Transcript Advanced Protocol Workshop

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
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)
1.10
Collagen Induction Therapy
Microinjuries allow for release of serum
containing cytokines and growth factor*
*Fernandes, D. OralL Maxillofacial Surg Clin 2005; 17:51-63
1.19
Phases of Wound Repair
1.16
Most Effective Uses
of Dermal Needling
 Wrinkles
 Epidermal density and strength
 Thin skin
 Lax skin
 Hyperpigmentation
 UV damage
 Rosacea
 Stretch marks
 Loss of Resiliency
 Hair restoration
 Premature aging
 Scars
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
1.4
The Three Layers of the Skin
1.5
Key Goals of Skin Rejuvenation
1 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)
2 Preserve integrity of the epidermis- provides natural barrier against pathogens,
UV radiation, and free radicals
3 Strengthen dermal/epidermal junction-prevents flattening of dermal/epidermal
junction ,which presents as wrinkles
4 Preserve dermal papillae-facilitates exchange of oxygen nutrients, and waste
products between epidermis and dermis. Provides strength between dermal/epidermal
junction to prevent wrinkles
5 Break down scar tissue- allows epidermis to lay flat
6 Release epidermal growth factors
7 Increase natural collagen: transforming growth factor ß3 (TGF-ß3)
8 Induce regenerative healing
1.6
Optimize Cell Function
1 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.”
2 Melanocyte- Ensures even skin color
3 Fibroblast- to stimulate collagen, elastin and
glycosaminoglycans(GAGS) for firm, tight hydrated skin
1.7
Optimizing the Keratinocytes
Basic epidermal topical requirements:
Omega 3
Omega 6
Ceramide
Squalenes
Sphingolipid
Phospholipid
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
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
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
Product Ingredients Affecting Melanogenesis*
Active Ingredient
MSH
Tyrosinase
Magnesium ascorbyl phosphate

Ascorbyl tetra isopalmitate

Pigment
Granule

Niacinamide
Arbutin

Azelaic acid

Paper mulberry


Aloesin
Glabridin

Glucosamine

Ascorbic acid

*Florence Barrett-Hill. Secretions. Cosmetic Chemistry.
Melanosome
Transfer
Compounds Affecting Melanogenesis*
Compounds
MSH
Tyrosinase
Melanosome
Transfer



Lumixyl
Melanostat

Sulforawhite

Whitesphere

Lightocean

*Florence Barrett-Hill. Secretions. Cosmetic Chemistry.
Pigment
Granule
Ingredients TO AVOID* with microneedling
Substance
MSH
Tyrosinase
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.
Pigment
Granule
Melanosome
Transfer

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
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
Aids in
GAG
Synthesis
Prevents
Oxidative
Stress
Growth Factors



Magnesium ascorbyl phosphate



Ascorbyl tetra isopalmitate




Retinyl palmitate



Retinol


Copper peptides


Beta-carotene
Prevents
Lipid
Peroxidation



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
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
Questions?
1.5
Key Goals of Skin Rejuvenation
1 Optimize cell function
2 Preserve integrity of the epidermis
3 Strengthen dermal/epidermal junction
4 Preserve dermal papillae
5 Break down scar tissue
6 Release epidermal growth factors
7 Increase natural collagen: transforming growth
factor ß3 (TGF-ß3)
8 Induce regenerative healing
Preserve the Epidermis
• Epidermis is complex, highly specialized organ
• 0.2mm thick
• Only protection from the environment
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
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
1 . 11
Collagen Induction Therapy
What does old vs. young skin look like?*
Biopsy of young skin showing thick
bundles of collagen bundles.
*Abd El-Aal NH, et al. J Dermatol 2012;57:181-6
Biopsy of aged skin showing thin
and loose collagen fibers (MassonTrichrome ×100).
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
1.13
Increased Dermal Thickness
Before
After
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
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
*Fernandes, D. OralL Maxillofacial Surg Clin 2005;17:51-63.
1.5
Key Goals of Skin Rejuvenation
1 Optimize cell function
2 Preserve integrity of the epidermis
3 Strengthen dermal/epidermal junction
4 Preserve dermal papillae
5 Break down scar tissue
6 Release epidermal growth factors
7 Increase natural collagen: transforming growth
factor ß3 (TGF-ß3)
8 Induce regenerative healing
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
1 Optimize cell function
2 Preserve integrity of the epidermis
3 Strengthen dermal/epidermal junction
4 Preserve dermal papillae
5 Break down scar tissue
6 Release epidermal growth factors
7 Increase natural collagen: transforming
growth factor ß3 (TGF-ß3)
8 Induce regenerative healing
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*
*Fernandes, D. OralL Maxillofacial Surg Clin 2005; 17:51-63
1.5
Key Goals of Skin Rejuvenation
1 Optimize cell function
2 Preserve integrity of the epidermis
3 Strengthen dermal/epidermal junction
4 Preserve dermal papillae
5 Break down scar tissue
6 Release epidermal growth factors
7 Increase natural collagen: transforming growth
factor ß3 (TGF-ß3)
8 Induce regenerative healing
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
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
1 . 11
Ablative vs. Non-Ablative Treatments
1.20
Comparison with Other Treatments
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
1.17
Microchannel Characteristics
Recovery of skin barrier function following microneedling
treatment as measured by transepidermal water loss (TEWL)
Figure from: The AAPS Journal, Vol. 13, No. 3,
September 2011
1.18
Microchannel Characteristics
INTACT SKIN
0 HOURS
4 HOURS
6 HOURS
8 HOURS
10 HOURS
12 HOURS
18 HOURS
24 HOURS
Figure from: The AAPS Journal, Vol. 13, No. 3, September 2011
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.
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
*Figure from: The AAPS Journal, Vol. 13, No. 3, September 2011
10 passes
15 passes
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!
*Needles are ~1 mm apart (1000 microns) and the cartridge head has a diameter of 3.5 mm
3.36
Enhancement of Topical Penetration
MICRONEEDLING + DEPIGMENTING SERUM
DEPIGMENTING SERUM ALONE
BEFORE
AFTER 2 MONTHS
Plast Surg Int. ID 15824. Epub 2011 Apr 7
Microneedling has been
shown to enhance penetration 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
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. 2012 Dec 8. [Epub ahead of print].
3.5
Recommended Needle Depth
Average Skin Thickness Measurements
Site
AVG ABC
Upper lip
Lower lip
Philtrum
Chin
Upper eyelid
Lower eyelid
Forehead
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
Right cheek
1.07 ± 0.09
Plast Reconstr Surg. 2005 May;115(6):1769-73
Site
Left cheek
Malar eminence
Submental
Nasal tip
Nasal dorsum
Right neck
Left neck
AVG ABC
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
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
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
Before
After
After one treatment.
Photos courtesy of Spectacular Skin
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?
3.6
Basic Protocols
3.35
Atrophic Scarring
Indication: Improved appearance of atrophic scarring
Treatment Frequency: 3–6 treatments at monthly intervals
1 Prepare the affected area by applying preferred anesthetic
and sterilization protocols.
2 Apply HA Peptide Gel provided in kit to treatment area.
3 Set the SkinPen depth to 1.5-2 mm depending on
skin thickness.
4 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
3.35
Atrophic Scarring continued
5 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.
6 Wipe 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.
8 Wrap an ice pack with sterile gauze and place against the
treated area for 5 minutes.
3.34
Improvement in Atrophic Scars
A F T E R 3 – 4 T R E AT M E N T S
ACNE S CAR
P O X S CAR
BEFORE
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. 2009 Jan; 2(1):26–30
3.37
Hyperpigmentation
Indication: Improved appearance of hyperpigmentation
Treatment Frequency: 2-4 treatments at bi-monthly intervals
1 Prepare the affected area by applying preferred anesthetic
and sterilization protocols.
2 Apply HA Peptide Gel provided in kit to treatment area.
3 Set the SkinPen depth to 0.75-1.5 mm depending on skin
thickness.
4 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
3.39
Hyperpigmentation continued
5 This should be followed by two linear passes, one vertical and
one horizontal, both of which cover the entire affected area.
6 Wipe off any pinpoint bleeding and rinse the skin with sterile
saline solution.
7 Place depigmenting serum over treated area.
8 Wrap an ice pack with sterile gauze and place against the
treated area for 5 minutes.
3.38
Hyperpigmentation continued
5 This should be followed by two linear passes, one vertical and
one horizontal, both of which cover the entire affected area.
6 Wipe off any pinpoint bleeding and rinse the skin with sterile
saline solution.
7 Place depigmenting serum over treated area.
8 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
1.
2.
3.
4.
5.
Cleanse with Active 4 Cleanser
Degrease with alcohol or acetone
Apply topical numbing for 30-45 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.
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.
SkinPen + Perfect Peel
1.
2.
3.
4.
5.
6.
7.
8.
9.
Cleanse with Active 4 Cleanser
Degrease with alcohol or acetone
Apply topical numbing for 30-45 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
Degrease with alcohol or acetone
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
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.
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
1.
2.
3.
4.
5.
6.
7.
8.
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!!