Cosmetic Technique

Aesthetic Mesotherapy: The US

Approach and Contribution
Abdala Kalil, MD

Long before mesotherapy was used in cosmetic dermatology, it gained recognition in pain manage-
ment, sports medicine, and rheumatology. In the aesthetic arena, it had few indications and unim-
pressive results and was used mainly to treat cellulite. However, as the demand for more effective
noninvasive cosmetic surgery treatments grows, the popularity of mesotherapy continues to increase
nationwide. The latest spike in popularity is due to 2 newly created applications. One is the mesolift,
also known as mesoglow, which consists of injecting a mixture of vitamins, minerals, and hyaluronic

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acid into the skin. The other is the injection of phosphatidylcholine and enzymes (collagenase and
hyaluronidase) to treat fat deposits for body sculpting. Thus, US fascination with mesotherapy has
been limited to its aesthetic applications. When mesotherapy was introduced to the United States,
the procedure was much less aggressive in terms of the ingredients used and the volume of those
ingredients as a result of heavy French influence. However, US physicians quickly adopted their
own methods and variations on the procedure, and the approach changed radically because of a

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major difference in the mentality, habits, and expectations between the markets. Today, mesother-
apy in the United States has products and protocols that are original and much more efficient. For
once, innovation in aesthetic medicine, which usually travels from east to west, is now crossing the
Atlantic in the opposite direction. In this article, we will explain some of these products and protocols.
Before proceeding, it is important to mention that there have been no controlled studies of meso-
therapy to date, although one is reported to be under way in the United States. Physicians rely mostly
on anecdotal experience until the results of such studies are published. Therefore, although it is true
that there has been no systematic evaluation of toxicity, there are no reports of such adverse events
despite the wide use of mesotherapy today. However, this does not necessarily mean that mesotherapy
is completely safe, and dermatologists must keep in mind that no aesthetic treatment should in any way
endanger a patient’s health—“first, do no harm.”

S
temming from a simple and fortuitous discov- smaller doses were needed to avoid side effects and other
ery by Michel Pistor in 1952, mesotherapy interactions. Pistor described it as “a little, not so often
began as a great idea. The concept was to and where you need it” treatment.1 The intent was that
superficially inject active pharmacologic ingre- these ”close-to-the-target” doses would be distributed
dients into the mesoderm, the middle layer of locally through the mesoderm mesh. As previously noted,
the skin, to treat local affections. Mesotherapy was used mesotherapy acquired its credibility initially in sports
mainly in sports medicine and rheumatology. As such, medicine and rheumatology. Mesotherapy is a concept of
delivering active ingredients into the mesoderm manually
Dr. Kalil is Director, Vitality Institute, Miami Beach, Florida. or through an electronic injector.
The author reports no actual or potential conflict of interest in Mesotherapy soon involved a complementary treat-
relation to this article. ment with active ingredients (pentoxifylline and others)
Vol. 19 No. 12 • December 2006 • Cosmetic Dermatology 753
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 Aesthetic Mesotherapy

to stimulate vascular circulation for patients with condi- Almost all localized fat deposits can be successfully
tions such as cellulite. However, it is the use of phospha- treated, including those on the abdomen, hips, love
tidylcholine (PDC) that revolutionized the treatment of handles, upper back (Figure 1), chin, and lower eyelids
local fat deposits. (Figure 2). Mesotherapy works well for body sculpting
but not for weight loss. Its primary use should be for
Pharmacology and Indications diet-resistant areas in patients who are correctly follow-
Cellulite and Fat Deposits ing a diet regimen. There is no substitute for healthy
PDC, a soy extract, is a liquid form of lecithin, which eating habits.
occurs naturally in the body.2,3 An Italian physician,
Maggiori,4 was the first to inject PDC to treat xanthe- Mesolift or Mesoglow
lasma. From this, Rittes,5,6 a dermatologist in San Paolo, Treating aging skin with mesotherapy represents a novel,
Brazil, envisioned injecting Lipostabil®, a PDC solution, valid approach. In addition to delivering nutrients to the
into the fat pouches on the lower eyelid. Lipostabil was skin through creams, where they are often unreliable and
previously used to treat and prevent atherosclerosis and unpredictable, or through the blood, where they often
fat embolism.3 It was available in 5-mL ampoules at interact with the gastrointestinal tract and are mostly
5 mg/mL only in Germany and Italy. In the United States, excreted by the kidney nearly instantly, mesotherapy
PDC is available to physicians through compounding delivers vitamins, multiple trace elements, minerals,
pharmacies as a generic product. It is considered to be tretinoin, hyaluronic acid, 2-dimethylaminoethanol, and
a nutritional supplement and is not regulated by the more directly into the dermis with a concentration that

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Food and Drug Administration. It is dosed at 50 or was previously unachievable. This advent rendered the
100 mg/mL. There were few reports of successful treat- treatment doubly effective through its direct delivery and
ments for fat deposits with PDC; one such report was the stimulating effect of the needle itself.
from Ablon and Rotunda,7 who discussed their results of Hyaluronic acid, popular as a soft-tissue filler, is avail-
treating the lower eyelid fat pads. able in a nonreticulated form in concentrations from 10
Since a recent study by Rotunda et al8 raised ques- to 40 mg/mL. This is in contrast to the reticulated or
tions about which ingredient in PDC solution (PDC stabilized form of hyaluronic acid used in fillers such as

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or the preservative deoxycholate) is the active one, Restylane® and Juvéderm®, which lasts much longer but
50 mg/mL has become the most common dosage. at a much higher cost. Two other favorites are injectables
Deoxycholate, a detergent used in many pharma- tretinoin 0.01% or higher and glycolic acid 1% to 10%.
ceutical preparations, was determined to physically
damage the fat cell membrane and cause cell death Mesohair
and release of fat content. A follow-up study by Rose In this application, a new milestone is achieved. After
and Morgan 9 showed that fat lobules were infiltrated injecting a range of ingredients into the scalp (eg, minoxi-
by increased lymphocytes and, in particular, macro- dil, finasteride, vitamins) for many years with no results,
phages. The macrophages consisted of conventional we now have a protocol effective for treating male pat-
forms, foam cells, and multinucleated fat-containing tern baldness (MPB). In one study, dutasteride, the only
giant cells. The inflammation was associated with 5a-convertase inhibitor specific to both receptor 1 (skin
serous atrophy and microcyst formation. For the and liver) and receptor 2 (prostate), has been clinically
authors, this demonstrated that mesotherapy with proven to regrow hair, with significant results in MPB.10
PDC and deoxycholate affects the subcutaneous fat, The price often paid is an increase in side effects—mainly
and they theorized that reduction of subcutaneous fat a decreased libido, especially at the most effective dose of
likely follows inflammatory-mediated necrosis and 2.5 mg/d or 5 capsules daily.
resorption via the macrophages. By blocking the 5a-reductase, the production of
PDC is usually diluted in a 2-to-1 ratio with other ingre- 5-dihydrotestosterone is decreased. Dutasteride may
dients, such as collagenase or lidocaine, and injected into block up to 90% of the activity of this enzyme, whereas
the hypodermis by using a needle of at least 6 mm. finasteride, specific only to receptor type 2 (prostate),
For treatment of cellulite, the use of hyaluronidase, in at best can block 70%. By injecting dutasteride directly
combination with collagenase, is thought to soften the into the scalp at a depth of 2 to 3 mm, we were able to
hardened fibrotic septa that contributes to the orange- reverse MPB and avoid any side effects because most of
peel appearance. Hyaluronidase also facilitates the diffu- the medicine stays local and the injected dosage is lower
sion of the cocktail and helps to prevent posttreatment than the oral dosage. Initial treatment is given anywhere
nodules under the skin, although the nodules are benign from once a week to once every 4 weeks. Dutasteride has
and always resolve. a very long half-life (5 weeks).

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 Aesthetic Mesotherapy

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Figure 1. Love handles and upper back before (A) and 8 weeks after (B) 1 mesotherapy treatment.

Vol. 19 No. 12 • december 2006 • Cosmetic Dermatology 755

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 Aesthetic Mesotherapy

Mesofat
Head and Neck
To treat excessive swelling, apply a meth-
ylprednisolone dose pack 2 days before
Figure not Figure not treatment, add a drop of corticosteroids
available online available online to the solution in the syringe, or both.
For infiltration, use a 3-cc syringe to
apply 2 cc of PDC 50 mg/mL, 0.5 cc of
lidocaine 2%, and 0.25 cc of collagen-
Figure 2. Lower eyelid fat pads before (A) and 12 weeks after (B) 2 mesotherapy treat- ase 1000 IU/mL. Collagenase should be
ments 6 weeks apart. used only in fat pads resistant to treat-
ment with PDC alone, or it can be used
This represents a perfect application of mesotherapy in combination with PDC for a more aggressive approach.
for addressing the problem at its root to avoid systemic Also consider adding 0.25 to 0.5 cc of triamcinolone
interactions and achieve much higher tissue, cellular, 10 mg/mL. For eyelid fat pads, apply 1 cc under each eye
and intercellular levels of the ingredients injected. Fig- according to size. Use a 30-gauge, 1-in needle, but do not
ure 3 shows the author’s own head treatments spaced give dermal injections, since this may cause ulceration
8 months apart. (Figure 4; in this case they healed very well). The cheeks
and jowls may use 2 to 3 cc on each side. Use a 25-gauge,

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Protocols 1-in needle because it will not bend during infiltration.
The following protocols are given as an indication. They The chin may also receive 2 to 3 cc on each side; use a
reflect the author’s clinical experience to date. These are 25-gauge, 1-in needle in this area as well. Treatments may
only some of the combinations commonly used; these be repeated every 6 to 8 weeks if needed.
combinations tend to change frequently as experience
grows. Physicians should be properly trained, confident, Body
and experienced before attempting to treat patients. Ulti- Use a 12-cc syringe to apply 7 cc of PDC 50 mg/mL, 2 cc

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mately, expertise is not limited to delivering treatments; of l-carnitine 500 mg/mL, 2 cc of collagenase 1000 IU/mL,
it also requires the knowledge to avoid or minimize, and and 2 cc of lidocaine 2% (when the piston is pulled back
learn how to deal with, the inevitable complications. completely, the syringe total will be 13 cc).

Figure 3. Subject with male pattern baldness before (A) and 8 months after (B) 16 mesotherapy treatments.

756 Cosmetic Dermatology • december 2006 • Vol. 19 No. 12

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 Aesthetic Mesotherapy

Mesohair
Use a 6-cc syringe to apply 3 cc of biotin and 3 cc of
dexapanthenol to areas of nonhormonal hair loss. If the
patient has hormonal hair loss, MPB, or is menopausal,
apply 3 cc or more of dutasteride 0.01% and 3 cc min-
oxidil 0.2%. Use all 6 cc to cover the affected areas of the
scalp. Use a standard, 4-mm mesoneedle for a depth of 2 to
3 mm. Initially, 4 or more treatments every 1 to 2 weeks are
recommended until significant results are yielded. Mainte-
nance should include 1 treatment every 1 to 2 months.

Follow-up
In general, no follow-up is needed except to assess prog-
ress and the need for further treatments or to evaluate
concerns and treat any complications that arise.
When following up with further treatment, remember
Figure 4. An eyelid ulcer caused by dermal injections. to give fat treatments time to progress, since reabsorption
is slow and takes approximately 6 to 8 weeks. For skin
rejuvenation and hair treatments, there is an obvious

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Collagenase is not for beginners, as it can cause ulcers advantage to initially providing frequent treatments; this
if inadvertently injected into the dermis. Substitute it will kick-start repair and yield quicker results.
with more l-carnitine; this formula works even without
collagenase. Use a standard, 6-mm mesoneedle and, Complications
again, avoid dermal injection, the cause of dermal necro- Bruising is the most common complication, especially
sis. Also consider infiltration if working on small areas. with such a high number of injections. The severity var-
Treatments may be repeated every 6 to 8 weeks if they ies but may be lessened by avoiding nonsteroidal anti-

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are well tolerated. inflammatory drugs and pretreatment vitamin E and by
taking the homeopathic ingredients Arnica montana and
Mesocellulite bromelain pretreatment and posttreatment. Undereye
Use a 12-cc syringe to apply 3 cc of hyaluronidase bruising is avoidable by introducing a 30-gauge, 1-in
150 U/mL, 2 cc of collagenase 1000 IU/mL, 6 cc of PDC needle laterally, starting under the lateral canthus in the
50 mg/mL, and 2 cc of lidocaine 2%. Use a standard, middle of the fat pad.
6-mm mesoneedle and, again, avoid dermal injection. Infections are very rare and avoidable with nonaggressive
Treatments may be repeated every 2 to 4 weeks. cleansing of the skin with alcohol. Inflammatory response
is invariably present, the extent of which depends on the
Mesorejuvenation: Mesoglow product and volumes injected. PDC will generate the most
Use a 6-cc syringe to apply 1 cc of multivitamins (mainly inflammation. Skin ulcers and necrosis, though rare, are
vitamins A, C, and E in addition to pyridoxine and des- due mostly to the incorrect injection of collagenase and
panthenol), 1 cc of hyaluronic acid 20 mg/mL, 1 cc of PDC into the dermis, rather than the hypodermis. Undereye
tretinoin 0.01%, 1 cc of glycolic acid 1%, 1 cc of pro- ulcers (Figure 4) tend to be small and heal perfectly well.
caine or 0.5 to 1 cc of lidocaine 2%, and Multitrace-5 Edema is an important factor, especially in the treatment
Concentrate (trace elements injection of zinc, copper, of fat pouches in the lower lids. It may be minimized by
selenium, manganese, and chromium). There are many using the methylprednisolone dose pack pretreatment or
other possibilities as well. adding a cortisonic agent, such as triamcinolone acetonide,
Use approximately 1 cc on the neck and 2 to 3 cc on to the injection. The daily use of 20 mg of furosemide is
the face, but for the first treatment, use less to test the helpful, too. In 2005, an outbreak of mycobacterium caused
patient’s response. It is optional to use 1 cc on the décol- skin infections associated with needle contamination in the
leté area and 1 cc on the hands. Use a standard, 4-mm unhygienic work areas of a nonlicensed provider.
mesoneedle for an injection depth of 2 to 3 mm.
The frequency of treatments varies. Initially, 4 treat- Comment
ments every 2 to 4 weeks are recommended. This can In the treatments overall, it was determined that fat
be increased according to skin damage, and maintenance injections yielded positive, reproducible results in almost
should take place every 3 to 4 months. all cases when the patients were well screened. We treat

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 Aesthetic Mesotherapy

only patients with 1 or 2 areas of excess fat who follow of delivery only and nothing more. The new name should
a healthy diet, including a low consumption of carbohy- be intradermotherapy.
drates, and exercise moderately. This is in no way a treat-
ment for obesity, but rather for body sculpting on limited References
areas of fat deposits, such as genetically determined or 1. Pistor M. Abrégé de mésothérapie du practicien. Paris, France:
Maloine; 1976.
diet-resistant areas. 2. Lichtenberg D, Robson RJ, Dennis EA. Solubilization of phospha-
In the treatment of cellulite, the results are not as tidylcholine by detergents. Structural and kinetic aspects. Biochim
impressive and certainly not as reproducible. We have Biophys Acta. 1983;737:285-304.
found that when the appearance of cellulite was improved, 3. Banerjee P, Joo JB, Buse JT, et al. Differential solubilization of lipids
along with membrane proteins by different classes of detergents.
it was usually associated with excess fat that we were Chem Phys Lipids. 1995;77:65-78.
able to shrink. It was the fat shrinkage that seemed to 4. Maggiori S. Mesotherapy treatment of xanthelasma with polyun-
improve the uneven look of the fat deposit, and therefore saturated phosparitidylcholine (EPL) [abstract]. Presented at the 5th
it appeared that the patient had less cellulite. International Conference of Mesotherapy; 1988; Paris, France.
5. Rittes PG. The use of phosphatidylcholine for correction of
The rejuvenation and hair-loss areas achieved the lower lid bulging due to prominent fat pads. Dermatol Surg.
most remarkable results. The simple concept of directly 2001;27:391-392.
delivering known effective ingredients to the target area 6. Rittes PG. The use of phosphatidylcholine for correction of local-
is reasonable and in the core of conventional medicine. ized fat deposits. Aesthetic Plast Surg. 2003;27:315-318.
7. Ablon G, Rotunda AM. Treatment of lower eyelid fat pads using
We can compare using mesotherapy with injecting local phosphatidylcholine: clinical trial and review. Dermatol Surg.
versus general anesthesia. Mesotherapy will open the 2004;50:422-427.

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door to new possibilities. Treatment for hair loss is only 8. Rotunda AM, Suzuki H, Moy RL, et al. Detergent effects of sodium
one of them; many more are certain to come. Future deoxycholate are a major feature of an injectable phosphatidylcho-
line formulation used for localized fat dissolution. Dermatol Surg.
improvement will involve newer, safer, more effective 2004;30:1001-1008.
products and new methods of more practical, less painful 9. Rose PT, Morgan M. Histological changes associated with meso-
delivery. The term mesotherapy has been very confusing to therapy for fat dissolution. J Cosmet Laser Ther. 2005;7:17-19.
the public and equally to medical personnel, who equate 10. GlaxoSmithKline. A double-blind, placebo-controlled, dose-
ranging clinical evaluation of dutasteride GI198745 and finasteride
it with treatment for fat deposits. This is the reason we in subjects with male pattern baldness (MPB) [study ARIA2004].

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have proposed using new, more succinct terminology that Available at: http://ctr.gsk.co.uk/Summary/dutasteride/studylist.asp.
describes mesotherapy exactly for what it is—a concept Accessed November 12, 2006. n

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