Carboxytherapy: seeking evidence for its use in plastic surgery and dermatology
Lydia Masako FerreiraI; Edina Koga da SilvaII; Carlos Alberto JaimovichI; Denis CalazansI; Edgard Rocha SilvaI; Fabianne FurtadoIII; Ognev CosacI; Pedro NaderI; Wanda Elizabeth Massiere y CorrêaI
IMembers of the Technical Chamber of Plastic Surgery of the Federal Council of Medicine, São Paulo, SP, Brazil
IIDepartment of Medicine, Discipline of Emergency and Evidence Based Medicine, Escola Paulista de Medicina/Universidade Federal de São Paulo (EPM/UNIFESP), São Paulo, SP, Brazil
IIIPostdoctoral researcher in Plastic Surgery of the EPM/UNIFESP, São Paulo, SP, Brazil
There is now a strong trend for clinical practice to reaffirm its commitment to scientific medicine. This does not mean that research and experience are decoupled. On the contrary, it recognizes that both are part of a systematic and continuous process of self-learning and self-assessment, without which, performance becomes outdated and irrational1.
Professionals must daily decide which treatments work (in aesthetics, it is worth noting that many "promising options" are reported regularly). Traditionally, such decisions have been based on pathophysiological principles, logical reasoning, personal observation, and intuition, which collectively constitute what is called "clinical experience"1. If a treatment seems to work, it will be repeated; if its results are disappointing, the treatment will be abandoned. However, this type of assessment is totally unpredictable because it is unknown which factors contribute to therapeutic success or failure2.
The search for guidelines for performing certain procedures is a movement pioneered by David L. Sackett, who has been keen to spread a new way of following and imparting medical practice since 1992. Sackett defines this idea as "the conscious, explicit and judicious use of the best available evidence for making decisions about the care of individual patients"3. More scientific and efficient decisions based on more vigorous evaluation methods aim to optimize benefits and minimize risks and costs2. These concepts are critical if a doctor wants to carefully examine whether the newest and most advanced methods are indeed optimal for a given patient4.
The medicinal use of carbon dioxide (CO2) is not new. In 1932, at the Spy de Royat Spa, France, CO2 was used for patients with peripheral artery diseases in which patients were subjected to dry bathing or soaking in carbonated water5. In 1953, after 20 years of research, the cardiologist Jean Baptiste Romuef published the results of subcutaneous therapeutic use of CO25. The topic was largely forgotten for 4 decades, and was picked up again in the 1980s and 1990s with some studies targeting its use for vascular surgery.
In addition to its therapeutic action, CO2 is commonly used to inflate the abdominal cavity during videolaparoscopy, hysteroscopy, contrast arteriography, and ventriculopathy. Health regulators such as the National Agency for Sanitary Surveillance and the Food and Drug Administration have registered equipment to control the flow of injected CO2, which makes its use safe.
CO2 may have a novel application for aesthetic purposes. Its uses include treating cellulite (i.e., gynoid lipodystrophy), saggy skin, stretch marks, and unsightly scars as well as complementary treatment in liposuction to reduce irregularities and lessen the appearance of "wrinkled" skin by improving skin elasticity. These benefits are derived from the promotion of local arteriovenous vasodilation, increased regional blood flow6, increased blood and lymph drainage, and lipolysis7. In turn, these increase oxygen availability to the tissues, increase collagen turnover, and reduce the amount of adipose tissue.
However, the most reliable source of evidence about treatments is derived from randomized controlled trials (RCTs). In RCTs, a new treatment is experimentally compared to the standard therapy as a reference for disease management or a placebo if no such treatment exists. The randomization ensures that the groups being compared are similar in terms of demographics (e.g., gender, age, and race), illness severity, and frequency of comorbidities. This avoids selection bias4.
However, none of the almost 15 manuscripts available in the literature on the therapeutic use of CO2 in plastic surgery or dermatology are RCTs with adequate methodology. The methodological adequacy of research is the basis for the credibility of conclusions8.
Critical reading of the scientific literature is becoming increasingly important because of the abundance of articles published in specialized journals. The publication of books and periodicals is currently increasing; moreover, electronic bibliographic databases have enabled even greater access to information8. However, only 10–15% of the published material proves to be of scientific value9.
The application of the best available scientific information aims to provide more accurate, ethical, and scientifically based treatments1. Although there is constant dissemination of the techniques and indications for the use of CO2 for treating scars and cellulite, there is currently no literature that has the internationally recommended scientific rigor.
The credibility of carboxytherapy currently depends solely on its own promoters. Therefore, above all, this editorial aims to encourage professionals to conduct RCTs to scientifically prove (or disprove) the effectiveness of carboxytherapy. Information from personal experience and questionable studies is insufficient. Impartial information should be universal and prioritized, and sufficient for public interest. It is only through this process that doubtful treatments can be improved on, to develop optimal ones.
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- 3. Sackett DL, Richardson WS, Rosenberg W, Haynes RB. Evidence-based medicine. How to practice and teach EBM. New York: Churchill Livingstone; 1997. 250p.
- 4. Maluf-Filho F. A contribuição da medicina baseada em evidências para a introdução de novo conhecimento na prática clínica. Arq Gastroenterol. 2009;46(2):87-9.
- 5. Leibashoff G. Carboxytherapy. In: Goldman MP, Hexsel D, eds. Cellulite: pathophysiology and treatment. New York: Taylor & Francis; 2006. p. 197-208.
- 6. Schnizer W, Erdl R, Schöps P, Seichert N. The effects of external CO2 application on human skin microcirculation investigated by laser Doppler flowmetry. Int J Microcirc Clin Exp. 1995;4(4):343-50.
- 7. Brandi C, D'Aniello C, Grimaldi L, Bosi B, Dei I, Lattarulo P, et al. Carbon dioxide therapy in the treatment of localized adiposities: clinical study and histopathological correlations. Aesthetic Plast Surg. 2001;25(3):170-4.
- 8. Crato NA, Vidal LF, Bernardino PA, Ribeiro Júnior HC, Zarzar PMPA, Paiva SM, et al. Como realizar uma análise crítica de um artigo científico. Arq Odontol. 2004;40(1):5-17.
- 9. Patussi PM, Freire MCM. Leitura crítica de artigos científicos. In: Estrela C, ed. Metodologia científica: ensino e pesquisa em Odontologia. São Paulo: Artes Médicas; 2001. p. 308-25.
Publication in this collection
13 Mar 2013
Date of issue