Mesotherapy

What is mesotherapy?

Mesotherapy is the injection of a mixture of substances into or under the skin, in very small doses and at many points, with very fine needles. The injections are given in the problem area or right next to it. In this method, medicines are used in much lower doses.

The method grew out of the observations of a French doctor in the 1950s and was first used to treat painful conditions. Today it is used in a range of fields, including pain management, sports medicine, rehabilitation, vascular disease, dermatology and aesthetic medicine. In aesthetics, interest came later, particularly through injections for fat and cellulite.

Mesotherapy should not be thought of as a single procedure. Research shows that the medicine injected, the injection technique and the number of sessions vary with the problem being treated. Mesotherapy on the face, the scalp or the body carries the same name, but its aim, contents and evidence differ.

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What is injected in mesotherapy?

There is no single answer to this question. Mesotherapy is the name of a treatment technique, not of a product; in two treatments given under the same name, the contents of the syringe can be completely different. A few examples from studies show this difference. One study on the face used a solution of sodium hyaluronate (the salt form of hyaluronic acid) with four added amino acids; another, around the eyes, used a solution containing multivitamins and plant extracts. For hair loss, six different groups of substances have been tried, ranging from preparations containing medicines to growth factors and multivitamin mixtures.

Even hyaluronic acid (a water-holding molecule found naturally in the skin) is not all the same. When its chains are chemically linked to one another, it is called cross-linked hyaluronic acid; when they are not, it is called non-cross-linked hyaluronic acid. Studies with the two types also differ in the number of sessions and the intervals between them. Researchers state that there is no common standard for treatment regimens in mesotherapy, and they attribute the adverse reactions linked to mesotherapy to the wide use of the method and to this lack of a standard.

The line between skin boosters and mesotherapy is not sharp either. ‘Skin booster’ is a name used for injectable products that are given into the skin to improve skin quality. Research shows that these products are increasingly delivered into the skin using the mesotherapy technique; in other words, the same treatment may be called mesotherapy in one place and a skin booster in another. What matters is not the name but the substance in the syringe. When thirteen studies on facial skin quality were assessed together, treatments containing hyaluronic acid alone and mixtures (cocktails) were not found to have the same effect.

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When is it considered?

In aesthetics, mesotherapy is considered for the concerns below. The contents used, the aim and the strength of the evidence differ for each one:

• Face: skin quality concerns such as dryness, dullness, visible pores, loss of elasticity and fine lines.
• Around the eyes: fine lines and skin quality.
• Hair: mainly pattern hair loss (androgenetic alopecia).
• Pigmentation: uneven skin tone, especially melasma.
• Acne: post-acne redness and acne scars, separately from the treatment of active acne.
• Body: localised pockets of fat.
• Cellulite: a dimpled, ‘orange-peel’ look on the surface of the skin.

Mesotherapy is not limited to aesthetics; it is also used for bone and joint pain, in rehabilitation and in dermatology. Whether one of these areas matches your concern becomes clear once the source of your concern has been identified.

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Face and eye area

The aim of facial mesotherapy is not volume but the skin itself: hydration, elasticity, surface smoothness and fine lines. In thirteen studies on the effect of injected hyaluronic acid on facial skin quality, improvements in hydration, firmness, radiance and elasticity were reported; the need for large randomised trials was also emphasised. In recent years, two randomised trials (trials in which participants are randomly assigned to groups) with 448 and 456 people showed improvements in hydration and elasticity; in both, the comparison group received no injections at all. However, researchers who have looked critically at mesotherapy for skin rejuvenation state that the method cannot be recommended for routine use until more definitive data are available.

In a study with six volunteers, a solution containing multivitamins and plant extracts was used for wrinkles around the eyes in six sessions, two weeks apart; no significant change was found either on clinical assessment or in tissue samples taken from the skin (biopsies). This result applies only to that mixture and to a small number of people. Mesotherapy does not add volume to the face or the area around the eyes and does not tighten sagging skin; under-eye hollows are also a separate topic.

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Hair

In hair mesotherapy, active ingredients are injected into the scalp. According to research, injecting into the skin may help the substance stay longer in the area where it is applied. In pattern hair loss (androgenetic alopecia), 30 studies on injection treatments reported results ranging from increased hair density and thicker hairs to hair loss stopping. However, the studies are small, the treatment methods differ and the follow-up periods are short; standardised randomised trials are needed before the method can be recommended as a routine treatment.

New patchy hair loss at the injection site (paradoxical alopecia) has also been reported. Three women developed this after mesotherapy with a medicine called dutasteride, and none of them had full regrowth of their hair. At the clinic, hair mesotherapy is considered after the cause of the hair loss has been assessed.

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Pigmentation

In pigmentation mesotherapy, substances that target pigmentation are injected into the skin. The condition discussed most often here is melasma: a chronic pigment disorder (pigment is the substance that gives skin its colour) that tends to come back and is mostly seen in women. Although mesotherapy is widely used in aesthetic dermatology, research shows that there is little information on injection details, effectiveness and side effects in melasma.

One of the substances studied in this area is tranexamic acid. Studies in which tranexamic acid was injected into the skin have reported a significant reduction in the severity of melasma. However, the results are not the same in every analysis: in an analysis that combined randomised trials (a meta-analysis), injection into the skin showed no significant difference compared with supportive (adjuvant) treatment, and it was stated that more data are needed for this route. The foundation of melasma treatment is strict sun protection; pigmentation mesotherapy does not permanently remove pigmentation.

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Acne and acne scars

Active acne, meaning ongoing spots, is a skin disease whose treatment is set out in guidelines. The treatments strongly recommended in the current acne guideline are medicines applied to the skin and medicines taken by mouth; mesotherapy is not among these strong recommendations. Mesotherapy is not a substitute for treating active acne.

For redness left behind after acne (post-acne erythema), a small randomised trial with non-cross-linked hyaluronic acid compared the two halves of the face. In the 23 patients who completed the study, redness scores were significantly lower than on the control side. For pitted acne scars, research comparing minimally invasive methods shows that confidence in the evidence is low or very low, and that the methods cannot be reliably ranked against each other.

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Body and cellulite

Body mesotherapy is the collective name for injections aimed at localised pockets of fat in areas such as the abdomen, waist or thighs; it is not a weight-loss method. There are two approaches in this area: mixtures that stimulate the breakdown of fat inside fat cells, and injections that break down the fat cells themselves with a detergent-like substance, deoxycholate (deoxycholic acid). The second is also described as a method separate from classic mesotherapy. Of 25 studies on fat-dissolving injections in areas other than under the chin, most reported a reduction in fat, but this reduction was statistically significant in only 37.5% of them. In a controlled study, a mixture was applied once a week for 12 weeks to one thigh in 20 women, and the other thigh was left untreated; no significant difference was found between the two sides in thigh circumference or fat layer thickness.

Cellulite is dimpled, ‘orange-peel’ skin on the surface, and it occurs in 80–90% of women after puberty. There are experimental data suggesting that some substances in traditional mesotherapy mixtures may reduce fat, but this effect has not been supported by peer-reviewed studies (studies checked by independent experts). In 67 studies assessing cellulite treatments, no clear evidence of good effectiveness was found for any of the methods examined either.

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Where does the evidence stand?

The short answer: the evidence varies with the substance injected and the area treated, and overall it is limited. Mesotherapy is widely used around the world, but until recently there was no internationally accepted, evidence-based standard for its various clinical uses. It has also been reported that there are few rigorous studies proving the effectiveness and safety of the method. Consensus statements published in recent years aim to fill this gap and to separate practices supported by evidence from those that are outdated; they also stress that high-quality research is still needed.

In two large randomised trials of hyaluronic acid on the face, with 448 and 456 people, the comparison group received no injections at all. Comparing with a group that receives no treatment does not give the same information as a placebo-controlled comparison, in which the same procedure is done without the active ingredient (a dummy treatment). Researchers who revisited mesotherapy for skin rejuvenation also state that they have found no new clinically valuable data since their previous review.

The picture is similar in the other areas:

• Hair: standardised randomised trials are needed before injection treatments can be recommended as a routine treatment.
• Pigmentation: results for tranexamic acid injected into the skin vary from analysis to analysis, and more data are needed.
• Body: new studies are needed to standardise protocols and assess long-term effectiveness.
• Cellulite: there is no clear evidence of good effectiveness for any of the methods examined.

So there is no single answer to the question ‘Does mesotherapy work?’; the answer depends on which substance is used for which problem.

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Limits of this treatment

Mesotherapy is a treatment aimed at the skin itself, the scalp or a limited area of fat. Its limits can be summarised by area as follows:

• On the face and around the eyes, it does not add volume, tighten sagging skin or lift the face.
• For hair, it does not on its own remove the cause of hair loss and is not a substitute for investigating the cause.
• It does not permanently remove pigmentation and is not a substitute for sun protection.
• In active acne, it is not a substitute for treatment with medicines.
• On the body, it does not make you lose weight; it only targets fat in a limited area.
• It does not remove the appearance of cellulite.
• It is not a substitute for surgery.

What the facial studies measured also shows this limit: the outcomes measured were hydration, elasticity, surface texture, fine lines and overall appearance; volume and sagging were not measured. According to an international expert consensus on skin quality, a feature seen in the skin may come from deeper tissues; in that case, a treatment plan that targets more than one tissue layer may be needed. If there is volume loss or sagging, mesotherapy does not reach that source.

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How do the sessions work?

At the clinic, mesotherapy is usually planned as a course of treatment, based on your needs. The contents and the session protocol are not the same for every treatment area; the contents are chosen according to the aim of the treatment. A treatment takes about 20 to 30 minutes. If needed, a topical anaesthetic (numbing cream) is used; follow-up appointments are scheduled according to the session plan.

Studies do not follow a single session schedule either; the number of sessions and the interval between them vary with the problem treated and the substance used. In studies on the face with non-cross-linked hyaluronic acid, one to six sessions were given, at intervals ranging from once a week to once every two months. It has also been reported that hyaluronic acid mesotherapy needs a maintenance treatment every few months to keep the result. On the body, mixtures that stimulate fat breakdown do not destroy fat cells; this is why they need more frequent sessions, and the cells can fill up again over time. Injections that break down fat cells need fewer sessions, but they cause inflammation in the tissue and scar tissue resulting from the death of fat tissue. These numbers show the protocols used in the studies, not your own plan.

For the first 24 hours after the treatment, it is recommended that you do not apply heavy make-up or cosmetic products to the treated area. It is also recommended that you avoid saunas, steam rooms or hammams, extreme heat, strenuous exercise and massaging the treated area.

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Known risks

Although mesotherapy is known as a relatively safe method, adverse reactions of varying severity have been reported. These reactions have been described in case series (publications describing small groups of patients) and in individual case reports; larger studies are needed to clarify safety. Temporary redness, tenderness or small bruises related to the procedure can occur.

At a later stage, a granulomatous reaction that is not caused by infection (small inflammatory lumps in the skin) can develop. Researchers describe these late reactions as an ongoing problem and link the risk of adverse reactions to non-standard protocols and overuse. With hyaluronic acid treatments, placing the substance in the correct layer of the skin is considered key to reducing side effects such as unevenness in the skin and the Tyndall effect (a bluish tint under the skin). On the scalp, patchy hair loss at the injection site, which can be permanent, has been reported.

A rare but serious risk is atypical mycobacterial infection. It is caused by bacteria called non-tuberculous mycobacteria, that is, mycobacteria other than those that cause tuberculosis (TB). When data from 92 patients who had this infection after aesthetic procedures were analysed together, the highest rate (34%) was seen after mesotherapy. In most cases, inadequate sterility and non-sterile water play a role in transmission. In most patients, the diagnosis was missed when they first sought care, and the infection sometimes left severe and irreversible effects.

Data from 423 patients whose infection was linked only to mesotherapy show that the infection mostly appeared on the abdomen, buttocks and thighs, as multiple localised skin lesions. Most patients recovered with antibiotics; however, many needed more than one course of antibiotics, recovery took weeks and scarring was common. In 200 cases that developed after aesthetic procedures, the median time (the middle value) until symptoms began was 28 days, and the median treatment time was 6 months; the most common finding was lumps that can be felt in the skin (nodules).

What this means in practice: symptoms can start weeks after the procedure, and you may not link them to the procedure. Contact the clinic if you have redness, swelling or pain that lasts longer than expected or keeps getting worse, or any unusual reaction. For sudden and severe symptoms, such as difficulty breathing or a serious allergic reaction, call 112.

At the clinic, mesotherapy is not given during pregnancy, or when there is an active infection or inflammation in the treatment area. A medical assessment is needed if you have a bleeding or clotting disorder, a significant chronic illness or an immune system disease, or if you have a known allergy to the contents to be used. At your consultation, tell your doctor about all the medicines you take, especially blood thinners; do not stop taking any prescription-only medicines on your own.

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