Introduction

It is now 10 years since a number of committed mesotherapists – in particular with a background in dermatology – set about developing a standardised treatment protocol for mesotherapy [1-2]. At that time, we had no way of foreseeing whether and how good this standardization would be and whether it would find acceptance among our colleagues. With the publication of the newly created standards, the interdisciplinary NETWORK operating in the field of mesotherapy that had already existed for many years also gave itself a new organisational structure under the name NETWORK-AestheticMeso, with the aim of establishing standardised training and of continuing along the development path that had already been begun. In the last few years, mesotherapy has experienced a boom that has taken even us by surprise. This can be seen both from the number of patient inquiries we receive and also from the many “Likes” on our Facebook sites (Mesotherapy, Mesotherapie) devoted to this topic. After 10 years, therefore, it is now time to give an updated presentation of the therapy and how it works.

Background

The advanced therapy for the treatment of aesthetic indications that we know today was originally created by a doctor by the name of Michel Pistor, who developed the basics of mesotherapy in 1952. Michel Pistor was a French country doctor, and he was a brilliant observer and experimenter. One event that proved to be a key experience for him was when he injected procain into the ear of a deaf patient, who subsequently was able to hear again.

He developed the idea of infiltrating active substances in very small doses directly into the body through the skin, thereby evading the metabolic process. And indeed – his method worked!

His knowledge, acquired solely through experiment and experience, still forms the basis for every mesotherapist today. His motto was always: Use only little – Only seldom – But in the right place! The idea is to administer substances in low dosages over an extended area at a defined skin depth (meso = mid-dermis). The administration of revitalising and regenerating substances aims at reinforcing the body’s own repair and regeneration processes. The therapy makes use of local stimuli, pharmacological, herbal, homoeopathic and orthomolecular substances, the depot effect of the skin and the diffusion of the substances to deeper layers of the skin and connective tissue.

For aesthetic physicians with a dermatological background, one of the interesting aspects of this method is, of course, that the target organ and the organ through which the substances are introduced into the body are one and the same. Therefore, and because we use only very low dosages – around 10 to 100 times small than in the case of systemic administration – the danger of complications is almost negligible, provided the relevant information on contraindications is complied with.

Fig. 1a+b: Mesolift before and after eight Sessions.

In our activities, we ourselves have concentrated on those active substances which, on the one hand, are able to provide a positive outcome for the aesthetic indication concerned, and on the other have been shown through scientific monographs to have a genuine effect.

Fig. 2a+b: Acne treatment Dr. Rezai. Combination treatment needling and Mesoglow.

It does not make sense to me that some ready-made mixtures are stated as containing more than 40 active substances, some of which have no discernible relevance for the proposed indication. Some other ready-made mixtures, on the other hand, contain only non-crosslinked hyaluronic acid and vitamins, but are sold at a horrendous price.

Within the NETWORK-AestheticMeso, of which I have been the Medical Director since its formation, we have adopted an approach that is supported by all the members and is based on the following premises:

1. We seek to ensure that all indications treated by us are recorded statistically; this provides us with information on outcomes, successes, failures, side-effects and complications and hence also, for the first time, an objective statistical basis for evaluation of the indications treated by us (initial survey: 2011 [3]; the Meso Report 2015 has been evaluated and is due for publication in the near future).
2. We all work according to the same, uniform treatment standards.
3. We all use the same active substances. We are not dependent on having to sell a mixture unchanged; rather, we can modify our mixtures in response to improvement suggestions from our members. Thus, for example, we have altered our MesoHair Mixture because recent publications have shown one of the active substances to be closely associated with an elevated allergy potential.

The current NETWORK-AestheticMeso treatment protocol

Injection techniques

Mesotherapy employs 2 injection techniques, which are performed by us one after the other for every indication. First, there is a single injection, in which a somewhat higher quantity of the active substance is injected in one place into the skin; this is then followed by the nappage technique, which involves the simultaneous administration of a large number of injections, all positioned very close together but each containing only a very small quantity of the active substance. Nappage is closely related to the procedure known as needling, which as an addition to nappage can improve the effect on the skin.

Indications

1. Skin preservation and complexion improvement
   The aspect of prevention and preservation is playing an increasingly important role in the field of modern aesthetics. Self-aware patients, who have also been educated in sustainability, are no longer prepared to wait until the skin has already become damaged before starting to do something about it; instead, they prefer to take action at an earlier age and so delay the onset of the processes that cause skin ageing for as long as possible. For this indication there is, in my view, no better treatment than mesotherapy. The injections do not cause fibrosis, but instead supply the skin with nutrients that strengthen the immune defences, especially against extrinsic skin ageing factors. I have a reputation among my colleagues as being an experienced laser user and am therefore often asked why I insist on using mesotherapy where laser treatment would have a much greater effect. My answer is always that effect alone is not the only thing that matters. As a preventive measure and with only a small risk of side-effects, mesotherapy allows us to already treat younger patients whom I would never treat with laser.
   Prior treatment with mesotherapy has proved itself to be very helpful in connection with operations, enhancing and accelerating the post-surgery healing process of the skin.
   In combination with needling, we use MesoGlow for successfully treating smaller acne scars. Percutaneous collagen induction [4] on the one hand and the administration of skin-regenerating substances on the other has proved itself to be a very good combination.
   Mixture: NWM-MesoGlow.

2. Skin and complexion improvement
   Recent studies in the field of attractiveness research have emphasized the importance of the appearance of our skin. Where it was assumed in the early days of aesthetics that above all wrinkles were a major aesthetic problem, this view now no longer applies.

3. We have developed a wide range of capabilities in aesthetics for improving the condition and appearance of the skin with more or less invasive procedures: facelifts, ablative and fractional laser, peelings, radio frequency procedures and, with a lesser degree of intervention, also needling, mesotherapy and cosmeceuticals.

Some of these procedures can be used as alternatives to each other, despite the fact that they employ different technologies and therefore tackle the mechanisms of skin ageing in different ways. Nevertheless, it is seen as desirable – and this goal has meanwhile also been achieved by the lecturers at the Globalhealth Academy for Aesthetic Medicine – for the fields of application of the various methods to be defined, so that based on the diagnosis for the individual patients, the procedure that represents the lowest degree of intervention for the particular indication⁵ can be chosen.

In the case of older skin – especially skin that has suffered extrinsic damage – there are many factors that have to be considered: How elastic is the skin, how large are the pores, how much hyaluronan is still in the skin, how great is the pigment change caused by age spots? These are just some of the most important questions that need to be answered in order to perform a precise diagnosis of the skin status. Then there is the question of the smaller wrinkles that are not amenable to treatment with fillers or botox. Skin colour also plays a major role in determining a healthy appearance.

Aesthetic mesotherapy can bring about improvements to some, though by no means all, of the aspects of skin ageing indicated above. But everyone involved, i.e. therapists and patients alike, must be aware right from the start that a sequence of at least 5, or preferably, 8 treatment sessions is necessary if the skin status is to be improved. They should also be aware that MesoLift, like every mesotherapy treatment, requires subsequent maintenance therapy if it is to be successful in the long term. My preferred patients are those who are able to accept such slow and gradual change in their skin status. The degree of intervention offered by mesotherapy lies at the bottom end of the scale; consequently, miracles should not be expected of this kind of therapy: It is very well suited for treating large-pored skin and smoker’s skin, which tends to have a greyish colour. Improvement can also be promised to patients who have been using sunbeds for decades and have therefore acquired the typical leathery skin. Only very small wrinkles can experience partial improvement through this treatment, which can be further assisted through combination with needling. For the past 2 years, therefore, needling has been part of our standardised further training.
For the indications detailed above, mesotherapy is also highly suited for combination with other procedures, e.g. superficial peeling (age spots), PRP (wrinkles, hairs) or needling (acne scars) [6]. The latest statistics document the treatment of no fewer than 962 patients. The patient satisfaction survey for this multi-session treatment produced figures of 48% highly satisfied patients and 32% satisfied patients, i.e. an altogether more than good result [7].
Mixture: NWM-MesoLift

4. Hair loss
   Originally, we restricted the indication to hair loss in female patients. I continue to view this approach as fundamentally correct, although I must state that increasing numbers of male patients are also coming to the practice. We treat androgenetic alopecia, with alopecia areata also shows a very good response.

We always make the following stipulations in the name of the NETWORK: 1. The patients should have already undergone conventional medical treatment. Only if the conservative therapy has proved unsuccessful should an attempt with mesotherapy be proposed to the patients. 2. The hair loss should have started not more than 2 years previously. The more recent the situation is, the greater is also the likelihood of the therapy being successful.
Last year, we improved the focus of our therapy once more because for this indication, a phased goal orientation is far better suited:
a – The first goal is to stop acute hair loss.
b – The second goal is to strengthen and revitalise the existing hair.
c – And the third – and naturally most important goal – is to instigate new hair growth.
Achieving this latter, maximum goal is naturally not possible for every patient, but many patients are already very happy if a and b are achieved.
In terms of numbers, hair loss is the biggest indication by far. According to the latest Meso Report 2015, a total of 12,500 patients were treated. The patient satisfaction rating, with 58% of patients declaring themselves highly satisfied, 27% satisfied and only 16% not satisfied, is very high and is confirmation of the correctness of our concept.
As a further step, we are currently working on a combination protocol for MesoHair and PRP, with the aim of improving our results for those patients who do not show a good response [8].
Mixture: NWM-MesoHair

6. Cellulite
   In composing the mixture, we were not so presumptuous as to believe that we would be able to successfully treat the complex processes involved in with cellulite with a single therapy. Rather, it was our intention right from the start to treat the various levels involved in cellulite by applying a combination therapy. The goal was – and continues to be – to bring about improvement by offering a solution with long-lasting effect. The treatment seeks to target the deep and middle-depth fat cells, the fat-skin boundary and the skin itself. At the present time, we are working with 2 therapies, namely injection lipolysis (for treat the fat) and mesotherapy (for treating the skin). After several years of experience, it is possible to state that a marked improvement in appearance can be found in for all patients. We thereby restrict our efforts to grade 1-3 cellulite, and only treat grade 4 in a small number of special cases. Depending on the individual case, the protocol developed by us can be varied. The criteria in this case are the cellulite grade, the thickness of the fatty layer and the condition of the skin’s surface.

7. Drawbacks to our therapy at the present time are the long duration of the treatment (1 year and more) and the number of therapy sessions required, which push the costs for successful treatment into the four-figure range. We are therefore grateful to our colleague, Prof. Steinert, for taking this issue on board with the aim of establishing whether the procedure could be influenced by further therapies such as needling, PRP, shockwave therapy, LDM ultrasound or other alternatives.
   Mixture: NWM-MesoCellu

Mixtures

Our mixtures are in some cases tailored to the various indications as far as the active substance spectrum is concerned; at the same time, we also have some active substances with a generally skin-improving effect which act as precursors or catalysts, supporting the activity of the tailored active substances.

In conservative mesotherapy, procaine is used as a catalyst (adjuvant). Our thinking on discontinuation of the use of this substance was to find an alternative which as well as having catalytic properties should also be an active substance in its own right. With a combination of silicium (silicon), rutin and multivitamins we have, in my experience, achieved this very successfully. Silicon supports the blood circulation, is a good “radical catcher”, and as a structural element in the connective tissue, supports the reorganisation of the collagen and elastic fibres. Rutin is an antioxidant, has anti-inflammatory properties and exerts a positive effect on the lipid metabolism. The positive effect of many vitamins on the skin has already been shown in a large number of studies, especially in relation to dermatocosmetic substances; I will therefore not unnecessarily overburden this publication by giving a detailed list.

In the case of MesoGlow, we have added the active substance Centella asiatica, which has skin-regenerating and circulation-stimulating properties.

The composition of MesoLift corresponds to that of MesoGlow, though with the addition by us of 2 important active substances that have an effect on the indication spectrum, namely DMAE and non-crosslinked hyaluronic acid. The water-storing effect of hyaluronic acid is well-known. We have arranged for the development of a very low-viscosity, easily injectable form of hyaluronic acid, which is also available as an active substance by itself so as to allow adjustment of the dosage in line with the individual skin picture; this also applies to the other mixtures. MesoLift contains 1 ml HA, and a further 1-2 ml HA can be additionally added. DMAE (dimethylaminoethanol) is an interesting molecule that produces a lifting effect through increased acetylcholine secretion and additionally enhances the elasticity of the dermis.

In the case of MesoHair, we have added caffeine and also increased the dose of Biotin/Vit H and Bepanthen/Vit B5. Caffeine increases the concentration of the cyclical AMP and intensifies the lipase activity: an insufficient supply of biotin results in hair loss; it also regulates the sebum.

As well as caffeine, MesoCellu also contains artichoke extract and L-carnitine. The effect of L-carnitine as a fat burner will doubtless be sufficiently familiar, while the artichoke extract influences the lipid and glucose metabolism, maintains the cholesterol synthesis and stimulates the bile acid production and is therefore particularly effective in connection with oedematous forms of cellulite.

A first result of the studies of Markus Steinert into cellulite was his proposal to broaden the anti-inflammatory character of our MesoCellu and supplement some of the active substances of MesoLift in a new formulation so as to also optimise the skin-tightening properties. Work is currently in progress on the galenics for the new MesoCellu formulation.
 

Contraindications

With one exception, the list of contraindications is limited to the same groups of persons identified for all aesthetic treatments in general, i.e. pregnant women, children, feeding mothers etc. The exception are allergy sufferers. Especially patients with an elevated allergy risk should always be tested before any treatment. I personally exclude all patients with multiple allergies because for me, the risk of triggering an allergic shock is too great. While we have never had a case of that kind within the Network, the risk is nevertheless familiar from casuistics and personal experience.

Fig. 3: Colour coding of the Network mixtures ensures easy handling in the medical pactice.

Finally, permit me to make some comments on the technology employed. We recommend the use of compressor guns as these provide the least unpleasant treatment experience for the patients. In combination with specially ground needles, which are slightly more expensive, the treatment is almost pain-free for the patients. One exception to this is the injection lipolysis treatment used in connection with cellulite, as the treatment is administered in this case not with a gun but with multi-injectors and the familiar side-effects also occur in this area as well; thanks to PSM – Pain & Side Effect Management – however, these can be well controlled.