1

Carboxitherapy

Gustavo Leibaschoff, MD

Director of the International School of Carboxitherapy

www.internationalschoolofcarboxitherapy.com

[email protected]

CARBOXITHERAPY CONSISTS IN THE THERAPEUTIC USE OF CARBON DIOXIDE

(CO2) IN ITS GASEOUS STATE, EITHER TRANSCUTANEOUS OR BY
SUBCUTANEOUS INJECTION.

CARBODIOXIDETHERAPY (CDT) IS THE ADMINISTRATION SUBCUTANEOUSLY

OF THE GAS.

This therapy was first performed in Argentina(1) and in France, in the

thermal waters station of Royat, near Clermont Ferrand.(2) There a
group of cardiologists from the hospital of Clermont Ferrand, began to
treat patients with peripheral organic and functional arteriopathies
(atherosclerotic, Buerger's disease, Raynaud's disease, etc). In 1953
the cardiologist Jean Baptiste Romuef, published a paper about his 20
years of experience with the subcutaneous injection of CO2.(3)
Afterwards, the Parisian cardiologist Jerome Berthier, along with Luigi
Parassoni from Gaillard A, started its application on patients with
cellulite.(4)
 2

First paper about the use of CDT publish in the Journal of the
Argentine Medical Association (1934)

Up to 1983 402,000 patients had been treated in Royat. By 1994,

20,000 patients were treated per year. This number of patients
confirms the popularity and perhaps the efficacy of this therapeutic
method.

Carbon dioxide (CO2) is an odorless colorless gas first discovered by

Van Helmont, in 1648. The clinical use of CO2 is not new. Many years
ago, in France, Clermont Ferrand used thermal CO2 (CO2 99.4%, N
0.558%, O2 0.021%, plus argon, xenon, and krypton traces) for
treating lower limb peripheral arteriopathies, especially the obliterating
ones.(5)

When administered sub-cutaneously, CO2 immediately diffuses at the

coetaneous and muscular microcirculatory level.
After the administration of 200 cc of CO2 in the canine thigh
subcutaneous tissue, CO2 is detected in femoral venous blood in
 3

approximately 5 minutes, with a maximum time lag of 30 minutes. This

demonstrates the ability of CO2 to diffuse across fasciae, and reach
the underlying muscles.(6)
Most of the gas is eliminated through the lungs (expiration), while a
smaller portion is converted into carbonic acid in tissues and
eliminated through the kidneys.
At the vascular level, CO2 increases vascular tone and produces
active microcirculatory vasodilatation. CO2 - induced vasodilatation
results from its direct activity on arteriole smooth muscle cells.(7)
In addition, this promotes Bohr's effect, a mechanism that allows tissue
CO2 transfer to lungs and lung O2 transfer to tissues through the oxy-
hemoglobin dissociation curve. When administered through an external
route, CO2 promotes this mechanism, resulting in a higher tissue
oxygenation and neoangiogenesis.

Although it is toxic when inhalated (10% in air may cause asphyxia),

Subcutaneous or intra-abdominal administration of CO2 has not shown
any toxic effects, even at high doses (2-10 liters).

Pharmacodynamics
Active vasodilatation
Direct activity on arteriolar smooth muscle fiber
Sympathicolytic activity
 4

Increase in arterio-arteriolar sphygmicity

Increase of oxidative phenomena, with the resulting hydrolysis of
triglycerides into fatty acid in the adipose tissue
Haemorheologic activity
Improves erythrocyte deformation

INDICATIONS
Cosmetic medicine
Cellulite PEFE (8)
Localized adiposity
Skin laxity
Aging skin of the face (22-23)
Stretch marks (estriae)
Cosmetic Surgery
Pre & post Lipo
Complications of Lipo
Angiology
Organic and functional artheriopathies
Microangiopathies (Atherosclerosis, Diabetic)
Urology
 5

Erectile dysfunction
Dermatology
Psoriasis
Phlebology
Ulcers

Before and after with CO2, twice a week plus mesotherapy, look the
surface of the skin
 6

COSMETIC SURGERY
In this case I use CO2 three week before the liposculpture and
continue the treatment 10 days after the surgery, during two month,
twice a week (Pre and post liposculpture)(9)

According to the most recent studies, the cellulite has its origins in the
ECM (extracellular matrix) and in the microcirculatory alterations, the
network of diminutive arteries, veins and lymphatics that crosses the
connective.
If this microcirculatory system starts failing, the tissue is not fed
efficiently.
The substances start accumulating and forming edemas, nodules, and
skin retractions.
The CO2 reverts this situation when injected in the affected zones
through a very thin needle (27 G )
It produces vasodilatation (10)
 7

Improves the speed of the microcirculation( increase flowmotion),

The tissue receive more oxygen and the toxins are eliminated,
The edema is reduced.
It also favors the lipolisis ( reduce the size of the fat cells), and the
lipoclasis (the destruction of the fat cells).(13)
Another interesting fact is that Carboxitherapy provides excellent
results for patients with long time cellulite
It also provides great results to young patients as a prevention method.

Lipodystrophy and cellulite are pathologies in which microcirculatory

disorders resulting in interstitial edema constitute triggering factors that
also support the pathological process Since subcutaneous CO2
improves capillary blood flow and reduces stasis, carboxytherapy
contributes to the restoration of microvascular-tissue unit exchanges.
Administrated through subcutaneous route, CO2 causes subcutaneous
microcirculation vasodilatation expressed in an increase of blood flow
and the opening of virtual capillaries that normally are closed. This
seems to occur from dilatation of arteriole smooth muscle cells.(12)
with an increase in tissue PO2 that is maintained for a certain post-
therapy period.(13)

In the case of cellulite and lipolymphoedema, carboxytherapy shows

an effective activity. Cellulite and lipolymphoedema show
 8

microvascular alterations (stasis micro-angiopathy) and

histomorphological disorders (adipocyte aggregation and fibrosis).

Carboxitherapy technique produces a lipolysis action by increasing the

blood flow in pre-capillary arterioles and also by stimulating the fat cells
beta1-2 adreno-receptors (24)

The concept of localized adiposity is often misunderstood.

Histological studies showed hypertrophic fat cells ( larger size) ,
hyperplasy fat cells ( larger number) and always a microcirculatory and
lymphatic alteration is reported.
This is why CDT is suggested as an initial treatment in the Localized
Obesity, because it will improve the microcirculation and the lymphatic
system helping in that way to eliminate the metabolites of the fat cells

The sections show subcutaneous cell tissue with varying degrees of

mucinosis, interstitial edema, and proliferation of blood and
lymphatic vessels with varying degrees of microangiopathies (grade
1 and 2, according to Handelsman). There is fibrous thickening of
the interlobar connective septa and inflammatory perivascular and
interstitial infiltrates. (25)

Diagnosis: Edematous-fibrosclerotic panniculopathy (cellulite)

This was also evident in treatments for systemic multiple lipomatosis in

which, in combination with surgery, a reduction in adipose masses was
observed. Hence, it is evident that carboxitherapy has good results
both in terms of clinical manifestations and histology.(14)

Treatment Method
 1

EQUIPMENT
Allows CO2 administration in a controlled manner: flow velocity,
injection time, total volume and monitoring of administration dose
percentage.
The gas in the canister is administered in sterile conditions, in very low
pressure.

Inject the gas through a state of the art computerized unit at a constant
pressure and volume in a period of time; also allow a perfect control of
the amount of gas, from 1cc to 100cc.

CO2 is applied in the subcutaneous through a small needle, very fine.

(27G, 30G) and in a different depth accord the aesthetic pathology
1mm
In stretch marks, laxity in the face and neck,
 1

2mm
Detachment in the face and neck (for example in deep
nasolabio fold)
4mm
Laxity in the body, and in the treatment of cellulite
8-10mm
Subcutaneous administration in localized adiposity

The goal for the successfully subcutaneous application of CO2 are

inject in different planes, superficial ( 1 mm) medium ( 3-4 mm) for
collagen stimulation and more uniform surface, and subdermal inside
the fat deposit ( 6-10mm) for lipolysis.

The carboxitherapy (CDT) effects start in the microcirculation and can be

observed through a Videocapilaroscopy(VCP), allowing doctors to
demonstrate the action of the technique before results are visualized on
the surface .(15)
Until now, the absence of clinical parameters and instruments, for the
semiologic characterization and differential diagnosis limited treatment
investigation to inspection and palpation.
With the VCP we can see the changes at microcirculatory level and
know if we are making the right treatment.
VCP is a non-invasive method that analyzes capillaries through static
and dynamic images. (16)
Also, the VCP allows the observation of:
 1

morphology of vascular micro architecture

morphology of capillaries
degree of capillary filling
type of capillary flow (color)
assessment of an increase in vascularization
increase in capillary density
morphology of the venular system.
.

One of the most scientific classifications of cellulite was made for the
Plastic and Reconstructive Surgery Cathedra of the University of
Sienna, headed by the Dr. Prof. DAniello. They use the clinical, the
videocapillaroscopy (VCP), the laser fluxometry and the histopathology
allow diagnostic classification.
This linkage of the morphologic and biologic, allows us also to evaluate
evolutionary purposes and prognoses.
 1

Videocapillaroscopy before the use of CO2

After administration of subcutaneous CO2, there is an increase in

vertical capillaries (black points) and transverse capillaries.

Before CO2, less number of vertical capillaries (VC), After increase the
number of VC and the color look more pink (increase of
microcirculation)
 1

The Scalar VL-7EX video visualization systems enhance skin analysis.

A complete system consists of a probe, a lens, a power supply, and a

monitor. The hand-held probe is comfortable and lightweight. Lenses
are easily installed and switched. The VL-7EX features freeze-frame
capability.
The VL-7EX video microscope is a high quality, low cost, light weight,
and hand-held electronic imaging system. Video microscopy allows the
medical professional to perform evaluations of skin conditions
"live(microcirculation), while patients view their condition on the
screen as the analysis is being performed. With the VL-7EX video
microscope, one can see both the surface and sub-surface details in
high resolution on a full-color video monitor display.
When used by aesthetic physicians, the Scalar VL-7EX video
microscope enhances the client's understanding of the specific
characteristics of the microcirculation and features of their skin.
Scalar VL-7EX video microscopes add efficiency and depth to
analyses of skin (microcirculation). Effective treatment and services
performed can be verified with before-and-after comparisons that are
achieved by archiving video images to printers or VCRs attached to the
instruments.

Gustavo Leibaschoff, MD Cosmetic Surgeon Luis Coll, MD ( Universitary

Dermatologist UBA) development an study about the Cellulite,
 1

Carboxitherapy ( Carboxipen)and Videocapilaroscopy in 15 patients

with cellulite syndrome (EFP)
The images obtained in the prospective study by VCP showed that
Immediately after the first session using carboxytherapy in different
doses, 150cc and 50 cc Vertical capillaries significantly increases
35.2 +/- 3.3% per mm2 in the area of injection
After a week of the Carboxitherapy session the images showed a
decreased of 8.2% of vertical capillaries comparing with the previous
images post injection

CONTRAINDICATIONS of CDT
Recent or acute myocardial infarction.
Inestable angina.
Congestive Heart failure
Severe High Blood Pressure.
Acute thrombophlebitis.
Gangrene.
Localized infections.
Epilepsy.
Respiratory failure.
 1

Renal failure.
Pregnancy.

SIDE EFFECTS of CDT

Side Effects
Local Burning or oppressive pain, fleeting, at the injection site are
related to flow velocity and patients threshold.
Carboxipen device uses an special regulator allowing a progressive
control of the flow pressure of the gas injection obtaining less side
effects

Limb heaviness sensation (no longer than 2 hs), is related to dose (more
than 300cc in each limb)

Rubor at the injection site, during 30 minutes

Echymosis.( try to avoid vessels and varicose veins)

Subcutaneous crepitation, of variable duration (no longer than 30

minutes)

PROTOCOL IN CELLULITE
 1

Subcutaneous injection using volumes between 100 200 cc per limb.

Initial flow may vary between 10 50 cc/ min. (17)
It is advisable to make punctures in different directions (downward-
upward and upward-downward) with a 27 G or 30 G needle.
Divide the area into 4 to 6 quadrants per limb (look the diagram below)
The first session is suggested to inject no more of 10-20cc per
quadrant and then in the following sessions increase up to 50 cc per
quadrant.
Accompany with manual massage (move fingers as in piano playing
over subcutaneous emphysema areas) in order to contribute to gas
diffusion, to control emphysema and to reduce patients possible
discomfort.

Frequency of sessions

On a daily basis
Ideal for patients staying at thermal centers or patients receiving one-
week treatment. Generally, two or three cycles per year are suggested.

Two or three sessions per week

It is the more widespread frequency and the most recommended,
particularly if symptoms and an important microcirculatory stasis are
present. Also used for achieving lipolytic effects (to reduce localized
obesities).
 1

One session per week

An alternative for patients with aesthetic problems, showing no
symptoms. At least, 15 sessions should be performed.

In each quadrant inject 50 cc (follow blue arrow)

 1

before liposculpture

After Liposuction and after. 20 sessions of CO2 300cc each leg.

 2

CDT its use in the facial treatment as well, in the laxity of the skin, in
the periocular area for decrease the dark circles, increase the firmness
of the skin and reduce the hyperpigmentation.

In the skin rejuvenation before the mesotherapy CDT increase the

aesthetic results.

For a full Facial treatment, the total of CO2 is around 10cc

In the Forehead several punctures (6-8), weekly, 1mm depth, 1cc of

CO2
In the temporal and preauricular area (close to the hair line) one
puncture in each area, weekly, 1 mm depth, 1 cc of CO2
Over the Crowns feet one puncture in each small line, weekly, 1 mm
depth, 1 cc of CO2
In the Superior eyelid, one puncture, monthly, 2mm depth for detach,
1-2 cc of CO2. The same for the inferior eyelid
Over the Nasogenian fold first one puncture monthly. 2 mm depth for
detach, 1 cc of CO2 and 2 superficial puncture, 1 mm depth in the line
of the nasogenian fold, monthly, 1cc of CO2 each

In the Neck, if there are only laxity of the skin, three punctures, one
below lateral jaw angle ( both sides) , one below the chin, 2mm depth
 2

for detach, 1-2 cc of CO2 in each puncture each 15 days. With

localized obesity in the neck, a subcutaneous puncture 6mm depth,
below the chin, 5-10 cc of CO2 each 15 days.

For the revitalization of the Chest, several punctures (6 to 8) with a

regular distribution, 1 mm depth, 1cc of CO2, weekly .

The eyelid treatment with Carboxitherapy used once weekly typically

begin to show an improvement in eyelid pigmentation after one to three
weeks, the texture after two to four weeks and the eyelid contour in 3 to
five weeks.
When carboxitherapy is performed less frequently the results occur more
gradually.
The treatments continue for 2/3 months and need to be repeated after
6/12 months depending the case. (22)
The technique of Marian Zilkha, MD, N.York used some times several
sessions in the same week

C02 insufflation for periorbital skin rejuvenation

 2

Courtesy of Marian Zilkha, MD.

Intradermal, daily for a week, multiple puncture

Courtesy of Marian Zilkha, MD

Once a week 6 sessions

Stretch Marks
 2

The first results with the use of CDT are seen after a few sessions
(21).The quality of the skin is important in the treatment of the stretch
marks. Will be have a better result if there are a soft skin texture, a
good firmness of the skin and a homogeneous color of the stretch
marks (more pink).
One session each 15 days during 3- 4 month
The technique is a combination of a single deep puncture ( 6mm)
injecting CO2 200cc and multiples superficial ( 1 mm) punctures
injecting CO2 5 cc in each stretch mark path.

CONCLUSIONS
Its a useful tool for the treatment of Cellulite, Localized adiposities,
Stretch marks, skin laxity etc.
Easy application with no significant or adverse side effects
Possible association to other types of procedure (Mesotherapy,
radiofrequency etc)

Device: Its important to have a device that allows a progressive

control of the flow, slow or fast, small or larger amount of gas (1cc to
100cc) according to treatment needs. These are the conditions to
obtain a painless application
 2

References

1- El anhidrico carbonico y el carbogeno en el tratamiento de las arteriopatias

perifericas. Dr. Mariano castex - de. Alfredo v. Di cio
boletines de la academia nacional de medicina de buenos
buenos aires, 1934

2 - Mal perforante plantar con calcificacion arterial - Resultados del tratamiento con
carbogeno.Dr. Mariano Castex - Dr. Alfredo v. Di cio - Dr. Gregorio a. Lista.
Revista de la Asociacin Medica Argentina DICIEMBRE 30 DE 1934.

3- Etude sur linjection sous cutanee de gaz thermaux de Royat. Clermont

Ferrand.Romeuf J. B. Imp Moderne, 15 rue du Port 31. Mars 1940

4- Interet de la technique des perfusions de gaz dans le traitment thermal des

arteriopathies.Gaillard A. Clemont Ferrand Thermal Royat.1988

5- Guide thermal de Royat 12 eme ed ,

Petit CA, 1880-1898, Clermont Ferrand 1980

6- Arteriopathie diabetique et thermalisme.

Berthier J. Reunion de lAssociation Nationale de Formation Continue en Medicine
Thermale, Paris 17 decembre 1993

7- Sur laction vasodilatatrice du dioxyde de carbone injecte sous forme gazeuse

dans le tegument delhomme
Colin C, Lagneaux D, Lecomte J, Presse Thermale Climatique,116, 4 255-258,
 2

1979 France

8- Rol del CO2 como complemento de la lipoplastia. International School of

Aesthetic Medicine. 8 Course of Aesthetic Medicine Postgraduate C.Brandi MD
Dpto. Of Plastic & Aesthetic Surgery University of Siena, 28-29/11/2003 - Italy

9- Vasomotor effects of transcutaneous CO2 in Stage II peripheral occlusive

arterial disease
Savin E, Bailliart O, Bonin P, Bedu M, Coudert J:Angiology;46(9):786-91, 1995 sep

10- Effect of Carbon Dioxide enriched water on the cutaneous microcirculation and
oxygen tension in the skin of the foot
Hartman BR, Bassenge E, Pittier M: Angiology; 48(11):957-63 1997 Nov

11- Role of carbossiterapy in plastic surgery - Strategies for prevention :The role of
medical sciences and nutrition - European Congress G.Brandi, Lgrimaldi, Bbossi,
CDAniello et als The Ageing Society - Salsomaggiore Terme October 27-29 2000 -
Italy

12- Topical application of CO2 increase skin blood flow

Ito T, Moore JL J. Invest. Dermato 93:259, 1989

13- Carbon dioxide therapy in the treatment of localized adiposities: clinical study
and histopathological correlations
c. Brandi, c. Daniello, l.grimaldi, p. Lattarulo aesthetic plastic surgery vol. 25 (3)
May June, 2001

14- The role of carbon dioxide in Symmetric Multiple Lipomatosis therapeutic

strategy .
 2

DAniello C., Brandi C., Bacci P.A., Lattarulo P. Unita operativa di Chirugia Plastica
, Universita degli Studi di Siena RIV. ITAL.CHIR.PLASTICA 31; 265-269, 1999
Siena

15- Cinical Capillaroscopy

BollingerA Fagrell B 1990

16- Relationship between dosis and the microcirculatory answer in patients with
Cellulite Sindrome, after the injection of CO2.
Albergati Lattarulo Curri XVII Congreso Nacional de Medicina Estetica Roma
1997

17- The role of carbondioxide therapy as a complement of liposuction

Brandi C.M.D., Grimaldi L.,M.D., Bosi B.,M.D., Dei J.,M.D., Malatesta F.,M.D.,
Caiazzo Unit of Plastic Surgery University Study of Siena The xvi. Mondial
congress of isaps abstract book, 2002 / MAY, 2002 - 07- 26 -29 - ISTANBUL
TURKEY

18- Microangiopatia de estasis

Curri & Ryan 1989

19- Symetric Lipomatoses in female patients

Stavropoulos PG et als: Dermatology;194(1):26-311997

20- Cellulite. Treatment and clinic therapeutic approach.

Leibaschoff, G,MD, Am. J. Cosm. Surg.1997

21- CO2 insuflation for gynoid lipodystrophy treatment: Brazilian experience in Cellulite

Valeria Campos, MD, Hospital da Clinicas, San Pablo, Brazil

 2

J.Am Academy of Dermatology 2007, February 2007

22- Tretament of the laxity of the eyelid with Carboxitherapy (CDT)

Dr,Thiago Jevaoun

Hospital General of Bonsucesso Brasil

23-Increase in collagen turnover induced by intradermal injection of carbon dioxide in rats

Julio Cesar Tavares Ferreira, MD et alts

2008, Journal of Drugs in Dermatology

24- Recent developments on lipolysis regulation in humans and discovery of a new lipolytic
pathway.
Lafontan M; Sengenes C; Galitzky J; Berlan M; De Glisezinski I; Crampes F; Stich V; Langin
D; Barbe P; Rivire D
International journal of obesity and related metabolic disorders: journal of the International
Association for the Study of Obesity 2000;24 Suppl 4():S47-52

25- A double-blind, prospective, clinical, surgical, histopathological and ultrasound

study comparing the effectiveness and safety of liposuction performed using
Laserlipolysis and Internal Ultrasound Lipoplasty method, and assessing the evolution
in patients.
Dr. Gustavo Leibaschoff et alts
Congress of the Australasian College of Cosmetic Surgery, Gold Coast, Australia, May, 2008