Spain Essay Medical. Mesotherapy
By: Ruth Diaz Molina
Graduate of Nursing
From the age of 25, human beings begin to show the first signs aging on the surface of the skin. At first, fine lines appear and, in the course of time, wrinkles, loss of Wrinkles volume and loss of density are perceived.. Currently the explosion of images reflecting “youth and perfection” by the media have created the need to investigate and develop facial rejuvenation treatments with non-invasive techniques such as facial mesotherapy.
It is because of this concern about the advancement in the field of facial treatments that this descriptive observational study conducted through documentary research aims to provide insight into the state of mesotherapy and PRP (platelet-rich plasma) as facial rejuvenation techniques and compare hyaluronic acid (product used in mesotherapy) with PRP.
What these two products are used in order to maximum optimization of their results are concepts that are developed in this study and in conclusion lead us to consider what are the needs that the skin presents to be treated. Is it a passive nutritional contribution that that skin attains or does it need active tissue nutrition to regenerate?
Aging, Mesotherapy, Facial rejuvenation, Platelet-rich plasma, Hyaluronic acid
For a better understanding of facials and a better choice of these we should first talk about two concepts: beauty and aging.
The concept of beauty is by itself a subject worthy of study. Even the Holy One himself
Thomas Aquinas, in the Summa Theologiae (I. Q. 5, Art. 4, ad 1) simply says that “pulchra dicuntur quae visa placent” (“things are said to be beautiful if they place when they are seen”). It can be said that this is the vision of beauty that spontaneously presents itself to the minds of most people when it comes to beauty (1). A very changing vision that will depend on many variables such as fashion, culture, society, etc. and in which the signs of aging are not usually well received.
On the other hand, there is aging, a very complex process unique and exclusive to each individual linked to their genetic load that brings with it molecular changes that manifest themselves at the cellular, histological and anatomical level, where skin aging is one of its most obvious manifestations. Signs of aging are due to loss of skin elasticity and falling subcutaneous structures, which modify the volumes of the face, causing a sad and tired appearance. (2)
It is accentuated by environmental factors such as solar radiation (ultraviolet), air pollution, and individual habits or behaviors, including tobacco and stress. Clinically, it is possible to distinguish chronological aging (marked by our biological clock) and that produced by photo aging (actinic radiation). In the exposed skin of the face, neck, neckline and back of hands are caused by the solar action, major alterations such as: drying, loss of tonicity, dysromies, along with the appearance of lesions such as alltigo and other premalignants (actinic kerathitis). There is a gradual decrease in collagen and alteration of elastic fibers and it results in skin atrophy, sagging and wrinkled skin (skin cracking), this condition is called “skin elastosis”. (2)
Over the years there is a gradual loss of support of the soft tissues of the face. To this is added a progressive bone involution with oily displacement and muscle sagging blurring the parameters of youth and beauty.
Facial mesotherapy acts on the causes of skin aging and provides elasticity and luminosity to the skin of the face, neck and neckline. It is a therapeutic procedure that involves applying micro injections, intradér-mica, to deposit small doses of medicine in the area to be treated. According to the “Manual of Mesotherapy, combined and related techniques in Aesthetic Medicine” by Ignacio Ordiz the products used in mesotherapy are a combination of active substances such as vitamins, amino acids, polynucleotids, trace elements, unlinked hyaluronic acid in different concentrations and organic silicon. (3)
PRP, in contrast, is an injection, not of substrates and raw materials such as conventional mesotherapy, but a large number of inflammatory mediators and growth factors that actively stimulate skin regeneration are infiltrated. (4)
Simply put, in mesotherapy there is a maintenance and supply of passive nutrients within the skin while in PRP what happens is an active stimulation of the tissue to regenerate. (4)
Mesotherapy was first described in France in 1952 by Dr. Michel Pistor. The technique was to inject the medication directly through the skin to correct diseases of lymphatic and vascular origin. In 1987 mesotherapy was recognized by the French Academy of Medicine as a medical specialty. The products that are injected are very varied, vasodilator de-vasodilators, anti-inflammatory drugs, antibiotics, hormones, enzymes and many others. They were able to treat chronic pain, psoriasis, cellulite and weight loss. Very few studies have been published on the mechanism of action of the drugs used. However, it is commonly accepted that, if you inject the substance into us over the affected area, its concentration will be much higher than if oral or intramuscular treatment is performed. One of the latest applications of mesotherapy is to use hyaluronic acid alone or in combination with other substances to treat facial photoaging. (5)
To quantify the degree of photo aging we use the Glogau Classification:
- Mild (28 to 35 years) wrinkles and incipient, dynamic lines, without associated skin lesions.
- Moderate (35 to 50 years) most obvious wrinkles, incipient actinic lesions. Requires moderate makeup.
- Advanced (50 to 65 years) Stable wrinkles, resting lines. Actinic dysromies and injuries. Permanent use of makeup.
- Severe (60 to 75 years) Severe aging photo, with deep and persistent wrinkles, gravitational facial changes and abundant solar skin lesions. Little coverage with makeup. (6)
As an anti-aging technique, mesotherapy finds an ideal complement to surface and medium peelings (provided that the premise of not performing the two therapeutic acts in the course of the same session is respected to prevent the agent from chemical penetrates through the microherides caused by punctures), hyaluronic acid and botulinum toxin. Combining these four therapies we would act on the skin you see (peelings), on the superficial dermis (mesotherapy), on the deep dermis (filling implants) and on the musculature of the expression (botulinum toxin), obtaining a more satisfactory final result. It is about acting on the superficial musculoaponeurotic system of the face through the skin connections healing the wounds and for this reason, a “dry” mesotherapy would already have a therapeutic effect in itself, as achieved with collagen stimulation techniques using dry multipoints. The mesotherápica technique is important for obtaining results. The administration of medicines can be done by techniques such as point by point or burst being preferable to assisted mesotherapy than manual. “In burst”, the skin of the face, neck and neck (and hands) is punctured at a depth less than 2 mm, practically subpidermic, performing the classic nappage. This technique dispenses with the peepholes of the pistols as they hinder the injective method. We will “draw” the plasma muscle to its full extent, from the upper pectoral region and anterior deltoids to the lower edge of the jaw and the skin of the lower part of the face. In the area of the face we will draw upward and cross paths (in mesh or net), not forgetting the crow’s feet and the front wrinkles. The prevention of bruising must be extreme especially in the frontal and periocular area, as well as adapting the movement of the hand to the speed of the burst sequence so as not to cause cuts with the needles (meso-softnes technique). It is advisable that we approach the patient’s skin with the gun in the running position to avoid excessive penetration of the needle at the first puncture: the depth of the puncture is calibrated with visu (no peephole) and it is important to control it. Some of the liquid we use will water the treated area. In the case of making a manual nappage it is preferable to do so with a needle of 13 mm in length and bent (bent needle technique), which allows us to insert the needle not with a swinging movement of the hand with which it is difficult to control the injection depth, but with a flexo-extension of the wrist that naturally limits its penetration.
In the skin, silicon is involved in collagen synthesis, particularly in the hydroxylation of proline in OH-proline. It also has a great relationship with the elastin content since its synthesis also depends on silicon, so the loss of the elastic properties of elastin is one of the most skin aging related to the reduction of silica content. In addition, skin hydration depends on the content in glycosaminoglycans, macromolecules that contain a lot of silicon. Decreased skin thickness, which is a sign of dehydration, is also observed before wrinkles appear. This thickness, and therefore hydration, is enhanced by organic silicon. It even seems that queratinization would also depend heavily on organic silicon. Therefore, we consider it an active substance that should never be missing from our syringe. The frequency of sessions should be fortnightly for the first 2 or 3 times, and subsequently it will be monthly, bimonthly or quarterly uninterrupted, adapting to the situation of each patient. It is important to inform the patient that we are not looking for an “anti-wrinkle” effect, but a delay in aging considered a global phenomenon. Therefore, the end result is a more vital skin, more hairy, less scared, brighter, firmer and hydrated, especially when we do combined treatment techniques. (3)
Of the medicines used in Mesotherapy:
The main requirement that any active substance must meet to be incorporated into the therapeutic arsenal of Mesotherapy is that it be legal in the country in which it will be used. The development of the Internet has allowed the presence in the pharmacological market around the world of supposed medical specialties with indications in Mesotherapy, especially in its aesthetic applications. To check it, just type the appropriate words in any internet search engine. This ease of buying medicines without any control has conditioned the dramatic increase in side effects related to this type of therapy. Normally, considering that these supposed medical specialties are most often clandestine products that, at best, have been registered in some generally distant country as cosmetics and even as dietary supplements so they escape any control by the corresponding Health Administrations. And most commonly they are counterfeit medicines that for any reason “are fashionable”, which would add the crime of fraud to the drug trafficking. Anyone who has an internet access and is used to payment by credit card can buy virtually any of the wonderful products that are offered crushingly on the network. Another important handicap for completing a minimally operational therapeutic arsenal for the practice of Mesotherapy is that injectable presentations under those marketed as commonly used drugs do not consider intradermal administration except very rare exceptions so we have no choice but to use them empirically through this different parenteral route of administration, even if in their data sheet it is not considered such an eventuality. Health administrations in all countries are often very “conservative” about the use of certain medicines as they have to protect the health of their citizens. And to this we must add the fact that, usually the routes of administration preferred by end-users of medicines, these are, patients, are those that do not cause pain or discomfort, giving preference to the oral or topical route, so we have seen how the therapeutic arsenal of Mesotherapy has been significantly reduced over the years, with the disappearance of commercial presentations, which so many and so good pages have given to Mesotherapy since its origins. The Spanish Medicines Act dated July 27, 2006, the full text of which can be found in http://www.boe.es/boe/dias/2006/07/27/pdfs/A28122-28165.pdf, includes another option that is the use of masterful formulations. The medicinal product intended for an individualized patient, prepared by a pharmacist, or under his direction, is defined as a master formula in order to expressly complete a detailed optional prescription of the active ingredients which includes, in accordance with the rules of correct elaboration and quality control established for this purpose, dispensed in the pharmacy office or pharmaceutical service and with due information to the user in the terms provided for in Article 42.5. (3)
Hyaluronic acid was discovered in 1934 by Karl Meyer and John Palmer (Columbia University) in the vitreous humor of a bovine’s eye. Its primary biochemical structure corresponds to acid and uronic hexosamines, chemically behaving like salt. In 1937 Kendall et al discovered a polysacchaid identical to hyaluronic acid in the Streptococus alpha hemolytic capsule. In the 1950s, Meyer again discovered the presence of hyaluronic acid in synovial fluid, as well as in the fundamental substance of connective tissue, umbilical cord, skin or crest. In parallel with this discovery, Albert Dorfman was able to synthesize hyaluronic acid from Streptococus alpha hemolytic. During the following decade it began to be used in animals by intraarticular injections into racehorses affectionate of post-traumatic arthropathies. As early as the 70s-80s of the last century, this molecule began to be used for therapeutic purposes in humans in the areas ophthalmology (as a viscoelastic supplement in the post-surgical treatment of cataracts) and rheumatology (in arthrosic knees). Approximately 10 years after the commercialization of bovine collagen (1981) in the United States, hyaluronic acid appeared on the cosmetic medicine market. In 1995, the first crosslinked hyaluronic acid was released. Currently the source of obtaining is by bacterial fermentation.
Chemically hyaluronic acid is a polysaccharide macromolecule in the glycosaminoglycan family (formerly known as mucopolysaccharides). It has an unbranched chain of about 2500 units of non-sulfated disaccharides formed by the binding of glucuronic acid and N-acetylglucosamine by beta-type bonds. Its molecular weight is 2000 KDa. Hyaluronic acid is one of the essential components of the extracellular matrix of connective tissue. It is estimated that an adult individual weighing 70 kg possesses about 15 to 17 grams of hyaluronic acid located primarily in the skin and musculoskeletal system. In addition, hyaluronic acid has antioxidant activity by being able to capture the electrons of free radicals, although however this property causes it to be destroyed by progressive depolymerization decreasing over time the viscosity of synovial fluid and the elasticity of the skin. At the same time it is extremely sensitive to UV rays which depolymerize it very easily leading to skin dehydration. At the extracellular matrix level, hyaluronic acid is rapidly degraded by lysosomal enzymes secreted by connective tissue (hyaluronidase, glucuronidase, N- acetylglucosaminidasas and kinases) so a way has been sought to stabilize it with the aim of increasing its half-life in situ. This is achieved in part by crosslinking the long chains of the molecule together by two bridges. The most commonly used crosslinking agent is butanediol diglicedileter (BDDE) although some manufacturers prefer to use formaldehyde and diepoxictane. The more crosslinked hyaluronic acid occurs, the greater its viscosity and its resistance to degradation, the greater its durability over time may be several months when injected. When choosing one type of hyaluronic acid or another according to therapeutic needs, we will have to take into account several factors that will influence both its viscosity and the resistance that the syringe will offer for injection. It is important to have counts the amount of the crosslinking agent, the performance of crosslinking and its effectiveness, that is, the number of effective bridges it actually forms. If crosslinks form exclusively between long chains, the result will be an une homogeneous hyaluronic acid that is difficult to inject; if crosslinks are divided between short and long chains, the result will be a more homogeneous hyaluronic acid and therefore easier to apply.
In the market they come in two forms:
- Biphasics have a continuous phase of hyaluronic acid little or nothing crosslinked containing suspended hyaluronic acid microparticles. They are easy to inject, but also easy to degrade, forcing frequent retouching for the short duration of their effect.
- Monophasics are made up of a more stable and less degradable but harder to inject isotropic continuous phase. In this case crosslinking is capital to obtain a homogeneous product that is easy to inject and at the same time resistant to enzymatic degradation. There are monodensified ones, whose surface is not uniform, and polydensified that have a uniform surface, without particles, which gives it greater effectiveness, better dermal integration and lower risk of side effects.
In general, presentations that are indicated for use by mesotherapanthropic or superficial intradermal pathway contain only sodium hyaluronate or very few traces of crosslinked hyaluronic acid to ensure an optimal result without the presence of very unsightly, if passing, overcorrections in rice grains. In the mesotherápica application, the moisturizing effect is more sought than the filling effect. Normally the product is used as it comes in its commercial presentation. Mixed protocols are common in which, for example, 3 or 4 sessions of mesotherapy are included using hyaluronic acid-free products, alternating them with a hyaluronic acid session.
The injection technique is usually point by point, applying the product in those areas (such as cheeks, crow’s feet, facial oval, neck, neckline, back of hands) where we want to increase skin hydration. (3)
In facial rejuvenation techniques using filler materials, good clinical evaluation is essential to obtain a correct indication of the technique and material to be used and obtain a favorable aesthetic result.
The main treatment area corresponds to NGS and the most used material is AH, with which we achieve good and lasting results when applied at the dermis level.
It is recommended to apply in the same anatomical region 1 ml, maximum 2 ml. In 80% of patients it is usually sufficient to use 1 ml of product. If more product is needed, we will perform a reinforcement in another treatment session, because due to the anatomical characteristics of the dermis and the ease that the AH has of joining the water, it is very common the rapid appearance of edema that prevents most of the time from re-evaluating the region during the infiltration session, so we could lose the reference anatomical parameter and overcorrect or correct defectively.
When AH is applied to the hypodermis, the result of wrinkle or groove elevation is minimal and larger quantities of product are required since the filler is directed to the depth and not to the surface. In addition, this plane contains less water, so the AH is reabsorbed more quickly and therefore the technique fails.
When AH is applied very superficially, it can cause irregularities or necrosis of the epidermis with extrusion of the material. We believe that this can only happen when the professional is not familiar with dermal inclusion techniques, as it is much easier to make an inclusion in the subcutaneous, which does not produce resistance, unlike in the dermis, where there is greater resistance when injecting. Irregularities caused by very superficial AH inclusions can be corrected by massaging the area during the first 2 weeks. (7)
Side effects linked to the use of hyaluronic acid intravenously, both superficial and profound, highlights the appearance of bruises, usually pointiforms and transient erythema/edema that spontaneously subside. They can be prevented using cryogens (a simple ice cube inserted into a disposable glove can be very useful to us). Arnica 7CH in granules is useful for shortening the evolution of bruises. No granulomatous reactions have been reported in the short or medium term with the use of unlinked hyaluronic acid. We must avoid overcorrection or the formation of large papules in areas such as the forehead or sternum where the absence of a subcutaneous cell tissue pad makes the presence of nodules more apparent.
Hyaluronic acid cannot be used in people who have a history of allergic to chicken or egg proteins.
Platelet-rich plasma or PRP:
In the context of biochemical research to counteract the cellular processes of aging, platelet-rich plasma (and rich in platelet-derived growth factors) was studied and used for its modulating and stimulating properties of the proliferation of cells derived from mesenchymal stem cells (fibroblasts, osteoblasts, endothelial cells , epithelial cells, adipocytes, myocytes, and chondrocytes, mainly), and as a useful auxiliary element to improve tissue regeneration. PRP was initially used in certain surgical specialties to improve healing of introgenic wounds and recalcitrantly evolving wounds. But its current applications extend beyond use to repair surgical wounds and regeneration of lost tissues, and prp has become popular in other branches of medicine. In the field of aesthetic medicine prp is mainly used for its role in the biostimulation of skin fibroblast, and as a biopowerer of adipose tissue filler treatments. (8)
Activation of dermal fibroblasts is essential for the rejuvenation of aged skin. Extracellular matrix remodeling is necessary for rejuvenation of aged skin, and activated fibroblasts play a role in this process. Matrix metaloproteinase proteins (MPMs) are involved in the aging process by degrading collagen and ECM proteins.
Various techniques have been tested for clinical use of PRP in skin rejuvenation; however, a clearly defined form is not available.
- Topical application under occlusion.
- Direct intradermal injections (ID).
Platelet-rich plasma can be used as a laser adjuvant or microneedle. It is usually done once every 4-6 months for 1 year and then annually as maintenance therapy.
Monthly intra-dermal injections of PRP in 3 sessions have shown satisfactory results in rejuvenation of the face and neck and scar reduction.
In addition, PRP has been combined with fractional ablative lasers (carbon dioxide) for deep wrinkles and severe photodaged skin and has been shown to be effective in reducing it with less downtime. (9)
A bibliographic review of a total of 18 original articles published in Pubmed, Medline, Scielo and Google academics in the English and Spanish languages was carried out through the bibliographic reference manager Mendeley Desktop, of which 9 selected citations were used to carry out the review.
Result and discussion:
Facial mesotherapy is an uninvasive technique that helps us fight skin aging. The most commonly used products are hyaluronic acid, vitamins, amino acids and platelet growth factor using the nappage technique, multiple product injections into the surface dermis. In areas that require a higher product input, a tank is injected into the deep middle dermis, which manages to give more volume. The function of the products injected into the dermis is to moisturize the skin and prevent the damage of free radicals. Therefore, the number of sessions will depend on the chronological age and photoaging of the patient.
Molecular evidence from various studies on hyaluronic acid revealed that the rejuvenating and anti-wrinkle effects of the skin produced by the application/administration of HA are due to its ability to stimulate collagen synthesis by induction of fibroblasts in the dermis. Increased collagen production softens the skin, reduces wrinkles and improves skin elasticity and longevity.
Platelet-rich plasma treatment is a technique that stimulates cell regeneration and renews epidermal tissues using the patient’s own blood.
The plasma facial procedure is very simple. Blood is drawn from the patient’s arm and inserted into a specific machine that is responsible for centrifuging it. Once the blood is centrifuged, the plasma obtained is injected into the area to be treated.
On the one hand, PRP provides growth factors, which increases at the site of treatment the number of fibroblasts and thus the stimulation of local collagen production. Mesotherapy with hyaluronics and vitamins provides hydration and raw materials in the form of vitamins, minerals and nucleotides so that those fibroblasts that we have increased and stimulated with PRP work and form new collagen.
This study concludes that they are complementary techniques with which synergy with a much higher effect is achieved by combining both.
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