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

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Presentation on theme: "© COPYRIGHT 2013 BELLUS MEDICAL LLC. ALL RIGHTS RESERVED. Advanced Microneedling Training."— Presentation transcript:

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

2 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

3 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) 1.15

4 1.10 Collagen Induction Therapy *Fernandes, D. OralL Maxillofacial Surg Clin 2005; 17:51-63 Microinjuries allow for release of serum containing cytokines and growth factor*

5 1.19 Phases of Wound Repair

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

7 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 1.3

8 The Three Layers of the Skin 1.4

9 Key Goals of Skin Rejuvenation 1Optimize 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) 2Preserve integrity of the epidermis - provides natural barrier against pathogens, UV radiation, and free radicals 3Strengthen dermal/epidermal junction- prevents flattening of dermal/epidermal junction,which presents as wrinkles 4Preserve dermal papillae- facilitates exchange of oxygen nutrients, and waste products between epidermis and dermis. Provides strength between dermal/epidermal junction to prevent wrinkles 5Break down scar tissue- allows epidermis to lay flat 6Release epidermal growth factors 7Increase natural collagen: transforming growth factor ß3 (TGF-ß3) 8Induce regenerative healing 1.5

10 Optimize Cell Function 1Keratinocyte -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.” 2Melanocyte- Ensures even skin color 3Fibroblast- to stimulate collagen, elastin and glycosaminoglycans(GAGS) for firm, tight hydrated skin 1.6

11 Optimizing the Keratinocytes  Basic epidermal topical requirements:  Omega 3  Omega 6  Ceramide  Squalenes  Sphingolipid  Phospholipid 1.7

12 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

13 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.

14 Optimizing the Melanocyte 1.9

15 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 1.8

16 Product Ingredients Affecting Melanogenesis* Active IngredientMSHTyrosinasePigment 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. 

17 Compounds Affecting Melanogenesis* CompoundsMSHTyrosinasePigment Granule Melanosome Transfer Lumixyl  Melanostat  Sulforawhite  Whitesphere  Lightocean  *Florence Barrett-Hill. Secretions. Cosmetic Chemistry.

18 Ingredients TO AVOID* with microneedling SubstanceMSHTyrosinasePigment 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.

19 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

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

21 Ingredients for Optimal Fibroblast Function Aids in Collagen Synthesis Aids in GAG Synthesis Prevents Oxidative Stress Prevents 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. 

22 Ingredients for Optimal Fibroblast Function Aids in Collagen Synthesis Aids in GAG Synthesis Prevents Oxidative Stress Prevents 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

23 Questions?

24 Key Goals of Skin Rejuvenation 1Optimize cell function 2Preserve integrity of the epidermis 3Strengthen dermal/epidermal junction 4Preserve dermal papillae 5Break down scar tissue 6Release epidermal growth factors 7Increase natural collagen: transforming growth factor ß3 (TGF-ß3) 8Induce regenerative healing 1.5

25 Preserve the Epidermis Epidermis is complex, highly specialized organ 0.2mm thick Only protection from the environment

26 Preserve the Epidermis Traditional Ablative Therapies Damage the skin to cause fibrosis of the papillary dermis Epidermis thinned Dermal papillae destroyed Severe changes in dermis

27 Preserve the Epidermis 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

28 1.1 1 Collagen Induction Therapy *Abd El-Aal NH, et al. J Dermatol 2012;57:181-6 What does old vs. young skin look like?* Biopsy of young skin showing thick bundles of collagen bundles. Biopsy of aged skin showing thin and loose collagen fibers (Masson- Trichrome ×100).

29 1.12 Collagen Induction Therapy CIT Promotes deposition of fresh new collagen without scar formation* 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

30 1.13 Increased Dermal Thickness BeforeAfter 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

31 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 1.14 Microchannel Formation *Fernandes, D. OralL Maxillofacial Surg Clin 2005;17:51-63.

32 Key Goals of Skin Rejuvenation 1Optimize cell function 2Preserve integrity of the epidermis 3Strengthen dermal/epidermal junction 4Preserve dermal papillae 5Break down scar tissue 6Release epidermal growth factors 7Increase natural collagen: transforming growth factor ß3 (TGF-ß3) 8Induce regenerative healing 1.5

33 The Three Layers of the Skin 1.4

34 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

35 Key Goals of Skin Rejuvenation 1Optimize cell function 2Preserve integrity of the epidermis 3Strengthen dermal/epidermal junction 4Preserve dermal papillae 5Break down scar tissue 6Release epidermal growth factors 7Increase natural collagen: transforming growth factor ß3 (TGF-ß3) 8Induce regenerative healing 1.5

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

37 1.10 Collagen Induction Therapy *Fernandes, D. OralL Maxillofacial Surg Clin 2005; 17:51-63 Microinjuries allow for release of serum containing cytokines and growth factor*

38 Key Goals of Skin Rejuvenation 1Optimize cell function 2Preserve integrity of the epidermis 3Strengthen dermal/epidermal junction 4Preserve dermal papillae 5Break down scar tissue 6Release epidermal growth factors 7Increase natural collagen: transforming growth factor ß3 (TGF-ß3) 8Induce regenerative healing 1.5

39 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

40 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 1.10

41 Ablative vs. Non-Ablative Treatments 1.1 1

42 Comparison with Other Treatments 1.20

43 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 1.8  Atrophic acne scars  Stretch marks  Traumatic scars  Photo aging

44

45 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.

46 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

47 1.17 Recovery of skin barrier function following microneedling treatment as measured by transepidermal water loss (TEWL) Microchannel Characteristics Figure from: The AAPS Journal, Vol. 13, No. 3, September 2011

48 1.18 I N T A C T S K I N 6 H O U R S 1 2 H O U R S 0 H O U R S 8 H O U R S 1 8 H O U R S 4 H O U R S 1 0 H O U R S 2 4 H O U R S 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. Figure from: The AAPS Journal, Vol. 13, No. 3, September 2011 Microchannel Characteristics

49 Microchannel Formation 1.15 *Figure from: The AAPS Journal, Vol. 13, No. 3, September 2011 For dermal rollers, the number of microchannels increases as a function of the number of passes made 1 pass3 passes5 passes10 passes15 passes

50 Microchannel Formation *Needles are ~1 mm apart (1000 microns) and the cartridge head has a diameter of 3.5 mm 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! 1.16

51 Plast Surg Int. ID Epub 2011 Apr 7 MICRONEEDLING + DEPIGMENTING SERUM DEPIGMENTING SERUM ALONE BEFOREAFTER 2 MONTHS Microneedling has been shown to enhance pen- etration of a depigmenting serum in a 20-subject study for treatment of melasma. 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:  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 Enhancement of Topical Penetration 3.36

52 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]. 3.4

53 Recommended Needle Depth Plast Reconstr Surg May;115(6): Average Skin Thickness Measurements Site AVG ABC Upper lip Lower lip Philtrum Chin Upper eyelid Lower eyelid Forehead Right cheek 0.83 ± ± ± ± ± ± ± ± 0.09 Site AVG ABC Left cheek Malar eminence Submental Nasal tip Nasal dorsum Right neck Left neck 1.17 ± ± ± ± ± ± ±

54 QUESTIONS?

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

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

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

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

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

60 Before Photos courtesy of Spectacular Skin After After one treatment.

61 Before After After one treatment. Photos courtesy of Spectacular Skin

62 BeforeAfter After one treatment. Photos courtesy of Spectacular Skin

63 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

64

65 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

66 QUESTIONS?

67 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. 1.21

68 Comparison with IPL Collagen Induction Therapy in 54 mice (IPL vs. microneedling)  18 control mice  18 microneedling mice  18 IPL mice 1.22 Moon, HS et. al; Department of Dermatology, Eulji University School of Medicine

69 Comparison with IPL Skin Thickness 1.23 Moon, HS et. al; Department of Dermatology, Eulji University School of Medicine

70 Comparison with IPL Histology (MT stain x100) Control IPLMicroneedling Moon, HS et. al; Department of Dermatology, Eulji University School of Medicine 1.24

71 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 Collagen ß-actin 3-C3-I3-M 4-C4-I4-M needling group of mice (3-M and 4-M) as opposed to the control (C) or IPL (I) Moon, HS et. al; Department of Dermatology, Eulji University School of Medicine

72 Comparison with IPL Conclusion: 1.Skin thickness: Control < IPL < Microneedling 2.MT Stain (collagen fiber): Control < IPL < Microneedling 3.Collagen quantative anaysis (ELISA,WB): Control < IPL < Microneedling 1.27

73 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.

74 Plast Surg Int. ID Epub 2011 Apr 7 MICRONEEDLING + DEPIGMENTING SERUM DEPIGMENTING SERUM ALONE BEFOREAFTER 2 MONTHS Microneedling has been shown to enhance pen- etration of a depigmenting serum in a 20-subject study for treatment of melasma. 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:  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 Enhancement of Topical Penetration 3.36

75 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

76 Treating Hyperpigmentation 5 intervention points: 1.Block UV radiation 2.Block Melanin Stimulating Hormone (MSH) before it stimulates the kertinocytes and melanocytes 3.Inhibit tyrosinase, the enzyme needed to form melanin in the melanosome 4.Interfere with L-Dopa, the building blocks for pigment in the melanosomes 5.Interfere with transfer of pigment from the melanosome to the keratinocyte 1.8

77 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

78 How Does Micro-Needling Improve Various Skin Conditions?

79 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

80 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)

81 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

82 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

83 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].

84 Stretch Marks Difficult to treat 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

85 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 2012 Nov:38(11):

86 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 2012 Nov:38(11):

87 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

88 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.

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

90 Synergistic Treatment Modalities Ranked according to effectiveness, invasiveness, and safety 1.Light Emitting Diode (LED) 2.IPL 3.Nd:YAG 4.Fraxel 5.Chemical Peels 6.Microdermabrasion 7.Laser 8.Radio Frequency (RF)

91 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

92 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

93 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.

94 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

95 Chemical Peels AHAs 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

96 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.

97 Questions?

98 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 3.2

99 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 Skin Analysis and Patient Presentation continued 3.3

100 Basic Protocols 3.6

101 Atrophic Scarring Indication: Improved appearance of atrophic scarring Treatment Frequency: 3–6 treatments at monthly intervals 1Prepare the affected area by applying preferred anesthetic and sterilization protocols. 2Apply HA Peptide Gel provided in kit to treatment area. 3Set the SkinPen depth to mm depending on skin thickness. 4Begin 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 3.35

102 Atrophic Scarring continued 5This 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 shouldbe 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. 6Wipe off any pinpoint bleeding and rinse the skin with sterile saline solution. 7(Optional) Place serum containing vitamin E and Vitamin C over treated area. 8Wrap an ice pack with sterile gauze and place against the treated area for 5 minutes. 3.35

103 Improvement in Atrophic Scars  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 BEFOREAFTER 3–4 TRE A TMENTS ACN E SCA R PO X SCA R 3.34

104 3.37 Hyperpigmentation Indication: Improved appearance of hyperpigmentation Treatment Frequency: 2-4 treatments at bi-monthly intervals 1Prepare the affected area by applying preferred anesthetic and sterilization protocols. 2Apply HA Peptide Gel provided in kit to treatment area. 3Set the SkinPen depth to mm depending on skin thickness. 4Begin 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

105 3.39 Hyperpigmentation continued 5This should be followed by two linear passes, one vertical and one horizontal, both of which cover the entire affected area. 6Wipe off any pinpoint bleeding and rinse the skin with sterile saline solution. 7Place depigmenting serum over treated area. 8Wrap an ice pack with sterile gauze and place against the treated area for 5 minutes.

106 3.38 Hyperpigmentation continued 5This should be followed by two linear passes, one vertical and one horizontal, both of which cover the entire affected area. 6Wipe off any pinpoint bleeding and rinse the skin with sterile saline solution. 7Place depigmenting serum over treated area. 8Wrap an ice pack with sterile gauze and place against the treated area for 5 minutes.

107 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

108 SkinPen + Hydrafacial red carpet ready hydration no downtime collagen remodeling 1.Cleanse with Active 4 Cleanser 2.Degrease with alcohol or acetone 3.Apply topical numbing for minutes occluding with plastic wrap 4.Remove plastic wrap and topical with alcohol or acetone 5.Apply hyaluronic acid to treatment area, start SkinPen treatment following face graph for appropriate depth on each area. 6.Wash area with Active 4 Cleanser 7.Start Hydrafacial treatment using all steps including red LED at the end of the treatment 8.After red LED, use 2-4 pumps of the Antiox serum followed by the Pure Moist and a tinted SPF.

109 SkinPen + Perfect Peel 1.Cleanse with Active 4 Cleanser 2.Degrease with alcohol or acetone 3.Apply topical numbing for minutes occluding with plastic wrap 4.Remove plastic wrap and topical with alcohol or acetone 5.Apply hyaluronic acid to treatment area, start SkinPen treatment following face graph 6.Wash area with Active 4 Cleanser 7.Degrease with alcohol or acetone 8.Apply vaseline or aquaphor to the corner of the eyes, nouth and nose prior to applying peel 9.Pour Perfect Peel in measuring cup and use the 4x4 gauze pads that come with the peel and saturate in the peel solution

110 SkinPen + Perfect Peel cont’d 10.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. 11.Patient will feel a mild to moderate burning sensation, provide a hand held fan for patient comfort. 12.No products can be applied to the skin the first day, not even sunblock. 13.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. 14.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.

111 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

112 SkinPen + Radio Frequency Body Treatment 1.Cleanse area 2.Perform SkinPen Treatment using 1.5 to 2.5 depth on body 3.Wipe area with wet 4x4 gauze pads 4.Use baby oil or grape seed oil and treat area following the recommended parameters for the area you are treating 5.When finished, wipe off gel and massage the area with body cream for 1-2 minutes 6.Encourage patients to stay hydrated drinking a gallon of water the day of treatment and throughout the duration of the treatments 7.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 8.Treatments can be done in a series with re-treatment every 7-10 days. Maintenance minimum 3 times per year.

113 THANK YOU!!


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