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Aesthetic Mesotherapy

Edited by

Shirley Madhère MD PC MMS

Aesthetic Mesotherapy

Edited by
Shirley Madherè MD PC MMS
Associate Adjunct Surgeon of Plastic Surgery
New York Eye and Ear Infirmary
New York City, NY
USA
CRC Press
Taylor & Francis Group
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Boca Raton, FL 33487-2742
© 2008 by Taylor & Francis Group, LLC
CRC Press is an imprint of Taylor & Francis Group, an Informa business

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Version Date: 20130325

International Standard Book Number-13: 978-0-203-01627-5 (eBook - PDF)

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Contents
Harryono Judodihardjo

Foreword vii
Peter B Fodor

Preface xi
Shirley Madhere

Contributors xiii

Acknowledgments xv

Disclaimers xvii

1. Introduction 1
Shirley Madhere

2. Anatomy and physiology of the skin 7

Harryono Judodihardjo

SECTION I Mesotherapy – evolution of practice 17

3. The history of mesotherapy 19

Philippe Petit

SECTION II Mesotherapy and modern practice 23

4. The scientific basis of mesotherapy 25

Lisa A Merritt

5. Materials and methods: the techniques 35

Phillippe Petit

6. Patient evaluation and selection 41

Shirley Madhère

SECTION III Non-surgical body contouring – mesotherapy and injection lipolysis 47

7. ‘American’ mesotherapy and the treatment of localized fatty deposits 49

A Peter Salas and JP Cardosa
vi CONTENTS

8. The role of phosphatidylcholine in non-surgical body contouring 61

Diane Irvine Duncan

9. Non-surgical body contouring: the Brazilian experience 77

Patricia G Rittes

10. Mesotherapy in the treatment of cellulite 85

Shirley Madhère

SECTION IV Aesthetic mesotherapy of the face and hair 99

11. Mesotherapy for facial rejuvenation: mesoglow 101

Shirley Madherè

12. The treatment of hair loss in mesotherapy 109

Françoise Omer

13. The pharmacopeia of mesotherapy 145

Leon James

14. Prevention and management of complications: ensuring patient safety 177

Shirley Madherè

SECTION V Mesotherapy and the future 181

15. Mesotherapy and aesthetic plastic surgery 183

Shirley Madherè

16. Non-cosmetic applications of mesotherapy 187

Lisa A Merritt and Shirley Madherè

Appendix 1 – Educational and training resources 189

Appendix 2 – Patient Treatment Forms 191

Index 195
Foreword
Harryono Judodihardjo

If the science of medicine is constantly evolv- technologies in order to be ‘cutting edge?’

ing, must the art of medicine change as well? Despite informed consent in the United
How are we to define the ‘standard’ of care in States, malpractice premiums continue to
medicine if that upon which the standard is skyrocket in part due to favorable legal
based is frequently being reinvented and outcomes for the plaintiffs. Is it, then, the
improved? The fundamental pillars of responsibility of the doctor to further ‘protect’
medicine, elucidated in theory in the patients from injury or adverse sequelae by not
Hippocratic oath, and expressed in practice offering the new modality at all, even when
through the doctor–patient relationship, patients ask for it? Yet, if physicians do not stay
remain intact throughout the decades. Yet, abreast of new technologies, then they may
new technologies require physicians to contin- lose out on potential ‘market share’ and, more
ually adjust to a revised or altogether novel importantly, may potentially do a disservice to
paradigm of practice. And what if older the patient by not being informed and educat-
technologies become introduced to new ing the patient about all of the potential
communities? Should these be readily options available. Is either alternative worth
adopted? the risk to the physician? According to the
The internet, globalization, miscegenation, American Society for Aesthetic Plastic
and world events have helped to engender a Surgery’s (ASAPS) mission statement, the
modern society whose residents are becoming objectives of the organization are to:
increasingly knowledgeable about trends and
technologies both within and outside of their advance the science and art of aesthetic
physical borders. This fact is even more (cosmetic) plastic surgery among qualified
profoundly evident within large cosmopolitan surgeons through medical education and
hubs. Media-driven consumers wish to be ‘in research; promote ethical conduct and
the know’ and demand the most up-to-date responsible patient care; serve the public
products and advances, whether an MP3 by providing accurate and timely informa-
player, cell phone, PDA, skin care line, or tion on aesthetic (cosmetic) plastic
medical treatment. This ‘need to know’ and surgery; and advance the medical profes-
need to ‘be the first’ is particularly pervasive sion and plastic surgery specialty.
among consumers of cosmetic surgery services
and goods. What drives this phenomenon? Recently, the concept of patient safety was
More poignantly, how are practitioners of officially added to the mission statement of
aesthetic surgery and medicine to ascertain the Society. Patient safety applies foremost to
the safety and efficacy of these ever-emerging all aesthetic patient care. Mesotherapy is no
methods? exception. As immediate past president of the
Trendsetters of the baby-boom generation Society, I have been in the privileged position
are inherently risk takers. Under the pressure of being exposed to emerging technologies
of the media, obsession with celebrities, and from all over the world. During my year-long
adulation of super- (1990s) and übermodels tenure from 2004 to 2005, I also liaised with
(2000s), are physicians to yield to new media personnel from major markets whose
viii FOREWORD

influences resound throughout every village, initially introduced in the United States, it,
town, and city. Moreover, ASAPS is responsi- too, was surrounded by myth and was believed
ble for collecting, collating, and disseminating to be ‘too good to be real.’ Many disregarded
annual statistics on plastic surgery and it and considered it unsafe. Even though,
cosmetic trends performed in the United eventually, I embraced lipoplasty wholeheart-
States. We, therefore, had first-hand access to edly, I was initially amongst the ones who
information such as the volume of surgical as voiced reservations and was very reluctant to
well as non-surgical cosmetic procedures; offer it to patients. After its introduction to the
patterns of use by various ethnic groups and United States, the technique rapidly gained
between the sexes; and the cost and financial popularity with patients and surgeons, and has
impact of these procedures. I am also, regret- remained the most commonly performed
tably, familiar with the consequences of when aesthetic surgery procedure in the United
new technologies fail us and lead the user or States and abroad. ASAPS has collected
practitioner to cause, uncover, or potentiate aesthetic surgery procedural statistics for the
illness, injury, or deformity. In the case of last 7 years, which also confirmed this.
mesotherapy, reports of hepatitis and skin Relatively speaking, the minimally invasive
infection with unusual and recalcitrant strains nature of lipoplasty, coupled with the ability to
of bacteria are neither comforting nor produce (in competent hands) predictable
encouraging. It is with this background and results, was most likely responsible for the
insight that I comment on the practice of meteoric rise in the popularity of this proce-
mesotherapy in the United States. dure. Could mesotherapy follow suit or will it
Mesotherapy has been in existence since end up discarded along with most novel
1952, when it was discovered by its founder, techniques surrounded by hype? One of our
Michel Pistor, in France. Since then, the roles as plastic surgeons and physicians is to
technique has gained wide acceptance in educate – our patients, the public, and our
Europe for the treatment of medical ailments medical colleagues. We can achieve this by
as well as aesthetics, and even in Asia, as an supporting academic publications and scien-
adjunct in the treatment of infertility. In the tific research that will help to clarify which
cosmetic arena, mesotherapy has been new therapies have merit or not. If our
advocated for the non-surgical amelioration of patients’ curiosity has been piqued by the
cellulite, localized fatty deposits, facial aging, media, their friends, or their personal experi-
and hair loss. Despite its purported success ence abroad, then it is our responsibility as
abroad, the practice of mesotherapy in the doctors to objectively discern, inform, and
United States is still in its infancy. enhance their knowledge. Unfortunately,
Nevertheless, the fact that the technique is nowadays, more than ever before, the
recognized worldwide and that global clinical paradigm of science to precede commerce is
experience resulting in positive outcomes has not observed. It is regrettable to see that the
been reported, warrants investigation. current state of mesotherapy is no exception.
Although the gold standard in experimental Nevertheless, that of which we know little, we
data, the double-blind randomized controlled should further study. That of which we know
trial, has not established the safety and efficacy some, we should expand and expound upon.
of mesotherapy as a therapeutic option, a That in which we are proficient, we should
plethora of anecdotal evidence does exist in provide our patients and share with our
the foreign literature. Should mesotherapy, colleagues. This is why I have formed within
therefore, be dismissed for lack of well- ASAPS an ad-hoc committee which will aim to
executed clinical trials? study mesotherapy in a scientific format,
In pondering the fascinating history of establish safety protocols, and if mesotherapy
lipoplasty, a possible analogy with mesother- proves safe and effective, to develop standard-
apy comes to mind. When liposuction was ized practices that will help to ensure efficacy
 FOREWORD ix

but also will allow modifications so as to treat and compassion for the patient. Yet, we must
every patient as a unique individual with also accept and progress with change because
diverse and specific needs. Our ad-hoc it is those aforementioned tenets of practice
committee already has clinical protocols on that also serve, collectively, as an impetus for
the drawing board. These studies, I trust, physicians to be as dynamic as the new
should already be in progress by the time of technologies we face. In order to improve our
the publication of this book. patients, we must improve ourselves by being
Therefore, I ask the question again: if the flexible, responsible, inquisitive, and master-
science of medicine is constantly evolving, ful of our science. Mesotherapy has arrived in
must then the art of medicine change as well? the United States, and it may be here to stay.
The answer is, unequivocally, mixed. The art, like the proverbial writing, is on the
Physicians must maintain the basic tenets that wall. Let it be open-mindedly studied, inter-
embody the art of medicine: respect, honor, preted, and valued accordingly.

Peter Fodor MD
Preface
Harryono Judodihardjo

Mesotherapy dates back to the 1950s when physicians from Singapore, Russia, Croatia,
Michel Pistor first conceptualized the practice. Argentina, England, Turkey, Belgium, Puerto
Since then, the technique has been practiced Rica, India, China, the United States, and
around the world and has led to results that many other countries. Not surprisingly, as a
warrant attention. Although mesotherapy has result of the widespread dispersion and
its roots in general medicine, its applications presumed efficacy of mesotherapy worldwide,
are relevant to many branches of the field. the International Society of Mesotherapy
Doctors in Asia have used it to increase fertility; comprises nation-chapters represented by
physicians in Latin America use it as an adjunct Algeria, Germany, Argentina, Brazil,
to improve lower extremity circulation and Columbia, Spain, France, Great Britain,
venous drainage; the French also use it as an Greece, Israel, Mexico, Portugal, Russia,
aid to smoking cessation and in stress manage- Switzerland, Tunisia, Turkey, Venezuela,
ment; other Europeans as well believe it to be Jordan, Lithuania, Korea, the Caribbean,
essential in the treatment of acute and chronic Poland, Croatia, Cambodia, and Canada
pain syndromes and Dupuytren’s contracture; among an expanding list of nations. How
and Americans are beginning to appreciate its could a therapy that is not well established in
contributions to aesthetics, including what I the United States have such impact, albeit
term ‘non-surgical body contouring’ (NSBC). primarily anecdotal, on so many physicians
NSBC is not appropriate in the management and patients as to galvanize international
of obesity, massive weight loss, or excess support and organization? Does not anecdotal
sagging skin. However, it may become a useful success (or a consensus of positive results at a
adjunct in the treatment of localized fatty minimum) often precede scientific inquiry,
deposits and cellulite. Regardless of one’s which may then lead to documented verifica-
professional opinion of mesotherapy, it is tion and acceptance of a phenomenon? These
undeniable that the technique compels closer questions were among some that were at the
observation and further study. crux of my investigations into mesotherapy
My research on mesotherapy began several and another technique that it spawned – injec-
years ago, when a close friend and top-earning tion lipolysis.
model told me how she and her colleagues My purpose in seeing this book come to
would fly to Paris for slimming ‘shots.’ Upon fruition is to help to educate. It is intended
further inquiry, I discovered the world of not to instruct how to perform mesotherapy or
mesotherapy and quickly began to investigate injection lipolysis injections, but rather to
its origins, methods, and effects. My self- teach the inquisitive about such techniques. I
directed research urged me to travel globally advocate scientific inquiry while also respect-
in order to understand, experience, and learn ing the power of creative thought and vast
from those who not only master mesotherapy experience supported by a foundation of
but also who were Dr Pistor’s first students. I patient education and safety. It is my hope that
am also fortunate to have learned from the this book will serve to ignite intrigue, stimulate
originators of mesotherapy in France and to further study, and elucidate that which may
determine the scope of the entity by engaging have been unclear about mesotherapy or lost
xii PREFACE

in translation. Whether mesotherapy and motivate scientific thinkers from across many
injection lipolysis become standard accepted aspects of medicine to come to a unanimous
therapeutic modalities in the United States accord about mesotherapy and NSBC, includ-
has yet to be determined. Regardless of this ing injection lipolysis, that will increase the
outcome, however, the current controversy knowledge base and benefit medical profes-
signifies attention, and that attention garners sionals and patients alike. Is this not one of
interest. It is anticipated that this interest will our basic responsibilities as physicians?

Shirley Madhère PhD

Contributors
Harryono Judodihardjo

J P Cardosa Françoise Omer MD

Medical student Mesotherapy and Aesthetic Medicine
St George’s University School of Medicine University V Segalen
Bordeaux
Diane Irvine Duncan MD France
[email protected]
Philippe Petit MD DIU CES
Leon James MS RPH Pharm D President of the International Society of
Pharmacy Director Mesotherapy
New York Eye and Ear Infirmary Teacher at Vicot Segalen Bordeaux 2
New York University
USA Bordeaux
France
Harryono Judodiahardjo MBBS Dip GUM Past President of the French Society of
MSc in Dermatology PhD Mesotherapy
Professor of Dermatology
Medical Director of Cellite Clinic, Cardiff Patricia G Rittes MD
Cardiff Rua Afonso Brás 864
UK Of 72 7th Floor
Vila Nova Conceicão
Shirley Madhère MD PC MMS Brazil
Associate Adjunct Surgeon of Plastic Surgery
at the New York Eye and Ear Infirmary A Peter Salas MD FACS FACM
New York City Clinical Professor of Surgery and
Private practice Director of Plastric Surgery Section
SoHo Aesthetics and Plastic Surgery Surg Elite Institute
New York
USA

Lisa A Merritt, MD
Morehouse School of Medicine
Adjunct Clinical Assistant Professor
Department Preventive and Community
Medicine
Stone Mountain
Georgia
USA
Acknowledgements
Harryono Judodihardjo

In seeing this project to completion, I wish to Rupal Malde

thank all of those who contributed to this Lisa Merritt MD
endeavor. In addition, I am grateful to the Marie Munday
following people for their teaching, patience, My wonderful patients
support, mentorship, assistance, or contribu- Françoise Omer MD
tion: Robert Peden
Philippe Petit MD
The One Elliana Placas
Guez, Papi, Joanie, and my family Sandra Ripert
Marie Aiello, Marie Aiello Design Studio Patricia Rittes MD
Stephanie Badini, Stephanie Badini Peter Salas MD
Photography Melanie Sheer
Madeleine Bengsston Stan Stalnaker
Christian Bonnet MD Michelle Vanparys
Dirk Brandl MD Patrick Gerald Wah, Wahpage
Josette Bullon Donald Wood-Smith MD
Emily Campbell Esq.
Kelly Cornish PhD I am also thankful for the guidance, both
Jillian Crane direct and indirect, given to me by the follow-
Anne Marie Corominas-Dewitt Esq. ing:
Diane Duncan MD
Peter Fodor MD Harry Adelson MD
Catherine de Goursac MD Albert Benouaische MD
Franz Hasengschwandtner MD Lionel Bissoon MD
Sherylee Hawes Abdala Kalil MD
Professor Harryono Judodihardjo Alain Lajeunie MD
Candice Ku Alan Matarasso MD
Leon James Pharm D Bernadette Pasquini MD
Jacques Le Coz MD Marilyn Rellanos
Adrienne Lopez Rod Rohrich MD
Mamie Macdonald, Mamie’s Day Spa
Disclaimer
Harryono Judodihardjo

The work in this book is the product of each methods presented. The authors reserve the
respective author and does not necessarily right not to be responsible for any actions or
completely represent the specific practice of effects caused by the use of the content
each contributor. This book is not intended to provided within this publication. In addition,
teach the techniques presented therein. It is they, including the editor, disclaim all liability
recommended that prospective practitioners for any results or consequences derived from
understand that none of the therapies information found in this book. Moreover,
described in this book are approved or wholly they make no warranty, expressed or implied,
accepted by various groups within the United with respect to data available from their work,
States, including the Food and Drug fitness for a particular purpose, or usefulness
Administration (FDA). Moreover, it is urged of any information, apparatus, product, or
that those physicians who wish to further study process disclosed. Material included in this
non-surgical body contouring, including publication should not be interpreted as
techniques in mesotherapy and injection instruction, standard of care, practice guide-
lipolysis, investigate it further through other lines, consensus or position statements, or
credible sources. Additionally, reference commentary from any official organization
herein to any specific commercial products, within or outside of the United States.
process, service, trademark, manufacturer, or This book was written with the intention of
otherwise, does not particularly constitute or educating physicians and surgeons worldwide
imply the endorsement, favoring, or recom- about the history and practice of mesotherapy,
mendation thereof by the editor. The authors’ as well as techniques that stem from it, such as
views, opinions, or observations expressed injection lipolysis. It is also anticipated that
herein may not reflect those of the editor, and the work would enlighten our colleagues;
shall not be used outside of the context of this clarify current misconceptions; stimulate
book for advertising, product endorsement, scientific research; galvanize effort to help
course development, or other promotional further explore the potential for therapies
purposes. such as mesotherapy and injection lipolysis;
The authors who contributed to this work and lead to the establishment of universal
have had significant experience with the safety protocols and standards of care.
List of Abbreviations
Harryono Judodihardjo

DHEA dehydroepiandrosterone IU international unit

DMAE dimethylaminoethanol LCAT lecithin cholesterol acyl
DX deoxycholate transferase
ECM extracellular matrix NSAIDs non-steroidal anti-inflammatory
EL endothelial lipase drugs
FDA Food and Drug Administration NSBC non-surgical body contouring
GAGs glycosaminoglycans PMS premenstrual syndrome
GI gastrointestinal PPC phosphatidylcholine
GLD gynoid lipodystrophy PPC/DX phosphatidylcholine/deoxycholate
IDH intrahypodermal PPP point by point
(intrahypodermic) RDA Recommended Daily Allowance
IDP intradermal – profound SAL suction-assisted lipoplasty
IDS intradermal – superficial SC subcutaneous
IED intraepidermal (intraepidermic?) SFM Société Française de Mésothérapie
IgE immunoglobulin E TEBG testosterone-estradiol-binding
IM, IV intramuscular(ly), intravenous(ly) globulin
ISM International Society of UAL ultrasound-assisted lipoplasty
Mesotherapy UV ultraviolet (radiation)
ch01 27/3/07 1:16 pm Page 1

Introduction 1
Shirley Madhère

Mesotherapy, also known as intradermal the United States, mesotherapy is (and at least
therapy, is not simply a technique; it is a for now, must be) practiced differently in the
philosophy. Having first been developed by United States than it is in France or elsewhere.
Michel Pistor in 1952, initially in the treat- This is at the crux of why there is lack of
ment of rheumatologic and traumatic disor- standardization of the ingredients contained
ders, the results of mesotherapy for these within ‘cocktails.’ Nevertheless, it was
indications began to ‘surprise its critics.’1 mesotherapy as a technique that was intro-
Particularly appealing about the method was duced into the United States and that ignited
its ability to augment the local microcircula- much fervor and fury as a potential treatment
tion and induce minimal pain or discomfort for localized fatty deposits; and it is commonly
to the patient. In 1958, Pistor published the known as ‘mesotherapy’ in the media, public,
results of his research and experimentation, and medical community. The widespread use
with the term ‘mésotherapie’ being intro- of mesotherapy, along with its recognition
duced into the literature for the first time. internationally, whether scientifically proven
Since then, mesotherapy has been practiced or not, as a potentially effective non-operative
all over France (and the world) with results adjunct in cosmetic medicine and plastic
that compel attention. Although mesotherapy surgery of the body, has led to the categoriza-
was only formally recognized by the French tion by this author of all techniques similar to
Academy of Medicine as an integral compo- and under the umbrella of cosmetic mesother-
nent of traditional (allopathic) medicine in apy in the management of localized fatty
1987, it has been used in the armamentarium deposits and cellulite as ‘non-surgical body
for the treatment of fatty deposits, cellulite, contouring’ (NSBC). Non-surgical body
hair loss, and facial aging for at least three contouring, therefore, generally refers to
decades. mesotherapy in the treatment of localized
adiposity and cellulite as well as to injection
lipolysis, including the use of the more recent
INDICATIONS
Lipodissolve, whose active ingredients are the
The indications for mesotherapy in general well-known phosphatidylcholine (PPC) and
medicine are numerous; however, it has been deoxycholate (DX). PPC/DX has been impli-
purported throughout the European and cated in decreasing cholesterol ester synthesis
South American literature that mesotherapy is and secretion. The bile salt manufactured with
efficacious in the treatment of stress, facial PPC, sodium deoxycholate, has been surmised
rhytids, alopecia, cellulite, stretch marks, and to have a major lipolytic effect when used in
localized adiposity. Mesotherapy has been the subcutaneous injections. Studies are
adopted from the French and applied to currently ongoing both in the United States
numerous management protocols within and abroad to help determine whether it is the
general and cosmetic medicine worldwide. PPC or the DX component that has the
However, as a result of differences in pharma- primary lipolytic effect. Lipodissolve has been
cologic availability and laws regulating medical trademarked by a group within the United
and dispensing practices between Europe and States.
ch01 27/3/07 1:16 pm Page 2

2 AESTHETIC MESOTHERAPY

The most common indications for which metabolism. It has been approved in the
mesotherapy has received attention in the United States for the treatment of fat
United States are cosmetic – cellulite reduc- embolism and as an oral nutritional supple-
tion, alopecia, localized fatty deposits, and ment. However, it is not approved by the Food
facial rejuvenation. In particular, the and Drug Administration (FDA) for subcuta-
technique has garnered much media and neous injection for ‘dissolving fat.’
medical attention for its action as a ‘fat-dissolv- Nonetheless, Norman Orentreich, a dermatol-
ing’ treatment. In the past, mesotherapy ogist in New York, conducted a study using
formulations sometimes included homeo- PPC in animal models. He concluded that,
pathic preparations for specific conditions after exposure to PPC, adipocytes ruptured in
and only in some patients, such as cynara or vitro. Since the 1980s, therefore, in part as a
artichoke extract, in the treatment of cellulite. result of these earlier observations, PPC has
However, as newer, more effective medica- been used subcutaneously for the treatment of
tions were presented to the market, mesother- localized fatty deposits in the face, abdomen,
apy ‘cocktails’ began to utilize fewer such trunk, and extremities. The prominence and
preparations and restricted the formulations positive anecdotal results of PPC have led to its
to three or fewer allopathic agents. Moreover, re-emergence as a ‘newer’ form of mesother-
since the traditional, older mesotherapeutic apy, ‘American mesotherapy,’ or as a separate
regimens were ‘mild,’ results often did not entity referred to as injection lipolysis.
manifest for several weeks. Since patients in Regardless of the terminology, the basic
Europe paid a nominal fee for treatment, it premise is the same: the use of the active
was not unreasonable to have patients return ingredient of PPC (with or without its deter-
for multiple sessions at 1–2-week intervals. gent carrier, DX) as a subcutaneous or
Due to the lack of availability of certain hypodermic injection for the non-operative
medications and the prolonged length of time resolution of localized fatty deposits in NSBC.
for some results to become evident using some
of the homeopathic preparations, however,
TECHNIQUES
some physicians outside of France began to
investigate other compounds that could be Mesotherapy is based upon injection of ‘micro-
used within the realm of mesotherapy. In the doses’ of ‘active’ medications onto the epider-
late 1980s, Sergio Maggiori of Italy described mis or into the dermis (embryologically
the use of PPC for the amelioration of xanthe- derived from the ‘mesoderm’) of the skin at
lasma. He presented his findings at the 5th relatively infrequent but regular intervals. As
International Congress of Mesotherapy in such, intentional placement of these pharma-
Paris, France in 1988. `It should be noted that cologic (or homeopathic, in some cases)
Maggioro referred to the use of PPC as agents into layers of the skin where the vascu-
‘mesotherapeutic’ in his seminal work lature is not large or extensive permits their
‘Traitment mésothérapique de xanthelasmas à la effects to be prolonged and concentrated at
phosphatidylcholine polyinsturée. In 1999, the the site of locoregional injection. Whereas the
Brazilian dermatologist Rittes published her dermis and hypodermis have a rich blood
series on the non-surgical treatment of lower- supply, the smaller caliber of these vessels
eyelid bags. She injected the lower eyelids of prevents the rapid absorption of the injected
15 patients with a trademarked preparation medications that would otherwise be evident
called Lipostabil (Aventis), the main ingredi- with intravenous or intra-arterial injection.
ent of which is PPC. Lipostabil is currently Thus, the formulaic ingredients of the
registered as an approved drug in over 50 mesotherapy mixture may take effect at the
countries. PPC is a medication that is specific site of the ailment or abnormality, with
approved in Europe in the management of detectable and measurable drug levels at that
liver cirrhosis and abnormalities of lipid site2 but without the risk of systemic toxicity.
ch01 27/3/07 1:16 pm Page 3

INTRODUCTION 3

Injection techniques
Intraepidermic mesotherapy
Wet and dry mesotherapy
1 Papule
2 Nappage
3 Point by point – 4 mm
Mesoperfusion
4 mm
Systematic injection
therapy mesotherapy

Figure 1.2 Depths of injection in mesotherapy.

(Reprinted from Dr JJ Perrin, with permission.)
Figure 1.1 The different depths of injection in classic
mesotherapy will vary depending upon the thickness of
the skin at the particular injection site. (Reprinted from aforementioned techniques. Despite these
Bonnet et al,3 with permission. Photo endorsed by the potential adverse effects, the latter methods
French Society of Mesotherapy, SFM for the DIU de
Mésothérapie de Paris.)
are either indicated for particular conditions
that would not otherwise be as effectively
treated with the more superficial injections or
There are multiple techniques of injection are required when using some specific
in mesotherapy, as there are several layers of medications (non-steroidal anti-inflammatory
the skin. The methods relevant to aesthetic drugs (NSAIDs) and phosphatidylcholine, for
mesotherapy are (Figure 1.1): intraepidermal example). Therefore, practitioners perform-
(IED), intradermal – superficial (IDS), ing mesotherapy must have knowledge and
papule, nappage, intradermal – ‘profound’ or expertise in all techniques so as to be able to
deep (IDP), dermohypodermal (DHD), point modify their approach to the diverse needs of
by point (PPP), subcutaneous (SC), and, most the NSBC patient (Figure 1.2).
recently, mesodissolution (an innovation by One of the basic tenets of aesthetic plastic
French doctors Bonnet, Perrin, and Pasquini surgery is that the care plan or approach to
specifically for the treatment of localized fatty each patient must be highly individualized.
deposits and cellulite). Each technique has its What underlies this concept is the foremost
advantages and limitations. Specifically, the establishment of patient safety. These funda-
IED technique is advantageous in that it mental parameters must also be applied in the
induces no bleeding. However, it results in evaluation and treatment of the mesotherapy
delayed penetration of the medications or NSBC patient. In the case of mesotherapy,
(although, at subsequent treatment sessions, not only will the ‘formulae’ for each patient
this delay becomes less significant).3 The differ but also the medications in and volume
papule, nappage, and IDS techniques cause of each ‘cocktail’ may vary from one body
minimal discomfort to the patient but result in region to another and may also change with
wasting of medication due to loss of the liquid time. Physicians performing injection lipoly-
between points of skin contact. The deeper sis, on the other hand, adhere to one
methods of injection, such as IDP, intrahypo- standardized formula, the safety of which has
dermal (IHD), DHD, mesodissolution, and been documented by Hasengschwandtner.4
SC, potentially cause some pain and are associ- Irrespective of this dynamism, it is imperative
ated with significant risks of hematoma forma- that the physician perform vigilant and
tion as well as an increased risk of systemic frequent assessment and re-evaluation of the
absorption of agent in comparison to the patient’s progress (or lack thereof) on a
ch01 27/3/07 1:16 pm Page 4

4 AESTHETIC MESOTHERAPY

mesotherapy protocol. Moreover, there are experience. For example, French mesothera-
several basic and irrefutable elements that all pists prohibit the use of multi-injectors, as
mesotherapy mixtures must adhere to in these devices do not allow accurate control of
order to help assure patient safety and satisfac- injections and may lead to significant local
tion.1,3 These mixtures must be: complications.1 In addition, the French clini-
cians express caution in the general use of the
• hydrosoluble
subcutaneous technique, as it is associated
• isotonic
with a higher risk of hematoma and a more
• pH-balanced between pH 5–7
rapid rate of absorption (and thus, decreased
• biocompatible
efficacy of some) of the medications.
• physiologic
Additionally, Le Coz cautions against aggres-
• therapeutic
sive injection techniques in patients of color
• well-tolerated
since they are at increased risk of developing
• sterile and safe for human injectable use.
scars and traumatic tattoos in the event of
The omission of any of these factors renders hematoma formation. Dr Pistor established a
mesotherapy ineffectual and ostensibly technique decades ago that will well serve
precarious. modern physicians of various backgrounds to
In general, there are no specialized materi- study and validate.
als or equipment for performing mesother-
apy. Typically, a mesotherapist will utilize basic
PATIENT EVALUATION
equipment or supplies that are readily avail-
able, including: A complete history and physical examination
are essential in the evaluation of the patient
• A 5–12 cc syringe with Luer lock.
who presents for an aesthetic procedure. By
• A large-bore needle for drawing up
necessity, the initial consultation must
medication.
document an assessment of the patient’s
• Multiple fine bore (27–32 gauge),
complaint, an evaluation of the physical abnor-
2–13 mm needles for actual treatment,
mality or condition, and a determination of the
mesotherapy needles. (It is advisable to
appropriateness of the patient’s request for
change needles at least once or twice
surgery or a procedure. The patient should
during any given session. This contributes
understand the benefits, risks, limitations, and
to a less traumatic technique.)
potential complications of the proposed inter-
• 70% alcohol for disinfection.
vention, and should have realistic expectations
• Sterile gauze.
of possible outcomes. An explanation of the
• Procedure gloves.
procedure as well as alternatives to the therapy,
• A clean environment and a disinfected
including no treatment, should be provided so
surface.
that the patient may make an informed
Mesotherapy, as in other procedures involving decision that is untainted by external influence,
percutaneous injections, need not be under- coercion, or lack of information. It behooves
taken as completely sterile, but as assuredly the examining physician to further evaluate the
clean and without any contamination. prospective patient’s motivations for therapy in
Moreover, the technique must be performed an attempt to rule out any emotional instability
with strict attention to aseptic technique, with or psychological or mental disturbance. In the
appropriate and adequate disinfection of the context of mesotherapy and NSBC, including
areas to be injected. injection lipolysis, particular attention should
As originators of mesotherapy, French also be paid to a history of drug allergies,
physicians provide valuable practice guide- pregnancy, concurrent skin conditions,
lines that are current, ethical, and based upon ongoing infection, or immunosuppressive state,
sound preliminary research and decades of as these are generally contraindications to
ch01 27/3/07 1:16 pm Page 5

INTRODUCTION 5

mesotherapy. A detailed medical history is about whether or not mesotherapy or injection

paramount prior to treatment by mesotherapy lipolysis is an option to help them achieve their
and injection lipolysis. As in plastic surgery, a body contouring or facial rejuvenation goals. It
thorough physical examination should be is important to inform the patient that,
supplemented by medical photography in currently, neither of these techniques is
NSBC and mesotherapy, in general, both approved in the United States by the FDA; full
before and after a procedure, as well as at disclosure is imperative. Once mesotherapy or
certain treatment intervals. Anthropometric injection lipolysis has been undertaken,
data, such as patient body measurements, patient evaluation does not end. Reassessment
height, weight, and the calculation of body mass of the response (or lack thereof) to any given
index (BMI), are also often helpful indices to treatment session must be an ongoing and
help track results. While the physician may use dynamic process. In general, if a patient does
these findings as objective evidence in the not respond significantly (typically by at least
determination of treatment efficacy, the subjec- 50%) to NSBC intervention after two or three
tive patient response to the treatment will also sessions (or at the ‘half-way’ point), other
serve as a factor that contributes to the overall options must be addressed, including other
success of treatment. In the example of NSBC, non-operative therapies, plastic surgery, and
patients will often note that their clothes ‘fit cessation of mesotherapy. This principle
differently,’ and will be encouraged by this should be applied not only in NSBC but also in
observation, despite the result being difficult to facial rejuvenation, hair loss, and other realms.
accurately measure or quantify. It remains that while these new modalities may
In summary, the patient evaluation that serve as choices for the correction of certain
takes place prior to treatment should include: conditions for a select group of patients,
neither mesotherapy nor injection lipolysis
1. A thorough history, with attention to drug
should be offered exclusive of other perhaps
allergy, thyroid condition, hypertension,
more effective therapies, including surgery.
cardiovascular disease, anticoagulation,
Ideally, safety profiles and toxicology studies
immunosuppressive state, concurrent skin
will help to elucidate practice guidelines for
conditions, and reproductive history;
mesotherapy, including NSBC and injection
2. A history of previous treatment of
lipolysis, in the near future.
problem;
3. A complete physical examination, with
focus on areas of concern to the patient; REFERENCES
4. A psychological assessment; 1. Le Coz J. Mesotherapie et Medecine Esthetique.
5. For body contouring: height, weight, BMI, Marseilles: Solal, 1994.
previous weight loss, presence of excess or 2. Le Coz J, Dupont JY. Arthroscopie prelevement p 24.
sagging skin, skin tone and laxity; Traite de Mésotherapie. Masson biblio No. 57,
parution 1983.
6. Body measurements specific to area(s) to 3. Bonnet C, Mrejen D, Perrin JJ. Mesotherapy in
be treated; Esthetic Medicine and General Medicine. Paris:
7. Standard medical photography of area(s) Mesodiffusion, 2003.
to be treated; 4. Hasengschwandtner F. Injection lipolysis for effective
8. Informed consent; reduction of localized fat in place of minor surgical
lipoplasty. Aesthetic Surg J 2006; March/April:
9. Laboratory testing, as dictated by history 125–30.
and physical examination.
An integral part of the initial consultation
provides patients with a realistic perspective as
ADDITIONAL SELECTED
regards their appropriateness as candidates for BIBLIOGRAPHY
mesotherapy. An honest and objective opinion Boigard S, Daturi Y. Le chirurgien et la mésothérapie. La
should leave patients educated and informed Revue de Mésothérapie 2002; 115.
ch01 27/3/07 1:16 pm Page 6

6 AESTHETIC MESOTHERAPY

Bonnet C, ed. Adapted from Esthétique et Anti-âge; Mon vasculaire: à propos de 13 cas. La Revue de Méso-
peau et mon bien-être. Document AMME, France, thérapie 2003; 117: 28–31.
translated by Shirley Madhère MD. Mathur SN, Born E, Murthy S, Field FJ. Phosphatidylcholine
Clark J. PC injections may replace some surgery. Dermatol increases the secretion of triacylglycerol-rich lipopro-
Times 2004; July 1. teins by CaCo-2 cells. Biochem J 1996; 314: 569–75.
Hasengschwandtner F. 2004 Annual Lipodissolve Clinical Mrejen D. Sémiologie clinique et pharmacocinétique:
Report. Publication of the Network-Lipodissolve of application aux différentes techniques en méso-
the American Society of Aesthetic Lipodissolve thérapie. La Revue de Mésothérapie 1999; 107: 27–32.
(ASAL). Otrompke J. A new look at lipolysis. Dermatol Times 2004;
Heinrich K. Efficacy of injections of phosphatidylcholine October 1.
into fat deposits: a non-surgical alternative to liposuc- Palkhivala A. Noninvasive fat melting: the facts and the
tion in body-contouring? Presented at the conven- fantasy. Cosmetic Surg Times 2004; Jan 1.
tion ‘Operative Dermatologie’ in Frankfurt, Rotunda AM, Suzuki H, Moy RL, Kolodney MS. Detergent
Germany, October, 2004. effects of sodium deoxycholate are a major feature of
Lecomte P, Galvez J. Evaluation de la mésothérapie dans an injectable phosphatidylcholine formulation used
le traitment des ulcers artériels et veineux dans le for localized fat dissolution. Dermatol Surg 2004; 30:
cadre d’une consultation hospitalière de chirurgie 1001–8.
ch02 27/3/07 1:16 pm Page 7

Anatomy and physiology of the skin 2

Harryono Judodihardjo

INTRODUCTION conditions. The aim of this chapter is to

describe briefly the structure and function of
The skin is arguably the largest organ of the individual cell types of the normal skin as well
body. The skin of an average adult male covers as the embryological development of the skin.
an area of about 2 m2 and weighs approxi-
mately 3–4 kg. The skin’s primary function is
EMBRYOLOGY OF THE SKIN
to act as a barrier to protect the internal milieu
from harsh chemicals and pathogens in the The human skin consists of three layers:
environment. The skin also acts to help to epidermis, dermis, and subcutaneous fat.
regulate body temperature and protect against During early development, human skin is
physical injury. It is also an excretory, immuno- derived embryologically from the ectoderm
logic, psychosocial, and aesthetic organ. and mesoderm. Ectoderm, or the outer layer,
The anatomy and physiology of the skin are forms the epidermis. Mesoderm or the middle
important to understand, since many different layer forms the dermis, subcutaneous fat, and
disease states affect the skin. Therefore, other organs such as bone and blood (Figure
important information may be derived from 2.1). The earliest embryologic development of
this knowledge vis-à-vis treating some of these the skin can be seen at 3 weeks of gestation. At

Zygote

Blastula

Gastrula

Ectoderm Endoderm

Epidermis, Brain and Digestive and

hairs, nails nervous system respiratory tract,
liver, pancreas, etc.
Mesoderm

Notochord Mesenchyme Somites

Muscle, gonads,
excretory system, etc.

Circulatory system Dermis, subcutaneous fat Bones and cartilage

Figure 2.1 Flow chart of human embryologic development.

ch02 27/3/07 1:16 pm Page 8

8 AESTHETIC MESOTHERAPY

this stage, the epidermis is only a single layer of

cuboidal epithelial cells. This gradually devel-
ops into the stratified layer of the epidermis
with evidence of cornification (formation of
the dead cell layer) at the 5th month of gesta-
tion. Complete cornification can be seen by
the 6th month of gestation. The dermis can be
seen as a cellular layer at about the 6th week of
gestation. However, at this stage, it still has no
clear separation from the subcutaneous layer.
By the 9th week, collagen can be seen in
increasing amounts in the cellular matrix. By
the 12th week of gestation, the dermis has
been transformed from a cellular layer to a
fibrous layer and its deep boundary is defined
by blood vessels and a nerve plexus that both
sit along a plane between the dermis and fat.
The subcutaneous fat is the last layer of skin
to develop. It first appears in the 4th–5th
month of gestation. Adipose cells are
organized into lobules that are divided by
fibrous septa. Throughout their lifetime, these
Figure 2.2 Schematic of epidermal differentiation.
cells function to continuously synthesize and (Courtesy of Dr Paul E Bowden, Cardiff University.)
store fat. Brown fat that is present in the
newborn can first be seen at 28 weeks of gesta-
tion. This type of adipose appears brown granulosum, and stratum corneum (Figure
mainly because of a rich blood supply and 2.2). Sometimes the term ‘Malpighian layer’ is
numerous mitochondrial cytochromes. Brown used to mean both the stratum basale and
fat functions to generate heat in the newborn, stratum spinosum.
but its relationship to adult white fat is still The cell of the stratum basale is cuboidal in
unknown. shape and normally is only one cell thick. In
some non-hair-bearing skin such as the palms
and sole where the epidermis is more active,
ANATOMY OF THE SKIN
the stratum basale can be two–three cells
thick. The basal cells continuously divide to
Epidermis
replace the cells that are shed on the surface
The normal epidermis is made of terminally of the skin. The time taken for the cell to
differentiated stratified squamous epithelium. mature from the basal layer until the cornified
About 95% of the cells in the epidermis are layer is normally about 4 weeks. Diseases that
keratinocytes that progressively move from shorten this turnover time, such as psoriasis,
their attachments at the basement membrane will lead to scaling of the skin.
towards the skin surface. During this progres- Immediately above the basal layer is the
sion, the keratinocytes gradually change to stratum spinosum (the spinous or prickle-cell
become anucleated cells found in the surface layer). This layer appears spinous because the
of the epidermis. These morphological cells are interconnected by cell surface inter-
changes can be seen microscopically and allow connections called desmosomes. The desmo-
simple division of the epidermis into four some has both intercellular and intracellular
distinct layers: stratum basale or stratum components that provide stability in the
germinativum, stratum spinosum, stratum epidermis. During inflammation, when there
ch02 27/3/07 1:16 pm Page 9

ANATOMY AND PHYSIOLOGY OF THE SKIN 9

is edema in the epidermis, the desmosomes

can be seen more clearly because they are
stretched by the fluid that is present in the
epidermis. Desmosome dysfunction that
occurs in certain immunologic or hereditary
conditions can lead to superficial blistering, a
condition known as pemphigus.
The stratum granulosum appears granular
because of the multitude of intracellular
granules containing keratohyalin. Many of the
cellular organelles and proteins are no longer
needed at this stage of keratinocyte progres-
sion and begin to be degraded. Viewing the
granular layer with higher magnification will
reveal numerous smaller granules called lamel-
lar bodies (Odland bodies or membrane-
coating granules).1 These lamellar bodies
contain lipids that are then discharged into the
intercellular space, enhancing the barrier
function of the skin as well as strengthening
intercellular cohesion.
The stratum corneum or the cornified layer
is the outermost layer of the skin. The cells in
Figure 2.3 Electron microscopy of the stratum corneum
this layer have lost nuclei and cytoplasmic cells, which lack nuclei and organelles. The dark arrow is
organelles, and have become flattened. This pointing to the desmosomal attachment plaque.
layer also has a highly insoluble plasma (Courtesy of Dr Paul E Bowden, Cardiff University.)
membrane and is characterized by keratin that
has become aligned and cross-linked into
macrofibers (Figure 2.3). At this stage of Melanocytes are cells that produce the
progression, the keratinocyte is called a pigment melanin, which determines the skin
corneocyte. The corneocyte layer is thinnest color. There are no significant differences in
on the eyelids and genitalia and is thickest on the number or distribution of melanocytes
the palms and soles. The stratum lucidum is an between races.2 Nevertheless, skin color
additional layer of the epidermis that is present appears darker because of increased produc-
only in the palms and sole. This layer lies in tion, and variegated distribution and reten-
between the strata granulosum and corneum; tion, of melanin, and not because of a greater
it has nucleated cells, but opaque membranes number of melanocytes. When melanin has
and a dense cytoplasm. Most of the barrier been produced, it is stored in nearby
function of the skin is provided by the stratum keratinocytes in the form of pigment granules
corneum. The main function of the epidermis known as melanosomes. Moreover, each
is therefore to produce the cornified layer as melanocyte, through its dendrites, can be in
the primary layer of protection from the exter- contact with about 36 keratinocytes, forming
nal environment. Disruption of, or abnormal- groups of cells known as epidermal melanin
ity in, the production of corneocytes will units. Langerhans cells are other dendritic
therefore lead to skin diseases that are charac- cells in the epidermis that are similar to
terized mainly by scaling and flaking. melanocytes but are free of pigment. This cell
Other cells that can be found in the epider- was first discovered by Langerhans after stain-
mis are melanocytes, Langerhans cells, and ing the epidermis with gold chloride, and is
Merkel cells. thought to have originated from the bone
ch02 27/3/07 1:16 pm Page 10

10 AESTHETIC MESOTHERAPY

marrow. Its main function is to process

antigens that are in contact with the skin and
to present part of the antigen to T cells in
order to invoke an immune reaction. When
the skin is exposed to ultraviolet (UV) radia-
tion or to topical or systemic glucocorticoids,
the number of Langerhans cells decreases.
This may be one of the explanations as to how
UV radiation causes skin malignancy, as the
decreased number of Langerhans cells leads
to decreased immunologic surveillance of the
epidermis. Similarly, the reduced number of
Langerhans cells may also be one of the ways
by which glucocorticoids reduce inflamma-
tion in the skin.
Finally, Merkel cells are large oval-shaped
cells that can be found in the basal layer of the
epidermis. They function as sensors for touch.

Dermis
The dermis is the structure that lies in
between the epidermis and the subcutaneous
fat. It has a thickness that varies from about
1 mm on the face up to approximately 4 mm
on the back and thighs. It is made up primar-
ily of connective tissues such as collagen,
elastic fibers, and ground substance that can
cushion the body against mechanical injury. Figure 2.4 The biopsy was stained red with a lipophilic
Few cells are found in the dermis. The most solution (oil red O) and the protein was stained
abundant cells in the dermis are fibroblasts blue/green with aqueous bromocresol green, highlight-
that produce the dermal connective tissues. ing the subcutaneous fat and sebaceous glands (red) and
the dermal collagen (green). (Courtesy of Dr Paul E
Other cells in the dermis include mast cells,
Bowden, Cardiff University.)
histiocytes or macrophages, lymphocytes, and
melanocytes. Structures such as blood vessels,
lymphatics, nerves, and various kinds of nerve
endings can also be found in the dermis. dermis is thin and lies superficially such that it
Collagen forms the major structural compo- interdigitates with the underside of the
nent of the dermis. It is a protein fiber that epidermis. It is made up of a finely woven
gives the dermis its tensile strength. It repre- meshwork of fibers. In contrast, the deeper
sents about 75% of the dry weight of the collagen of reticular dermis appears as thick
dermis and can occupy from 18% to 30% of collagen bundles. They make up about 90% of
the dermal volume. With a conventional the dermal thickness and blend proximally
microscope, dermal collagen can be seen as with the subcutaneous fat (Figure 2.4).
fibers measuring from 2 µm to 15 µm. There are at least 28 known types of connec-
According to the size and arrangement of the tive tissue collagen. The two major types of
collagen fibers, the human dermis can be collagen in the human skin are types I and III.3
divided into two distinct regions: papillary The tensile strength of the human dermis is
dermis and reticular dermis. The papillary mainly owing to collagen type I, which
ch02 27/3/07 1:16 pm Page 11

ANATOMY AND PHYSIOLOGY OF THE SKIN 11

Table 2.1 Types of collagen* They measure 1–3 µm in diameter. The main
Collagen type Tissue distribution property of elastic fibers is that they can be
I This is the most abundant collagen of the
stretched by 100% or more and still return to
human body. It is present in skin, scar their original length when the force that
tissue, tendons, and the organic part of stretched them has been removed. This gives
bone the skin its elastic property and resilience.
II Articular cartilage Using special staining methods, elastic fibers
III This is the collagen of granulation tissue
can be seen under light microscopy as wavy,
that can be produced quickly by young delicate freely branching fibers.
fibroblasts before the tougher type I Ground substance is an amorphous mater-
collagen is synthesized. It is present in ial that fills the spaces between the fibrous and
skin, lung, blood vessels, and is cellular components of the dermis. It is mainly
predominant in the fetus
made up of glycosaminoglycans (GAGs),
IV Basal lamina of skin; eye lens which are repeated chains of two different
V Skin, most interstitial tissue, associated saccharides. The glycosaminoglycans are
with type I covalently linked to protein, resulting in a
VI Extracellular microfibrils of skin, substance known as proteoglycan, which can
associated with type I hold 1000 times its own volume of water. This
VII Skin, cornea, microfibrils property of the proteoglycan allows it to play a
significant role in maintaining the homeosta-
VIII Some endothelial cells
tic balance of salt and water. This hydrophilic
IX Cartilage, associated with type I property also renders GAGs to serve as lubri-
X Cartilage cants. GAGs also act as anticoagulants and
XI Cartilage help to provide support for the other compo-
nents of the dermis. In the dermis, the most
XII Skin, tendons, associated with type I and
III common GAGs are hyaluronic acid and
dermatan sulfate. Another important
XIII Cell matrix junction, interacts with types I
and II
constituent of the ground substance is
fibronectin. This is the name that is given to
XIV Skin, tendons, associated with type I
high-molecular-weight glycoproteins that can
XV In most human tissues be found at the cell surfaces, in extracellular
XVI Fibroblast fluid and connective tissues. Fibronectin
XVII Skin basement membrane
*There are at least 28 different types of collagen in the
vertebrates. They occur in many places throughout the body
and this table lists some of them.

accounts for about 80% of the total collagen

in the dermis. Collagen type III makes up
about 15% of the total collagen and can be
found mainly in the papillary dermis, where it
plays an important role in anchoring the
epidermis to the dermis. Other collagens that
are important in the skin include collagen
types IV–VII, type XII, and types XIV–XVII
Figure 2.5 Schematic of fibroblasts and fibrocytes. A
(Table 2.1). fibroblast contains numerous endoplasmic reticulums,
Elastic fibers are made of protein and consti- indicating its high activity in producing ground substance
tute about 3% of the dry weight of the dermis. and collagen in the dermis.
ch02 27/3/07 1:16 pm Page 12

12 AESTHETIC MESOTHERAPY

functions mainly to facilitate the attachment high-affinity receptors, the cell membrane
of cells such as fibroblasts, macrophages, and changes and causes a complex sequence of
keratinocytes to cell membranes, basement reactions in the cell, leading to activation of
membranes, collagen, and fibrin. the cell and degranulation. Mast cells can be
The most abundant cells that can be found found in most tissues, but are particularly
in the dermis are the fibroblasts, which numerous in the layers between the external
develop from the mesenchyme in the environment and the internal milieu, such as
mesoderm (Figure 2.5). Some fibroblasts that the skin, gut, nasal mucosa, perivascular
appear during the repair of the skin might tissues, and the bronchus.
also originate from either other mesenchymal- The blood supply to the dermis originates
derived cells, such as the vascular endothe- from a vascular network situated in the deep
lium, or by transformation of macrophages. reticular dermis. Communicating vessels then
Conversely, fully differentiated fibroblasts also connect the deep vascular network to three
have the ability to transform into other additional superficial vascular networks:
mesenchymal-derived cells such as osteoblasts, subpapillary, perifollicular (around hair folli-
fat cells, and smooth muscle cells. The main cles), and around the eccrine glands. From
function of the fibroblast is to produce all of these superficial vascular networks, smaller
the dermal ground substance or its precur- arterioles ascend and branch into capillaries
sors. Considering the large number of that supply blood and nutrients to each subepi-
elements that are present in the ground dermal papilla. Blood then drains into progres-
substance, it has been shown that there are sively larger veins that empty into the veins of
multiple variants of fibroblasts in the dermis, the deep reticular dermis. The blood supply to
even though morphologically they all look the skin is much more elaborate and numer-
similar. Fibroblasts from developing connec- ous than what is needed to supply the skin with
tive tissue, when viewed under electron nutrients because it is also used as the body’s
microscopy, reveal extensive endoplasmic temperature regulator. The lymphatics of the
reticulum, Golgi apparatus, and ribosomes. skin form a network following the distribution
These features are typical of cells that are of arterioles and venules. The main function of
geared for active synthesis and secretion of the skin lymphatics is to transport fatty acids to
elements. In contrast, in matured skin, the and from the adipose tissues.
fibroblasts are inactive. The cells appear to
have heterochromatic nuclei and minimal
Subcutaneous fat
cytoplasm. These types of inactive fibroblasts
are known as fibrocytes. The deepest layer of the skin is the subcuta-
Mast cells are derived from hematopoietic neous fat layer. This is an important layer
stem cells. Morphologically, the mast cell is because it acts as a shock absorber to protect
larger than an eosinophil or basophil. The other vital structures, as an insulator helping to
mast cell was first noted by Paul Ehrlich in 1878 maintain body heat, and as storage for energy.
because of its unique staining characteristics The adipose cells in this layer are organized
and large granules.4 These granules made into microlobules. Each microlobule is
Ehrlich mistakenly believe that they existed to composed of a few adipocytes and measures
nourish the surrounding tissues and he named about 1 mm in diameter. These microlobules
the cell ‘mastzellen,’ meaning ‘feeding cells.’ in turn are grouped together forming larger
The granules actually contain inflammatory lobules which are separated from each other
mediators such as histamine, heparin, by fibrous septa. These connective tissue septa
prostaglandins, leukotriene, and cytokines. On are attached superiorly to the reticular dermis
the surface of the mast cell are numerous high- and inferiorly to the fascia of the skeletal
affinity receptors for immunoglobulin E (IgE). muscle. The fibrous septa in males are aligned
When two or more IgE molecules bind to these diagonally, whereas in females they mainly
ch02 27/3/07 1:16 pm Page 13

ANATOMY AND PHYSIOLOGY OF THE SKIN 13

changes in its morphology or function due to

aging can be seen or detected much sooner
than the other organs which are not visible.
With advancing medicine and improving
standards of living, people are now living
much longer and healthier. In the past,
people who were 50 years old would be consid-
ered as elderly, but now people in developed
countries who are in the sixth decade are still
considered as middle-aged. Therefore, many
people now do not want to ‘look old’ on the
outside, because internally they still feel
young. This change in public perception has
led to much research into the causes and
possible remedies or retardants for the aging
skin.
The skin ages by two methods: intrinsic and
extrinsic aging or photoaging. Intrinsic aging
results from genetic programming and is
Figure 2.6 Cellulite. The skin has numerous dimples, independent of any other external or environ-
and resembles a ‘mattress’ or ‘orange peel.’ mental factors. Photoaging results from UV
radiation and other environmental insults that

have a vertical orientation. When the

adipocytes are filled with fatty acids, they grow
larger and exert pressure on these fibrous
septa. In the female, the vertical alignment of
the fibrous septa anchors the skin down, and
the enlarged size of the adipocytes gives the
skin surface an irregular appearance, a condi-
tion commonly called ‘cellulite’5 (Figure 2.6).
The fibrous septum that separates the
adipocyte lobules also carries the blood vessels
that supply the adipocytes. Therefore, as the
adipocytes enlarge, the blood vessel may be
compressed. This will then reduce the amount
of oxygen and blood and nutrients reaching
the adipocytes and, at the same time, may also
reduce the elimination of the metabolic waste
products from the subcutaneous layer. In
severe cases, the fat cell function will then be
compromised and may even lead to inflamma-
tion, which can sometimes be seen in severe
forms of cellulite.

SKIN AND AGING

Figure 2.7 Intrinsic aging. Photograph of a woman in
The skin is one of the most exposed organs in her 60s with only mild hyperpigmentation and fine
the body. Unlike other organs in the body, wrinkles on her face.
ch02 27/3/07 1:16 pm Page 14

14 AESTHETIC MESOTHERAPY

with hyperpigmentation and telangiectasia

(Figure 2.8). It is thought that in sun-exposed
skin, intrinsic aging only accounts for 10% of
age-related skin damage, whereas photodam-
age accounts for the remaining 90%.6 The
following paragraphs will discuss the changes
in each skin cell layer due to aging.
Microscopically, the youthful epidermis is
relatively thick, with about seven layers of strat-
ified keratinocytes (Figure 2.9). The keratino-
cytes are layered in an orderly fashion, and
there is no cell atypia. Melanocytes are few,
and the cornified layer is thin and appears
‘basket-woven.’ The papillary dermis has thin
and loosely arranged collagen fibers. The
deeper reticular dermis has pinkish collagen
and is free of the bluish solar elastosis that is
formed by broken down collagen. The dermal
vessels are not dilated or tortuous. There is
also no noticeable sign of an inflammatory
infiltrate.
The aged epidermis microscopically
appears to have fewer keratinocyte layers,
sometimes being only four cells thick. The
normal progression of the keratinocyte from
the basal layer to the cornified layer becomes
Figure 2.8 Extrinsic aging. Photograph of a woman in disorganized, with the cells progressing in
her 60s with thickened skin and deep wrinkles on her various directions. The normal shedding of
face. She smoked heavily and had exposed her skin to the the cornified layer becomes less efficient,
sun excessively. which leads to a thicker cornified layer. The
accumulation of non-active cornified cells
makes the skin appear dull from the surface.
One of the most significant extrinsic factors
to contribute to aging skin is sun damage. In
humans, most of the UVB that reaches the
skin is absorbed by the epidermis. However,
50% of UVA rays, indeed, do reach the papil-
lary dermis. The energy from UV radiation
Figure 2.9 Hematoxylin and eosin (H&E) staining of can be picked up by organic molecules in the
the epidermis showing seven layers of epidermal cells and dermis, causing their electrons to jump into a
staining for melanin. (Courtesy of Dr Paul E Bowden, higher-energy orbit. These exited molecules
Cardiff University.)
are free radicals, which may cause damage or a
secondary reaction to various other molecules
in the vicinity. Mitochondria are the power-
accelerate the process of intrinsic aging. From house of any cell as they produce energy in the
the surface, the changes that result from form of adenosine triphosphate (ATP) that
intrinsic aging are fine and pale wrinkles can be used by the cell. During the manufac-
(Figure 2.7), whereas photoaging leads to ture of ATP, mitochondria are susceptible to
rough, leathery, coarse, and yellowish wrinkles free radical damage. Damage to mitochondr-
ch02 27/3/07 1:16 pm Page 15

ANATOMY AND PHYSIOLOGY OF THE SKIN 15

ial DNA will lead to diminished ATP produc- their body to become more prominent. This
tion and, therefore, cause the cell to function may cause changes in the body fat distribution
less or even go into apoptosis (programmed from the typical gynecoid fat distribution to
cell death). Fibroblasts that contain damaged the android fat distribution. Body shapes then
mitochondria may not be able to produce change from ‘pear-shaped’ to ‘apple-shaped’
collagen, elastin, and other ground substances when the subcutaneous fat undergoes the
that maintain a healthy dermis. Moreover, free variety of changes inherent in the aging
radicals may increase the oxidation of protein process.
in the cell. Oxidized proteins may have Aging of the skin takes place on many levels,
decreased function, which can lead to cellular the effects of which influence a variety of cells
damage and further apoptosis. For example, within each of the skin’s layers. In order to
oxidized membrane transport protein may reduce the signs of aging, if not prevent them
lead to altered intracellular concentrations of altogether, treatments must address the
essential elements such as calcium and potas- mechanisms that result from the different
sium. Oxidized enzymatic proteins may slow insults that aging skin sustains. It may not be
down chemical reactions, leading to dimin- sufficient to simply apply the latest lotion onto
ished cellular function. Normally, oxidized skin. Although some factors, such as genetic,
proteins can be degraded intracellulary by may not be manipulated to help abate aging of
proteosomes. However, free radicals may also the skin, it is possible to reduce the ill effects
damage the proteosome, causing rapid of some of the extrinsic contributors to the
accumulation of oxidized protein in the cell. degenerative process. Avoidance of prolonged
Free radicals may also cause glucose in the sun exposure, appropriate eating habits, an
dermis to be cross-linked to amino acids such active exercise regimen, as well as a healthy
as lysine. This process is known as glycation. In and dedicated skin care protocol will certainly
the aged skin, proteins such as collagen and give positive results. The implementation of
elastin undergo glycation that can change these practices lies with the individual.
their properties. Glycated collagen, for Scientists and medical professionals may inter-
instance, is undeformable and has reduced vene in the quest for ‘ageless’ skin by research-
ability to allow cell adhesion. The effect of ing products and procedures that help to
photoaging is therefore evident in a number address the issues of aging on levels that are
of cells as well as on a multitude of cell not readily seen on the skin’s surface.
functions.
The human sebaceous gland also under-
THE SKIN AND MESOTHERAPY
goes both extrinsic and intrinsic aging. The
number of sebaceous glands remains the same The skin is one of the most accessible organs
throughout life, but sebum production tends in the body. This makes it facile for the skin to
to decrease steadily through each decade.7 be examined by the individual or others. Most
The level of androgen decreases as one gets laypersons do not realize that the skin is
older and this leads to a slower cell turnover in actually an organ and, therefore, just like any
the sebaceous glands, which may cause hyper- other organ, it needs to be looked after, other-
plasia of the facial sebaceous glands. This wise it will become unwell. Regrettably, owing
process may also be accelerated by UV. to this lack of knowledge by the general
Decreased sebum production is also responsi- public, a person actually taking good care of
ble for skin dryness in the elderly. his or her skin may be labelled as ‘vain.’
Finally, subcutaneous fat does not escape Therefore, it is important to continue to
the aging process. The adipose cells in mature increase public awareness that the skin is,
subcutaneous fat are larger than in a younger indeed, another organ that requires attention
skin. During menopause, women produce less and vigilance. It is a protective cover that
estrogen, allowing low levels of androgens in needs to be cared for and not abused.
ch02 27/3/07 1:16 pm Page 16

16 AESTHETIC MESOTHERAPY

Despite being the one of the most superfi- on the other hand, is a method that is perhaps
cial organs in the body, it is not easy to treat more readily accepted outside of European
the skin. Drug delivery from the skin surface is medical communities, primarily because of its
blocked by the skin’s tough horny layer that more direct action on its target cell – the
prevents water and other chemicals from adipocyte. Simply, whether by apoptosis or
entering the skin. Chemicals or drugs that are localized cellular disruption, the active ingre-
ingested or injected intravenously into the dients used in performing injection lipolysis
body also cannot be specifically directed to the have the particular goal of reducing fat. As an
skin alone without affecting the other organs. additional but secondary effect, inflammation
Many doctors and scientists spend their entire of adjacent elastic fibers and connective
lives thinking of ways to deliver drugs to the tissues may result in skin retraction over time.
skin. Notably, mesotherapy may have effects upon
Mesotherapy is one way of delivering drugs multiple cell types in the skin, via potentially
into the skin. Using this method, small more complex mechanisms. For example,
amounts of medication are injected at regular vitamins applied in mesoglow, or for facial
intervals to cover a predefined area. Some of rejuvenation, may affect the pH balance of the
the more common chemicals that are injected intercellular milieu. Mild doses of vasoactive
in mesotherapy are vitamins that can help the substances clearly affect the localized vascula-
facial skin to repair itself. It has been reported ture. The unique features of the dermis and
that some physicians also inject homeopathic epidermis impart the skin with both the ability
medicine whose base is water. How these to accept and heal and to reject and protect.
medications can work within the skin is still Therapies that take advantage of these proper-
hotly debated. Perhaps the combination of the ties, while not posing a threat to the system as
neutral pH of water and the injection a whole, may hold promise in the present day
produces a small inflammatory response that and in the near future.
triggers a repair mechanism in the skin.
During repair, new collagen and other dermal REFERENCES
ground substances are produced, which can
lead to more youthful and healthy-looking 1. Odland GF. A submicroscopic granular component
in human epidermis. J Invest Dermatol 1960; 34:
facial skin. With regard to localized fatty 11–15.
deposits, the inflammatory response that is 2. Szabo G. The number of melanocytes in human
caused by the injection of certain agents in epidermis. BMJ 1954; 4869: 1016–17.
mesotherapy and injection lipolysis, such as 3. Bornstein P, Sage H. Structurally distinct collagen
types. Annu Rev Biochem 1980; 49: 957–1003.
phosphatidylcholine/deoxycholate, may lead
4. Ehrlich P. Beitrage zur theorie und praxis der histol-
to the rupture of fat cells at the injected site. ogischem farbung. In: Himmelweit F, ed. The
The mechanisms by which mesotherapy may Collected Papers of Paul Ehrlich. London:
lead to an improvement in cellulite-affected Pergamon, 1956; 1: 29–64.
limbs are purported to be via several pathways. 5. Nurnberger F, Muller G. So-called cellulite: an
invented disease. J Dermatol Surg Oncol 1978; 4(3):
Plausibly, mesotherapy exploits the physio-
221–9.
logic properties of the skin, such as the 6. Leyden JJ. Clinical features of ageing skin. Br J
network of blood vessels, in order to affect its Dermatol 1990; 122 (Suppl 35):1–3.
results. Because the interactions between and 7. Jacobsen E, Billings JK, Frantz RA, et al. Age-related
among various cells within the skin are not changes in sebaceous wax ester secretion rates in
men and women. J Invest Dermatol 1985; 85(5):
wholly understood, the science of mesother-
483–5.
apy has also to be clarified. Injection lipolysis,
ch03 27/3/07 1:16 pm Page 17

Section I
Mesotherapy – evolution of practice
ch03 27/3/07 1:16 pm Page 19

The history of mesotherapy 3

Philippe Petit (translated by Shirley Madhère)

. . . However, the action of the mesodermal custom of performing injections that were
tissue is of such importance, that those either preceded or were followed by the appli-
treatments dealing with action upon or cation of an ointment. It was even surmised
within the mesoderm merit the global that Hippocrates himself treated and duly
name of ‘mesotherapy.’ healed a shepherd who suffered from shoul-
der pain by injecting the patient with needles
This realization essentially represents why from the Barbarie cactus that is indigenous to
Michel Pistor (1925–2003) (Figure 3.1) the Mediterranean region. Hippocrates also
created the term ‘mesotherapy’ in an article used the leaves from the Ficus plant in a salve
entitled ‘Exposé sommaire des propriétés that was known to have anti-inflammatory
nouvelles de la procaïne locale en pathologie properties. This was said to occur in 460 BC.
humain’ (‘Discussion of the summary of the The subsequent history of mesotherapy can
new properties of local procaine on human be found intertwined with other discoveries of
pathology’), which appeared in the June 4, modern medical techniques, including the
1958 issue of the French journal Presse first intravenous injection by JD Major in 1668.
Médicale. Later, the term was perceived as In 1728, Pierre Fauchard, a French dentist,
describing a therapeutic milieu between treated gingival disease by paying attention to
classic medicine and ‘soft’ medicine. This the periodontal tissue. In 1844, Francis Rynd,
discovery was not exactly a fortuitous one. an Irish medical doctor, practiced the first
However, mesotherapy is a technique that is subcutaneous injections, while Gabriel Pravaz,
rooted in traditional medicine. a French orthopedic surgeon, popularized the
In 3000 BC, whether in China, Brazil, India, syringe with a hollow needle.
or Egypt, physicians were engaged in the The 20th century (1905) brought the
creation of Novocaine (procaine) by the
German pharmacologist Alfred Einhorn.
Novocaine was commonly used as a local
anesthetic by the Belgian physician Albert
Lemaire, to alleviate rheumatologic pain
(1924). In a similar fashion, René Leriche, a
French surgeon, reportedly injected procaine
into the deep dermis in order to reduce artic-
ular pain and alleviate pathologies of the
joints (1928). The history of mesotherapy
would be incomplete without citing the work
of two investigators: Jean Jarricot, who in 1932
described the evolution of various local injec-
tion techniques; and Ferdinand Huneke, who
discovered neural therapy in 1938. There is no
doubt that Dr Pistor was influenced by this
Figure 3.1 Dr Michel Pistor. historical foundation in his own studies.
ch03 27/3/07 1:16 pm Page 20

20 AESTHETIC MESOTHERAPY

In 1952, at Bray et Lu, a small town situated Jules Bordet, a professor of veterinary surgery.
75 km northeast of Paris, France, a young Veterinarians are typically a bit more
internist named Michel Pistor established his pragmatic than their colleagues in human
medical practice. It is here that the marvelous medicine and, thus, quickly saw indications
history of mesotherapy really begins. for mesotherapy in their therapeutic arsenal.
One evening during consultations, Dr Therefore, the technique was readily adopted
Pistor was greeted by an elderly man, Jules by these doctors first. During the same period,
Paré, who was suffering from an acute asthma Mario Lebel, a surgeon, introduced the 4 mm
attack. The patient, well known to Dr Pistor, long needle with a diameter of 4/10, which
presented with acute hearing loss. Dr Pistor permitted the injection of medication
decided to treat the patient with what was then precisely and strictly into the dermis. This
a standard treatment for other ailments – discovery, too, would have influence on Dr
10 cc of IV procaine – then advised his patient Pistor.
to return home to rest. In order to make Mesotherapy as a formal technique
certain that his patient heard some of what he appeared in 1961 in Editions Maloine in an
was advising, Dr Pistor raised his voice, almost article by Dr Pistor. In 1964, he created the
shouting. The following day, Dr Pistor was French Society of Mesotherapy (SFM), which
awakened by a knock on his door by this same was presided over by Dr Lebel, and in April of
patient, who reported to the physician that, all the same year, the first General Assembly for
night, he heard ringing in his ears, when he Mesotherapy convened. Sixteen doctors were
had heard nothing for the past 15 years. That in attendance.
morning, however, the ringing stopped. The The first doctoral thesis about mesotherapy
patient beseeched Dr Pistor to re-treat him in medicine was written in 1972 by André
with the same injections so that he could once Dalloz-Bourguignon; in 1972, he performed
again hear sounds. This was the pivotal experi- the first hospital consultation where mesother-
ence that gave birth to the clinical practice of apy was recommended as a possible treatment
mesotherapy. option. International conferences soon
Mr Paré’s improvement was not repro- followed: in 1976 at Bray et Lu; in 1979 at
ducible. However, the publicity from the event Chantilly; and in 1982 at Rome, Italy.
brought forth a large group of deaf persons on In the 1980s, the progress of mesotherapy
whom Dr Pistor could refine his technique. It was accelerated by its further development in
was at this time that the internist had the idea France, as well as by the creation in 1980 of the
of injecting procaine in close proximity to the Cercles d’Etude et de Recherche en
ear into the superficial dermis. Although he Mésothérapie (CERM), a research group
noted only transient improvement, it was whose mission was to study mesotherapy and
especially remarkable that certain patients expand the use of the technique globally.
perceived that their cervical pain was dimin- Thus, in 1982, Dr Pistor created the
ished! Little by little, therefore, Dr Pistor International Society of Mesotherapy (ISM).
began injecting as close as possible to the area The year 1987 marked a turning point in the
of affliction or pain, with a mixture of medica- history of mesotherapy, since in that year, the
tions specifically adapted to the pathology in French Ministry of Health, based on an inves-
question. This may have seemed exciting, but tigation by the French Academy of Medicine,
at that time, despite his anecdotal success, Dr approved of and categorized mesotherapy as a
Pistor was marginalized and seen as a ‘healer’ safe, acceptable, and efficacious technique
rather than a true allopathic physician. In that may be incorporated within the practice
addition, mesotherapy in this era was not seen of general allopathic medicine. Also in 1987,
as suitable for use in humans, an idea exempli- the first advanced degree in mesotherapy, the
fied by the fact that the first uses of mesother- Diplôme Universitaire (DU), was established
apy were for veterinary purposes, primarily by in Marseille by Didier Mrejen. In 1996,
ch03 27/3/07 1:16 pm Page 21

THE HISTORY OF MESOTHERAPY 21

Philippe Petit (author) organized a similar born 51 years previously. Today, in 2006, the
program in Bordeaux, thus expanding the SFM has over 1500 members who hail from
opportunity to obtain such an advanced numerous countries. The ISM comprises 22
degree in Bordeaux, and created an inter- national society branches from four continents.
national course in mesotherapy at the The 21st century will come to regard mesother-
University of Bordeaux, France. apy as a true medical technique, not only in the
This national ‘diffusion’ of mesotherapy was realm of pain management but also in aesthetic
rapidly accomplished by an international medicine. Mesotherapy will have longevity
explosion of interest in the technique, such because of its therapeutic advantages, efficacy,
that, today, mesotherapy is well-known, safety, simplicity, and reproducibility.
accepted, and practiced in many areas of
medicine and surgery worldwide. In actuality, ADDITIONAL SELECTED
in France, mesotherapy is an integral part of BIBLIOGRAPHY
the standard of healthcare. It is recognized by
Herbin P. Doctoral thesis. Histoire de la mésothérapie,
all sectors of medicine – professional, govern-
Université Louis Pasteur, Faculté de Médicine de
mental, and administrative – as well as by clini- Strasbourg, 1994; Number 189.
cal branches. Dr Pistor passed away on August Personal discussions with Michel Pistor. Presse Médicale 4
3, 2003 at Bray et Lu where mesotherapy was June 1958; Volume 66: Number 44.
ch04 27/3/07 1:17 pm Page 23

Section II
Mesotherapy and modern practice
ch04 27/3/07 1:17 pm Page 25

The scientific basis of mesotherapy 4

Lisa A Merritt

GENERAL HISTORY led by Mario Lebel. In 1982, after further

collaborative efforts with several other
The rapidly evolving field of mesotherapy
countries, the International Society of
began as an accidental side effect observed
Mesotherapy (ISM) was established, with Dr
during a small clinical experiment conducted
Pistor as its first president. The society
over 50 years ago. Michel Pistor, a French
currently (at the time of this writing) is
physician, theorized that there could be alter-
headed by Philippe Petit of the Victor Segalen
nate delivery systems of medications to treat a
University of Bordeaux, France. In 1987, the
variety of ailments.1,2 In attempting to treat a
French National Academy of Medicine recog-
deaf patient for asthma with this approach, he
nized the University Diploma in Mesotherapy.
incidentally ‘cured’ the patient’s deafness,
Dr Petit was instrumental in the establishment
presumably by improving circulation to the
of a specialized training protocol for
inner ear. Thus, the field of mesotherapy was
mesotherapy, adhering to the original tenets
born.
set forth by Dr Pistor. There are now residency
In fact, the concept of impregnating the skin
training programs subspecializing in meso-
via cutting, puncturing, and administration of
therapy, with an estimated 1200 practicing
various traditional remedies dates back
mesotherapists in France.9 The training
hundreds of years to traditional healers in
program in France has recruited members of
Africa and Asia.3 Injections of various substances
the ISM from around the world. This univer-
into the mesoderm – tissue derived from the
sity-based approach has resulted in synergy
embryonic mesoderm level, including subcuta-
amongst departments in refining the
neous structures such as muscles, bones, circula-
techniques to treat a wide range of conditions,
tory system, lymphatics, and connective tissue –
including musculoskeletal and neuropathic
have been found to have both local and
pain, vascular insufficiencies and hair loss, and
widespread impact on tissue metabolism.
cosmetic indications such as reduction of
Using animal and human models, studies of
cellulite and localized fat deposits.
the diffusion patterns of mesotherapy injec-
Spurred by the efforts of the ISM, the world
tions using technetium 99m demonstrated
literature regarding this technique is rapidly
widespread migration of the material from the
expanding as a result of greater national and
point of contact to deeper tissue and organ
international collaboration.
levels.4–6 This mode of delivery presumably is
Initial published studies about mesotherapy
facilitated by local lymphatic drainage and
focused on the rare infectious complications,
microvascular circulation.7,8
most often with atypical mycobacteria.10–13
Subsequent work focused on the initial use of
mesotherapy with other modalities in the
INITIAL APPLICATIONS AND treatment of pain syndromes, joint and muscle
RESEARCH disorders, and vascular insufficiency.14–18 The
The field of mesotherapy has evolved over the popularization of cosmetic applications of
last 50 years, culminating in the establishment mesotherapy without consistent adherence to
of the French Society of Mesotherapy in 1964, standard hygienic practices has given rise to
ch04 27/3/07 1:17 pm Page 26

26 AESTHETIC MESOTHERAPY

an increase in recent documented outbreaks deposits purportedly result from the appropri-
of infectious complications.19,20 ate administration of the desired ‘cocktail’ of
More recent work has centered on struc- medications. The various combinations of
tural and physiologic mechanisms of action, pharmacologic compounds impact different
with continued emphasis on the need for stages of lipolysis, improve localized circula-
further studies. For the purposes of this tion, and stimulate immune response in the
chapter, we will focus on studies regarding the form of enhanced phagocytosis and resolution
cosmetic applications of mesotherapy for of induced tissue necrosis.
localized fat reduction and elimination of
cellulite.
Localized fat reduction
The deposition of these compounds in the
APPLICATIONS OF MESOTHERAPY
subcutaneous tissues harnesses the cellular
AND SUPPORTING RESEARCH
metabolism and depends upon the activity
Cosmetic mesotherapy involves application of level of the patient for greatest effect. More
various injectable compounds with the inten- aerobic activity, for example, causes greater
tion of impacting cellular metabolism, circula- muscle contractions and energetic demand
tion, and immune and lymphatic response. for accelerated fat degradation in the areas
Cosmetic improvements in the form of injected. There are many compounds that
improved skin tone and hydration, smoothing may be utilized in localized fat reduction and
of cellulite, and localized reduction of fat treatment of cellulite (Tables 4.1 and 4.2).

Table 4.1 Summary of compounds used in mesotherapy applications

Medication Concentration Dose Mechanism of action Depth Contraindications/ Comments
side effects
Local anesthetics
Lidocaine Xylocaine 0.5–2 cc Local anesthetic, All No epinephrine, Acute
1% membrane stabilizer, porphyria, otherwise treatment
potentiates beta blockers very safe
Procaine 2% Procaine 1–2 cc Vasodilator, non-specific Incompatible with Chronic
2% immune stimulant/ NSAIDS, salmon calci- treatment
metabolic properties tonin, no pediatric/
pregnant patients,
rare sul allergy
Diluents
NaCl 0.9%
Vitamins/minerals
MgSO4 1% 2 cc Antispasmotic, antiatopic, Gastrointestinal Only dilute
membrane stabilizer, effects Valium
antioxidant (diazepam)
with this
Vitamin cocktail 0.5 cc Antioxidant Cosmetics
Pantothenic acid 500 mg/ml 0.5 cc Antioxidant
Biotin 10 mg/ml 0.5 cc Alopecia/
Cobalamin color
B complex
B12 5000 µg Analgesic Pain
HPV Hydrosol polyvitamins
Vitamin C 222 mg Antioxidant, connective tissue
support
Vitamin A Antioxidant
Zn 10 mg/ml 0.05 cc Blocks 5-alpha reductase
Se 15–50 µg Antioxidant
 ch04
Table 4.2 Summary of compounds used in mesotherapy applications

27/3/07
Cosmetic Concentration Dose Mechanism of action Depth Precautions Comments
Facial treatment
Hyaluronic acid 10 mg/ml 1 cc Non-reticulated hydrator 1 g abs 50 Blebs Dilute, otherwise swelling. Use for wrinkles,

1:17 pm
Use alone in formulation ‘glow’. May cause
transient redness
Placenta* 2–3 cc
Silicium/conjuntyl 1% (or equiv) 2 cc Inhibits interstitial fibrosis/lipid Fibrosclerotic cellulite
peroxidation, augments cyclic AMP,

Page 27
stimulates fibroblasts, gives
structure/shape
PCSA* Proteochondroitin 7 mg/2 ml Hydrator, tissue repair regulator
sulfate 1–2 cc
Cellulite
Esberiven Melilotus 100 mg/ 1 cc Venoconstricts, reduces edema, Edematous cellulite Stages 1, 2, 3
rutin 2.5–5 mg dilates precapillary sphincter,
macrophage stimulation
Silicium/conjuntyl 15–50 mg Reduces wrinkles, atherosis Cellulite, reduces fibrosis Stages 2, 3
Pentoxifylline 20 mg/ml Increased blood flow
Coumarin 0.25% Stage 3, 4
Asian Centella 20 mg/ml Stage 3, 4
Lipolytic
Phosphatidylcholine PTC 50– 2.5 cc/5 cc Emulsifier 8 mm Localized obesity not cellulite, Banned in France
100 mg/ml NaCl symmetric, may cause swelling/itching and Brazil
caution
Aminophylline 50 mg/ml 25 mg, 2-4 cc Blocks adenosine receptor, inhibits
phosphodiesterase

THE SCIENTIFIC BASIS OF MESOTHERAPY

Caffeine 250 mg/ml Blocks adenosine receptor, inhibits
phosphodiesterase
L-Carnitine 500 mg/ml 1 cc Fatty acid transport
Isoproterenol** Major vasodilator beta-1/ Tachycardia/palpitations
beta-2 agonist including blood pressure,
Yohimbine 1 mg/ml Blocks alpha-2, stimulates lipolysis altered mental status

Circulation
Fonzylane (France) Buflomedil* Alpha-blocking vasodilator Toxic with lidocaine
Trental 20 mg/ml 1 cc of Microcirculation disorders, stabilizes Circulation, pain,
(pentoxifylline) 20 mg/ml blood cells/improves their flexibility, headache, alopecia,
improves tissue O2 cosmetics
Vadilex Alpha-blocking vasodilator
Dicynone Etamsylate Improves venous tone Potential sulfur allergy reaction
Disinfectants
70% alcohol
Biseptine*
Chlorhexidine* May be better for facial

27
cleansing
**Not recommended due to dangerous side effects
ch04 27/3/07 1:17 pm Page 28

28 AESTHETIC MESOTHERAPY

The intention of localized fat reduction tions that impacted lipolytic pathways.23 They
therapy is to somehow impact the rate of noted that lipolysis could be initiated through
storage, breakdown, release, and transport of adipocyte receptor stimulation (beta adrener-
fats during the various stages of fatty acid gic) or inhibition (alpha-2 adrenergic), or by
metabolism. The desired effect will be shrink- inhibition of phosphodiesterase. Testing
age of the adipocytes and localized reduction various formulations of medications, a statisti-
of the fatty region. cally significant change in thigh circumfer-
ence was noted in treated vs contralateral
Structural research – fat metabolism untreated thighs.
In 1995, Greenway et al24 selected isopro-
In the mid 1960s, the work of Butcher and terenol, forskolin, yohimbine, and ami-
Sunderland produced greater understanding nophylline to evaluate for in-vivo impact on fat
of the process of fat metabolism and potential metabolism. They theorized that if the proper
adrenergic and hormonal impact on the rate concentrations of lipolytic substances reached
of lipolytic activity in adipocytes.21,22 The the fat cell, local fat reduction would be possi-
adrenergic lipolytic pathway is influenced by a ble. Evaluation of varying topical and injectable
series of biochemical reactions which stimu- formulations was performed with monitoring
late or inhibit it by the effects of chemical of blood chemistry, complete blood count
mediators upon cell membrane receptor sites. (CBC), theophylline levels, and patch testing.
The beta receptor, which is a G-coupled recep- There was no evidence of toxicity or adverse
tor with inhibitory and stimulatory G proteins, physiologic side effects noted in their studies.
initiates the lipolytic cascade. The adenosine Moreover, there was significant reduction in
receptor and alpha-2 receptor inhibit stimula- girth of the treated thighs. The results of the
tion of cyclic AMP. Cyclic AMP is broken down study led to the conclusion that injections of
by the enzyme phosphodiesterase, which isoproterenol could be successfully adminis-
limits completion of the lipolytic pathway. tered with minimal side effects. Nevertheless,
Cyclic AMP is needed to couple with although this medication has been used with
hormone-sensitive lipase for cleavage of fat to some anecdotal success in the United States,
fatty acids and glycerol, completing the lipoly- European mesotherapists caution its use in
tic pathway (Figure 4.1). mesotherapy formulations, owing to the possi-
In 1987, Greenway and Bray at the bility of adverse cardiovascular effects.
University of California, Los Angeles, demon- Pedersen et al25 observed that adipose tissue
strated that fat reduction in women’s thighs on women’s thighs is difficult to mobilize,
was achievable through application of medica- owing to increased alpha-2 adrenergic recep-
tor activity induced by estrogen, which
Lipolysis encourages storage of fat and inhibits lipolysis
and liberation of fat from the adipocyte. This
Beta receptor observation is perhaps one of the reasons why
Adenosine V Alpha-2
receptor
receptor
the search for the most effective method(s) of
V Gs Gs V improving the appearance of this anatomic
GI Adenylate cyclase GI area continues feverishly.
It has been noted that combining agents can
Phosphodiesterase Cyclic AMP 5' AMP
simultaneously impact the complex lipolytic
Adenylate cyclase A-kinase
pathway.26,27 Xanthine agents such as ami-
Glycerol and
nophylline and caffeine block the adenosine
Hormone-sensitive lipase
fatty acids receptors, which inhibit the beta receptors,
Fat cell thereby releasing the lipolytic pathway from
inhibition, and inhibit phosphodiesterase,
Figure 4.1 which breaks down cyclic AMP, resulting in
ch04 27/3/07 1:17 pm Page 29

THE SCIENTIFIC BASIS OF MESOTHERAPY 29

Isoproterenol

Beta receptors – adrenergic stimulation +

Blocks Yohimbine

Alpha-2 receptors –
Adenylate cyclase adrenergic inhibition –

Aminophylline
Cyclic AMP
inhibits 5'-AMP
Phosphodiesterase

Adenylate cyclase

Hormone-sensitive lipase

Adipocyte
Glycerol and fatty acids

L-Carnitine= carrier molecule transports fatty

acids to muscle

Figure 4.2

greater lipolytic activity. Agents such as isopro- deposits. Lionel Bissoon has developed
terenol simulate both beta-1 and beta-2 recep- approaches for treating certain conditions by
tors, causing acceleration of lipolysis (Figure combining treatments that target cellular
4.2). Yohimbine inhibits the alpha-2 receptor, metabolism in conjunction with inciting
which inhibits the beta receptor, causing mechanical changes in the tissues.28 Recent
increased lipolysis (see Table 4.2). collaboration between this practitioner and
others has demonstrated the physiologic
effects of agents such as isoproterenol, ami-
COMBINATION THERAPIES
nophylline, and yohimbine in increasing lipo-
A number of mesotherapy practitioners have lysis in adipocyte tissue assays.29 In addition,
reported positive effects of using combination they noted an inhibitory effect of lidocaine on
therapies for the limited reduction of fatty lipolysis and suggested that it not be included
ch04 27/3/07 1:17 pm Page 30

30 AESTHETIC MESOTHERAPY

as a component of the mixture of medications there is increased storage of fat, there is herni-
used to instigate localized fat reduction. Work ation of enlarged adipocytes between the
in this arena by several investigators worldwide bands,37,38 causing the appearance of cellulite
continues to focus on improving outcomes, to be more pronounced.
establishing safety, and isolating more
specific, standardized formulae.
Cellulite reduction
In addition to the treatment of localized fat
reduction using agents to impact cellular The instillation of vascular agents such as
metabolism, there has been widespread use of pentoxifylline, buflomedil, and vadilex results
agents to mechanically ‘dissolve’ adipocytes, in greater vascular flow through the areas
ultimately resulting in volume reduction of affected by cellulite. Jorge Silva, president of
the fat deposit. The use of phosphatidyl- the Argentinian Society of Mesotherapy and
choline has been greatly popularized by vice president of the ISM (at the time of this
Rittes.30 Injections of phosphatidylcholine, a writing), has demonstrated a statistically
phospholipid derived from soybean lecithin, significant thermographic change in areas of
affect the movement of fats in and out of instillation of mesotherapy compounds as
cells.31 It appears that a mechanical effect of compared with inert, uninjected controls.39 It
these injections is to stimulate localized fat is believed that these areas of increased circu-
necrosis and increase macrophage activity.32 lation not only help to reduce tissue conges-
Recent work by Rotunda has demonstrated tion of extracellular fluid but also permit
that the addition of sodium deoxycholate, as localized drainage through the lymphatic
part of the processing of phosphatidylcholine, system to ‘decompress’ the region and release
further enhances localized reduction of fat by the stippled pattern.40 The combination of
its detergent action.33,34 Initially it was thought previously described lipolytic agents aid in
that phosphatidylcholine was the agent reduction of the size of the fat cells straining
responsible for the non-specific lysis of cell against the fibrotic bands, helping to smooth
membranes – emulsification of fat cells (lipoly- the lumpy appearance of the tissue. A practi-
sis) – and was the cause of fat reduction. tioner in the United States, Robert Pitera,
Rotunda’s data suggest that cell lysis may result notes the importance of individualizing
from the action of deoxycholate, a natural cellulite treatments. For example, he includes
detergent used in these formulations to keep a localized fat reduction treatment along with
the phosphatidylcholine soluble in water. an increased circulation treatment in a patient
with cellulite and saddle bag-localized fat
deposits, rather than focusing solely on circu-
CELLULITE ANATOMY AND
latory improvement in thin patients with
TREATMENT
cellulite as their main or only complaint.41
The layer of connective tissue immediately There remains quite a bit of controversy in the
below the dermis differs between men and field of cellulite treatment. It is anticipated
women. As a result of hormonally mediated that future studies will result in better classifi-
effects – primarily estrogen in women – there cation of the disease and will clarify appropri-
is a diffuse pattern of irregular and discontin- ate treatment approaches based on more
uous connective tissue, permitting depres- scientific investigation and documentation.42–44
sions and protrusions of fat cells.35,36 This
‘mattressing’ effect gives rise to the various
FACIAL REJUVENATION
stages of cellulite most commonly seen in
women over the thighs and buttocks. This The ideal purpose of facial rejuvenation
surface irregularity, known as ‘cellulite,’ therapy is to physiologically slow, and in some
results from focally enlarged fibrosclerotic instances reverse, the usual effects of the aging
bands that section off the subcutis layer. When process. The targeted approach in meso-
ch04 27/3/07 1:17 pm Page 31

THE SCIENTIFIC BASIS OF MESOTHERAPY 31

therapy for facial rejuvenation, or mesoglow, related to technique and the pharmacologic
includes improving hydration, repairing purity of compounds utilized. With the increas-
damaged tissue structures, providing cellular ing demand for this technique, it is imperative
nutritional support, and improving microcir- that practitioners continue to upgrade their
culation. This is achieved by a combination of knowledge base and skill sets to avoid unfortu-
agents that include hyaluronic acid, vitamin nate outcomes. Recently, a series of women in
cocktails, and vascular agents. the Washington, DC area developed facial
Hyaluronic acid is commonly used in many ulcerations and infections from an as-yet-
facial preparations for its outstanding hydrat- unidentified organism after undergoing
ing effect on tissues. An essential component ‘mesotherapy’ treatments by an unlicensed
of connective tissue, it is a glycosaminoglycan provider.20 Known pharmacologic side effects
with well-known water-attracting properties. of various compounds used must be taken into
This naturally occurring polysaccharide is account when treating patients. For example,
found in the intercellular matrix, where it has caution should be exercised when treating
a protective, stabilizing, and shock-absorbing patients with mitral valve prolapse or other
role.45 It has been studied for use in a variety of cardiac abnormalities. The need for antibiotic
clinical applications, including arthritis, eye prophylaxis has not been clearly established in
surgery, and facilitation of wound healing. It is these situations, but may be prudent. The
also being investigated as a drug delivery agent possible cardiac side effects, such as
in ophthalmic, nasal, and pulmonary routes, tachyarrhythmias resulting from using agents
as well as parenteral and transdermal routes. such as isoproterenol, may not be well-toler-
Changes in appearance associated with ated in some patients. Yohimbine can cause
facial aging are felt to be due partially to loss of altered mental status and elevation of blood
subcutaneous fat, changes in the facial pressure in certain patients. Thus, it is impera-
muscles, reduction of collagen, and perma- tive that the clinician review potential known
nent DNA-based changes in the fibroblasts side effects with the patient – such as pain,
responsible for matrix production and mainte- swelling, redness, and light headedness – and
nance.46 To improve collagen synthesis and to alert the patient to observe for possible allergic
combat the degenerative effects of oxidation, reactions or drug side effects. Moreover, the
vitamins C and E, as antioxidants, are often physician must be prepared to care for adverse
incorporated into the treatment mixtures.39 reactions if they occur. Nonetheless, preven-
Vitamin C is also involved in the hydroxylation tion is preferable. Standard aseptic hygienic
of proline, which creates the rigidity and stabil- practices, including use of skin disinfectants,
ity of collagen. Trace elements such as zinc are sterile solutions and techniques, and universal
included to enhance production of the antiox- precautions will go a long way toward reducing
idant enzyme superoxide dismutase, which is some of these undesirable events.
required for DNA and protein synthesis. Other
antioxidants that support vitamin effects
REFERENCES
include trace elements such as manganese and
selenium.39 The inclusion of these ingredients 1. Pistor M. What is mesotherapy? Chir Dent Fr 1976;
46(288): 59–60.
in various mesotherapy or mesoglow formula-
2. Petit P. Introduction to Mesotherapy. Cours
tions is less well studied, and is based primarily International de Mesotherapie 2005; 1: 5–8.
on data derived from sources describing the 3. Madamombe I. Traditional healers boost primary
alternative uses of these agents. health care, reaching patients missed by modern
medicine. African Renewal 2006; 19(4): 10.
4. Kaplan J. Medecine nucleaire et mesotherapy. Bull
COMPLICATIONS Soc Franc Mesother 1988; 73: 4–7.
5. Corbel D, Itti R. Mesotherapie et medecine nucle-
Although complications in mesotherapy are aire: approche pharmacocinetique. Tempo Med
rare, when they occur they are invariably 1986; 227: 21–6.
ch04 27/3/07 1:17 pm Page 32

32 AESTHETIC MESOTHERAPY

6. Corbel D, Guilloteau D, Itti R. [Pharmacokinetics of 24. Greenway FL, Bray GA, Heber D. Topical fat reduc-
intradermally-administered drugs]. Bull Acad Natl tion. Obes Res 1995; 3(4): 561–7.
Med 1989; 173(2): 223–7. 25. Pedersen S, Kristensen K, Hermann P,
7. Itti R, Casset D, Corbel D, Baulieu J, Baulileu F. Katzenellenbogen J, Richelsen B. Estrogen controls
Cinetique d’un traceur administre par voie intrader- lipolysis by up-regulating alpha2A-adrenergic recep-
mique. J Biophys Biomecanique 1985; 9: 195. tors directly in human adipose tissue through the
8. Thierree RA, Mrejen D. [Microcirculation, mesother- estrogen receptor alpha. Implications for the female
apy and thermography]. J Mal Vasc 1985; 10 (Suppl fat distribution. J Clin Endocrinol Metab 2004; 89(4):
A): 207–8. 1869–78.
9. Societe Francaise de Mesotherapie. 15, rue des 26. Kalra P, Stelios T. Regulation of lipolysis: natriuretic
Suisses, 75014 Paris. peptides and the development of cachexia. Int J
10. Petit P. Mesotherapie et pathologies infectieuses Cardiol 2004; 85: 125–32.
recidivantes. Vie Medicale 1983; (Suppl AVP): 61. 27. Jensen M. Adipose tissue and fatty acid metabolism in
11. Ferrand V, Huteau Y. Les necroses cutanees – a humans. J R Soc Med 2002; 95 (Suppl 42): 3–7.
propos de quatre nouveaux cas – analyse–discussion. 28. Bryant R. Controversial mesotherapy: could it be the
Bull SFM Fevrier 1992; 81. next Botox? Dermatology Times December 1, 2004.
12. Pitzurra M. Immunogenesis and mesotherapy: 29. Caruso MD, Roberts A, Bissoon L, Guillot T,
immune response to antigens inoculated intrader- Greenway F. An evaluation of solutions used in
mally. Giornale di Mesoterapia 1981; 1: 1. mesotherapy for lipolysis and body recontouring.
13. Doutre MS, Beylot C. [Side effects of mesotherapy]. 2006 (in press).
Therapie 1997; 52(2): 93–6. 30. Rittes PG. The use of phosphatidylcholine for correc-
14. Mrejen D. La mesotherapy ponctuelle systematisee. tion of localized fat deposits. Aesthetic Plast Surg
Mediffusion Ed 1989. 2003; 27(4): 315–18.
15. Mrejen D. La douleur en rhumatologie. Medecine- 31. Hexsel D, Serra M, Mazzuco R, Dal’Forno T,
mesotherapie 1983; 1: 15–41. Zechmeister D. Phosphatidylcholine in the treatment
16. Mrejen D. Medecine du sport et mesotherapie of localized fat. J Drugs Dermatol 2003; 5: 511–18.
ponctuelle systematisee. Mediffusion Ed 1989. 32. Rose PT, Morgan M. Histological changes associated
17. Lavignolle B. L’Anatomie Fonctionnelle Du Rachis, with mesotherapy for fat dissolution. Cosmet Laser
Maitre De Conference d’Anatomie, Practicien Ther 2005; 7(1): 17–19.
Hospitalier Specialisie, C.H.U. Pellegrin, Bordeaux, 33. Rotunda AM, Suzuki H, Moy RL, Kolodney MS.
presented at Cours International de Mesotherapie, Detergent effects of sodium deoxycholate are a major
Universite Victor Segalen Bordeaux Laboratoire feature of an injectable phosphatidylcholine formu-
d’Anatomie Faculte Paul Broca. February 2005; lation used for localized fat dissolution. Dermatol
Vol 2. Surg 2004; 30(7): 1001–8.
18. Lavignolle G, de Seze M, de Boysson A, et al. La 34. Rotunda A, Kolodney M. Mesotherapy and
mesotherapie dans le traitement des douleurs proje- phosphatidylcholine injections: historical clarifica-
tees de la pathologie degenerative du rachis. Etudes tion and review. Dermatol Surg 2006; 32(4): 465–80.
controlees randomisees versus infiltrations. 1st 35. Rosenbaum M, Prieto V, Hellmer J, et al. An
Congres National de Mesotherapie, Paris, March exploratory investigation of the morphology and
2003: 22–3. biochemistry of cellulite. Plast Reconstr Surg 1998;
19. Henry F, Pierard-Franchimont C, Pierard GE. 101(7): 1934–9.
[Clinical case of the month. Atypical mycobacteria 36. Querleux B, Cornillon C, Jolivet O, Bittoun J.
and mesotherapy]. Rev Med Liege 2005; 60(1): 7–10. Anatomy and physiology of subcutaneous adipose
20. Centers for Disease Control and Prevention (CDC). tissue by in vivo magnetic resonance imaging and
Outbreak of mesotherapy-associated skin reactions – spectroscopy: relationships with sex and presence of
District of Columbia area, January–February 2005. cellulite. Skin Res Technol 2002; 8: 118–24.
MMWR Morb Mortal Wkly Rep 2005; 54(44): 37. Pierard GE, Nizet JL, Perard-Franchimont C.
1127–30. Cellulite: from standing fat herniation to hypodermal
21. Butcher RW, Baird CD, Sutherland EW. Effects of stretch marks. Am J Dermatopathol 2000; 22(1): 34–7.
lipolytic and antilipolytic substances on adenosine 38. Nurnberger F, Muller G. So-called cellulite: an
3',5'-monophosphate levels in isolated fat cells. J Biol invented disease. J Dermatol Surg Oncol 1978; 4(3):
Chem 1968; 243(8): 1705–12. 221–8.
22. Beavo JA, Rogers N, Crofford OB, et al. Effects of 39. Silva J. Mesoglow treatments. Documentation from
xanthine derivatives on lipolysis and on adenosine International Society of Mesotherapy Training
3',5'-monophosphate phosphodiesterase activity. Mol Course, Salt Lake City, Utah, 2004.
Pharmacol 1970; 6: 597–603. 40. Silva J. Lipodysmorphia. Documentation from
23. Greenway FL, Bray GA. Regional fat loss from the International Congress on Anti-Aging Medicine Post
thigh in obese women after adrenergic modulation. Congress Mesotherapy course and workshop, Las
Clin Ther 1987; 9(6): 663–9. Vegas, Nevada, 2005.
ch04 27/3/07 1:17 pm Page 33

THE SCIENTIFIC BASIS OF MESOTHERAPY 33

41. Pitera R. Physiopathology of cellulitis. Documenta- there a role for injectables? J Cosmet Laser Ther
tion from International Congress on Anti-Aging 2005; 7(3–4): 147–54.
Medicine Post Congress Mesotherapy course and 45. Brown MB, Jones SA. Hyaluronic acid: a unique
workshop, Las Vegas, Nevada, 2005. topical vehicle for the localized delivery of drugs to
42. Lotti T, Ghersetich I, Grappone C, Dini G. the skin. J Eur Acad Dermatol Venereol 2005; 19(3):
Proteoglycans in so-called cellulite. Int J Dermatol 308–18.
1990; 29(4): 272–4. 46. Rodriguez R. Skin rejuvenation. Documentation
43. Avram MM. Cellulite: a review of its physiology and from International Congress on Anti-Aging Medicine
treatment. J Cosmet Laser Ther 2004; 6(4): 181–5. Post Congress Mesotherapy course and workshop,
44. Rotunda AM, Avram MM, Avram AS. Cellulite: is Las Vegas, Nevada, 2005.
ch05 27/3/07 1:17 pm Page 35

Materials and methods: the techniques 5

Philippe Petit (translated by Shirley Madhère)

MATERIALS classic mesotherapy needle is 4 mm long with

a diameter of 4/10 (Figure 5.2). Lebel intro-
A ‘hand, syringe, and needle’ – these should
duced this needle in the 1950s; he was a
suffice to perform most maneuvers in
surgeon and friend of Michel Pistor. The
mesotherapy. However, oftentimes, an
reason for this particular length of needle in
electronic injector may be used to optimize
mesotherapy is essentially that it permits
the technique (Figure 5.1).
precise intradermal puncture. Since the
dermis has a thickness of <4 mm, it was logical
The syringes to conceive a needle that would allow exact
puncture to a depth not exceeding dermal
Generally, 5–10 cc standard medical syringes
thickness. However, as the thickness of the
are used. Injections should be performed
dermis varies throughout the body, use of this
using a sterile technique with single-use
specific needle must be individualized on a
syringes only. Recall that mesotherapy is a
case-by-case basis. In the example of mesother-
technique of general medicine; therefore, all
apy for facial evaluation, or Mesoglow, it is
rules regarding asepsis should be strictly
advisable to use a 29–30 gauge needle, as a
followed. In addition, 1–3 cc syringes may be
finer needle produces less discomfort.
used in cases of immunologic stimulation or
The 13 mm long, 29 gauge needle (Figure
another maneuver in mesotherapy referred to
5.3) is a needle that is often used to reduce
as ‘mésothérapie ponctuelle systématisée’ or
pain upon injection. Moreover, such a needle
systematized specific mesotherapy.

The needles
Two types of needles are commonly used in
mesotherapy. According to Mario Lebel, the

Figure 5.2 The 4 mm mesotherapy needle.

Figure 5.1 Assisted mesotherapy. Use of an electronic

injector in mesotherapy. Figure 5.3 The 13 mm needle in mesotherapy.
Other documents randomly have
different content
 Great Crested Grebe.

The Arctic Diver enjoys among the Norwegians the reputation of

being a most excellent weather-prophet. When the skies are big with
rain, the birds fly wildly about, and make the most horrible hoarse
noise, fearing that the swelled waters should invade their nest; on
the contrary, in fine weather, their note is different, and seemingly in
an exulting strain. For this reason, the Norwegians, who, being
mostly a maritime population, pay the greatest attention to the
aspect of the sky, think it impious to destroy, or even to disturb, this
species.
The family of Alcadæ, comprising the Guillemots, Auks, Razor
Bills, and Puffins, is in form of body very similar to the Divers: the
legs, which are short and thick, are inserted very far back, and give
a still more erect carriage to the bird when on shore. The wings are
short and small in proportion to the bulk of the body, and in the
(now probably extinct) Great Auk, so much so as to be unfitted for
flight. The Auks are strictly sea-birds, and nestle on its borders,
breeding in caverns and rocky cliffs, and laying only one large egg.
They obtain their food by diving, at which they are very expert. They
are of social habits, and congregate in vast flocks on the rocky islets
and head-lands of the northern coasts. At the head of the Magdalen
Bay, on Spitzbergen, for instance, there is a high pyramidal mountain
of granite, termed Rotge Hill, from the myriads of small birds of that
name (Little Auk, Alca alce), which frequent its base, and which
appear to prefer its environs to every other part of the harbour. They
are so numerous that Admiral Beechey frequently saw an
uninterrupted line of them extending full half-way over the bay, or to
a distance of more than three miles, and so close together that thirty
fell at one shot. This living column, on an average, might have been
about six yards broad, and as many deep; so that allowing sixteen
birds to a cubic yard, there must have been nearly four millions of
birds on the wing at one time.
The calling or crying of the rotges amongst one another sounds
at a distance as if you heard a great many women scolding together;
so that the noise of millions uniting in a chorus must be terrific. On a
fine summer's day, when a glorious sunshine gilds the snow peaks
and glaciers of Spitzbergen, the merry cry of the little auk unites
with that of the willocks, divers, cormorants, gulls, and other aquatic
birds; and everywhere groups of walruses, basking in the sun,
mingle their playful roar with the husky bark of the seal. It is
pleasant to reflect that in those arctic wilds, uninhabitable by man,
there are still millions of creatures enjoying life, all owing their
support to the inexhaustible "garners" of the deep.
In the Penguins of the southern hemisphere, the shortness of
wing and aptitude for swimming and diving are still more
conspicuous than in the auks of the northern regions. In the water,
the penguin makes use of its small featherless wing-stumps as
paddles; on land, as fore feet, with whose help it scales so rapidly
the grass-grown cliffs, as to be easily mistaken for a quadruped.
When at sea, and fishing, it comes to the surface for the purpose of
breathing, with such a spring, and dives again so instantaneously,
that at first sight no one can be sure that it is not a fish leaping for
sport. Other sea-birds generally keep part of their body out of the
water while swimming; but this is not the case with the penguin,
whose head alone appears upon the surface; and thus it swims with
such rapidity and perseverance, as almost to defy many of the fishes
to equal it. How much it feels itself at home on the waters, may be
inferred from the fact that Sir James Ross once saw two penguins
paddling away a thousand miles from the nearest land.
On many uninhabited islands in
the higher latitudes of the southern
hemisphere, this strange bird is met
with in incredible numbers. On
Possession Island, for instance, a
desolate rock discovered by Sir James
Antarctic Penguin. Ross in lat. 71° 56″, not the smallest
appearance of vegetation could be
found; but inconceivable myriads of
penguins completely and densely covered the whole surface of the
island, along the ledges of the precipices, and even to the summits
of the hills, attacking vigorously the sailors as they waded through
their ranks, and pecking at them with their sharp beaks, disputing
possession, which, together with their loud coarse notes, and the
insupportable stench from the deep bed of guano which had been
forming for ages, made them glad to get away again. Sir James took
possession of the island in the name of Queen Victoria; but
unfortunately its treasures of manure are hidden beyond a far too
formidable barrier of ice ever to be available to man.
Duperrey ("Voyage de la Coquille,") found the Falklands
swarming with penguins. In summer and autumn these strange birds
leave their burrows early in the morning, and launch into the sea for
fishing. After having filled their capacious stomachs, they waddle on
shore, and remain for a time congregated on the strand, raising a
dreadful clamour; after which they retire to enjoy a noon-tide sleep
among the high tussack grass or in their burrows. In the afternoon
the fishing recommences. Lesson says that about sunset on fine
summer evenings, which unfortunately are but of rare occurrence on
those foggy, storm-visited islands, all the penguins together raise
their discordant voices, so that at a distance the noise might be
 mistaken for the hoarse murmur of a
great popular assembly. As soon as the
young are sufficiently strong, the whole
band leaves the island, departing no one
knows whither, though the mariners
frequenting those seas believe that they
spend the winter on the ocean. This
opinion seems to be corroborated by the
observations of Sir James Ross, who, on
the 4th of December, in 49° S. lat., met
on the high sea a troop of penguins that
were doubtless on the way to their
breeding place. He admired the
Penguin.
astonishing instinct of these creatures,
half fish, half bird, which leads them
hundreds of miles through the pathless
ocean to their accustomed summer abodes.
It may be imagined how the neighbouring seas must abound
with fish, to be able to nourish such multitudes of penguins, whose
stomach is capable of holding more than two pounds, and whose
voracity is so great that they are often obliged to disgorge their
superabundant meal. The elongated stomach reaches to the lower
part of the abdomen, and the whole length of the intestinal canal is
twenty-five feet, fifteen times longer than the body, so that nature
has evidently provided for a most vigorous appetite, whetted by sea-
bathing and sea air.
There are several species of penguins. The largest (Aptenodytes
antarctica) weighs about eighty pounds. It is a rare bird, generally
found singly, while the smaller species always associate in vast
numbers. In 77° S. lat., Sir James Ross caught three of these giant
penguins, the smallest of which weighed fifty-seven pounds. In the
stomach of one of them he found ten pounds of quartz, granite, and
trap fragments, swallowed most likely to promote digestion.
 The penguin, like his northern representative the auk, lays but
one single egg. His not unsavoury flesh is black. Besides his dense
plumage, he is protected against the cold of the higher latitudes by a
thick cover of fat under his skin.
Humboldt's penguin (Spheniscus Humb.) is frequently found in
the Bay of Callao. This bird is a little smaller than the common grey
penguin, with a somewhat differently coloured back and breast. The
Peruvians call it pajaro niño, "little darling bird," and keep it in their
houses; it is very easily tamed, gets very familiar, and follows its
master like a dog. The sight of the fat creature, awkwardly waddling
about the streets on its short feet, and violently agitating its wing-
stumps to maintain its equilibrium, is inexpressibly grotesque.
Tschudi kept one of these tame penguins, which punctually obeyed
his call. At dinner it regularly stood like a stiff footman behind his
chair, and at night slept under his bed. When "Pepe" wanted a bath,
he went into the kitchen and kept striking with his beak against an
earthen jar, until some one came to pour water over him.
 To the pelican tribe, which is generally
distinguished by a surface of naked skin
about the throat, capable of considerable
dilatation, and serving as a pouch for the
reception of unswallowed food, belong
among others the Cormorant
(Phalacrocorax), the Frigate-Bird
(Tachypetes aquila), and the Gannet (Sula
bassana), or Solan goose. All these birds
are of much more active habits than the
last named family, with bodies of more
Common Pelican.
shapely form, more ample wings, and a
stronger flight.
The common cormorant with his long bill, bent
at the point, and furnished with a nail, his black
livery, and yellowish chin-pouch, is a most
disagreeable comrade. His smell, when alive, is
more rank and offensive than that of any other
bird, and his flesh is so disgusting, that it turns
the stomach even of an Esquimaux. In spite of his
voracity, he always remains thin and meagre, the
picture of a hungry parasite. But fishing he
understands remarkably well, and formerly used
to be trained for this purpose in England, in the
same manner as a nearly related species is to the
present day employed in China. Mr. Fortune thus Common Cormorant.
describes this original chase, which he witnessed
on the Yellow River:—"There were two boats, each
containing one man, and about ten or twelve birds. The latter stood
perched on the sides of the boats, and seemed to have just arrived upon
the scene of action. Their masters now commanded them to leave the
boats; and so excellent was their training, that they instantly obeyed,
scattered themselves over the canal, and began to look for prey. They have
a splendid sea-green eye, and quick as lightning they see and dive upon
the finny tribe, which, once caught in the sharp notched bill, finds escape
impossible. As soon as a cormorant rises to the surface with his prey in his
bill, his master calls him, when, docile as a dog, he swims to the boat and
surrenders the fish, after which he again resumes his labours. And what is
more wonderful still, when one of them has got hold of a fish so large as to
be with difficulty dragged to the boat, the others come to his assistance,
and by their united strength overpower the sprawling giant. Sometimes
when a cormorant is lazy or playful, and seems to forget his business, the
Chinaman strikes the water with a long bamboo near to the dreamer, and
calls out to him in an angry tone. Immediately the bird, like a schoolboy
caught nodding over his lesson, gives up his play, and returns to his duty. A
small string is tied round the neck of the birds, for fear they might be
tempted to swallow the fish themselves."
The frigate-bird hovers over the tropical
waters. Its singularly easy and graceful
flight affords all the charm of variety.
Sometimes it is seen balanced in mid air,
its wings spread, but apparently
motionless, its long forked tail expanding
and closing with a quick alternate motion,
and its head turned inquisitively
downwards; sometimes it wheels rapidly,
and darts to the surface of the water in Frigate-Bird.
pursuit of prey; and then again it soars so
as to be lost to vision, its elevation alone
being sufficient to distinguish it from all other sea birds. Sometimes it is
seen 400 leagues from land; and yet it is said to return every night to its
solitary roost. Its expanded pinions measure from end to end fourteen feet,
a prodigious extent of wings, equalling or even surpassing that of the
condor, the lordly bird of the loftiest Andes. Being unable to swim or dive, it
seizes the flying-fish, that, springing out of the water to avoid the jaws of
the bonito, often falls a prey to the frigate-bird, or else it compels boobies
or tropic birds to disgorge. On volcanic coasts it builds its nest in the
crevices of the high cliffs, and on the low coral islands in the loftiest trees.
In the Paumotu Group, Captain Wilkes saw whole groves covered with the
nests of the frigate-bird. When the old birds flew away, they puffed up their
red pouches to the size of a child's head, so that it looked as if a large
bladder full of blood was attached to their neck.
 Flying Fish.

The Gannet or Soland-goose (Sula

Bassana) haunts the Bass Island, a high
steep rock in the Frith of Forth, whose
black precipices are painted with dazzling
stripes of white guano, the product of the
inconceivable number of birds which settle
upon the weather-beaten ledges. The
gannets incubate in the turf of the slopes
above, and you may sit down by them and
their great downy young while their mates
Common Gannet. hover over you with discordant screams
and almost touch you with their outspread
pinions. There is but one landing-place,
and this sole entrance to the natural fastness is closed by a barred gate,
proclaiming that man has taken possession of the rock. Some years ago it
was let at an annual rent of thirty-five pounds. The eggs are not collected,
and no old bird is allowed to be shot, under a penalty of five pounds; only
the young birds are persecuted. The chase begins on the 1st of August.
They are taken with the hand or knocked on the head with sticks, and sent
to the Edinburgh market, where they fetch about half a crown a piece. The
gannet breeds also on Lundy Island, in the Severn, on Ailsa, on the coast
of Ayrshire, on the island of St. Kilda, and hardly anywhere else in Europe.
As it must let itself fall before taking wing, it requires a steep and
precipitous breeding-station. Its mode of fishing is particularly graceful.
Rapidly skimming the surface of the sea, as soon as it spies a fish
swimming below, it rises perpendicularly over the spot, and then, suddenly
folding its wings, drops head-foremost on its prey swifter than an arrow,
and with almost unerring aim. The prevalent colour of the full-plumaged
bird is white, the tips of its wings only being black, and some black lines
about the face, resembling eyebrows or spectacles. The pale yellow eyes
are encircled with a naked skin of fine blue, the head and neck are buff
colour, the legs black, and greenish on the fore part. The plumage of the
young bird is very different, being blackish, dotted irregularly with small
white specks.
The family of the Laridæ, which comprises the gulls, the sea-swallows,
the petrels, and the albatrosses, is widely spread over the whole surface of
the ocean. All the birds of this tribe have a powerful flight, and are
distinguished by the easy grace of their motions, striking the air at long
intervals with their wings, and generally gliding or soaring with
outstretched pinions. Their form is handsome and well-proportioned, some
of them resembling the swallow, others the dove; but their mode of life
does not correspond with their beauty, as they are all ill-famed for their
predatory habits and insatiable voracity. The cry of the sea-mew is peculiar,
being a mixture of screaming and laughing. When in the solitude of a wild
rocky coast it is heard mingling with the hoarse rolling of the surge and the
moaning wind, it harmonises well with the character of the dreary scene,
and produces a not unpleasing effect. It is amusing to witness the
movements of the sea-mews at the mouths of the larger rivers, where they
are seen in numbers, picking up the animal substances which are cast on
shore, or come floating down with the ebbing tide. Such as are near the
breakers will mount up the surface of the water, and run splashing towards
the crest of the wave, to get hold of the object of their pursuit, while
others are seen every now and then diving, and reappearing with a fish in
their bill. Sometimes the more powerful sea-hawk interrupts their pleasure,
pounces upon the robbers, and scatters the screaming band.
Many different species of gulls inhabit the northern shores, and various
are the places which they choose for breeding. The Kittiwake or Tarrock
(Larus tridactylus), one of the commonest sea-birds in Greenland, Iceland,
the Feroës and the Scotch islands, builds its sea-weed nest on the highest
and most inaccessible rocks. According to Faber (Prodromus of Icelandic
Ornithology), its swarms are so numerous on Grimsoe, that they darken
the sun when they fly, deafen the ear when they scream, and deck the
green-capped rocks with a white covering when they breed.
In the famous "bird-city" at the north point of Sylt, the Silvery or
Herring-gull plays a prominent part. Its great size, equal to that of the
raven, but with much longer wings—its agreeable form, its pure white
plumage, of metallic brilliancy on the back, gradually melting into light ash-
 blue; the velvet-black ends of the wings,
with snowy feather tips, the lovely
yellow eye, and the deep yellow beak,
with its coral-red spot, all this together
forms a beautiful picture. "There we
stood," says Naumann, "surrounded by
thousands, that partly hovered close
over our heads, uttering their shrill
screams, partly stood before us in pairs;
Herring Gull (Young). some on their nests, the males keeping
guard, some sleeping on one leg, and
others leisurely stretching themselves.
In one word, one hardly knew what most to admire, the uncommon
cleanliness and beauty of their plumage, the great variety and elegance of
their attitudes, their tameness, or the immense numbers collected in so
small a space."
In the same "bird-city," but apart from
the former, breed also the Common Gull
(Larus canus) which is much smaller and of
a more slender shape, and also the
Sandwich and Caspian Terns. It is
astonishing to see how each kind of sea-
bird seeks its particular spot for breeding;
only the auks and guillemots herd
promiscuously. What may induce the birds
to meet in such large bodies and then
Herring Gull, or Silvery Gull always to choose some particular cliff? The
(Adult). gulls yield the fortunate possessor of their
district an annual income of at least two
hundred rix-dollars. More than thirty
thousand of the eggs, which are larger than those of the turkey, are
collected every year, packed up with moss in baskets, and sent to the
market. Two or three persons are busy from morning till evening, during
the whole season, collecting the eggs, and receive for their trouble those of
the smaller birds, which may also amount to about twenty thousand. But
although the terns appear in considerable numbers on Sylt, they have
chosen the small flat island, Norder Oog, to the west of Pelworm, for their
chief residence. The breeding colony of the Sandwich tern amounts here to
at least a million of individuals, so that when the birds are at rest, the
island, at the distance of a mile, resembles a white stripe in the sea; but
when their innumerable multitudes hover above it, they seem an immense
white rotatory cloud. The eggs lie in some places so close together, that it
is almost impossible to walk between them without treading upon them;
the breeding birds often touch one another, and would not find room, if,
like all sea-swallows that breed socially on the coast, they did not sit in the
same posture, with their head facing the water. It is incomprehensible how
each bird can find its eggs; it would even seem impossible, did we not
know the miracles of animal instinct. Their noise is incessant, for even
during the night they keep up a continual and lively prattle. He who
approaches them during the day is soon surrounded by these screamers,
whose whirling thousand-tongued multitudes stun his senses; and these
birds, at other times so shy, flutter so close over his head, as often to touch
him with their wings.
On Nowaja Semlja's ice-bound coast, on the peaks of isolated cliffs, and
suffering no other bird in his vicinity, dwells the fierce imperious
Burgomaster (Larus glaucus). None of its class dares dispute the authority
of the lordly bird, when with unhesitating superiority it descends on its
prey, though in the possession of another. Although not numerous, yet it is
the general attendant on the whale-fisher whenever spoils are to be
obtained. Then it hovers over the scene of action, and having marked out
its morsel, descends upon it and carries it off on the wing. On its descent,
the most dainty pieces must be relinquished, though in the grasp of fulmar,
snow-bird, or kittiwake.
The larger parasitical or raptorial gulls (Lestris parasiticus,
catarrhactes), are incapable of diving or plunging, their feathers being too
large in proportion to their bulk. They are therefore obliged to live by the
exertions of the lesser species, making them disgorge what they have
eaten, and dexterously catching the rejected fish before it reaches the
water. Thus we see the old feudal relations of baron and serf established as
a natural institution among the gull-tribe.
Although the sea-swallows and sea-mews are endowed with great
power of wing, yet the petrels and albatrosses alone deserve the name of
oceanic birds, as they are almost always found on the high seas, at every
distance from land, and only during breeding-time seek the solitary coasts
and islands. Petrels are scattered over the whole extent of the ocean, but
 the petrels which inhabit the northern seas
are different from those of the antarctic
ocean, and between both are other
species, that never forsake the intertropical
waters.
The Fulmar (Procellaria glacialis) is at
home in the high north. As soon as the
Broad-billed Petrel. whale-fisher has passed the Shetland
Islands, on his way to the Arctic Seas, this
bird is sure to accompany his track, eagerly
watching for anything thrown overboard.
Walking awkwardly on land, the fulmar flies
to windward in the most terrific storms.
Many thousands frequently accumulate
round a dead whale, rushing in from all
quarters. The sea immediately about the
ship's stern, when the men are engaged in
skinning their gigantic prey, is sometimes so
completely covered with them that a stone
can scarcely be thrown overboard without
Fork-tailed Petrel. striking one of them. When anything is thus
cast among the crowd, those nearest take
alarm, and so on, till a thousand are put in
motion; but as in rising they strike the water with their feet, a loud and
most irregular splashing is produced. It is amusing to observe with what
jealousy they view, and with what boldness they attack, any of their
species engaged in devouring the finest morsels, and to hear the curious
chuckling noise they make in their anxiety for despatch, lest they should be
disturbed. The voracious birds are frequently so glutted as to be unable to
fly, in which case they rest upon the water until the advancement of
digestion restores their wonted powers. They then return to the banquet
with the same gusto as before, and although numbers of the species may
have been killed with boat-hooks, and float among them, the others,
nothing daunted, and unconscious of danger to themselves, continue their
gormandising labours. When carrion is scarce, the fulmars follow the living
whale, as if they had a presentiment of his future fate, and sometimes, by
their peculiar motions while hovering on the surface of the water, point out
to the fisherman the position of the animal. As their beak cannot make an
impression on the dead whale until some more powerful creature tears
away the skin, it may be imagined how delighted they are when man takes
upon himself the trouble of peeling a whale for them.
The Glacial Petrel (Procellaria gelida) does not seem to approach the
pole so near as the fulmar. He appears but seldom in Iceland, but breeds
frequently in Newfoundland. The same is the case with the Shearwater (P.
puffinus), which breeds in great numbers on the Feroë islands, and in
Orcadia. The tropical petrels are the least known. They do not appear to
gather troopwise, and but seldom follow ships. Towards 45° S. lat. the first
Pintados (P. capensis) make their appearance, and are more rarely seen
after having passed 60° S. lat. The Giant Petrel (P. gigantea), extends its
flight as far as the ice-banks of the south, where the Antarctic and the
Snowy (P. antarctica et nivea) Petrels first appear, birds which never leave
those dreary seas, and are often seen in vast flocks floating upon the drift
ice. Thus nature has set bounds to petrels, as to all other creatures that
swim or fly in and over the ocean, and has divided the wide deserts of the
sea among their different species. Who can tell us the mysterious laws
which assign to each of them its limits? Who can show us the invisible
barriers they are not allowed to pass?

Stormy Petrel.

The Stormy Petrel (P. pelagica) seems to belong to every sea. It is

about the size of a swallow, and in its general appearance and flight is not
unlike that bird. Although the smallest web-footed bird known, it braves
the utmost fury of the tempest, often skimming with incredible velocity the
trough of the waves, and sometimes gliding rapidly over their snowy crests.
Like all of its kind, it lives almost constantly at sea, and seeks during the
breeding season some lonely rock, where it deposits in some fissure or
crevice its solitary egg.
The mode of life of the petrels corresponds but little with their external
beauty; they are in fact the crows of the ocean, and live upon the dead
animal substances floating on its surface. Wherever the carcase of a whale,
borne along by the current, covers the sea with a long stripe of putrid oil,
they are seen feasting in the polluted waters. All petrels have the
remarkable faculty of spouting oil of a very offensive smell, from their
nostrils when alarmed, and this apparently as a means of defence.
The Albatross (Diomedea exulans) is the monarch of the high seas; the
picture of a hero, who, under every storm of adverse fortune, preserves
the immoveable constancy of an undaunted heart. Proud and majestic, he
swims along in his own native element, and without ever touching the
water with his pinions, rises with the rising billow, and falls with the falling
wave. It is truly wonderful how he bids defiance to the fury of the
unshackled elements, and how quietly he faces the gale. "He seems quite
at home," say the sailors; and indeed this expression is perfectly
characteristic of his graceful ease as he hovers over the agitated ocean.
The albatross exceeds the swan in
size, attains a weight of from 12lbs. to
28lbs., and extends his wings from ten to
thirteen feet. His plumage is white and
black, harmonising with the wave-crest
and the storm-cloud. For weeks and
months together he is seen to follow the
course of a ship; but, according to Mr.
Harvey (Sea Side Book), "the time he can
remain on the wing seems to have been
much exaggerated, for although, like the Wandering Albatross.
gull and the petrel, he is no diving-bird,
he swims with the greatest ease; and
notwithstanding the enormous length of his pinions, knows well how to rise
again into the air. He is indeed unable to take wing from a narrow deck,
but when he wishes to rise from the sea, he runs along flapping the waters
until he has acquired the necessary impetus, or meets with a wave of a
sufficient height, from whose lofty crest he starts as from a rocky pinnacle,
and resumes his extensive flight over an immense expanse of ocean." A
short-winged species frequents the waters of Kamtschatka and Japan; but
the wandering albatross (D. exulans) belongs more particularly to the
southern hemisphere, being rarely seen to the north of 30° S. lat., and
appearing more frequently as the higher latitudes are approached. The
regions of storms—the Cape of Good Hope and Cape Horn—are his
favourite resorts, and all travellers know that the southern point of Africa is
not far distant as soon as the albatrosses show themselves in larger
numbers. These birds are the vultures of the ocean; their crooked sharp-
edged beak is better adapted to lacerate a lifeless prey, than to seize upon
the rapid fish as it darts swiftly along below the surface of the waters.
From a vast distance they smell the floating carcase of a whale, and soon
alight in considerable numbers upon the giant carrion. They also feed upon
the large cephalopods that inhabit mid-ocean, and remains of these
molluscs are generally found in their stomach. The Auckland and Campbell
islands seem to be two of their favourite breeding-stations. When Sir
James Ross visited these secluded groups, the birds were so assiduously
breeding as to allow themselves to be taken with the hand. The nest is
built of sand mixed with dried leaves and grasses, generally eighteen
inches high, with a diameter of twenty-seven inches at the surface, and of
six feet at the base. While breeding, the snow-white head and neck of the
bird project above the grasses, and betray it from afar. On endeavouring to
drive it from its eggs it defends itself valiantly, snapping with its beak. Its
greatest enemy is a fierce raptorial gull (Lestris antarcticus), which is
always on the look-out, and, as soon as the albatross leaves the nest,
shoots down upon it to steal the eggs.
Swift flies the albatross, but fancy travels with still more rapid wings
through the realms of space, and leads us suddenly from the lone islands
of the Pacific to the north of another hemisphere. Saint Kilda rises before
us—a glorious sight when the last rays of the setting sun, as he slowly
sinks upon the ocean, light up with dazzling splendour the towering cliffs of
the island, which one might almost fancy to be some huge volcano newly
emerged from the deep, or the impregnable bulwark of some enchanted
land. St. Kilda, one of the most striking examples of the grandest rock-
scenery, plunges on all sides perpendicularly into the sea, so that although
six miles in circumference, it affords but one single landing-place,
accessible only in fair weather. Four of the promontories are perforated,
and as many large caverns are formed, through which the sea rolls its
heaving billows. From the eastern extremity, which rises nearly
perpendicularly to the height of 1380 feet, and is supposed to be the
loftiest precipice in Britain, the view is of indescribable sublimity. Far below,
the long heavy swell of the ocean is seen climbing up the dark rock, whose
base is clothed with sheets of snow-white foam. In many places the naked
rock disappears under the myriads of sea-birds sitting upon their nests; the
air is literally clouded with them, and the water seems profusely dotted
with the larger fowl, the smaller ones being nearly invisible on account of
the distance. Every narrow ledge is thickly covered with kittiwakes, auks,
and guillemots; all the grassy spots are tenanted by the fulmar, and honey-
combed by myriads of puffins; while close to the water's edge on the wet
rocks, which are hollowed out into deep recesses, sit clusters of
cormorants, erect and motionless, like so many unclean spirits, guarding
the entrance of some gloomy cave.
On rolling down a large stone from the
summit, a strange scene of confusion ensues.
Here, falling like a thunderbolt on some
unfortunate fulmar sitting upon its nest, it
crushes the poor creature in an instant; then
rolling down the crags, and cutting deep
furrows in the grassy slopes, it scatters in
dismay the dense groups of auks and Black Guillemot.
guillemots. Its progress all along is marked by
the clouds of birds, which affrighted shoot out
from the precipice to avoid the fate to which nevertheless many fall a prey,
until at length it reaches the bottom along with its many victims. The
scared tenants of the rock now return to their resting-places, and all is
again comparatively quiet.
Several species of gulls are of common
occurrence on St. Kilda: Larus marinus, fuscus,
canus, and tridactylus. The last, or kittiwake, is
the most abundant; a social bird, choosing the
most inaccessible spots. On disturbing a colony
of kittiwakes, most of the birds leave their
nests and fly about the intruder, uttering
incessantly their clamorous but not unmusical
cry. The noise from a large flock is almost
Common Puffin.
deafening; the flapping of their wings and their
loud screams, joined to the deep guttural
notes of the passing gannets, and the shrill tones of the larger gulls, form a
combination of sounds without a parallel in nature. Probably on account of
its vigilance, the kittiwake is not pursued by the fowler.
The fulmar breeds in almost incredible numbers on St. Kilda (the only
place in Britain where he is found), and is to the natives by far the most
important production of their barren land. On the crest of the highest
precipices, and only on such as are furnished with small grassy shelves, on
every spot above a few inches in extent, the fulmars have taken possession
of the rock. On being seized, they instantly disgorge a quantity of clear
amber-coloured oil, which imparts to the whole bird, its nest and young,
and even the very rock which it frequents, a peculiar and very disagreeable
odour.
Fulmar oil is one of the most valuable productions of St. Kilda. The best
is obtained from the old bird by surprising it at night upon the rock, and
tightly closing the bill until the fowler has seized the bird between his knees
with its head downwards. By opening the bill, the fulmar is allowed to eject
about a table-spoonful, or rather more, of oil into the dried gullet or
stomach of a solan-goose. The islanders use fulmar oil for their lamps, and
consider it as an infallible remedy against chronic rheumatism.
It is chiefly in pursuit of the fulmar that the St. Kildian often endangers
his life. Two of the fowlers generally proceed in company, each furnished
with several coils of rope, about half an inch in diameter. One of them
fastens one of the ropes under his arm-pits, and holding the extremity of
another rope in one hand, is lowered down the cliff. His comrade stands a
little away from the edge, holding the supporting rope firmly with both
hands and letting it out very slowly, while he allows the other, or guide-
rope, to slip out as is required from under one foot, which loosely secures
it. On reaching a ledge occupied by birds, the fowler commences his
operations, easily securing the eggs and young birds, and knocking down
the old ones with a short stick, or catching them by a noose attached to a
long slender rod. He then secures his sport by bundling the birds together,
and tying them to a rope let down from above, depositing at the same time
in a small basket the eggs he has gathered. The dexterity of these
rocksmen is truly astonishing. The smallest spot is considered by them as a
sufficiently secure standing-place, and they will creep on hands and knees,
though cumbered with a load of birds, along a narrow ledge, seemingly
without concern for their personal safety. When exhibiting before strangers,
a precipice about six hundred feet high, overhanging the sea, at a short
distance from the village, is generally chosen for a display of their agility.
About midway they strike against the rock, and rebound twelve feet or
more with all the agility of a tight-rope dancer.
The Gannet, or Solan-goose, which abounds in the north of Scotland
and on the numberless islands and rocky fiords which line the Norwegian
coast, likewise congregates in vast numbers about St. Kilda, from whence a
portion of them take their departure every morning to fish for herrings,
their favourite food, in the bays and channels of the other Hebrides, the
nearest of which is about fifty miles distant. This bird is very select in the
choice of its breeding-places, which it occupies to the total exclusion of
every other species. None are to be found in Hirta, but the island of
Borreray is almost entirely occupied with them, as are also the adjacent
rocks, Stack Ly and Stack Narmin. These cliffs are remarkable for their
pointed summits and towering height, and appear, even from the distance
of many miles, as if they were covered with snow, the deceptive
appearance being caused by the myriads of gannets with which the rock is
thickly covered, as well as the dense clouds of these white-plumed birds
passing and repassing in the neighbourhood of their nests. Petrels,
shearwaters, puffins, guillemots, and auks, are also very abundant about
the weather-beaten cliffs of St. Kilda.

Puffin.

If we consider that similar bird-republics are to be found on almost

every rocky coast or surf-beaten cliff of the northern seas, we must needs
 be astonished at the inexhaustible prodigality of
Nature, which covers desolate rocks with such a
profusion of life. The vast number of sea-birds is the
more surprising, as many species, such as the
guillemot, the auk, the fulmar, and the puffin, lay but
one single egg on the naked rock, and often in so
precarious a situation, that it is almost inconceivable
how breeding can take place. When the birds are
surprised and suddenly fly off, many of the eggs
tumble down into the surf. Sea-eagles, falcons, and
Auk. raptorial gulls destroy a great number, and pounce
upon the young; thousands fall a prey to the rigours
of an Arctic winter; the spring-tides sweeping over low
shores, often carry away whole generations at once, and many a maritime
population lives entirely upon the sea-fowl that breed upon the sterile soil.
And yet, in spite of so many enemies and persecutions, their numbers
remain undiminished, nor has their importance ever ceased in the domestic
economy of the rude islanders of the north.

Sea-Fowl Shooting.

But however valuable the eggs and the oil, the feathers and the flesh of
the hyperborean bird-republics may be to man, they are far from equalling
in importance the guano producing sea-fowl of the tropical seas. This
inestimable manure, which has become so indispensable to the British
agriculturist, is found scattered over numerous localities in the intertropical
regions. It abounds on many of the rocky islets of the Red Sea, where the
life-teeming waters afford sustenance to innumerable sea-gulls,
cormorants, and pelicans; but its most widely celebrated stores cover the
small Chincha Islands, not far from Pisco, about a hundred miles to the
south of Callao, where they form enormous layers 50 or 60 feet deep.
The upper strata are of a greyish-brown colour, which lower down
becomes darker; and in the inferior strata the colour is a rusty red, as if
tinged by oxide of iron. The guano becomes progressively more and more
compact from the surface downwards, a circumstance naturally accounted
for by the gradual deposit of the strata and the increasing superincumbent
weight. As is universally known, guano is formed of the excrements of
different kinds of marine birds; but the species which Tschudi, the
celebrated Peruvian traveller, more particularly enumerates are—Larus
modestus (Tschudi), Rhynchops nigra (Linn.), Plotus anhinga (Linn.),
Pelecanus thayus (Mol.), Phalacrocorax Gaimardii and albigula (Tsch.), and
chiefly the Sula variegata (Tsch.).
The immense flocks of these birds, as they fly along the coast, appear
like aërial islands; and when their vast numbers, their extraordinary
voracity, and the facility with which they procure their food are considered,
we cannot be surprised at the magnitude of the beds of guano which have
resulted from the uninterrupted accumulations of countless ages. During
the first year of the deposit the strata are white, and the guano is then
called Guano blanco. In the opinion of the Peruvian cultivators, this is the
most efficacious kind. As soon as the dealers in guano begin to work one of
the beds, the island on which it is formed is abandoned by the birds. It has
also been remarked that, since the increase of trade and navigation, they
have withdrawn from the islands in the neighbourhood of the ports. Under
the empire of the Incas, the guano was regarded as an important branch
of state economy. It was forbidden, on pain of death, to kill the young
birds. Each island had its own inspector, and was assigned to a certain
province. The whole distance between Arica and Chaucay, a length of two
hundred nautical miles, was exclusively manured with guano. These wise
provisions have been entirely forgotten by the Spaniards, but the Peruvians
now begin to discover the error of their former masters, and look forward
with anxiety to the period when the guano will no longer suffice for the
wants of husbandry. At the present day they use it chiefly in the cultivation
of maize and potatoes. A few weeks after the seeds begin to shoot, a little
hole is made round each root and filled up with guano, which is afterwards
covered with a layer of earth. After the lapse of twelve or fifteen hours, the
whole field is laid under water, and left in that state for about half a day. Of
the guano blanco a less quantity suffices, and the field must be more
speedily and abundantly watered, otherwise the roots would be destroyed.
The effect of this manure is incredibly rapid. In a few days the growth of
the plant is doubled; if the manure is repeated a second time, but in
smaller quantity, a rich harvest is certain;—at least the produce will be
three times greater than that which would have been obtained from the
unmanured soil. The uniformity of climate, along a coast where rain is
never known to fall, contributes essentially to the superior quality of the
Chincha guano, as atmospherical precipitations naturally dissolve and wash
away many of the most fertilising salts.
The consumption of guano in Western Europe, and particularly in
England, increases with surprising rapidity. On the island of Iquique a layer
thirty feet deep, and covering a space of 220,000 square feet, has been
entirely removed within twenty-seven years. In the year 1854, 250,000
tons were dug in the Chincha Islands, and the actual annual exportation
amounts to double the quantity. The digestive functions of the Sula and her
companions thus bring in larger sums to the Peruvian Government than all
the silver mines of Cerro de Pasco, and the transport of the guano employs
larger fleets than ever Spain possessed at the brightest period of her
power.
"The Chincha Islands," says Castelnau (Expédition dans les Parties
Centrales de l'Amérique du Sud; Paris, 1851), "are completely desert and
devoid of vegetation; their granite soil is clearly distinguished by its colour
from the thick stratum of guano with which it is covered, and the surface of
which looks at a distance like snow. The steep banks render landing
difficult, but facilitate at the same time the shipping of the produce, as the
vessels lie at anchor close to the pits. Digging takes place at three places,
close to one another, and the traveller has only to compare the enormous
deposits with the smallness of the excavations, which at some distance are
hardly perceptible, to convince himself of the inexhaustible supply. Some
huts have been constructed on the island, where, in the midst of
ammoniacal effluvia, some Peruvian customhouse officers and soldiers
superintend the working of the guano-mines."
Birds of Passage.
 CHAP. XI.

THE REPTILES OF THE OCEAN.

The Saurians of the Past Seas.—The Anatomical Structure of
the Turtles.—Their Size.—Their Visits to the Shores.—The
Dangers that await their Young.—Turtles on the Brazilian
Coast.—Prince Maximilian of Neuwied and the Turtle.—
Conflicts of the Turtles with Wild Dogs and Tigers on the
Coast of Java.—Turtle-catching on Ascension Island.—
Tortoise-shell.—The Amblyrhynchus cristatus.—Marine
Snakes.—The Great Sea-Snake.
There was a time when the reptiles were the monarchs of the sea,
when the ocean swarmed with gigantic saurians, tyrants of the fishes,
combining the swiftness of the dolphin with the rapacity of the crocodile.
Had those monsters of the deep been endowed with human intelligence,
they would most likely also, with human arrogance, have boasted of an
eternal sway. For where in the whole ocean was the enemy that could cope
with them? Did not all beings flee wherever they appeared? and did not the
inexhaustible sea promise them an everlasting supply of food?
But in spite of their colossal power, the saurians, like all created beings,
have been forced to succumb to time.
Centuries and centuries passed on, the sea and air gradually changed,
the temperature of the elements no longer remained the same, and thus
by degrees a new ocean and a new atmosphere were formed, uncongenial
to the nature of those huge reptiles. Thus they have been effaced from the
roll of living things, and some petrified remains alone bear testimony to
their former existence.
The most powerful saurians of the present day—the crocodile the gavial
and the alligator—have left to the dolphins, the sharks, and other
monstrous or swiftly-swimming cetaceans and fishes the dominion of the
seas, and now merely infest the rivers and swamps of the tropical zone.
 The lizards also have long since retired from the
scene where they once abounded, and the ocean at
present harbours no other reptiles in its bosom than
turtles and sea-snakes.
Most of the animals belonging to this class are
either dangerous or of a disgusting appearance. Few
creatures are objects of such universal abhorrence as
the crocodile—the very type of brutal cold-blooded
ferocity; as the venomous snake—the emblem of
perfidy and ingratitude; or as the loathsome, but
innocent toad, to which, on account of its ugliness,
noxious properties have been ascribed which the poor
animal does not possess. The frogs, lizards, and
turtles alone seem to have escaped this general
detestation, either from their more active habits, or
their well-known harmlessness, or their various utility
to man.
The anatomy of the turtle offers many points of
interest; its vertebræ, ribs, and breast-bone growing
together so as to form a bony envelope round the
whole animal. This harness is covered by the skin,
Ichthyosaurus. which in its turn is bedecked with large scales, while
all the muscles and other soft parts are enclosed in
the inner cavity. Only the head, feet, and tail protrude
through openings between the upper and under carapace, and these can,
by the land tortoises at least, be withdrawn entirely under the former. This
is the only protection which Nature has afforded these animals against their
enemies, for they have neither swiftness of flight, nor any offensive
weapon at their command. But as soon as anything suspicious approaches,
they conceal themselves under their massive cover, and oppose to every
attack by tooth or nail the passive resistance of an impenetrable shield.
Most of their enemies find it, besides, no easy task to turn them on their
back, as many species attain a very considerable weight, so that their mere
bulk constitutes a good defence. It might be supposed that this protection
could only avail for a short time, as the want of air must soon force the
animal to stretch its head out of its hiding-place, and this indeed would be
the case, if kind Nature had not taken her measures against this
emergency, by giving the creature a cold blood, so that it can remain a
very long time without breathing; long enough, at least, to tire the patience
of the most obstinate foe.

Skeleton of Tortoise.

A, superior maxilla; B, inferior maxilla; C, ossiculum auditus; D, os hyoides;

E, cervical vertebræ; F, dorsal vertebræ; G, sacrum; H, caudal vertebræ; I,
dorsal ribs; K, marginal scales; N, scapula; O, coracoid bone; P, os humeri;
Q, radius; R, ulna; S, bones of the carpus; T, metacarpal bones; U, digital
phalanges; V, pelvis; W, femur; X, tibia; Y, fibula; Z, tarsus; Æ, metatarsus;
A.V., phalanges of the foot.
But how comes it, the reader may ask, that respiration, which pours a
warm current through our veins, fails in raising the temperature of the
turtle's blood?
Without entering into a lengthened description of the human heart, I
shall merely observe that it consists of two halves (each half being again
subdivided into two separate chambers), and that the right half, which
receives venous blood and pours it into the lungs, is completely separated
by a partition from the left half, which receives arterial or aërated blood
from the lungs, and propels it into every part of the body. Thus the two
different kinds of blood are completely separated, so that an unmixed
venous blood flows into the lungs, where it is converted by the oxygen of
the air into arterial blood. But this connection, like most chemical
processes, takes place under an evolution of heat, which is so considerable
that our internal temperature constantly maintains itself at the height of
98° F.

Theoretic Representation of the Circulation in Mammals

and Birds.
 Theoretic Representation of the Circulation in
Reptiles.

But the turtle's heart is differently formed, consisting, as the annexed

theoretic representation shows, of but one ventricle and two auricles, so
that a mixed, or only half aërated blood circulates throughout the body,
which naturally produces a torpidity of the whole vital process. Besides, the
lungs of the reptiles are incapable of aërating so great a quantity of blood
as ours, as their cells are much larger, thus offering less surface to the
action of the air; and finally, the ribs of the turtles being immovable, they
are incapable of extending the lungs, so that the animal is absolutely
obliged to swallow the necessary supply of air, and to pump it, as it were,
into the lungs, by contracting the muscles of the throat. Thus we see that
every precaution has been taken to reduce respiration to a low standard,
and prevent the evolution of heat. With this indolence of its cold-blooded
circulation, the whole nature of the animal is in harmony; the bluntness of
its senses, its want of intelligence, its slow movements, and its long
endurance of hunger, thirst, and want of air. It leads but a drowsy dream-
like existence, and yet, we may be sure, it is far from unhappy, for all its
functions and organs agree perfectly one with the other, and when concord
reigns, enjoyment of some kind must exist.
The turtles are distinguished from the land tortoises particularly by their
large and long fin-shaped feet, and also by a longer tail, which serves them
as a rudder. They have no teeth, but the horny upper jaw closes over the
lower like the lid of a box, thus serving them as excellent shears, either for
crushing shells or dividing the tough fibres of the sea-grass.
 They are at home in all the warmer seas,
but sometimes they are carried by oceanic
streams far away from their accustomed
haunts. Thus, in the year 1752, a Green turtle,
six feet long, and weighing 900 pounds,
Green Turtle. stranded near Dieppe; and in 1778 another,
seven feet long, on the coast of Languedoc.
One taken on the coast of Cornwall in July,
1756, measured from the tip of the nose to the end of the shell, six feet
nine inches, and the weight was supposed to be nearly 800 pounds. These
few examples show us that the turtles rank among the larger inhabitants of
the ocean, although they are far from attaining the fabulous proportions
assigned to them by Pliny (who makes the Indians use their shells as boats
or roofs), or the enormous size of some colossal extinct species, such as
the fossil tortoise from the Siwala hills, preserved in the East Indian
Museum, which measures twelve feet in length. They live almost constantly
at sea, partly on shell-fish, like the fierce Loggerhead turtle (Testudo
Caretta), partly on sea-grass, like the Green turtle (T. Midas), and only go
on shore during the warmest months of the year, for the purpose of laying
their eggs.
"We followed the monotonous sea-coast,"
says Prince Maximilian of Neuwied, in his
interesting "Travels through the Brazils;" "our
two soldiers, a Negro and an Indian,
frequently stopping to dig turtle-eggs out of
the sand, which, boiled in sea-water, used to
form our evening repast. Once, while they
were busy gathering drift-wood for cooking, Loggerhead Turtle.
we found at a small distance from our fire an
enormous turtle busy laying her eggs. We
could not possibly have met with anything more agreeable; the creature
seemed to have crawled there for the express purpose of providing for our
supper. Our presence did not discompose her in the least; she allowed
herself to be touched, and even raised from the ground, for which purpose
four men were required. During our loud deliberations on her future fate,
she gave no other sign of uneasiness than a blowing sound, and continued
to work slowly with her hind fins, throwing up the earth at regular
intervals.
 "One of the soldiers stretched himself out at full length on the ground
near the purveyor of our kitchen, inserted his arm into the earth-hole, and
threw out the eggs as they were laid by the turtle. In this manner above a
hundred were collected in about ten minutes. A council was now held as to
the means of adding the beast to our collection, but as it would have
required an additional mule for the transport, we gave it its life. These
colossal turtles—Midas, Coriacea, and Caretta—especially choose these
desert coasts for the laying of their eggs. They emerge from the sea in the
dusk of evening, and then crawl back again into the water one or two
hours after the setting of the sun. Thus also the friendly turtle, which had
so abundantly provided for our wants, disappeared after a short time; we
found the large hole filled up, and a broad trace in the sand showed that
the animal had again retreated to its favourite element. The Midas is said
to lay from ten to twelve dozen, and the Coriacea from eighteen to twenty
dozen eggs at once."
The wild sand coast of Bantam (Java) is annually frequented by a large
number of turtles. They are often obliged to creep over nearly a quarter of
a mile of the beach, before finding at the foot of the sand-dunes a dry and
loose soil fit for their purpose; and on this journey, which for them is a very
long one, they have many dangers to encounter. Hundreds of their
skeletons lie scattered about the strand, many of them five feet long, and
three feet broad; some bleached and cleaned by time, others still half filled
with putrid intestines, and others, again, quite fresh and bleeding. High in
the air a number of birds of prey wheel about, scared by the traveller's
approach. Here is the place where the turtles are attacked by the wild
dogs. In packs of from twenty to fifty, the growling rabble assails the poor
sea-animal at every accessible point, gnaws and tugs at the feet and at the
head, and succeeds by united efforts in turning the huge creature upon its
back. Then the abdominal scales are torn off, and the ravenous dogs hold a
bloody meal on the flesh, intestines, and eggs of their defenceless prey.
Sometimes, however, the turtle escapes their rage, and dragging its
lacerating tormentors along with it, succeeds in regaining the friendly sea.
Nor do the dogs always enjoy an undisturbed repast. Often during the
night, the "lord of the wilderness," the royal tiger, bursts out of the forest,
pauses for a moment, casts a glance over the strand, approaches slowly,
and then with one bound, accompanied by a terrific roar, springs among
the dogs, scattering the howling band like chaff before the wind. And now
it is the tiger's turn to feast, but even he, though rarely, is sometimes
disturbed by man. Thus, on this lonely, melancholy coast, wild dogs and
tigers wage an unequal war with the inhabitants of the ocean.
The cold-blooded turtle is obliged to confide the hatching of her eggs to
the sun, which generally accomplishes the task in three weeks. On
creeping out of the egg, the young, even those of the largest species, are
not larger than half-a-crown and of a white colour. Unprotected by a
parent's tenderness, the poor little creatures seem only to be born for
immediate death. Their first instinctive movements are towards the
element for which they are destined; slowly they drag themselves towards
the water, but the sea meets them with a rough embrace, and the
unmerciful waves generally throw them back again upon the shore. Here
they are attacked by great sea-birds, storks and herons, against which, in
spite of their smallness, they make feeble efforts of defence, or by still
more powerful beasts of prey; and thus the greater part of the unfortunate
brood is destroyed at its very first entrance into life; while those which
reach the sea, are generally devoured by sharks and other sharp-toothed
fishes. It is therefore not in vain that the turtle lays four or five hundred
eggs in the course of a single summer, for were she less fruitful, the race
would long since have been extinguished.
I need hardly mention, that the flesh of the green turtle is everywhere
esteemed as a first-rate delicacy. The king of the Manga Reva Islands in
the South Sea keeps them in a pen for the wants of his table; and the
London alderman is said to know no greater enjoyment than swallowing a
basin of turtle soup. Hence it is no wonder that the mariner, tired of salt-
beef and dried peas, persecutes them on all the coasts of the tropical seas,
wherever solitude, a flat beach, and a favourable season promise to reward
his trouble.
Bernardin de St. Pierre gives us the following picturesque description of
turtle-catching on Ascension Island;—"Fire-wood, a kettle, and the great
boat-sail were landed, and the sailors lay down to sleep, as the turtles do
not emerge from the sea before night-fall. The moon rose above the
horizon and illumined the solitude, but her light, which adds new charms to
a friendly prospect, rendered this desolate scene more dreary still. We were
at the foot of a black hillock, on whose summit mariners had planted a
great cross. Before us lay the plain, covered with innumerable blocks of
black lava, whose crests, whitened by the drippings of the sea-birds,
glistened in the moonbeam. These pallid heads on dark bodies, some of
which were upright, and others reclined, appeared to us like phantoms
hovering over tombs. The greatest stillness reigned over this desolate
earth, interrupted only from time to time by the breaking of a wave, or the
shriek of a sea-bird. We went to the great bay to await the arrival of the
turtles, and there we lay flat upon the sand in the deepest silence, as the
least noise frightens the turtles, and causes them to withdraw. At last we
saw three of them rising out of the water, and slowly creeping on shore,
like black masses. We immediately ran up to the first, but our impatience
caused it to drop immediately again into the sea, where it escaped our
pursuit. The second, which had already advanced too far, was unable to
retreat; we turned it on its back. In this way we caught about fifty turtles,
some of which weighed five hundred pounds. Next morning, at ten, the
boat came to fetch the produce of our nocturnal sport. This work occupied
us the whole day, and in the evening the superfluous turtles were restored
to the sea. If suffered to remain a long time on their back, their eyes
become blood-red, and start out of their sockets. We found several on the
strand that had been allowed to perish in this position, a cruel negligence,
of which thoughtless sailors are but too often guilty."
In the sea, also, the turtles are pursued by man. In the clear West
Indian waters, where they are frequently seen at great depths, feeding on
the sea-grass meadows, divers plunge after them and raise them to the
surface. Sometimes they are harpooned, or even caught sleeping on the
waters.
The ancient Romans, who spent such extravagant sums upon dishes
repugnant to our taste, seem to have had but little relish for turtle flesh,
which otherwise the conquerors of the world might easily have obtained
from the Red Sea; for though we read that Vitellius feasted upon the brains
of pheasants, and the tongues of nightingales, it is nowhere mentioned,
that he ever, like the Lord Mayor of London, set seven hundred tureens of
turtle soup before his guests.
On the other hand, they made a very extensive use of tortoise-shell, the
produce of the Hawk's-bill turtle (Testudo imbricata) a native both of the
American and Asiatic seas, and sometimes, but more rarely, met with in the
Mediterranean. The flesh of the animal is not held in any estimation as a
food, but the plates of the shell being thicker, stronger, and cleaner than
those of any other species, render it of great importance as an article of
trade.
 "Carvilius Pollio," says Pliny, "a man of great invention
in matters pertaining to luxury, was the first who cut the
plates of the tortoise for veneering or inlaying." The
Romans imported large quantities of this precious article
from Egypt, and under the reign of Augustus, the wealthy
patricians used even to inlay the doors and columns of
their palaces with it. When Alexandria was taken by Julius
Cæsar, the warehouses were so full of tortoise-shell that
Hawk's-bill the conqueror proposed to make it the principal ornament
Turtle. of his triumph.
The use of tortoise-shell for the decoration of houses
and furniture is long since out of fashion, but it is still in great request for
the making of combs and boxes. By steeping it in boiling water it softens,
and may then, by a strong pressure, be moulded into any form. When a
considerable extent of surface is required, different pieces must be joined
together. This is done by scraping thin the edges of the pieces to be united,
and laying them over each other while they are in the heated and softened
state; strong pressure being then applied, they become completely
agglutinated. It is in this way that gold, silver, and other metals for
different ornaments are made to adhere to tortoise-shell.

When, at the beginning of the chapter, I mentioned that the lizards had
entirely forsaken the ocean, I forgot that the Galapagos Islands in the
South Sea, right under the Equator, exclusively possess a maritime animal
of this kind, which, from its being the sole existing representative, or
dwindled descendant of the giant oceanic saurians of yore, is far too
interesting to be passed unnoticed. This lizard is extremely common on all
the islands throughout the Archipelago. It lives exclusively on the rocky
sea-beaches, and is never found,—at least Mr. Darwin never saw one,—
even ten yards inshore. It is a hideous-looking creature, of a dirty black
colour, stupid and sluggish in its movements. The usual length of a full-
grown one is about a yard, but there are some even four feet long. These
lizards were occasionally seen some hundred yards from the shore,
swimming about; and Captain Collnett, in his "Voyage," says they go out to
sea in shoals to fish. With respect to the object, Mr. Darwin believes he is
mistaken; but the fact, stated on such good authority, cannot be doubted.
When in the water the animal swims with perfect ease and quickness by a
serpentine movement of its body and flattened tail; the legs, during this
time, being motionless and closely collapsed on its sides. A seaman of the
"Beagle" sank one with a heavy weight attached to it, thinking thus to kill it
directly; but when an hour afterwards he drew up the line the lizard was
quite active. Their limbs and strong claws are admirably adapted for
crawling over the rugged and fissured masses of lava, which every where
form the coast. In such situations a group of six or seven of these hideous
reptiles may oftentimes be seen on the black rocks, a few feet above the
surf, basking in the sun with outstretched legs.
Mr. Darwin opened the stomach of several, and in each case found it
largely distended with minced sea-weed, of a kind growing at the bottom
of the sea, at some little distance from the coast. The nature of this lizard's
food, as well as the structure of its tail, and the certain fact of its having
been seen voluntarily swimming out at sea, absolutely prove its aquatic
habits; yet there is in this respect one strange anomaly, namely, that when
frightened it will not enter the water. From this cause it is easy to drive
these lizards down to any little point overhanging the sea, where they will
sooner allow a person to catch hold of their tail than jump into the water.
They do not seem to have any notion of biting; but when much frightened
they squirt a drop of fluid from each nostril. One day Mr. Darwin carried
one to a deep pool left by the retiring tide, and threw it in several times as
far as he was able. It invariably returned in a direct line to the spot where
he stood. It swam near the bottom with a very graceful and rapid
movement, and occasionally aided itself over the uneven ground with its
feet. As soon as it arrived near the margin, but still being under water, it
either tried to conceal itself in the tufts of sea-weed, or it entered some
crevice. As soon as it thought the danger was past, it crawled out on the
dry rocks and shuffled away as quickly as it could. Mr. Darwin several times
caught this same lizard by driving it down to a point, and, though
possessed of such perfect powers of diving and swimming, nothing could
induce it to enter the water; and as often as he threw it in, it returned in
the manner above described.
Perhaps this singular piece of apparent stupidity may be accounted for
by the circumstance that this reptile has no enemy whatever on shore,
whereas at sea it must often fall a prey to the numerous sharks. Hence,
probably urged by a fixed and hereditary instinct that the shore is its place
of safety, whatever the emergency may be, it there takes refuge. On a
comparison of this singular animal with the true iguanas, the most striking
and important discrepancy is in the form of the head. Instead of the long
pointed narrow muzzle of those species, we have here a short obtusely
truncated head, not so long as it is broad; the mouth consequently is
capable of being opened to only a very small extent. From this
circumstance, and from the crest on its head, it has received the Latin
name of Amblyrhynchus cristatus.

The serpent race, which thrives so abundantly in the tropical forests

and morasses, has also its marine representatives in the Indian and Pacific
Oceans, where more than fifty species of Hydrophis, Pelamys, and
Chersydra have been found. They are distinguished from their terrestrial
relations by the flattened form of their tail, the planes of which being
directed vertically give it the properties of a powerful oar, in striking the
water by lateral oscillations. These sea-snakes always appear to prefer
calms, swimming on the still surface in an undulating manner, never raising
the head much from the surface, or vaulting out of the water. They dive
with facility on the approach of danger, but do not appear to be particularly
timid.
The Pelamys bicolor is very common from India to
Otaheite. In the seas of Mindoro and Sooloo, Mr. Adams
saw thousands swimming on the top of the water,
especially in eddies and tide-ways where the ripple
collects numerous fish and medusæ, which principally
constitute their prey. Their tongue is white and forked,
differing in respect of its colour from the tongue of other
snakes, which is generally black. The water-snakes, which
are frequently beautifully banded, and as thick as a man's
leg, are said to be highly venomous. Captain Cook, in one Water-Snake.
of his voyages, "saw abundance of water-snakes, one of
which was coming up the side of our ship, and our men
beat it off. The Spaniards affirm there is no cure for such as are bit by
them; and one of our blacks happened to fall under that misfortune, and
died notwithstanding the utmost care was taken by our surgeons to
recover him."
Such are the real sea-snakes as they are met with by ordinary
travellers, while the great sea-serpent, which from time to time dives up in
the columns of the newspapers, must, until better evidence be brought
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