deposited in their abdomen. The authors also reported a significant reduction in lower abdominal circumference after sessions of subcutaneous CO2 injection (P < 0.01) . Parallel to the results of US measurement of subcutaneous fat thickness in the current study, Pianez et al.  used the panoramic US to evaluate the results of the treatment of localized fat depositions in specific areas (lower abdomen and thigh) with carboxytherapy. They reported that local application of CO2 can promote the improvement of peripheral circulation, increasing tissue perfusion and oxygen partial pressure by reflex vasodilation, and stimulate neoangiogenesis . Another factor that may contribute to the effectiveness of carboxytherapy in the treatment of localized obesity is the decrease in the density and shape of adipocytes in the treated area . In the current study, minimal side effects were recorded including ecchymosis and pain. Regarding ecchymosis 10 participants exported ecchymosis that occurred after some sessions and subsided within a few days. Regarding pain, all our participants experienced pain that ranged from mild to moderate and occurred at the time of the session and lasting 2–3 h after injection. Therefore, we suggested that carboxytherapy is a safe technique. Supporting our observation Lee  found minor side effects that included pain at the injection site, crepitus, and minor aches, which did not last for more than 30 min. Some bruising was also noted and resolved within 7–10 days. Also, Pianez et al.  performed 80 sessions with carboxytherapy. They observed that none of their participants had any sort of significant adverse effects. The authors reported only mild transient discomfort during treatment, and only one subject had two small bruises that resolved spontaneously.
| Conclusion|| |
Carboxytherapy appeared to be effective in the treatment of localized obesity, without remarkable adverse effects and can be used as a safe complementary treatment option.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2]