Advanced Microneedling Training

Advanced Microneedling Training
© COPYRIGHT 2013 BELLUS MEDICAL LLC. ALL RIGHTS RESERVED.

Today’s Agenda Goals of Skin Rejuvenation The Science of Microneedling
Microneedling Compared to Other Popular Therapies Break Microneedling + Topicals How Does Microneedling Affect Common Skin Conditions Synergistic Treatment Modalities to Microneedling Basic Protocols/Advanced Protocol Workshop Packaging Treatments

How Does Medical Needling Work?
1.15 How Does Medical Needling Work? 0.5mm – 3.0mm Uses very fine, surgical stainless steel needles to make channels into the epidermis and dermis to release growth factors Promotes scarless healing and deposition of normal woven collagen rather than scar collagen Similar to Fraxel, without the negative loss of dermal papillae, potential destruction of melanocytes, abnormal collagen, coagulated growth factors Allows 80% more product into the skin (compared to 7-10% normally)

Collagen Induction Therapy
1.10 Collagen Induction Therapy Microinjuries allow for release of serum containing cytokines and growth factor* Main benefit of microneedling is allowing for leakage of serum into the microchannels and release of growth factors. Benefits of platelet rich plasma naturally. Pinpoint bleeding is good thing, redness in good thing, that is the release of the growth factors. PDGF Platelet derived growth factor TGF-B Transforming growth factors EGF Epidermal growth factors VEGF Vascular endothelial growth factors FGF Fibroblast growth factors *Fernandes, D. OralL Maxillofacial Surg Clin 2005; 17:51-63

Phases of Wound Repair Inflammatory Phase (1-3 days)
1.19 Phases of Wound Repair Inflammatory Phase (1-3 days) Proliferative Phase (3-5 days) So what happens after the injury. Growth factors start the wound repair process. Macrophages start cleaning up dead cells . Cell infiltration, blood profusion to the ssite, granulation to occur, occurs immediately. Swelling redness and tenderness. Then roliferation phase begins. Temporary collagen with tightness. Contraction phase of wound repari, then phase 3 where long term benefit occurs happens 3 weeks to 1 year 1 depneds on age and skin. Most at 6 months Type 3 is temporary collagen then replaced with type 1. No sooner than 1 month between treatments. .5 and under can do more often but anything deeper not more than once per month. Dermis is 1.5mm 2.5 mm is hitting fat, hypodermis. Not going to be building collagen beyond 1.5mm on the face. Beyond that for other parts of body. Doing more harm than good beyond 1.5mm on the face. Causing more injury than necessary.

Most Effective Uses of Dermal Needling
1.16 Most Effective Uses of Dermal Needling Wrinkles Thin skin Hyperpigmentation Rosacea Loss of Resiliency Premature aging Scars Epidermal density and strength Lax skin UV damage Stretch marks Hair restoration

Features of Healthy Skin
1.3 Features of Healthy Skin Soft, compact stratum corneum, with strong skin barrier Dense spinosum layer with consistent, strong cell-to-cell adhesion Even color, with melanocytes that distribute melanin uniformly Resilience Dermis rich with collagen and elastin fibers Good dermal and epidermal hydration: Extracellular matrix rich with glycosaminoglycans

The Three Layers of the Skin
1.4 The Three Layers of the Skin Stratum Spinosum are where the dermal pappilie are. Nutrients and oxygen are exchanged there. Dermal Epidermal junction is the wavy line below the egg shaped, and it flattens out over time as dermal papille are destroyed. 1mm in dermis, 1.5mm is in the fatty layer…

Key Goals of Skin Rejuvenation
1.5 Key Goals of Skin Rejuvenation Optimize cell function- supply skin cells with essential building blocks through oral nutrition, topical ingredients, and vigorous exercise to increase blood flow and encourage lymphatic system. Tell the cells what to do with release of growth factors ( causes cells to differentiate ,proliferate, grow) and cytokines (signaling molecules released by cells to assist in communication) Preserve integrity of the epidermis- provides natural barrier against pathogens, UV radiation, and free radicals Strengthen dermal/epidermal junction-prevents flattening of dermal/epidermal junction ,which presents as wrinkles Preserve dermal papillae-facilitates exchange of oxygen nutrients, and waste products between epidermis and dermis. Provides strength between dermal/epidermal junction to prevent wrinkles Break down scar tissue- allows epidermis to lay flat Release epidermal growth factors Increase natural collagen: transforming growth factor ß3 (TGF-ß3) Induce regenerative healing Supply skin cells with the essential building blocks they require through oral nutrition and supplements, topical ingredients, and vigorous exercise to increase blood flow and encourage lymphatic system. Tell the cells what to do with release of growth factors (cause cells to differentiate, proliferate, grow) and cytokines (signaling molecules released by cells to assist in communication). Provides natural barrier against pathogens, UV radiation, and free radicals from pollution. Prevents flattening of the dermal/epidermal junction which presents as wrinkles. Facilitates exchange of oxygen nutrients, and waste products between epidermis and dermis. Provides strength between dermal/epidermal junction to prevent wrinkles. Breaking down scar tissue allows the epidermis to lay flat. 6.

Optimize Cell Function
1.6 Optimize Cell Function Keratinocyte -Epidermis is 90% keratinocytes; to improve epidermal density, stimulate proper keratinization (smoothness) and produce a strong compact barrier function; “Until recently, the keratinocyte, which as considered less important than the fibroblast in creating healthy skin, was abused shamelessly with a variety of ablative treatments. New research, however, suggests the humble keratinocyte is responsible for releasing several key growth factors that conduct the orchestra of cells beneath it to facilitate ideal skin rejuvenation.” Melanocyte- Ensures even skin color Fibroblast- to stimulate collagen, elastin and glycosaminoglycans(GAGS) for firm, tight hydrated skin Keratinocyte: Epidermis is 90% keratinocytes; to improve epidermal density, stimulate proper keratinization (smoothness) and produce a strong compact barrier function. Melanocyte: Ensures even skin color Fibroblast: to stimulate collagen, elastin and glycosaminoglycans for firm, tight and hydrated skn

Optimizing the Keratinocytes
1.7 Optimizing the Keratinocytes Basic epidermal topical requirements: Omega 3 Omega 6 Ceramide Squalenes Sphingolipid Phospholipid Keratinocyte is often abused; releases several growth factors to assist with cell turnover

Epidermal Cell Requirements
Omega 3 Kiwifuit seed oil Lecithin Hemp see oil Flax seed oil Camelina oil Omega 6 Hemp seed oil Borage oil Evening Primrose oil Rice bran oil Ceramide Yeast (pichia anomala extract) Wheat extracts Squalenes Rice bran oil Olive oil Sphingolipid Yeast (pichia anamola extract) Phospholipid Lecithin These are the things we are looking for in advanced topicals are used for cell requirements

Optimizing the Melanocyte
Unfortunately, melanocytes lie between most anti-aging treatment modalities and the targeted fibroblasts, and are often sacrificed in overzealous attempts to obtain greater injury through aggressive injury.

1.9 Optimizing the Melanocyte Picture of melanocytes in the Stratum spinosum and when they are triggered by sunlight, ablative therapies, damaging protective layers dendrites are sent up and transferring melanin up into upper layers of skin.

1.8 Optimizing the Melanocyte 5 intervention points: Block UV radiation Block Melanin Stimulating Hormone (MSH) before it stimulates the keratinocytes and melanocytes Inhibit tyrosinase, the enzyme needed to form melanin in the melanosome Interfere with L-Dopa, the building blocks for pigment in the melanosomes Interfere with transfer of pigment from the melanosome to the keratinocyte 5 different pathways to block melanin creation

Product Ingredients Affecting Melanogenesis*
Active Ingredient MSH Tyrosinase Pigment Granule Melanosome Transfer Magnesium ascorbyl phosphate  Ascorbyl tetra isopalmitate Niacinamide Arbutin Azelaic acid Paper mulberry Aloesin Glabridin Glucosamine Ascorbic acid *Florence Barrett-Hill. Secretions. Cosmetic Chemistry. Reccomended ingredients and the pathways they block. Florence Barrett –Hill is internationally renowned Cosmetic Chemist and practioner.

Compounds Affecting Melanogenesis*
MSH Tyrosinase Pigment Granule Melanosome Transfer Lumixyl  Melanostat Sulforawhite Whitesphere Lightocean *Florence Barrett-Hill. Secretions. Cosmetic Chemistry. Branded compounds in skin care

Ingredients TO AVOID* with microneedling
Substance MSH Tyrosinase Pigment Granule Melanosome Transfer Kojic Acid**  Hydroquinone*** *Florence Barrett-Hill. Secretions. Cosmetic Chemistry. **Banned in some countries. May cause dermatitis long term. ***Banned is some countries. Potential carcinogenic effect. Hydroquinone cycling off can have rebound hyperpigmentation. Kojic Acid has been seen to derm. This is one persons opinion.

Lance Setterfield, Dermal Needling, Medical Edition, 2010
Medical Needling eliminates the risk of melanocyte heat injury and actually optimizes cell function, making it the ideal treatment for all skin types. Lance Setterfield, Dermal Needling, Medical Edition, 2010 Dermal needling is the only treatment that respects all three cell types. New Book edition just came out last week..

Optimizing the Fibroblast
Requires injury to stimulate: chemical peels Levulan and photodynamic therapy IPL Thermage Fraxel CO2 Laser

Ingredients for Optimal Fibroblast Function
Aids in Collagen Synthesis GAG Prevents Oxidative Stress Lipid Peroxidation Growth Factors  Magnesium ascorbyl phosphate Ascorbyl tetra isopalmitate Retinyl palmitate Retinol Copper peptides Beta-carotene DMAE Hyaluronic Acid *Florence Barrett Hill. Secretions, Cosmetic Chemistry 2009 **all above have antioxidant and anti-inflammatory properties and can be used on compromised and high-risk skins excepts retinol.

Ingredients for Optimal Fibroblast Function
Aids in Collagen Synthesis GAG Prevents Oxidative Stress Lipid Peroxidation Glucosamine  Super dismutase oxide Resveratrol (Bioflavanoid) Matrixyl® Amino acid Proline Amino acid Lysine Ascorbic acid Zinc Calcium *Florence Barrett Hill. Secretions, Cosmetic Chemistry 2009

Questions?

1.5 Key Goals of Skin Rejuvenation Optimize cell function Preserve integrity of the epidermis Strengthen dermal/epidermal junction Preserve dermal papillae Break down scar tissue Release epidermal growth factors Increase natural collagen: transforming growth factor ß3 (TGF-ß3) Induce regenerative healing Supply skin cells with the essential building blocks they require through oral nutrition and supplements, topical ingredients, and vigorous exercise to increase blood flow and encourage lymphatic system. Tell the cells what to do with release of growth factors (cause cells to differentiate, proliferate, grow) and cytokines (signaling molecules released by cells to assist in communication). Provides natural barrier against pathogens, UV radiation, and free radicals from pollution. Prevents flattening of the dermal/epidermal junction which presents as wrinkles. Facilitates exchange of oxygen nutrients, and waste products between epidermis and dermis. Provides strength between dermal/epidermal junction to prevent wrinkles. Breaking down scar tissue allows the epidermis to lay flat. 6.

Preserve the Epidermis
Epidermis is complex, highly specialized organ 0.2mm thick Only protection from the environment Most important goal of this layer is to provide a natural barrier against pathogens and protection against external environmental influences such as UVR and free radicals caused by pollution. Roller’s tear up the epidermis still has value as you are in the epidermis and increase health and thickness of skin.

Traditional Ablative Therapies Damage the skin to cause fibrosis of the papillary dermis Epidermis thinned Dermal papillae destroyed Severe changes in dermis Right under DEJ is the papillary dermis. Dr. Fernadez pioneer in microneedling has many studies on destroying epidemis equals scar type collagen repair

Resultant Collagen from Ablative Therapies: Parallel (scar) orientation rather than normal, lattice network Scar collagen will be resorbed by the body over time – all scar collagen is Fine wrinkles will be visible due to thinned epidermis and lack of dermal papillae Laticce network collagen lasts longer. Think about burn victim. Same thing the collagen underneath the skin is not normal. Synergistic approach with other ablative technologies to rebuild the skin with microtherapy.

1.1 1 Collagen Induction Therapy What does old vs. young skin look like?* Cross section of skin. Epidermis gives fullness and undulation to skin. A thin epidermis leads to crepeiness and fine lines. Undulations resolve in older patients due to miscommunication of layers. Sparse collagen fibers. Ropes are not as thick. This is what we are trying to repair with microneedling. Biopsy of young skin showing thick bundles of collagen bundles. Biopsy of aged skin showing thin and loose collagen fibers (Masson- Trichrome ×100). *Abd El-Aal NH, et al. J Dermatol 2012;57:181-6

1.12 Collagen Induction Therapy CIT Promotes deposition of fresh new collagen without scar formation* Took biopsy, performed microneedling, then took another biopsy. This stain is looking for extra cellular matrix. More collagen and elastin in second pic. Improved epidermal thickness Left, before CIT. Right, six months after CIT, more collagen (pink) and elastin (brown) can be detected. Estimated > 400% more collagen and improved epidermal/dermal thickness *Fernandes, D. OralLMaxillofacial Surg Clin 2005; 17:51-63

Increased Dermal Thickness
1.13 Increased Dermal Thickness Before After Ultrasound. Dermal thickness increased 0.5mm after 5 months. We have shown multiple studies proving that microneedling thickens the dermis and epiddermis which leads to a more youthful appearance with no fine lines and wrinkles. Patient had an increase in dermal thickness after 5 months. Dermal thickness increased from 1.91 mm to 2.41 mm. Moon, HS et. al; Department of Dermatology, Eulji University School of Medicine

Microchannel Formation
1.14 Microchannel Formation Creation of microchannels in the skin with minimal damage to epidermis* Microchannels are open for a short time, which allows for more efficient penetration of topicals Minimal damage to tissue equals minimal downtime How do we create this change? Vertical insertion microneedling provides minimal destruction to the epidermis. Receive all of the benefits of skin rejuventation yet minimize the risk of scarring, hyperpigmentation and infection. No disruption of the skin barrier function. Minimizes downtime. *Fernandes, D. OralL Maxillofacial Surg Clin 2005;17:51-63.

1.5 Key Goals of Skin Rejuvenation Optimize cell function Preserve integrity of the epidermis Strengthen dermal/epidermal junction Preserve dermal papillae Break down scar tissue Release epidermal growth factors Increase natural collagen: transforming growth factor ß3 (TGF-ß3) Induce regenerative healing Supply skin cells with the essential building blocks they require through oral nutrition and supplements, topical ingredients, and vigorous exercise to increase blood flow and encourage lymphatic system. Tell the cells what to do with release of growth factors (cause cells to differentiate, proliferate, grow) and cytokines (signaling molecules released by cells to assist in communication). Provides natural barrier against pathogens, UV radiation, and free radicals from pollution. Prevents flattening of the dermal/epidermal junction which presents as wrinkles. Facilitates exchange of oxygen nutrients, and waste products between epidermis and dermis. Provides strength between dermal/epidermal junction to prevent wrinkles. Breaking down scar tissue allows the epidermis to lay flat. 6.

The Three Layers of the Skin
1.4 The Three Layers of the Skin

Preserve the dermal papillae
Exchanges oxygen, nutrients, and waste products between the epidermis and dermis Provides strength between the epidermis and dermis to prevent the deterioration and separation of the dermal/epidermal junction, which presents as wrinkles

1.5 Key Goals of Skin Rejuvenation Optimize cell function Preserve integrity of the epidermis Strengthen dermal/epidermal junction Preserve dermal papillae Break down scar tissue Release epidermal growth factors Increase natural collagen: transforming growth factor ß3 (TGF-ß3) Induce regenerative healing Supply skin cells with the essential building blocks they require through oral nutrition and supplements, topical ingredients, and vigorous exercise to increase blood flow and encourage lymphatic system. Tell the cells what to do with release of growth factors (cause cells to differentiate, proliferate, grow) and cytokines (signaling molecules released by cells to assist in communication). Provides natural barrier against pathogens, UV radiation, and free radicals from pollution. Prevents flattening of the dermal/epidermal junction which presents as wrinkles. Facilitates exchange of oxygen nutrients, and waste products between epidermis and dermis. Provides strength between dermal/epidermal junction to prevent wrinkles. Breaking down scar tissue allows the epidermis to lift and lay flat, eliminating shadowing 6. The most beneficial of the growth factors

Break Down Scar Tissue Allows the epidermis to lift and lay flat,
eliminating any shadowing

1.10 Collagen Induction Therapy Microinjuries allow for release of serum containing cytokines and growth factor* Main benefit of microneedling is allowing for leakage of serum into the microchannels and release of growth factors. Benefits of platelet rich plasma naturally. Pinpoint bleeding is good thing, redness in good thing, that is the release of the growth factors. PDGF Platelet derived growth factor TGF-B Transforming growth factors EGF Epidermal growth factors VEGF Vascular endothelial growth factors FGF Fibroblast growth factors *Fernandes, D. OralL Maxillofacial Surg Clin 2005; 17:51-63

1.5 Key Goals of Skin Rejuvenation Optimize cell function Preserve integrity of the epidermis Strengthen dermal/epidermal junction Preserve dermal papillae Break down scar tissue Release epidermal growth factors Increase natural collagen: transforming growth factor ß3 (TGF-ß3) Induce regenerative healing Supply skin cells with the essential building blocks they require through oral nutrition and supplements, topical ingredients, and vigorous exercise to increase blood flow and encourage lymphatic system. Tell the cells what to do with release of growth factors (cause cells to differentiate, proliferate, grow) and cytokines (signaling molecules released by cells to assist in communication). Provides natural barrier against pathogens, UV radiation, and free radicals from pollution. Prevents flattening of the dermal/epidermal junction which presents as wrinkles. Facilitates exchange of oxygen nutrients, and waste products between epidermis and dermis. Provides strength between dermal/epidermal junction to prevent wrinkles. Breaking down scar tissue allows the epidermis to lift and lay flat, eliminating shadowing 6. The most beneficial of the growth factors

Induce Regenerative Healing
Collagen forms from the base upwards Opposite of Regenerative Healing is “Cicatricial healing”: leaves a scar when the formation of new connecting tissue overlies a wound

Microneedling Meets All Goals
1.10 Microneedling Meets All Goals Optimize cell function Preserve integrity of the epidermis Strengthen dermal/epidermal junction Preserve dermal papillae Break down scar tissue Release epidermal growth factors Increase natural collagen: transforming growth factor ß3 (TGF-ß3) Induce regenerative healing

Ablative vs. Non-Ablative Treatments
1.1 1 Ablative vs. Non-Ablative Treatments

Comparison with Other Treatments
1.20 Comparison with Other Treatments

Introducing SkinPen 2013: SkinPen modernizes microneedling
1.8 Introducing SkinPen 2013: SkinPen modernizes microneedling Stainless steel, cordless design Single, use disposable Advanced Microneedle Cartridge Minimizes epidermal destruction while delivering over 1400 microchannels per second Ideal for clinical practice Fine lines or moderate wrinkles Diminished skin texture, tone and color Atrophic acne scars Stretch marks Traumatic scars Photo aging

Topicals + Microneedling
The secret to successful rejuvenation is to provide all the necessary building blocks for optimum results. Needling and all other treatment modalities, used alone, are not effective. They sap the cell of resources needed to rebuild and repair. Lance Setterfield, Dermal Needling, 2010.

Dr. Des Fernandes – Topical A & C
Pre-treats patients with topical A and C three weeks to three month prior to needling. Vitamin A is essential for the normal physiology of the skin and for collagen preservation; maximizes collagen production and the skin will heal as rapidly as possible Vitamin C needs to replaced daily to ensure for natural protection and repair of DNA; essential for the production of normal collagen

Microchannel Characteristics
1.17 Microchannel Characteristics Recovery of skin barrier function following microneedling treatment as measured by transepidermal water loss (TEWL) Important, how soon do the channels close. Most penetration is immediately after treatment. The longer you wait, less penetration. 4 ours back at same permeability as before the therapy. Measured by leakage, tEWL Several benefits to microneedling and this is one of them, but this is transient. Figure from: The AAPS Journal, Vol. 13, No. 3, September 2011

Microchannel Characteristics
1.18 Microchannel Characteristics Calcein imaging to study closure of microchannels formed by 0.7 mm microneedles. Channels closed by 18 hours post treatment, showing the reversible nature of the channels. Channels are progressively closing. 4 hours is already at a level of signficantly less permeability. No makeup first 24 hours. I N T A C T S K I N 0 H O U R S 4 H O U R S 6 H O U R S 8 H O U R S H O U R S H O U R S H O U R S H O U R S Figure from: The AAPS Journal, Vol. 13, No. 3, September 2011

1.15 Microchannel Formation For dermal rollers, the number of microchannels increases as a function of the number of passes made 1 pass 3 passes 5 passes 10 passes 15 passes You can get microchannels with rollers as well but it is about time efficiency. You cn form hundreds of channels but takes 15 passes. Pain and discomfort. *Figure from: The AAPS Journal, Vol. 13, No. 3, September 2011

1.16 Microchannel Formation For SkinPen, the number of microchannels depends on how quickly you move the SkinPen across the surface of the skin. ► Needles cycle at 142 Hz or 142 “stamps”/second, potentially creating 1704 microchannels/second when moving the skin pen ► Slower movement at a rate of 1 cm/second, you can create roughly 4858 microchannels/ cm2 of skin* ► Faster movement at a rate of 3 cm/second, you can create roughly 1621 microchannels/ cm2 of skin* ► The SkinPen produces significantly more microchannels with one pass than created by a dermal rollers after many passes! Skinpen not as technician dependent. As long as the cartridge is flucsh Need graphic to show the *Needles are ~1 mm apart (1000 microns) and the cartridge head has a diameter of 3.5 mm

Enhancement of Topical Penetration
3.36 Enhancement of Topical Penetration Microneedling has been shown to enhance penetration of a depigmenting serum in a 20-subject study for treatment of melasma. MICRONEEDLING + DEPIGMENTING SERUM Microneedling + depigmenting serum: Mean MASI score of 19.1 at baseline Mean MASI score of 14.4 (P < .001) at 1 month Mean MASI score 9.2 (P < .001) at 2 months DEPIGMENTING SERUM ALONE Depigmenting serum alone: Mean MASI score of 20.4 at baseline Mean MASI score of 17.4 (P < .05) at 1 month Mean MASI score of 13.3 (P < .05) at 2 months BEFORE AFTER 2 MONTHS Plast Surg Int. ID Epub 2011 Apr 7

Recommended Needle Depth
3.4 Recommended Needle Depth Needle depth is contingent on: Thickness of dermis in area to be treated: The dermis of the face is variable, typically no deeper than 1.5 mm Dermis in other areas of the body may be thicker or thinner, with the dermis of the back typically the thickest (~3 mm) Reason for Treatment: Facial rejuvenation for improvement of skin texture of fine lines will require less penetration Improvement of scar tissue will require a more aggressive treatment and therefore deeper penetration Fabbrocini G, et al.. J Dermatolog Treat Dec 8. [Epub ahead of print].

Recommended Needle Depth
3.5 Recommended Needle Depth Average Skin Thickness Measurements Site AVG ABC Upper lip Lower lip Philtrum Chin Upper eyelid Lower eyelid Forehead Right cheek Site AVG ABC Left cheek Malar eminence Submental Nasal tip Nasal dorsum Right neck Left neck 0.83 ± 0.17 0.82 ± 0.15 0.83 ± 0.10 1.15 ± 0.11 0.38 ± 0.09 0.82 ± 0.21 1.03 ± 0.15 1.07 ± 0.09 1.17 ± 0.08 1.05 ± 0.45 0.89 ± 0.19 1.22 ± 0.15 1.15 ± 0.11 0.52 ± 0.23 0.54 ± 0.20 Plast Reconstr Surg May;115(6):

QUESTIONS?

Before After After three weeks. One localized area treatment using a 2.0mm needle. Photos courtesy of the Women’s Centre for Excellence

After After three weeks. One localized area treatment using a 2.0mm needle. Photos courtesy of the Women’s Centre for Excellence

Before After After one treatment. First pass at 0.5 mm; second pass at 1.0 mm. Photos courtesy of Dr. Ken Oleszek, LaFontaine Aesthetics

Before After Four weeks after one treatment. Three passes at 1.0 mm.
Photos courtesy of Dr. Christie Matter, North Texas Dermatology

Before After After one treatment. Photos courtesy of Spectacular Skin

Why Bellus Medical? Ongoing Advanced Training at no cost to our Practice Partners Skinpen.com specifically educates the patient and easily drives them into your practice Skinpen.com drove over 3,000 into our partner practices in October! Referral program rewards you with cash or needles the same day your referral purchases SkinPen Social media team dedicated to connecting with your practice and your patients to educate on microneedling and draw interest to SkinPen

Why SkinPen? Stainless steel, cordless design
The most advanced microneedle cartridge on the market: Bio-Sleeve technology eliminates cross-contamination and protect the pen 12 medical grade steel, 32 gauge needles to reduce epidermal destruction for superior results and positive patient experience Exhaust port to reduce suction and risk of broken capillaries

QUESTIONS?

Lasers vs. CIT Advantages of CIT over laser treatments
1.21 Lasers vs. CIT Advantages of CIT over laser treatments ► The biggest differences are cost and treatment recovery time. ► Either will take several sessions to treat your acne scars. ► Lasers run risk of post-inflammatory hyperpigmentation; CIT does not. ► The recovery time is longer between laser treatments than it is with CIT. ► Microneedling helps your body to create more collagen naturally. ► CIT does not burn your skin. ► CIT tightens what is already there. (Be cautious when comparing CIT to lasers. Laser fans won’t believe that microneedling can get the same benefits as laser nor want to jeopardize their laser business) Biggest difference is cost and recovery time. Cost to practice and cost to patient is significantly higher. Learning curve with laser is much higher. There are many types of laser. Clear and Brilliant is relatively mild with no significant injury. Lasers are not appropriate for all patients. Risk of hyperpigmentation in darker patients, summer months and patients that tan are a concern. Lasers cause minimal release of growth factors. A burn does not leave normal tissue and neither does a laser.

1.22 Comparison with IPL Collagen Induction Therapy in 54 mice (IPL vs. microneedling) 18 control mice 18 microneedling mice 18 IPL mice This slides sets up the study that is outlined in the next 3 slides. This is a poster presentation. Mice were evaluated 3 times, weeks. Mice lived to 8 weeks then portions of their skin was evaluated. Moon, HS et. al; Department of Dermatology, Eulji University School of Medicine

Comparison with IPL Skin Thickness
1.23 Comparison with IPL Skin Thickness After 8 weeks, when you took measurement of skin thickness, you see an increase is the IPL group, yet even greater in the microneedling group. Moon, HS et. al; Department of Dermatology, Eulji University School of Medicine

Comparison with IPL Histology (MT stain x100) Control IPL
1.24 Comparison with IPL Histology (MT stain x100) Control IPL Microneedling This was also shown to be true when evaluting with s stain. Moon, HS et. al; Department of Dermatology, Eulji University School of Medicine

1.26 Comparison with IPL Collagen Quantitation (Western Blot) β-actin serves as a “loading control” to show the same amount of sample was loaded for each experimental group As can be seen here, the Western Blot confirms the elisa assay results showing significantly more production of collagen protein in the micro- And when you compare collagen content among the 3 groups through Western Blot, you seen the microneedling group (3-M and 4-M) show greater collagen increase. (Western Blot measures protein; gel separates protein by size and molecular weight; take an antibody to that protein and determine if that protein is in your sample and how much. B lactin is in every cell so used as a sample group. We know from the B lactin group that the collagen increase is true b/c same amount of protein is loaded in each well. This represents 2 of the 18 mice. They want to show that these results were duplicatable.) needling group of mice (3-M and 4-M) as opposed to the control (C) or IPL (I) 3-C 3-I 3-M 4-C 4-I 4-M Collagen ß-actin Moon, HS et. al; Department of Dermatology, Eulji University School of Medicine

Comparison with IPL Conclusion: Skin thickness:
1.27 Comparison with IPL Conclusion: Skin thickness: Control < IPL < Microneedling MT Stain (collagen fiber): Control < IPL < Microneedling Collagen quantative anaysis (ELISA,WB): Control < IPL < Microneedling Looking across all three forms of evaluation, results were consistently in favor of microneedling in increasing skin thickness through building collagen.

Topicals + Micro-needling
The secret to successful rejuvenation is to provide all the necessary building blocks for optimum results. Needling and all other treatment modalities, used alone, are not effective. They sap the cell of resources needed to rebuild and repair. Lance Setterfield, Dermal Needling, 2010.

Enhancement of Topical Penetration
3.36 Enhancement of Topical Penetration Microneedling has been shown to enhance penetration of a depigmenting serum in a 20-subject study for treatment of melasma. MICRONEEDLING + DEPIGMENTING SERUM Microneedling + depigmenting serum: Mean MASI score of 19.1 at baseline Mean MASI score of 14.4 (P < .001) at 1 month Mean MASI score 9.2 (P < .001) at 2 months DEPIGMENTING SERUM ALONE Depigmenting serum alone: Mean MASI score of 20.4 at baseline Mean MASI score of 17.4 (P < .05) at 1 month Mean MASI score of 13.3 (P < .05) at 2 months BEFORE AFTER 2 MONTHS Plast Surg Int. ID Epub 2011 Apr 7

Dr. Des Fernandes – Topical A & C
Pre-treats patients with topical A and C three weeks to three month prior to needling. Vitamin A is essential for the normal physiology of the skin and for collagen preservation; maximizes collagen production and the skin will heal as rapidly as possible Vitamin C needs to replaced daily to ensure for natural protection and repair of DNA; essential for the production of normal collagen

Treating Hyperpigmentation
1.8 Treating Hyperpigmentation 5 intervention points: Block UV radiation Block Melanin Stimulating Hormone (MSH) before it stimulates the kertinocytes and melanocytes Inhibit tyrosinase, the enzyme needed to form melanin in the melanosome Interfere with L-Dopa, the building blocks for pigment in the melanosomes Interfere with transfer of pigment from the melanosome to the keratinocyte

Topicals: Increase collagen synthesis
Amino acids such as Proline and Lysine Copper peptides Peptides such as palmitoyl oligopeptide, Matrixyl 3000, palmitoyl tetrapeptide 7, kinetin Zinc Bioflavinoids: plant-derived antioxidants such as grape seed extract/resveratrol, green tea extract Stem cells Omega 3 & 6

How Does Micro-Needling Improve Various Skin Conditions?

Lax Skin & Wrinkles Increases availability of cell nutrients
Triggers wound healing cascade to bring platelets, fibroblasts, epithelial, endothelial, and immune cells together for wound healing Restores normal cell communication between keratinocytes and fibroblasts, increases glycosaminoglycans (GAG) production and collagen Myofibroblasts produce tightening effect through myofibril contraction

UV Damage Increases availability of cell nutrients and antioxidants
Attracts macrophages, monocytes, dendritic cells (Langerhans cells), T-helper cells and natural killer cells into damaged area Releases Epidermal Growth Factor Releases Interleukins (group of cytokines that regulate the immune system) Releases Interferons (glycoproteins with anti-tumor properties that modulate immune system, reducing cell proliferation)

Hyperpigmentation Increases availability of skin lightening actives
Restores keratinocyte function, normalizing communication with melanocytes and optimizing pigment uptake Restores fibroblast function, normalizing cross-talk with melanocytes Normalizes melanogenesis, melanocyte differentiation, dendrite formation, and proliferation

Scars Mechanical breakdown of scarring
Promotes new, natural wound healing cascade Increased MMPs remodel scar tissue TGF B3 down-regulates TGF B1 & TGF B2 leading to a pronounced anti-scarring result

2.22 Clinical Study: Scars Microneedling offers a simple and safe modality to improve the appearance of acne scars without risk of dyspigmentation in patient of all skin types 60 patients of skin types phototype I to VI were treated with microneedling for treatment of acne scars Three treatments at monthly intervals. Evaluated by using a Global Aesthetic Improvement Scale (GAIS), and analyzed statistically by computerized image analysis of the patients’ photographs. Average reduction of 31% of scarring. No short- or long-term dyschromia was observed. Fabbrocini G, et al.. J Dermatolog Treat Dec 8. [Epub ahead of print].

Stretch Marks Difficult to treat Needling:
Epidermis is atrophied and support structure beneath it is compromised Melanocytes are sparse or absent, distance to cover is too great for migration Needling: Improves density of the epidermis through release of epidermal growth factor Considered to be the most effective solution for stretch marks Important to not overpromise and under-deliver results

Clinical Study: Stretch Marks
Treatment of striae distensae using needling therapy: a pilot study. 16 Korean volunteers 3 microneedling treatments at 4-week intervals Assessed by pre and post-treatment clinical photographs, skin biopsies, and patient satisfaction scores. Dermatological Surgery Nov:38(11):

Clinical Study: Stretch Marks
Results: 7 patients (43.8%): marked to excellent improvement 9 patients: minimal to moderate improvement Patient Satisfaction Scores: 6 patients (37.5%): highly satisfied 8 patients (50%): somewhat satisfied 2 patients (12.5%): unsatisfied No significant side effects except mild pain, erythema, and spotty bleeding. Dermatological Surgery Nov:38(11):

Rosacea Stimulates EGF (epidermal growth factor) to increase density of epidermis, lessening appearance of vessels under the skin and overall redness Strengthens collagen in vessel walls and connective tissue that supports the vessels Increases Platelet GF which attracts monocytes into the wound which release interleukin 10 (anti-inflammatory cytokine) Increases availability of cell nutrients and antioxidants

Hair Loss Increases availability of cell nutrients
Stimulates blood flow Releases vascular endothelial growth factor (VEGF) which improves follicle vascularization, promotion hair growth and increasing follicle and hair size Platelet derived growth factor (pdgf) signals are involved in both the epidermis-follicle interaction and the dermal-follicle interaction required for hair canal formation and the growth of the dermal mesenchyme Might stimulate through fibroblast growth factor-7 (FGF-7) upregulation in dermal papilla cells.

Synergistic Treatment Modalities
Synergy: whereby two or more treatments combine to create a better result than their individual effects

Synergistic Treatment Modalities
Ranked according to effectiveness, invasiveness, and safety Light Emitting Diode (LED) IPL Nd:YAG Fraxel Chemical Peels Microdermabrasion Laser Radio Frequency (RF)

Light-Emitting Diode Deliver energy to stimulate a response from the body to heal itself; cells grow % faster Benefits to Skin Cells: Increase collagen production via ATP (adenosine triphosphate) Increase circulation and strengthening of capillary system Increase lymphatic system activity Increase in RNA and DNA synthesis Stimulate fibroblast activity Increase phagocytosis (for fighting infection) Increase cell membrane permeability; allow for deeper penetration of active ingredients

Lymphatic Drainage A form of very light massage that encourages lymph flow in the body, particularly good for detoxification, edema, pre- and post-plastic surgery and post-liposuction. It can also help with cellulite treatments, scar tissue, spider veins, redness and acne. Lymphatic Drainage: Accelerates removal of waste products Speeds up wound healing Increases blood flow Relaxes muscle Reduces lactic acid build-up to reduce inflammation

Intense Pulsed Light (IPL)
Wavelengths of light filtered to obtain the wavelength needed to reach target (melanin, hemoglobin, or water) Melanin absorbs energy and is destroyed by resulting heat Improvement in skin texture and wrinkles is minimal Most effective for hair removal, superficial hyperpigmentation and telangiecstasia. Risk includes burning the skin, dyschromia, and scars.

Mid-Infrared Lasers Nd:YAG Weakly attracted to melanin
Safer for darker skin types, including patients with a tan Good for permanent hair reduction, veins, wrinkles and tightening Without a skin cooling device, may produce pitted scars and hyperpigmentation. Fraxel Absorbed by water, low absorption in hemoglobin Treatment for wrinkles, hyperpigmentation, blood vessels and scars Penetrates deeper than CO2 Heat from energy is below ablation threshhold Risks are burns, scarring, hyperpigmentation, hypopigmentation, keloid scarring

Chemical Peels AHAs GLYCOLIC
Realign and balance water phase of lipid bilayers and raise % of free water in upper epidermis Strength and action is in the pH, not the %; lower pH will not compromise skin barrier functions GLYCOLIC Not first line for dehydrated or compromised skin

Combination with Peels for Acne Scars
3.33 Combination with Peels for Acne Scars 24 patients with post-acne atrophic scars were randomly divided into two groups. Group 1 was subjected to one session of deep peeling using phenol, improvement by a mean of 75.12% * Group 2 was subjected to four sessions of PCI combined with TCA 20%, improvement by a mean of 69.43% * Highest degree of improvement in the rolling type (p = 0.005) in group 2. Conclusion: Deep peeling using phenol and PCI with TCA 20% were effective in treating post-acne atrophic scars.

Questions?

Pre-treatment and Preparation
3.2 Pre-treatment and Preparation Objective: Review the steps that should be taken in order to assess the optimal treatment for each patient Skin Analysis Patient Presentation(cause of issue related to skin) Recommended needle depth Present Case studies with before and after photos

Skin Analysis and Patient Presentation continued
3.3 Skin Analysis and Patient Presentation continued Do the patient’s expectations match the results achievable with CIT? Improvement in fine lines/wrinkles Improvement in skin texture/quality Reduction in the appearance of scars/acne scars Improvement in the appearance of hyperpigmentation

3.6 Basic Protocols

Atrophic Scarring continued
3.35 Atrophic Scarring Indication: Improved appearance of atrophic scarring Treatment Frequency: 3–6 treatments at monthly intervals Prepare the affected area by applying preferred anesthetic and sterilization protocols. Apply HA Peptide Gel provided in kit to treatment area. Set the SkinPen depth to mm depending on skin thickness. Begin treatment of the affected area with an initial pass consisting of small circular movements in an outward and down direction until the entire area is covered. Use your free hand to keep the skin taut. continued

Atrophic Scarring continued
3.35 Atrophic Scarring continued This should be followed by two linear passes, one vertical and one horizontal, both of which cover the entire affected area. For deep scarring, the skin should be stretched perpendicular to the direction of the pass to ensure proper skin penetration at the scar base. A stamping motion can be used to provide extra penetration to deep scars. Wipe off any pinpoint bleeding and rinse the skin with sterile saline solution. (Optional) Place serum containing vitamin E and Vitamin C over treated area. Wrap an ice pack with sterile gauze and place against the treated area for 5 minutes.

Improvement in Atrophic Scars
3.34 Improvement in Atrophic Scars BEFORE AFTER 3–4 TRE A TMENTS POX SCAR ACNE SCAR 34 of 36 patients achieved a reduction in scar severity by one or two grades.* More than 80% of patients assessed their treatment as “excellent” on a 10-point scale.* *J Cutan Aesthet Surg Jan; 2(1):26–30

3.37 Hyperpigmentation Indication: Improved appearance of hyperpigmentation Treatment Frequency: 2-4 treatments at bi-monthly intervals Prepare the affected area by applying preferred anesthetic and sterilization protocols. Apply HA Peptide Gel provided in kit to treatment area. Set the SkinPen depth to mm depending on skin thickness. Begin treatment of the affected area with an initial pass consisting of small circular movements in an outward and down direction until the entire area is covered. Use your free hand to keep the skin taut. continued

Hyperpigmentation continued
3.39 Hyperpigmentation continued This should be followed by two linear passes, one vertical and one horizontal, both of which cover the entire affected area. Wipe off any pinpoint bleeding and rinse the skin with sterile saline solution. Place depigmenting serum over treated area. Wrap an ice pack with sterile gauze and place against the treated area for 5 minutes.

Hyperpigmentation continued
3.38 Hyperpigmentation continued This should be followed by two linear passes, one vertical and one horizontal, both of which cover the entire affected area. Wipe off any pinpoint bleeding and rinse the skin with sterile saline solution. Place depigmenting serum over treated area. Wrap an ice pack with sterile gauze and place against the treated area for 5 minutes.

Advanced Protocol Workshop
SkinPen + Vitamin A, C, E = overall collagen production HydraFacial + SkinPen = red carpet ready, hydrated, not downtime collagen remodeling Perfect Peel + SkinPen = melasma/hyperpigmentation VI Peel + SkinPen = acne/melasma Nectifirm + Botox + SkinPen = neck tightening Exillis/Radiofrequency + SkinPen = face/neck tightening

SkinPen + Hydrafacial red carpet ready hydration no downtime collagen remodeling
Cleanse with Active 4 Cleanser Degrease with alcohol or acetone Apply topical numbing for minutes occluding with plastic wrap Remove plastic wrap and topical with alcohol or acetone Apply hyaluronic acid to treatment area, start SkinPen treatment following face graph for appropriate depth on each area. Wash area with Active 4 Cleanser Start Hydrafacial treatment using all steps including red LED at the end of the treatment After red LED, use 2-4 pumps of the Antiox serum followed by the Pure Moist and a tinted SPF.

SkinPen + Perfect Peel Cleanse with Active 4 Cleanser
Degrease with alcohol or acetone Apply topical numbing for minutes occluding with plastic wrap Remove plastic wrap and topical with alcohol or acetone Apply hyaluronic acid to treatment area, start SkinPen treatment following face graph Wash area with Active 4 Cleanser Apply vaseline or aquaphor to the corner of the eyes, nouth and nose prior to applying peel Pour Perfect Peel in measuring cup and use the 4x4 gauze pads that come with the peel and saturate in the peel solution

SkinPen + Perfect Peel cont’d
Apply the first pass to the treatment area and wait 60 seconds, then apply the second pass vigorously rubbing on the area. Use all of the peel solution. Patient will feel a mild to moderate burning sensation, provide a hand held fan for patient comfort. No products can be applied to the skin the first day, not even sunblock. Sleep with the peel on overnight. The next morning, wash skin with gentle cleanser, pat dry and apply the first towelette vigorously rubbing into skin. Apply a broad spectrum UVA/UVB block SPF. That evening, 1 hour before bed, wash your skin and apply the second towelette vigoroursly rubbing into skin. On day 3, start using the post op cream and apply as needed. If itching occurs before day 3, start using the post op cream at that time.

Protocol Workshop SkinPen as maintenance between Fraxel Laser in peri oral and crows feet areas The Power of Three: SkinPen + Filler + Neurotoxin for overall rejuvenation Kiss Your Lip Lines Goodbye: SkinPen + Filler + Neurotoxin in lower face

SkinPen + Radio Frequency Body Treatment
Cleanse area Perform SkinPen Treatment using 1.5 to 2.5 depth on body Wipe area with wet 4x4 gauze pads Use baby oil or grape seed oil and treat area following the recommended parameters for the area you are treating When finished, wipe off gel and massage the area with body cream for 1-2 minutes Encourage patients to stay hydrated drinking a gallon of water the day of treatment and throughout the duration of the treatments Suggest home care of Resolution MD Cellulite system and apply to the treated areas twice a day to maintain results and help smooth the appearance of uneven skin and/or cellulite Treatments can be done in a series with re-treatment every 7-10 days. Maintenance minimum 3 times per year.

THANK YOU!!

Advanced Microneedling Training

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