Percutaneous
Collagen Induction
With Microneedling
A Step-by-Step Clinical Guide
Emerson Lima
Mariana Lima
123
Percutaneous Collagen Induction With
Microneedling
Emerson Lima • Mariana Lima
Percutaneous Collagen
Induction With
Microneedling
A Step-by-Step Clinical Guide
Emerson Lima
Dermatological Surgery
Santa Casa de Misericórdia do Recife
Recife
Brazil
Mariana Lima
Dermatological Surgery
Santa Casa de Misericórdia do Recife
Recife
Brazil
ISBN 978-3-030-57540-3 ISBN 978-3-030-57541-0
https://doi.org/10.1007/978-3-030-57541-0
(eBook)
© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature
Switzerland AG 2021
This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether
the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of
illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and
transmission or information storage and retrieval, electronic adaptation, computer software, or by similar
or dissimilar methodology now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication
does not imply, even in the absence of a specific statement, that such names are exempt from the relevant
protective laws and regulations and therefore free for general use.
The publisher, the authors and the editors are safe to assume that the advice and information in this book
are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the
editors give a warranty, expressed or implied, with respect to the material contained herein or for any
errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional
claims in published maps and institutional affiliations.
This Springer imprint is published by the registered company Springer Nature Switzerland AG
The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland
To our most inspiring loves, Miguel
and Betina
Presentation
Dear colleagues
This work seeks to offer a roadmap for study and research in innovative techniques, with the aim of diversifying our already extensive arsenal in cosmetic
treatments.
Percutaneous Collagen Induction (PCI) with needles has contributed to the
expansion of resources used in hard-to-drive injuries.
The intention is to share experiences and discoveries in procedures that use needles and micro needles, deepened in the last 10 years in Brazil, based on our experience of more than 20 years in the treatment of scars, wrinkles, stretch marks,
flaccidity, alopecia, scleroderma, cellulite, and vitiligo.
The primary purpose is to benefit patients, whose quality of life is affected by
unaesthetic injuries, rescuing in essence the talent and creativity of the
dermatologist.
Emerson Lima and Mariana Lima
vii
Acknowledgments
To our patients, whose pains awaken in us a thirst for knowledge, by giving us the
opportunity to contribute, even if modestly, to the relief of their anguishes and the
sanity of their emotions.
Emerson Lima and Mariana Lima
ix
Contents
1Fundamentals of Percutaneous Collagen Induction (PCI) with
Needles������������������������������������������������������������������������������������������������������ 1
1.1Percutaneous Needle Collagen Induction (PCI)
Versus Ablative Procedures�������������������������������������������������������������� 1
1.2Principles of the PCI Technique�������������������������������������������������������� 2
1.3Characteristics of the PCI Technique������������������������������������������������ 5
1.4PCI Advantages�������������������������������������������������������������������������������� 7
1.5Disadvantages of PCI������������������������������������������������������������������������ 8
Sources������������������������������������������������������������������������������������������������������ 8
2Classification and Characteristics of the Injury Provoked by PCI ���� 9
2.1Level of the Injury and Its Relationship to the
Length of the Needle������������������������������������������������������������������������ 9
2.2Classification of Injury Level������������������������������������������������������������ 14
2.3Final Considerations ������������������������������������������������������������������������ 15
Sources������������������������������������������������������������������������������������������������������ 17
3Devices for PCI���������������������������������������������������������������������������������������� 19
3.1Available Devices������������������������������������������������������������������������������ 20
3.1.1Microneedle Rollers�������������������������������������������������������������� 20
3.1.2Microneedle Pens������������������������������������������������������������������ 23
3.1.3Microneedles Associated with Technologies������������������������ 24
3.2Final Considerations ������������������������������������������������������������������������ 25
Sources������������������������������������������������������������������������������������������������������ 25
4Pain Management in PCI: Analgesia and Anesthesia�������������������������� 27
César Romão
4.1Local Anesthetics������������������������������������������������������������������������������ 27
4.1.1Infiltrative Anesthesia ���������������������������������������������������������� 31
4.2Tumescent Anesthesia���������������������������������������������������������������������� 32
4.2.1Topical Anesthesia���������������������������������������������������������������� 35
4.2.2TAC �������������������������������������������������������������������������������������� 37
xi
xii
Contents
4.2.3LET �������������������������������������������������������������������������������������� 38
4.2.4Dermomax® ������������������������������������������������������������������������ 38
4.2.5Betacaine® LA �������������������������������������������������������������������� 38
4.2.6Tetracaine 4%������������������������������������������������������������������������ 38
4.2.7S-Caine Patch®�������������������������������������������������������������������� 39
4.2.8Pliaglis® ������������������������������������������������������������������������������ 39
4.2.9Toperma® ���������������������������������������������������������������������������� 39
4.2.10Peripheral Nerve Blocks ������������������������������������������������������ 40
4.2.11Blocking the Supraorbital and Supratrochlear Nerves���������� 41
4.2.12Infraorbital Nerve Block ������������������������������������������������������ 41
4.2.13Nasociliary Nerve Block������������������������������������������������������ 42
4.2.14Lacrimal Nerve Block���������������������������������������������������������� 42
4.2.15Zygomatic Nerve Block�������������������������������������������������������� 43
4.2.16Mental Nerve Block�������������������������������������������������������������� 43
4.3Local Anesthetic Intoxication ���������������������������������������������������������� 44
4.3.1Special Features of Anesthesia for PCI�������������������������������� 46
Sources������������������������������������������������������������������������������������������������������ 46
5Preparing the Skin for PCI and Postoperative Management�������������� 49
5.1Skin Care That Favors Treatment ���������������������������������������������������� 51
5.2Detailing the Guidelines for Moderate Injury���������������������������������� 52
5.3Detail of the Guidelines for Deep Lesion ���������������������������������������� 54
5.4Biocellulose in Post-procedure �������������������������������������������������������� 56
5.5Closing Considerations �������������������������������������������������������������������� 57
Sources������������������������������������������������������������������������������������������������������ 57
6Histopathological Evidences of the Percutaneous
Collagen Induction with Microneedling������������������������������������������������ 59
Helio Miot
6.1Introduction�������������������������������������������������������������������������������������� 59
6.2Photoaging and Melasma������������������������������������������������������������������ 61
6.3Acne and Stretch Mark Scars������������������������������������������������������������ 64
Sources������������������������������������������������������������������������������������������������������ 65
7Managing Complications in PCI������������������������������������������������������������ 69
7.1PCI Versus Ablative Interventions���������������������������������������������������� 69
7.2Expected Reactions and Adverse Effects������������������������������������������ 70
7.2.1Edema ���������������������������������������������������������������������������������� 70
7.2.2Erythema ������������������������������������������������������������������������������ 73
7.2.3Hematoma, Petechiae, and Purple���������������������������������������� 73
7.2.4Crusts������������������������������������������������������������������������������������ 73
7.2.5Post-inflammatory Hyperpigmentation�������������������������������� 74
7.2.6Desquamation ���������������������������������������������������������������������� 74
7.2.7Burning and Awareness�������������������������������������������������������� 74
7.2.8Infections������������������������������������������������������������������������������ 75
7.2.9Pain �������������������������������������������������������������������������������������� 75
7.2.10Depressed or Elevated Scars ������������������������������������������������ 75
Sources������������������������������������������������������������������������������������������������������ 76
Contents
xiii
8PCI in Aging Skin������������������������������������������������������������������������������������ 77
8.1PCI Fundamentals in Skin Aging������������������������������������������������������ 77
8.2Applicability of PCI to Skin Aging�������������������������������������������������� 80
8.3Thickness of Skin������������������������������������������������������������������������������ 80
8.4Wrinkle Depth���������������������������������������������������������������������������������� 81
8.5Flaccidity������������������������������������������������������������������������������������������ 81
8.6Step-by-Step�������������������������������������������������������������������������������������� 82
8.6.1Deep Injury �������������������������������������������������������������������������� 83
8.7Methodological Sequence for Deep Injury �������������������������������������� 83
8.7.1Moderate Injury�������������������������������������������������������������������� 85
8.8Final Considerations ������������������������������������������������������������������������ 86
Sources������������������������������������������������������������������������������������������������������ 86
9PCI in the Treatment of Melasma���������������������������������������������������������� 87
9.1Lima Protocol������������������������������������������������������������������������������������ 88
9.2Mechanism of Action������������������������������������������������������������������������ 90
9.2.1Proposed Methodological Sequence ������������������������������������ 92
9.3Final Considerations ������������������������������������������������������������������������ 97
Sources������������������������������������������������������������������������������������������������������ 97
10PCI Correcting Post-inflammatory Hyperpigmentation �������������������� 99
10.1Rational PCI in Post-inflammatory
Hyperpigmentation (PIH) �������������������������������������������������������������� 99
10.2Step by Step: Lima Protocol ���������������������������������������������������������� 101
10.3Evaluation and Conduct������������������������������������������������������������������ 105
10.4Final Considerations ���������������������������������������������������������������������� 107
Sources������������������������������������������������������������������������������������������������������ 107
11Correcting Acne Scars Using PCI����������������������������������������������������������
11.1PCI Fundamentals in Acne Scars����������������������������������������������������
11.2Applicability of PCI on Acne Scars������������������������������������������������
11.2.1Skin Thickness��������������������������������������������������������������������
11.2.2Scar Characteristics������������������������������������������������������������
11.2.3Flaccidity and Needle Length ��������������������������������������������
11.2.4Deep Injury ������������������������������������������������������������������������
11.3Step by Step������������������������������������������������������������������������������������
11.4Final Considerations ����������������������������������������������������������������������
Sources������������������������������������������������������������������������������������������������������
109
109
114
114
115
115
115
117
118
122
12Correcting After Accident Scars Using PCI������������������������������������������
12.1Applicability of Needle Techniques������������������������������������������������
12.1.1Patient Assessment��������������������������������������������������������������
12.1.2Step by Step������������������������������������������������������������������������
12.1.3Complementary Techniques������������������������������������������������
12.1.4Complications ��������������������������������������������������������������������
12.2Final Considerations ����������������������������������������������������������������������
Sources������������������������������������������������������������������������������������������������������
123
126
126
127
130
130
130
130
xiv
Contents
13Correcting Post-surgical Scar Using PCI����������������������������������������������
13.1PCI Fundamentals in Post-surgical Scars ��������������������������������������
13.2Indications of PCI in Post-surgical Scars����������������������������������������
13.2.1Conduct ������������������������������������������������������������������������������
13.3Final Considerations ����������������������������������������������������������������������
Sources������������������������������������������������������������������������������������������������������
133
133
134
135
136
138
14Correcting Post-burn Scar Using PCI����������������������������������������������������
14.1Rational Use of PCI in Post-burn Scars������������������������������������������
14.2Applicability of PCI to Post-burn Scars������������������������������������������
14.3Care in the Technical Execution ����������������������������������������������������
14.4Adverse Effects ������������������������������������������������������������������������������
14.5Closing Considerations ������������������������������������������������������������������
Sources������������������������������������������������������������������������������������������������������
141
142
145
147
150
150
150
15Correcting High and Hypertrophic Scars with PCI ����������������������������
15.1PCI Fundamentals in High Scars����������������������������������������������������
15.2Applicability of PCI in High Scars ������������������������������������������������
15.2.1Methodological Sequence for the Approach����������������������
15.3Final Considerations ����������������������������������������������������������������������
Sources������������������������������������������������������������������������������������������������������
153
153
156
156
160
160
16Correcting Stretch Marks Using PCI����������������������������������������������������
16.1Fundamentals in Stretch Marks������������������������������������������������������
16.2Applicability of PCI on Stretch Marks ������������������������������������������
16.2.1Stretch Marks Characteristic����������������������������������������������
16.2.2Needle Length��������������������������������������������������������������������
16.2.3Depth Injury������������������������������������������������������������������������
16.2.4Step by Step������������������������������������������������������������������������
16.3Final Considerations ����������������������������������������������������������������������
Sources������������������������������������������������������������������������������������������������������
163
163
165
165
166
167
167
169
171
17Correcting Laxity and Cellulitis Using PCI������������������������������������������
17.1PCI in Gynoid Lipodystrophy (Cellulite) ��������������������������������������
17.2PCI Fundamentals in Cellulite Treatment��������������������������������������
17.3Applicability of PCI in Cellulite ����������������������������������������������������
17.3.1Skin Thickness��������������������������������������������������������������������
17.3.2Cellulite Ratios ������������������������������������������������������������������
17.3.3Flaccidity and Needle Length ��������������������������������������������
17.3.4Deep Injury ������������������������������������������������������������������������
17.3.5Step-by-Step������������������������������������������������������������������������
17.3.6Dressing Recommended by the Author After PCI��������������
17.4Final Considerations ����������������������������������������������������������������������
Sources������������������������������������������������������������������������������������������������������
173
173
176
178
178
178
178
179
179
180
183
183
18PCI and Transcutaneous Drug Delivery������������������������������������������������ 185
18.1Introduction������������������������������������������������������������������������������������ 185
18.2Fundamentals of the Association of PCI to Drug Delivery������������ 186
Contents
xv
18.3Indications and Contraindications��������������������������������������������������
18.4Pre- and Post-treatment Considerations������������������������������������������
18.5Final Considerations ����������������������������������������������������������������������
Sources������������������������������������������������������������������������������������������������������
188
190
192
193
19PCI Associated with Fillers and Botulinum Toxin��������������������������������
19.1Rational Addition of Techniques����������������������������������������������������
19.2Association Protocols����������������������������������������������������������������������
Sources������������������������������������������������������������������������������������������������������
197
197
197
205
20PCI in the Treatment of Alopecias����������������������������������������������������������
20.1PCI in the Treatment of Androgenetic Alopecia ����������������������������
20.2IPCA with Drug Delivery in the Treatment of Alopecia����������������
20.3Contraindications and Adverse Effects ������������������������������������������
20.4Therapeutic Proposal����������������������������������������������������������������������
20.5Conclusion��������������������������������������������������������������������������������������
Sources������������������������������������������������������������������������������������������������������
207
208
210
212
214
214
215
21PCI in the Treatment of Scleroderma����������������������������������������������������
21.1Rational Use of PCI������������������������������������������������������������������������
21.2Treatment Protocol��������������������������������������������������������������������������
21.3Technical Aspects����������������������������������������������������������������������������
21.4Step-by-Step������������������������������������������������������������������������������������
21.4.1Asepsis and Anesthesia of the Area������������������������������������
21.4.2Evolution and Postoperative Care��������������������������������������
21.4.3Pain and Discomfort ����������������������������������������������������������
21.5Dermal Tunneling Indication����������������������������������������������������������
Sources������������������������������������������������������������������������������������������������������
219
220
223
225
226
226
226
227
228
233
22PCI in the Hypochromias and Achromias ��������������������������������������������
22.1Rational Use of PCI in Depigmented Lesions��������������������������������
22.2Step-by-Step������������������������������������������������������������������������������������
22.2.1Patient Selection������������������������������������������������������������������
22.2.2Instrumental������������������������������������������������������������������������
22.2.3Anesthesia ��������������������������������������������������������������������������
22.2.4Transurgery ������������������������������������������������������������������������
22.2.5After Surgery����������������������������������������������������������������������
22.2.6Evolution����������������������������������������������������������������������������
22.3Final Considerations ����������������������������������������������������������������������
Sources������������������������������������������������������������������������������������������������������
235
235
240
240
241
241
242
243
243
244
244
23PCI Associated with Intense Pulsed Light ��������������������������������������������
23.1Why Associate Intense Pulsed Light with PCI? ����������������������������
23.2Step-by-Step������������������������������������������������������������������������������������
23.3Final Considerations ����������������������������������������������������������������������
Sources������������������������������������������������������������������������������������������������������
247
247
248
252
252
xvi
Contents
24PCI Associated with Peelings������������������������������������������������������������������
24.1PCI Fundamentals Associated with Peelings����������������������������������
24.2Prepare for the Procedure����������������������������������������������������������������
24.3Safety Profile and Origin of the Substances Used��������������������������
24.3.1Step-by-Step������������������������������������������������������������������������
24.4Final Considerations ����������������������������������������������������������������������
Sources������������������������������������������������������������������������������������������������������
255
255
257
265
265
267
267
25Fundamentals of the Dermal Tunneling (DT):
A Subcision™ Variant ����������������������������������������������������������������������������
25.1Introduction������������������������������������������������������������������������������������
25.2Principles and Technique of DT������������������������������������������������������
25.2.1Step-by-Step������������������������������������������������������������������������
25.2.2Advantages of DT ��������������������������������������������������������������
25.2.3Disadvantages of DT����������������������������������������������������������
25.3Closing Considerations ������������������������������������������������������������������
Sources������������������������������������������������������������������������������������������������������
269
269
270
270
275
276
276
276
26Dermal Tunneling in the Treatment of Depressed Scars����������������������
26.1Dermal Tunneling (DT) in Scars����������������������������������������������������
26.1.1Fundamentals of Dermal Tunneling in the Correction of
Scars������������������������������������������������������������������������������������
26.2DT Foundations and Technique in Acne Scars ������������������������������
26.2.1Step-by-Step������������������������������������������������������������������������
26.2.2Evolution and Postoperative Care��������������������������������������
Sources������������������������������������������������������������������������������������������������������
27Dermal Tunneling in the Treatment of Static
Wrinkles and Grooves ����������������������������������������������������������������������������
27.1Fundamentals of Dermal Tunneling (DT) for the
Treatment of Static Wrinkles����������������������������������������������������������
27.1.1Step-by-Step������������������������������������������������������������������������
27.2Evolution����������������������������������������������������������������������������������������
27.3Final Considerations ����������������������������������������������������������������������
Sources������������������������������������������������������������������������������������������������������
28PCI Associated with Multi-needle Radiofrequency for the
Treatment of Periorbital and Perioral Wrinkles and Laxity ��������������
28.1Fundamental Concepts of Pulsed High-Frequency
Electrosurgery ��������������������������������������������������������������������������������
28.2Principles of Multi-needle Radiofrequency (MNR) ����������������������
28.3MNP in the Periorbital Region ������������������������������������������������������
28.3.1Step-by-Step������������������������������������������������������������������������
28.4MNR in Perioral Region ����������������������������������������������������������������
28.4.1Step-by-Step������������������������������������������������������������������������
28.5Final Considerations ����������������������������������������������������������������������
Sources������������������������������������������������������������������������������������������������������
279
279
279
281
281
283
287
289
289
290
294
296
297
299
299
300
303
304
307
309
314
317
Contents
xvii
29PCI Associated to Multineedle Radiofrequency for
Treatment of Scars ����������������������������������������������������������������������������������
29.1Fundamentals of the Use of Multineedle
Radiofrequency (MNR) in Scars����������������������������������������������������
29.2Applicability of MNR in Scars ������������������������������������������������������
29.2.1Step-by-Step������������������������������������������������������������������������
29.3Final Considerations ����������������������������������������������������������������������
Sources������������������������������������������������������������������������������������������������������
319
322
323
327
328
30PCI on Ethnic Skin����������������������������������������������������������������������������������
30.1Introduction������������������������������������������������������������������������������������
30.2PCI��������������������������������������������������������������������������������������������������
30.3Radiofrequency Pulsed with Multi-needles������������������������������������
Sources������������������������������������������������������������������������������������������������������
331
331
332
334
339
319
Index������������������������������������������������������������������������������������������������������������������ 341
About the Authors
Emerson Lima
Post-doctorate in Applied Immunology from the
Federal University of Pernambuco (UFPE).
PhD in Dermatology from the University of São
Paulo (USP).
Preceptor of the Dermatology Service of Santa
Casa de Misericórdia de Recife, Brazil.
Coordinator of Cosmiatria and Dermatological
Surgery of Santa Casa de Misericórdia do
Recife, Brazil.
Dermatologist Collaborator of the Psoriasis and
Psoriatic Arthritis Research Clinic of the Hospital
das Clínicas da UFPE.
Specialist by the Brazilian Society of Dermatology
(SBD) and Brazilian Medical Association (AMB).
Mariana Lima
Coordinator of the Outpatient Clinic for Hair and
Scalp Diseases of Santa Casa de Misericórdia do
Recife, Brazil.
Preceptor of the Dermatology Service of Santa
Casa Misericórdia do Recife, PE. Specialist in
Dermatology by the Brazilian Society of
Dermatology (SBD) and the Brazilian Medical
Association (AMB).
Fellow in hair diseases by the University of
Miami, USA.
xix
Chapter 1
Fundamentals of Percutaneous Collagen
Induction (PCI) with Needles
1.1
ercutaneous Needle Collagen Induction (PCI) Versus
P
Ablative Procedures
The proposal to use ablative treatments to promote collagen stimulation and remodeling is enshrined in dermatology. The removal of the epidermis performed mechanically or chemically favors the release of cytokines, including interleukin-1 (IL-1),
particularly inflammatory, and cellular migration, which culminates in the replacement of damaged tissue by scar tissue.
Medium and deep chemical peelings, as examples of ablative treatments, are
widespread among dermatologists for the undeniable stimulus in collagen production, which results in the attenuation of wrinkles and flaccidity; improvement of
texture, brightness, and coloring of the skin surface; and substantial attenuation of
the photodanum, in addition to the potential for cosmetic scar improvement
(Figs. 1.1 and 1.2). In contrast, recovery from these procedures is long and results
in more light-sensitive tissue, subject to post-inflammatory hyperpigmentation and
photosensitivity, in addition to the risk of complications such as the formation of
hypertrophic scars, persistent erythema, and dyschromias.
In ablation, the epidermis and its basal membrane are removed and replaced by
a scar tissue with rectification of the dermal papillae. An inflammatory response is
triggered by the destruction of the epidermis, which causes the production of parallel oriented thick bundles of collagen, unlike the interlacing network of collagen
found in normal skin. The appearance of the treated skin is more rigid, despite the
good appearance.
Studies have shown that the beta tissue growth factor (TGF-β) plays a significant
role in the first 48 hours of scar formation. So, as TGF-β1 and TGF-β2 promote the
formation of scar collagen, TGF-β3 appears to promote wound regeneration and
healing at the expense of normal collagen, virtually without the characteristics of
scar tissue.
The Editor(s) (if applicable) and The Author(s), under exclusive license
to Springer Nature Switzerland AG 2021
E. Lima, M. Lima, Percutaneous Collagen Induction With Microneedling,
https://doi.org/10.1007/978-3-030-57541-0_1
1
2
1
Fundamentals of Percutaneous Collagen Induction (PCI) with Needles
Fig. 1.1 Patient before and after 3 months of treatment with surgical abrasion associated with
trichloroacetic acid peeling (TCA) 35% offering improvement in wrinkles and flaccidity. (Personal
file of the author)
Fig. 1.2 Patient before and after 3 months of phenol peeling 88% for correction of dyschromias
and dystrophic scars. (Personal file of the author)
Currently, in the search for a shorter post-procedural recovery time and a
decreased risk of complications, there is a tendency to indicate less invasive procedures alone or in association. In view of this, percutaneous collagen induction (PCI)
with microneedling proposes a stimulus in the production of collagen without causing the total deepithelialization observed in ablative techniques. The term “microneedling” will not be used in this work because we do not consider that there is a
standardization of this intervention following the methodology, safety criteria,
approach to the patient, and direction of indications as we established, in the last
10 years, for the PCI. Moreover, the popularization of the term confuses the patient,
who does not have the understanding of the need of knowledge and training for the
delivery of results in an essentially technical-dependent procedure.
1.2
Principles of the PCI Technique
Orentreich and Orentreich [10] were the first to report the use of needles in order to
stimulate the production of collagen in the treatment of depressed scars and wrinkles,
a technique widespread under the name of Subcision™. Their studies were confirmed
1.2 Principles of the PCI Technique
3
by other authors based on the same precept: rupture and removal of the damaged
subepidermal collagen followed by substitution for new collagen and elastin fibers.
The twenty-first century began with the proposal of using a system of micropunctures
embedded in a roll, which, when applied to the skin, produces multiple micropunctures, long enough to reach the dermis and trigger, with bleeding, inflammatory stimulus and activation of a cascade that results in the production of collagen.
The percutaneous collagen induction (PCI) with needling, initially evaluated by
the African plastic surgeon Fernandes [7], whose studies in 480 patients with scars,
wrinkles, and flaccidity offered good results, has been practiced worldwide. In
Brazil, dermatologist Emerson Lima has been studying PCI since 2009, presenting
his protocols and results in congresses, 12 scientific papers and 2 authorial books.
This intervention starts with the loss of the cutaneous barrier integrity, targeting the
dissociation of keratinocytes, which results in the release of cytokines such as IL-1
alpha (predominantly), besides IL-8, IL-6, tumor necrosis factor alpha (TNF-α),
and granulocyte-macrophage colony-stimulating factor (GM-CSF). This results in
dermal vasodilatation and migration of keratinocytes to restore epidermal damage.
Three phases of the healing process, consequent to needle trauma, can be didactically delineated for better understanding:
• First phase – Injury: release of platelets and neutrophils responsible for the availability of growth factors, which act on the keratinocytes and fibroblasts such as
alpha tissue growth factor (TGF-α), TGF-β, platelet-derived growth factor
(PDGF), connective tissue activating protein III, and connective tissue growth
factor (Fig. 1.3).
Petachiae
formation
Needle
puncture
Release of
platelets
and RBC
Release of
growth factors
TGF-a, b,
PDGF, FGF, VEGF
Inflammatory
cell invasion
Chemotaxis - minute to days
Fig. 1.3 First phase of inflammation immediately after microperforation. TGF-α, alpha tissue
growth factor; PDGF, platelet-derived growth factor; FGF, fibroblast growth factor; VEGF, vascular endothelial growth factor
4
1
Fundamentals of Percutaneous Collagen Induction (PCI) with Needles
• Second phase – Healing: neutrophils are replaced by monocytes. Angiogenesis,
epithelialization, and proliferation of fibroblasts occur, followed by production of
type III collagen, elastin, glycosaminoglycans, and proteoglycans. In parallel, the
fibroblast growth factor (FGF), TGF-α, and TGF-β are secreted by monocytes.
Approximately 5 days after the lesion, the fibronectin matrix is formed, which
allows the deposit of collagen just below the basal layer of the epidermis (Fig. 1.4).
• Third stage – Maturation: type III collagen, predominant in the initial phase of
the healing process, is slowly replaced by type I collagen, which is more permanent. The latter is believed to persist for a time varying from 5 to 7 years.
After minutes or days
For all this inflammatory cascade to settle, the needle trauma must reach the skin
at a depth of 1–2 mm, with partial preservation of the epidermis, which was only
punctured and not removed completely. Hundreds of microlesions are created,
resulting in hematic columns in the dermis, accompanied by edema of the treated
area and almost immediate hemostasis. The intensity of these reactions is proportional to the length of the needle used in the procedure. Figure 1.5 shows the evolution of a patient submitted to PCI with a 2.5-mm-long needle, immediately after the
intervention, showing substantial bleeding (A), 10 minutes later (B), and 20 minutes later (C). The gradual closure of the holes leaving by the microneedles leads to
a significant bleeding reduction in less than 20 minutes. In the 20 sequential minutes, there is almost no bleeding, leaving only micropunctures, microscopic hematomas, and an exudation that tends to become serous [8, 9].
However, it is necessary to understand that the needle does not fully penetrate the
skin during the rolling process. It is estimated that a 3 mm needle penetrates only
1.5–2 mm, or approximately 50–70% of its extension. Therefore, when the needle length
is 1 mm, the damage is very superficial, and consequently the inflammatory response is
much more limited compared to that produced by a longer needle length (Fig. 1.6).
Invasion of
fibroblasts,
RBC,
WBC
Synthesis of elastin,
glycosaminoglycans,
proteoglycans,
collagen type III
Migration of
new components
to surface
Collagen, types I and III
Type III - high concentrations:
3 to 7 days
Collagen maturation
Collagen type I replaces
collagen type III
Tissue modulation
(until 2 years)
Fig. 1.4 Second phase after microneedle stimulation
1.3 Characteristics of the PCI Technique
5
Fig. 1.5 Evolution of a patient undergoing PCI immediately after intervention. (Personal file of
the author)
Epidermis
Dermis
Hipodermis
Fig. 1.6 Variation of needle penetration in the rolling process
1.3
Characteristics of the PCI Technique
The 20-year experience of Brazilian dermatologist Emerson Lima in treating scars
and his experience using ablative techniques such as dermabrasion, lasers, and deep
peelings were fundamental for the development of a precise methodology in the
execution of PCI. The instrument used to perform the procedure consists of a polyethylene roller jammed with stainless steel needles and sterile, aligned symmetrically in rows, making a total of 190 units on average, varying according to the
manufacturer. The length of the needles is maintained along the entire roll structure
and varies from 0.25 to 2.5 mm, according to the model (Fig. 1.7). Commonly,
intervention under local anesthesia is well tolerated with needles not exceeding
1.5 mm in length. From this size, infiltrative anesthesia is recommended.
Fundamentals of Percutaneous Collagen Induction (PCI) with Needles
0,25 mm
0,50 mm
1,00 mm
1,50 mm
1
2,00 mm
2,50 mm
6
Epidermis
Dermis
Hipodermis
Fig. 1.7 Schematic drawing showing the versatility of PCI using different needle lengths with
varying degrees of skin penetration
Normal Pressure (5 Newtons)
~ 0,5 kg
High Pressure (> 20 N)
Skin
Surface
Bones
Bones
Fig. 1.8 Needle roller force printed in N (Newtons) demonstrating the need for horizontal
movement
Although it treats most of its patients exclusively under infiltrative anesthesia,
some cases may require sedation or general anesthesia in a hospital setting. PCI is a
technical-dependent procedure; therefore, familiarization with the device used and
mastery of the technique are factors that directly influence the result. The vertical
force vector exerted on the needle roller, for example, should not exceed 6 Newtons
(N), thus avoiding damage to deeper anatomical structures and more pain than
expected (Fig. 1.8). Thus, it is recommended to position the device as if holding a
hashi, between the index and thumb fingers, controlling the force exerted with this
last finger. However, the handle is customized and depends on the comfort of the
1.4 PCI Advantages
7
Fig. 1.9 Schematic drawing showing the need for crossing the micropuncture strips during PCI
performer, being more important to master the technique and be precise in the
movements.
It is also crucial to create micropuncture strips in short and precise shuttle movements. It does not matter how many steps are taken; it is fundamental to observe the
end point to be reached depending on the injury you want to deliver. The crossing of
these strips by new strips vertically and diagonally should only be initiated when the
first one has already fulfilled its purpose (Fig. 1.9). The objective varies from a diffuse erythema with petechial points to a uniform purple.
The time of appearance of the petechial pattern varies with the thickness of the
treated skin, the location (on the bone surface or not), the face or body (cushioning
by the adipose cushion), and the length of the chosen needle. The thinner and looser
skin, commonly photoaged, will present a uniform petechial pattern earlier than the
thick and fibrous skin, observed in patients with acne scars, for example.
The applicability of the technique has increased. The experience of dermatologist Emerson Lima in more than 3000 treated cases, from the scalp to the back of
the foot, in different phototypes and skin types, has enabled the understanding that
this is a safe and versatile technique that can offer extraordinary results in challenging cases.
1.4
PCI Advantages
PCI provides a stimulus to collagen production without removing the epidermis,
and tissue regeneration time is commonly shorter when compared to ablative techniques, which substantially reduces the risk of adverse effects when benchmarked.
In addition, the skin becomes more resistant and thicker, unlike in ablative techniques, where the resulting scar tissue is reactive.
The PCI indication is extended to all skin types and tones and can also be used
in areas of lower concentration of sebaceous glands such as the neck and limbs. It is
also low cost when compared to procedures that require high investment
technologies.
8
1.5
1
Fundamentals of Percutaneous Collagen Induction (PCI) with Needles
Disadvantages of PCI
PCI is a technical-dependent procedure and requires specialized training and in-­
depth knowledge of the skin. It also requires recovery time if a deep injury is indicated. The doctor demands a careful evaluation of the patient and a therapeutic
proposal compatible with the possible results to be achieved, avoiding false expectations. Besides, it is a painful procedure and, therefore, depends on an effective
anesthesia, either topical or infiltrative.
Sources
1. Aust MC. Percutaneous collagen induction therapy: an alternative treatment for scars, wrinkles, and skin laxity. Plast Reconstr Surg. 2008;121(4):1421–9.
2. Bal SM, Caussian J, Pavel S, et al. In vivo assessment of safety of microneedle arrays in human
skin. Eur J Pharm Sci. 2008;35(3):193–202.
3. Brody HJ. Trichloroacetic acid application in chemical peeling, operative techniques. Plast
Reconstr Surg. 1995;2(2):127–8.
4. Camirand A, Doucet J. Needle dermabrasion. Aesthet Plast Surg. 1997;21(1):48–51.
5. Cohen KI, Diegelmann RF, Lindbland WJ. Wound healing: biochemical and clinical aspects.
Philadelphia: WB Saunders Co; 1992.
6. Fabroccini G, Fardella N. Acne scar treatment using skin needling. Clin Exp Dermatol.
2009;34(8):874–9.
7. Fernandes D. Minimally invasive percutaneous collagen induction. Oral Maxillofac Surg Clin
North Am. 2006;17(1):51–63.
8. Fernandes D, Massimo S. Combating photoaging with percutaneous collagen induction. Clin
Dermatol. 2008;26(2):192–9.
9. Lima E, Lima M, Takano D. Microneedling experimental study and classification of the resulting injury. Surg Cosmet Dermatol. 2013;5(2):1104.
10. Orentreich DS, Orentreich N. Subcutaneous incisionless (subcision) surgery for the correction
of depressed scars and wrinkles. Dermatol Surg. 1995;21(6):543–9.
Chapter 2
Classification and Characteristics
of the Injury Provoked by PCI
2.1
evel of the Injury and Its Relationship to the Length
L
of the Needle
Percutaneous collagen induction (PCI) with needling is an absolutely technical-­
dependent intervention. The use of different needle lengths alone provides a versatility that requires direction between the lesion to be treated and the proposed level
of injury (Fig. 2.1). The length of available needle rollers and pens ranges from 0.25
to 2.5 mm, and the penetration of these needles may be limited to the epidermis and
reach the most superficial dermis, reaching the deep dermis. Therefore, it is necessary to establish a relationship between the depth of damage produced by the needles and the response to this trauma to better define the indications. In comparison,
this rationale is observed with the peelings, when choosing the product to provide a
superficial and not deep peel, depending on what you want to treat. It is important
to point out that the needle length is not the only relevant factor in the choice of
treatment; other variables directly affect the procedure, such as:
• Vector of force and its intensity: dependent on the executor and his technical
training. The force interferes both in the choice of the injury and the risk of traumatizing structures. Therefore, this vector should be precise and obey a horizontality on the skin, seeking the uniformity of results regardless of the treated
surface. Figure 2.2a, b shows, in the same region, different degrees of injuries
determined by the executor.
• Skin thickness: the thicker the skin, the greater the resistance offered to needles.
Younger, thicker, and oiler skin offers more difficulty in achieving a purple pattern compared to thin, dry, and aged skin (Fig. 2.3).
• Flaccidity: flaccid skin is more subject to trauma and therefore responds more
easily to needles. Therefore, even needles with shorter lengths can cause substantial injury (Fig. 2.4).
The Editor(s) (if applicable) and The Author(s), under exclusive license
to Springer Nature Switzerland AG 2021
E. Lima, M. Lima, Percutaneous Collagen Induction With Microneedling,
https://doi.org/10.1007/978-3-030-57541-0_2
9
10
2
Classification and Characteristics of the Injury Provoked by PCI
Fig. 2.1 Visualization of different needle lengths by scanning microscopy
Fig. 2.2 Left side moderate injury, right side deep injury
Fig. 2.3 Patient with thin skin before and immediately after PCI with 2.5 mm needle length.
(Fig. 3a, b)
2.1 Level of the Injury and Its Relationship to the Length of the Needle
11
Fig. 2.4 Patient with flaccid skin immediately after PCI with a 2.5 mm needle length in the genian
region. (Fig. 4a, b)
Fig. 2.5 Patient with inframammary and breast hypertrophic scar, respectively, submitted to PCI
with a 2.5 mm needle length. (Fig. 5a, b)
• Elastosis: the more elastotic the skin, the more difficult it is to achieve a uniform
pattern of injury. Extrafacial areas can be traumatized by needles when the
degree of elastosis is substantial. The tissue is less flexible, and the trauma caused
may not be proportional to the expected results. Therefore, technique is essential
(Fig. 2.5).
12
2
Classification and Characteristics of the Injury Provoked by PCI
Fig. 2.6 Submentonian
scar patient undergoing
PCI with 2.5 mm needle
length. (Fig. 5)
• Thickness of the adipose cushion: in areas where the hypodermis is thicker, such
as the buttocks, thighs, and abdomen, a cushioning of the trauma caused by the
needles is observed when compared to areas such as the forehead and neck.
Thus, in these areas, longer needle lengths are needed to obtain the same injury,
which would be possible with shorter needles on the face (Fig. 2.6).
• Bone eminence: it acts on concave and convex surfaces, since there is no totally
flat surface in the human body. In this way, the roller cannot work alone; it must
be appropriated by those who handle it, making it as uniform as possible. In addition, using a horizontal force vector, paying attention to the need to vary the
curvature of the handle in dependence on each area treated in the same follow­up, is fundamental for obtaining the degree of injury proposed; therefore, technique is essential.
• Fibrosis and scars: they offer a resistance that, to be overcome, requires greater
needle length and strength to the right extent by the operator. Breaking fibrosis
beams with microneedles arranged at a 90° angle to the skin requires precision
and mastery of the technique.
Some of the PCI indications on different skin types demonstrate the versatility of
the technique.
Once the characteristics of the skin and the region to be treated have been evaluated, it is important to establish the objective of the treatment, which can be to break
fibrotic beams, to uniform skin color, to improve its texture and brightness, to treat
2.1 Level of the Injury and Its Relationship to the Length of the Needle
13
superficial wrinkles, to approach recent or old stretch marks, to stimulate collagen
in a region of flaccid skin, or to restructure an abnormal collagen in a rigid skin area.
All of this will influence the choice of the length of needles and the planning of the
injury to be provoked.
As this is a painful procedure, it is also essential that the anesthesia chosen is in
accordance with the degree of the injury. Thus, when a shorter needle length is used,
topical anesthesia is sufficient, unlike a longer needle length, which requires infiltrative anesthesia. The infiltration of this solution also interferes in the penetration
of the needle, since the skin will be swollen, facilitating the distension of the skin or
requiring a more directed force vector due to the resistance offered.
Emerson Lima et al. [9] proposed, in an experimental study, a relationship
between the length of the needle and the depth of damage achieved, using live pigskin, because they consider it a model that approximates human skin. The interventions were performed by the same operator and at the same surgical time, establishing
the same pattern of strength and number of needle roll passes. Macroscopically, it
was possible to identify the difference in damage caused by needles with lengths of
0.5, 1.0, 1.5, 2.0, and 2.5 mm (Fig. 2.7). The microscopic examination in this first
phase (immediately after the injury) revealed predominantly vascular ectasia with
RBC overflow. This finding was observed superficially, affecting the papillary dermis in the 0.5-mm-long needle (Fig. 2.8), and extended to the reticular dermis in the
longer needles (Fig. 2.9). The amount of bleeding caused was also proportional to
the increase in the length of the needles. The epidermis was apparently intact by
optical microscopy, except at the site of needle passage (Fig. 2.10). None of the
samples showed injury to the subcutaneous cellular tissue.
Fig. 2.7 Macroscopic evaluation in live pigskin demonstrating the difference in damage caused by
needles of lengths 0.5 mm, 1.0 mm, 1.5 mm, 2.0 mm, and 2.5 mm
14
2
Classification and Characteristics of the Injury Provoked by PCI
Fig. 2.8 Papillary dermis
restricted surface bleeding
caused by 0.5 mm needle
length (HE 100×).
(Courtesy Dr.
Daniela Takano)
Fig. 2.9 Deep bleeding
affecting the reticular
dermis caused by 2.5 mm
needle length (HE 100×).
(Courtesy Dr.
Daniela Takano)
2.2
Classification of Injury Level
Based on the results, the authors proposed a classification of the injury in light,
moderate, and deep, relating it to the length of the needle and its ability to cause the
planned trauma (Table 2.1). Subsequently, they also suggested the relationship
between the type of injury and the most appropriate indications described in
Table 2.2. This pedagogical presentation aims to establish the relationship between
the length of the needle used in the roll and the damage caused to the skin, which
facilitates the choice of the instrument in the different indications. Figure 2.11 presents six different regions of the body (anterior face of the chest, back of the foot,
shoulder, abdomen, thigh, and breast) where uniform purpura was achieved by the
author as the end point of the PCI technique (Fig. 2.12).
2.3 Final Considerations
15
Fig. 2.10 Needle passage path associated with bleeding. Adjacent epidermis without significant
changes (HE 100×). (Courtesy Dr. Daniela Takano)
Table 2.1 Classification of
the intensity of the injury
caused by PCI related to
needle length
Stimulus characteristic
Light injury
Moderate injury
Deep injury
Needle length
0.25 and 0.5 mm
1 and 1.5 mm
2 and 2.5 mm
Adapted from Lima et al. [9]
Table 2.2 Classification of the intensity of the injury caused by PCI according to the indications
Stimulus
characteristic
Mild injury
Moderate injury
Deep injury
Main indications
Drug delivery, fine wrinkles, improvement of brightness and texture
Skin flaccidity, average wrinkles, global rejuvenation
Distinguishable depressed scars, stretch marks, wave and retractable
scars
Adapted from Lima et al. [9]
2.3
Final Considerations
It is essential to understand the relationship between needle length and degree of
injury when indicating the PCI technique for each specific situation. This is because
it is an extremely technical-dependent procedure; therefore, it is necessary to count
16
2
Classification and Characteristics of the Injury Provoked by PCI
Fig. 2.11 Six different body regions where uniform purple has been achieved by the author as the
end point of the PCI technique. The examples show the anterior face of the chest (a), the back of
the foot (b), the shoulder (c), the abdomen (d), the thigh (e), and the breast (f), validating the safety
of treatment in these regions with the degree of injury recommended
Fig. 2.12 Six regions other than the body where the uniform purple was achieved by the author as
the end point of the PCI technique. The examples show the anterior face of the chest (a), the back
of the foot (b), the shoulder (c), the abdomen (d), the thigh (e) and the breast (f), validating safety
of treatment in these areas with the degree of insult
Sources
17
on all the variables that affect the intervention and its results. The treatment is individualized, and its customization, through diagnosis and delivery of results, is mandatory in determining real expectations and the satisfaction of the doctor and patient.
Regardless of the injury, if moderate or deep, the intervention will always be
surgical; the term “nonsurgical” does not fit for PCI. The treatment requires anesthesia, either topical or infiltrative, as well as local asepsis, the most aseptic environment possible, and a trained specialist physician to ensure the accuracy of all the
carefully documented methodology such as IPCI.
Sources
1. Aust MC. Percutaneous collagen induction therapy: an alternative treatment for scars, wrinkles, and skin laxity. Plast Reconstr Surg. 2008;121(4):1421–9.
2. Bal SM, Caussian J, Pavel S, et al. In vivo assessment of safety of microneedle arrays in human
skin. Eur J Pharm Sci. 2008;35(3):193–202.
3. Brody HJ. Trichloroacetic acid application in chemical peeling, operative techniques. Plast
Reconstr Surg. 1995;2(2):127–8.
4. Camirand A, Doucet J. Needle dermabrasion. Aesthet Plast Surg. 1997;21(1):48–51.
5. Cohen KI, Diegelmann RF, Lindbland WJ. Wound healing: biochemical and clinical aspects.
Philadelphia: WB Saunders Co; 1992.
6. Fabroccini G, Fardella N. Acne scar treatment using skin needling. Clin Exp Dermatol.
2009;34(8):874–9.
7. Fernandes D. Minimally invasive percutaneous collagen induction. Oral Maxillofac Surg Clin
North Am. 2006;17(1):51–63.
8. Fernandes D, Massimo S. Combating photoaging with percutaneous collagen induction. Clin
Dermatol. 2008;26(2):192–9.
9. Lima E, Lima M, Takano D. Microneedling experimental study and classification of the resulting injury. Surg Cosmet Dermatol. 2013;5(2):1104.
10. Orentreich DS, Orentreich N. Subcutaneous incisionless (subcision) surgery for the correction
of depressed scars and wrinkles. Dermatol Surg. 1995;21(6):543–9.
Chapter 3
Devices for PCI
It is already well established that the perforation caused by needles triggers the
cascade of wound healing, and in this process, through the release of growth factors,
collagen production occurs. To demonstrate this, two split face clinical trials were
conducted. The aim was to evaluate the improvement in skin quality: brightness,
elasticity, pore reduction, and texture. Saline solution was injected on one side of
the face of patients and the other side mesotherapy with vitamin B complex or
microdoses of botulinum toxin, referred to the literature as responsible for pore
reduction, oiliness, elasticity, and even production of collagen fibers. It was concluded that there was improvement in the appearance of the skin, but without significant difference in the parameters when comparing the two sides in both studies.
In one of the studies, a biopsy was performed before and after the treatments,
observing an increase in collagen production through histopathology equally on
both sides, leading the researchers to question whether this effect was due to the
injected drugs or just the punctures performed.
The use of needles in order to stimulate the production of good quality collagen
in the treatment of scars was initially described by Orentreich and Orentreich in
1995, who successfully reported the use of the Subcision™ technique. Shortly after,
Camirand and Doucet [3] reported cases of scar improvement after performing scar
scarification using the needles of a tattoo machine [9].
It was then that, in 2002, Fernandes devised a method for perforating the skin
with needles that penetrate but do not remove the epidermis, creating cracks that
regenerate quickly. He developed a manual device with a cylindrical device in which
several thin needles are attached, so that they roll over the skin, causing perforations
without scarification. This device became known as Dermaroller™ [3–7, 9].
The technique was called microneedling, also known as percutaneous collagen
induction (PCI). In Brazil, the procedure is registered as percutaneous collagen
induction with needles (IPCA®) by the dermatologist Emerson Lima [8]. Lima
The Editor(s) (if applicable) and The Author(s), under exclusive license
to Springer Nature Switzerland AG 2021
E. Lima, M. Lima, Percutaneous Collagen Induction With Microneedling,
https://doi.org/10.1007/978-3-030-57541-0_3
19
20
3
Devices for PCI
began his studies in microneedling in 2009 and developed a series of protocols for
the treatment of various dermatological diseases, using different degrees of injuries
and lengths of needles [8].
3.1
Available Devices
3.1.1
Microneedle Rollers
After the needles used in Subcision™ and the tattoo machines, the roller was the
first equipment specially developed for IPI purposes. Some of its greatest advantages are the low cost and the important stimulus to produce collagen when well
used. The amount of collagen formed and, consequently, the result of the treatment
depend, in part, on the length of the needle, but mainly on the end point achieved for
each procedure.
The size of the needles of medical rollers varies from 0.5 to 3.0 mm in length.
Equipment with less than 0.5 mm usually pierce only part of the stratum corneum
and increase the absorption of substances applied to the skin, a process known as
drug delivery.
Figure 3.1 shows models of equipment available on the market that use this rolling system. The fastening of the needles happens in a variable way, depending on
the manufacturer. This factor is considered crucial for the safety of the intervention,
since the detachment of the needle during treatment or its malfunction may compromise the results and damage the patient’s skin, with needle breakage inside the skin,
undesirable grooves that may cause hyperchromias, scars, or “train track effect,”
among other complications. Figure 3.2 shows one of the systems used by a manufacturer to fix the needles.
1
5
4
3
2
Fig. 3.1 (a) Different brands of needle roll available on the market. (b) Model of a microneedle
stamp. (c) Narrower needle roller with applicability to linear injuries
3.1
Available Devices
21
Fig. 3.2 Demonstration of the attachment of the microneedles to one of the rollers available on
the market
Fig. 3.3 Three different brands of product in 100× increase demonstrating the difference in the
quality of microneedles
The origin of the instruments used is also important with respect to the quality of
the needles. Figure 3.3 shows, in an increase of 100×, different materials used in the
manufacture of the needles, which directly interferes with the resistance, the characteristic of the injury caused, and, consequently, the results.
The needles are diagonally arranged in some instruments, seeking optimization
of results. Figure 3.4 schematically presents this arrangement. The scanning microscopy shows the difference in length of the needles, which directly interferes in the
intensity of the lesion caused in the skin (Fig. 3.5).
The microneedles attached to the device are made of stainless steel and generally
pre-sterilized with gamma radiation. Therefore, sterile technique should be used
during the procedure.
The rollers used for medical treatment are for single use. They should not be re-­
sterilized, as they lose their cut and buckle the needles, compromising the result and
the safety of the procedure.
The risk of home use of these instruments is huge. This is because the use of
needles requires standards of hygiene and asepsis, as well as an appropriate environment, which is not observed in the execution by laypeople in domestic space.
Furthermore, the layman will probably not recognize possibly infected areas of the
22
3
Devices for PCI
Diagonal arrangement of needles
Fig. 3.4 Demonstration of the diagonal arrangement of the microneedles in one of the rollers
available on the market
0.5mm
0.1mm
Fig. 3.5 Needle length difference and consequent injury. M.E.
1.5mm
3.1
Available Devices
23
skin and may use the device in these regions, spreading viruses and bacteria. In
2018, Leatham et al. reported a case in which a patient used the microneedle roller
in a herpes zoster area, believing it to be acne, and then used the device on her face
with the intention of treating wrinkles. There was autoinoculation of the varicella
zoster virus on the patient’s face, and the lesions were only resolved after specific
treatment [1–4].
There are several devices available on the market. Thus, it is important to choose
instruments with very fine needles with good quality. This will influence directly in
your results.
3.1.2
Microneedle Pens
Microneedle pens are spring devices that act by producing stamper-like movements
on the skin. The first to be created was Dermapen (Dermapen, Salt Lake City, UT,
USA). This device consists of a tip in which 12 individually sterilized, portable, and
disposable microneedles are inserted (Fig. 3.6). It is a motorized surgical instrument, whose speed and depth of PCI are adjustable. Like other pen devices, it should
be used perpendicularly to the skin, stamping it evenly, lifting, and lowering the pen
to each set of perforations, thus avoiding dragging the needles over the skin in order
to perforate it, without deepithelialization occurring.
The use of pens becomes especially interesting for the treatment of small areas,
such as the eyelid, nose, and perioral region, and small scars, besides being able to
provide a localized treatment in static wrinkles.
Fig. 3.6 Note two different types of instruments that are not made to roll: stamp (a) and microneedle pen (b)
24
3
3.1.3
Microneedles Associated with Technologies
3.1.3.1
Electromagnetic Nonionizing Radiofrequency
Devices for PCI
Fractionated radiofrequency (RF) microneedle, popularized with the term “robotic
microneedle,” is a technology developed to deliver radiofrequency directly to the
dermis using microneedles. Unlike lasers that use chromophores, RF is an independent chromophore and depends on the electrical properties of the target tissue;
therefore, it has a good safety profile for all phototypes. Furthermore, the skin
between the needles remains intact in order to accelerate healing and maintain the
integrity of the epidermis.
RF devices use a sterile tip with microneedle electrodes in varying numbers,
according to the manufacturer’s standards. The penetration depth varies from 0.5 to
3.5 mm and is generally adjusted according to skin thickness and proximity to bone
areas (on the eyelid skin, e.g., the needle size should be adjusted up to a maximum
of 0.5 mm). The RF energy also depends on the region to be treated, and the heat
generated by it will depend on the resistance of the tissue to the passage of electric
current (impedance). Thus, in different fabrics, heat will be formed in several
degrees and depths.
The objective of the device is to associate the dermal remodeling caused by the
microneedle with the activation of the dermal fibroblasts by the heat of the RF, with
consequent formation of collagen. The needles are inserted into the skin by means
of an electronically controlled motor in shuttle movements that, theoretically, minimize patient discomfort. When the needle reaches the preset depth, radiofrequency
is emitted, selectively heating the dermis while saving the epidermis, which
decreases the risk of side effects such as post-inflammatory hyperpigmentation.
Because it is released into the dermis, radiofrequency enables effective coagulation,
which results in minimal or no bleeding.
There are devices with isolated and non-isolated microneedles. The big difference between them is that those with isolated needles release radiofrequency only at
the tip of the needle, sparing the epidermis and the dermoepidermal junction; therefore, they do not require cooling of the skin. On the other hand, those who have a
non-isolated needle release radiofrequency throughout the needle, making cooling
necessary, but producing a more effective coagulation and greater electric field in
the dermis.
Moreover, it is a treatment modality that promotes benefits, such as minimum
downtime, good tolerance, and low incidence of side effects; however, it presents a
high financial cost.
Sources
3.2
25
Final Considerations
PCI treatments, regardless of the device used, promote neocollagenosis and neovascularization, increasing skin thickness. These minimally invasive procedures may
be recommended for patients who are not willing to undergo surgery or lasers with
a long recovery period. They can be performed in several parts of the body where
the laser would cause greater complications, such as the arms, abdomen, thighs, and
buttocks.
The roller is the lowest cost device and offers good results when used correctly.
PCI is a technical-dependent procedure, and familiarization with the device used
and mastery of the technique are factors that directly influence the result. The vertical pressure exerted by the roller should not exceed 6 N, as superior force can lead
to damage to deeper anatomical structures and more pain than expected.
Sources
1. Bal SM, Caussian J, Pavel S, et al. In vivo assessment of safety of microneedle arrays in human
skin. Eur J Pharm Sci. 2008;35(3):193–202.
2. Brody HJ. Trichloroacetic acid application in chemical peeling, operative techniques. Plast
Reconstr Surg. 1995;2(2):127–8.
3. Camirand A, Doucet J. Needle dermabrasion. Aesthet Plast Surg. 1997;21(1):48–51.
4. Cohen KI, Diegelmann RF, Lindbland WJ. Wound healing: biochemical and clinical aspects.
Philadelphia: WB Saunders Co; 1992.
5. Fabroccini G, Fardella N. Acne scar treatment using skin needling. Clin Exp Dermatol.
2009;34(8):874–9.
6. Fernandes D. Minimally invasive percutaneous collagen induction. Oral Maxillofac Surg Clin
North Am. 2006;17(1):51–63.
7. Fernandes D, Massimo S. Combating photoaging with percutaneous collagen induction. Clin
Dermatol. 2008;26(2):192–9.
8. Lima E, Lima M, Takano D. Microneedling experimental study and classification of the resulting injury. Surg Cosmet Dermatol. 2013;5(2):1104.
9. Orentreich DS, Orentreich N. Subcutaneous incisionless (subcision) surgery for the correction
of depressed scars and wrinkles. Dermatol Surg. 1995;21(6):543–9.
Chapter 4
Pain Management in PCI: Analgesia
and Anesthesia
César Romão
Pain is defined by the World Health Organization (WHO) as an unpleasant emotional and sensory experience associated with actual or potential tissue injury. Each
individual learns to use this term from their previous experiences, modulated also by
subjective and cultural factors. In recent decades, doctors have learned to treat pain
as the fifth vital sign. Patients have been taught that they have the right not to feel it.
The advances in dermatology in the surgical field, both aesthetic and reparative,
have brought to these professionals, used to outpatient care, an apparent problem:
How to offer patients the painful treatments in the office and adapt to their expectations of not feeling pain? In addition, an extra problem is: How to offer analgesia to
these individuals in accordance with the strict rules that regulate these procedures,
especially in the ambulatory setting?
For more painful and extensive interventions and/or in patients with greater clinical impairment, a hospital structure and the participation of an anesthesiologist may
be necessary. However, most procedures can be performed in an outpatient setting
under local anesthesia.
The objective of this chapter is to review the use of local anesthetics for aesthetic
and reparative dermatological surgical procedures, with special attention to the two
most commonly used types for ambulatory procedures: topical local anesthesia and
infiltrative local anesthesia (with its variant, tumescent anesthesia) [1–3].
4.1
Local Anesthetics
They include drugs that reversibly block nerve conduction, causing loss of sensations (and, depending on their concentration, motricity) without altering the level of
consciousness. Reversibility of effect represents the main characteristic that
C. Romão
Albert Einstein Hospital, Recife, Brazil
The Editor(s) (if applicable) and The Author(s), under exclusive license
to Springer Nature Switzerland AG 2021
E. Lima, M. Lima, Percutaneous Collagen Induction With Microneedling,
https://doi.org/10.1007/978-3-030-57541-0_4
27
28
4
Pain Management in PCI: Analgesia and Anesthesia
differentiates local anesthetics from neurolytic agents such as phenol and alcohol.
The molecule of a typical local anesthetic, exemplified in Fig. 4.1 by lidocaine and
procaine, contains a tertiary amine linked to an aromatic ring with some substitution, linked by an intermediate chain containing an ester or amide bond. Thus, local
anesthetics are classified into two groups according to their intermediate chain: aminoamides and amino esters.
There is an important practical implication in knowing which group a local anesthetic belongs to. The amino esters are metabolized in the plasma by nonspecific
esterases and the aminoamides in the liver. Amino esters have greater potential for
triggering allergic reactions, as their degradation produces para-aminobenzoic acid
(PABA). Thus, knowing which group an anesthetic belongs to makes it possible to
indicate, contraindicate, and predict possible adverse reactions to the anesthetic chosen.
Table 4.1 presents the local anesthetics used in clinical practice divided into
these two groups. There is a very useful mnemonic rule to know if an anesthetic
belongs to the ester or amide group: if in its name there is only one letter “i,” it is an
Aromatic
group
Medium
chain
Tertiary
amines
H3C
H3C
CH2
O
AMINO AMIDES
Lidocaine
NH
C
CH2
N
CH2
H3C
H3C
Amida
H3C
CH2
AMINO ESTERS
H2N
Procaine
C
O
CH2
CH2
N:
CH2
Éster
H3C
Fig. 4.1 Chemical structure of local anesthetics
Table 4.1 Local anesthetics
used in clinical practice
Anesthetic group
Amino esters Benzocaine, procaine, chloroprocaine,
dibucaine, tetracaine
Aminoamides Lidocaine, mepivacaine, prilocaine,
bupivacaine, levobupivacaine, ropivacaine
4.1
29
Local Anesthetics
ester (procaine, tetracaine, benzocaine); if in its name there are two letters “i,” it is
an anesthetic from the amide group (lidocaine, prilocaine, bupivacaine, ropivacaine). There are no exceptions to this rule.
Local anesthetics block the electrically excitable sodium channels in the tissues
and, by doing so in the peripheral nerves, prevent the conduction of painful stimuli
from the periphery to the central nervous system. This is the desired effect when
using these drugs. However, by blocking the sodium channels in the brain and heart,
local anesthetics promote their toxic and undesirable effects. In this chapter, we will
also review how to work in a safe range of doses and how to recognize and treat
local anesthetic intoxication.
Nerve fibers are classified according to their thickness, from thin, unmyelinated
C-fibers to thick and myelinated Aα-fibers (Fig. 4.2 and Table 4.2). The thicker the
fiber, the more difficult it is to block it with the local anesthetic; therefore, anesthetics in higher concentrations should be used. As seen in Fig. 4.2, the fibers that conduct the painful stimulus are relatively thin – C-fibers and Aδ-fibers. They are
blocked with low concentrations of local anesthetics.
The practical importance of this lies in the fact that, since it is possible to employ
low concentrations, larger volumes can be used without reaching toxic doses.
Therefore, to increase the safety of the procedures done with infiltrative anesthesia,
the anesthetics should be diluted.
Due to the blockage of thinner nerve fibers (responsible for pain), and not the
thicker ones (touch and motricity), the patient can have analgesia without loss of
touch. However, for some people, not feeling pain, but manipulation, can be very
distressing, making them anxious, with the thought: “if I am feeling movement, it is
Fig. 4.2 Fibers
Motor neuron axon
Sensitive neuron axon
Perineurium
Epinerium
Endoneurium
C-nerve fibers
Aβ
Aα
Aδ
Afferrent nerve
fiber
Myelin
Schwann cell
Efferrent nerve fiber
30
4
Pain Management in PCI: Analgesia and Anesthesia
Table 4.2 Classification of nerve fibers, with emphasis on the fibers that conduct noxious stimuli
(Aδ and C)
Nerve fibers
Myelinated somatic
Myelinated
autonomic
Unmyelinated
Aα
Aβ
Aγ
Aδ
Aε
B
C
Diameter
(μm)
6–22
Conduction
velocity (m/s)
30–120
3–6
1–4
2
<3
15–35
5–25
5
3–15
0.3–1.3
0.7–1.3
Function
Motor
Proprioception
Muscular tone
Pain, touch, temperature
Sympathetic preganglionic
Autonomic postganglionic,
pain
Based on Paul G Barash – Clinical Anesthesia – 7th edition, Chapter 21
because it is not well anesthetized and at any moment I will feel pain!” This phenomenon is more common in tumescent and topical anesthesia.
Local anesthetics have physical-chemical properties that give each of them a
latency (time between administration and the beginning of action) and a duration of
action (time until the loss of the desired effect). It is not the purpose of this chapter
to review these properties. However, some knowledge that will guide the good practice of local anesthesia derives from them; thus, the doctor who will administer the
local anesthetic needs to know that:
• The more diluted the anesthetic, the longer the latency time. To promote analgesia, the anesthetics can be more diluted, since the intoxication is associated to the
mass of anesthetic employed (amount in milligrams). The more diluted ones
offer less mass for the same volumes, that is, larger volumes can be used if the
anesthetic is more diluted. This gain can be essential when it is necessary to
anesthetize large and very vascularized areas, such as the complete face.
• Lidocaine has a small latency but less time of action. Depending on the duration
of the procedure, it may be necessary to supplement the anesthesia.
• If the procedure is associated with moderate to intense pain in the post-­procedure,
it is possible to opt for longer acting anesthetics such as bupivacaine and
ropivacaine.
• When choosing one of these anesthetics of longer duration, it should be remembered that its latencies are greater; therefore, it is necessary to wait longer to start
the procedure.
• Lidocaine intoxication is usually lighter and easier to reverse; however, intoxication by ropivacaine and, mainly, bupivacaine is more severe and should be considered with a lot of criteria.
• The addition of epinephrine to the anesthetic decreases local perfusion, which
reduces absorption, and has two beneficial effects: it decreases the chance of
intoxication and increases the length of action. It has also the desirable effect of
decreasing bleeding (if applied at the site of the procedure, and not on peripheral
nerve blocks).
4.1
Local Anesthetics
31
• The vasoconstriction obtained by epinephrine is already achieved with a
1:400,000 dilution (equivalent to taking a volume of lidocaine with vasoconstrictor 1:200,000 and diluting to half). Larger concentrations do not significantly
reduce bleeding but increase the risk of systemic absorption of epinephrine and
the consequent tachycardia and hypertension, unwanted effects in patients with
cardiac impairment.
• Local acid pH at the site of anesthetics infiltration or acid diluting solution increases
latency. Therefore, we should avoid infiltration of anesthetics in infected areas, and
it is preferred to dilute them (in the sequence, from the best to the worst) in Ringer’s
lactate, 0.9% sodium chloride (saline), and distilled water [4–6].
In general, the concentrations of local anesthetics are expressed as a percentage
(e.g., lidocaine 2%), but maximum doses are usually expressed in milligrams (mg)
or milligrams per kilogram of body weight (mg/kg). The concentration expressed in
percentage means grams per 100 mL (g/100 mL). As a rule of thumb, to transform
the concentration from a percentage into mg/mL, just multiply it by 10, as follows:
• Lidocaine 2% = 2 g/100 m = 2000 mg/100 m = 20 mg/m
• Tetracaine 0.5% = 0.5 g/100 m = 500 mg/100 m = 5 mg/m
Or the practical rule:
• Lidocaine 2% = 2 × 10 = 20 mg/m
• Tetracaine 0.5% = 0.5 × 10 = 5 mg/m
4.1.1
Infiltrative Anesthesia
In this type of anesthesia, the local anesthetic is infiltrated through a needle in two
possible places: the place that will suffer the painful stimulus or close to some
peripheral nerve distal to the site of the intervention but responsible for the sensitive
innervation of that region (peripheral nerve block, nerve plexus blocks, and spinal
blocks – spinal or epidural anesthesia). However, the term “infiltrative anesthesia”
is usually used for situations where the anesthetic is infiltrated at the specific site of
the intervention. It can be applied in small volumes and higher concentrations (classic infiltrative technique) or in large volumes and low concentrations (tumescent
technique, which will be seen below).
Patients often report pain after subcutaneous infiltration of anesthetic solutions,
partly because of the acid nature of their formulations. The addition of sodium
bicarbonate to the anesthetic increases its pH, reduces the pain to infiltration, and
decreases the latency to analgesia.
With respect to topical anesthesia, the advantage of infiltration lies in the greater
depth that can be reached in the epidermis and dermis. Topical anesthetics can penetrate up to 3 mm into the stratum corneum (eventually 5 mm). Therefore, for procedures where the painful stimulus is beyond 3 mm, infiltrative anesthesia is more
32
4
Table 4.3 Anesthetics used
in local infiltration
Pain Management in PCI: Analgesia and Anesthesia
Anesthetic Onset (min) Duration (min) Maximum
recommended dose for adults
Without epinephrine With epinephrine Without
epinephrine With epinephrine
Amides
Articaine 2 to 4 30 to 120 60 to 240 5 mg/kg or 350 mg
7 mg/kg or 500 mg
Bupivacaine 2 to 10 120 to 240 240 to 480 2,5 mg/kg or
175 mg 3 mg/kg or 225 mg
Etidocaine 3 to 5 200 240 to 360 4,5 mg/kg or 300 mg
6,5 mg/kg or 400 mg
Lidocaine <1 30 to 120 60 to 400 4,5 mg/kg or 300 mg
7 mg/kg or 500 mg
Mepivacaine 3 to 20 30 to 120 60 to 400 6 mg/kg or
400 mg 7 mg/kg or 500 mg
Prilocaine 5 to 6 30 to 120 60 to 400 7 mg/kg or 400 mg
10 mg/kg or 600 mg
Esters
Chloroprocaine 5 6 30 to 60 N/A 11 mg/kg or 400 mg
14 mg/kg or 1000 mg
Procaine 5 15 to 90 30 to 180 10 mg/kg 14,0 mg/kg
Tetracaine 7 120 to 240 240 to 480 2 mg/kg 2 mg/kg
effective. It is mandatory when layers beyond the epidermis are involved, such as
nerve excision, blepharoplasties, and whenever skin flaps are rotated.
The disadvantages of infiltrative anesthesia are pain during injection (the pinprick and the infusion of the anesthetic), psychological discomfort associated with
the injection, and distortion of local anatomy, which can hinder certain dermatological procedures, such as fillers [1–8].
The maximum doses of anesthetics (Table 4.3) should be respected in order to
avoid systemic intoxication. In addition, syringes that allow aspiration before injection should be used to minimize the risk of intravascular injection. Table 4.3 also
presents latency times and duration of action of the main anesthetics used in infiltrative anesthesia.
Table 4.4 presents the levels of evidence and degrees of recommendation for
performing infiltrative anesthesia in dermatologic surgeries.
4.2
Tumescent Anesthesia
It is a technique widely used when large areas must be anesthetized, such as in cases
of liposuction or full face procedures. Its disadvantages consist of long latency and
anatomical deformation, which can hinder some of the dermatological procedures.
Tumescent anesthesia is performed with the subcutaneous infusion of large volumes of diluted local anesthetic, usually with the addition of epinephrine and
4.2
Tumescent Anesthesia
33
Table 4.4 Levels of evidence and degrees of recommendation for performing infiltrative
anesthesia in dermatologic surgery
Recommendation Degree of recommendation Level of evidence
Use of infiltrative anesthesia to obtain material for biopsy, excision, wound closure, flap
rotation, skin grafts, cauterization, non-ablative laser and ablative resurfacing C III
Combination of local anesthesia methods for ablative facial laser (total area) and hair shaft C III
Maximum lidocaine dose without epinephrine = 4.5 mg/kg and with epinephrine = 7 mg/kg in
adults C III
Maximum bupivacaine dose without epinephrine = 1.5–2 mg/kg and with
epinephrine = 3–4.5 mg/kg C III
Maximum lidocaine dose = 500 mg for staggered micrographic surgery of Mohs B II
Use of local ester-type anesthetic for patients allergic to lidocaine C III
Use of diphenhydramine for patients allergic to lidocaine C III
Use of bacteriostatic saline solution for patients with lidocaine allergy C III
Prevention of systemic toxicity of local anesthetics A I, II
bicarbonate. For liposuction, the volume to be infiltrated is approximately the same
expected volume to be aspirated (in case it is intended to aspirate 1000 mL, 1000 mL
of anesthetic solution is infused). Naturally, this recommendation is not precise, and
the choice of volume is much more based on the experience acquired with the
practice.
Several solutions have already been described; however, the most widely used
one consists in:
•
•
•
•
Sodium chloride 0.9%: 1000 m
Lidocaine 2%: 50 mL (1000 mg)
Epinephrine: 1 mL (1 mg)
Sodium bicarbonate 8.4%: 10 mL
For tumescent technique, the maximum dose of lidocaine is 55 mg/kg. For an adult
of 70 kg, this is equivalent to the infusion of 3850 mL of the solution described,
which should be infiltrated slowly over 15–40 min (the larger the volume, the slower
the infusion should be). After the infiltration, one should wait at least 30 min (in
general, 45 min to 1 h), since, as seen before, very diluted anesthetics have higher
latency. Epinephrine latency must also be considered, which will make the appropriate vasoconstriction for the procedure after approximately 30 min. This action
can be followed clinically, observing the anesthetized area becoming pale as the
epinephrine takes effect. Figure 4.3 presents images of before and after the tumescent anesthesia.
The discrepancy between the maximum dose of lidocaine with vasoconstrictor
for infiltrative anesthesia (9 mg/kg) and for tumescent anesthesia stems from the
fact that, when injecting such a diluted solution (a 0.1% lidocaine solution) and over
a long time, pharmacokinetics of the anesthetic is altered, so that the speed with
which it is systematically absorbed is compensated by the speed with which the
body eliminates it, without allowing the plasma concentration to rise, minimizing
the risk of systemic intoxication. Therefore, despite this high dose, the technique
34
a
4
Pain Management in PCI: Analgesia and Anesthesia
b
Fig. 4.3 Patient before (a) and after (b) tumescent anesthesia infiltration
has proven to be safe; however, the one originally described foresees that the patient
does not make concomitant use of any medication that is metabolized by the same
isoform of cytochrome P450 as lidocaine (isoform 3A4, which metabolizes quinidine, cyclosporine, erythromycin, midazolam, nifedipine, and triazolam; and isoform 1A2, which metabolizes caffeine, paracetamol, tamoxifen, theophylline,
verapamil, and warfarin). Naturally, this concern should be greater when using large
volumes of anesthetic, which is not common in dermatological procedures [6–9].
Peak plasma concentration of lidocaine used in this technique occurs after
8–12 hours, and intoxication may be delayed. Therefore, it is recommended that
additional doses of local anesthetics not be used during this period.
The recommendations for the use of tumescent anesthesia in dermatologic surgeries are:
• Both lidocaine and prilocaine are safe and recommended for use in local tumescent anesthesia for outpatient liposuction in the office. Bupivacaine is not recommended for this use.
• Use of prilocaine is not approved in the United States for tumescent anesthesia.
• The addition of epinephrine to lidocaine is recommended and safe for use in local
tumescent anesthesia for liposuction. A maximum dose of 55 mg/kg of lidocaine
with epinephrine has been shown to be safe and can be used for local tumescent
anesthesia for liposuction in patients between 43.6 and 81.8 kg.
• The use of heated anesthetic solutions and slow infiltration are recommended to
reduce the discomfort during the administration of local tumescent anesthesia.
4.2
Tumescent Anesthesia
4.2.1
35
Topical Anesthesia
Widely used for several medical procedures, it consists in the production of loss of
superficial painful sensitivity after direct application of the anesthetic. It can be
applied to the mucous membranes, the conjunctiva, or the whole skin through different formulations of local anesthetics – aqueous solution, gel, and ointment.
Its advantage is the possibility of producing analgesia without tissue infiltration
with a needle, a painful procedure that can promote anxiety, besides producing tissue edema and distortion of the anatomy, which can be unwanted for certain dermatological procedures.
There are three mechanisms by which topical anesthetics penetrate the entire skin:
• Intercellular route (through the spaces between the corneal keratocytes)
• Transcellular (though corneal cells)
• Transpedicular or shunt route (through the openings of hair follicles and
sweat glands)
There are three principles that rule the absorption of local anesthetics by the skin:
• In usual solutions, local anesthetics are stored in their salt forms (e.g., lidocaine
hydrochloride). The salts cannot penetrate the skin and need additional mechanisms to pass through the stratum corneum, as shown below. The anesthetic-free
bases are lipophilic and cross the stratum corneum.
• The liquefaction point of anesthetics is also important and the lower one, the
greater the absorption by the skin. The combination of anesthetics in equal concentrations in their base form (eutectic mixture) results in solutions with lower
liquefaction point and better absorption when compared to its isolated
components.
• The higher the concentration of anesthetic in the vehicle, the greater the penetration through the stratum corneum.
The absorption of the anesthetic is optimized through liposomal formulations and
their variants. Studies with these formulations revealed that liposomes disperse in
the upper layers of the stratum corneum, without penetration by the epidermis, dermis, or deeper layers. The liposomal formulation of tetracaine 5% produces superficial analgesia superior to the eutectic mixture of lidocaine 5% and prilocaine 5%
(EMLA). The disadvantages of liposomal formulations are their instability and predisposition to oxidative degradation. The niosomal formulations are more stable but
do not penetrate deeper than the liposomal formulations.
When choosing the anesthetic, one should remember the allergenic potential of
the amino esters (procaine, tetracaine). The following are the commercial preparations of anesthetics for topical anesthesia, with emphasis on those capable of penetrating the skin. Other formulations are possible and usually manipulated for use in
the office, containing anesthetics in higher concentrations than the commercial
36
4
Pain Management in PCI: Analgesia and Anesthesia
formulations and effectively promoting analgesia with lower latency (as seen before,
higher concentrations have a faster effect), but with a higher risk of intoxication.
It is common to find the maximum dose recommendation according to surface
area. Table 4.5 presents the surface area corresponding to each part of the body, differentiating men and women and the size of the patient (expressed in percentiles). It
is not necessary to know exactly to which percentile the patient belongs; it is enough
to use common sense and classify him/her as a normal, small, or large adult.
Table 4.6 presents the levels of evidence and degrees of recommendation for
matters relating to topical anesthetics in dermatologic surgeries. The main ones are
in Table 4.7.
Table 4.5 Surface area corresponding to each body part (adults in cm2)
Body part Percentage
10 25 50 75 95
Man Woman Man Woman Man Woman Man Woman
Head 1.210 1.070 1.240 1.090 1.300 1.110 1.350 1.140 1.430 1.170
Trunk (includes neck) 6,220 5,070 6,740 5,380 7,390 5,790 8,070 6,360 9,350 7,520
Arms (including forearms on women) 2,520 2,140 2,700 2,210 2,910 2,300 3,140 2,380 3,540
2,530
Forearms 1.110 - 1.210 - 1.310 - 1.440 - 1.660 Hands 880 746 930 770 990 817 1,050 868 1,170 966
Thighs 3.310 2.810 3.540 3.000 3.820 3.260 4.110 3.570 4.630 4.210
Legs 2,260 1,920 2,400 2,040 2,560 2,180 2,720 2,330 2,990 2,610
Feet 1.180 1.030 1.240 1.080 1.310 1.140 1.380 1.210 1.490 1.340
Total 17,200 14,900 18,200 15,800 19,400 16,900 20,700 18,200 22,800 20,900
Table 4.6 Levels of evidence and degrees of recommendation for issues regarding topical
anesthetics in dermatologic surgery
Recommendation Degree of recommendation Level of evidence
Use of topical non-cocaine anesthetics A II
Topical anesthesia as a first-line method for treatment with non-ablative laser C III
Topical anesthesia for use in small procedures in adults C III
Topical anesthesia to reduce pain of local anesthetic injection C III
Limiting the amount of topical lidocaine in pregnant women and breastfeeding C III
Postpone the use of topical anesthesia for after pregnancy or second trimester if possible C III
Topical anesthetics not lidocaine are contraindicated in pregnancy C III
Topical anesthesia is the first-line method for dermis repair in children A I, II
Use of topical anesthesia as a first-line method for other minor procedures in children C III
Adjunct use of topical anesthesia to reduce the discomfort of infiltrative anesthesia in
children C III
Use of topical and infiltrative anesthesia as an alternative to sedation and general anesthesia C III
4.2
Tumescent Anesthesia
37
Table 4.7 Main topical anesthetics used in dermatologic surgery
Anesthetic Onset (min) Duration (min) Special considerations
Benzocaine <5 15 to 45 Possible methemoglobinemia
Cocaine 1 to 5 30 to 60 Dibucaine <5 15 to 45 For mucous membranes
Diclonia 2 to 10 < 60 For mucous membranes except conjunctiva
Lidocaine <2 30 to 45 Lidocaine + prilocaine (EMLA™) <60–120 after removal of occlusion Only for whole skin,
methemoglobinemia possible
Lidocaine + tetracaine (Pliaglis™) <60–120 after removal of occlusion Whole skin
EMLA®
Table 4.8 Recommended maximum doses of EMLA®
Age and body weight Maximum total dose of cream Maximum area of application Maximum
time of application
0–3 months or <5 kg 1 g 10 cm2
1 h
3–12 months and >5 kg 2 g 20 cm2
4 h
1–6 years and >10 kg 10 g 100 cm2
4 h
7–12 years and >20 kg 20 g 200 cm2
4 h
It is formed by a 5% creamy emulsion with a liquefaction point of 18 °C, composed of lidocaine 25 mg/mL + prilocaine 25 mg/mL + thickener + emulsifier +
distilled water with pH adjusted to 9.4. It is applied as a thick layer of cream
(1–2 g/10 cm2, up to a maximum of 20 g/200 cm2) on intact skin to be anesthetized.
The maximum recommended doses of EMLA™ are shown in Table 4.8. After
application, the area should be covered with waterproof material, such as plastic
film, to facilitate penetration into the stratum corneum. The depth of the skin to be
anesthetized depends on the time of contact with EMLA™, and the anesthetic effect
reaches 3 mm of depth after 60 min of application and 5 mm after 120 min. The
analgesia increases progressively for up to 3 h after application and occlusion and
persists for 1–2 h after its removal. EMLA® should not be applied to the palm of
the hands and the soles of the feet because its absorption in these regions is erratic
and unpredictable. Care should also be taken when using it on women who are
breastfeeding, as lidocaine is excreted in milk.
4.2.2
TAC
It is a mixture composed of tetracaine 0.5% + epi (adrenaline) 0.05% + cocaine
11.8%. It does not penetrate all layers of the skin; it can only be applied on the skin
lacerated or prepared previously by abrasion and laser and on mucous membranes.
38
4
4.2.3
Pain Management in PCI: Analgesia and Anesthesia
LET
Composed of lidocaine 4% + epinephrine 0.1% + tetracaine 0.5%, it is also unable
to penetrate all layers of the skin.
4.2.4
Dermomax®
Lidocaine compound liposomal 4%. Its onset is 7 min (neurometry) after the application, although it is considered real only after 30 min. Its analgesic potential was
evidenced in children submitted to venous puncture and in adults treated with laser
for depilation and rejuvenation, with maintenance of the analgesic effect detected
even in 15–30 min after its removal.
The advantages of liposomal encapsulation of lidocaine are:
•
•
•
•
•
Faster onset by optimization of transcutaneous absorption
Long action time due to slow degradation
Safety guaranteed by gradual local metabolism
Low risk of erythema, irritation, and skin hypersensitivity
Easier to use because occlusion is not necessary
Liposomal lidocaine had its safety validated in volunteers after 30 g (face) and 60 g
(abdomen) use, through cardiac, gastrointestinal, neurological, and serum dosage
evaluations (1, 2, 6, and 24 h), attesting confidence in the parameters tested, with no
sign of toxicity evidenced. The time in contact with the skin should not exceed 3 h.
It is suggested to read Chap. 11, IPCA® in Conducting Post-Inflammatory
Hyperpigmentation, in order to check the protocol proposed by Lima for the use of
liposomal lidocaine in dermatological procedures.
4.2.5
Betacaine® LA
The formulation contains lidocaine, prilocaine, and epinephrine, but their concentrations are not revealed by the manufacturer. Studies show concentrations up to
four times higher than those of EMLA®; therefore, smaller areas can be safely
anesthetized.
4.2.6
Tetracaine 4%
This is a long-lasting anesthetic formulated as a lecithin-based gel. It should be
applied 30 minutes before the procedure and occluded with plastic film. The maximum dose is 50 g for adults.
4.2
Tumescent Anesthesia
4.2.7
39
S-Caine Patch®
It comprises an eutectic mixture of lidocaine 70 mg + tetracaine 70 mg (base), plus
an oxygen-activated substance that increases in a controlled manner the local temperature (39–41 °C) for a period of 2 h, in order to accelerate the penetration of the
active principles through the stratum corneum.
4.2.8
Pliaglis®
It is also a mixture of lidocaine 70 mg + tetracaine 70 mg per gram of cream. It
should be applied with the aid of a tongue depressor or spatula, forming a thin layer
(1 mm thick) over the whole skin area to be anesthetized. The area should not be
occluded. Onset of anesthesia varies from 30 to 60 minutes, depending on the depth
required for the procedure. After the appropriate time of application, the product
forms a film that can be removed by pulling it over the edge.
4.2.9
Toperma®
Lidocaine plaster 5% containing 700 mg water-based anesthetic. It is most used for
the treatment of chronic pain, such as that from herpes zoster.
Some tips to optimize the use and minimize the discomfort of patients undergoing topical anesthesia procedures are:
• Apply the topical anesthetic only on the healthy skin. Avoid inflamed, eczematous, or scarred areas.
• Avoid contact of the topical anesthetic with the eyes to avoid eye irritation.
• Avoid the use of topical anesthetics from the amide group in patients with hepatic
insufficiency.
• Limit the use of EMLA® in neonates, particularly those on methemoglobinemia-­
inducing drugs.
• Be aware of the amount of product applied, the total area covered, the thickness
of the stratum corneum, and the duration of application.
• For large treatment regions, limit the application of the product to selected more
sensitive areas (hot spots) and give up the application of topical anesthetics in
less sensitive areas.
• Supplement topical anesthesia with oral anxiolytics, analgesics, peripheral nerve
blocks, infiltrative anesthesia, and venous sedation when appropriate.
• Facilitate the procedure with prior prescription of painkillers purchased in
pharmacy.
40
4
Pain Management in PCI: Analgesia and Anesthesia
• Apply ice, ultrasound with refrigerated gel and forced cold air devices during
treatments to increase patient comfort and decrease or abolish the use of topical
anesthetics.
• Distract the patient with conversation, with deep breathing exercises, or with the
“ball” to tighten and decrease tension and anxiety.
4.2.10
Peripheral Nerve Blocks
Peripheral blocks are one of the categories of regional anesthesia. Nerves can be
blocked from their origin (when they leave the spinal cord), as the roots come
together to form nerve plexus (brachial plexus, femoral plexus) and as peripheral nerves.
In general, these blocks require the expertise of an anesthesiologist trained in
these techniques, since these structures are deep and pass close to other important
ones, such as large vessels. Many of these blocks are performed with the aid of
ultrasonography. Another factor that limits the use of these techniques in the office
is the large volume of anesthetics usually required for these blockades, and continuous monitoring of the patient is required due to the higher risk of intoxication.
However, some of the peripheral nerve blocks are relatively simple from the
technical point of view and require small amounts of anesthetics, which makes them
safe to perform in the office. Of particular interest for dermatological surgical procedures are face blocks.
The advantage of blockades in relation to infiltrative anesthesia is that larger
areas of analgesia are obtained with smaller amounts of anesthetics and without the
deformation of the anatomy. However, in addition to greater technical difficulty, the
disadvantage is the higher latency, which varies from 10 to 20 minutes. It is recommended that professionals who propose to perform such blocks – even the simplest
ones – receive adequate training before performing them on their patients.
Among the simplest face blocks that can be performed with small amounts of
local anesthetic are:
•
•
•
•
•
•
Supraorbital and supratrochlear nerve blocks
Infraorbital nerve block
Nasociliary nerve block
Lacrimal nerve block.
Zygomatic nerve block
Mental nerve block
The combination of these blocks can promote analgesia on virtually the entire face.
In cases of nose procedures, extra blocks of small specific branches may be necessary, but this knowledge goes beyond the objective of this chapter.
The techniques for each block will be presented below. The corresponding
images show the anatomy of the nerve in relation to the bones of the face, the area
of analgesia, and the puncture site on the skin for its performance.
4.2
Tumescent Anesthesia
a
b
41
c
Fig. 4.4 Supraorbital nerve blocks (1) and supratrochlear nerve blocks (2). (a) Location of the
nerve near the skull bones. (b) Location of the puncture for the blockade. (c) Area of analgesia.
(Adapted from Wolf-Heidegger [14])
The most indicated anesthetic for these blocks is lidocaine, whose onset is short,
and the risk of severe intoxication is low. All blockades should follow strict asepsis
and antisepsis techniques.
4.2.11
Blocking the Supraorbital and Supratrochlear Nerves
The foramen or supraorbital incision is palpated at the upper edge of the eyelid,
2.5 cm from the midline, on a vertical plane that passes through the pupil when the
patient looks forward. A fine needle (13 × 0.45 mm) is inserted at this point and,
without the need for paresthesia, 1.0–1.5 m of anesthetic is injected, followed by
digital compression for better dispersion (Fig. 4.4).
The supratrochlear nerve can be anesthetized with the same puncture, the needle
being directed medially along the edge of the orbit and 1 mL of anesthetic being
injected.
4.2.12
Infraorbital Nerve Block
The infraorbital nerve can be blocked by transcutaneous or intraoral route (Fig. 4.5).
By transcutaneous route, it can be performed around the infraorbital foramen, palpable on the anterior face of the maxilla above the canine fossa, 1.5 cm below the
lower orbital border, on a line connecting the supraorbital and mentonian foramen
(easily palpable). The needle should not enter the foramen, at risk of causing nerve
and vascular damage. Inject 2 mL of anesthetic, followed by digital compression to
disperse it. The infraorbital foramen is palpated intraorally with the index finger,
and the upper lip is raised with the thumb of the same hand, exposing the oral
42
a
4
Pain Management in PCI: Analgesia and Anesthesia
b
c
Fig. 4.5 Infraorbital nerve block. (a) Location of the nerve near the skull bones. (b) Location of
the puncture for the blockage. (c) Area of analgesia. (Adapted from Wolf-Heidegger [14])
a
b
c
Fig. 4.6 Nasociliary nerve block. (a) Location of the nerve near the skull bones. (b) Site of the
puncture for the blockade. (c) Area of analgesia. (Adapted from Wolf-Heidegger [14])
mucosa at the height of the first premolar. A 13 × 0.45 mm needle is inserted at this
point towards the index finger, which is on the infraorbital foramen. Then, 2 mL of
anesthetic is injected, followed by digital compression.
4.2.13
Nasociliary Nerve Block
At the point 4 mm above the inner corner of the orbit, a 20 × 0.5 mm needle is
inserted perpendicularly next to the inner wall of the orbit at a depth of 2 cm, injecting 2 mL of anesthetic (Fig. 4.6).
4.2.14
Lacrimal Nerve Block
Palpating the supero-external angle of the orbit, the needle is punched 13 × 0.45 mm
towards the orbital angle, touching the bone. The needle is pulled back by 1 mm and
aspirated. Inject 2 mL of anesthetic and compress digitally to disperse it (Fig. 4.7).
4.2
Tumescent Anesthesia
a
43
b
c
Fig. 4.7 Lacrimal nerve block. (a) Location of the nerve near the skull bones. (b) Location of the
puncture for the blockade. (c) Area of analgesia. (Adapted from Wolf-Heidegger [14])
a
b
c
Fig. 4.8 Zygomatic nerve block (1) and malar divisions (2) and temporal (3). (a) Location of the
nerve near the skull bones. (b) Location of the puncture for the blockade. (c) Area of analgesia.
(Adapted from Wolf-Heidegger [14])
4.2.15
Zygomatic Nerve Block
The orbital rim is palpated in the outer corner of the orbit, near the malar prominence. Then a 13 × 0.45 mm needle is inserted until the orbital edge is touched, and
2 m of anesthetic is aspirated and injected, followed by digital compression
(Fig. 4.8).
4.2.16
Mental Nerve Block
This blockage can also be performed by intra or extraoral technique (Fig. 4.9). In
the extraoral technique, the patient remains with the mouth at rest. A vertical line is
drawn passing through the labial commissure, over which the mentonian foramen
can be palpated at half distance between the upper and lower margins of the mandible. Using a 13 × 45 mm needle, 2 mL of anesthetic is injected into the foramen
mentonium, followed by digital compression to disperse the anesthetic.
44
4
a
Pain Management in PCI: Analgesia and Anesthesia
b
c
Fig. 4.9 Mental nerve block. (a) Location of the nerve near the skull bones. (b) Location of the
puncture for the blockage. (c) Area of analgesia. (Adapted from Wolf-Heidegger [14])
The patient keeps his teeth clenched. Through the oral vestibule, the mental foramen is palpated on the vertical line separating the two lower premolars, at half distance between the upper and lower margins of the mandible. Using a 13 × 45 mm
needle, 2 mL of anesthetic is injected into the foramen mentonium, and digital compression is continued to disperse the anesthetic.
The syringe should always be aspirated before injection, because of the proximity of the mentonian artery to the respective nerve. It is necessary to avoid entering
the foramen, under risk of causing nerve damage.
4.3
Local Anesthetic Intoxication
Local anesthetics are very safe drugs if given in appropriate doses and in the right
anatomical locations. However, adverse reactions may arise from accidental intravascular injection or administration of an inappropriately large dose. Therefore, the
best prophylaxis of intoxication is the compliance with the technique. In addition,
specific adverse effects are associated with the use of certain drugs, such as allergic
reactions to amino esters and methemoglobinemia after the use of prilocaine (clinical doses used in dermatological procedures hardly trigger clinically relevant
methemoglobinemia).
Systemic intoxication occurs by blocking nerve transmission in the central nervous and cardiovascular systems. The physician who administers local anesthetics
must know how to recognize an intoxication, as well as how to treat it.
As the plasma concentration of the local anesthetic increases, the patient presents
the following signs and symptoms:
•
•
•
•
Sensation of lightness
Lip tingling
Metallic taste in the mouth
Dizziness
4.3 Local Anesthetic Intoxication
•
•
•
•
•
•
•
•
45
Difficulty of focus
Buzz
Tremor
Muscle spasms (initially on the face and ends)
Generalized tonic-clonic seizure
Coma
Respiratory arrest
Cardiac arrest
The plasma concentration necessary for the patient to present the first symptoms is
six to ten times lower than for severe symptoms such as seizures, coma, and respiratory and cardiac arrests. Prophylaxis of intoxication is essential, especially for procedures that occur in the office, without immediate hospital support, without the
presence of an anesthesiologist, and without the availability of monitoring.
Respecting the recommended doses, aspirating the syringe before injecting, and
adding vasoconstrictor to the anesthetics minimize the chance of intoxication.
As seen at the beginning of this chapter, it is fundamental to give preference to
more diluted anesthetics, such as lidocaine 1%, when using large volumes, remembering that dilution increases latency. The physician should respect this time,
because a common source of anesthetic overdose (and greater risk of intoxication)
comes from not waiting for the effect of the anesthetic; then, the patient complains
of pain, and the physician complements the anesthesia unnecessarily.
It is also part of the prophylaxis to recognize patients with greater intoxication
potential, such as those who are under antiarrhythmics and anticonvulsants.
Initially, the treatment of intoxication consists of clinical support, and the administration of anesthetics should be stopped immediately. It is necessary to ensure
patency of the airway, ventilation, and oxygenation. Ensuring that the patient ventilates well is also part of the treatment to prevent intoxication from progressing to
more serious signs and symptoms, which occurs when there is hypoxia, hypercarbia, and acidemia. When less powerful and short duration anesthetics are used, these
measures are usually enough to prevent progression and reverse the symptoms.
If the patient progresses to muscular tremors and tonic-clonic seizure, some anticonvulsant drug, preferably benzodiazepines, should be administered. The patency
of the respiratory tract may, in these cases, require tracheal intubation.
Cardiocirculatory collapse may be treated with vasopressor and inotropic drugs.
Cardiac arrest requires supportive treatment as described in resuscitation protocols
(e.g., Advanced Cardiac Life Support [ACLS]).
Until a few years ago, cardiac arrest by local anesthetics was treated by putting
the patient on cardiopulmonary bypass until the effect of the anesthetic on the heart
ceased. Currently, there is a pharmacological alternative to reverse intoxication with
high success rates: intravenous infusion of a lipid emulsion, which is the lipid component used in parenteral nutrition. An initial infusion of 1.5 m/kg of 20% lipid
emulsion followed by an infusion of 0.25 m/kg for at least 10 min after the return of
cardiac function. If the instability remains, the initial dose is repeated, and
46
4
Pain Management in PCI: Analgesia and Anesthesia
maintenance dose is increased to 0.5 m/kg. The total recommended dose of lipid
emulsion is 10 mg/kg for 30 min.
Fortunately, the anesthetic doses used for outpatient procedures have little potential to trigger severe intoxication. In the face of initial symptoms, stopping the
administration of anesthetics, keeping the patient at rest, and if possible offering
supplemental oxygen should already be enough to stop the progression of intoxication [9–11].
4.3.1
Special Features of Anesthesia for PCI
PCI causes microperforations in the dermis and epidermis, structures that contain
approximately 4000 nerve endings per square millimeter. Therefore, it is an
extremely uncomfortable procedure if performed without any anesthetic technique.
Some points can be particularly unpleasant for the patient during the procedure, and
some deserve highlighting. The nociception itself, that is, the direct painful stimulus
on C-fiber and A-fiber skin, obviously causes discomfort. Proprioception, especially
in regions with bone protuberances with little fat tissue cushioning, such as the
malar, mentonian, and frontal regions, in which the movements with more pressure
of the microneedle device occur, can cause a lot of pain. Last but not least, the
uncertainty on the part of the patient that the next movement performed by the doctor will be painful or cannot cause a state of tension comparable to that experienced
in dentists’ chairs in more anxious individuals. It is also important to emphasize that
the depth of the proposed injury is directly proportional to the expected painful
stimulus [9–11].
When a moderate lesion is chosen, topical anesthesia is usually enough (see
Lima Protocol, in Chap. 11 (“Correcting Acne Scars Using PCI”)); however, in
cases where a purple end point is chosen and, consequently, a deep lesion, infiltrative anesthesia is mandatory. In the latter case, the author proposes a more concentrated solution when compared to the tumescent solution (Chap. 11, PCI in
Acne Scars).
Sources
1. Barash PG, Cullen BF, Stoelting RK et al. Clinical anesthesia. 8th. ed. LWW; 2017.
2. Cangiani LM, Nakashima ER, Gonçalves TAM, et al. Atlas de técnicas de bloqueios regionais.
Sociedade Brasileira de Anestesiologia; 2013.
3. Cohen JL. Pain treatment with lidocaine and tetracaine 7%/7% with LASER dermatologic
procedures. J Drugs Dermatol. 2013;12(9):986–9.
4. Cohen JL, Gold MH. Evaluation of the efficacy and safety of a lidocaine and tetracaine
(7%/7%) cream for induction of local dermal anesthesia for facial soft tissue augmentation
with hyaluronic acid. J Clin Aesthet Dermatol. 2014;7(10):32–7.
Sources
47
5. El-Fakahany H, Medhat W, Abdallah F, et al. Fractional microneedling: a novel method
to enhancement of topical anesthesia before skin aesthetic procedures. Dermatol Surg.
2016;42(1):50–5.
6. Gaitan S, Markus R. Anesthesia methods in laser resurfacing. Semin Plast Surg.
2012;26:117–24.
7. Greveling K, Prens EK, Ten Bosch N, et al. Comparison of lidocaine/tetracaine cream and
lidocaine/prilocaine cream for local anaesthesia during laser treatment of acne keloidalis nuchae and tattoo removal: results of two randomized controlled trials. Br J Dermatol.
2017;176(1):81–6.
8. Kouba DJ, LoPiccolo MC, Alam M, et al. Guidelines for the use of local anesthesia in office-­
based dermatologic surgery. J Am Acad Dermatol. 2016;74:1201–19.
9. Kumar M, Chawla R, Goyal M. Topical anesthesia. J Anesthesiol Clin Pharmacol.
2015;31(4):450–6.
10. Miller RD, Eriksson LI, Fleisher LA et al. Miller’s anesthesia. 8th ed. Saunders; 2014.
11. Sobanko JF, Miller CJ, Alster TS. Topical anesthetics for dermatologic procedures: a review.
Dermatol Surg. 2012;38:709–21.
12. Tran AN, Koo JY. Risk of systemic toxicity with topical lidocaine/prilocaine: a review. J Drugs
Dermatol. 2014;13(9):1118–22.
13. Wan K, Jing Q, Sun QN, et al. Application of a peripheral nerve block technique in laser
treatment of the entire facial skin and evaluation of its analgesic effect. Eur J Dermatol.
2013;23(3):324–30.
14. Wolf-Heidegger. Atlas de anatomia. 6th ed. Rio de Janeiro: Guanabara Koogan; 2006.
Chapter 5
Preparing the Skin for PCI
and Postoperative Management
Brazil is a tropical country, with a mixed skin population, subject to post-procedural
complications, sometimes not foreseen in a dermatological evaluation. Therefore,
the prevention of unexpected effects has been carefully observed, with skin preparation and care measures before and after the intervention. Unlike ablative treatments,
the use of microneedles preserves the epidermis, provides greater postoperative
safety, and reduces the incidence of adverse effects. It is known that removal of the
epidermis mechanically or chemically releases cytokines and the migration of
inflammatory cells culminating in the replacement of damaged tissue with scar tissue, which happens with medium and deep chemical peelings. However, recovery
from these procedures is long, and the result is more light-sensitive tissue subject to
post-inflammatory hyperpigmentation and photosensitivity. In addition to these
aspects, there is also an increased risk of complications, such as formation of hypertrophic scars, persistent erythema, and dyschromias [1, 2].
The need to be absent for a long time from their work activities often limits the
choice of the candidate for these interventions. In percutaneous collagen induction
(PCI) with needling, the choice of a proposal for a mild, moderate, or deep lesion
determines post-procedural care and guidance. The preparation of the skin to be
treated is recommended in dermatological procedures, aiming to prevent complications. A treated skin, adapted to the sun filter and with less melanin available to the
possibility of post-inflammatory hyperpigmentation, is always welcome. However,
it is observed that the risks of complications, even in a skin that has not been previously prepared, are lower with the PCI if compared to the techniques that dehepithelialize. In this chapter, the factors involved and possible conducts prior to the
procedure will be discussed [3].
• It is worth highlighting the importance of good quality photography, in at least
three positions: one front and two profile, on each side. This is because a common fact is the forgetfulness of small defects that already existed by the patient
The Editor(s) (if applicable) and The Author(s), under exclusive license
to Springer Nature Switzerland AG 2021
E. Lima, M. Lima, Percutaneous Collagen Induction With Microneedling,
https://doi.org/10.1007/978-3-030-57541-0_5
49
50
5
Preparing the Skin for PCI and Postoperative Management
before the procedure. Thus, with the photos, it is possible to control their appearance, even marking the day of the photo after the surgical act [4].
• An adequate anamnesis is also fundamental before any procedure, highlighting
the importance of the following points:
1. Prevention of simple herpes: consider surgical stress and the recalcitrant
character of the infection, even when facing a non-ablative procedure.
Routinely, there is no need for prevention, since the keratinocytes are not
removed. However, if there is a history of repeated herpetic lesions in the
individual to be treated, it is necessary to treat with usual preventive doses.
2. Checking for medications: it is necessary to monitor the use of anticoagulants and similarly, antihypertensives (warning about hypertensive peak during the intervention), hypoglycemic agents, or insulin (decompensated
diabetes mellitus and delayed healing process), as well as the chronic use of
systemic corticotherapy.
3. Pregnancy and breastfeeding: we contraindicate the intervention because the
need for topical or infiltrative anesthesia compromises the level of safety of
the intervention during these periods.
4. History of post-inflammatory hyperpigmentation after the procedure: is not
considered an absolute contraindication.
5. Allergies to drugs or metals and topical or systemic anesthetics.
6. Autoimmune diseases: not considered contraindications.
7. Hypersensitivity to pain in the presence of neuropathies.
8. History of previous surgical interventions and bleeding behavior in surgical
procedures (the deficiency of some factors involved in coagulation is not
detected by tests).
9. Current use of isotretinoin: it is not considered a contraindication for intervention, regardless of the proposed injury. Even in the author’s experience,
the results obtained with a deep lesion in the treatment of acne scars on an
oily skin, for example, are optimized by the introduction of PCI already
7 days postoperatively.
10. Unrealistic anxiety and expectation: it is necessary to talk about previous
procedures carried out for the same purpose, particularly with regard to acne
scars. In addition, it is necessary to confirm the degree of satisfaction and
avoid promising results measured by percentage of improvement, remembering that each individual can respond with particularities to the procedures.
11. Time of isolation: it is important to clearly establish the time when the
patient should not sunbathe, as well as absences from work and the return to
social life.
12. Adequacy of the patient’s profile to the intervention: the versatility of PCI,
varying from moderate to deep injury, enables a range of possibilities (see
Chap. 2, Classification and Characteristics of Injury Caused by PCI) [4–6].
5.1
5.1
Skin Care That Favors Treatment
51
Skin Care That Favors Treatment
PCI produces micro-orifices long enough to break through the integrity of the skin
barrier and affect the dermis, depending on the length of the needle. This triggers an
inflammatory stimulus and future formation of a new collagen with the bleeding
caused. Because of this, we recommend a preparation that should start 2–4 weeks
before the procedure, which consists of the association of topical agents that are part
of the arsenal prescribed by the dermatologist and which will be listed in this
chapter.
A skin that has already been taken care of regularly may often not require a specific pre-treatment, or a complementary treatment may be instituted. Prepared skin
provides more effective and uniform treatment results when compared to unprepared skin. It is also possible to minimize possible adverse effects, such as hypo- or
hyperpigmentation post-inflammatory and persistent erythema, in addition to promoting faster reepithelialization and improved healing.
Thus, the main objective of the preparation would be to promote skin alterations
capable of favoring the outcome of the procedure, such as:
• To reduce the skin barrier of the stratum corneum, making it less thick and more
responsive to PCI
• To encourage the process of reepithelialization and healing, minimizing
adverse effects
• To minimize the chance of post-inflammatory hyperpigmentation
• To decrease the chance of post-procedural residual hypochromia
• To reduce the chances of increased oiliness or development of post-procedural
acne lesions
This includes the use of soap for sensitive skin, sun filters, antiaging actives, skin
lighteners, and regenerators. With these measures, it is also possible to evaluate the
sensitivity and tolerance of the skin; thus, knowing the patient’s skin, it is possible
to define more safely the degree of lesion to be proposed.
• Soap for sensitive skin. They should be prescribed according to the type of skin
of the patient who will undergo the procedure and can be maintained until the
day of the procedure. Depending on the product used, they should be discontinued after the procedure, according to the recommendations in this period; however, normally, if they have moderate detergency power, they can be kept at home
after the PCI.
• Sunscreen. Same that the patients are in the habit of using in their daily life.
Avoiding risk of having contact dermatitis, intolerance, increased oiliness, or
dryness of the skin, which would compromise adherence. It is always recommended a sunscreen with a wide spectrum of protection, preferably toned, which
will be useful both as a physical barrier and to mask the erythema, peeling, or
52
5
Preparing the Skin for PCI and Postoperative Management
crust in the postoperative period. Depending on the injury, the sunscreen can be
introduced 12 hours after the procedure (moderate injury) or after reepithelialization (around 5 days) for the deep injury. In the author’s experience, the
­introduction of sunscreen 1 hour after surgery of a moderate injury, over the
biological dressing resulting from a modest exudation that had already solidified,
is safe. No complaints of burning, irritation, or additional erythema.
• Topical retinoic acid and alpha-hydroxy acid (AHA). Its action on the horny
extract can optimize the results of PCI. Whether in cream or gel form, its use is
recommended in advance to ensure better quality skin, facilitating the penetration of microneedles. Tretinoin makes the stratum corneum thinner, besides
accelerating the process of post-inflammatory reepithelialization. The use of this
product should also be stimulated after the procedure, as it has a great value in
the skin rejuvenation program and in the improvement of scars, due to its action
in the remodeling of the collagen. AHA have a different mechanism of action
when compared to retinoic acid, but the effect is similar to the stratum corneum,
acting in synergy and being recommended both before and after reepithelialization (7 days – deep injury), or already the day after a moderate lesion.
• Vitamin C. It is a powerful antioxidant that has a similar function to that proposed by retinoic acid in the formation of collagen. The product must be reapplied every day so that the natural protection and repair of DNA can be maintained.
According to Fernandes and Signorini [10], researchers in microneedles, the use
of vitamin C after the PCI is essential for the formation of a new collagen. With
the production of more collagen, the need for this vitamin increases; therefore,
after the procedure, it is suggested to increase it in diet and topical use. The
authors indicate the topical use of ascorbyl tetraisopalmitate, which has been
shown to be less irritating to the skin, being the most efficient form of vitamin C.
• Whitenings. The most used is still hydroquinone. Its depigmenting action happens mainly by inhibition of the tyrosinase enzyme and control of DNA and
RNA synthesis, with concomitant degradation of melanosomes and destruction
of melanocytes. It is very useful in the control of hyperpigmentation, before the
procedure and after the procedure, produced in the last case by the inflammatory
action, the vasodilation, and the subsequent healing process. For patients allergic
to this phenolic compound, the use of kojic acid, arbutin, azelaic acid, phytic
acid, and dioic acid, among others, alone or in association, is recommended.
These products have lesser whitening power than hydroquinone, but have their
effects optimized when associated with retinoic acid or glycolic acid [4–6].
5.2
Detailing the Guidelines for Moderate Injury
When the programmed injury is moderate, using needle lengths of 1.5 mm, topical
anesthesia is usually sufficient. The end point expected is a moderate punctiform
bleeding that results in satellite petechiae on a diffuse erythema. The application of
5.2 Detailing the Guidelines for Moderate Injury
53
4% liposomal lidocaine is recommended 1 hour before the intervention. The amount
of 30 g is safe for the treatment of the entire face, while up to 60 g can be used for
body treatments. The author proposes the following use protocol:
1. Apply the 4% liposomal lidocaine, initially 15 g, on the face (do not wash the
face before).
2. Massage, taking advantage of the greasy skin as a favorable means for the anesthetic delivery.
3. After 30 minutes of the first 15 g, apply another 15 g and proceed in the same
way, massaging.
4. There is no need for occlusion.
5. After 1 hour of anesthetic and total use of 30 g, remove it with an antiseptic
(chlorhexidine 2%) and perform the intervention.
This anesthesia is commonly effective to perform the moderate injury PCI. When
the option is deep injury PCI, the methodology can also be applied followed by
infiltrative anesthesia.
There is no need for removal of the exudation after PCI, since growth factors and
stem cells released with the penetration of needles as an additional therapeutic
mechanism can be counted on. In a few minutes, the holes close, and the deposition
of an active substance glimpsing a drug delivery can be performed at the end of the
lesion. The choice of this substance depends on the dermatologist’s practice (see
Chap. 18).
However, it is necessary to warn about the safety of these products. The corneal
layer and the epidermis are traumatized; therefore, the skin barrier is destabilized.
Although there is no consensus on the risk of administration on traumatized skin of
a dermocosmetic available in non-sterile tubes, creams, or serum, it should be
remembered that they were made for use on the whole skin. In the sequence, modest
serous exudation is observed, which tends to persist for 30 minutes to 2 hours and
is beneficial for the treatment and should not be removed. In minutes they close, and
the deposition of an asset glimpsing a drug delivery can be performed already at the
end of the injury, or not.
Thus, if there is the option of making the medicine available, the patient follows
it over the treated area; removes it after 6–8 hours, cleansing the skin with water and
soap of low detergency; and starts the use of sunscreen. If you are using any home
treatment that includes the use of acids, lighteners, or dermocosmetics, the reintroduction already happens the next day. It is also recommended to restrict sun exposure and artificial lighting on the following days, with the help of a broad-spectrum
sunscreen, with SPF >30, preferably toned. In addition, extreme exposures in recreational activities, such as in beaches, pools, parks, and fields, should be avoided for
at least 1 week, but the return to work can happen the following day. For a moderate
injury PCI, a modest peeling can be installed in the first 72 hours, without causing
any inconvenience. Often, there is no need to use a specific skin regenerator due to
the degree of the lesion, since reepithelialization occurs quickly. A new stimulus
with the same intensity may be recommended in 15–30 days, depending on the
54
5
Preparing the Skin for PCI and Postoperative Management
proposed protocol. Makeup can be used the following day. There is no postoperative pain.
Only the stimulus of the needles is sufficient for angiogenesis and neocollagenesis, and the choice of this substance depends on the dermatologist’s practice. In
our experience and based on the latest publications by our group of professionals,
this lesion is suitable for whitening of melasma, without the addition of any active
ingredient, according to the protocol proposed by Emerson Lima (2016) (see
Chap. 9, PCI in Melasma). This lesion is also used for the 5% retinoic acid peeling
permeate recommended by Emerson Lima (2018). The patient follows with it and
removes it after 2 hours, sanitizing the skin with water and soap of low detergency
and already starting the use of sunscreen (see Chap. 9). Another option is to apply
a mask of biocellulose and, after 30–40 minutes, remove it and send the patient
home. After this period, the use of sunscreen is safe, according to the author’s
experience. The procedure for home treatment is identical to that adopted with
mild lesions [15–19].
As a modest edema and a diffuse erythema are left, the return to labor activities
is likely to happen the next day. Furfuraceous peeling can be installed in the first
72 hours, without causing any inconvenience. Topical or systemic antibiotics are not
recommended, as it is considered unnecessary to perform anti-herpetic prophylaxis,
since it is a non-ablative procedure. Frequently, there is no need to use a specific
skin regenerator, due to the modest depth of the lesion; however, in case of discomfort, the use can be done. The reepithelialization occurs in a few days; however, the
skin is more sensitive and, consequently, more subject to external damages.
Therefore, direct sun exposure should be avoided. A new stimulus with the same
intensity may be recommended in 30 days, depending on the proposed protocol.
The use of analgesics and/or anti-inflammatories is not necessary. Topical or systemic corticotherapy is prohibited.
5.3
Detail of the Guidelines for Deep Lesion
This goal is commonly achieved with lengths ranging from 2.0 to 2.5 mm (see
Chap. 2), providing substantial bleeding, which gives way to serosanguinolent exudation (20–30 minutes) and then serous (40–60 minutes). After 60 minutes, the
treated area presents itself only as a uniform purple, end point that should be pursued when the choice is a deep injury. This intervention is performed under infiltrative anesthesia, and the transoperative takes place with the need to contain bleeding
and exudation. Hygienization is performed with the aid of gauzes and compresses.
In the sequence, an intense serous exudation is observed, which tends to persist
for 4–6 hours; therefore, it is necessary to use a dressing that contains this serosity
(a generous amount of gauzes and Micropore® is recommended directly on the
skin). It is not recommended the deposition of any asset when the lesion is deep,
because there is a counterflow in the newly opened channels full of blood incompatible with the predictable absorption of any substance. The dressing remains for at
5.3
Detail of the Guidelines for Deep Lesion
55
least 12 hours and is removed at home by the patient with the aid of running water
and a soap with low detergency potential, in the shower, in long baths. Direct sun
exposure should be avoided within 5–7 days after the procedure; therefore, it is
recommended not to leave home. The dressing does not need to be renewed; however, after removal, the use of a regenerating balm, siliconized gel, or dexpanthenol-­
based gel is indicated until reepithelialization, which occurs in 5–7 days. From then
on, the use of lightening agents and sunscreen is recommended.
Extreme exposures in recreational activities, such as in the beach, swimming
pools, parks, and fields, should be avoided for at least 1 month. The use of topical
or systemic antibiotic therapy is not recommended.
Although this practice is accepted in dermatology, the Food and Drug
Administration (FDA) has condemned its use because of the risk of developing
bacterial resistance. Thus, studies have compared the use of topical antibiotics in the
post-procedure with that of a humectant, demonstrating that healing occurs to satisfaction and with the same quality through the use of the latter. Publications also
point to the risk of sensitization to the topical antibiotic, even if the allergy has not
been evidenced before, suggesting a mechanism of cross-reaction with other assets,
which prolongs and hinders conventional healing. Figure 5.1 presents a patient
before and at 7 days postoperatively, demonstrating sensitization to the use of the
topical antibiotic [12–6].
In deep injury PCI, the edema is substantial in the first 24 hours and progressive
up to 72 hours, when it starts to regress. The diffuse hematoma of the treated area is
replaced by crusts that can be hematic and melicic, and they release spontaneously,
and should not be removed mechanically under any circumstances. Figure 5.2
shows the evolution of a patient before, after 24 hours, and after 7 days of
intervention.
Fig. 5.1 Patient before and at 7 days postoperatively presenting sensitization to the use of topical
antibiotic
56
5
Preparing the Skin for PCI and Postoperative Management
Fig. 5.2 Evolution of a patient with acne scars before, after 24 hours, and after 7 days of PCI with
2.5 mm needle length
The return to the labor activities is likely to occur only after the fifth to the seventh day, when there is only a very consistent erythema that regresses with the passing of the days, followed by a furfurous peeling, without causing any inconvenience.
At this stage, however, post-inflammatory hyperpigmentation may occur if the necessary precautions are not taken.
Topical or systemic antibiotics are not recommended. The postoperative period
is painless, and the use of anti-inflammatory or analgesic is unnecessary. Topical or
systemic corticosteroid to contain the edema is outlawed.
5.4
Biocellulose in Post-procedure
The biocellulose mask is a new alternative for immediate post-procedure handling,
with the promise of more comfort and practicality. It is produced from a biotechnological process, the result of bacterial fermentation and its subsequent purification.
The product is a thick, gelatinous membrane whose microscopic structure consists
of a 3D network of cellulose nanofibers. This arrangement provides some properties, such as high mechanical resistance, malleability, and high water retention
power. Its ability to absorb exudates and to be easily removed favors PCI. It is also
capable of accelerating skin recovery by regulating angiogenesis and connective
tissue formation.
A comparative study conducted in vivo indicated greater epidermal and dermal
thickening, increased collagen production in the early days, improved granulation
tissue formation, and increased amount of blood vessels in the group treated with
biocellulose. In addition, a significant decrease in mast cell tissue infiltration and
production of vascular endothelial growth factor (VEGF) was also observed. Its use
after PCI is justified by its ability to provide an occluded and hydrated environment,
favoring the acceleration of reepithelialization and helping to reduce erythema and
contain symptoms such as pain and burning [2–11].
Sources
5.5
57
Closing Considerations
PCI is an innovative technique that results in the stimulation of collagen production,
used mainly in rejuvenation and scar correction. With the right tool and technique,
it shows promise in this wide arsenal of dermatological procedures, becoming an
excellent alternative to laser treatment, besides having lower investment cost with
shorter recovery time (downtime).
The preparation of the skin pre-procedure is a fundamental step, since the more
detailed knowledge of the patient’s skin to be treated makes it possible to obtain
better results. Although there is no absolute contraindication to perform the procedure, it is also possible to evaluate the patient’s commitment and ability to adhere to
the information received, which ensures that the objectives will be achieved.
Although IPCA® is considered an outpatient corrective procedure more routinely
performed in dermatology offices with limited complications, it is suggested that
pre-treatment skin care and immediate preparation before the procedure should be
rigorous, avoiding risks of complications and ensuring the best possible results.
Sources
1. Cohen KI, Diegelmann RF, Lindbland WJ. Wound healing: biochemical and clinical aspects.
Philadelphia: WB Saunders Co; 1992.
2. Costa IMC, Igreja ACS, Costa MC. Dermabrasão, microdermabrasão e microagulhamento. In:
Tratado de cirurgia dermatológica, cosmiatria e laser da Sociedade Brasileira de Dermatologia.
Rio de Janeiro: Elsevier; 2012.
3. Czaja W, Krystynowicz A, Bielecki S, et al. Microbial cellulose – the natural power to heal
wounds. Biomaterials. 2006;27(2):145–51.
4. Czaja WK, Young DJ, Kawecki M, et al. The future prospects of microbial cellulose in biomedical applications. Biomacromolecules. 2007;8(1):1–12.
5. Desmond F, Massimo S. Combating photoaging with percutaneous collagen induction. Clin
Dermatol. 2008;26:192–9.
6. Draelos Z. A comparison of post-procedural wound care treatments: do antibiotic-based ointments improve outcomes? J Am Acad Dermatol. 2011;64:S23–9.
7. Fabroccini G, Fardella N. Acne scar treatment using skin needling. Clin Exp Dermatol.
2009;34(8):874–9.
8. Fernandes D. Minimally invasive percutaneous collagen induction. Oral Maxillofac Surg Clin
North Am. 2006;17(1):51–63.
9. Fernandes D, Massimo S. Combating photoaging with percutaneous collagen induction. Clin
Dermatol. 2008;26(2):192–9.
10. Fernandes D, Signorini M. Combating photoaging with percutaneous collagen induction. Clin
Dermatol. 2008;26:192–9.
11. Kalil CLPV, Frainer RH, Dexheimer LS, et al. Tratamento das cicatrizes de acne com a técnica
de microagulhamento e drug delivery. Surg Cosmet Dermatol. 2015;7(2):144–8.
12. Kede MPV, Sabatovich O. Dermatologia estética. 3. ed. rev. e ampl. São Paulo: Atheneu; 2015.
13. Kwak MH, Kim JE, Go J, et al. Bacterial cellulose membrane produced by Acetobacter sp.
A10 for burn wound dressing applications. Carbohydr Polym. 2015;122:387–98.
14. Leyden JJ, Shergill B, Micali G, et al. Natural options for the management of hyperpigmentation. J Eur Acad Dermatol Venereol. 2011;25(10):1140–5.
58
5
Preparing the Skin for PCI and Postoperative Management
15. Lina F, Zhang Y, Li C, et al. Skin tissue repair materials from bacterial cellulose by a multilayer
fermentation method. J Mater Chem. 2012;22:12349–57.
16. Mateus A, Palermo E. Cosmiatria e laser: prática no consultório médico. São Paulo: AC
Farmacêutica; 2012.
17. Nathan ST. Treatment of minor wounds from dermatologic procedures: a comparison of three
topical wound care ointments using a laser wound model. J Am Acad Dermatol. 2011;64:S8–15.
18. Orentreich DS, Orentreich N. Subcutaneous incisionless (subcision) surgery for the correction
of depressed scars and wrinkles. Dermatol Surg. 1995;21:6543–9.
19. Resnik BI. O papel da preparação da pele para o peeling. In: Rubin MG, editor. Peeling
químico. Rio de Janeiro: Elsevier; 2007.
Chapter 6
Histopathological Evidences
of the Percutaneous Collagen Induction
with Microneedling
Helio Miot
6.1
Introduction
Both the epidermis and dermis react to skin trauma by releasing inflammatory
mediators, activating tissue enzymes and components of the coagulation that promote the initiation of tissue repair and change in skin physiology. However, the
nuances of tissue response modulation according to the type and intensity of the
aggression promoted are not known in detail.
There is extensive literature on the repair process, morphogenesis, and neocollagenesis, which follow different chemical peelings, dermabrasion, and lasers (and
light technologies), both ablative and non-ablative (fractionated or not), in addition
to microneedling. Interestingly, all these interventions present particularly different
responses due to the pattern of damage they promote. A thorough knowledge of
these patterns and the repair cascades they induce not only tends to maximize results
based on the best indications but also can lead to idealize new treatments or a combination of procedures.
In the case of percutaneous induction of collagen with needles, the tissue
response is extremely dependent on the density of the perforations and the depth
they reach. In the conditions that will be described later, the different types of
aggression induced by microneedling also lead to their own effects on skin physiology, which should be clarified in further research.
Figure 6.1 demonstrates the immediate microneedle-induced tissue damage with
rollers of 0.5 and 1 mm in depth. The depth the needle reaches, in addition to its
length, depends on the intensity of the operator pressure; however, in general, there
is a penetration of 50–70% of the needles into the tissue.
H. Miot
Botucatu - Sao Paulo University, Brazil, Recife, Brazil
The Editor(s) (if applicable) and The Author(s), under exclusive license
to Springer Nature Switzerland AG 2021
E. Lima, M. Lima, Percutaneous Collagen Induction With Microneedling,
https://doi.org/10.1007/978-3-030-57541-0_6
59
60
a
6
Histopathological Evidences of the Percutaneous Collagen Inducti…
b
Fig. 6.1 Histological skin sections stained by hematoxylin and eosin (H&E) immediately after
skin microneedling. (a) Microneedle 0.5 mm deep. (b) Microneedle 1 mm deep
In the 0.5 mm needle injury, the damage occurs predominantly within the epidermis, in the basal membrane area, and with slight involvement of the upper dermis.
Clinically, there is no obvious bleeding, recovery is faster, and the skin response is
reflected especially in the overall improvement of skin brightness and quality. In
thinner epithelia (e.g., photoaged face), the damage can spread more deeply.
In needle-induced lesions of 1 mm or longer, the endothelium of the capillary loops
of the upper dermis or beyond is clearly affected, promoting from vivid bleeding to a
purplish coloration. The edema is more prominent, as is pain and recovery time.
In all needling regimes, epidermal perforation is occluded with fibrin and reepithelialized within 24 hours, which minimizes the downtime of the procedure.
Microneedling perforation increases transepidermal permeability by more than
72 hours, which maximizes drug delivery, although it favors adverse effects and
sensitivity to commonly administered topical products on the whole epidermis.
The residual erythema reflects the underlying dermal repair, a process that lasts
more than 60 days, and may represent greater sensitivity to heat and sun exposure,
both by vasodilation and by the release of inflammatory mediators.
In general, changes in photoaging and melasma are satisfactorily treated with
microneedling regimes that privilege damage to the upper dermis. The acne scars
and stretch marks need the remodeling of the collagen in the intermediate dermis.
Finally, the microneedling of areas with thicker epithelium (e.g., gluteus) or fibrous
areas, by definition, requires longer needles (e.g., 2.5 mm) to achieve the same
results as shorter needles on the face.
There is some consensus that the promotion of neocollagenesis and tissue remodeling is proportional to the dermal damage promoted; however, there are differences
between dermal remodeling and the epidermal response of damage at the same
depth induced by different treatments such as microneedling and fractionated
CO2 laser.
6.2 Photoaging and Melasma
61
A valuable contribution to the functional understanding of micrografting was the
study in an organoid (3D) skin model, which enables the sequential evaluation of
morphological and molecular phenomena involved. Complete reepithelialization
was evidenced after 5 days after trauma. Genes related to dermal remodeling showed
positive regulation (COL1, COL8A1, TIMP3), as well as those involved in epithelial proliferation (KRT13, IGF1), leukocyte chemotaxis (CCL1), and innate immune
activation (HSPB6). On the other hand, some pro-inflammatory cytokines commonly activated by trauma have undergone negative regulation (interleukin [IL]-1α,
IL-1β, IL-24, IL-36γ, IL-36RN), as well as antimicrobial peptides (S100A7A,
DEFB4). These data provide a skin remodeling signature that differs from other
damages, especially thermal ones, which release high levels of IL-1. This may justify the rarity of post-inflammatory hyperpigmentation (PIH) following
microneedling-­induced trauma, in contrast to dermabrasion, medium peelings, and
ablative laser technologies.
6.2
Photoaging and Melasma
Microneedling with slight to moderate skin damage produces tissue changes that
promote the reversal of histological changes characteristic of photoaging and
melasma. Figure 6.2 presents, side-by-side, examples of histological sections of the
skin with different levels of photoaging. The main histological alterations of the
procedure can be verified by hyperkeratosis and compression of the corneal layer,
atrophy and rectification of the epithelium, hypergranulosis, depolarization of the
nuclei, solar elastosis, and fragmentation of dermal collagen with telangiectasis.
Besides the effects of endogenous aging, the main promoters of photoaging are
the ultraviolet B (UVB) and ultraviolet A (UVA) radiations, which produce, among
many other changes, mutations in the epidermis, with a reduction in its synthesis
a
b
Fig. 6.2 Histological sections of skin stained by hematoxylin and eosin (H&E) (100×). (a) Skin
without signs of photoaging. (b) Skin with signs of photoaging
62
6
Histopathological Evidences of the Percutaneous Collagen Inducti…
and repair capacity, in addition to dermal damage, with the activation of metalloproteinases that ensure a pro-inflammatory environment in the upper dermis.
Figure 6.3 presents in detail the basal membrane zone with photoaging alterations, such as hypermelanogenesis, basal layer vacuolization, loss of basal keratinocyte polarity, basal membrane discontinuity and structural damage, elastonization,
and fragmentation of collagen fibers.
In photoaged or melasma skin (Figs. 6.4, 6.5, 6.6, 6.7, and 6.8), microneedling
promotes consistent thickening of the epithelium, with regularization of the nuclear
polarity of the basal layer, reduction of solar elastosis, increase of types I and III
collagen and of type VII collagen (component of the basal membrane zone). A 5%
reduction in melanin density and granulation of melanosomes, structural increase of
the basal membrane zone, and 32% increase in keratinocyte proliferation rate (Ki67)
Fig. 6.3 Histological
section of skin stained by
periodic acid-Schiff
(PAS) (400×)
a
b
Fig. 6.4 Histological sections of the skin with melasma stained by Fontana-Masson (100×). (a)
Before microneedling. (b) After two microneedling sessions (45 days), showing an increase in the
thickness of the epidermis and a reduction in the density of melanin
6.2 Photoaging and Melasma
a
63
b
Fig. 6.5 Histological sections of the skin with melasma stained by Herovici (100×). (a) Before
microneedling. (b) After a microneedling session (7 days), showing increased density of collagen
fibers and deposition of fibrin and proteoglycan
a
b
Fig. 6.6 Histological sections of the skin with melasma stained by Picrosirius red (100×). (a)
Before microneedling. (b) After two sessions of microneedling (45 days), showing a consistent
increase in the thickness of the epidermis and increased density of collagen in the upper dermis
can also be observed. These changes in the epidermis may justify the appearance of
improvement in skin texture.
The reduction in epidermal melanin density may be the reason why microneedling has gained popularity in people with more pigmented skin (e.g., Latinos,
Africans, and Indians and people in the Middle East), since ablative procedures
often take place with PIH in the most melanized skin.
In summary, clinical changes in photoaging and melasma are supported by
changes in the epidermis and dermis. Repair of the upper dermis and basal membrane zone re-establishes the physiology of dermoepidermal interaction.
64
a
6
Histopathological Evidences of the Percutaneous Collagen Inducti…
b
Fig. 6.7 Histological skin sections with melasma stained by periodic acid-Schiff (PAS) (100×).
(a) Before microneedling. (b) After a microneedling session (7 days), showing early reconstitution
of the basal membrane area
a
b
Fig. 6.8 Histological skin sections with melasma marked by Ki67 (100×). (a) Before microneedling. (b) After a microneedling session (7 days), showing early increase in kinetics of keratinocytic replication
The combination of treatments for photoaging and melasma (not only the drug
delivery but also the association with peelings and light technologies) should lead to
optimal results. In melasma, the sum of this triple combination with photoprotection
and micro-nursing promotes a lower recurrence rate in 60 days, when compared to
other treatments.
6.3
Acne and Stretch Mark Scars
The largest volume of publications on microneedling repair refers to the most evident dermal damage necessary for the treatment of acne scars, surgical scars, and
stretch marks. However, most of the works do clinical evaluation. A few histological
and functional evaluations are described below.
Sources
65
In an Egyptian study, with ten volunteers treated for facial acne scars, after
3 months (six sessions) of microneedling, it was shown increased thickness of the
epithelium (26%), tropoelastin (47%), type I collagen (21%), type III collagen
(22%), and type VII collagen (41%).
Facial acne scars treated with microneedling sessions (1.5 mm) revealed a substantial increase in dermal collagen, elastin, and dermal thickness, in addition to the
previously mentioned epidermal changes such as acanthosis and depigmentation.
The authors warn about the risk of hematoma in places with thinner epidermis (and
dermis), such as the periorbital region.
In an evaluation of microneedling versus carboxytherapy for atrophic acne scars
of the face (split face), in 32 patients, besides clinical improvement, the treatments
promoted objective increase of dermal collagen, elastic fibers, and dermis reorganization, when evaluated after 2 months.
There is no substantial medical literature regarding the histological changes promoted by microneedling in cases of vitiligo, alopecia, burn scars, exogenous ochronosis, and scleroderma. Similarly, the different microneedling systems were not
systematically compared (e.g., roller versus electrical).
Sources
1. Abdel-Motaleb AA, Abu-Dief EE, Hussein MR. Dermal morphological changes following
salicylic acid peeling and microdermabrasion. J Cosmet Dermatol. 2017;16:e9–e14.
2. Agamia N, Badawi A, Sorror O, et al. Clinical and histopathological comparison of microneedling combined with platelets rich plasma versus fractional erbium-doped yttrium aluminium
garnet (Er: YAG) laser 2940 nm in treatment of atrophic post traumatic scar: a randomized
controlled study. J Dermatolog Treat. 2020:1–24.
3. Alster TS, Graham PM. Microneedling: a review and practical guide. Dermatol Surg.
2018;44:397–404.
4. Andrade Lima EV, Aandrade Lima MMD, Miot HA. Induction of pigmentation through
microneedling in stable localized vitiligo patients. Dermatol Surg. 2010;46(3):434–5.
5. Bandral MR, Padgavankar PH, Japatti SR, et al. Clinical evaluation of microneedling therapy
in the management of facial scar: a prospective randomized study. J Maxillofac Oral Surg.
2019;18:572–8.
6. Berneburg M, Plettenberg H, Krutmann J. Photoaging of human skin. Photodermatol
Photoimmunol Photomed. 2000;16:239–44.
7. Bhawan J, Andersen W, Lee J, et al. Photoaging versus intrinsic aging: a morphologic assessment of facial skin. J Cutan Pathol. 1995;22:154–9.
8. Bonati LM, Epstein GK, Strugar TL. Microneedling in all skin types: a review. J Drugs
Dermatol. 2017;16:308–13.
9. Cassiano D, Esposito Lemos AC, Hassun K, et al. Efficacy and safety of microneedling and
oral tranexamic acid in the treatment of facial melasma in women: an open, evaluator-blinded,
randomized clinical trial. J Am Acad Dermatol. 2020;
10. Cassiano DP, Esposito ACC, Hassun KM, et al. Early clinical and histological changes
induced by microneedling in facial melasma: a pilot study. Indian J Dermatol Venereol Leprol.
2019;85:638–41.
11. de Andrade Lima EV, de Andrade LM, Takano D. Microagulhamento: estudo experimental e
classificação da injúria provocada. Surg Cosmet Dermatol. 2013;5:110–4.
66
6
Histopathological Evidences of the Percutaneous Collagen Inducti…
12. Dhurat R, Sukesh M, Avhad G, et al. A randomized evaluator blinded study of effect of
microneedling in androgenetic alopecia: a pilot study. Int J Trichology. 2013;5:6–11.
13. Ebrahim HM, Elkot R, Albalate W. Combined microneedling with tacrolimus vs tacrolimus
monotherapy for vitiligo treatment. J Dermatolog Treat. 2020:1–6.
14. El-Domyati M, Attia S, Saleh F, et al. Intrinsic aging vs. photoaging: a comparative histopathological, immunohistochemical, and ultrastructural study of skin. Exp Dermatol.
2002;11:398–405.
15. El-Domyati M, Barakat M, Awad S, et al. Multiple microneedling sessions for minimally invasive facial rejuvenation: an objective assessment. Int J Dermatol. 2015;54:1361–9.
16. El-Domyati M, Hosam W, Abdel-Azim E, et al. Microdermabrasion: a clinical, histometric,
and histopathologic study. J Cosmet Dermatol. 2016;15:503–13.
17. El-Domyati MB, Attia SK, Saleh FY, et al. Trichloroacetic acid peeling versus dermabrasion: a histometric, immunohistochemical, and ultrastructural comparison. Dermatol Surg.
2004;30:179–88.
18. El-Fakahany H, Medhat W, Abdallah F, et al. Fractional microneedling: a novel method
for enhancement of topical anesthesia before skin aesthetic procedures. Dermatol Surg.
2016;42:50–5.
19. Iosifidis C, Goutos I. Percutaneous collagen induction (microneedling) for the management of
non-atrophic scars: literature review. Scars Burn Heal. 2019;5:2059513119880301.
20. Ismail ESA, Patsatsi A, Abd El-Maged WM, et al. Efficacy of microneedling with topical
vitamin C in the treatment of melasma. J Cosmet Dermatol. 2019;18(5):1342–7.
21. Jha AK, Vinay K. Androgenetic alopecia and microneedling: every needling is not microneedling. J Am Acad Dermatol. 2019;81:e43–e4.
22. Kligman AM, Baker TJ, Gordon HL. Long-term histologic follow-up of phenol face peels.
Plast Reconstr Surg. 1985;75:652–9.
23. Konicke K, Knabel M, Olasz E. Microneedling in dermatology: a review. Plast Surg Nurs.
2017;37:112–5.
24. Krieg T. Cell-cell and cell-matrix interactions in the skin – implications for tissue repair and
chronic wounds. Bull Mem Acad R Med Belg. 2010;165:393–7; discussion 8.
25. Kumar MK, Inamadar AC, Palit A. A randomized controlled, single-observer blinded study to
determine the efficacy of topical minoxidil plus microneedling versus topical minoxidil alone
in the treatment of androgenetic alopecia. J Cutan Aesthet Surg. 2018;11:211–6.
26. Lee Peng G, Kerolus JL. Management of surgical scars. Facial Plast Surg Clin North Am.
2019;27:513–7.
27. Lima EVA, Lima M, Paixao MP, et al. Assessment of the effects of skin microneedling as
adjuvant therapy for facial melasma: a pilot study. BMC Dermatol. 2017;17:14.
28. Meddahi A, Caruelle JP, Gold L, et al. New concepts in tissue repair: skin as an example.
Diabetes Metab. 1996;22:274–8.
29. Minh PPT, Bich DD, Hai VNT, et al. Microneedling therapy for atrophic acne scar: effectiveness and safety in Vietnamese patients. Open Access Maced J Med Sci. 2019;7:293–7.
30. Moftah NH, El Khayyat MAM, Ragai MH, et al. Carboxytherapy versus skin microneedling
in treatment of atrophic postacne scars: a comparative clinical, histopathological, and histometrical study. Dermatol Surg. 2018;44:1332–41.
31. Priya SG, Jungvid H, Kumar A. Skin tissue engineering for tissue repair and regeneration.
Tissue Eng Part B Rev. 2008;14:105–18.
32. Rana S, Mendiratta V, Chander R. Efficacy of microneedling with 70% glycolic acid peel
vs microneedling alone in treatment of atrophic acne scars-A randomized controlled trial. J
Cosmet Dermatol. 2017;16:454–9.
33. Scattone L, de Avelar Alchorne MM, Michalany N, et al. Histopathologic changes induced
by intense pulsed light in the treatment of poikiloderma of Civatte. Dermatol Surg.
2012;38:1010–6.
34. Schmitt L, Marquardt Y, Amann P, et al. Comprehensive molecular characterization of microneedling therapy in a human three-dimensional skin model. PLoS One. 2018;13:e0204318.
Sources
67
35. Schwarz M, Laaff H. A prospective controlled assessment of microneedling with the
Dermaroller device. Plast Reconstr Surg. 2011;127:146e–8e.
36. Stanimirovic A, Kovacevic M, Korobko I, et al. Combined therapy for resistant vitiligo lesions:
NB-UVB, microneedling, and topical latanoprost, showed no enhanced efficacy compared to
topical latanoprost and NB-UVB. Dermatol Ther. 2016;29:312–6.
37. Starace M, Alessandrini A, Brandi N, et al. Preliminary results of the use of scalp microneedling in different types of alopecia. J Cosmet Dermatol. 2020;19:646–50.
38. Stuzin JM, Baker TJ, Baker TM, et al. Histologic effects of the high-energy pulsed CO2 laser
on photoaged facial skin. Plast Reconstr Surg. 1997;99:2036–50; discussion 51–5.
39. Urdiales-Galvez F, Trelles MA, Martin-Sanchez S, et al. Histopathological changes after
experimental skin resurfacing using an improved fractional high-power 1064-nm Q-Switched
Nd:YAG laser. J Drugs Dermatol. 2019;18:1261–6.
40. Wells A, Nuschke A, Yates CC. Skin tissue repair: matrix microenvironmental influences.
Matrix Biol. 2016;49:25–36.
41. Yamaba H, Haba M, Kunita M, et al. Morphological change of skin fibroblasts induced by UV
Irradiation is involved in photoaging. Exp Dermatol. 2016;25(Suppl 3):45–51.
Chapter 7
Managing Complications in PCI
7.1
PCI Versus Ablative Interventions
Unlike in ablative interventions, microneedles treat the skin without removing the
epidermis. The preservation of this noble layer structure is the basis for the prevention of adverse effects, giving PCI ample advantage over other procedures. It is
known that mechanical or chemical removal of the epidermis favors the release of
cytokines and migration of inflammatory cells, culminating in the replacement of
damaged tissue by a scar (Fig. 7.1). Treatments with medium and deep chemical
peelings, as well as mechanical abrasion, require long recovery of the skin and
result in a more light-sensitive tissue, subject to post-inflammatory hyperpigmentation (IPH) and photosensitivity, adding to the risk of complications such as hypertrophic scarring, persistent erythema, and dyschromias. These conditions are likely
Effects of epidermal removal
- Scar tissue not very elastic
- Risk of scarring
- Risk of hyperpigmentation
- Risk of acromias
- Risk of persistent erythema
- Long recovery time
- Increased sensitivity:
thinner epidermis and fibrosis of the
papillary dermis
Fig. 7.1 Consequences of epidermis removal in ablative procedures
The Editor(s) (if applicable) and The Author(s), under exclusive license
to Springer Nature Switzerland AG 2021
E. Lima, M. Lima, Percutaneous Collagen Induction With Microneedling,
https://doi.org/10.1007/978-3-030-57541-0_7
69
70
7
Managing Complications in PCI
to occur because it is a replacement of the epidermis and its basal membrane
removed by a scar tissue with rectification of the dermal papillae. In these processes, the inflammatory response triggered by the destruction of the epidermis
causes the production of parallel oriented thick bundles of collagen, differently
from the interlacing network of collagen found in normal skin.
In view of this, PCI proposes a stimulus to the production of collagen by perforating the epidermis, reaching the dermis without causing deepithelialization. Thus,
the author’s practice and the reports of scientific articles that offer the experience of
specialists from around the world point to greater safety, less risk of adverse effects,
and shorter recovery time when comparing the use of needles with ablative
procedures.
7.2
Expected Reactions and Adverse Effects
Below are some of the most observed adverse effects in the postoperative period of
PCI, even if not frequent (Figs. 7.2, 7.3, 7.4, 7.5, 7.6, and 7.7).
7.2.1
Edema
It varies from moderate to intense, depending on the length of needle used in the
intervention, as well as the methodology instituted by the operator – proposing a
light, moderate, or deep injury (see Chap. 2, Classification and Characteristics of
Fig. 7.2 Immediate postoperative exudation (a) and skin after 72 hours of PCI (b)
7.2 Expected Reactions and Adverse Effects
71
Fig. 7.3 Immediate postoperative evolution of PCI for the treatment of retractile neck scar
Fig. 7.4 Postoperative
5 days demonstrating the
existence of crusts
Injury Caused by PCI) The edema observed in the immediate post-procedure is light
and may be covered up when needle lengths ranging from 0.5 to 1.5 mm are used,
commonly in cases of melasma or when the objective is the propagation of topical
assets. The regression is very perceptible in the first 24 hours, which allows the
return to the labor activities without inconvenience. The edema becomes a limitation for the patient who returns to his/her routine, when the surgical proposal uses
infiltrative anesthesia and the needle length chosen varies from 2.0 to 2.5 mm. In
these cases, the inflammatory cascade triggered by the intervention results in significant and progressive edema in the first 48–72 hours after the treatment, when it
slowly regresses, becoming discrete from the fifth to seventh day. During this
period, it is essential to restrict the sun and visible light, as the area is particularly
subject to IHP.
72
Fig. 7.5 Postoperative
48 hours demonstrating
substantial edema
Fig. 7.6 7-day
postoperative period
showing dyschromia
Fig. 7.7 Postoperative
15 days with persistent
erythema
7
Managing Complications in PCI
7.2 Expected Reactions and Adverse Effects
7.2.2
73
Erythema
As with edema, erythema depends on the injury caused. When a mild one is chosen,
the erythema works as a parameter to interrupt the procedure. In this case, it is
desired that a diffuse and uniform erythema of the treated area is only to leave a
slight exudation, followed by hematic crusts, only for the deposition of an active on
the needled area, guided by the drug delivery proposal. For this, the corneal barrier
rupture condition and the ease of permeation in an area prone to absorption are
taken advantage of.
Persistent erythema is very rare and, in the author’s experience, almost never
observed. Some individuals with skin reactive to trauma may present an extension
of this erythema, but still this condition is self-limited. Even patients with rosacea,
who are commonly subject to this complication, are not contraindicated. On the
contrary, there is a substantial improvement in the quality of the skin, which stimulates the proposal of a deep lesion for these patients. It is believed that this result is
secondary to the modification of the dermis and epidermis by the intervention,
reflecting in the containment of inflammatory disease.
7.2.3
Hematoma, Petechiae, and Purple
The penetration of fine, sharp needles into the skin causes moderate and rapidly
reversible bleeding. When the lesion is mild, only a diffuse erythema with satellite
bleeding spots is observed macroscopically, followed by rapid coagulation and mild
serous exudation. In some situations, the exposure of thinner skin, such as the lower
eyelid, or in an individual who constitutionally or due to age has the most tenuous
skin, the needles cause more significant bruising, which resorb in 5–7 days.
The objective of PCI with the proposal of a deep lesion is concluded when a
uniform purpura of the whole treated area is achieved. The bleeding, initially
intense, gives way to a modest sero-bloody exudation, followed by only serous exudation with closure of the ostia caused by the microneedles. It is common the
appearance of hematomas inside stretch marks, by the laxity of the tissue. This
effect, which may seem adverse, is actually desired. It contributes to the process of
replacement of damaged tissue by regenerated tissue. In this phase of purpura, the
hyperpigmentation may be inadvertently installed, due to the deficiency of postoperative care. This is an alert for abstinence from sun exposure and heat.
7.2.4
Crusts
They are expected in the healing process and should not be manipulated. They
should be observed more frequently when a deep lesion occurs and 2.5-mm-long
needles have been used. The hematic crusts observed in the transoperative and
74
7
Managing Complications in PCI
immediate postoperative period can be removed, but there is no requirement for
total avulsion. After a few days, new crusts settle, but the elimination should occur
spontaneously, contributing to good healing and avoiding dyschromias resulting
from traumatic removal.
When the lesion is light to moderate using 1.5-mm-long needle, the crusts that
are in small amount can be left, since it is possible to count on the contribution of
growth factors and stem cells favoring the gains of the treated area.
7.2.5
Post-inflammatory Hyperpigmentation
The darkening of the area treated by PCI is commonly associated with poor postoperative care and lack of adequate preparation of the treated skin. It is worth emphasizing that restriction of exposure to lights, appropriate photoprotection immediately
after reepithelialization, as well as the use of a lightener already with healing and
30 days before the intervention are essential for the success of the treatment and the
prevention of hyperpigmentation. The browning of the treated region, when it
occurs, is commonly transient and easily reversible. The author’s experience has
shown this complication in restricted cases, more frequent in skins with more melanin, when the lesion is deep and when some active with ablative potential is added,
such as acid solutions for peelings.
7.2.6
Desquamation
A discrete peeling, almost furfuric, is expected after 48–72 hours of a mild to moderate lesion on the occasion of the disappearance of the edema. When the lesion is
deep, the peeling occurs later, between the fifth and seventh day, coinciding with the
regression of the edema. At that moment, it is important to use sunscreen and lighteners, preventive orientation of IPP, since the treated area is more susceptible.
Sometimes, the sensation of burning and discomfort can be established, with the
need to alternate the prescribed asset for the night, without giving up the mandatory
daily use of sunscreen with color, as well as the emphatic recommendation of its
reapplication.
7.2.7
Burning and Awareness
During the most intense peeling process, the use of a skin regenerator in a nongreasy
vehicle is recommended. This is because it is necessary to avoid increasing the oiliness of the treated area, which can cause acne lesions and sebaceous mildew.
Nevertheless, it is recommended to leave the region always hydrated, which favors
7.2 Expected Reactions and Adverse Effects
75
the healing process. Keeping the treated area dry stimulates itching, even unconditionally, and may cause discomfort, sensitization, bleeding suffusions, and delay in
the healing process, especially when the injury caused was deep.
7.2.8
Infections
The foundation of PCI is to maintain the partial integrity of the epidermis, i.e., not
to destroy it by removing the keratinocytes, but only to puncture and remove these
cells. Therefore, the risk of viral infection is limited, since the installation of simple
herpes, a mandatory intracellular organism, requires denuding of the area, deepithelialization. Even so, when the individual has a history of recalcitrant herpes, preventive treatment is recommended, understanding that surgical stress alone can be the
trigger for triggering infection. For this, the institution of the usual posological
scheme 2 days before the procedure is oriented, extending to the regression of the
edema and complete epidermal regeneration, 3–5 days, depending on the
injury caused.
The risk of bacterial infection occurs due to contamination of the instruments
used and the consequent inoculation of microorganisms. It is important that there is
prudence and attention in the choice of the roll, verifying its reliable origin, possible
adulteration, and storage of the equipment, besides the observation of all the asepsis
and antisepsis precepts required for a surgical procedure. In addition, one must not
forget to respect the careful choice of environment for the surgical act and the
appropriate paramentation of the operator.
7.2.9
Pain
Modest discomfort in cases of deeper interventions may occur due to the edema, but
pain is not a complaint observed in the treated patients. When this happens, it is
necessary to investigate the existence of another associated complication, such as
herpes infections or bacteria, never observed in the author’s experience.
7.2.10
Depressed or Elevated Scars
PCI has in its spectrum of indications the treatment of these lesions. Even in individuals with a history of keloid lesions, the development of scars as a complication of the
technique has not been observed. The author has submitted patients with risk of developing hypertrophic scars to PCI without being surprised by the development of these
lesions. Additionally, this therapeutic proposal can be considered with one of the few
treatment options for those patients who present good results, when well selected.
76
7
Managing Complications in PCI
Sources
1. Aust MC. Percutaneous collagen induction therapy: an alternative treatment for scars, wrinkles, and skin laxity. Plast Reconstr Surg. 2008;121(4):1421–9.
2. Bal SM, Caussian J, Pavel S, et al. In vivo assessment of safety of microneedle arrays in human
skin. Eur J Pharm Sci. 2008;35(3):193–202.
3. Brody HJ. Trichloroacetic acid application in chemical peeling, operative techniques. Plast
Reconstr Surg. 1995;2(2):127–8.
4. Cohen KI, Diegelmann RF, Lindbland WJ. Wound healing: biochemical and clinical aspects.
Philadelphia: WB Saunders Co; 1992.
5. Fabroccini G, Fardella N. Acne scar treatment using skin needling. Clin Exp Dermatol.
2009;34(8):874–9.
6. Fernandes D. Minimally invasive percutaneous collagen induction. Oral Maxillofac Surg Clin
North Am. 2006;17(1):51–63.
7. Fernandes D, Massimo S. Combating photoaging with percutaneous collagen induction. Clin
Dermatol. 2008;26(2):192–9.
Chapter 8
PCI in Aging Skin
8.1
PCI Fundamentals in Skin Aging
The aging process occurs through intrinsic and extrinsic factors. This process offers
to face a considerable reduction in its volume. Bone resorption, muscle mass reduction, fat redistribution, and ligamentous laxity are observed. The skin, which covers
all this structure like an envelope, becomes loose and lax, resulting in leftovers and
flaccidity with fine and deep wrinkles. Ablative treatments, such as medium and
deep chemical peelings, provide undeniable stimulus in collagen production, which
results in attenuation of wrinkles, flaccidity, and improved texture, brightness, and
coloring of the skin surface. Very good results are also observed with the association
of peelings with surgical abrasion (chemabrasion). Figures 8.1, 8.2, and 8.3 show
results obtained with the association of abrasion with 35% TCA and phenol.
However, as mentioned in Chap. 1, Fundamentals of Percutaneous Induction of
Fig. 8.1 Patient before and after 3 months of the association of surgical abrasion with 35% TCA
for the treatment of photodanus
The Editor(s) (if applicable) and The Author(s), under exclusive license
to Springer Nature Switzerland AG 2021
E. Lima, M. Lima, Percutaneous Collagen Induction With Microneedling,
https://doi.org/10.1007/978-3-030-57541-0_8
77
78
8
PCI in Aging Skin
Fig. 8.2 Patient before and after 3 months of association of surgical abrasion with TCA 35% for
treatment of photodanus
Fig. 8.3 Patient before and after 3 months of the association of surgical abrasion with 88% phenol
for the treatment of wrinkles and facial flaccidity
Collagen with Needles (PCI), the disadvantages of these procedures are long recovery, a more light-sensitive tissue, and subject to post-inflammatory hyperpigmentation and photosensitivity, adding to the risk of complications such as formation of
hypertrophic scars, persistent erythema, and dyschromias (Fig. 8.4). The epidermis
is removed, a rectification of the dermal papillae occurs, and the resulting scar tissue
consists of thick parallel oriented bundles of collagen, unlike the interlacing network of collagen found in normal skin.
Current interventions seek to promote fractional skin damage, which allows the
integrity of the microregion adjacent to the trauma to be maintained intact, favoring a
shorter recovery time and reduced risk of complications. The fractionated CO2 laser
is an example of this proposal, as is the PCI. It is important to note that, even when
the patient is submitted to surgeries that remove skin leftovers, attenuating flaccidity
and wrinkles, the resulting skin must offer a good quality. This is the PCI proposal,
offering a good quality of skin based on neocollagenosis and neoangiogenesis.
8.1 PCI Fundamentals in Skin Aging
79
Fig. 8.4 Evolution of different patients presenting dyschromias and persistent erythema after
ablative interventions
Fig. 8.5 Patient treated with microneedles, demonstrating improvement in skin quality, color, and
wrinkle attenuation
Fig. 8.6 Microneedle-treated patient showing improvement of skin quality, staining, and wrinkle
attenuation
Figures 8.5 and 8.6 show patients treated by PCI, showing an improvement in
skin quality and color, as well as wrinkle attenuation. The PCI proposes a stimulus
80
8
PCI in Aging Skin
in the production of collagen, without causing the total deepithelialization observed
in ablative techniques. The epidermis and dermis are perforated but not removed. In
this way, we can see improvement of deep wrinkles resulting from the treatment of
elastosis in photoaged skin, which often behave as deep scars difficult to be treated.
Microneedles break the rigidity and stiffness frequently seen in deep static wrinkles
such as those observed in the perioral, forehead, and periorbital regions, especially
in individuals with thick, seborrheic skin, as well as in smokers (Fig. 8.7).
8.2
Applicability of PCI to Skin Aging
The needles, initially idealized for the treatment of scars, also demonstrated valuable therapeutic response in aged skin. The studies of Orentreich and Orentreich
[10] were the first to report their use with the objective of stimulating the production
of collagen in depressed scars and wrinkles, a technique widespread under the name
of Subcision™. Other authors confirmed the rupture and removal of the damaged
subepidermal collagen followed by the substitution of new collagen and elastin
fibers by the intervention of needles. More recently, it has been proposed the use of
a system of microneedles applied to the skin in order to generate multiple micropunctures, long enough to reach the dermis and trigger, with bleeding, inflammatory
stimulus and activation of an inflammatory cascade that would result in the production of collagen and, subsequently, its maturation. The choice of which needle
length to use depends on the degree of injury you wish to cause: light, moderate, or
deep (see Chap. 2, Classification and Characteristics of Injury Caused by PCI). In
the case of aged skin, the following items should be considered.
8.3
Thickness of Skin
Very thin skins offer less resistance to shorter needle lengths when compared to
thick skins. The history of acne and the existence of scars should be considered. In
these individuals, the skin is usually thicker and with depressions that make it difficult for the microneedles to roll and, consequently, compromise the uniformity of
its penetration, observing a reduction of up to 50% of the total length penetration.
Elastosis, typical of a substantial photodanus, also interferes with this treatment.
The more elastotic the skin, the greater the evidence of resistance. In smokers, this
same process is observed. To compensate for and overcome this reluctance, the
operator often imposes excessive force on the instrument, which can traumatize
nervous or vascular structures and not achieve the expected effect. Therefore, it is
recommended that the force vector on the roller always tangents the horizontal
plane it is working on and is never perpendicular to that surface. Figure 8.8 shows a
patient with an unaesthetic appearance after facial lifting, treated by PCI with a
2.5-mm-long needle and a 1-month postoperative period, demonstrating
8.5 Flaccidity
81
Fig. 8.7 Flaccidity and deep wrinkles in a patient with thick skin treated with PCI
Fig. 8.8 Unaesthetic appearance of skin folding after facial lifting, treated by PCI with a 2.5-mm-­
long needle, immediately after the procedure and 30 days postoperatively, showing correction of
the defect
improvement. Observe the purpura in the immediate post-procedure secondary to
the marked tissue laxity.
8.4
Wrinkle Depth
Deep wrinkles behave like scars and need to be detached, as their bottom will not
easily surface. In such cases, it is necessary to intervene as if a perpendicular
Subcision™ were being performed, hence the indication of needle lengths from 2.0
to 2.5 mm. Figure 8.9 presents a patient with wrinkles in the glabella, perioral
region, and forehead difficult to be corrected with short needle lengths.
8.5
Flaccidity
Flaccidity of the face is more easily treated than body flaccidity. The thicker adipose
pad in the body offers a cushioning of needle penetration, which results in greater
resistance. The bone eminences of the face act as a support surface, which facilitates
82
8
PCI in Aging Skin
Fig. 8.9 Different patients: glabella, perioral region, and forehead wrinkles. Difficult to be corrected with short needle length
Fig. 8.10 Substantial face flaccidity treated with PCI using 2.5-mm-long needle
the introduction of needles. Thus, several sessions with a shorter needle length and
interval of 1 month or a single session with a proposal of deep injury can be chosen
and reassessment after 3 months. Figure 8.10 presents a patient with substantial
facial flaccidity treated with PCI (2.5-mm-long needle), offering significant results
after a single session, including the disappearance of solar melanosis.
8.6
Step-by-Step
The treatment of skin aging can be established in sessions, once a month, for example, with the addition of actives (vitamin C, vitamin E, tranexamic acid, growth
factors, and liposomes, among others) with collagen-stimulating properties. In such
cases, the microneedles fulfill their role of breaking the epidermal barrier, favoring
the penetration of these substances, and there is no need for the use of needle lengths
longer than 1.5 mm. This option with 1.5 mm needles or even shorter lengths is sufficient for delivery of these products (see Chap. 18, PCI and Drug Delivery).
8.7 Methodological Sequence for Deep Injury
83
Fig. 8.11 Flaccidity and wrinkles treated by phenol 88% and PCI association
8.6.1
Deep Injury
This intervention is proposed when the objective is to offer good results in a single
session. Thus, it is possible to approach wrinkles, flaccidity, and loss of volume at
once. Commonly, an approach using a 2.5-mm-long needle under infiltrative anesthesia provides a cosmetic gain compatible with the patient’s and dermatologist’s
expectations; however, if a second intervention is desired, it is prudent to wait at
least 90 days for the results to stabilize. The association with peelings such as phenol 88% or TCA 35% is an innovative proposal, triggered and published by Emerson
Lima [9] (Fig. 8.11) (see Chap. 24, PCI Associated to Peelings).
8.7
Methodological Sequence for Deep Injury
Patient Assessment The applicability of PCI is established independently of the
phototype. Even in higher phototypes, subject to post-inflammatory hyperpigmentation commonly transient, the technique is well indicated. The most important in
these cases is skin preparation. The less melanin the treated skin is providing, the
lower the risk of darkening. Therefore, it is recommended the use of depigmentant
and sunscreen 30 days before the intervention.
Instruments It is preferable to use a roll with an average of 192 needles of 2.5 mm
in length. The treatment should be performed in a procedure room carefully ­prepared
for a surgical intervention and by a trained and qualified professional. It is essential
not to trivialize these safety criteria, which include the use of sterile gloves, the use
of sterile surgical drapes, and an environment that follows strict disinfection
standards.
84
8
PCI in Aging Skin
Asepsis and Anesthesia of the Area After antisepsis with 2% chlorhexidine, it is
suggested the association of anesthetic blocking of the infraorbital and mentonian
nerves and supplementation with 2% lidocaine solution without 1:2 vasoconstrictor
0.9% saline, respecting the maximum dose of the active agent allowed (see Chap. 4,
Analgesia and Anesthesia). The addition of bicarbonate in order to offer more comfort to the patient, reducing the burning, is optional.
Transerperative The instruments are then rolled, forming parallel and adjacent
strips of micropunctures, which intersect diagonally, seeking to achieve a uniform
purple with thousands of microperforations. The bleeding is substantial, but limited.
After 10 minutes of the end of the intervention, a significant reduction in bleeding
can already be observed, giving rise to a serous exudation, which progressively
regresses in the first 6 hours (Fig. 8.12).
Post-immediate Surgery The dressing is performed using sterile gauze in large
quantities (in order to contain the exudation) and Micropore®, without the addition
of any humectant. Topical or systemic antibiotic therapy is not indicated. It is a
clean procedure, and, according to the Food and Drug Administration (FDA) rules,
this precaution is unnecessary. Cryotherapy or hot compresses are not indicated. It
is preferable that the accommodation of bruises and the inflammatory response
resulting from their presence follow their natural course.
Evolution and Postoperative Care The dressing can be removed by the patient
himself at home, wetting him in the shower, when the treated area can be washed
with liquid soap with low detergency potential, avoiding sensitization. From then
on, it is recommended to use a regenerating balm until reepithelialization for
approximately 5–7 days, when lightening creams and broad-spectrum toned
­sunscreen can be used. The restriction to lights should be oriented. In the following
days, edema and hematoma are substantial. In the author’s practice, the patient will
be able to return to his laborative activities around the seventh postoperative day. If
the treated area is covered (arms, thigh, buttock), the return to public coexistence
may happen the following day.
Immediatelly after PCI
10 minutes after PCI
Fig. 8.12 Evolution of post-treatment with PCI
20 minutes after PCI
8.7 Methodological Sequence for Deep Injury
85
Complementary Techniques If the dermatologist wishes to use a filler as hyaluronic acid, it is recommended to schedule this intervention for at least 30 days after
the PCI, making sure that the edema has completely regressed. The application of
botulinum toxin should not be performed at the same surgical time. According to the
author’s experience, the application of the toxin is safe 15 days after the intervention. Adverse effects can occur while there is edema, due to increased diffusion of
the toxin’s action halo, reaching muscle fibers alien to the proposal.
Complications Generally, they are much more related to expected effects such as
edema, hematomas, transient post-inflammatory hyperpigmentation, and transient
erythema. Once the proper care has been taken in the preparation of the skin and
attention has been established to the postoperative recommendations with rigor, the
PCI presents itself as a safe and reproducible technique for acne scars, provided that
the operator is duly qualified and trained.
Pain and Discomfort The postoperative period is smooth. The author’s experience
ensures that pain is not a usual complaint; however, if it occurs, he should warn of
secondary infection, especially if installed after 48 hours of intervention. Usually,
there is no need for analgesic or anti-inflammatory in the postoperative period, but
if there is a complaint of discomfort, without any other aggravating factor, it is recommended to use dipyrone 1 g every 6 hours.
Prophylaxis for Herpes Prophylaxis for herpes is not routinely recommended, as
it is not an ablative intervention that removes the epidermis completely and, consequently, allows infection by an organism that needs the loss of keratinocyte integrity
to proliferate. However, in cases where the frequent and recalcitrant character of the
viral infection is identified, prophylaxis is mandatory, taking into account mainly
surgical stress.
8.7.1
Moderate Injury
Although this proposal offers a modest inflammatory cascade and consequently a
lower production and transformation of dermal collagen, when compared to deep
injury, moderate injury also offers a significant stimulus. It promotes an improvement in the brightness, texture, and color of the skin. For this proposal, a sequence
of at least two sessions with an interval of 30 days is recommended. For this, the
addition of an active can optimize the results. For more information about the
author’s experience and his protocols associating intense pulsed light and PCI with
retinoic acid peeling, we recommend reading Chaps. 23 and 24, respectively.
86
8.8
8
PCI in Aging Skin
Final Considerations
PCI adds a safe and effective tool to the therapeutic arsenal of aging skin conduction
at trained hands. It improves color, texture, and depth of wrinkles, even producing
moderate injuries. The addition of peelings (detailed theme later in this work) has
offered surprising results.
Sources
1. Aust MC. Percutaneous collagen induction therapy: an alternative treatment for scars, wrinkles, and skin laxity. Plast Reconstr Surg. 2008;121(4):1421–9.
2. Bal SM, Caussian J, Pavel S, et al. In vivo assessment of safety of microneedle arrays in human
skin. Eur J Pharm Sci. 2008;35(3):193–202.
3. Brody HJ. Trichloroacetic acid application in chemical peeling, operative techniques. Plast
Reconstr Surg. 1995;2(2):127–8.
4. Camirand A, Doucet J. Needle dermabrasion. Aesthet Plast Surg. 1997;21(1):48–51.
5. Cohen KI, Diegelmann RF, Lindbland WJ. Wound healing: biochemical and clinical aspects.
Philadelphia: WB Saunders Co; 1992.
6. Fabroccini G, Fardella N. Acne scar treatment using skin needling. Clin Exp Dermatol.
2009;34(8):874–9.
7. Fernandes D. Minimally invasive percutaneous collagen induction. Oral Maxillofac Surg Clin
North Am. 2006;17(1):51–63.
8. Fernandes D, Massimo S. Combating photoaging with percutaneous collagen induction. Clin
Dermatol. 2008;26(2):192–9.
9. Lima EA. Association of micro-needle with phenol peeling: a new therapeutic proposal in
flaccidity, wrinkles and facial acne scars. Surg Cosmet Dermatol. 2015;7(4):328–31.
10. Orentreich DS, Orentreich N. Subcutaneous incisionless (subcision) surgery for the correction
of depressed scars and wrinkles. Dermatol Surg. 1995;21(6):543–9.
Chapter 9
PCI in the Treatment of Melasma
Melasma is a common acquired hypermelanosis, characterized by irregularly contoured macules with a lacy appearance, with a color ranging from light brown to
dark brown. The lesions occur in photo-exposed areas, mainly on the face. Melasma
predominantly affects women of intermediate phototype fertile age. It causes great
impact on the quality of life of patients, which makes it a frequent complaint in the
dermatological office. Figure 9.1 presents melasma in different areas and different
phototypes.
The diagnosis is clinical, and, during the physical examination, the doctor can
use Wood’s lamp to characterize the extent of the stains. The ultraviolet light (UV)
Fig. 9.1 Presents melasma in different areas and different phototypes
The Editor(s) (if applicable) and The Author(s), under exclusive license
to Springer Nature Switzerland AG 2021
E. Lima, M. Lima, Percutaneous Collagen Induction With Microneedling,
https://doi.org/10.1007/978-3-030-57541-0_9
87
88
9
PCI in the Treatment of Melasma
exam, on the other hand, has been proven to help evaluate the depth of the pigment,
meaning difficulty in the therapeutic response.
At histopathological examination, the skin with melasma presents epidermal
hyperpigmentation. There is an increase of melanin in all layers of the epidermis
and an increased number of mature melanosomes. There is no difference in the
number of melanocytes, but these are hypertrophied and present more dendrites and
cytoplasmic organelles, which indicates a higher metabolic activity. However, the
skin with melasma, proportionally, presents an increase in the number of pendulum
melanocytes (melanocytes of the basal layer that project towards the dermis) and
greater fragmentation of the basal membrane zone, thinning of the dense lamina,
and loss of fibrilla anchorage of the lucid lamina.
Comparing the skin with melasma with the adjacent healthy skin, there is no difference in the amount of dermal melanin. Therefore, the authors no longer consider
the classification of melasma in epidermal, dermal, or mixed. The amount of dermal
melanin is minute (<100×) compared to the epidermal. However, other histological
findings in the dermis of melasma may help to understand the pathophysiology of
this disease, such as prominent solar elastosis, increase in elastotic material, greater
heterogeneity of collagen, and increased number of vessels and mast cells.
The standard treatment of melasma still consists of the use of broad-spectrum
toned sunscreen and topical lighteners, particularly tyrosinase inhibitors. Home
treatment, however, is limited in bleaching and relapses are frequent. Therefore,
adjuvant treatments are proposed to improve outcomes and decrease relapses.
Percutaneous collagen induction (PCI) has been shown to be effective in both
bleaching and staining.
9.1
Lima Protocol
In 2015, Emerson Lima published a protocol for the treatment of a series of 22 cases
of recalcitrant melasma (Fig. 9.2). The protocol consists of two sessions of PCI
moderate injury (technique explained later in this chapter) with an interval of
15–30 days between them, associating the use of sunscreen toned during the day
and triple formula (hydroquinone 4%, tretinoin 0.05%, and fluocinolone acetonide
0.01%) at night, started already in 24 hours after the intervention. It is important to
emphasize that this the first protocol published where no drug delivery is proposed
to treat melasma, only the needling. It is based on the author’s 10-year experience
treating hyperpigmented scar with PCI with very good whitening as presented in
Figs. 9.3 and 9.4.
All cases treated in the evaluation, even those with more than 20 years of evolution, responded to the Lima Protocol, with whitening. In order to optimize the
results and maintain the lightening, the use of the topical lightener should be introduced as soon as possible, according to the skin tolerance. Other lightening agents
can be used instead of the triple formula depending on each doctor’s experience.
9.1
Lima Protocol
89
Before
After
Before
Before
After
Before
After
After
Fig. 9.2 Patients before and after the Lima Protocol (Lima [2])
Fig. 9.3 Hyperpigmented scar in areas of the body that pose a challenge to whitening. Treated
with PCI deep injury – two sessions
In a recent study, PCI has been shown to add benefit to standard treatment and
decrease the recurrence of melasma. When compared to the control group (use of
sunscreen only and triple formula), the group that performed two additional PCI
sessions showed a greater relative decrease in the severity score 1 month after the
last session. However, during the 2 months of maintenance with only solar filter and
topical bleaching, the groups that performed PCI had less relapse. In addition, the
90
9
PCI in the Treatment of Melasma
Fig. 9.4 Hyperpigmented scar in the perioral area treated with PCI deep injury – two sessions
Fig. 9.5 Patient with melasma. (a) Pre-treatment. (b) After Lima Protocol. (c) 90 days after Lima
Protocol. There was no relapse
group that performed the two PCI sessions showed a higher quality of life improvement when compared to the other group. Besides bleaching, there was a perception
of improvement in the quality of the skin. No post-inflammatory hyperpigmentation
was observed after the procedure even in patients with higher phototype (Figs. 9.5,
9.6, and 9.7).
9.2
Mechanism of Action
After the publication of the Lima Protocol [2] using the PCI in recalcitrant melasma,
the authors presented histopathological changes in a second group of patients treated
for melasma. The authors presented histopathological alterations in a second group
of patients treated for melasma. In this last evaluation, a reduction of melanin in the
epidermis, an improvement of elastosis in the dermal papillae can be identified in all
9.2
Mechanism of Action
91
Fig. 9.6 Lima Protocol after 3 months, two sessions. Improvement in very recalcitrant melasma,
phototype IV, lasting for 15 years
Fig. 9.7 Lima Protocol (four sessions) in very recalcitrant melasma patient, phototype IV, lasting
for 12 years
patients evaluated, frequently observed in patients with melasma, and a regeneration of the basal membrane after two sessions of PCI, following the Lima Protocol
(Figs. 9.8 and 9.9). In a third study, it was observed that 7 days after a single PCI
session, there was acanthosis, and an increase in epidermal proliferation represented
by the Ki67 immunomarker, which resulted in a slight decrease in epidermal melanin (Fig. 9.10). In addition, a restructuring of the basal membrane, a decrease in
pendulum melanocytes, and deposition of extracellular matrix components and
fibroblast proliferation were also observed.
In another study, in which the effect of the Lima Protocol was evaluated 15 days
after the second PCI session, a decrease in melanin, epidermal thickening, and
improvement of the solar elastosis in the upper dermis were evidenced.
Restructuring of the upper dermis and basal membrane impairs the contact of
melanocytes with melanogenesis-stimulating dermal factors. In addition, increased
keratinocyte turnover promotes greater clearance of epidermal melanin. These two
factors explain the action of PCI in melasma. However, more studies should be
conducted in order to better understand the role of PCI in the treatment of melasma.
92
9
PCI in the Treatment of Melasma
Fig. 9.8 Bundles of collagen (Picrosirius red). Improvement of upper dermis solar elastosis before
(a) and after (b) Lima Protocol. (BMC Dermatology)
Fig. 9.9 Basal membrane restructuring (PAS). (a) Before. (b) After Lima Protocol. (BMC
Dermatology)
9.2.1
Proposed Methodological Sequence
• Patient assessment. The applicability of PCI is established regardless of the phototype or the existence of post-inflammatory hyperpigmentation (PIP). Even in
higher phototypes, subject to commonly transient IPPH, the technique is well
9.2
Mechanism of Action
93
indicated. These patients need to be in use of a night lightener and well adapted
to a broad-spectrum toned sunscreen. The preparation before the procedure is
mandatory. The less melanin the treated skin is providing, the lower the risk of
darkening post-procedure.
• Instrumental. It is preferable to use a roller with an average of 192 needles of
1.5 mm in length. The treatment should be performed in a procedure room carefully prepared for a surgical intervention and by a trained and qualified professional. It is essential not to trivialize these safety criteria, which require the use
of sterile gloves, sterile surgical fields, and an environment that follows strict
standards of disinfection.
• Asepsis and anesthesia of the area. The application of liposomal lidocaine is suggested. The patient’s face should not be sanitized before applying this topical
anesthetic, since the penetration in the greasy skin optimizes the availability of
liposomal lidocaine. A vigorous massage of 10 g of the anesthetic is recommended on every face, leaving a thick layer for 30 minutes. After 30 minutes, the
same procedure is repeated using 10 g of liposomal lidocaine, leaving a thick
layer on the skin for another 30 minutes (Fig. 9.11). After 1 hour of topical
a
b
c
d
Fig. 9.10 Increased Ki67 marking. (a) Before. (b) 7 days after IPCA. Basal membrane recovery
(PAS). (c) Before. (d) 7 days after IPCA. Increase in glycosaminoglycans and fibrin in the upper
dermis (Herovici). (e) Before. (f) 7 days after IPCA. Decrease in epidermal melanin. (g) Before.
(h) 7 days after IPCA. (Indian Journal of Dermatology, Venereology and Leprology)
94
9
e
f
g
h
PCI in the Treatment of Melasma
Fig. 9.10 (continued)
a­nesthesia, it is removed with 2% chlorhexidine using gauze. This way, the
patient is well anesthetized and allows the procedure to be performed with
tranquility.
• Transoperative. The instrument is then rolled, in back and forth movements, constructing parallel horizontal bands with a 10% overlap, aiming to avoid untreated
spaces between the bands. Afterwards, the back and forth movements continue
perpendicular to the already built tracks, and finally diagonal movements are
performed with the roller, following the same precept of building tracks, never
performing zigzag movements. The number of steps is not important. The important thing is the end point at the end of the procedure. In the authors’ experience,
this end point for melasma is a diffuse erythema in every area treated with the
presence of petechial points. The bleeding is modest, punctual, and limited.
Figure 9.12 presents the correct PCI end point for melasma and erythema immediately after cleaning the skin with saline solution. The Lima Protocol recommends no cleaning of the skin after the procedure, only after at least 2 hours. The
exudation is very important for the results; thus, it does not have to be removed.
• Immediate postoperative. After 30–40 minutes of waiting, enough time for the
formation of a biological dressing resulting from the serosanguinolent exudation, the patient will be ready to go home. The thin layer of exudation that has
9.2
Mechanism of Action
95
Fig. 9.11 Patient with
thick layer of anesthetic in
the pre-procedure
Fig. 9.12 Patient immediately treated with PCI and after facial hygiene with saline solution demonstrating the resulting erythema
formed in the 30–40 minutes after the intervention should not be removed. This
material is rich in growth factors and cytokines that will contribute to the process
of skin regeneration and whitening. After this period, when the ostia produced by
the microneedles of a moderate injury are already closed, a toned sunscreen can
be applied on this newly formed biological dressing. Although the sunscreen is
96
9
PCI in the Treatment of Melasma
not a sterile product, we do not consider that the patient will be subject to risks.
In our experience of more than 10 years performing the Lima Protocol, we have
not observed sensitization or infection. Two hours after the procedure, the face
can be sanitized with running water and a soap for sensitive skin. We recommend
after cleaning the skin to apply a thin layer of moisturizing cream or a skin regenerator. Topical antibiotic therapy is not indicated because it is a clean procedure,
and, according to the Food and Drug Administration (FDA) rules, this precaution
is unnecessary. Cryotherapy or hot compresses are not indicated.
• Postoperative evolution and care. The use of lighteners can be resumed in the
first 24–48 hours after the intervention, depending on the patient’s tolerability. It
is recommended that they be reintroduced gradually, on alternate nights.
Maintenance of sunscreen and restriction to bright lights should be directed. A
slight edema and microhematomas may occur in the following 48 hours, which
regress in 3–5 days and can be easily covered by tinted sunscreen or makeup. In
the authors’ practice, the patient will be able to return to his/her labor activities
the day after the procedure. Figures 9.13 and 9.14 present patients treated with
Lima Protocol.
• Complications. In the experience of the authors, taking due care in the preparation of the skin, establishing the attention to the postoperative recommendations
with rigor, the PCI presents itself as a safe and reproducible technique for
melasma, provided that the operator is duly qualified and trained.
Fig. 9.13 Patient with facial melasma 90 days after Lima Protocol (two sessions)
Sources
97
Fig. 9.14 Patient with extra-facial melasma. 90 days after Lima Protocol (two sessions)
• Pain and discomfort. Tolerable during the intervention, as long as the protocol
proposed by the authors is followed. In the postoperative period, these complaints are not observed.
• Prophylaxis for herpes. It is not routinely recommended, since it is not an ablative intervention, i.e., it removes the epidermis completely and consequently
allows the infection by an organism that needs the loss of keratinocyte integrity
to proliferate. However, in cases where the patient has repeated herpes, prophylaxis is recommended, taking into account, mainly, pre-intervention anxiety and
the stress resulting from the procedure.
9.3
Final Considerations
PCI following the Lima Protocol, using 1.5-mm-long needle alone, without the
addition of any active agent, is able to promote whitening of melasma stains in
patients, whether easy to treat or recalcitrant, besides improving the quality of the
skin. We should consider that in the patient with melasma, we observe, besides the
stains, an opacity and aging of the skin resulting from the elastosis observed in the
histopathology, as well as the degeneration of the basal layer. All these conditions
are treated with microneedles. The trauma caused in the procedure must be uniform.
Always treat areas that present staining and also those that do not have them. The
use of bleachers and sunscreen after the procedure becomes mandatory.
Sources
1. Lima EVA, Lima MMDA, Paixão MP, et al. Assessment of the effects of skin microneedling as
adjuvant therapy for facial melasma: a pilot study. BMC Dermatol. 2017;17(1):14.
2. Lima EA. Microneedling in facial recalcitrant melasma: report of a series of 22 cases. An Bras
Dermatol. 2015;90(6):919–21.
98
9
PCI in the Treatment of Melasma
3. Cassiano DP, Espósito ACC, Hassun KM, et al. Early clinical and histological changes
induced by microneedling in facial melasma: a pilot study. Indian J Dermatol Venereol Leprol.
2019;85(6):638–41.
4. Espósito ACC, Brianezi G, de Souza NP, et al. Ultrastructural characterization of damage in the
basement membrane of facial melasma. Arch Dermatol Res. 2020;312(3):223–7.
5. Handel AC, Miot LDB, Miot HA. Melasma: a clinical and epidemiological review. An Bras
Dermatol. 2014;89(5):771–82.
6. Kang WH, Yoon KH, Lee ES, et al. Melasma: histopathological characteristics in 56 Korean
patients. Br J Dermatol. 2002;146:228–37.
7. Sheth VM, Pandya AG. Melasma: a comprehensive update: part I. J Am Acad Dermatol.
2011;65(4):689–97.
Chapter 10
PCI Correcting Post-inflammatory
Hyperpigmentation
10.1
ational PCI in Post-inflammatory
R
Hyperpigmentation (PIH)
The darkening of the skin in a reactive way to a trauma, which results in inflammation, erythema, and consequently pigment migration, is often a therapeutic challenge. This is because a constitutional tendency to dermatosis is often observed, and
these patients have a history of skin staining, often since childhood. In Brazil, miscegenation and the tropical climate favor a high incidence of these cases.
Hyperchromic scars in exposed areas, darkening of fold areas, or even unexpected
pigmentation of treated areas in patients who have undergone certain procedures are
also common complaints.
Lightening and depigmentation actives applied to the skin at home can be effective when associated with regular use of sunscreen, but they cannot offer good
results in all cases. Complementary treatments performed in the office, such as peelings and lasers, have their responses linked to the experience of each dermatologist:
some patients have good responses; others may even worsen their lesions.
Currently, there is the proposal of transmitting actives with whitening potential
through techniques that increase the permeability of the skin, either by light beams
or by the perforation of the skin by microneedles, an intervention called drug delivery. Considering the latter, a roller jammed by sterile stainless steel needles, or even
its presentation in pen of similar needles, is used with subsequent deposit of the
solution with bleaching potential on the skin. When the evaluation of this therapeutic proposal begins, a question arises: is the substance with bleaching potential the
only one responsible for the bleaching observed in the investigations carried out, or
would the needles also have their role in isolation in this process? The lightening of
pigmented scars after treatment by PCI calls our attention, as can be seen in
Figs. 10.1, 10.2, 10.3, and 10.4.
The Editor(s) (if applicable) and The Author(s), under exclusive license
to Springer Nature Switzerland AG 2021
E. Lima, M. Lima, Percutaneous Collagen Induction With Microneedling,
https://doi.org/10.1007/978-3-030-57541-0_10
99
100
10
PCI Correcting Post-inflammatory Hyperpigmentation
Fig. 10.1 Hyperpigmented scar treated with one sessions of deep injury PCI after 45 days
treatment
Fig. 10.2 Hyperpigmented scar treated with one session of deep injury PCI before and after 90 days
The experience of the author treating these scars and individuals with recalcitrant
melasma with microneedles, with whitening in 100% of the cases and without the
addition of any asset, led him to believe in the potential of needles as a whitening
agent. This hypothesis was also validated by histopathological evaluations that present significant reduction of melanin granules in specimens stained by the Masson-­
Fontana method (see Chap. 9, PCI in Melasma) after which it was recommended as
the Lima Protocol (developed by the authors). Figures 10.4 and 10.5 present cases
of recalcitrant melasma, respectively, with 18 and 23 years of evolution treated by
the Lima Protocol.
10.2 Step by Step: Lima Protocol
101
Fig. 10.3 Hyperpigmented scar after hidradenitis treated with one session of deep injury PCI
Fig. 10.4 Recalcitrant melasma after treatment with Lima Protocol (two sessions)
10.2
Step by Step: Lima Protocol
1. The use of topical anesthesia is sufficient for moderate injury. For that, 4% liposomal lidocaine is recommended as anesthetic, following the following
guidelines:
• Use up to 30 g (for the face) and up to 60 g (for the body), based on safety
criteria of the asset.
102
10
PCI Correcting Post-inflammatory Hyperpigmentation
Fig. 10.5 Melasma recalcitrant after Lima Protocol treatment (two sessions)
• The application of anesthetic in the area to be treated must be without prior
hygienization, since the greasy skin is a propitious means for the activation of
the product and the excellence of the anesthesia.
• Vigorously massage 50% of the total recommended amount of anesthetic
1 hour before intervening in the area to be treated.
• After 30 minutes of this first application, the remaining 50% should be used
in the same way as described above, waiting another 30 minutes for the beginning of the intervention.
2. Cleaning the skin with aqueous chlorhexidine, removing all the applied anesthetic and makeup residues and sunscreen, among others.
3. Use a 1.5 mm needle length roller looking for a moderate lesion as an end point
(see Chap. 2). For this purpose, horizontal strips should be created with shuttle
motion until a uniform erythema with petechial points is achieved. Crossing in
vertical and diagonal directions may complement the intervention to achieve the
recommended lesion appearance (Figs. 10.6 and 10.7).
4. At the end of the intervention, blood or serous exudation should not be removed.
This platelet-rich plasma contains growth factors and stem cells, which assist in
the process of skin regeneration and in obtaining results.
After 30 minutes of performing the procedure, a serosanguinolent crust is
observed, which coagulates and provides a biological dressing to the treated area.
The patient can be released after applying sunscreen if the area is exposed. Another
option is to apply a 5% toned retinoic acid peel, according to the protocol proposed
by Emerson Lima (2018) (see Chap. 24).
After 24 hours and in the days that follow, patients can be advised about the use
of industrialized whitening formula at night (retinoic acid 0.05% + hydroquinone
4% + fluocinolone acetonide 1%) and industrialized toned sunscreen with sun protection factor (SPF) 60. The Lima Protocol can be repeated 30 days after the first
10.2 Step by Step: Lima Protocol
Fig. 10.6 Face of a patient
presenting with the
proposed IPH end point
based on the Lima Protocol
Fig. 10.7 Armpit of a
patient presenting with the
proposed HPI end point
based on the Lima Protocol
103
104
10
PCI Correcting Post-inflammatory Hyperpigmentation
treatment, and patients can return to their activities immediately after the procedure.
There are no restrictions.
The results observed are good when compared to other procedures, even in challenging cases such as the one presented in Fig. 10.8. We observe the before and after
two sessions with an interval of 15 days of a patient undergoing aesthetic treatment
by a non-medical practitioner using an unidentified machine for treatment of stretch
marks. Figure 10.9 shows another indication of success with the Lima Protocol: a
Fig. 10.8 Patient undergoing aesthetic treatment by a non-medical practitioner using an unidentified machine for treatment of stretch marks. (a) HPI with a 5-month progression treated with topical bleachers, without success. (b) Result after two sessions of Lima Protocol
Fig. 10.9 Arm and armpit of a patient presenting the before and after 90 days of two sessions of
PCI, based on the Lima Protocol, for HPI after herpes-zoster
10.3 Evaluation and Conduct
105
patient with constitutional hyperpigmentation affecting the malar and periorbital
regions after two treatment sessions.
10.3
Evaluation and Conduct
Patient assessment The applicability of PCI is established independently of the
phototype; even at the highest, the technique is well indicated. These patients need
to be in use of a night lightener and well adapted to a broad-spectrum toned sunscreen. Pre-procedure preparation is mandatory. The less melanin the treated skin is
providing, the less risk of darkening in the post-procedure.
Instrumental It is preferable to use a roller with an average of 192 needles of
1.5 mm in length. The treatment should be performed in a procedure room carefully
prepared for a surgical intervention and by a trained and qualified professional. It is
essential not to trivialize these safety criteria, which range from the use of sterile
gloves and sterile surgical fields to an environment that follows strict disinfection
standards.
Asepsis, anesthesia of the area, transoperative, and postoperative. The methodology presented in the Lima Protocol should be followed.
Complications They are much more related to expected effects such as modest
edema, small hematomas, and transient erythema.
Pain and discomfort They are tolerable during the intervention, as long as the
protocol proposed by the author is followed. In the postoperative period, these complaints are not observed.
Prophylaxis for herpes It is not routinely recommended, since it is not an ablative
intervention, which removes the epidermis completely and, consequently, allows
infection by an organism that needs the loss of keratinocyte integrity to proliferate.
However, in cases where the frequent and recalcitrant character of the viral infection
is identified, this prophylaxis is considered mandatory, taking into account mainly
the surgical stress.
According to author’s experience, the results are satisfactory in cases of IPP,
considering that the therapeutic arsenal for this conduction is limited and the use of
lightening agents, especially in body areas, is little tolerated by patients. The number of sessions depends on the severity of the case.
The need to offer results more quickly means that the intervals between sessions
are reduced to 15 days, as skin regeneration happens very quickly. In the author’s
experience, there is no contraindication to perform PCI in various IPH situations.
Figure 10.10 presents a case of IPH after herpes zoster treated with two 30-day
interval sessions. Other challenging case is presented in Fig. 10.11, which show a
constitutional hyperpigmentation and a post-acne conglobata BIPH, respectively,
both treated with the Lima Protocol.
106
10
PCI Correcting Post-inflammatory Hyperpigmentation
Fig. 10.10 Patient with post-acne conglobata hyperpigmentation on the back after two treatment
sessions with the Lima Protocol
Fig. 10.11 Patient before and after 30 days PCI
Sources
10.4
107
Final Considerations
PCI has been proposed as an effective treatment for IPH. In author’s experience,
when the methodology with all the recommended criteria is followed, the procedure
always offers whitening. The number of sessions with an interval of 30 days depends
on the intensity of BIPH, and there is no limit to the number of interventions.
Moreover, according to the author’s experience, each intervention offers a gain in
pigment reduction and improvement in skin quality.
Sources
1. Bal SM, Caussin J, Pavel S, et al. In vivo assessment of safety of microneedle arrays in human
skin. Eur J Pharm Sci. 2008;35:193–202.
2. Fernandes D. Minimally invasive percutaneous collagen induction. Oral Maxillofac Surg Clin
North Am. 2005;17:51–63.
3. Gupta AK, Gover MD, Nouri K, et al. The treatment of melasma: a review of clinical trials. J
Am Acad Dermatol. 2006;55:1048–65.
4. Hsiao CY, Sung HC, Hu S, et al. Fractional CO2 laser treatment to enhance skin permeation of
tranexamic acid with minimal skin disruption. Dermatology. 2015;230(3):269–75.
5. Lima EA. Microagulhamento em melasma facial recalcitrante: uma série de 22 casos. Na Bras
Dermatol. 2015a;90(6):917–9.
6. Lima EA, Lima M, Takano D. Microneedling experimental study and classification of the
resulting injury. Surg Cosmet Dermatol. 2013;5:110–4.
7. Lima EA. Microneedling in facial recalcitrant melasma: report of a series of 22 cases. An Bras
Dermatol. 2015b;90(6):919–21.
8. Lima EVA, Lima MMDA, Paixão MP, et al. Assessment of the effects of skin microneedling
as adjuvant therapy for facial melasma: a pilot study. BMC Dermatology. 2017:1–6.
9. Lu YG, Liu J, Gao YH, et al. Modeling of transdermal drug delivery with a microneedle array.
J Micromech Microeng. 2006;16:151–4.
10. Miot LD, Miot HA, Silva MG, et al. Physiopathology of melasma. An Bras Dermatol.
2009;84:623–35.
11. Orentreich DS, Orentreich N. Subcutaneous incisionless (subcision) surgery for the correction
of depressed scars and wrinkles. Dermatol Surg. 1995;21:543–9.
12. Vachiramon V, Sahawatwong S, Sirithanabadeekul P. Treatment of melisma in men with low-­
fluence q-switched neodymium-doped yttrium-aluminumgarnet laser versus combined laser
and glycolic acid peeling. Dermatol Surg. 2015;41:457–65.
13. Vandervoort J, Ludwig A. Microneedles for transdermal drug delivery; mini review. Front
Biosci. 2008;13:1711–5.
14. Cassiano D, Esposito Lemos AC et al. Efficacy and safety of microneedling and oral tranexamic
acid in the treatment of facial melasma in women: an open, evaluator-blinded, randomized
clinical trial. J Am Acad Dermatol. 2020. pii: S0190-9622(20)30164-X.
15. Cassiano DP, Espósito ACC, Hassun KM, et al. Early clinical and histological changes
induced by microneedling in facial melasma: a pilot study. Indian J Dermatol Venereol Leprol.
2019;85(6):638–41.
16. Espósito ACC, Brianezi G, de Souza NP, et al. Ultrastructural characterization of damage in
the basement membrane of facial melasma. Arch Dermatol Res. 2020;312(3):223–7.
17. Handel AC, Miot LDB, Miot HA. Melasma: a clinical and epidemiological review. An Bras
Dermatol. 2014;89(5):771–82.
108
10
PCI Correcting Post-inflammatory Hyperpigmentation
18. Kang WH, Yoon KH, Lee ES, et al. Melasma: histopathological characteristics in 56 Korean
patients. Br J Dermatol. 2002;146:228–37.
19. Ramaut L, Hoeksema H, Pirayesh A, et al. Microneedling: where do we stand now? A systematic review of the literature. J Plast Reconstr Aesthet Surg. 2018;71(1):1–14.
20. Sheth VM, Pandya AG. Melasma: a comprehensive update: part I. J Am Acad Dermatol.
2011;65(4):689–97.
Chapter 11
Correcting Acne Scars Using PCI
11.1
PCI Fundamentals in Acne Scars
Cystic acne usually results in scars that are difficult to treat. The consumption of the
dermis and hypodermis, as well as the deterioration of the epidermis resulting from
the destructive action of inflammatory cytokines, gives rise to depressed, elevated,
dystrophic lesions, in addition to loss of pigment, hyperpigmentation, flaccidity, and
development of superficial and deep rhytides. This polymorphism, commonly
observed in patients after severe and prolonged inflammatory acne, presents itself as
a therapeutic challenge. For this reason, it is necessary to evaluate these lesions in a
particular way, examining their architecture and directing the option of more specific intervention to the correction of each cicatricial unit. We consider it important
to present the morphological classification of acne scars proposed by Kadunc and
Trindade de Almeida [9] – Table 11.1.
Frequently, we observe the need to associate more than one technique in the
same individual, seeking the optimization of results. We consider surgical interventions such as Subcision™, micrografts, shavings, excisions, and ablative techniques
Table 11.1 Morphological
classification of acne scars
High scars
Hypertrophic
Keloidian
Anethodermy-sylem
In bridge
Dystrophic scars
Depressed scars
Distinguishable: shrinkage and ripples
Non-distensible: superficial, medium, and deep
The Editor(s) (if applicable) and The Author(s), under exclusive license
to Springer Nature Switzerland AG 2021
E. Lima, M. Lima, Percutaneous Collagen Induction With Microneedling,
https://doi.org/10.1007/978-3-030-57541-0_11
109
110
11
Correcting Acne Scars Using PCI
indicated for the most severe cases. Ablative treatments such as medium and deep
chemical peelings bring undeniable stimulus to the production of collagen, providing an improvement in texture, brightness, and color of the skin surface. Very good
results are also observed with the association of the peelings to the surgical abrasion
or isolated surgical abrasion. Figures 11.1, 11.2, 11.3, and 11.4 present patients
treated by ablative techniques.
Fig. 11.1 Depressed acne scars treated with surgical abrasion
Fig. 11.2 Depressed acne scars treated with surgical abrasion
11.1 PCI Fundamentals in Acne Scars
111
Fig. 11.3 Depressed scars treated with association of ACT 35% and surgical abrasion
Fig. 11.4 Persistent erythema after 30 days of treatment with ACT 35% and surgical abrasion
However, as mentioned in Chap. 1 (Fundamentals of PCI), in ablative procedures, recovery is long and results in a more light-sensitive tissue, subject to post-­
inflammatory hyperpigmentation (IPH) and photosensitivity, adding to the risk of
complications such as hypertrophic scarring, persistent erythema, and dyschromias.
After the epidermis is removed, the dermal papillae are rectified, and the resulting
scar tissue consists of thick bundles of collagen-oriented parallel, unlike the interlacing network of collagen found in normal skin.
Currently, interventions using ablative technologies seek to cause fractional
damage to the skin, which allows the integrity of the microregion adjacent to the
trauma to be maintained intact, favoring a shorter recovery time and a decreased risk
of complications. The fractionated CO2 laser is an example of this proposal, as is
the PCI. Figure 11.5 shows the evolution of a patient before, after 5 days of the
intervention that associated surgical abrasion with 35% trichloroacetic acid and followed by 30 days, observing substantial erythema.
112
11
Correcting Acne Scars Using PCI
Fig. 11.5 Evolution of treatment with surgical abrasion and TCA 35% after 5 days and then 30 days
Before
30 days after
24 H after
5 days after
8 years after
Fig. 11.6 Evolution of PCI treatment after 24 hours and after 5 days of intervention, after 30 days
and after 8 years
In comparison, Fig. 11.6 presents the evolution of a patient submitted to PCI in
five photos: before the intervention, the following day, 5 days after the intervention,
after 30 days and the last one after 8 years. A faster evolution can be observed when
compared to ablative techniques and the maintenance of results, after a long period
of time only with the use of daily sunscreen.
PCI promotes a stimulus in the production of collagen, without causing the total
deepithelialization observed in ablative techniques. The epidermis and dermis are
perforated but not removed. Thus, the penetration of needles used in this technique
in the skin produces micropunctures at the bottom of the scars, modifying their
surface, destructuring the abnormal collagen, favoring neovascularization and neoangiogenesis (Fig. 11.7). The depressed scars, even the widest and deepest, respond
to the needles. The more superficial and narrower they are, the better the therapeutic
result will be obtained, and it is often necessary to increase the length of the needles
11.1 PCI Fundamentals in Acne Scars
113
Fig. 11.7 Depressed acne scar perforated by PCI technique, schematically demonstrating the process of tissue regeneration that takes place after the procedure
Fig. 11.8 Static and dynamic evaluation of the flaccidity observed in a patient with cystic acne
in order to effectively reach the bottom of these lesions. High scars also respond to
PCI, as well as dystrophic, flat, and dyschromic scars. The degree of improvement
is variable, depending on the severity of these lesions, i.e., the deeper, elevated,
dyschromic, and irregular the scar the more modest the cosmetic gain. There is also
an effect of detachment or elevation of the region consumed by the inflammation
and affected by fibrotic beams that retract the tissue, anchoring the skin surface in
deep planes.
Roughly, we can compare this rupture to the one that would occur with the
release of cords that we can see in a capitonê aspect on a cushion. Similar to what
occurs with Subcision™, which acts with windshield movements, or to the proposal
of dermal tunneling (DT), which acts with shuttle movements, the PCI needle the
epidermis and dermis, leading to an improvement of fibrosis of the treated area. In
older individuals, intrinsic aging and photodanus worsen the appearance of scars.
Characteristics that together with flaccidity and the redistribution of fat on the face
produce an accentuation of the unaesthetic aspect. It should be reported that even
when the patient is submitted to procedures that remove skin leftovers, attenuating
flaccidity and wrinkles, the resulting skin must offer a good appearance, and this
translates into tissue renewal, the result of an intervention based on neocollagenosis
and neoangiogenesis. Figures 11.8 and 11.9 exemplify what was said showing two
114
11
Correcting Acne Scars Using PCI
Fig. 11.9 Static and dynamic evaluation of flaccidity observed in a patient with cystic acne
sisters who had cystic acne in adolescence, evolved with depressed scars and consumption of the genian region, causing flaccidity worsened with aging. Note that
from static analysis (patients at rest) to dynamics (patients smiling), scars, deep
wrinkles, and flaccidity are significantly worse. Despite the good volumerization
results offered by autologous and heterologous fillers, they are not able to fulfill
their role well in these cases, because there is a need to intervene particularly in
scars and deep wrinkles. In some situations, where fibrotic beams are known to be
present, we consider the deposition of these products inappropriate, before a surgical intervention to release them. The justification is that the fillers will be trapped
between this web, not fulfilling their role with excellence and offering an unnatural
aspect (Fig. 11.8). The author recommends the use of PCI as an initial step in the
approach to acne scars, regardless of the characteristics and architectural classification, since he states that all will respond to microneedles either significantly or
poorly. The longer the needle length used, the more dramatic the therapeutic
response (see Chap. 2, Classification and Characteristics of Injury Caused by PCI),
and the greater the chance of resolution.
11.2
Applicability of PCI on Acne Scars
PCI offers the proposal to improve the texture, color, and relief of acne scars with
microneedles, preferably needles 2.5 mm long. For the success of the technique, the
items described below should be considered.
11.2.1
Skin Thickness
Very thin skins offer less resistance to shorter needle lengths when compared to
thick skins. However, as patients with acne scars often have thick skin, the use of
2.5 mm long needles is recommended. These individuals commonly present recesses
11.2 Applicability of PCI on Acne Scars
115
that make it difficult for the microneedles to roll and, consequently, compromise the
uniformity of their penetration, observing a reduction of up to 50% of the total
length penetration. In older individuals, the more elastotic the skin, the greater the
evidence of resistance. In smokers, we observe this same process, and in order to
compensate and overcome this reluctance, many times the operator imposes exaggerated force to the instrument, which may traumatize nervous or vascular structures and not achieve the expected effect. Therefore, we recommend that the force
vector we imprint on the roller always tangents the horizontal plane we are working
on and is never perpendicular to that surface.
11.2.2
Scar Characteristics
The deeper the scar, the greater the challenge. Scars in which the epidermis has been
completely destroyed with melanin loss and result in atrophic scarring are also more
difficult to treat. The lesions on the face are more responsive to PCI when compared
to those found on the chest or back; the latter need more interventions to offer the
same result as the former. Scars located in more oily areas, in the author’s experience, offer a better response to treatment, when compared to those arranged in
regions with fewer seborrheic glands. This characterizes a differential of PCI, a
technique that only needle the skin, in relation to the incision. In the latter, the
enlargement and often the worsening of the scar is evidenced, most commonly in
oily skin.
11.2.3
Flaccidity and Needle Length
Flaccidity of the face is more easily treated than body flaccidity. The thicker adipose
cushion on the body offers a cushioning of needle penetration, resulting in greater
resistance. The bone eminences of the face act as a support surface, which facilitates
the introduction of needles.
11.2.4
Deep Injury
It is proposed when the objective is to extract the maximum from this intervention
in a single procedure. Commonly, an approach using a 2.5 mm needle length under
infiltrative anesthesia provides a cosmetic gain compatible with the patient’s and
dermatologist’s expectations; however, if a second intervention is desired, it is prudent to wait at least 90 days for the results to stabilize. Figure 11.9 clearly presents,
with the end point, the difference between the ablative technique (Fig. 11.9a – post-­
abrasion surgery) and PCI (Fig. 11.9b). Note that the first presents the exposure of
the dermis at the expense of deepithelialization, while the second presents a uniform
116
11
Correcting Acne Scars Using PCI
Fig. 11.10 Filling between fibrotic beams compromising the cosmetic result
Fig. 11.11 The presentation of the difference between an ablative technique, photo on the left
after surgical abrasion, and the PCI on the right. Note that the former presents the exposure of the
dermis at the expense of deepithelialization, while the latter presents a uniform purple secondary
to thousands of microperforations, without the epidermis having been removed
purpura secondary to thousands of microperforations, without the epidermis having
been removed. In Fig. 11.10 a substantial improvement of acne depressed scars,
difficult to treat, after a single session of PCI deep injury, 4 years after the intervention, demonstrating the support of the results with the technique performed following the author’s protocol. Figure 11.11 presents the correction of the loss of volume
11.3 Step by Step
117
of the genian region achieved by the deep injury PCI after 90 days of evolution. An
example of the collagenic stimulus of and rupture of scar fibrotic beams provided by
the treatment. Figure 11.13 shows patient before and after 90 days of PCI treatment,
showing volumerization of the area after collagenic stimulus and fibrotic beam
rupture.
11.3
Step by Step
A sequence is suggested below to guide the implementation of the treatment, considering a proposal of deep injury in the treatment of acne scars.
Patient assessment. Even higher phototypes, subject to commonly transient IPH,
may undergo PCI, but skin preparation is crucial. As already mentioned, the less
melanin the skin to be treated is providing, the lower the risk of darkening.
• Instrumental. Scarred skin responds more difficult to microneedle injury than
aged skin. In the face of greater resistance, it is preferable to use the roller-­
shaped device with 2.5-mm-long needles, although shorter needles also have
correction potential. Every care in a surgical intervention should be taken. It is
essential not to trivialize these safety criteria, which range from the use of sterile
gloves and sterile surgical drapes to an environment that follows strict disinfection standards.
• Asepsis and anesthesia of the area. Chlorhexidine 2% is preferred as an antiseptic. To anesthetize, 2% lidocaine solution is used without a 1:2 vasoconstrictor
0.9% saline solution, respecting the maximum dose of the active agent allowed
(see Chap. 4, Analgesia and Anesthesia). After the rolling of the microneedles,
bleeding is observed that varies according to the friability of the scars and the
degree of fibrosis.
• Immediate postoperative. The bleeding is contained with pads and followed by a
dressing using sterile gauze in large quantities (in order to contain the exudation)
and Micropore®, without the addition of any humectant. As already mentioned,
topical or systemic antibiotic therapy is not indicated. It is a clean procedure and,
according to the Food and Drug Administration (FDA) regulations, this precaution is unnecessary. There is also no need for cold or hot compresses to contain
the large amount of micro-hematomas, much less corticotherapy.
• Postoperative care. A gel regenerator is recommended, considering that these
patients usually have some degree of oiliness. After reepithelialization, its use is
discontinued in order to start the use of a lightener with sunscreen. The restriction to lights is oriented. Despite the edema and bruises presented on subsequent
days, if the treated area is covered (neck, chest, back), the return to daily activities and public coexistence may happen the next day. If the area is exposed, it is
necessary to stay away from socializing for at least 5 days.
• Complementary techniques. In acne scars, the consumption essentially observed
in the genial region sometimes requires complementary treatments with fillers
118
11
Correcting Acne Scars Using PCI
Fig. 11.12 Patient before and after 4 years of PCI treatment with retained results
such as hyaluronic acid. In these cases, it is recommended to perform the PCI
after at least 30 days, making sure that the edema has regressed. The botulinum
toxin, in the author’s experience, can be used after 15 days.
• Complications. They are more related to expected effects such as edema, hematomas, transient HPI, and transient erythema. Taking due care in the preparation
of the skin, establishing the attention to postoperative recommendations with
rigor, the PCI presents itself as a safe and reproducible technique for acne scars,
provided that the operator is duly qualified and trained. Driving by a qualified
specialist is mandatory. These cases revert as long as they are properly treated.
Figure 11.12 shows an HPI 15 days after PCI. It is a very rare condition, in the
author’s experience, easily conducted with bleachers and sunscreen. Figure 11.14
shows an HPI 15 days after PCI. It is a very rare condition, in the author’s experience, easily conducted with bleachers and sunscreen.
11.4
Final Considerations
PCI in the author’s opinion is a water divisor in the treatment of acne scars. The
technique makes it possible to treat scars with different architectural aspects, always
offering results in all of them. According to the author’s vast experience, the grafting treatments, excisions, abrasion, and other techniques used in his practice have
been replaced by microneedles and their associations, as we will see in the chapters
11.4 Final Considerations
119
Fig. 11.13 Patient before and after 90 days of PCI treatment, showing volumerization of the area
after collagenic stimulus and fibrotic beam rupture
Fig. 11.14 Patient before and after PCI treatment showing post-inflammatory hyperpigmentation
after 7 days
that describe the techniques of dermal tunneling (DT) and multi-needles associate
with radiofrequency. The quality of the results offered depends essentially on the
operator. The more challenging the case, the more sessions will be necessary, without any limitation. The goal is patient and specialist satisfaction. We are facing a
new concept: the transformation of a scar tissue into a tissue closer to the physiological, without the need for its removal. Figures 11.13, 11.14, 11.15, 11.16, and 11.17
present examples of areas in which the patient can be treated. Figures 11.15, 11.16,
11.17, 11.18, and 11.19 present examples of areas in which the patient can be
treated.
120
11
Correcting Acne Scars Using PCI
Fig. 11.15 Patient before and after 90 days PCI treatment
Figs. 11.16, 11.17, 11.18, and 11.19 Patient before and after 90 days PCI treatment
11.4 Final Considerations
Fig. 11.16, 11.17, 11.18, and 11.19 (continued)
121
122
11
Correcting Acne Scars Using PCI
Sources
1. Aust MC. Percutaneous collagen induction therapy: an alternative treatment for scars, wrinkles, and skin laxity. Plast Reconstr Surg. 2008;121(4):1421–9.
2. Bal SM, Caussian J, Pavel S, et al. In vivo assessment of safety of microneedle arrays in human
skin. Eur J Pharm Sci. 2008;35(3):193–202.
3. Brody HJ. Trichloroacetic acid application in chemical peeling, operative techniques. Plast
Reconstr Surg. 1995;2(2):127–8.
4. Camirand A, Doucet J. Needle dermabrasion. Aesthet Plast Surg. 1997;21(1):48–51.
5. Cohen KI, Diegelmann RF, Lindbland WJ. Wound healing: biochemical and clinical aspects.
Philadelphia: WB Saunders Co; 1992.
6. Fabroccini G, Fardella N. Acne scar treatment using skin needling. Clin Exp Dermatol.
2009;34(8):874–9.
7. Fernandes D. Minimally invasive percutaneous collagen induction. Oral Maxillofac Surg Clin
North Am. 2006;17(1):51–63.
8. Fernandes D, Massimo S. Combating photoaging with percutaneous collagen induction. Clin
Dermatol. 2008;26(2):192–9.
9. Kadunc BV, Trindade de Almeida AR. Surgical treatment of facial acne scars based on a morphological classification: a Brazilian experience. Dermatol Surg. 2003;29:1200–9.
10. Lima EVA, Lima MMDA, Paixão MP, et al. Assessment of the effects of skin microneedling
as adjuvant therapy for facial melasma: a pilot study. BMC Dermatology. 2017:1–6.
11. Lima EA. Microneedling in facial recalcitrant melasma: report of a series of 22 cases. An Bras
Dermatol. 2015;90(6):919–21.
12. Lima EVA, et al. Induction of pigmentation through microneedling in stable localized vitiligo
patients. Dermatol Surg. 2020;46(13):434–5.
13. Lima EA. Microagulhamento em melasma facial recalcitrante: uma série de 22 casos. Na Bras
Dermatol. 2015;90(6):917–9.
14. Lima EA, Lima M, Takano D. Microneedling experimental study and classification of the
resulting injury. Surg Cosmet Dermatol. 2013;5:110–4.
15. Lima EVA. Dermal tunneling: a proposed treatment for depressed scars. An Bras Dermatol.
2016;91(5):697–9.
16. Lima EVA. Indução percutânea de colágeno com agulhas em cicatrizes após acidentes automobilísticos: correção cosmética e funcional. Surg Cosmet Dermatol. 2017;9(2):127–9.
17. Lima EVA. Dermal tunneling (TD®): a therapeutic option for static glabellar wrinkles. Surg
Cosmet Dermatol. 2016;8(1):42–5.
18. Lima EVA. Pulsed radiofrequency with multineedles (RFPM®) in the treatment of atrophic
stretch marks. Surg Cosmet Dermatol. 2016;8(3):242–5.
19. Lima EA, Lima MA, Araújo CEC, Nakasawa YMM, Leal NC. Investigation on the use of 3%
and 5% retinoic acid in peeling solution as a drug delivery agent after percutaneous induction of collagen with needles (IPCA®): safety profile and application protocol. Surg Cosmet
Dermatol. 2018;10(1):21–6.
20. Lima EAV. Pulsed radiofrequency with multineedles: a therapeutic proposal for wrinkles, sagging, and periorbital pigmentation. Surg Cosmet Dermatol. 2015;7(3):223–6.
21. Lima EVA. Association of microneedling with phenol peeling: a new therapeutic approach for
sagging, wrinkles and acne scars on the face. Surg Cosmet Dermatol. 2015;7(4):328–31.
22. Lima EVA. Pulsed radiofrequency with multineedles for earlobe aging treatment. Surg Cosmet
Dermatol. 2016;8(4):307–10.
23. Lima EVA. Indução percutânea de colágeno com agulhas (IPCA®) associada a radiofrequência pulsada com multiagulhas (RFPM®) na condução de cicatrizes de acne deprimidas: protocolo de tratamento. Surg Cosmet Dermatol. 2017;9(3):234–6.
24. Orentreich DS, Orentreich N. Subcutaneous incisionless (subcision) surgery for the correction
of depressed scars and wrinkles. Dermatol Surg. 1995;21:6543–9.
Chapter 12
Correcting After Accident Scars Using PCI
Accidents that result in unaesthetic scars happen more and more frequently in our
environment; they are a relatively common cause of visits to specialist offices. The
sources and causes that cause these scars are diverse; for this reason there is almost
always an injurious polymorphism that can be distinguished from normotrophic to
hypertrophic and atrophic injuries, with variation in color and shape, which often
requires the association of techniques aiming at the best therapeutic gain (Fig. 12.1).
Besides cosmetic improvement, functional correction of the area should be considered. With a certain frequency, there is impairment of the elasticity of the affected
region, with function deficit. Figure 12.2 represents a submentonian scar immediately after treatment with PCI and 30 days after the intervention.
Figure 12.3 presents the cosmetic and functional gains of the patient mentioned
in Fig. 12.2. It is recommended that treatment with PCI be instituted before
Fig. 12.1 Architectural polymorphism of post-accident scars
The Editor(s) (if applicable) and The Author(s), under exclusive license
to Springer Nature Switzerland AG 2021
E. Lima, M. Lima, Percutaneous Collagen Induction With Microneedling,
https://doi.org/10.1007/978-3-030-57541-0_12
123
124
12 Correcting After Accident Scars Using PCI
Fig. 12.2 Submentonian region immediately after PCI treatment for cosmetic scar improvement
Fig. 12.3 Cosmetic gain (a) and functional gain (b) of the patient mentioned in Fig. 12.2 treated
with PCI
cosmetic correction. The indication of flaps or large grafts deserves to be prioritized
because new scars can be created. For the correction of acne scars, dermatologic
surgery in Brazil proposes the following techniques: micrografting, peelings, dermabrasion, Subcision™, autologous or heterologous filling, technologies with light,
and application of botulinum toxin. These techniques can be used in post-accident
scars as long as their architecture is well evaluated, thus seeking a direction in the
choice of intervention (the format and characteristic of the injury determine the
choice of specific treatment). PCI provides good results in acne scars and, according
to the author’s experience, is a useful tool in the treatment of all forms of scars,
regardless of the presentation. The gains are substantial in shallower, normochromic,
12.1 Applicability of Needle Techniques
125
Fig. 12.4 Patient with scar secondary to an automobile accident. Before and after cosmetic
improvement with PCI
and elastic lesions and more modest in deep, dyschromic, and rigid ones, but it
always happens. The use of dermal tunneling (see Chap. 26, DT in Scars) can be
effective when you have thick, rigid, and deep fibrotic beams that need loosening
and release of the skin surface. PCI associated with radiofrequency (see Chap. 29) is
a good option when a more delicate surgical approach is required, using needles of
100 μ to treat different aspects of the scars with the electrodes Lima 8, Lima 4, and
Lima 2 and obtain good results. The experience of the author confirms the optimization of results when associating these last three proposals. There is not necessarily a
mandatory sequence to be followed, and commonly the peculiarity of each case will
determine how this association should be performed. It is suggested that the use of
complementary techniques such as fillers, botulinum toxin, or laser technologies be
incorporated to the treatment after at least 30 days, taking into consideration the
reduction of edema and accommodation of the stimulus whose results can be completed within 3–6 months. Figures 12.4, 12.5, 12.6, and 12.7 present patients submitted to PCI for correction of polymorphic scars. Observe the improvement of the
treated areas in terms of color, relief, and flexibility.
126
12 Correcting After Accident Scars Using PCI
Fig. 12.5 Patient with scarring secondary to an automobile accident. Before and after cosmetic
improvement with PCI
Fig. 12.6 Patient with scarring secondary to an automobile accident. Before and after cosmetic
improvement with PCI
Fig. 12.7 Patient with scarring secondary to childhood accident. Before and after cosmetic
improvement with IPCA®. Static evaluation
12.1
12.1.1
Applicability of Needle Techniques
Patient Assessment
After diagnosing the scars and their peculiarities, a therapeutic planning is crucial,
considering the previously mentioned arsenal and the direction for each case. The
healing needs to be well established, with well-coapted edges and firm repaired
12.1 Applicability of Needle Techniques
127
Fig. 12.8 Patient with scarring secondary to childhood accident. Before and after cosmetic
improvement with PCI. Dynamic assessment
tissue, avoiding dehiscence. It is often necessary to wait 3 months or to obtain
authorization from the multiprofessional team involved in the case, respecting ethical issues. It is important that the skin is prepared for the procedure, regardless of
the phototype. The author’s current tendency is to intervene as early as possible,
waiting an average of 30 days. Even the highest phototypes, subject to commonly
transient post-inflammatory hyperpigmentation (HPI), may benefit from these techniques. Knowing that the less melanin available, the lower the risk of darkening, it
is recommended the use of depigmentant and sunscreen 30 days before the intervention. Figures 12.7 and 12.8 show examples of patients treated by PCI.
12.1.2
Step by Step
• Instrumental – When the proposal is PCI, we prefer the use of rolls with an average of 192 needles of 2.5 mm length. The lower needle lengths commonly offer
modest results, as we are faced with stiffened skin. The treatment must be performed in a procedure room carefully prepared for a surgical intervention and by
a trained and qualified professional. It is essential not to trivialize these safety
criteria, which range from the use of sterile gloves and sterile surgical fields to an
environment that follows strict disinfection standards. Any existing infectious
involvement is mandatory for surgical suspension.
• Asepsis and anesthesia of the area – After antisepsis with 2% chlorhexidine, it is
suggested the use of 2% lidocaine solution without vasoconstrictor 1:2 saline
solution 0.9%, respecting the maximum dose of the active ingredient allowed
(see Chap. 4, Analgesia and Anesthesia). The addition of bicarbonate in order to
offer more comfort by reducing burning is optional. Truncal blocking can also
help in patient comfort, but is often not required. It is important to be aware of
the total volume of anesthetic used.
• Transoperative – The choice of the technique that will be initially instituted
depends on the proposed association and the type of scar that is being treated.
The association can be performed at the same time the surgery occurs or at different times. The bleeding is substantial, but limited with the containment of
128
12 Correcting After Accident Scars Using PCI
compresses and gauzes. After the end of the intervention, a significant reduction
in bleeding can already be observed, which gives rise to serous exudation, with
progressive regression in the first 6 hours. Figure 12.9 presents PCI transoperative for post-mastoplasty scar correction. Figure 12.10 shows a patient with purpura produced by deep PCI injury.
• Post immediate surgery – The dressing is made by using abundant amounts of
sterile gauze (in order to contain exudation) and Micropore®, without the addition of any humectant. Topical or systemic antibiotic therapy is not indicated. It
is a clean procedure, and, according to the Food and Drug Administration (FDA)
rules, this precaution is unnecessary. We prefer that the accommodation of the
bruises and the resulting inflammatory response follow its natural course. Nor is
the use of topical or systemic corticotherapy recommended to contain the
expected effects of the self-limited inflammatory process, for reasons already
known. Figure 12.10 presents a patient who was the victim of a white-arm accident with a laparotomy scar treated by PCI in a single session, with visible
improvement in color and texture.
Fig. 12.9 PCI transoperative for post-mastoplasty scar correction
Fig. 12.10 Laparotomy scar patient treated by PCI in a single session
12.1 Applicability of Needle Techniques
129
Fig. 12.11 Scar on supercilium treated with PCI
Fig. 12.12 Patient with periorbital scar secondary to motorcycle accident. Before and after cosmetic improvement with PCI
Fig. 12.13 Patient with atrophic and achromatic scars secondary to a motorcycle accident. Before
and after cosmetic improvement with PCI
• Evolution – The following day, after the dressing is removed, the area should be
sanitized by removing loose hematic crusts, without traumatizing or rubbing the
region. The use of regenerative balm is indicated until the reepithelialization, and
lighteners can be used after the reepithelialization, always associated with sunscreen during the day. Light restriction is recommended. In the following days,
edema and hematoma can be substantial or modest. Figures 12.11, 12.12, and
12.13 show examples of patients treated by PCI.
130
12 Correcting After Accident Scars Using PCI
12.1.3
Complementary Techniques
A second intervention is recommended only after a prior evaluation of the result
obtained after 90 days. If the dermatologist wishes to use a filler as hyaluronic acid
as a complementary technique, we recommend that this intervention be programmed
for at least 30 days postoperatively, always making sure that the edema has completely regressed. According to the author, the application of botulinum toxin is safe
already after 15 days of this intervention.
12.1.4
Complications
The association of techniques in the same surgical act can provide much more
expected effects, such as edema, hematomas, transient PIH, and transient erythema,
than adverse effects. Therefore, having a skin prepared for the intervention is a basic
condition for the prevention of complications. Transient IPPH can occur, even if
there is no deepithelialization as seen in the three techniques proposed here. The
conduction by a qualified dermatologist is mandatory. Complications are reverted as
long as they are properly treated. Often the physical coverage of the area by UV
protected clothing will bring benefits.
In the case of simple herpes, postoperative analgesia and prophylaxis indicated
follow the precepts presented in Chap. 8, PCI in Aging Skin.
12.2
Final Considerations
Techniques using needles described in this work have the advantage of addressing
scars without excision and synthesis, which could favor situations such as enlargement or dystrophy in the postoperative period. These are techniques that perforate,
without cutting, cause punctures without deepithelialization of the area, and, therefore, offer more safety regarding the cosmetic results and reduction of complications. Whether isolated or in association, the proposals presented here have shown,
in the author’s experience, good options in the approach to scars after accidents and
can be included in the therapeutic arsenal of challenging injuries.
Sources
1. Aust MC. Percutaneous collagen induction therapy: an alternative treatment for scars, wrinkles, and skin laxity. Plast Reconstr Surg. 2008;121(4):1421–9.
2. Bal SM, Caussian J, Pavel S, et al. In vivo assessment of safety of microneedle arrays in human
skin. Eur J Pharm Sci. 2008;35(3):193–202.
Sources
131
3. Brody HJ. Trichloroacetic acid application in chemical peeling, operative techniques. Plast
Reconstr Surg. 1995;2(2):127–8.
4. Camirand A, Doucet J. Needle dermabrasion. Aesthet Plast Surg. 1997;21(1):48–51.
5. Cohen KI, Diegelmann RF, Lindbland WJ. Wound healing: biochemical and clinical aspects.
Philadelphia: WB Saunders Co; 1992.
6. Fabroccini G, Fardella N. Acne scar treatment using skin needling. Clin Exp Dermatol.
2009;34(8):874–9.
7. Fernandes D. Minimally invasive percutaneous collagen induction. Oral Maxillofac Surg Clin
North Am. 2006;17(1):51–63.
8. Fernandes D, Massimo S. Combating photoaging with percutaneous collagen induction. Clin
Dermatol. 2008;26(2):192–9.
9. Lima EVA, Lima MMDA, Paixão MP, et al. Assessment of the effects of skin microneedling
as adjuvant therapy for facial melasma: a pilot study. BMC Dermatology. 2017:1–6.
10. Lima EA. Microneedling in facial recalcitrant melasma: report of a series of 22 cases. An Bras
Dermatol. 2015;90(6):919–21.
11. Lima EVA, et al. Induction of pigmentation through microneedling in stable localized vitiligo
patients. Dermatol Surg. 2020;46(13):434–5.
12. Lima EA. Microagulhamento em melasma facial recalcitrante: uma série de 22 casos. Na Bras
Dermatol. 2015;90(6):917–9.
13. Lima EA, Lima M, Takano D. Microneedling experimental study and classification of the
resulting injury. Surg Cosmet Dermatol. 2013;5:110–4.
14. Lima EVA. Dermal tunneling: a proposed treatment for depressed scars. An Bras Dermatol.
2016;91(5):697–9.
15. Lima EVA. Indução percutânea de colágeno com agulhas em cicatrizes após acidentes automobilísticos: correção cosmética e funcional. Surg Cosmet Dermatol. 2017;9(2):127–9.
16. Lima EVA. Dermal tunneling (TD®): a therapeutic option for static glabellar wrinkles. Surg
Cosmet Dermatol. 2016;8(1):42–5.
17. Lima EVA. Pulsed radiofrequency with multineedles (RFPM®) in the treatment of atrophic
stretch marks. Surg Cosmet Dermatol. 2016;8(3):242–5.
18. Lima EA, Lima MA, Araújo CEC, Nakasawa YMM, Leal NC. Investigation on the use of 3%
and 5% retinoic acid in peeling solution as a drug delivery agent after percutaneous induction of collagen with needles (IPCA®): safety profile and application protocol. Surg Cosmet
Dermatol. 2018;10(1):21–6.
19. Lima EAV. Pulsed radiofrequency with multineedles: a therapeutic proposal for wrinkles, sagging, and periorbital pigmentation. Surg Cosmet Dermatol. 2015;7(3):223–6.
20. Lima EVA. Association of microneedling with phenol peeling: a new therapeutic approach for
sagging, wrinkles and acne scars on the face. Surg Cosmet Dermatol. 2015;7(4):328–31.
21. Lima EVA. Pulsed radiofrequency with multineedles for earlobe aging treatment. Surg Cosmet
Dermatol. 2016;8(4):307–10.
22. Lima EVA. Indução percutânea de colágeno com agulhas (IPCA®) associada a radiofrequência pulsada com multiagulhas (RFPM®) na condução de cicatrizes de acne deprimidas: protocolo de tratamento. Surg Cosmet Dermatol. 2017;9(3):234–6.
23. Orentreich DS, Orentreich N. Subcutaneous incisionless (subcision) surgery for the correction
of depressed scars and wrinkles. Dermatol Surg. 1995;21:6543–9.
Chapter 13
Correcting Post-surgical Scar Using PCI
13.1
PCI Fundamentals in Post-surgical Scars
Scars resulting from surgical interventions are commonly the cause of discomfort
among patients. They can have several etiologies, such as removal of tumors on the
face or body, secondary to elective or emergency surgeries, cesarean sections, or
after plastic or corrective surgeries. More often, these scars are linear and subject to
enlargement, elevation, or atrophy, depending on the constitutional elements of each
individual and their area of location. Thorax, limb, and abdomen are more subject
to unaesthetic scars because they are areas of constant movement and contain fewer
sebaceous glands. However, a very seborrheic face is also prone to the development
of unaesthetic scars after excision and suture. In addition to carefully following the
force lines, the operator, in a preventive manner, should decrease the superficial tension of the incision during the procedure. For this, the use of internal stitches can be
advantageous. Some treatments are proposed to correct the scars that occur after the
surgeries. Among them we can mention the surgical removal of the scar, generating
a new incision, the use of ablative techniques such as peelings and dermabrasion,
besides the use of fillers, botulinum toxin, and technologies with light, which seek
from the improvement of color to the treatment of relief and texture. Although they
constitute a surgical procedure, the techniques with needles have the differential of
not causing cuts, which are subject to enlargement. Instead, they cause multiple
micropunctures that aim to break micro and macro fibrotic beams, restructuring and
renewing the scar tissue. PCI provides good results in acne scars and, according to
the author’s experience, is a useful technique for the treatment of all forms of scars,
regardless of their presentation. In shallower, normochromic, and elastic lesions, the
gains are substantial, and in those deep, dyschromic, and rigid, they are more modest, but always happen. The use of dermal tunneling (see Chap. 11) may be indicated when facing thick, rigid, and deep fibrotic beams that need loosening and
release of the skin surface. Multi-needles associated with radiofrequency is a good
The Editor(s) (if applicable) and The Author(s), under exclusive license
to Springer Nature Switzerland AG 2021
E. Lima, M. Lima, Percutaneous Collagen Induction With Microneedling,
https://doi.org/10.1007/978-3-030-57541-0_13
133
134
13 Correcting Post-surgical Scar Using PCI
option when a more delicate surgical approach is required (See Chap. 8). Not infrequently, author’s experience demonstrates the optimization of results when associating these last three proposals. There is not necessarily a mandatory sequence to be
followed, and the peculiarity of each case will determine how this association
should be performed. Considering the linear characteristic of post-surgical scars,
the instrument with motorized needles can be effective to perform the treatment
with great practicality.
13.2
Indications of PCI in Post-surgical Scars
Scar stabilization, before an intervention for cosmetic correction, is fundamental.
When a treatment such as PCI is chosen, we assume that the scar will be microperforated, without a solution of continuity being established. In accordance with the
study of the healing process, the period of accommodation of a scar happens around
3 months. However, it is essential that the decision about the right time to intervene
should be made by an experienced specialist. The less old these lesions are, the better the result of their corrections, says the author. According to the results seen in his
practice, scars with 30 days of evolution, very early, can be treated safely with the
PCI technique, especially in regions of the body where the tissue does not suffer
stretching with movement. It is crucial a therapeutic planning, considering the arsenal previously mentioned and the direction for each case. The choice of the best
technique alone or in association depends on the characteristics of the scar. It is
essential that the skin is prepared for the procedure, regardless of the phototype.
Even the taller ones, subject to post-inflammatory hyperpigmentation (PIH), commonly transient, can benefit from these techniques, always taking into consideration
the proposal of microneedles: preservation of the epidermis and, consequently,
lower risk of complications. Knowing that the less melanin available, the lower the
risk of darkening, it is recommended the use of depigmentant and sunscreen 30 days
before the intervention. Figure 13.1 shows a patient with a phototype IV treated for
a breast scar.
Fig. 13.1 Patient with an IV phototype treated for a breast scar, during the treatment and after
5 days postoperative
13.2 Indications of PCI in Post-surgical Scars
13.2.1
135
Conduct
Instrumental See details in the Chap. 2 on PCI and DT presented in this work.
Asepsis and anesthesia of the area. Follow the same precepts recommended in
previous chapters.
Transurgery The use alone or in association with a certain treatment depends on
the depth, texture, and color of the scar, as well as its location area. The methodology follows the same precepts reported in the specific chapters on PCI and DT. PCI
alone is capable of providing great cosmetic gains, especially when we opt for needle lengths greater than 1.5 mm. The author opts for deep injury (commonly 2.5 mm
needle length) to drive these lions. The bleeding is substantial, but limited with the
containment of compresses and gauzes. After the end of the intervention, it is possible to observe a significant reduction of bleeding, and then the serous exudation
occurs, which regresses progressively in the first 6 hours. Figures 13.2 and 13.3
show scars on the breast and arm, respectively, with the purple end point (deep
injury) recommended for the treatment of scars. Another patient treated by PCI is
present in the Fig. 13.4.
Fig. 13.2 Patient with mammoplasty scar at PCI transoperative (deep injury)
Fig. 13.3 Patient with arm scar at PCI transoperative (deep injury)
136
13 Correcting Post-surgical Scar Using PCI
Fig. 13.4 PCI transoperative (deep injury) in shoulder scar
Intermediate and long-term postoperative We recommend reading Chap. 9, PCI
in skin aging, which provides guidance on dressing, evolution details and postoperative care, complementary techniques, complications, postoperative analgesia,
and anti-herpetic prophylaxis.
13.3
Final Considerations
The techniques, which use needles, described in this work have the advantage of
dealing with post-surgical linear scars without the need for cutting and stitches.
These are techniques that perforate, without cutting, and cause punctures without
deepithelialization of the area. Therefore, they offer more safety regarding cosmetic
results and reduced risk of complications. Whether isolated or in association, the
proposals presented here have shown, in the experience of the author, good options
in the approach of post-surgical scars. Figures 13.5, 13.6, 13.7, 13.8, 13.9, and
13.10 present patients treated by PCI with a good improvement.
13.3 Final Considerations
137
Fig. 13.5 Patient with scar secondary to the removal of dorsal nasal tumor. Before and after cosmetic improvement with PCI
Fig. 13.6 Patient with an abdomen retractile scar. Before and after cosmetic improvement
with PCI
Fig. 13.7 Patient with a facial scar. Before and after cosmetic improvement with PCI
138
13 Correcting Post-surgical Scar Using PCI
Fig. 13.8 Patient with a nose scar treated by single session PCI. Before and after 90 days
postoperatively
Fig. 13.9 Patient with a forehead scar treated by single session PCI. Before and after 90 days
postoperatively
Fig. 13.10 Patient with a forehead scar treated by single session PCI. Before and after 90 days
postoperatively
Sources
1. Aust MC. Percutaneous collagen induction therapy: an alternative treatment for scars, wrinkles, and skin laxity. Plast Reconstr Surg. 2008;121(4):1421–9.
2. Bal SM, Caussian J, Pavel S, et al. In vivo assessment of safety of microneedle arrays in human
skin. Eur J Pharm Sci. 2008;35(3):193–202.
3. Brody HJ. Trichloroacetic acid application in chemical peeling, operative techniques. Plast
Reconstr Surg. 1995;2(2):127–8.
4. Camirand A, Doucet J. Needle dermabrasion. Aesthet Plast Surg. 1997;21(1):48–51.
5. Cohen KI, Diegelmann RF, Lindbland WJ. Wound healing: biochemical and clinical aspects.
Philadelphia: WB Saunders Co; 1992.
Sources
139
6. Fabroccini G, Fardella N. Acne scar treatment using skin needling. Clin Exp Dermatol.
2009;34(8):874–9.
7. Fernandes D. Minimally invasive percutaneous collagen induction. Oral Maxillofac Surg Clin
North Am. 2006;17(1):51–63.
8. Fernandes D, Massimo S. Combating photoaging with percutaneous collagen induction. Clin
Dermatol. 2008;26(2):192–9.
9. Lima EVA, Lima MMDA, Paixão MP, et al. Assessment of the effects of skin microneedling
as adjuvant therapy for facial melasma: a pilot study. BMC Dermatology. 2017:1–6.
10. Lima EA. Microneedling in facial recalcitrant melasma: report of a series of 22 cases. An Bras
Dermatol. 2015;90(6):919–21.
11. Lima EVA, et al. Induction of pigmentation through microneedling in stable localized vitiligo
patients. Dermatol Surg. 2020;46(13):434–5.
12. Lima EA. Microagulhamento em melasma facial recalcitrante: uma série de 22 casos. Na Bras
Dermatol. 2015;90(6):917–9.
13. Lima EA, Lima M, Takano D. Microneedling experimental study and classification of the
resulting injury. Surg Cosmet Dermatol. 2013;5:110–4.
14. Lima EVA. Dermal tunneling: a proposed treatment for depressed scars. An Bras Dermatol.
2016;91(5):697–9.
15. Lima EVA. Indução percutânea de colágeno com agulhas em cicatrizes após acidentes automobilísticos: correção cosmética e funcional. Surg Cosmet Dermatol. 2017;9(2):127–9.
16. Lima EVA. Dermal tunneling (TD®): a therapeutic option for static glabellar wrinkles. Surg
Cosmet Dermatol. 2016;8(1):42–5.
17. Lima EVA. Pulsed radiofrequency with multineedles (RFPM®) in the treatment of atrophic
stretch marks. Surg Cosmet Dermatol. 2016;8(3):242–5.
18. Lima EA, Lima MA, Araújo CEC, Nakasawa YMM, Leal NC. Investigation on the use of 3%
and 5% retinoic acid in peeling solution as a drug delivery agent after percutaneous induction of collagen with needles (IPCA®): safety profile and application protocol. Surg Cosmet
Dermatol. 2018;10(1):21–6.
19. Lima EAV. Pulsed radiofrequency with multineedles: a therapeutic proposal for wrinkles, sagging, and periorbital pigmentation. Surg Cosmet Dermatol. 2015;7(3):223–6.
20. Lima EVA. Association of microneedling with phenol peeling: a new therapeutic approach for
sagging, wrinkles and acne scars on the face. Surg Cosmet Dermatol. 2015;7(4):328–31.
21. Lima EVA. Pulsed radiofrequency with multineedles for earlobe aging treatment. Surg Cosmet
Dermatol. 2016;8(4):307–10.
22. Lima EVA. Indução percutânea de colágeno com agulhas (IPCA®) associada a radiofrequência pulsada com multiagulhas (RFPM®) na condução de cicatrizes de acne deprimidas: protocolo de tratamento. Surg Cosmet Dermatol. 2017;9(3):234–6.
23. Orentreich DS, Orentreich N. Subcutaneous incisionless (subcision) surgery for the correction
of depressed scars and wrinkles. Dermatol Surg. 1995;21:6543–9.
Chapter 14
Correcting Post-burn Scar Using PCI
On average, there are 450,000 burn injuries throughout the United States each year
that require medical treatment. Each year, about 3500 people are fatally injured in a
fire or burn accident. In addition to causing significant functional loss, the scars
resulting from these accidents substantially affect the color, elasticity, texture, and
relief of the affected region, causing cosmetic disorders that deeply compromise the
victims’ quality of life. Figure 14.1 shows the polymorphism of these lesions in different areas.
The modification of the skin, established by the destruction of sebaceous and
sweat glands, hair follicles, nerves, and vessels, results in impairment of its homeostasis, with dramatic alteration of physiological functions. Complaints, such as neuropathic pain, itching, eczema, and exulcerations, are frequent over areas of late
scarring and always translate into a therapeutic challenge before the modest arsenal
of possibilities available (Fig. 14.2).
Fig. 14.1 Architectural polymorphism of scars after third-degree burns
The Editor(s) (if applicable) and The Author(s), under exclusive license
to Springer Nature Switzerland AG 2021
E. Lima, M. Lima, Percutaneous Collagen Induction With Microneedling,
https://doi.org/10.1007/978-3-030-57541-0_14
141
142
14 Correcting Post-burn Scar Using PCI
Fig. 14.2 Patients victimized by burning with chronic eczematization and xerose
Scar treatments after burns include surgical interventions, expansion and compression techniques, silicone plates and gels, corticosteroid infiltration, and use of
ultrasound, lasers, and pulsed intense light (IPL).
A recent consensus for the use of laser in post-traumatic scars proposes the use
of ablative and non-ablative fractionated lasers in normotrophic, atrophic, and
hypertrophic scars, presenting, through scientific evidence, significant cosmetic and
histopathological improvements. Through the production of coagulated columns
that transfix the epidermis and dermis without producing deepithelialization, non-­
ablative fractionated lasers have been used in order to remodel the dermal collagen
affected by burning.
As a parameter, we can consider a study that randomized 20 patients submitted
to monthly non-ablative fractional laser sessions (erbium 1540 nm) and revealed
improvement in texture, color, and relief, as well as remodeling of damaged dermal
collagen, respectively, macroscopically and microscopically demonstrated by histopathological examination. Similar findings were found in another study in which 15
patients were treated monthly with 3 sessions of ablative fractionated CO2 laser.
14.1
Rational Use of PCI in Post-burn Scars
Compared to the “light needles” of fractionated lasers, microneedles act by producing micropunctures and hematic columns at epidermal-dermal depth, causing the
rupture of collagen and elastic fibers altered by burning, which favors their replacement by a new tissue. This technique can act in the different formats of scars, in any
area of the body, in any type of skin, and at all ages. Even in areas with decreased
concentration of sebaceous glands, the percutaneous induction of collagen with
needles (PCI) is a possibility of treatment. By means of a roll of microneedles, PCI
causes thousands of microperforations translated into uniform purple, as can be
seen in Fig. 14.3.
These injuries, called deep (classification Emerson Lima, 2013), originate a neocollagenosis without causing deepithelialization: epidermis and dermis are
14.1
Rational Use of PCI in Post-burn Scars
143
Fig. 14.3 Immediate
postoperative of PCI (deep
injury) in a patient with
post third-degree calf
burn scar
Fig. 14.4 Patient before (a) and after 30 days treatment of calf by PCI
perforated, but not removed. Both the normotrophic scars and the atrophic and
hypertrophic scars respond to PCI.
Two other techniques implemented in association with PCI have been indicated
in the conduction of burn scars: dermal tunneling (DT) and multi-needle radiofrequency (MNR). See Chap. 29. In DT, variant of Subcision™, an 18G suction needle
is used in shuttle movements in four vertices of an imaginary rhombus, which provides detachment or elevation of the region consumed by the thermal damage,
releasing fibrotic beams that retract the tissue, responsible for anchoring the skin
surface in deep planes. In this way, besides the cosmetic gain, there is a functional
improvement of the treated region, which allows the realization of movements that
previously the indivisible was unable to perform. In a rough way, this rupture can be
compared to the one that would occur with the release of cords that produce the
capitonê aspect on a pillow. In MNR, multi-needles of 100 m in diameter and 2 mm
in depth, associated with a pulsed fractionated random energy, produce double
injury (mechanical and thermal), providing the modification of the healing collagen
to one closer to the physiological. The degree of improvement is variable and
depends on the severity of the lesions.
PCI in post-burn scars produces changes in color, texture, depth, relief, and flexibility, in addition to the similar effects proposed by DT and MNR when in association (Fig. 14.4).
The scarcity of scientific articles on the subject made the author of this chapter
construct his own protocols, through results obtained in isolation with the use of
144
14 Correcting Post-burn Scar Using PCI
techniques in the management of scars resulting from trauma, which varied from
infectious/inflammatory diseases to surgical interventions and accidents.
Figure 14.5 shows a patient treated by PCI (single session) demonstrating functional gain in the movement of the feet by releasing retraction, as well as significant
improvement in the quality of the skin with control of repetitive eczema and xeroderma. Figure 14.6 shows a patient treated with an PCI session showing a reduction
in scar volume and staining, as well as a functional improvement in hand movement. The end point of the intervention is exemplified in Fig. 14.7, showing deep
PCI injury.
a
b
c
d
Fig. 14.5 Patient before (a, c) and after PCI treatment, showing decrease in scar volume and
functional gain in the feet (b, d)
a
b
Fig. 14.6 Patient before (a) and after treatment with PCI (b). Decreased scarring volume and
functional gain in hands can be seen
14.2 Applicability of PCI to Post-burn Scars
145
Fig. 14.7 PCI end point: deep injury
14.2
Applicability of PCI to Post-burn Scars
The earlier you start treatment, the more likely you are to get better results. At
home, it is recommended to use, as soon as possible, silicone plates, silicon gels,
broad-spectrum sunscreen, and topical tretinoin alone or with depigmentants.
Interventions can already be initiated as long as the acute thermal damage process
is established. When facing high scars, the introduction of topical corticosteroids
categorized as high potency may be useful to destabilize the evolving fibrosis.
Intense pulsed light (IPL) can be very useful in recent and neovascularized scars.
This technique is also indicated in the completion of PCI treatment.
The infiltration of triamcinolone associated with IPL 15–30 days before the
intervention with microneedles or during the surgical time is often used for the
author. Scars after burns are rigid and often benefit from this treatment. It is preferred the injection of the active at a concentration of 20 mg/m in deep dermis.
Very thin skins offer less resistance to shorter needle lengths compared to thick
skins. However, it is common for patients with post-burn scars to have rigid, fibrotic,
and inelastic skin; in this sense, rollers with 2.5-mm-long needles are recommended.
Moreover, these individuals often present reliefs and indentations that make it difficult to roll the microneedles, compromising, consequently, the uniformity of their
penetration; there is a reduction of up to 50% in the penetration of their total length.
To compensate and overcome this resistance, the operator often imposes exaggerated force on the instrument, being able to deepithelialize the skin that presents a
“plastic” surface after burns.
The PCI is the last of the three needle interventions proposed, in case it is decided
to perform DT and MNR at the same surgical time. However, even in isolation, it
offers good results in burn scars. When the introduction of needles is desired to happen perpendicularly, it is proposed the construction of strips with the roller, never in
zigzag movement, because this can compromise the uniformity of the result and
allow the microneedle to penetrate diagonally. The horizontal, vertical, and diagonal intercrossing, based on the construction of strips, seeks to obtain a purple as
end point.
146
14 Correcting Post-burn Scar Using PCI
It is recommended that the force vector printed on the roller always tangents the
horizontal plane on which it is working and is never perpendicular to that surface.
See Chap. 29.
The treatment must be performed in a procedure room carefully prepared for a
surgical intervention and by a trained and qualified professional. It is essential not
to trivialize these safety criteria, which include from the use of sterile gloves and
sterile surgical fields to the promotion of an environment that follows strict disinfection standards.
For the DT, a 1,20 × 25 mm (18 G × 1) suction needle is used which is inserted
transpidermally into the depth of the dermal plane, forming a canal path with consequent ruptures of the fibrotic beams and creation of linear tunnels within the
altered dermis. The movements performed by the needle are shuttle, starting from
the vertices of an imaginary diamond. See Chap. 26.
The next tunnel is formed following the same precept, immediately adjacent to
the previous one; to this end, the needle is introduced into the same orifice, resulting
in the creation of several horizontal hematic columns arranged in parallel. In this
way, the fibrosis is destabilized. Figure 14.8 shows the transoperative of a patient,
presenting shows the recommended end point. On the right side, immediately after
Fig. 14.8 Recommended
end point for deep injury
PCI. On the right side,
immediately after PCI and
on the left side after
30 minutes, showing
coagulation and mild
serous exudation
14.3
Care in the Technical Execution
147
a
b
c
d
Fig. 14.9 Patient before (a, c) and after treatment with IPCA®, showing decrease in scar volume
and functional gain (b, d)
PCI and on the left side after 30 minutes, showing coagulation and mild serous
exudation (Fig. 14.9).
14.3
Care in the Technical Execution
The deeper and more rigid the scar, the greater the challenge. Uniformity becomes
more difficult to treat when you have different shades of brown, offering polychromy with loss and gain of melanin. Facial lesions are more responsive to PCI
compared to those found on the chest, back, limbs, or abdomen. These areas need
more interventions in order to offer the same result as the first.
Scars located in more oily areas offer a better response to treatment when compared to those in regions with fewer seborrheic glands. Figure 14.10 presents a
patient after treatment with PCI, showing decrease in scar volume and functional gain.
Asepsis should be done with 2% chlorhexidine. If the burn scar is located on the
face, it is suggested to associate anesthetic blocking of the infraorbital and
148
14 Correcting Post-burn Scar Using PCI
mentonian nerves and complement it with 2% lidocaine solution without a 1:2 vasoconstrictor with 0.9% saline solution, respecting the maximum dose of the active
agent allowed. The addition of bicarbonate in order to offer more comfort and
reduce burning is optional. In other areas of the body, infiltration with the same
solution and, if possible, field blocking using 2% lidocaine are recommended.
The dressing is performed with sterile gauze in large quantities (in order to contain the exudation) and Micropore®, without the addition of any humectant. Neither
topical nor systemic antibiotic therapy is indicated; since it is a clean procedure and
according to the Food and Drug Administration (FDA) standards, this precaution is
unnecessary.
Cryotherapy or hot compresses are not indicated. It is preferred that the accommodation of bruises and the inflammatory response resulting from their presence
follow their natural course. Topical or systemic corticotherapy is also not recommended to contain the expected effects of the self-limited inflammatory process.
a
b
c
d
Fig. 14.10 (a–h) Before and after PCI -treated patients
14.3
Care in the Technical Execution
e
g
149
f
h
Fig. 14.10 (continued)
The patient himself, at home, can remove the dressing by moistening it in the
shower. The treated area can be sanitized with liquid soap with low detergency
potential, avoiding sensitization. From then on, the use of a regenerating balm for
3–5 days is recommended, when lightening creams and broad-spectrum toned sunscreen can be used. Restriction to lights should be targeted.
Edema and hematoma in the days following the procedure are moderate. The
patient is usually able to return to his or her laborative activities around the seventh
postoperative day. If the treated area is covered (neck, chest, and back), the patient
may return to public coexistence on the following day.
Edema, hematomas, post-inflammatory hyperpigmentation, and transient erythema can be expected. As long as the operator is duly qualified and trained, taking
due care in the preparation of the skin and paying attention to the postoperative
recommendations with rigor, both PCI and DT and MNR in post-burn scars are safe
and reproducible techniques.
150
14.4
14 Correcting Post-burn Scar Using PCI
Adverse Effects
Although postoperative is not problematic, infiltrative anesthesia is uncomfortable.
Many times the doctor chooses to operate on patients with post-burn scars in the
hospital, under general anesthesia or sedation, given the discomfort of infiltrative
anesthesia in a very rigid tissue and in a commonly extensive area.
Pain is not a usual complaint, but if it occurs, it should alert for secondary infection, especially if installed 48 hours after the intervention. Commonly, there is no
need for analgesic or anti-inflammatory in the postoperative period, but when there
is a report of discomfort, without any other aggravating factor, dipyrone 1 g effervescent is recommended every 6 hours.
14.5
Closing Considerations
IPCA® is considered a safe therapeutic approach with acceptable cosmetic results
in post-burn scars, when well indicated and performed. For this purpose, it is essential that the operator is qualified and safe of the proposal and its adequacy to the
individual who will be treated. When associated with DT and MNR, this technique
presents even better results.
Sources
1. Anderson RR, Donelan MB, Hivnor C, et al. Laser treatment of traumatic scars with an
emphasis on ablative fractional laser resurfacing: consensus report. JAMA Dermatol.
2014;150(2):187–93.
2. Bal SM, Caussian J, Pavel S, et al. In vivo assessment of safety of microneedle arrays in human
skin. Eur J Pharm Sci. 2008;35(3):193–202.
3. Camirand A, Doucet J. Needle dermabrasion. Aesthet Plast Surg. 1997;21(1):48–51.
4. Cohen KI, Diegelmann RF, Lindbland WJ. Wound healing: biochemical and clinical aspects.
Philadelphia: WB Saunders Co; 1992.
5. Fabroccini G, Fardella N. Acne scar treatment using skin needling. Clin Exp Dermatol.
2009;34(8):874–9.
6. Fernandes D. Minimally invasive percutaneous collagen induction. Oral Maxillofac Surg Clin
North Am. 2006;17(1):51–63.
7. Fernandes D, Massimo S. Combating photoaging with percutaneous collagen induction. Clin
Dermatol. 2008;26(2):192–9.
8. Lima EVA, Lima MMDA, Paixão MP, et al. Assessment of the effects of skin microneedling
as adjuvant therapy for facial melasma: a pilot study. BMC Dermatol. 2017;17:14.
9. Lima EA. Microneedling in facial recalcitrant melasma: report of a series of 22 cases. An Bras
Dermatol. 2015;90(6):919–21.
10. Lima EVA, et al. Induction of pigmentation through microneedling in stable localized Vitiligo
patients. Dermatol Surg. 2020;46(13):434–5.
11. Lima EA. Microagulhamento em melasma facial recalcitrante: uma série de 22 casos. An Bras
Dermatol. 2015;90(6):917–9.
Sources
151
12. Lima EA, Lima M, Takano D. Microneedling experimental study and classification of the
resulting injury. Surg Cosmet Dermatol. 2013;5:110–4.
13. Lima EVA. Dermal tunneling: a proposed treatment for depressed scars. An Bras Dermatol.
2016;91(5):697–9.
14. Lima EVA. Indução percutânea de colágeno com agulhas em cicatrizes após acidentes automobilísticos: correção cosmética e funcional. Surg Cosmet Dermatol. 2017;9(2):127–9.
15. Lima EVA. Dermal tunneling (TD®): a therapeutic option for static glabellar wrinkles. Surg
Cosmet Dermatol. 2016;8(1):42–5.
16. Lima EVA. Pulsed radiofrequency with multineedles (RFPM®) in the treatment of atrophic
stretch marks. Surg Cosmet Dermatol. 2016;8(3):242–5.
17. Lima EA, Lima MA, Araújo CEC, Nakasawa YMM, Leal NC. Investigation on the use of 3%
and 5% retinoic acid in peeling solution as a drug delivery agent after percutaneous induction of collagen with needles (IPCA®): safety profile and application protocol. Surg Cosmet
Dermatol. 2018;10(1):21–6.
18. Lima EAV. Pulsed radiofrequency with multineedles: a therapeutic proposal for wrinkles, sagging, and periorbital pigmentation. Surg Cosmet Dermatol. 2015;7(3):223–6.
19. Lima EVA. Association of microneedling with phenol peeling: a new therapeutic approach for
sagging, wrinkles and acne scars on the face. Surg Cosmet Dermatol. 2015;7(4):328–31.
20. Lima EVA. Pulsed radiofrequency with multineedles for earlobe aging treatment. Surg Cosmet
Dermatol. 2016;8(4):307–10.
21. Lima EVA. Indução percutânea de colágeno com agulhas (IPCA®) associada a radiofrequência pulsada com multiagulhas (RFPM®) na condução de cicatrizes de acne deprimidas: protocolo de tratamento. Surg Cosmet Dermatol. 2017;9(3):234–6.
22. Hantash BM, Bedi VP, Kapadia B, et al. Percutaneous collagen induction therapy (PCI)-an
alternative treatment for scars. Wrinkes skin laxity. Plast Reconstr Surg. 2008;121(4):1421–9.
23. Orentreich DS, Orentreich N. Subcutaneous incisionless (subcision) surgery for the correction
of depressed scars and wrinkles. Dermatol Surg. 1995;21:6543–9.
24. Ozog DM, Liu A, Chaffins ML, et al. Evaluation of clinical results, histological architecture,
and collagen expression following treatment of mature burn scars with a fractional carbon
dioxide laser. JAMA Dermatol. 2013;149:50–7.
25. Qu L, Liu A, Zhou L, et al. Clinical and molecular effects on mature burn scars after treatment
with a fractional CO2 laser. Lasers Surg Med. 2012;44:517–24.
26. Tanner H, Chan KF, Zachary CB. In vivo histological evaluation of a novel ablative fractional
resurfacing device. Lasers Surg Med. 2007;39:96–107.
27. Taudorf E, Danielsen P, Paulsen I. Non-ablative fractional laser provides long-term improvement of mature burn scars – a randomized controlled trial with histological assessment. Lasers
Surg Med. 2015;47:141–7.
Chapter 15
Correcting High and Hypertrophic Scars
with PCI
15.1
PCI Fundamentals in High Scars
Skin injury invariably leads to scar formation. The repair process consists of inflammation, formation of granulation tissue, and remodeling of the dermal matrix, which
may subject the tissue to varying degrees of fibrosis culminating in high or keloid
lesions. The keloids initiated in the reticular dermis project to the skin and do not
regress spontaneously. They are erythematous-violaceous, skin-colored, or hyperchromic and are distinguished from elevated scars by exceeding the limits of initial
injury. It is believed that there are no spontaneous keloids. Lesions without apparent
causes were probably the result of a mild injury, not perceived by the patient. The
most affected regions are dorsal, pre-sternal, deltoidea, ear lobe, and face. Although
palms and soles of the feet are subject to trauma, they never develop, just as the
involvement of regions such as eyelids and genital is rare. Pain, as a result of the
compression of free nerve endings by fibrosis, and itching from dryness due to the
absence of sebaceous glands are relatively frequent. By microscopy, a thin, flattened
epithelium is identified that covers a thick dermis with an increase in modified collagen fibers and a decrease in elastic fibers. Treatment is always a challenge due to
its recalcitrant character. The characteristic injurious polymorphism of these conditions usually requires the specialized physician experience and an accurate knowledge of their architecture when proposing an intervention (Fig. 15.1).
Techniques for keloid management have been used with variable responses, such
as intralesional injections with bleomycin and corticosteroids alone or in association, cryosurgery, use of silicone plates, lasers, intense pulsed light, in addition to
topical assets such as 5-fluorouracil, interferone, retinoids, 5% imiquimode, tacrolimus, verapamil. Botulinum toxin has shown good results in specific cases.
Corticosteroids present side effects such as risk of secondary infection, atrophy,
telangiectasis, and hypopigmentation. Cryosurgery, when performed by not very
experienced professionals, can lead to atrophy and hypochromia, and bleomycin
The Editor(s) (if applicable) and The Author(s), under exclusive license
to Springer Nature Switzerland AG 2021
E. Lima, M. Lima, Percutaneous Collagen Induction With Microneedling,
https://doi.org/10.1007/978-3-030-57541-0_15
153
154
15 Correcting High and Hypertrophic Scars with PCI
Fig. 15.1 Architectural polymorphism of raised scars in different areas. (Personal file of the author)
Fig. 15.2 Patient with cervical keloid scar before and after shaving and intralesional infiltration
with corticosteroids
can trigger hyperpigmentation. Conventional surgery or tangential excision aims to
reduce the high injury that offers the risk of worsening or subsequent relapse of the
keloid. Thus, we still do not have an ideal treatment for keloids and hypertrophic
scars. Figures 15.2 and 15.3 present patients treated by tangential excision associated with triamcinolone infiltration. Figures 15.4 and 15.5 present keloids also
treated by tangential excision and corticosteroid infiltration. The ablative techniques, because they lead to deepithelialization and exacerbated inflammatory reaction, result in a tissue more subject to complications such as new scars,
post-inflammatory hyperpigmentation, acromias, and persistent erythema, resulting
in a more sensitized skin.
PCI proposes to destructure fibrosis and abnormal collagen, creating hematic
columns with production of a new collagen, without causing the deepithelialization
observed in ablative techniques. The epidermis and dermis are perforated but not
removed. Thus, the penetration of these needles in the skin generates micropunctures in its surface that favor neovascularization and neoangiogenesis as well as
15.1 PCI Fundamentals in High Scars
155
Fig. 15.3 Patient with keloid scar in glabellar region before and after shaving and intralesional
infiltration with corticosteroids
Fig. 15.4 Patient with keloid scars in the genial region before and after surgical removal and
intralesional infiltration with corticosteroids
Fig. 15.5 Patient with keloid scars in the cervical region before and after surgical removal and
intralesional infiltration with corticosteroids
production of elastin. In high scars, these micropunctures do not settle as easily as
in atrophic scars, since the resistance offered is usually greater. In the author’s experience, the association of dermal tunneling (DT) with PCI optimizes the results in
156
15 Correcting High and Hypertrophic Scars with PCI
approaches to raised scars. DT contributes to the rupture of fibrosis and consequently makes the tissue less rigid. The addition of this intervention must be judicious, and the operator must be sure of the predictable results, through a precise
evaluation of the case to be treated. For cases in which the techniques will be associated, the author recommends that the TD® be performed immediately before the
DT, in the same surgical procedure.
15.2
15.2.1
Applicability of PCI in High Scars
Methodological Sequence for the Approach
• Scar characteristics. The surface of very fine keloid lesions offers less resistance
to needles compared to thicker ones. Stiffer and harder structures offer more
resistance, and there is often a need for previous treatment with corticosteroids,
either infiltrative or topical, under occlusion for at least 30 days. In this type of
structure, the penetration of needles will suffer a reduction proportional to tissue
stiffness. Lesions located on limbs and chest are commonly less responsive when
compared to those located on the face.
• Deep injury. Short needle lengths will have little effect on this type of lesion, and
there is a common need for a 2.5 mm needle under infiltrative anesthesia, as we
are facing rigid lesions. It is essential to follow all previously reported safety
precepts.
• Asepsis and anesthesia of the area. Both carpule with tubete and gingival needle,
for limited areas, and slightly diluted solutions containing 2% lidocaine, in larger
areas, can be used. Infiltration is often uncomfortable due to hardening of the
lesion. Therefore, in areas where there is the possibility of anesthetic blockage,
this should be preferred. Replacing the needle with cannula may also offer more
comfort during anesthesia.
• Transoperative. If the scar is very hypertrophic, the author recommends the use
of intralesional infiltration with corticosteroids, before performing PCI, following the application of intense pulsed light in conventional parameters for neovascularized lesions. After the last two interventions, PCI is performed at the same
surgical time, applying the same pattern of micropunctures proposed for other
types of scars. Purple takes longer to be reached, when compared to the time
required for uniformity in normotrophic scars. The author’s experience also recommends association with TD® immediately before IPCA® and before tangential excision, or even when the latter was not performed. The bleeding is
substantial but limited. After 10 minutes of the end of the intervention, a significant reduction in bleeding can already be observed, giving rise to serous exudation that progressively regresses in the first 6 hours. In the transoperative period,
it is suggested the application of triamcinolone in usual doses.
15.2 Applicability of PCI in High Scars
157
Fig. 15.6 Patients immediately after IPCA® intervention for scar treatment
• Postoperative care. It should follow the guidelines given in previous chapters.
The recovery time in hypertrophic scars may be longer when compared to normotrophic scars. Excessive needle trauma may result in ulcerations. Figure 15.6
presents patients soon after the intervention. Note that the proposed end point is
purple. The intention with this intervention is to break the hardened beams of the
raised scar by transforming the scarred collagen into a collagen closer to the
physiological one. We emphasize that this is an innovative proposal for elevated
scars, since there were only treatments that destroyed the exuberant tissue, both
by atrophy and thermal damage. With PCI, the goal is to transform this tissue.
Evolution and Postoperative Care For the removal of the dressing, one must wait
at least 24 hours. As previously recommended, this removal can be done at home by
the patient himself, moistening the dressing in the shower, when the treated area can
be sanitized and treated with regenerative balm until reepithelialization, on average
from 7 to 10 days. From then on, gel or silicone plate should be used for at least
30–45 days in a row, accompanied by sunscreen and lightener, in case hyperpigmentation is observed. Light restriction should be directed. The use of topical corticosteroid may be required, aiming at the prevention of recurrence. When this is the
option, it is recommended to wait at least 30 days after the PCI. Figures 15.7, 15.8,
15.9, 15.10, 15.11, and 15.12 show patients treated by PCI.
Complications As previously mentioned, PCI presents a limited chance of complications. Besides the expected effects such as edema, hematomas, transient post-­
inflammatory hyperpigmentation, and transient erythema, a greater tendency to
exulceration can be observed in scars elevated by tissue friability. This is a diagnosis
with risk of recurrence, so it is mandatory monthly monitoring of the patient for at
least 6 months. The use of topical corticosteroids at night with silicone gel in the
morning from the 30th postoperative day has offered, in most cases, maintenance of
the results. The use of complementary techniques such as intense pulsed light or
lasers with selectivity by hemoglobin is considered in the follow-up and also aims
to offer improvement and maintenance of results.
Postoperative Analgesia and Anti-herpetic Prevention They should follow the
same recommendations already reported in the corresponding chapters.
158
15 Correcting High and Hypertrophic Scars with PCI
Fig. 15.7 Patient with elevated scar treated with PCI after 90 days of postoperative
Fig. 15.8 Patient with keloid lesion in thorax after 120 days of treatment with 2 PCI sessions
Fig. 15.9 Patient with elevated breast scar before and after cosmetic improvement with PCI
15.2 Applicability of PCI in High Scars
159
Fig. 15.10 Patient with elevated shoulder scar before and after cosmetic improvement with PCI
Fig. 15.11 Patient (right/left) with elevated cervical scars before and after cosmetic improvement
with PCI
160
15 Correcting High and Hypertrophic Scars with PCI
Fig. 15.12 Patient with elevated scar in abdominal after 120 days of treatment with PCI 1 session
15.3
Final Considerations
The treatment of high scars is always a challenge, mainly because they are lesions
with potential risk of recurrence. Some therapeutic results can be quite modest,
which makes new proposals with corrective potential well accepted. We consider
PCI a safe approach, when well indicated and well performed. The association with
other therapies, as presented in this chapter, optimizes the results. For this, it is
essential that the operator is qualified and safe of the proposal and its adequacy to
the individual who will be treated.
Sources
1. Aust MC. Percutaneous collagen induction therapy: an alternative treatment for scars, wrinkles, and skin laxity. Plast Reconstr Surg. 2008;121(4):1421–9.
2. Bal SM, Caussian J, Pavel S, et al. In vivo assessment of safety of microneedle arrays in human
skin. Eur J Pharm Sci. 2008;35(3):193–202.
3. Brody HJ. Trichloracetic acid application in chemical peeling, operative techniques. Plast
Reconstr Surg. 1995;2(2):127–8.
4. Camacho-Martínez FM, Serrano FC. Results of a combination of bleomycin and triamcinolone acetonide in the treatment of keloids and hypertrophic scars. An Bras Dermatol.
2013;88(3):392–9.
5. Camirand A, Doucet J. Needle dermabrasion. Aesthet Plast Surg. 1997;21(1):48–51.
6. Cohen KI, Diegelmann RF, Lindbland WJ. Wound healing: biochemical and clinical aspects.
Philadelphia: WB Saunders Co; 1992.
7. Fabroccini G, Fardella N. Acne scar treatment using skin needling. Clin Exp Dermatol.
2009;34(8):874–9.
8. Fernandes D. Minimally invasive percutaneous collagen induction. Oral Maxillofac Surg Clin
North Am. 2006;17(1):51–63.
9. Fernandes D, Massimo S. Combating photoaging with percutaneous collagen induction. Clin
Dermatol. 2008;26(2):192–9.
10. Heppt MV, Breuninger H, Reinholz M, et al. Current strategies in the treatment of scars and
keloids. Facial Plast Surg. 2015;31:386–95.
11. Lima EVA, Lima MMDA, Paixão MP, et al. Assessment of the effects of skin microneedling
as adjuvant therapy for facial melasma: a pilot study. BMC Dermatol. 2017;17:14.
Sources
161
12. Lima EA. Microneedling in facial recalcitrant melasma: report of a series of 22 cases. An Bras
Dermatol. 2015;90(6):919–21.
13. Lima EVA, et al. Induction of pigmentation through microneedling in stable localized vitiligo
patients. Dermatol Surg. 2020;46(13):434–5.
14. Lima EA. Microagulhamento em melasma facial recalcitrante: uma série de 22 casos. An Bras
Dermatol. 2015;90(6):917–9.
15. Lima EA, Lima M, Takano D. Microneedling experimental study and classification of the
resulting injury. Surg Cosmet Dermatol. 2013;5:110–4.
16. Lima EVA. Dermal tunneling: a proposed treatment for depressed scars. An Bras Dermatol.
2016;91(5):697–9.
17. Lima EVA. Indução percutânea de colágeno com agulhas em cicatrizes após acidentes automobilísticos: correção cosmética e funcional. Surg Cosmet Dermatol. 2017;9(2):127–9.
18. Lima EVA. Dermal tunneling (TD®): a therapeutic option for static glabellar wrinkles. Surg
Cosmet Dermatol. 2016;8(1):42–5.
19. Lima EVA. Pulsed radiofrequency with multineedles (RFPM®) in the treatment of atrophic
stretch marks. Surg Cosmet Dermatol. 2016;8(3):242–5.
20. Lima EA, Lima MA, Araújo CEC, Nakasawa YMM, Leal NC. Investigation on the use of 3%
and 5% retinoic acid in peeling solution as a drug delivery agent after percutaneous induction of collagen with needles (IPCA®): safety profile and application protocol. Surg Cosmet
Dermatol. 2018;10(1):21–6.
21. Lima EAV. Pulsed radiofrequency with multineedles: a therapeutic proposal for wrinkles, sagging, and periorbital pigmentation. Surg Cosmet Dermatol. 2015;7(3):223–6.
22. Lima EVA. Association of microneedling with phenol peeling: a new therapeutic approach for
sagging, wrinkles and acne scars on the face. Surg Cosmet Dermatol. 2015;7(4):328–31.
23. Lima EVA. Pulsed radiofrequency with multineedles for earlobe aging treatment. Surg Cosmet
Dermatol. 2016;8(4):307–10.
24. Lima EVA. Indução percutânea de colágeno com agulhas (IPCA®) associada a radiofrequência pulsada com multiagulhas (RFPM®) na condução de cicatrizes de acne deprimidas: protocolo de tratamento. Surg Cosmet Dermatol. 2017;9(3):234–6.
25. Orentreich DS, Orentreich N. Subcutaneous incisionless (subcision) surgery for the correction
of depressed scars and wrinkles. Dermatol Surg. 1995;21:6543–9.
26. Rabello FB, Souza CD, Júnior JAF. Update on hypertrophic scar treatment. Clinics.
2014;69(8):565–73.
27. Verhiel S, Grzymala AP, Hulst RV. Mechanism of action, efficacy, and adverse events of
calcium antagonists in hypertrophic scars and keloids: a systematic review. Dermatol Surg.
2015;41:1343–50.
Chapter 16
Correcting Stretch Marks Using PCI
16.1
Fundamentals in Stretch Marks
Although the etiology of stretch marks is not well understood, it is understood that
lesions arise from the combination of mechanical stretching of the skin with genetic
factors. The most easily affected areas in men are the lumbosacral region and the
flanks, in women, abdomen, hip, and breasts. Conditions such as pregnancy, weight
gain, muscle hypertrophy, and adolescent stretching, as well as unregulated oral and
topical administration of corticosteroids and diseases such as Cushing’s syndrome,
are favorable factors for the emergence of these lesions. Figure 16.1 presents stretch
marks after the chronic use of oral corticosteroids, where the depth of the lesions
can be observed.
Literature reports confirm that during the third trimester of pregnancy, up to 90%
of women may have stretch marks. Besides the high levels of estrogen and progesterone, variables such as the age and skin type of the mother as well as the weight
Fig. 16.1 Patient with stretch marks on upper limbs after chronic use of oral corticosteroids for
alopecia areata
The Editor(s) (if applicable) and The Author(s), under exclusive license
to Springer Nature Switzerland AG 2021
E. Lima, M. Lima, Percutaneous Collagen Induction With Microneedling,
https://doi.org/10.1007/978-3-030-57541-0_16
163
164
16 Correcting Stretch Marks Using PCI
Fig. 16.2 Patient with
atrophic stretch marks in
abdomen after twin
pregnancy
of the fetus are considered significant. Figure 16.2 shows a young woman’s abdomen after twin pregnancy. Treatment of stretch marks is always a challenge, and
good results become even more difficult when old lesions are present. As a frequent
result of skin stretching and rupture of collagen and elastic fibers in the dermis, late
stretch marks present as scars, with substantial impairment of texture, relief, and
color of the affected skin.
Several treatments have been proposed that offer better results in reddish striations when compared to alba striations. Topical tretinoin in cream in high concentrations, applied as home therapy, improves the appearance of these lesions; however,
it may not be well tolerated by the patient, considering climatic conditions and
maintenance of her average activities. Interventions such as chemical peelings,
microdermabrasion, fractionated lasers, and intense pulsed light, alone or in association, are some of the therapeutic options used by dermatology for the management of these lesions. However, there is no treatment considered ideal, and the
results many times modest signal its challenge.
A study by Lee et al. [10] revealed a good cosmetic response after evaluating 27
patients with old stretch marks, treated with three fractional CO2 laser sessions.
Following the same line of conduct, that of causing a fractional injury on these
lesions without the deepithelialization of ablative processes, Park et al. [27] presented their observations based on the result studied in 16 patients, in which the
technique with a 1.5-mm-long microneedle roller was used in three sessions, with
an interval of 1 month and topical anesthesia. The authors took as standard the production of 600–750 micropunctures/cm2, having observed significant improvement
16.2
Applicability of PCI on Stretch Marks
165
Fig. 16.3 Patient with atrophic, buttock acromial stretch marks after an PCI session with a 2.5 mm
needle length showing improvement
of the lesions after 3 months. Other studies have shown additional improvement
after 6 months of interventions.
PCI, regarding treatments with microneedles that induce collagen production,
offers a stimulus in the production of this protein, without causing the deepithelialization observed in ablative techniques. The epidermis and dermis are perforated
but not removed. Thus, the penetration of its needles in the skin causes micropunctures in the stretch marks, modifying their surface, destructuring the abnormal collagen, and favoring neovascularization and neoangiogenesis. Both violent and white
stretch marks respond to PCI, but the former commonly present satisfactory results
with a smaller number of sessions, while the former need a longer time to achieve
such results. There is also an effect of modification in the characteristics of the
injury: an initially atrophic stretch mark may present violaceous after treatment,
signaling improvement and evolution to an aspect closer to that which is unapparent
with the performance of consecutive sessions (Fig. 16.3).
Based on findings obtained from previous scientific documentation around the
world, and his own experience treating scars over 17 years, the author has developed
an authorial methodology for PCI approach of recent and old stretch marks, considering that the latter present a substantial tissue dystrophy.
16.2
16.2.1
Applicability of PCI on Stretch Marks
Stretch Marks Characteristic
As mentioned above, stretch marks commonly respond more easily to PCI. When
facing pigmented lesions, with a lot of melanin, the preparation of the skin is essential, avoiding the almost always present post-inflammatory hyperpigmentation,
darkening often observed in post pregnancy stretch marks. Lighteners, depigmentants, and tretinoin can be used until 1 day before the intervention, being reintroduced right after the reepithelialization. When the loss of tissue is substantial, with
pale stretch marks and laxity of the tissue, there is a risk that the injury will break
166
16 Correcting Stretch Marks Using PCI
during the procedure. The friability of the injury makes it more susceptible to needle
trauma, and bleeding may be more important. In such cases, the epidermis and dermis are totally degenerated and replaced by atrophic scar tissue with loss of melanin, requiring more interventions to restore integrity by a new tissue.
16.2.2
Needle Length
You can choose to inflict moderate to profound injury – both offered results. In the
first, 1.5 mm needle length, topical anesthetic and more sessions are recommended.
In the second, a 2.5 mm needle length is used under infiltrative anesthesia, and the
results are more evident with a few sessions. In the author’s experience, the old
stretch marks show good results with deep injury. Stretch marks located in areas
with thick hypodermis and flaccidity offer greater resistance to needle penetration.
The adipose cushion offers cushioning to the penetration of the needle and a flaccid
area makes it difficult to slide the roller and maintain its contact with the treated
surface. Very thin skins are less resistant to shorter needle lengths when compared
to thick skins. To compensate and overcome this reluctance, the operator often
imposes excessive force on the instrument. It is recommended that the force vector
printed on the roller always tangents the horizontal plane being worked and is never
perpendicular to that surface (Fig. 16.4).
Fig. 16.4 Atrophic striated
patient hip immediately
after PCI treatment in
abdomen and breast
16.2
Applicability of PCI on Stretch Marks
16.2.3
167
Depth Injury
A profound injury is proposed when the objective is to extract the maximum from
the intervention in a single procedure. Commonly, an approach using a 2.5 mm
needle under infiltrative anesthesia provides cosmetic gain when compared to a
1.5 mm intervention under topical anesthesia; however, it is important to follow
cautiously the guidelines described below.
16.2.4
Step by Step
Patient Preparation Regardless of the area of location of stretch marks and the
patient’s phototype, the PCI has no restrictions on applicability. It is recommended
to prepare with tretinoin and bleachers for at least 1 month before the intervention,
as body areas are more subject to hyperpigmentation when compared to the face and
are commonly more resistant to bleaching.
Instrumental Short needles that cause moderate injury can be used in recent
stretch marks, requiring an average of four sessions. However, it is preferable to use
the rollers with a 2.5-mm-long needle, as these are mostly atrophic scars (old stretch
marks). If the area is limited, it is possible to opt for intervention in the office when
the area is limited or when it is decided to intervene in the sector. Large areas require
anesthetic volumes that may compromise the patient’s safety if the procedure is
performed in medical office. It is fundamental not to trivialize these safety criteria
(Fig. 16.5).
Area Anesthesia The anesthetic solution used should not be too diluted, which
would generate much discomfort during the intervention. It is important that the
Fig. 16.5 Patient arm with
recent stretch marks before
and immediately after PCI
treatment
168
16 Correcting Stretch Marks Using PCI
anesthesia be effective. Anesthesia with 2% pure lidocaine or 1:2 solution with
0.9% saline solution is suggested. As the lesions are linear, in the author’s practice,
the use of a gingival needle with anesthetic in a tube and a carpule syringe is well
tolerated by the patient. The limit dose of the anesthetic should always be respected,
considering the weight of the individual. The recommendation is to always treat the
lesions area by area, one segment at a time, for example, one buttock, one thigh, half
abdomen, and, after 15 days, resume treatment of the contralateral area, since an
interval of at least 1 month is recommended before the next intervention in the
same area.
Transoperative After demarcation of the area to be treated, performed in order not
to lose the limits after anesthesia, and asepsis with 2% chlorhexidine, the i­ nstruments
are then rolled, which may be narrower, exclusively to allow visualization of the
lesions. The bleeding is substantial, but limited. After 10 minutes from the end of
the intervention, a significant reduction in bleeding can already be observed, which
gives rise to a serous exudation that progressively regresses in the first 6 hours. The
recommended end point is a uniform purple (Fig. 16.5), the same as for scars.
Figure 16.6 presents a very difficult case with large lesions in abdomen after long
time of systemic corticoid, treated by a single session of PCI. Observe the initial
improvement in this very challenge case. Figures 16.7 and 16.8 present, respectively, a patient’s back and a patient’s leg after 90 days of a single PCI session.
Figure 16.9a, b presents the abdomen of one male after 120 days of treatment with
two PCI sessions.
Fig. 16.6 Large lesions in abdomen after long time of systemic corticoid, treated by a single session of PCI. Observe the initial improvement in this very challenge case
16.3 Final Considerations
169
Fig. 16.7 Atrophic stretch marks before and after a single PCI session
Postoperative Often the treated area does not accommodate the dressing well,
which should be done using sterile gauze in large quantities (to contain exudation)
and Micropore®, without the addition of any humectant. As it is often difficult to
keep the dressing on the body, due to the fact that it is easily detached, it is suggested the use of a girdle, elastic shorts, or cotton. This practice does not compromise the results and has offered more comfort to patients.
Evolution and Care in the Postoperative For the patient’s convenience, the bandage can be removed at home after 24 hours of postoperative. From then on, the use
of a regenerating balm is recommended until the reepithelialization; besides that, it
can be used cotton mesh or girdle in the place for 5–7 days. Lighteners and sunscreen of broad spectrum can be used from the seventh day on; however, one should
guide restriction to the lights. There is no need for bandages after this period. In case
there is still some left during the exudation, they can be kept, replacing them.
16.3
Final Considerations
From a therapeutic point of view, stretch marks are challenging lesions, especially
when they are atrophic. The ideal treatment has not yet been recommended and the
responses obtained with the current arsenal offer irregular results. Therefore, we
consider PCI a safe therapeutic approach with encouraging cosmetic results in
recent and old stretch marks.
170
16 Correcting Stretch Marks Using PCI
Fig. 16.8 Patient’s abdomen after 120 days of treatment with two PCI sessions
a
b
Fig. 16.9 (a, b) Patient’s abdomen after 120 days of treatment with two PCI sessions
Sources
171
Sources
1. Aust MC. Percutaneous collagen induction therapy: an alternative treatment for scars, wrinkles, and skin laxity. Plast Reconstr Surg. 2008;121(4):1421–9.
2. Bal SM, Caussian J, Pavel S, et al. In vivo assessment of safety of microneedle arrays in human
skin. Eur J Pharm Sci. 2008;35(3):193–202.
3. Brody HJ. Trichloracetic acid application in chemical peeling, operative techniques. Plast
Reconstr Surg. 1995;2(2):127–8.
4. Camirand A, Doucet J. Needle dermabrasion. Aesthet Plast Surg. 1997;21(1):48–51.
5. Cohen KI, Diegelmann RF, Lindbland WJ. Wound healing: biochemical and clinical aspects.
Philadelphia: WB Saunders Co; 1992.
6. Elsaie M, Baumann L, Elsaaiee L. Striae distensae (stretch marks) and different modalities of
therapy: an update. Dermatol Surg. 2009;35:563–73.
7. Fabroccini G, Fardella N. Acne scar treatment using skin needling. Clin Exp Dermatol.
2009;34(8):874–9.
8. Fernandes D. Minimally invasive percutaneous collagen induction. Oral Maxillofac Surg Clin
North Am. 2006;17(1):51–63.
9. Fernandes D, Massimo S. Combating photoaging with percutaneous collagen induction. Clin
Dermatol. 2008;26(2):192–9.
10. Lee S, Kim JH, Lee SJ, et al. Treatment of striae distensae using an ablative 10,600-nm
carbon dioxide fractional laser: a retrospective review of 27 participants. Dermatol Surg.
2010;36(11):1683–90.
11. Lima EVA, Lima MMDA, Paixão MP, et al. Assessment of the effects of skin microneedling
as adjuvant therapy for facial melasma: a pilot study. BMC Dermatol. 2017;17:14.
12. Lima EA. Microneedling in facial recalcitrant melasma: report of a series of 22 cases. An Bras
Dermatol. 2015;90(6):919–21.
13. Lima EVA, et al. Induction of pigmentation through microneedling in stable localized vitiligo
patients. Dermatol Surg. 2020;46(13):434–5.
14. Lima EA. Microagulhamento em melasma facial recalcitrante: uma série de 22 casos. An Bras
Dermatol. 2015;90(6):917–9.
15. Lima EA, Lima M, Takano D. Microneedling experimental study and classification of the
resulting injury. Surg Cosmet Dermatol. 2013;5:110–4.
16. Lima EVA. Dermal tunneling: a proposed treatment for depressed scars. An Bras Dermatol.
2016;91(5):697–9.
17. Lima EVA. Indução percutânea de colágeno com agulhas em cicatrizes após acidentes automobilísticos: correção cosmética e funcional. Surg Cosmet Dermatol. 2017;9(2):127–9.
18. Lima EVA. Dermal tunneling (TD®): a therapeutic option for static glabellar wrinkles. Surg
Cosmet Dermatol. 2016;8(1):42–5.
19. Lima EVA. Pulsed radiofrequency with multineedles (RFPM®) in the treatment of atrophic
stretch marks. Surg Cosmet Dermatol. 2016;8(3):242–5.
20. Lima EA, Lima MA, Araújo CEC, Nakasawa YMM, Leal NC. Investigation on the use of 3%
and 5% retinoic acid in peeling solution as a drug delivery agent after percutaneous induction of collagen with needles (IPCA®): safety profile and application protocol. Surg Cosmet
Dermatol. 2018;10(1):21–6.
21. Lima EAV. Pulsed radiofrequency with multineedles: a therapeutic proposal for wrinkles, sagging, and periorbital pigmentation. Surg Cosmet Dermatol. 2015;7(3):223–6.
22. Lima EVA. Association of microneedling with phenol peeling: a new therapeutic approach for
sagging, wrinkles and acne scars on the face. Surg Cosmet Dermatol. 2015;7(4):328–31.
23. Lima EVA. Pulsed radiofrequency with multineedles for earlobe aging treatment. Surg Cosmet
Dermatol. 2016;8(4):307–10.
24. Lima EVA. Indução percutânea de colágeno com agulhas (IPCA®) associada a radiofrequência pulsada com multiagulhas (RFPM®) na condução de cicatrizes de acne deprimidas: protocolo de tratamento. Surg Cosmet Dermatol. 2017;9(3):234–6.
25. Orentreich DS, Orentreich N. Subcutaneous incisionless (subcision) surgery for the correction
of depressed scars and wrinkles. Dermatol Surg. 1995;21(6):6543–9.
172
16 Correcting Stretch Marks Using PCI
26. Osman H, Rubeitz N, Tamin H, et al. Risk factors for development of striae gravidarum. Am J
Obstet Gynecol. 2007;196:62-e1–5.
27. Park K, Kim H, Kim S, et al. Treatment of striae distensae using needling therapy: a pilot
study. Dermatol Surg. 2012;38:1823–8.
28. Rangel O, Arias I, García E, et al. Topical tretinoin 0,1% for pregnancy-related abdominal
striae: an open-label, multicenter, prospective study. Adv Ther. 2001;8(4):182–6.
29. Al-Himdani S, Ud-Din S, Gilmore S, Bayat A. Striae distensae: a comprehensive review and
evidence-based evaluation of prophylaxis and treatment. Br J Dermatol. 2014;170:527–47.
Chapter 17
Correcting Laxity and Cellulitis Using PCI
17.1
PCI in Gynoid Lipodystrophy (Cellulite)
Cellulitis is a metabolic disorder located in subcutaneous cell tissue that causes
changes in body contour. It presents as a modification in the topography of the skin,
mainly in the pelvic region, thighs, and abdomen, a result of fat protrusion through
the dermohypodermic junction and fibrosis of the connective tissue that shows an
aspect of “orange peel” (Fig. 17.1).
Its occurrence is universal, affecting 85–98% of post-puberty women in varying
degrees. Among the predisposition factors, besides genetic ones, the influence of
ethnicity is observed, with white women more predisposed than Asian women; diets
rich in carbohydrates, which cause hyperinsulinemia and lipogenesis; sedentarism
and long periods sitting and standing, which result in venous stasis and impairment
of microcirculation; and pregnancy, due to the increase of hormones such as prolactin and insulin, leading to lipogenesis, besides water retention. Weight gain can
accentuate cellulite, particularly in regions such as the buttocks and abdomen.
Thinner and flaccid skin, aggravated by aging, also favors the evidence of characteristic herniations of gynoid lipodystrophy (Fig. 17.2). Rarely is it observed in men;
however, those who present it, in which the skin is usually thicker, visualization is
less frequent. The process originates in alterations in the dermal capillary walls by
the deposit of glycosaminoglycans that compromise microcirculation, interstice,
adipocytes, and interlobular septa, resulting in hypoxia, edema, and trapping of adipocytes, forming micronodules, macronodules, and fibrosclerosis (Fig. 17.3).
Depending on the severity, pain may occur, mainly due to palpation, sensation of
weight, cold feet, cramps, edema, and ecchymosis. Figure 17.4 schematically presents the pathophysiological process of installing gynoid lipodystrophy. Four degrees
of cellulite are considered, according to clinical aspects and evolutionary stages:
grade I, grade II, grade III, and grade IV (Table 17.1).
The Editor(s) (if applicable) and The Author(s), under exclusive license
to Springer Nature Switzerland AG 2021
E. Lima, M. Lima, Percutaneous Collagen Induction With Microneedling,
https://doi.org/10.1007/978-3-030-57541-0_17
173
174
17 Correcting Laxity and Cellulitis Using PCI
B
C
A
D
F
E
H
G
J
I
L
K
M
A - Posterior arm
B - Upper breast side
C - Lateral scapula
D -Upper abdomen
E - Lower abdomen
F - Lateral abdomen
G - Trochanteric
H - Sacral
I - Upper medial thigh
J - Buttock
M - Medial patella
K - Lateral thigh
L - Posterior thigh
Fig. 17.1 Preferential location of cellulite
There are several treatments proposed to attenuate the waviness aspect observed
in the skin affected by cellulite such as endermology, liposuction, use of topics with
potential to thicken the epidermis and dermis such as retinoids, and the use of peelings, which also act for this purpose. The use of needles with the intention of breaking the fibrous septum and releasing the imprisoned skin and the incarcerated
adipocytes has been recommended. Orentreich and Orentreich [26] were the first to
report the use of needles with the purpose of stimulating the production of collagen
in the treatment of depressed scars and wrinkles, a technique spread with the name
of Subcision™. Their studies were confirmed by other authors, who were based on
the same precept: rupture and removal of the damaged subepidermal collagen
17.1 PCI in Gynoid Lipodystrophy (Cellulite)
175
Fig. 17.2 Buttocks and thighs affected by cellulite
Fig. 17.3 Cellulite
etiopathogeny. Alterations
in dermal capillary walls
by deposition of
glycosaminoglycans,
compromising
microcirculation, interstice,
adipocytes, and
interlobular septa
followed by substitution by new collagen and elastin fibers. Subcision™ was presented as a therapeutic option in the treatment of cellulite for the first time by Hexsel
and Mazzuco [11], who studied 46 patients with different degrees of relief changes
(III–IV) treated with Nokor 18 G needle. The patients presented good cosmetic
results and few adverse effects, characterizing the good applicability and safety of
the technique in these cases.
Figure 17.5 shows a patient treated with Subcision™ by Dr. Rose Mazzuco,
demonstrating the result obtained after 3 months of treatment. More recently, it has
been proposed the use of a system of microneedles applied to the skin in order to
generate multiple micropunctures. These micropunctures are long enough to reach
the dermis and trigger, with bleeding, inflammatory stimulus and activation of a
176
17 Correcting Laxity and Cellulitis Using PCI
Dermis and Epidermis swell
Fatty tissue edema
Herniation of the adipocytes
incarcerated between the septa
Commitment to microcirculation
Fig. 17.4 Cellulite etiopathogeny. Hypoxia, edema, and trapping of adipocytes, secondary to vascular damage, resulting in micronodules, macronodules, and fibrosclerosis
Table 17.1 Classification of gynoid lipodystrophy (cellulitis) according to the clinical aspects of
the evolutionary stages
Grade I – latent
Asymptomatic patient, no clinical changes on inspection or palpation
Grade II – incipient
Patient asymptomatic to inspection, but with skin relief changes, evidenced by skin compression
or muscle contraction
Grade III – critical
Alteration of inspection relevance, quilted or “orange peel” appearance, nodules on palpation,
and adhesion to deep planes
Grade IV – fibrolipodistrópic
Characteristics of grade III and presence of large ripples with palpable, visible, painful nodules
and adhesions to deep planes
cascade that results in collagen production and improvement in skin quality, which
attenuates the appearance of cellulite. The percutaneous collagen induction, initially evaluated by the African plastic surgeon Des Fernandes [9], whose studies in
480 patients with scars, wrinkles, and flaccidity offered good results, has been practiced worldwide.
17.2
PCI Fundamentals in Cellulite Treatment
PCI proposes a stimulus in the production of collagen, without causing the total
deepithelialization observed in ablative techniques. For all the inflammatory cascade to be installed, resulting in the production of collagen and breaking fibrotic
17.2
PCI Fundamentals in Cellulite Treatment
177
Fig. 17.5 Patient treated with Subcision™. (Courtesy of Dr. Rose Mazzuco)
Fig. 17.6 Immediate postoperative of PCI, observe the micro-hematomas caused by the technique. Dressing recommended by the author after PCI
beams, the trauma caused by the needle must reach the skin at a depth of 1.5–3 mm,
thus preserving the epidermis, which was only perforated and not removed.
Hundreds of microlesions are created, resulting in hematic columns in the dermis,
accompanied by edema and hemostasis almost immediately from the treated area.
The intensity of these reactions is proportional to the length of the needle used in the
procedure.
Figure 17.6 shows the evolution of a patient submitted to PCI with a 2.5 mm long
needle immediately after the intervention, showing substantial but limited bleeding.
After 10–20 minutes, a significant reduction of this bleeding is observed with closure of many holes. In the following 20 minutes, almost no bleeding is identified,
leaving only micropunctures, microscopic hematomas, and an exudation that will
turn into serous. It is necessary to understand that the needle does not fully penetrate
the skin during the rolling process. It is estimated that a 3 mm long needle will only
penetrate 1.5–2 mm, i.e., approximately 50–70% of its extension. Therefore, when
the needle length is 1 mm, the damage is very superficial, and consequently the
inflammatory response is much more limited when compared to that produced by a
178
17 Correcting Laxity and Cellulitis Using PCI
longer needle length. In the case of cellulite, where cosmetic changes result from
compromised epidermis, dermis, and hypodermis, the use of long needle lengths is
necessary.
17.3
Applicability of PCI in Cellulite
PCI offers the proposal to improve texture, coloring, waving, and relief of the area
with cellulite by means of microneedles. For this, we must consider the items
described below.
17.3.1
Skin Thickness
Very thin skins offer less resistance to shorter needle lengths when compared to
thick skins. However, patients with cellulite often benefit from longer needle
lengths, so 2.5 mm needles are recommended. These individuals commonly have
indentations, which make it difficult to uniform the bearing of microneedles, as well
as the cushioning of movement by the thickness of the adipose cushion. Thus, there
is a reduction of up to 50% in penetration of the total length of the needles. In older
individuals, the more flaccid the skin, the lower the resistance. In young people and
smokers, the skin is more resistant to needle penetration. To compensate and overcome this reluctance, the operator often imposes excessive force on the instrument,
which is not recommended. Therefore, we suggest that the vector of the force
printed on the roller always tangents the horizontal plane it is working on and is
never perpendicular to that surface.
17.3.2
Cellulite Ratios
The higher the degree, the greater the challenge. Grades II and III respond better to
the intervention. Grade IV commonly requires complementary techniques such as
Subcision™ or dermal tunneling (DT). To obtain better results, there is often the
need to repeat the stimulus at intervals that can vary from 1 to 3 months, depending
on the involution of micro-hematomas and erythema (Fig. 17.7).
17.3.3
Flaccidity and Needle Length
Body flaccidity is more easily treated than ripples. The thicker adipose cushion in
areas such as the buttock, hip, and thigh offers a cushioning of needle penetration,
which results in greater resistance. It is observed that the abdomen commonly
responds better to stimulation.
17.3 Applicability of PCI in Cellulite
179
Fig. 17.7 Immediate postoperative of dermal tunneling and 7 days postoperative showing bruise
regression
17.3.4
Deep Injury
This intervention is proposed when the objective is to extract the maximum from the
intervention in a single procedure. Commonly, an approach using a 2.5 mm needle
length under infiltrative anesthesia provides a better cosmetic gain. Topical anesthesia and the use of needle lengths that do not exceed 1.5 mm (moderate injury) offer
modest results in the correction of cellulite.
17.3.5
Step-by-Step
• Patient assessment. The applicability of PCI is established independently of the
phototype. Even in higher phototypes, subject to post-inflammatory hyperpigmentation (IPH), commonly transient, the technique is well indicated. In such
cases, preparation is the most important. The less melanin the treated skin is
providing, the lower the risk of darkening. Therefore, it is recommended the use
of depigmentant and sunscreen 30 days before the intervention, time in which the
evaluation of the patient is performed. This evaluation should be done with the
patient in orthostatic position and the area to be treated demarcated after the
contraction of the musculature requested by the professional.
• Instrumental. We prefer the use of a roller with an average of 192 needles of
2.5 mm in length. The treatment should be performed in a procedure room carefully prepared for surgical intervention and by a trained and qualified professional. It is essential not to trivialize these safety criteria, which consist of the use
of sterile gloves, sterile surgical fields, and environment that follows strict standards of disinfection.
• Asepsis and anesthesia of the area. After antisepsis with 2% chlorhexidine, anesthesia with 2% lidocaine solution with 1:2 vasoconstrictor 0.9% saline, respecting the maximum dose of the active agent allowed (see Chap. 4, Analgesia and
180
17 Correcting Laxity and Cellulitis Using PCI
Anesthesia). The addition of bicarbonate in order to offer more comfort by
reducing burning is optional.
• Transoperative. The instruments are then rolled, forming parallel and adjacent
strips of micropunctures, which intersect diagonally, seeking to achieve a uniform purple with thousands of microperforations. The bleeding is substantial but
limited. After 10 minutes of the end of the intervention, a significant reduction in
bleeding can already be observed, which gives rise to a serous exudation that
progressively regresses in the first 6 hours.
• Immediate postoperative. The dressing is performed using sterile gauze in large
quantities (in order to contain the exudation) and Micropore®, without the addition of any humectant. Topical or systemic antibiotic therapy is not indicated. It
is a clean procedure, and, according to the Food and Drug Administration (FDA)
rules, this precaution is unnecessary. Cryotherapy or hot compresses are not indicated. It is preferable that the accommodation of bruises and the inflammatory
response resulting from their presence follow their natural course. Nor is topical
or systemic corticotherapy recommended to contain the expected effects of the
self-limited inflammatory process. It is recommended, already on the first day,
the use of clothes with potential for compression modeling or elastic clothes.
17.3.6
Dressing Recommended by the Author After PCI
• Evolution and postoperative care. The dressing can be removed by the patient
himself at home, wetting him in the shower, when the treated area can be sanitized with liquid soap with low detergency potential, avoiding sensitization.
From then on, it is recommended to use a regenerating balm until reepithelialization, on average 3–5 days, when lightening creams and broad spectrum tinted
sunscreen can be used. Restriction to lights should be oriented. Edema and
hematoma in the following days are substantial. The use of elastic clothing contributes to the recovery and perception of results. According to the author, the
patient will be able to return to his labor activities the next day. Figure 17.8
Cellulitis grade IV in the buttocks and thighs treated with PCI before and after
15 days. Figures 17.9, 17.10, 17.11, and 17.12 present patients treated for a single session of PCI
• Complementary techniques. When DT or Subcision™ and PCI is associated, it is
recommended that these techniques are performed at the same surgical time as
PCI. In situations where the dermatologist wishes to use a filler such as hyaluronic acid or a collagen stimulator such as polylactic acid, we recommend that
this intervention be programmed for at least 30 days after PCI, making sure that
the edema has completely regressed.
• Complications. They are much more related to expected effects such as edema,
bruising, transient IPH, and transient erythema. Once the proper care has been
17.3 Applicability of PCI in Cellulite
181
Fig. 17.8 Cellulitis grade IV in the buttocks and thighs treated with PCI before and after 15 days
Fig. 17.9 Cellulite grade IV in the thigh treated by PCI with 2.5 mm needles before and after
10 days postoperative showing bruise regression
taken in the preparation of the skin, following the postoperative recommendations rigorously, the PCI presents itself as a safe and reproducible technique for
cellulite, provided that the operator is duly qualified and trained.
• Pain and discomfort. The postoperative period is smooth. The author’s experience ensures that pain is not a common complaint; however, if it occurs, he
182
17 Correcting Laxity and Cellulitis Using PCI
Fig. 17.10 Cellulite grade IV treated by PCI with 2.5 mm needles before and after 90 days
Fig. 17.11 Cellulite grade IV treated by PCI with 2.5 mm needles before and after 90 days
should warn of secondary infection, especially if installed after 48 hours of intervention. Generally what is observed is pain due to edema and bruising. Usually
there is no need for analgesic or anti-inflammatory in the postoperative period,
but if there is a complaint of discomfort, without any other aggravating factor,
dipyrone 1 g effervescent is recommended every 6 hours.
• Prophylaxis for herpes. It is not routinely recommended, since it is not an ablative intervention that removes the epidermis completely and, consequently,
allows infection by an organism that needs the loss of keratinocyte integrity to
proliferate. However, in cases where the frequent and recalcitrant character of
the viral infection is identified, we consider mandatory prophylaxis, taking into
account mainly surgical stress.
Sources
183
Fig. 17.12 Cellulite grade IV treated by PCI with 2.5 mm needles before and after 90 days
17.4
Final Considerations
PCI is considered a safe therapeutic approach with interesting cosmetic results in
the treatment of modest cellulite conditions or as a complementary technique in
association with DT or Subcision™. To this end, it is essential that the operator is
skilled and safe in the proposal and ensures its suitability for the individual to be
treated.
Sources
1. Aust MC. Percutaneous collagen induction therapy: an alternative treatment for scars, wrinkles, and skin laxity. Plast Reconstr Surg. 2008;121(4):1421–9.
2. Avram MM. Cellulite: a review of its physiology and treatment. J Cosmet Laser Ther.
2005;7:1–5.
3. Bal SM, Caussian J, Pavel S, et al. In vivo assessment of safety of microneedle arrays in human
skin. Eur J Pharm Sci. 2008;35(3):193–202.
4. Brody HJ. Trichloroacetic acid application in chemical peeling, operative techniques. Plast
Reconstr Surg. 1995;2(2):127–8.
5. Camirand A, Doucet J. Needle dermabrasion. Aesthet Plast Surg. 1997;21(1):48–51.
6. Cohen KI, Diegelmann RF, Lindbland WJ. Wound healing: biochemical and clinical aspects.
Philadelphia: WB Saunders Co; 1992.
184
17 Correcting Laxity and Cellulitis Using PCI
7. Draelos Z, Marenus KD. Cellulite: etiology and purported treatment. Dermatol Surg.
1997;23:1177–81.
8. Fabroccini G, Fardella N. Acne scar treatment using skin needling. Clin Exp Dermatol.
2009;34(8):874–9.
9. Fernandes D. Minimally invasive percutaneous collagen induction. Oral Maxillofac Surg Clin
North Am. 2006;17(1):51–63.
10. Fernandes D, Massimo S. Combating photoaging with percutaneous collagen induction. Clin
Dermatol. 2008;26(2):192–9.
11. Hexsel DM, Mazzuco R. Subcision: uma alternativa cirúrgica para a lipodistrofia ginóide
(celulite) e outras alterações no relevo corporal. An Bras Dermatol. 1997;72(1):27–32.
12. Lima EVA, Lima MMDA, Paixão MP, et al. Assessment of the effects of skin microneedling
as adjuvant therapy for facial melasma: a pilot study. BMC Dermatol. 2017;17:14.
13. Lima EA. Microneedling in facial recalcitrant melasma: report of a series of 22 cases. An Bras
Dermatol. 2015;90(6):919–21.
14. Lima EVA, et al. Induction of pigmentation through microneedling in stable localized vitiligo
patients. Dermatol Surg. 2020;46(13):434–5.
15. Lima EA. Microagulhamento em melasma facial recalcitrante: uma série de 22 casos. An Bras
Dermatol. 2015;90(6):917–9.
16. Lima EA, Lima M, Takano D. Microneedling experimental study and classification of the
resulting injury. Surg Cosmet Dermatol. 2013;5:110–4.
17. Lima EVA. Dermal tunneling: a proposed treatment for depressed scars. An Bras Dermatol.
2016;91(5):697–9.
18. Lima EVA. Indução percutânea de colágeno com agulhas em cicatrizes após acidentes automobilísticos: correção cosmética e funcional. Surg Cosmet Dermatol. 2017;9(2):127–9.
19. Lima EVA. Dermal tunneling (TD®): a therapeutic option for static glabellar wrinkles. Surg
Cosmet Dermatol. 2016;8(1):42–5.
20. Lima EVA. Pulsed radiofrequency with multineedles (RFPM®) in the treatment of atrophic
stretch marks. Surg Cosmet Dermatol. 2016;8(3):242–5.
21. Lima EA, Lima MA, Araújo CEC, Nakasawa YMM, Leal NC. Investigation on the use of 3%
and 5% retinoic acid in peeling solution as a drug delivery agent after percutaneous induction of collagen with needles (IPCA®): safety profile and application protocol. Surg Cosmet
Dermatol. 2018;10(1):21–6.
22. Lima EAV. Pulsed radiofrequency with multineedles: a therapeutic proposal for wrinkles, sagging, and periorbital pigmentation. Surg Cosmet Dermatol. 2015;7(3):223–6.
23. Lima EVA. Association of microneedling with phenol peeling: a new therapeutic approach for
sagging, wrinkles and acne scars on the face. Surg Cosmet Dermatol. 2015;7(4):328–31.
24. Lima EVA. Pulsed radiofrequency with multineedles for earlobe aging treatment. Surg Cosmet
Dermatol. 2016;8(4):307–10.
25. Lima EVA. Indução percutânea de colágeno com agulhas (IPCA®) associada a radiofrequência pulsada com multiagulhas (RFPM®) na condução de cicatrizes de acne deprimidas: protocolo de tratamento. Surg Cosmet Dermatol. 2017;9(3):234–6.
26. Orentreich DS, Orentreich N. Subcutaneous incisionless (subcision) surgery for the correction
of depressed scars and wrinkles. Dermatol Surg. 1995;21(6):543–9.
27. Rossi AB, Vergnanini AL. Cellulite: a review. J Eur Acad Dermatol Venereol. 2000;141:251–62.
Chapter 18
PCI and Transcutaneous Drug Delivery
18.1
Introduction
Percutaneous microneedling collagen induction is a method used by dermatologists
as a treatment modality for scars, wrinkles, and melasma, even without the addition
of a drug during the procedure.
In 1998, Desmond Fernandes, a plastic surgeon from South Africa, designed a
manual rolling device with several micro needles. In the last 10 years, the technique
has been widely studied by dermatologist Emerson Lima in a wide range of
indications.
PCI performs thousands of controlled microscopic microperforations in the papillary and reticular dermis. Its objective is to perform mechanical stimulation of the
dermis, leaving the epidermis intact, promoting collagen formation, and increasing
angiogenesis. Thus, a dermal vasodilatation occurs and, immediately, the migration
of keratinocytes to restore the epidermal damage, resulting in the release of cytokines such as interleukin (IL)-1, IL-8, and IL-6, tumor necrosis factor alpha (TNF-­
α), and granulocyte colony-stimulating factor and macrophages (GM-CSF).
During treatment, needles pierce the stratum corneum and create the microchannels without damaging the epidermis, making it possible to create an accessible
means of transporting macromolecules and other hydrophilic substances to the skin.
The microchannels facilitate drug delivery efficiently and can increase the absorption of larger molecules by up to 80%.
The application of drugs by the transdermal drug delivery system has been used
as an alternative to the oral or parenteral administration of various substances.
Transdermal patches can, for example, be useful for the application of vaccines and
medications that require slow and controlled release into the skin. However, the
transdermal route of drug absorption faces a major challenge, which is the barrier
function of the skin, mainly exercised by the stratum corneum, which limits the
absorption of many actives.
The Editor(s) (if applicable) and The Author(s), under exclusive license
to Springer Nature Switzerland AG 2021
E. Lima, M. Lima, Percutaneous Collagen Induction With Microneedling,
https://doi.org/10.1007/978-3-030-57541-0_18
185
186
18
PCI and Transcutaneous Drug Delivery
In order to increase skin permeability and improve the penetration of substances
through the stratum corneum, several techniques have been associated with the
transdermal route of drug absorption, such as ultrasound (cavitational and non-­
cavitational), thermal ablation, iontophoresis, electroporation, microdermabrasion,
and microneedles.
18.2
undamentals of the Association of PCI
F
to Drug Delivery
The skin is the largest organ in the human body, and its main function is to be a
protective barrier against infectious and chemical thighs, as well as water loss.
Through the capacity of skin absorption, it can be considered a safe and effective
route for the application of various drugs. The active principles applied on the skin
surface use four skin pathways for penetration as presented in Fig. 18.1:
Via glandular sweat
Via Follicular
Via intercellular
Via intracellular
Fig. 18.1 Pathways of penetration of active ingredients into the skin (intracellular, intercellular,
follicular, and sweat gland)
18.2 Fundamentals of the Association of PCI to Drug Delivery
•
•
•
•
187
Sweat gland pathway
Follicular route
Intercellular route
Intracellular route
During transpidermal penetration, molecules pass through the layers of the epidermis. More externally is the stratum corneum, composed of rows of corneocytes
soaked in intercellular lipid matrix, which represents the main skin barrier to the
penetration of substances. The intracellular passage of the substances occurs through
the keratinocytes and allows the transport of hydrophilic or polar solutes. The transport through the intercellular spaces makes possible the diffusion of lipophilic or
non-polar solutes through the lipid matrix.
In the route through the skin attachments, the active principles penetrate through
the sweat glands or the hair follicles. Once the stratum corneum is penetrated, the
active substance may have a target in one of the layers of the epidermis or in the
dermis or even be absorbed and have systemic action. As the skin represents an
efficient barrier to the penetration of molecules, several chemical (passive) and
physical (active) methods have been developed to modify the barrier properties of
the stratum corneum and increase this permeability. Examples of chemical potentiators of permeation include interaction with intercellular proteins, extraction of intercellular lipids, increased hydration of the stratum corneum, and increased fluidity of
its lipid layer.
Physical (active) methods to increase skin permeability include those that destroy
the stratum corneum barrier and those that act through an external force that impacts
the active ingredients in the skin. These techniques provide an increase in the number of active ingredients that can be efficiently carried by the skin. The channels
produced by the microneedles present themselves as a way to transport drugs, but it
is important to note that the bleeding produced by PCI can compromise the permeation of the active ingredients. The ideal end point of PCI is decisive when the treatment proposal presupposes a drug delivery. As previously presented in Chap. 2,
Classification and Characteristics of the Injury Provoked by PCI, according to the
classification of Emerson Lima et al. [39], the most appropriate end point for drug
delivery would be a mild to moderate PCI injury, not being the best option the
deep injury.
In mild to moderate injury, microneedles create conduits in the keratin and epidermis that allow the penetration of hydrophilic molecules. Figure 18.2 shows the
channels produced by the microneedles and the simulation of the penetration reaching the papillary dermis (moderate injury).
There are four different types of needles that can be used:
• Solids: the substance is applied to the microchannels created by the needles,
which increase the penetration of the assets. This type of needle is present in the
most commonly used instruments in dermatology – the microneedle rollers and
the needle pens.
• Coated: solid needles are coated with the substance to be introduced into the skin.
• Dissolvable: needles dissolve along with the active that will penetrate the skin.
188
18
PCI and Transcutaneous Drug Delivery
Fig. 18.2 Channels produced by microneedles and the simulation of penetration reaching the
papillary dermis (moderate injury)
• Hollow, with central lumen: the active substance, in liquid form, passes through
the needle hole to be introduced into the skin, either passively (by diffusion) or
actively (when external force is applied for infusion).
18.3
Indications and Contraindications
Clinical studies demonstrate the efficacy and safety of PCI for the treatment of acne,
surgical or burn scars, as well as stretch marks, wrinkles, flaccidity, melasma, androgenetic alopecia, improving skin texture and tone, fine wrinkles, and flaccidity.
Clinical investigations have shown a considerable increase in collagen and elastin
fibers in the dermis treated by microneedles after 6 months of postoperative. The
epidermis showed a thickening of 40% of the thorny layer, and the epithelial ridges
were normal after 1 year of the procedure.
PCI combined with human embryonic stem cell drug delivery (HESC-EPC CM)
proved to be effective in improving the signs of aging and may be an excellent
option for skin rejuvenation. An in vitro study of human embryonic stem cells
showed a significant increase in proliferation and migration of dermal fibroblasts, in
addition to epidermal keratinocytes, which favor the synthesis of collagen by fibroblasts. In Fig. 18.3 we can identify the face of a patient immediately after PCI demonstrating the end point of moderate injury. Figure 18.4 present a dermatoscopy
immediately after moderate injury PCI.
A comparative pilot study described the first report of improvement in melasma
by combining microneedles to drug delivery, using a depigmentant serum containing rucinol and sophora-alpha. The experiment proved to be more effective than
placebo.
Another comparative study analyzed the efficacy and safety of tranexamic acid
for the treatment of melasma by localized microinjections (mesotherapy) and drug
18.3 Indications and Contraindications
189
Fig. 18.3 Face of a patient
immediately after PCI
demonstrating the end
point of moderate injury
delivery microneedles. The best results were found in the group that was treated
with the microneedles, proving that the procedure delivers the substance more uniformly and deeper into the skin when compared to mesotherapy.
PCI can be combined with photodynamic therapy (PDT) treatment, as it is a safe
and effective method. This combination produces superior results when compared
to conventional PDT with the use of the photosensitizing agent methyl aminolevulinate (MAL) or aminolevulinic acid (ALA), to improve light-damaged skin and the
results in the treatment of actinic keratoses.
PCI can also be useful to improve the penetration of MAL in PDT. Clementoni
et al. [12] treated 21 patients with photoaging using 630 nm light TFD after multiple
passages with a hand roll after 1 hour of MAL incubation.
Research has demonstrated the importance of PCI in cell stimulation and growth
factor production, showing increased gene expression related to hair growth
190
18
PCI and Transcutaneous Drug Delivery
Fig. 18.4 Dermatoscopy immediately after PCI moderate injury
stimulation. The drug delivery technique that uses minoxidil associated with
microneedles in the treatment of androgenetic alopecia has shown that a faster repilation occurs, in addition to improving hair texture and shine in the treated group,
when compared to the use of minoxidil alone.
The efficacy of PCI in combination with the use of triamcinolone as a drug delivery to stimulate hair growth has also been demonstrated. The mechanism of action
of PCI is to increase the blood supply to the hair follicles, and the microlesions created induce hair growth by stimulating growth factors.
18.4
Pre- and Post-treatment Considerations
When your option is to use drugs associated with microneedles, you must emphasize that all the safety measures below must be taken:
• Prior photographic documentation
• Preparation of the skin, ensuring the adhesion of the daily sunscreen and use of
a cream with whitening potential 30 days before the intervention
• Appropriate environment and antisepsis criteria for a surgical procedure
• Effective topical anesthesia
• Careful asepsis
• Use of sterile and disposable roller
18.4
Pre- and Post-treatment Considerations
191
The skin can be prepared for the procedure using retinoids, vitamin C, and
topical antioxidants 1 month before the procedure. This way, the stratum corneum
will be thinner, and we will have a lower availability of melanin in the epidermis,
optimizing the effects of the intervention. The technique promotes the rupture of
the stratum corneum, and this is proven microscopically by the visualization of
the channels and transpidermal water loss (TEWL). These channels will favor the
permeation of hydrophilic molecules and macromolecules of the formulations
applied after the perforations. The intervention should be performed in a procedure room properly prepared for a surgical intervention. There will be a partial
break in the stability of the skin barrier, and if antisepsis medications are not
taken, there may be the inoculation of microbial agents and the development of
possible infections. As the procedure uses needles up to 1.5 mm long, the area
must be properly anesthetized by topical anesthesia. We recommend a 4% liposomal lidocaine cream, massaged over clean, greasy skin (the no washed skin will
help to provide the liposomal anesthetic) and leaving a thick layer of cream on the
area for 1 hour, seeking optimization of the anesthetic effect. The authors suggest
the amount of 20–30 g of 4% liposomal lidocaine with safety for the intervention
of one face (see Chap. 9, Melasma – Lima Protocol). After 1 hour the anesthetic
should be removed completely using 2% aqueous or degermant chlorhexidine.
There must be no residue left from the anesthetic to guarantee the safety of the
procedure. If the anesthetic remains on the skin, it will be inoculated by the needles, promoting the risk of anesthetic intoxication (see Chap. 4). After sanitization, the skin will be ready for PCI, seeking a diffuse end point of erythema,
without major bleeding, as shown in Fig. 18.3. The treatment is performed using
a device composed of 192 0.07 mm thick and 1.5 mm long surgical steel microneedles. To perform the procedure, it is positioned in one of the hands, with a maximum pressure of 5 Newtons, at an angle of 45° on the skin surface, making
movements back and forth, by rolling the needles in horizontal, vertical, and right
and left diagonal directions. This technique ensures a homogeneous pattern of
penetration of the microneedles into the dermis, which results in about 250–300
punctures/cm2, at least. The thin needles produce intradermal bleeding and activate the wound healing mechanisms without causing significant damage to the
epidermis. In the process of post-traumatic regeneration occurs the formation of
new collagen and elastin fibers, with the advantage of a rapid recovery because the
healing time is shorter when compared to ablative technologies (Yan et al. 2014).
Around 70% of the needle length penetrates the skin during rolling. Bleeding is
minimal, followed by modest serosanguinolent exudation. We do not recommend
removing this exudation for the application of the asset. This exudation is rich in
growth factors and stem cells important for the treatment result.
Immediately after the procedure, a drug delivery is performed, with application
of the active ingredients with a gentle massage for 2 minutes.
The content of this solution and therefore the effectiveness of the chosen drugs
should be carefully chosen. The appropriate vehicle, solubility and spreadability,
adequate pH, and bioavailability of each active ingredient must be proven by the
manufacturer. The authors recommend that the solution be sterile.
192
18
PCI and Transcutaneous Drug Delivery
Fig. 18.5 Patient treated by PCI associated to retinoid acid 5% delivery. Before and after 60 days
(two sessions)
Controlled release actives can help to increase the depth achieved, such as liposomes, which increase the bioavailable concentration of the active that crosses the
stratum corneum for greater bioavailability in the skin. The choice of the ideal vehicle for the formulation is also another determining factor for good performance. The
fluid anhydrous serum is safe and effective, without causing burning or any discomfort to the patient at the time of application. It has the advantage of forming a film
on the skin, making the occlusion extremely important, by considerably increasing
the time of opening the pores and reducing TEW. Duration of asset availability is
limited by the length of time the channels remain open. Dendritic cells and stem
cells are closely associated with hair follicles, making them even more attractive for
the development of selective substance delivery systems. Recently, it has been demonstrated that particles that are between 300 and 600 nm in size effectively and
more deeply penetrate the hair follicles.
The severe adverse events described with microneedles included facial allergic
granuloma and systemic hypersensitivity reactions, possibly related to topical products used on the skin before the technique was performed. No studies reported bacterial infections after treatment. The solution chosen for drug delivery may remain
for 2 hours, knowing that the mean time of ostia closure varies from 15 to 40 minutes. However, the treated skin is more susceptible to the action of actives in the
following hours, since the skin barrier has been partially broken. Figures 18.5 and
18.6 present patients treated by the association of PCI to retinoid acid 5%.
18.5
Final Considerations
PCI is a simple, safe method with low incidence of side effects. The association
with drug delivery has the advantage of being a safe, low cost, and effective procedure that enhances the results of dermatological treatments.
Sources
193
Fig. 18.6 Patient treated by PCI associated to retinoid acid 5% delivery. Before and after 45 days
(single session)
Sources
1. Alkilani AZ, McCrudden MTC, Donnelly RF. Transdermal drug delivery: innovative pharmaceutical developments based on disruption of the barrier properties of the stratum corneum.
Pharmaceutics. 2015;7:438–70.
2. Al-Qallaf B, Das DB. Optimizing microneedle arrays to increase skin permeability for transdermal drug delivery. Ann N Y Acad Sci. 2009;1161:83–94.
3. Aust MC, Fernandes D, Kolokythas P, et al. Percutaneous collagen induction therapy: an alternative treatment for scars, wrinkles and skin laxity. Plast Reconstr Surg. 2008a;21:1421–9.
4. Aust MC, Reimers K, Repenning C, et al. Percutaneous collagen induction: minimally invasive skin rejuvenation without risk of hyperpigmentation – fact or fiction? Plast Reconstr Surg.
2008b;122:1553–63.
5. Azagury A, Khoury L, Enden G, et al. Ultrasound mediated transdermal drug delivery. Adv
Drug Deliv Rev. 2014;72:127–43.
6. Bal SM, Caussian J, Pavel S, et al. In vivo assessment of safety of microneedle arrays in human
skin. Eur J Pharm Sci. 2008;35(3):193–202.
7. Benson HA, Namjoshi S. Proteins and peptides: strategies for delivery to and across the skin.
J Pharm Sci. 2008;97(9):3591–610.
8. Budamakuntla L, Loganathan E, Suresh DH, et al. A randomised, open-label, comparative
study of tranexamic acid microinjections and tranexamic acid with microneedling in patients
with melasma. J Cutan Aesthet Surg. 2013;6:139–43.
9. Camirand A, Doucet J. Needle dermabrasion. Aesthetic Plast Surg. 2007;21(1):48–51.
10. Chandrashekar B, Yepuri V, Mysore V. Alopecia areata – successful outcome with microneedling and triamcinolone acetonide. J Cutan Aesthet Surg. 2014;7(1):63.
11. Cho SB, Lee SJ, Kang JM, et al. The treatment of burn scar induced contracture with the
pinhole method and collagen induction therapy: a case report. J Eur Acad Dermatol Venereol.
2008;22:513.
12. Clementoni MT, Gilardino P, Muti GF, et al. Non-sequential fractional ultrapulsed CO2
resurfacing of photoaged facial skin: preliminary clinical report. J Cosmet Laser Ther.
2007;9(4):218–25.
13. Cohen BE, Elbuluk N. Microneedling in skin of color: a review of uses and efficacy. J Am
Acad Dermatol. 2016;74(2):348–55.
14. Dogra S, Yadav S, Sarangal R. Microneedling for acne scars in Asian skin type: an effective
low cost treatment modality. J Cosmet Dermatol. 2014;13:180–7.
194
18
PCI and Transcutaneous Drug Delivery
15. Donnelly RF, Singh TR, Garland MJ, et al. Hydrogel-forming microneedle arrays for enhanced
transdermal drug delivery. Adv Funct Mater. 2012;22(23):4879–90.
16. Fabbrocini G, De Vita V, Fardella N, et al. Skin needling to enhance depigmenting serum penetration in the treatment of melasma. Plast Surg Int. 2011;2011:158241.
17. Fabbrocini G, Fardella N, Monfrecola A, et al. Acne scarring treatment using skin needling.
Clin Exp Dermatol. 2009;34:874–9.
18. Fernandes D, Signorini M. Combating photoaging with percutaneous collagen induction. Clin
Dermatol. 2008;26(2):192–9.
19. Gadkari R, Nayak C. A split face comparative study to evaluate efficacy of combined subcision and dermaroller against combined subcision and cryoroller in treatment of acne scars. J
Cosmet Dermatol. 2014;13(1):38–43.
20. Gill HS, Prausnitz MR. Coated microneedles for transdermal delivery. J Control Release.
2007;117(2):227–37.
21. Gill HS, Prausnitz MR. Pocketed microneedles for drug delivery to the skin. J Phys Chem
Solids. 2008;69(5–6):1537–41.
22. Gratieri T, Kalia YN, et al. Mathematical models to describe iontophoretic transport in vitro
and in vivo and the effect of current application on the skin barrier. Adv Drug Deliv Rev.
2013;65:315–29.
23. Gupta J, Gill HS, Andrews SN, et al. Kinetics of skin resealing after insertion of microneedles
in human subjects. J Control Release. 2011;154(2):148–55.
24. Haj-Ahmad R, Khan H, Arshad MS, et al. Microneedle coating techniques for transdermal
drug delivery. Pharmaceutics. 2015;7:486–502.
25. Harris AG, Naidoo C, Murrell DF. Skin needling as a treatment for acne scarring: an up-to-date
review of the literature. Int J Womens Dermatol. 2015;1(2):77–81.
26. Jeong K, Lee YJ, Kim JE, et al. Repeated microneedle stimulation induce the enhanced expression of hair growth related genes. Int J Trichology. 2012;4:117.
27. Kalil CLPV, Campos VB, Chaves CRP, et al. Estudo comparativo, randomizado e duplo-cego
do microagulhamento associado ao drug delivery para rejuvenescimento da pele da região
anterior do tórax. Surg Cosmet Dermatol. 2015;7(3):211–6.
28. Khater MH, Khattab FM, Abdelhaleem MR. Treatment of striae distensae with needling therapy versus CO2 fractional laser. J Cosmet Laser Ther. 2016;18(2):75–9.
29. Kim BJ, Lim YY, Kim HM, et al. Hair follicle regeneration in mice after wounding by
microneedle roller. Int J Trichology. 2012a;4:117.
30. Kim YC, Park JH, Prausnitz MR. Microneedles for drug and vaccine delivery. Adv Drug Deliv
Rev. 2012b;64(14):1547–68.
31. Lademann J, Knorr F, Richter H, et al. Hair follicles an efficient storage and penetration
pathway for topically applied substances. Summary of recent results obtained at the Center
of Experimental and Applied Cutaneous Physiology, Charite – Universitatsmedizin Berlin,
Germany. Skin Pharmacol Physiol. 2008;2:150–5.
32. Lademann J, Richter H, Teichmann A, et al. Triggering of drug release of particles in hair follicles. J Control Release. 2012;160(3):509–14.
33. Lee HJ, Lee EG, Kang S, et al. Efficacy of microneedling plus human stem cell conditioned medium for skin rejuvenation: a randomized, controlled, blinded split-face study. Ann
Dermatol. 2014;26(5):584–91.
34. Leheta TM, Abdel Hay RM, El Garem YF. Deep peeling using phenol versus percutaneous
collagen induction combined with trichloroacetic acid 20% in atrophic post-acne scars; a randomized controlled trial. J Dermatol Treat. 2014;25(2):130–6.
35. Lima EVA, Lima MMDA, Paixão MP, et al. Assessment of the effects of skin microneedling
as adjuvant therapy for facial melasma: a pilot study. BMC Dermatol. 2017;17:14.
36. Lima EA. Microneedling in facial recalcitrant melasma: report of a series of 22 cases. An Bras
Dermatol. 2015;90(6):919–21.
37. Lima EVA, et al. Induction of pigmentation through microneedling in stable localized vitiligo
patients. Dermatol Surg. 2020;46(13):434–5.
Sources
195
38. Lima EA. Microagulhamento em melasma facial recalcitrante: uma série de 22 casos. An Bras
Dermatol. 2015;90(6):917–9.
39. Lima EA, Lima M, Takano D. Microneedling experimental study and classification of the
resulting injury. Surg Cosmet Dermatol. 2013;5:110–4.
40. Lima EVA. Dermal tunneling: a proposed treatment for depressed scars. An Bras Dermatol.
2016;91(5):697–9.
41. Lima EVA. Indução percutânea de colágeno com agulhas em cicatrizes após acidentes automobilísticos: correção cosmética e funcional. Surg Cosmet Dermatol. 2017;9(2):127–9.
42. Lima EVA. Dermal tunneling (TD®): a therapeutic option for static glabellar wrinkles. Surg
Cosmet Dermatol. 2016;8(1):42–5.
43. Lima EVA. Pulsed radiofrequency with multineedles (RFPM®) in the treatment of atrophic
stretch marks. Surg Cosmet Dermatol. 2016;8(3):242–5.
44. Lima EA, Lima MA, Araújo CEC, Nakasawa YMM, Leal NC. Investigation on the use of 3%
and 5% retinoic acid in peeling solution as a drug delivery agent after percutaneous induction of collagen with needles (IPCA®): safety profile and application protocol. Surg Cosmet
Dermatol. 2018;10(1):21–6.
45. Lima EAV. Pulsed radiofrequency with multineedles: a therapeutic proposal for wrinkles, sagging, and periorbital pigmentation. Surg Cosmet Dermatol. 2015;7(3):223–6.
46. Lima EVA. Association of microneedling with phenol peeling: a new therapeutic approach for
sagging, wrinkles and acne scars on the face. Surg Cosmet Dermatol. 2015;7(4):328–31.
47. Lima EVA. Pulsed radiofrequency with multineedles for earlobe aging treatment. Surg Cosmet
Dermatol. 2016;8(4):307–10.
48. Lima EVA. Indução percutânea de colágeno com agulhas (IPCA®) associada a radiofrequência pulsada com multiagulhas (RFPM®) na condução de cicatrizes de acne deprimidas: protocolo de tratamento. Surg Cosmet Dermatol. 2017;9(3):234–6.
49. Majid I. Microneedling therapy in atrophic facial scars: an objective assessment. J Cutan
Aesthet Surg. 2009;2(1):26.
50. More S, Ghadge T, Dhole S. Microneedle: an advanced technique in transdermal drug delivery
system. Asian J Res Pharm Sci. 2013;3:141–8.
51. Ohyama M. Hair follicle bulge: a fascinating reservoir of epithelial stem cells. J Dermatol Sci.
2007;46:81–9.
52. Pahwa M, Pahwa P, Zaheer A. “Tram track effect” after treatment of acne scars using a
microneedling device. Dermatol Surg. 2012;38(7 pt1):1107–8.
53. Paudel KS, Milewski M, Swadley CL, et al. Challenges and opportunities in dermal/transdermal delivery. Ther Deliv. 2011;1(1):109–31.
54. Prausnitz MR. Microneedles for transdermal drug delivery. Adv Drug Deliv. 2004;56(5):581–7.
55. Schuetz YB, Naik A, Guy RH, et al. Emerging strategies for the transdermal delivery of peptide and protein drugs. Expert Opin Drug Deliv. 2005;2(3):533–48.
56. Sivamani R, Liepmann D, Maibach HI. Microneedles and transdermal applications. Expert
Opin Drug Deliv. 2007;4:19–25.
57. Soltani-Arabshahi R, Wong JW, Duffy KL, et al. Facial allergic granulomatous reaction and
systemic hypersensitivity associated with microneedle therapy for skin rejuvenation. JAMA
Dermatol. 2014;150(1):68–72.
58. Sullivan SP, Koutsonanos DG, Del Pilar MM, et al. Dissolving polymer microneedle patches
for influenza vaccination. Nat Med. 2010;16:915–20.
Chapter 19
PCI Associated with Fillers and Botulinum
Toxin
19.1
Rational Addition of Techniques
There is a tendency, supported by literature and medical experience, for the association of techniques seeking the optimization of results. The use of needles and
microneedles in procedures seeks the remodeling of collagen degraded by aging or
scarring after the inflammatory process. This transformation of collagen has been
able to correct wrinkles, furrows, flaccidity, and scars. The reflection proposed in
this chapter is to improve the quality of the affected tissue, before planning the
application of an asset with volumerizing potential or even with the potential to
relax the adjacent musculature. Percutaneous needle collagen induction PCI remodels the epidermis and dermis, without deepithelializing them, with a short recovery
period. Similarly, they act on dermal tunneling DT by releasing static creases and
multi-needle radiofrequency (MNR – see Chap. 28), by replacing damaged skin
with one closer to the physiological. The rationale is to treat this skin envelope that
covers the bone structure, muscles, ligaments, and fat compartments on the face
before applying fillers or botulinum toxin. The muscle activity on the skin deepens
depressions, the laxity of structures compromises the support, and the redistribution
of fat adds more weight to the excess skin, whether in aging or in the process of
consuming an inflammatory acne. Below are some conclusions of the author based
on his 10 years of experience with needles.
19.2
Association Protocols
1. When treating static wrinkles, such as those of the forehead or glabella with
TD®, one should wait for the reduction of the edema and the absorption, even if
partial, of the hematoma, typical of the intervention, before applying the
The Editor(s) (if applicable) and The Author(s), under exclusive license
to Springer Nature Switzerland AG 2021
E. Lima, M. Lima, Percutaneous Collagen Induction With Microneedling,
https://doi.org/10.1007/978-3-030-57541-0_19
197
198
19 PCI Associate to Fillings and Botulin Toxin
b­ otulinum toxin. It is suggested to wait 15 days after the procedure; however,
many times, it is intended to accommodate the crease filled by the hematoma
earlier, preventing the muscle from acting again in that region. In the author’s
experience, 7 days after the DT, most patients are already ready for the application. Figure 19.1 shows a patient 7 days after DT for correction of static wrinkles
on the forehead, a candidate for the application of botulinum toxin, even with a
modest hematoma in regression. Figure 19.2 shows the same patient at another
angle after 30 days, still without the application of botulinum toxin, maintaining
the results of abruption, even with activity of the frontal muscles and corrugators
very intense. It is worth reinforcing the need to relax this musculature to ensure
the maintenance of results. Figure 19.3 shows the forehead of a patient after the
association of DT with botulinum toxin. In cases where patients have already
undergone the application, and there are still static wrinkles, DT can be performed 15 days after the intervention. In these cases, the reabsorption of the
hematoma and edema may occur in a slower way, since the musculature will not
Fig. 19.1 Patient 7 days after DT for correction of static wrinkles on the forehead, candidate for
application of botulinum toxin, even with modest hematoma in regression
Fig. 19.2 Patient at
another angle, now after
30 days, still without the
application of botulinum
toxin, maintaining the
results of abruption, even
with very intense activity
of the frontal muscles and
corrugators
19.2
Association Protocols
199
Fig. 19.3 Patient after association of DT with botulinum toxin
Fig. 19.4 Cervical region after two treatment sessions with the association of MNR and PCI with
substantial improvement of flaccidity and use of microneedles only after 4 months
be in full activity to assist in its drainage. However, it is not considered
contraindication.
2. The application of botulinum toxin may also be useful in neck and neck treatment after PCI or even when associated with radiofrequency. In such cases, it
follows the same guidelines and can usually be performed 7 days after the intervention. If there is still remnant of edema, bruising, or crusts (deep injury), it is
recommended to wait 15 days. If it has already been applied, it does not compromise the performance of interventions with microneedles in the following days.
Figure 19.4 shows the cervical region after two treatment sessions with the association of MNR and PCI with substantial improvement of flaccidity, after
4 months. In these cases, we can suggest the association of calcium hydroxyapatite and/or botulinum toxin to optimize the rejuvenation of the area. Another
option is the use of hyaluronic acid to improve contours and support, but first we
perform a significant epidermal and dermal stimulus with PCI and MNR.
3. The use of hyaluronic acid may occur before or after the needle procedure. The
author recommends its use later. There are still not enough data or literature supporting its use during needle intervention as being more efficient. Commonly,
when interventions with DT, PCI, and MNR are performed, the remodeling of
the collagen has to be expected in order to calculate the amount of filler. However,
200
19 PCI Associate to Fillings and Botulin Toxin
it is possible to use it 15–30 days after the interventions, depending on each case,
considering that the recovery occurs in a short term. It is worth remembering
that, in the case of scars, fibrotic bars may compromise the uniformity of the
filler applied, and it is recommended to release these bars before applying the
product, as already mentioned.
4. When the patient presents a dermal consumption after severe acne or aging that
results in substantial thinning of the skin, the use of collagen biostimulators may
be an option before performing DT. In this case, it is proposed to wait at least
45 days, seeking a collagenic stimulus. With thicker skin, DT is performed more
safely. The skin can also be prepared with a collagen biostimulator, such as calcium hydroxyapatite or polylactic acid, before the PCI. When this methodological sequence is chosen, it is recommended to wait at least 60 days to obtain a
good stimulus. For the MNR or association of the three techniques, the same
rationale follows. In Fig. 19.5, a patient with acne scars and flaccidity examined
in a static and dynamic way is observed. Observe the laxity of tissue in the genial
region by lipodystrophy. Figure 19.6 depicts the application of calcium hydroxyapatite in this patient, and Fig. 19.7 shows its application before and after 60 days
of calcium hydroxyapatite use. In Fig. 19.8, it can be evaluated after the PCI
performed 2 months after the biostimulator. In this case, it is possible to see the
benefit of the association of techniques when comparing the photos before the
interventions and after the treatments.
5. The periorbital region can also benefit from the combination of techniques.
MNR was initially chosen, following the author’s protocol, detailed in previous
chapters. Figure 19.9 shows the improvement in skin thickness of the lower eyelid, as well as in color and brightness. When a filler is positioned for the treatment of a nasolacrimal groove and the skin is very thin and flaccid, there is a
Fig. 19.5 Patient with acne scars and flaccidity examined in a static and dynamic way
19.2
Association Protocols
201
Fig. 19.6 Patient
undergoing calcium
hydroxyapatite application
Fig. 19.7 Before and after 60 days of collagen biostimulation using calcium hydroxyapatite
substantial chance that the expected cosmetic result will not be achieved, and
there is still morning edema as a complication. The skin was not prepared to
receive the filler. The skin thickness of the eyelid is the thinnest in the human
body and therefore thinner when compared to the adjacency of the genial region.
Similarly, botulinum toxin performance in the periorbital region of very thin skin
may appear to be “cracked” as observed in Fig. 19.10. The authors recommend
improving the quality of the eyelid skin before use of botulinum toxin treating
the orbicular muscle of the eyes, as well as the application of the nasojugal filler.
202
19 PCI Associate to Fillings and Botulin Toxin
Fig. 19.8 Patient after PCI performed 2 months after collagen biostimulator
Fig. 19.9 Improved skin thickness of the lower eyelid, as well as color and brightness
Fig. 19.10 Use of
botulinum toxin in the
periorbital region on very
thin skin, with a “crackled”
appearance and
modest excess
19.2
Association Protocols
203
Fig. 19.11 Patient treated exclusively with MNR, with improvement of wrinkles, flaccidity, drip
and herniated pouch, which would be ready for fillers and toxin application
Figure 19.11 presents a patient treated exclusively by MNR with improvement
of wrinkles, flaccidity, leak, and herniated pouch, who would be ready for the
application of filler and toxin.
6. The treatment of nasogenic grooves with DT, surfacing them and preparing the
region for the use of filler, is another indication with good applicability of these
associations. Both in the use of the filler inside the furrow, the distance at malar
support points, and redoing contours of the mandible, hyaluronic acid and calcium hydroxyapatite are recommended, according to the authors’ protocol,
15–30 days after the detachment intervention. This wait is important because, in
some situations, DT can be repeated before the product is applied. The application of the product immediately after peeling has already been evaluated by the
authors, who considers the intervention more appropriate and safe at different
times. Figure 19.12 shows a patient treated with needles to surface grooves and
wrinkles rigid perioral by the thickness of the skin and is now a candidate for the
use of a filler or collagen biostimulator. In Fig. 19.13 there is another example of
microneedle treatment before fillers, showing the before and after 45 days of
MNR. Figure 19.14 shows a patient treated with DT for a very deep nasolabial
fold, who later received 1.5 ml of hyaluronic acid divided to both sides, with
good results. This example demonstrates another advantage of the technique,
product savings, following the author’s methodological sequence.
204
19 PCI Associate to Fillings and Botulin Toxin
Fig. 19.12 Patient treated by needles to surface superficial grooves and wrinkles rigid perioral by
the thickness of the skin
Fig. 19.13 Example of microneedle treatment before dermal filler, showing the before and after
45 days of MNR
Fig. 19.14 Patient treated with DT for very deep nasolabial fold, who subsequently received
1.5 mL of hyaluronic acid divided to both sides, with good result
Sources
205
Sources
1. Aust MC. Percutaneous collagen induction therapy: an alternative treatment for scars, wrinkles, and skin laxity. Plast Reconstr Surg. 2008;121(4):1421–9.
2. Bal SM, Caussian J, Pavel S, Bouwstra JA. In vivo assessment of safety of microneedle arrays
in human skin. Eur J Pharm Sci. 2008;35(3):193–202.
3. Brody HJ. Trichloroacetic acid application in chemical peeling, operative techniques. Plast
Reconstr Surg. 1995;2(2):127–8.
4. Camirand A, Doucet J. Needle dermabrasion. Aesthet Plast Surg. 1997;21(1):48–51.
5. Cohen KI, Diegelmann RF, Lindbland WJ. Wound healing: biochemical and clinical aspects.
Philadelphia: W.B. Saunders Co; 1992.
6. Fabroccini G, Fardella N. Acne scar treatment using skin needling. Clin Exp Dermatol.
2009;34(8):874–9.
7. Fernandes D. Minimally invasive percutaneous collagen induction. Oral Maxillofac Surg Clin
North Am. 2006;17(1):51–63.
8. Fernandes D, Massimo S. Combating photoaging with percutaneous collagen induction. Clin
Dermatol. 2008;26(2):192–9.
9. Lima EA. Microagulhamento em melasma facial recalcitrante: uma série de 22 casos. An Bras
Dermatol. 2015;90(6):917–9.
10. Lima EA, Lima M, Takano D. Microneedling experimental study and classification of the
resulting injury. Surg Cosmet Dermatol. 2013;5:110–4.
11. Lima EA. Microneedling in facial recalcitrant melasma: report of a series of 22 cases. An Bras
Dermatol. 2015;90(6):919–21.
12. Lima EVA, Lima MMDA, Paixão MP, et al. Assessment of the effects of skin microneedling
as adjuvant therapy for facial melasma: a pilot study. BMC Dermatol. 2017;17:14.
13. Lima EVA. Dermal tunneling: a proposed treatment for depressed scars. An Bras Dermatol.
2016;91(5):697–9.
14. Lima EVA. Indução percutânea de colágeno com agulhas em cicatrizes após acidentes automobilísticos: correção cosmética e funcional. Surg Cosmet Dermatol. 2017;9(2):127–9.
15. Lima EVA. Dermal tunneling (TD®): a therapeutic option for static glabellar wrinkles. Surg
Cosmet Dermatol. 2016;8(1):42–5.
16. Lima EVA. Pulsed radiofrequency with multineedles (RFPM®) in the treatment of atrophic
stretch marks. Surg Cosmet Dermatol. 2016;8(3):242–5.
17. Lima EVA, et al. Induction of pigmentation through microneedling in stable localized vitiligo
patients. Dermatol Surg. 2020;46(13):434–5.
18. Lima EA, Lima MA, Araújo CEC, Nakasawa YMM, Leal NC. Investigation on the use of 3%
and 5% retinoic acid in peeling solution as a drug delivery agent after percutaneous induction of collagen with needles (IPCA®): safety profile and application protocol. Surg Cosmet
Dermatol. 2018;10(1):21–6.
19. Lima EAV. Pulsed radiofrequency with multineedles: a therapeutic proposal for wrinkles, sagging, and periorbital pigmentation. Surg Cosmet Dermatol. 2015;7(3):223–6.
20. Lima EVA. Association of microneedling with phenol peeling: a new therapeutic approach for
sagging, wrinkles and acne scars on the face. Surg Cosmet Dermatol. 2015;7(4):328–31.
21. Lima EVA. Pulsed radiofrequency with multineedles for earlobe aging treatment. Surg Cosmet
Dermatol. 2016;8(4):307–10.
22. Lima EVA. Indução percutânea de colágeno com agulhas (IPCA®) associada a radiofrequência pulsada com multiagulhas (RFPM®) na condução de cicatrizes de acne deprimidas: protocolo de tratamento. Surg Cosmet Dermatol. 2017;9(3):234–6.
23. Orentreich DS, Orentreich N. Subcutaneous incisionless (subcision) surgery for the correction
of depressed scars and wrinkles. Dermatol Surg. 1995;21(6):543–9.
Chapter 20
PCI in the Treatment of Alopecias
Percutaneous collagen induction therapy is a technique used by dermatologists to
treat multiple conditions such as scars, wrinkles, stretch marks, acne, and melasma.
The technique was introduced in the medical literature in 1997 when a tattoo
machine without pigment was used to treat facial scars. In this chapter, we will refer
to the technique by the name of percutaneous induction of collagen (PCI) with
needles.
PCI performs thousands of controlled microperforations in the papillary and
reticular dermis. The objective is to execute a mechanical stimulation of the dermis
with minimal damage to the epidermis, thus promoting the formation of collagen
and increasing angiogenesis. Dermal vasodilatation and migration of keratinocytes
occur immediately, resulting in the release of cytokines such as interleukin-1, interleukin-­8, interleukin-6, TNF-α, and GM-CSF. This mechanism of action expands
the range of indications of the technique for the treatment of the various conditions cited.
Besides the primary benefit of stimulating angiogenesis, migration of growth
factors, and collagen production, PCI is also used as a means of increasing the permeation of topical substances across the skin.
The application of microneedles allows the creation of an accessible means of
transport of macromolecules and other hydrophilic substances through the skin,
which has in the stratum corneum its main barrier. The goal is to generate multiple
micropunctures, long enough to reach the dermis and trigger an inflammatory stimulus. This technique promotes the rupture of the stratum corneum from the width of
two to four cells, an effect proven microscopically by the visualization of the channels. Consequently, there is an increase in the permeation of hydrophilic molecules
and macromolecules of the formulations applied after the perforations.
Microchannels facilitate drug delivery efficiently and can increase absorption of
larger molecules by up to 80% (Fig. 20.1).
The Editor(s) (if applicable) and The Author(s), under exclusive license
to Springer Nature Switzerland AG 2021
E. Lima, M. Lima, Percutaneous Collagen Induction With Microneedling,
https://doi.org/10.1007/978-3-030-57541-0_20
207
208
20
Needle
puncture
Petechiae
formation
Release
of platelets
and RBC
Release of
growth factors
TGF-a, b,
PDGF, FGF, VEEGF
PCI in the Treatment of Alopecias
Inflammatory
cell invasion
Chemotaxis - minutes to days
Fig. 20.1 Micropuncture and growth factor release. TGF transforming growth factor, PDGF
platelet-derived growth factor, FGF fibroblast growth factor, VEGF vascular endothelial
growth factor
Several studies have demonstrated the importance of PCI in cell stimulation and
growth factor production, showing an increased expression of genes related to hair
growth stimulation.
20.1
PCI in the Treatment of Androgenetic Alopecia
Androgenetic alopecia is a genetically determined disorder characterized by the
gradual conversion of terminal hair into fine hair (velus). Although it is recognized
by some authors as a natural process, without any detriment to physical health,
changes in hair growth frequently promote deleterious effects on the quality of life
of affected patients. The prevalence varies from 80% of men aged 70 years and up
to 75% of women over 65 years.
There are still many doubts about the etiology of the condition and many differences in the causes and clinical manifestations in men and women. While in male
patients incontestable evidence points to the fundamental role of androgenic hormones, in women, the features are more heterogeneous, with only a minority presenting phenotypes compatible with their opposite sex counterpart. The response of
female patients to antiandrogen treatments or 5-alpha reductase inhibitors also does
20.1
PCI in the Treatment of Androgenetic Alopecia
209
not support the theory of an androgen-related process, the term “female pattern hair
loss (FPHL)” being more widely used in the literature.
The deleterious effects of androgenetic alopecia are predominantly of a psychosocial nature, which does not make the search for its treatment any less important.
Studies in selected groups indicate that patients with the condition who seek medical advice are dissatisfied and some present personality disorders with anxiety
regarding their self-esteem, increased stress levels, and reduced overall satisfaction
with body image.
Although the pathogenesis of male androgenic alopecia and female pattern alopecia involve changes in androgenic hormone metabolism, genetic background
inflammation, and signaling pathways, conventional therapies target androgens primarily, and 40% of male patients become bald despite treatment.
Standard treatment for androgenetic alopecia is based on the use of topical minoxidil and 5-alpha reductase inhibitors. However, recently the literature has pointed
out the efficacy of the percutaneous use of microneedles in the treatment of alopecia, especially androgenetic alopecia.
Studies indicate that PCI can be used alone or in association with drug delivery
in the treatment of alopecia. In a recent review study, Angela Wipf et al. [46] cited
two randomized studies in which the authors observed greater efficacy of the use of
microneedles in the treatment of androgenetic alopecia when compared to the isolated use of 5% minoxidil. In the first study, the authors compared a group treated
with microneedles associated with home use of minoxidil 5% versus isolated use of
minoxidil 5%, observing superior response of the first group. In the second study,
Bao et al. [48] evaluated 60 male patients with androgenetic alopecia divided into
three groups. The first group was treated with microneedles only, the second with
minoxidil 5% solution only, and the third with microneedles associated with home
use of minoxidil 5%. Positive response was achieved in all three groups, with superior results in the group that received association of treatments. This same review
cites publications on the treatment of alopecia areata with PCI, generally associated
with drug delivery (triamcinolone), with positive outcomes in some case reports.
In a more recent study, Kumar et al. [49] evaluated 68 men with androgenetic
alopecia divided into two groups and observed after 12 weeks better response to
treatment in the group that used minoxidil 5% solution associated with PCI sessions
using 1.5 mm needles (total of 08 sessions), when compared to the group that used
only minoxidil 5% solution BID.
The mechanisms proposed for the growth of new hair shafts using the PCI technique are the release of platelet-derived growth factors (PDGF), elevation of growth
factor levels as epidermal growth factors (EGF), activation of regeneration mechanisms, activation of stem cells in the bulge area of the dermal papilla, overexpression of genes related to hair growth, vascular endothelial growth factors, β-catenin,
and increased expression of Wnt proteins, especially Wnt3a and Wnt10b.
Figures 20.2, 20.3, 20.4, and 20.5 present patients treated by PCI.
210
20
PCI in the Treatment of Alopecias
Fig. 20.2 Androgenetic alopecia male, treated by PCI (four sessions)
Fig. 20.3 Androgenetic alopecia female, treated by PCI (four sessions)
20.2
IPCA with Drug Delivery in the Treatment of Alopecia
One of the objectives of the skin as the largest organ in the human body is to exercise its function as a protective barrier against infectious agents, chemical substances, and water loss. It can be considered as a safe and effective way to apply
various medications. The active ingredients are placed on the surface of the skin and
can penetrate through the epidermis or via the skin annexes.
20.2
IPCA with Drug Delivery in the Treatment of Alopecia
211
Fig. 20.4 Androgenetic alopecia female, treated by PCI (four sessions)
Fig. 20.5 Androgenetic alopecia female, treated by PCI (four sessions)
As the skin represents an efficient barrier to the penetration of molecules, especially hydrophilic and high-molecular-weight particles, several chemical and physical methods have been developed to modify the barrier properties of the stratum
corneum and increase its permeability.
212
20
PCI in the Treatment of Alopecias
Aiming to increase skin permeability and optimize the penetration of the substances, several techniques have been used such as ultrasound, iontophoresis, electroporation, microdermabrasion, thermal ablation by lasers, and microneedling. The
use of microneedles and lasers has been further studied as adjunct therapy in alopecia treatments, either alone or with the addition of topical substances.
Physical methods to increase skin permeability include those that destroy the
stratum corneum barrier and those that act by external force pressing the active
ingredients in the skin. These techniques provide an increase in the number of active
ingredients that can be efficiently transported. In procedures with microneedle
devices, conduits are produced in the skin, allowing substances (from small hydrophilic molecules to macromolecules) to penetrate.
Studies point to the penetration of the drug being related to the length of the
needle and the formulation of the active ingredients. There seems to be greater penetration with needles between 0.5 and 1 mm length. In addition, the time that the
channels remain open should be considered as one of the factors that interfere with
the absorption of the substances. There are indications that optimal penetration
occurs within the first 30 minutes of application of the drugs, although the final
closure of channels can take 72 hours, according to studies of electrical potential
among keratinocytes (Fig. 20.6).
The medications should be chosen according to the pathology to be treated. The
efficacy of PCI in combination with the use of triamcinolone as a drug delivery to
stimulate hair growth, especially in the treatment of alopecia areata, has been demonstrated (Fig. 20.7).
Although some studies cite the association of the use of microneedles and substances with growth factors, vitamins, minoxidil, and photosensitizing agents such
as aminolevulinic acid for the treatment of alopecia, it must be considered that there
is, with the exception of triamcinolone, no data of safety and efficacy studies and
little is known about the pharmacodynamics and pharmacokinetics of such drugs
when applied by this route. Numerous studies suggest that the association between
PCI and platelet-rich plasma (PRP) also appears promising for the treatment of both
androgenic alopecia and alopecia areata. Figure 20.8 presents an alopecia areata
patient treated by four sessions PCI.
20.3
Contraindications and Adverse Effects
PCI is a minimally invasive procedure in which the microperforations caused by
needles reach the dermis without causing epidermal damage. Thus, the risk of
adverse effects and the number of contraindications are relatively low.
Pregnancy, lactation, infectious and inflammatory conditions at the treatment
site, use of anticoagulants, autoimmune diseases, and diseases associated with the
Koebner phenomenon should be considered as factors to contraindicate the technique. The presence of neoplasms or preneoplastic lesions in the area to be treated
20.3 Contraindications and Adverse Effects
Via glandular sweat
213
Via Follicular
Via intercellular
Via intracellular
Fig. 20.6 Pathways of penetration of active ingredients into the skin (intracellular, sweat gland,
intercellular, and follicular)
Fig. 20.7 Needles create conduits in the skin allowing the penetration of small hydrophilic molecules and even macromolecules
214
20
PCI in the Treatment of Alopecias
Fig. 20.8 Alopecia areata patient treated by four sessions PCI
should also be assessed in advance, as should patients undergoing chemotherapy
and radiotherapy.
Most studies with PCI for the treatment of alopecia report very low rates of
adverse effects. Pain during the procedure, transient erythema, and burning are the
most common symptoms. Tram track-type scars, hypersensitivity reactions, contact
dermatitis, and foreign body granulomas have been rarely reported in the treatment
of other pathologies not associated with alopecia [52, 53].
Special care is needed regarding the use of permeation of substances. It is mandatory to use sterile drugs and molecules to patients whose physical-chemical composition does not predispose to the formation of granulomas.
20.4
Therapeutic Proposal
There are no studies yet that determine the ideal treatment protocol for each type of
alopecia. Thus, the suggestion of treatment is based on the experience of the authors,
associated with a certain consensus of most studies involving PCA and alopecia.
The procedure is commonly performed under topical anesthesia using a liposomal 4% lidocaine cream, applied 40 minutes before the intervention. We use rollers
with 1.5 mm long needles, performing movements back and forth, about ten times
in an average, in three directions, drawing strips that overlap, which results in diffuse erythema and discrete punctuated bleeding. The degree of discomfort during
treatment was tolerable. Figure 20.9 presents a lupus alopecia treated by PCI.
20.5
Conclusion
The use of microneedles has been more studied as an adjuvant therapy in alopecia
treatments, alone or with the addition of drugs. In the authors’ opinion, this therapeutic modality should be used as an adjunct method to already established
Sources
215
Fig. 20.9 Lupus alopecia treated by PCI (four sessions)
treatments, in cases of insufficient or nonexistent response to them. There are reports
of its applicability in androgenetic alopecia, alopecia areata, and lichen planopilaris
(LPP) not responsive to other approaches.
Studies using the technique show that the use of microneedles in the treatment of
androgenetic alopecia is a promising and safe alternative. Further research is needed
to ascertain its effectiveness, optimal length of needles, interval between procedures, and number of interventions needed to obtain the best possible results. Its
possible role as a therapeutic option in other alopecias, namely, alopecia areata and
scarring alopecias, has still to be determined.
Sources
1. Alkilani AZ, McCrudden MTC, et al. Transdermal drug delivery: innovative pharmaceutical developments based on disruption of the barrier properties of the stratum corneum.
Pharmaceutics. 2015;7:438–70.
2. Al-Qallaf B, Das DB. Optimizing microneedle arrays to increase skin permeability for transdermal drug delivery. Ann N Y Acad Sci. 2009;1161:83–94.
3. Arbache S, Roth DMP. Microinfusão de Medicamentos na Pele (MMP®)| Princípios,
Instrumental e Indicações. In: de Andrade Lima E, et al., editors. IPCA | Indução Percutânea
de Colágeno com Agulhas. 1st ed. Rio de Janeiro: Guanabara Koogan; 2016. p. 221–32.
4. Aust MC, Fernandes D, Kolokythas P, Kaplan HM, Vogt PM. Percutaneous collagen induction therapy: An alternative treatment for scars, wrinkles and skin laxity. Plast Reconstr Surg.
2008;21:1421–9.
5. Aust MC, Reimers K, Repenning C, et al. Percutaneous collagen induction: minimally invasive skin rejuvenation without risk of hyperpigmentation- fact or fiction? Plast Reconstr Surg.
2008;122:1553–63.
6. Azagury A, Khoury L, et al. Ultrasound mediated transdermal drug delivery. Adv Drug Deliv
Rev. 2014;72:127–43.
7. Bal SM, Caussian J, Pavel S, Bouwstra JA. In vivo assessment of safety of microneedle arrays
in human skin. Eur J Pharm Sci. 2008;35(3):193–202.
8. Benson HA, Namjoshi S. Proteins and peptides: strategies for delivery to and across the skin.
J Pharm Sci. 2008;97(9):3591–610.
9. Budamakuntla L, Loganathan E, Suresh DH, Shanmugam S, Suryanarayan S, Dongare A,
et al. A randomised, open-label, comparative study of tranexamic acid microinjections
and tranexamic acid with microneedling in patients with melasma. J Cutan Aesthet Surg.
2013;6:139–43.
216
20
PCI in the Treatment of Alopecias
10. Camirand A, Doucet J. Needle dermabrasion. Aesthet Plast Surg. 2007;21(1):48–51.
11. Chandrashekar BS, Sandeep MA, Vani Vasanth JP, Rajashekar ML. Triamcinolone acetonide
mesotherapy in the treatment of recalcitrant patches of alopecia areata – a pilot study. J Clin
Dermatol Ther. 2015;2:1–4.
12. Chandrashekar BS, Yepuri V, Mysore V. Alopecia areata-successful outcome with microneedling and triamcinolone acetonide. J Cutan Aesthet Surg. 2014;7(1):63.
13. Cohen BE, Elbuluk N. Microneedling in skin of color: a review of uses and efficacy. J Am
Acad Dermatol. 2016;74(2):348–55.
14. Contin L. Alopecia androgenética masculina tratada com microagulhamento isolado e associado a minoxidil injetável pela técnica de microinfusão de medicamentos pela pele. Surg
Cosmet Dermatol. 2016;8(2):158–61.
15. Donnelly RF, Singh TR, Garland MJ, Migalska K, Majithiya R, McCrudden CM. Hydrogel-­
forming microneedle arrays for enhanced transdermal drug delivery. Adv Funct Mater.
2012;22(23):4879–90.
16. Fabbrocini G, De Vita V, Fardella N, et al. Skin needling to enhance depigmenting serum
penetration in the treatment of melasma. Plast Surg Int. 2011;2011:158241. https://doi.
org/10.1155/2011/158241.
17. Fernandes D, Signorini M. Combating photoaging with percutaneous collagen induction. Clin
Dermatol. 2008;26(2):192–9.
18. Fertig RM, Gamret AC, Cervantes J, Tosti A. Microneedling for the treatment of hair loss. J
Eur Acad Dermatol Venereol. 2017;32:564–9.
19. Gill HS, Prausnitz MR. Pocketed microneedles for drug delivery to the skin. J Phys Chem
Solids. 2008;69(5–6):1537–41.
20. Gratieri T, Kalia YN, et al. Mathematical models to describe iontophoretic transport in vitro
and in vivo and the effect of current application on the skin barrier. Adv Drug Deliv Rev.
2013;65:315–29.
21. Gupta J, Gill HS, Andrews SN, Prausnitz MR. Kinetics of skin resealing after insertion of
microneedles in human subjects. J Control Release. 2011;154(2):148–55.
22. Harris AG, Naidoo C, Murrell DF. Skin needling as a treatment for acne scarring: an up-to-date
review of the literature. Int J Womens Dermatol. 2015;1(2):77–81.
23. Gill HS, Prausnitz MR. Coated microneedles for transdermal delivery. J Control Release.
2007;117(2):227–37.
24. Jeong K, Lee YJ, Kim JE, Park YM, Kim BJ, Kang H. Repeated microneedle stimulation
induce the enhanced expression of hair growth related genes. Int J Trichol. 2012;4:117.
25. Kalil CLPV, Campos VB, Chaves CRP, Pitassi LHU, Cignachi S. Estudo comparativo, randomizado e duplo-cego do microagulhamento associado ao drug delivery para rejuvenescimento da pele da região anterior do tórax. Surg Cosmet Dermatol. 2015;7(3):211–6.
26. Kalil CLPV, Campos V, Reinehr CPH, Chaves CRP. Drug delivery assistido por lasers: revisão.
Surg Cosmet Dermatol. 2016;8(3):193–204.
27. Khater MH, Khattab FM, Abdelhaleem MR. Treatment of striae distensae with needling therapy versus CO2 fractional laser. J Cosmet Laser Ther. 2016;18(2):75–9.
28. Kim BJ, Lim YY, Kim HM, Lee YW, Won CH, Huh CH, et al. Hair follicle regeneration in
mice after wounding by microneedle roller. Int J Trichol. 2012;4:117.
29. Kim BJ, Lim YY, An JH, Kim MN, Kim BJ. Transdermal drug delivery using disk microneedle
rollers in a hairless rat model. Int J Dermatol. 2012;51:859–63.
30. Lademann J, Knorr F, Richter H, Blume-Peytavi U, Vogt A, Antoniou C, Sterry W, Patzelt
A. Hair follicles—an efficient storage and penetration pathway for topically applied substances. Summary of recent results obtained at the Center of Experimental and Applied
Cutaneous Physiology, Charite –Universitatsmedizin Berlin, Germany. Skin Pharmacol
Physiol. 2008;2:150–5.
31. Lademann J, Richter H, Teichmann A, Otberg N, Blume-Peytavi U, Mak WCJ, Patzelt A,
Richter H, Renneberg R, Lai KK, Rühl E, et al. Triggering of drug release of particles in hair
follicles. J Control Release. 2012;160(3):509–14.
Sources
217
32. Lee HJ, et al. Efficacy of microneedling plus human stem cell conditioned medium for
skin rejuvenation: a randomized, controlled, blinded split-face study. Ann Dermatol.
2014;26(5):584–91.
33. Lima EVA, et al. Microagulhamento: estudo experimental e classificação da injúria provocada.
Surg Cosmet Dermatol. 2013;5(2):110–4.
34. Lima EVA, Lima MA. IPCA em Couro Cabeludo. In: de Andrade Lima E, et al., editors. IPCA
| Indução Percutânea de Colágeno com Agulhas. 1st ed. Rio de Janeiro: Guanabara Koogan;
2016. p. 145–52.
35. Majid I. Microneedling therapy in atrophic facial scars: an objective assessment. J Cutan
Aesthet Surg. 2009;2(1):26.
36. More S, Ghadge T, et al. Microneedle: an advanced technique in transdermal drug delivery
system. Asian J Res Pharm Sci. 2013;3:141–8.
37. Ohyama M. Hair follicle bulge: a fascinating reservoir of epithelial stem cells. J Dermatol Sci.
2007;46:81–9.
38. Pahwa M, Pahwa P, Zaheer A. “Tram track effect” after treatment of acne scars using a
microneedling device. Dermatol Surg. 2012;38(7pt1):1107–8.
39. Paudel KS, Milewski M, Swadley CL, Brogden NK, Ghos P, Stinchcom AL. Challenges and
opportunities in dermal/ transdermal delivery. Ther Deliv. 2011;1(1):109–31.
40. Pitassi L, Romiti AR, Lima EVA. IPCA e Drug Delivery. In: de Andrade Lima E, et al., editors. IPCA | Indução Percutânea de Colágeno com Agulhas. 1st ed. Rio de Janeiro: Guanabara
Koogan; 2016. p. 57–66.
41. Prausnitz MR. Microneedles for transdermal drug delivery. Adv. Drug Deliv. 2004;56(5):581–7.
42. Schuetz YB, Naik A, Guy RH, Kalia YN. Emerging strategies for the transdermal delivery of
peptide and protein drugs. Expert Opin Drug Deliv. 2005;2(3):533–48.
43. Rk S, Liepmann D, et al. Microneedles and transdermal applications. Expert Opin Drug Deliv.
2007;4:19–25.
44. Strazzulla LC, Avila L, Lo Sicco K, Shapiro J. An overview of the biology of platelet-rich
plasma and microneedling as potential treatments for alopecia areata. J Investig Dermatol
Symp Proc. 2018;19:S21–4.
45. Yan G, Arelly N, Farhan N, Lobo S, Li H. Enhancing DNA delivery into the skin with a motorized microneedle device. Eur J Pharm Sci. 2014;52:215–22.
46. Wipf A, Boysen N, Hordinsky MK, Dando EE, Sadick N, Farah RS. The rise of transcutaneous drug delivery for the management of alopecia: a review of existing literature and an eye
towards the future. J Cosmet Laser Ther. 2018:1–8.
47. Dhurat R, Sukesh M, Avhad G, Dandale A, Pal A, Pund P. A randomized evaluator blinded study
of effect of microneedling in androgenetic alopecia: a pilot study. Int J Trichol. 2013;5:6–11.
48. Bao L, Gong L, Guo M, Liu T, Shi A, Zong H, et al. Randomized trial of electrodynamic
microneedle combined with minoxidil 5% topical solution for the treatment of Chinese male
Androgenetic alopecia. J Cosmet Laser Ther. 2017.
49. Kumar MK, Inamandar AC, Palit A. A randomized controlled, single-observer blinded study
to determine the efficacy of topical minoxidil plus microneedling versus minoxidil alone in the
treatment of androgenetic alopecia. J Cutan Aesthet Surg. 2018;11(4):211–6.
50. Badran MM, Kuntsche J, Fahr A. Skin penetration enhancement by a microneedle device
(Dermaroller) in vitro: dependency on needle size and applied formulation. Eur J Pharm Sci.
2009;36(4–5):511–23.
51. Sasaki GH. Micro-needling depth penetration, presence of pigment particles, and fluorescein-­
stained platelets: clinical usage for aesthetic concerns. Aesthet Surg J. 2016;37(1):71–83.
52. Hou A, Cohen B, Haimovic A, Elbuluk N. Microneedling. Dermatol Surg. 2017;43(3):321–39.
53. Cary JH, Li BS, Maibach HI. Dermatotoxicology of microneedles (MNs) in man. Biomed
Microdevices. 2019;21:66.
Chapter 21
PCI in the Treatment of Scleroderma
Scleroderma is a connective tissue disease of unknown etiology, characterized
essentially by progressive fibrosis of the skin. A substantial impact on the quality of
life of affected patients is observed due to the unaesthetic aspect that they easily
identify on their faces. Progressive skin thickening, present in more than 90% of
them, is considered a marker of disease severity.
The disease can present itself in two ways:
• Limited skin scleroderma: restricted to the face, neck, and extensor surfaces
• Diffuse skin scleroderma: with generalized skin involvement and affection of
internal organs
The pathophysiological mechanisms include endothelial lesion, immune deregulation, activation of fibroblasts, and excessive production of the extracellular matrix,
resulting in fibrosis.
Besides skin thickening, telangiectasis, dyschromia, decreased oral opening
(microstomy), and calcinosis are observed. Extremely stigmatizing findings compromise self-esteem, promoting suffering. However, they are often neglected by
specialist doctors. Literature is scarce regarding the therapeutic possibilities of cosmetic correction of these lesions.
The pathognomonic aspect of the face is easily recognizable, with dull, inelastic,
rigid, and dyschromic skin, added to flaccidity and perioral rhytids incompatible
with the chronological age (Fig. 21.1). The treatment with microneedles of conditions such as burn scars, acne scars, perioral and genital wrinkles, and forehead and
glabella creases, with the proposal of a transformation of the cicatricial and elastotic
collagen by collagen closer to the physiological one, makes us believe that patients
with scleroderma can benefit from the technique.
The Editor(s) (if applicable) and The Author(s), under exclusive license
to Springer Nature Switzerland AG 2021
E. Lima, M. Lima, Percutaneous Collagen Induction With Microneedling,
https://doi.org/10.1007/978-3-030-57541-0_21
219
220
21 PCI in the Treatment of Scleroderma
Fig. 21.1 Patient affected
by scleroderma
21.1
Rational Use of PCI
Percutaneous needle induction of collagen (PCI) proposes replacing the damaged
collagen with a new one, without causing reepithelialization. David and Norman
Orentreich were the first to report the use of needles to stimulate collagen production in the treatment of depressed scars and wrinkles, a widespread technique under
the name of Subcision™. Their studies were confirmed by other authors based on
the same precept: rupture and removal of the damaged subepidermal collagen followed by substitution by new collagen and elastin fibers.
With the use of a polyethylene roll jammed by sterile stainless steel needles,
symmetrically aligned in rows composed of an average of 190 units, the PCI aims
the production of multiple micropunctures, long enough to reach the dermis and
trigger the inflammatory stimulus, and the activation of a cascade that results in the
production of collagen. Loss of integrity of the skin barrier promotes the release of
cytokines such as interleukin-11, interleukin-8, interleukin-6, tumor necrosis factor-­
alpha (TNF-α), and stimulant factor of granulocyte and macrophage colonies
(GM-CSF), which provokes dermal vasodilation and migration of keratinocytes to
restore epidermal damage. The thousands of microlesions created by the horizontal,
vertical, and diagonal intercrossing of strips result in building dermal hematic columns, which elicit hemostasis and serous exudation. Three phases of the healing
process, consequently to the trauma with the needles, can be didactically outlined
for better understanding:
• First phase – injury: the release of platelets and neutrophils responsible for providing growth factors, which act on keratinocytes and fibroblasts as transformation growth factors α1 and β3 (TGF-α1 and TGF-β3), platelet-derived growth
factor (PDGF), connective tissue-activating protein III,and connective tissue
growth factor (Fig. 21.2).
• Second phase – healing: neutrophils are replaced by monocytes. Angiogenesis,
epithelialization, and proliferation of fibroblasts occur, followed by the production of type III collagen, elastin, glycosaminoglycans, and proteoglycans. In parallel, the growth factor of the fibroblasts, TGF-α1, and TGF-β3 are secreted by
21.1 Rational Use of PCI
221
Needle
puncture
Petechiae
formation
Release
of platelets
and RBC
Inflammatory
cell invasion
Release of
growth factors
TGF-a, b,
PDGF, FGF, VEEGF
Chemotaxis - minutes to days
After minutes or days
Fig. 21.2 Initial phase of inflammation immediately after microperforation. (Reproduced from
Lima 2016)
Migration of
new components
to surface
Invasion of
fibroblasts,
RBC,
WBC
Collagen, types I and III
Type III – high concentration:
3 to 7 days
Synthesis of elastin,
glycosaminoglycans,
proteoglycans,
collgen type III
Collagen maturation
Collagen type I replaces
collagen type III
Tissue modulation
(untill 2 years)
Fig. 21.3 Phase following stimulation of microneedles. (Reproduced from Lima 2016)
monocytes. Approximately 5 days after the injury, the fibronectin matrix is
formed, allowing the deposit of collagen just below the basal layer of the epidermis (Fig. 21.3).
222
a
21 PCI in the Treatment of Scleroderma
b
Fig. 21.4 Patient before (a) and immediately after PCI – deep injury (b)
• Third phase – maturation: type III collagen, predominant in the initial stage of
the healing process, is slowly replaced by type I more durable collagen. The latter is believed to persist for a period ranging from 5 to 7 years.
Figure 21.4 shows the evolution of a patient immediately after PCI.
An inflammatory response triggered by the destruction of the epidermis causes
the production of parallel oriented thick bundles of collagen, unlike the interlacing
network of collagen found in normal skin. Studies have shown that TGF-COPY3
plays a significant role: TGF-COPY16 and TGF-COPY2 promote the formation of
scar tissue collagen, while TGF-COPY4 promotes wound regeneration and healing
at the expense of collagen closer to physiological. When a parallel is made with the
pathogenesis of scleroderma, it is observed that the GFR-β1 and the TGF-β2 are
considered the main regulatory factors of both physiological fibrogenesis and pathological fibrosis with pleiotropic activities on several cell types. Thus, it was possible to suggest that the action of PCI on this sclerotic collagen, due to the
modification of the inflammatory cascade triggered mostly by TGF-α1 and TGF-α3,
would result in skin that looks closer to the physiological.
Treatment of both patients with only skin involvement and those with systemic
form with skin lesions. A multidisciplinary follow-up with the rheumatologist is
mandatory, to establish optimal control of the disease and guidance as to the medications in use that should not be interrupted to perform the treatment. PCI proposes
to offer cosmetic and functional gain, by improving the flexibility of the skin in
plaque scleroderma that affects the entire face and body area.
21.2 Treatment Protocol
21.2
223
Treatment Protocol
The skin of the patient with scleroderma resists the penetration of microneedles,
which is also seen in post-burn scars. Therefore, it is proposed a deep injury (Injury
Classification – Emerson Lima [14]), using a 2.5-mm-long needle (Figs. 21.5, 21.6,
21.7, and 21.8). The needle will only partially penetrate the skin, and to compensate
and overcome this resistance, the operator can impose excessive force on the instrument, traumatizing nervous branches or vascular structures, without achieving the
expected effect. Therefore, it is recommended that the force vector exerted on the
roller always tangents the horizontal plane on which it is working and is never perpendicular to that surface.
It is recommended to prepare the skin beforehand with lightening formulas and
broad-spectrum sunscreen to reduce the availability of melanin.
Fig. 21.5 Patient
immediately after PCI –
moderate injury
224
21 PCI in the Treatment of Scleroderma
a
b
c
d
Fig. 21.6 (a–f) Patient before and 60 days after three PCI sessions – moderate injury, showing
significant improvement in sclerosis
21.3 Technical Aspects
e
225
f
Fig. 21.6 (continued)
21.3
Technical Aspects
When proposed, the deep injury aims to extract the maximum from the intervention
in a single session. Solid purpura, which can be obtained in flaccid and non-sclerotic
skins, will rarely be reached as an end point. In patients with scleroderma, if the
performance is not precise, i.e., performing rectilinear bands with the roller, which
later intersect vertically, horizontally, and diagonally, it tends to traumatize the skin,
deepithelializing it and favoring the emergence of adverse effects.
The association of PCI with radiofrequency can be used. Multi-needle radiofrequency (MNR) is preferred, using the Lima 8 electrode in the treatment of the perioral region, before performing PCI with a roller. Figure 21.9a–l presents patients
treated with MNR.
As already mentioned, the use of a roller with an average of 192 needles of
2.5 mm in length is recommended. However, in cases where patients are more fragile by the systemic disease, moderate injury is chosen, spacing the sessions
15–30 days. For this, a needle length of 1.5 mm is used. The treatment must be
performed in a procedure room carefully prepared for surgical intervention and by
a trained and qualified professional. It is essential not to underestimate the safety
criteria.
226
21.4
21.4.1
21 PCI in the Treatment of Scleroderma
Step-by-Step
Asepsis and Anesthesia of the Area
Application of 4% liposomal lidocaine, under massage, on non-sanitized skin, with
a pause of 1 hour, followed by antisepsis with chlorhexidine. Infiltration using 2%
lidocaine 1:2 saline solution (SF) 0.9%. If a moderate injury is targeted, topical
anesthesia is sufficient for tolerance during the intervention.
21.4.2
Evolution and Postoperative Care
After the intervention, bleeding is moderate; within 20–30 minutes, a serous exudation is observed. Dressing in sterile gauze and micropore adhesive, without the
addition of any other topical substances. Topical or systemic antibiotic therapy is
a
b
c
d
Fig. 21.7 Patient before (a, c, e) and after IPCA® (b, d, f)
21.4 Step-by-Step
e
227
f
Fig. 21.7 (continued)
not indicated, nor is the use of topical or systemic steroids recommended to contain
the expected effects of the self-limited inflammatory process. In cases of moderate
injury, after 1 hour of the procedure for exudation, and the application of a toned
sunscreen, the patient can be discharged.
In case of deep injury, after 12 hours, the dressing applied should be removed at
home by the patient, moistening it in the shower. The treated area can be sanitized,
following with the application of regenerating cream until the reepithelialization, an
average of 5–7 days, when lightening creams and sunscreen tinted broad-spectrum
can be used.
The edema and hematoma in the following days are substantial. The patient can
return to labor activities around the seventh postoperative day or if the treated area
is covered (neck, chest, back), the next day. The next session can be scheduled for
30–60 days.
21.4.3
Pain and Discomfort
Pain and discomfort are not usual complaints, but if they occur, alert for secondary
infection, especially if installed after 48 hours of intervention. Usually, there is no
need for analgesic or anti-inflammatory in the postoperative period. Still, if there is
a complaint of discomfort, dipyrone 1 g is recommended every 6 hours without any
other aggravating factor.
228
21 PCI in the Treatment of Scleroderma
Fig. 21.8 Patient
immediately after PCI
21.5
Dermal Tunneling Indication
Dermal tunneling (DT), a variant of Subcision™, is an authorial technique with one
specific instrument: the 1.20 × 25 mm 18 G × 1″ suction needle. He performed this
method of treatment in 18 patients with depressed scars and cystic post-acne lipodystrophy, obtaining good results.
To perform this technique, the area to be treated is marked (Fig. 21.10). The
design used to guide the intervention will depend on the lesion to be treated. In the
presence of a depressed lesion, a trace is made around the area of atrophy.
Antisepsis with 2% chlorhexidine and anesthesia with 2% lidocaine without
vasoconstrictor follows. With the suction needle already mentioned, the lesion is
approached at the height of the superficial dermis, making a canalicular path, with
consequent rupture of the fibrotic beams, creating narrow tunnels inside the altered
dermis. The movements performed by the needle are shuttle. The next tunnel is
formed following the same precept, immediately adjacent to the previous one; for
this, the introduction of the needle occurs in the same orifice, which results in the
creation of several horizontal hematic columns arranged in parallel. The same procedure is performed from the other vertices, from an imaginary diamond, so that the
columns intersect until the whole area is detached, with the formation of a hematoma (Fig. 21.11).
21.5 Dermal Tunneling Indication
229
The holes that made it possible to introduce the suction needle present substantial bleeding, by the caliber of the instrument, but this is a limited condition. Usually,
compression with sterile cotton facilitates hemostasis, which is established in a few
minutes. There is no need to suture the holes, and the healing happens by second
intention since it is a solution of continuity of less than 1 mm. It is recommended to
occlude the region treated with gauze and micropore adhesive tape. Topical or systemic antibiotic therapy is not indicated. Cryotherapy or hot compresses are not
advisable. It is preferred that the accommodation of the hematoma and the resulting
inflammatory response follow its natural course. Figure 21.12 presents the patient
60 days after the intervention.
a
b
c
d
e
f
Fig. 21.9 (a–l) presents patients treated with MNR
230
21 PCI in the Treatment of Scleroderma
g
h
i
j
k
l
Fig. 21.9 (continued)
231
21.5 Dermal Tunneling Indication
a
b
Fig. 21.10 (a, b) Marking before DT
a
Fig. 21.11 (a, b) Hematoma formation
b
232
21 PCI in the Treatment of Scleroderma
a
b
c
d
Fig. 21.12 Patient before (a, c) and 60 days after DT (b, d)
Sources
233
Sources
1. Abraham DJ, Krieg T, Distler J, et al. Overview of pathogenesis of systemic sclerosis.
Rheumatology (Oxford). 2009;48(Suppl. 3):iii3–7.
2. Aust MC. Percutaneuos collagen induction therapy (PCI) – an alternative treatment for scars.
Wrinkles skin laxity. Plast Reconstr Surg. 2008;121(4):1421–9.
3. Bal SM, Caussian J, Pavel S, et al. In vivo assessment of safety of microneedle arrays in human
skin. Eur J Pharm Sci. 2008;35(3):193–202.
4. Baraut J, Michel L, Verrecchia F, et al. Relationship between cytokine profiles and clinical
outcomes in patients with systemic sclerosis. Autoimmun Rev. 2010;10(2):65–73.
5. Brody HJ. Trichloroacetic acid application in chemical peeling, operative techniques. Plast
Reconstr Surg. 1995;2(2):127–8.
6. Camirand A, Doucet J. Needle dermabrasion. Aesthet Plast Surg. 1997;21(1):48–51.
7. Carvalho MV, Nascimento GJF, Andrade E, et al. Association of aesthetic and orthodontic
treatment in parry romberg syndrome. J Craniofac Surg. 2010;21:436–9.
8. Cohen KI, Diegelmann RF, Lindbland WJ. Wound healing: biochemical and clinical aspects.
Philadelphia: W.B. Saunders Co; 1992.
9. Dantas A. Avaliação do perfil de citocinas e quimiocinas em pacientes com esclerose sistêmica:
correlação com manifestações clínicas e com resposta ao tratamento. [Tese de Doutorado]
Programa de Pós-Graduação em Inovação Terapêutica da UFPE; 2016.
10. Deshingkar SA, Barpande SR, Bhavthankar JD, et al. Progressive hemifacial atrophy (Parry-­
Romberg syndrome). Contemp Clin Dent. 2012;3(1):78–81.
11. Fabroccini G, Fardella N. Acne scar treatment using skin needling. Clin Exp Dermatol.
2009;34(8):874–9.
12. Fernandes D, Massimo S. Combating photoaging with percutaneous collagen induction. Clin
Dermatol. 2008;26(2):192–9.
13. Fernandes D. Minimally invasive percutaneous collagen induction. Oral Maxillofac Surg Clin
North Am. 2006;17(1):51–63.
14. Lima E, Lima M, Takano D. Microneedling experimental study and classification of the resulting injury. Surg Cosmet Dermatol. 2013;5:110–4.
15. Lima EA. Dermal tunneling: a proposed treatment for depressed scars. An Bras Dermatol.
2016;91(5):697–9.
16. Lima EA. IPCA® – Indução percutânea de colágeno com agulhas. Rio de Janeiro: Guanabara
Koogan; 2016.
17. Lima EA. Microneedling in facial recalcitrant melasma: report of a series of 22 cases. An Bras
Dermatol. 2015;90(6):919–21.
18. Lima EA. Radiofrequência pulsada com multiagulhas (RFPM®) no tratamento de estrias atróficas. Surg Cosmet Dermatol. 2016;8(3):242–5.
19. Lima EVA, Lima MMDA, Paixão MP, et al. Assessment of the effects of skin microneedling
as adjuvant therapy for facial melasma: a pilot study. BMC Dermatol. 2017;17:14.
20. Lima EVA, et al. Induction of pigmentation through microneedling in stable localized vitiligo
patients. Dermatol Surg. 2020;46(13):434–5.
21. Lima EVA. Indução percutânea de colágeno com agulhas em cicatrizes após acidentes automobilísticos: correção cosmética e funcional. Surg Cosmet Dermatol. 2017;9(2):127–9.
22. Lima EVA. Dermal tunneling (TD®): a therapeutic option for static glabellar wrinkles. Surg
Cosmet Dermatol. 2016;8(1):42–5.
23. Lima EVA. Pulsed radiofrequency with multineedles (RFPM®) in the treatment of atrophic
stretch marks. Surg Cosmet Dermatol. 2016;8(3):242–5.
24. Lima EA, Lima MA, Araújo CEC, Nakasawa YMM, Leal NC. Investigation on the use of 3%
and 5% retinoic acid in peeling solution as a drug delivery agent after percutaneous induction of collagen with needles (IPCA®): safety profile and application protocol. Surg Cosmet
Dermatol. 2018;10(1):21–6.
234
21 PCI in the Treatment of Scleroderma
25. Lima EAV. Pulsed radiofrequency with multineedles: a therapeutic proposal for wrinkles, sagging, and periorbital pigmentation. Surg Cosmet Dermatol. 2015;7(3):223–6.
26. Lima EVA. Association of microneedling with phenol peeling: a new therapeutic approach for
sagging, wrinkles and acne scars on the face. Surg Cosmet Dermatol. 2015;7(4):328–31.
27. Lima EVA. Pulsed radiofrequency with multineedles for earlobe aging treatment. Surg Cosmet
Dermatol. 2016;8(4):307–10.
28. Lima EVA. Indução percutânea de colágeno com agulhas (IPCA®) associada a radiofrequência pulsada com multiagulhas (RFPM®) na condução de cicatrizes de acne deprimidas: protocolo de tratamento. Surg Cosmet Dermatol. 2017;9(3):234–6.
29. Nikpour M, Stevens WM, Herrick AL, et al. Epidemiology of systemic sclerosis. Best Pract
Res Clin Rheumatol. 2010;24(6):857–69.
30. Orentreich DS, Orentreich N. Subcutaneous incisionless (subcision) surgery for the correction
of depressed scars and wrinkles. Dermatol Surg. 1995;21(6):6543.
Chapter 22
PCI in the Hypochromias and Achromias
22.1
Rational Use of PCI in Depigmented Lesions
Unlike abrasive treatments, microneedles offer the advantage of preserving the epidermis. It is known that the removal of this layer of skin either mechanically or
chemically favors the release of cytokines and the migration of inflammatory cells
that culminate in the replacement of damaged tissue by scar tissue. The cytokines
and the growth factors involved in this inflammatory cascade, in our understanding,
are partially known. Much remains to be discovered about the potential of needles.
This limited knowledge becomes even more notorious when one observes the extension of the applicability of the PCI technique over the last 10 years by the author.
The basis of this vast applicability is linked to the safety of a method that transforms
damaged tissue without destroying it. Besides the modification of the affected epidermis and dermis, we also discovered the whitening potential of PCI in the conduction of melasma (see Lima Protocol in Chap. 10, PCI in the Conduction of
Post-Inflammatory Hyperpigmentation) and post-inflammatory hyperpigmentation,
without the addition of any active. In other words, the microneedles themselves can
reduce melanin, regenerate basal membrane, and correct the elastosis of the dermal
papilla when performing moderate injury [21] (see Chap. 6, Histological Changes
induced by PCI). The author’s experience in the treatment of scars and the monitoring of the regeneration potential of the tissue depigmented by microneedles made
him propose the PCI for the uniformity of skin tone. The encouragement to treat
these patients came from the initial challenge in treating patients with scars and
melasma carriers of vitiligo. This group opened a new avenue of investigation for
microneedles. The literature is silent on providing consistent data and studies supported by a broad casuistry on the safety of intervening with microneedles in these
patients. It is known, however, that as in other dermatoses, trauma to vitiligo may
induce injury, even though this trauma is commonly a continuity solution or a process of deepithelialization.
The Editor(s) (if applicable) and The Author(s), under exclusive license
to Springer Nature Switzerland AG 2021
E. Lima, M. Lima, Percutaneous Collagen Induction With Microneedling,
https://doi.org/10.1007/978-3-030-57541-0_22
235
236
22
PCI in the Hypochromias and Achromias
This phenomenon, also called an isomorphic response, was described in 1872 by
Heinrich Koebner, a renowned German dermatologist. Trauma to healthy skin triggers the appearance of lesions of the same type as those found elsewhere in the
body, such as lichen and psoriasis. The author’s observations originated from post-­
sorption findings or animal bites. In PCI, none of the conditions mentioned occur as
long as the technique is performed correctly: no grooves, incisions, or lacerations.
The micropunctures preserve the epidermis, and there is the integrity of keratinocytes adjacent to the injury, which allows a rapid process of skin regeneration.
Patients with melasma and vitiligo were treated and followed for long periods without the vitiligo stain developing in the treated area.
At the same time, patients with post-intervention discolorations also began to
benefit from the technique. Figure 22.1 exemplifies a patient treated for acne scarring with phenol peeling who presented with achromia complication 45 days after
the intervention and was treated with four Lima Protocol sessions.
This result encouraged the initiation of an investigation in patients with stable
vitiligo for more than 1 year who did not respond to systemic, topical corticosteroids or the association of immunomodulators. The same sequence of the Lima
Protocol described for melasma was recommended, establishing four sessions with
an interval of 30 days between them. Figures 22.2, 22.3, 22.4, 22.5, and 22.6 present
two patients who have been benefiting from the protocol, treated alone with PCI. In
an attempt to accelerate the treatment and optimize its results, it is currently recommended the prescription of a medium-powered topical corticosteroid applied during
the day, 24 hours after the intervention, associated with a topical immunomodulator
administered at night. The patients presented here were treated with four sessions of
PCI and maintained the use of the active topical in the interval between sessions. All
of them had more than 1 year of disease, without the topical and systemic treatments
offering any improvement. The authors’ experience so far has been positive.
Skin microneedling was proposed in the transcutaneous delivery of latanoprost
and tacrolimus, with favorable results in localized and stable forms. The
Fig. 22.1 Patient with melasma and vitiligo before (a) and after Lima Protocol treatment (b)
22.1 Rational Use of PCI in Depigmented Lesions
237
Fig. 22.2 Patient before (a) and after four sessions of Lima Protocol (b)
combination of weekly microneedling followed by topical corticosteroid therapy
with NBU-VB phototherapy for 3 months resulted in significantly higher pigmentation compared with the use of phototherapy alone. 3 Similarly, microneedling followed by the application of 5-fluorouracil demonstrated superior results compared
with microneedling followed by the application of tacrolimus. The ability to induce
epidermal changes in the upper dermis and promote the migration of melanocytes
forms the basis for our hypothesis that in the case of vitiligo, microneedling can act
not only as an agent in the promotion of drug delivery but also as a therapeutic
agent. However, thus far, microneedling has been neither reported nor investigated
as an exclusive treatment for vitiligo. Recently, Lima et al. [19] describe the satisfactory results for cutaneous microneedling tests as a clinical treatment in 12
patients with stable localized refractory vitiligo. Each patient had a stable disease
for more than 1 year but had not responded to the previously proposed treatments.
The subjects agreed to undergo four sessions of skin microneedling, according to a
moderate injury regimen (1.5 mm) at 15-day intervals in areas focally affected by
the disease. During the sessions, all participants were treated exclusively with topical tacrolimus 0.1%. There was pigmentation induction in 10 (83%) of the treated
patients. The facial forms demonstrated better responses, while the extremities did
not result in any pigmentation. All 12 patients completed the 4 sessions. There were
no adverse effects associated with the treatment that were considered to be of good
tolerability. Those who observed some pigmentation reported greater satisfaction
with the treatment. The pigmentary response was sustained for 12 months after
treatment. The pathophysiology of vitiligo is complex, involving oxidative damage
in the upper dermis, changes in melanocyte adhesion, loss of autophagy, and fibroblast senescence. Skin microneedling has been studied in relation to different dermatology disorders, as it promotes an increase in the rate of epidermal replication,
fibroblastic proliferation, and the regulation of metalloproteinases in the upper dermis, although its mechanisms of action are not yet fully known. The epidermal and
238
22
PCI in the Hypochromias and Achromias
the upper dermis repair promoted by microneedling can lead to a restructuring of
the microenvironment that favors the development of vitiligo, which thereby our
results. Future research should investigate the possible role of the reverse Koebner
phenomenon in vitiligo pigmentation. The favorable results of this preliminary case
series allude to the need for controlled studies exploring microneedling regimens in
the treatment of vitiligo.
a
b
c
d
e
f
Fig. 22.3 (a–h) Patient with vitiligo before and after four sessions of PCI, moderate injury
22.1 Rational Use of PCI in Depigmented Lesions
g
Fig. 22.3 (continued)
Fig. 22.4 Application of
30 g of anesthetic on
the face
h
239
240
22
PCI in the Hypochromias and Achromias
Fig. 22.5 Patient immediately after the intervention, where end point recommended by the author
is observed
Fig. 22.6 Patient with 4 years of unresponsive vitiligo after four interventions, following the
author’s protocol
22.2
22.2.1
Step-by-Step
Patient Selection
The applicability of PCI on achromic patches is established independently of the
phototype. Even in those higher, subject to post-inflammatory hyperpigmentation
commonly transient, the technique is well indicated. If hypochromia is the result of
22.2 Step-by-Step
241
a trauma, whether by a complication of a procedure or accidental, it is recommended
to start the treatment as early as possible. However, if the patient to be treated has
vitiligo, the author has recommended waiting at least 1 year for the disease to stabilize before proposing the treatment with the microneedles. It is important to emphasize that when facing an autoimmune disease, which even controlled at a given
moment, worsening may occur by several external factors that are independent of
the institution of PCI. Recently, an investigation published by Emerson Lima et al.
showed in the group with vitiligo treated by the Lima Protocol (2019, American
Society for Dermatologic Surgery) a significantly relevant potential to pigment
stains after four sessions. The regions of the face, neck, and chest showed better
results.
22.2.2
Instrumental
We always recommend a good-quality instrument, registered at the local health surveillance agency, with precise perforating potential, and arranged diagonally, which
ensures the uniformity of the horizontal pressure of traumas or grooves. It is preferred to use a roller with about 192 needles of 1.5 mm length. The treatment should
be done in a procedure room carefully prepared for surgical intervention and by a
trained and qualified professional.
It is essential not to trivialize these safety criteria, which consist of the use of
sterile gloves, sterile surgical fields, and an environment that follows strict disinfection standards.
22.2.3
Anesthesia
The growing number of outpatient procedures performed in clinical practice has
demanded from the dermatologist more and more concern about efficient analgesia.
For the excellence of the execution, it is essential to provide comfort to the patient
in interventions such as PCI. In addition to the anesthetic effectiveness, safety
should also be taken into account, considering that these interventions are mainly
performed in the office and not in the hospital.
The ideal topical anesthetic must overcome the skin barrier and act on the nerve
endings, without spreading to the bloodstream. Liposomal lidocaine 4% is approved
for use on the whole skin of adults and children, from 2 years of age on, with the
ability to produce dermal anesthesia by stabilizing neuronal membranes and inhibiting the ionic flows essential to the axonal conduction of painful stimuli. The liposomal encapsulation condition of dermal lidocaine delivery offers as advantages:
• Rapidity of action by optimization of transcutaneous absorption
• Long action time due to slow degradation
• Safety guaranteed by gradual local metabolism
242
22
PCI in the Hypochromias and Achromias
• Low risk of erythema, irritation, and skin hypersensitivity
• Commodity of use by unnecessary occlusion
• Acceleration of the auction start time
The analgesia of 4% liposomal lidocaine is already observed after 7 minutes
(neurometry) after the application. It increases, reaching in 1 hour a condition considered adequate for the intervention. Its anti-allergic potential has been widely evidenced in groups of children who underwent venous puncture and in adults treated
with laser for depilation and rejuvenation. In recent evaluations, liposomal lidocaine
4% also demonstrated superiority of anesthesia and speed of action when compared
to lidocaine 2.5% with prilocaine, as well as tetracaine 4% and betaine tested alone.
It is important to note that tetracaine and prilocaine have 4-aminobenzoic acid
(PABA) as a final metabolite and cannot be used in sensitive patients.
Another interesting documented fact was the maintenance of its analgesic effect,
detected even 15–30 minutes after its removal. Local anesthetic toxicity can be
diagnosed mainly by symptoms such as agitation, slowness, tremor, nausea, vomiting, arrhythmias, and, more rarely, seizures and respiratory depression.
The safety of 4% liposomal lidocaine was evaluated in volunteers after 30 g
(face) and 60 g (abdomen), through cardiac, gastrointestinal, and neurological evaluations, as well as serum dosage (1, 2, 6, and 24 hours), attesting confidence in all
parameters tested, without any sign of toxicity. Even under occlusion (1 hour), the
maximum serum level detected was ten times lower than the toxic dose. The time
spent on the skin should not exceed 3 hours. Clinical studies and package insert
indicate that a thick layer of lidocaine cream should be applied to the intact skin or
around the cut and that peak blood levels after application of 60 g on a 400 cm2 area
for 3 hours are 0.05–0.16 μg/m. In the Lima Protocol, at least 15 g of the product
(not to exceed 30 g) is recommended for intervention in the face area. When the area
to be treated is in the body, up to double the quantity mentioned is indicated (not to
exceed 60 g). It is suggested that half of this quantity is massaged vigorously over
the entire length of the unsanitized (greasy) skin; then, a new thick layer should be
applied and the product allowed to act. After 1 hour, remove the anesthetic with 2%
chlorhexidine and proceed with the treatment. Figure 22.4 presents a patient after
the application of the anesthetic, demonstrating what 30 g of the substance represents on the face.
22.2.4
Transurgery
The instruments are then rolled, forming parallel and adjacent strips of micropunctures, which do not necessarily have to cross each other. A moderate injury (classification Emerson Lima [21]) must be established as an end point, seeking to achieve
uniform erythema across the face, neck, or arms, with thousands of microperforations. The bleeding is very modest, punctual, and limited. Figure 22.5 presents a
patient immediately after the intervention.
22.2 Step-by-Step
243
The Lima Protocol does not recommend the removal of the serum exudate after
the intervention. The patient should remain at rest for an average period of 1 hour,
when the hematic crusts and precipitation of serous exudation are established, giving rise to a biological dressing, which functions as a barrier. After this period, the
toned sunscreen can be applied, and the hygienization of the face can be oriented
after 2 hours with water and soap with low detergency potential, at home.
22.2.5
After Surgery
It is a clean procedure, without indication of topical and systemic antibiotic therapy
and corticosteroids. Cryotherapy or hot compresses are also not recommended. A
regenerating balm, commonly prescribed in the first 24 hours, can be replaced by a
topic corticoid of medium power applied once a day associated with a topic with
immunomodulatory action such as tacrolimus 1–2 times a day, already the following day.
22.2.6
Evolution
Edema and small bruises may appear in the following days, but modestly. The use
of toned sunscreen is sufficient to disguise them. The patient will be able to return
to his or her work activities the next day.
A second session after 30 days is recommended. The number of sessions necessary for the pigmentation of the achromic area depends on each case. Figures 22.6
and 22.7 present the evolution of two patients after four interventions, following the
author’s protocol.
Fig. 22.7 Patient with 2 years of injury after four interventions, following the author’s protocol
244
22.3
22
PCI in the Hypochromias and Achromias
Final Considerations
The relationship between melanocytes and keratinocytes still holds secrets to be
unveiled, probably with strong supporting participation of other cells, such as fibroblasts and mast cells. The observations presented in this chapter may promote new
treatment perspectives and investigative lines for a more accurate understanding of
these dermatoses that result in a substantial impact on the quality of life of many
patients.
Sources
1. Aust MC. Percutaneous collagen induction therapy: an alternative treatment for scars, wrinkles, and skin laxity. Plast Reconstr Surg. 2008;121(4):1421–9.
2. Bal SM, Caussian J, Pavel S, et al. In vivo assessment of safety of microneedle arrays in human
skin. Eur J Pharm Sci. 2008;35(3):193–202.
3. Brody HJ. Trichloroacetic acid application in chemical peeling, operative techniques. Plast
Reconstr Surg. 1995;2(2):127–8.
4. Camirand A, Doucet J. Needle dermabrasion. Aesthet Plast Surg. 1997;21(1):48–51.
5. Clementoni MT, Roscher MB, Munavalli GS. Photodynamic photorejuvenation of the face
with a combination of microneedling, red light, and broadband, and pulsed light. Lasers Surg
Med. 2010;42:150–9.
6. Cohen KI, Diegelmann RF, Lindbland WJ. Wound healing: biochemical and clinical aspects.
Philadelphia: WB Saunders Co; 1992.
7. Costa IMC, Igreja ACS, Costa MC. Dermabrasão, microdermabrasão e microagulhamento. In:
Tratado de cirurgia dermatológica, cosmiatria e laser da Sociedade Brasileira de Dermatologia.
Rio de Janeiro: Elsevier; 2012.
8. Czaja W, Krystynowicz A, Bielecki S, et al. Microbial cellulose – the natural power to heal
wounds. Biomaterials. 2006;27(2):145–51.
9. Czaja WK, Young DJ, Kawecki M, et al. The future prospects of microbial cellulose in biomedical applications. Biomacromolecules. 2007;8(1):1–12.
10. Desmond F, Massimo S. Combating photoaging with percutaneous collagen induction. Clin
Dermatol. 2008;26:192–9.
11. Draelos Z. A comparison of post-procedural wound care treatments: do antibiotic-based ointments improve outcomes? J Am Acad Dermatol. 2011;64:S23–9.
12. Fabroccini G, Fardella N. Acne scar treatment using skin needling. Clin Exp Dermatol.
2009;34(8):874–9.
13. Fernandes D, Massimo S. Combating photoaging with percutaneous collagen induction. Clin
Dermatol. 2008;26(2):192–9.
14. Fernandes D. Minimally invasive percutaneous collagen induction. Oral Maxillofac Surg Clin
North Am. 2006;17(1):51–63.
15. Kalil CLPV, Frainer RH, Dexheimer LS, et al. Tratamento das cicatrizes de acne com a técnica
de microagulhamento e drug delivery. Surg Cosmet Dermatol. 2015;7(2):144–8.
16. Kwak MH, Kim JE, Go J, et al. Bacterial cellulose membrane produced by Acetobacter sp.
A10 for burn wound dressing applications. Carbohydr Polym. 2015;122:387–98.
17. Lima EVA, Lima MMDA, Paixão MP, et al. Assessment of the effects of skin microneedling
as adjuvant therapy for facial melasma: a pilot study. BMC Dermatol. 2017;17:14.
18. Lima EA. Microneedling in facial recalcitrant melasma: report of a series of 22 cases. An Bras
Dermatol. 2015;90(6):919–21.
Sources
245
19. Lima EVA, et al. Induction of pigmentation through microneedling in stable localized vitiligo
patients. Dermatol Surg. 2020;46(13):434–5.
20. Lima EA. Microagulhamento em melasma facial recalcitrante: uma série de 22 casos. An Bras
Dermatol. 2015;90(6):917–9.
21. Lima EA, Lima M, Takano D. Microneedling experimental study and classification of the
resulting injury. Surg Cosmet Dermatol. 2013;5:110–4.
22. Lima EVA. Dermal tunneling: a proposed treatment for depressed scars. An Bras Dermatol.
2016;91(5):697–9.
23. Lima EVA. Indução percutânea de colágeno com agulhas em cicatrizes após acidentes automobilísticos: correção cosmética e funcional. Surg Cosmet Dermatol. 2017;9(2):127–9.
24. Lima EVA. Dermal tunneling (TD®): a therapeutic option for static glabellar wrinkles. Surg
Cosmet Dermatol. 2016;8(1):42–5.
25. Lima EVA. Pulsed radiofrequency with multineedles (RFPM®) in the treatment of atrophic
stretch marks. Surg Cosmet Dermatol. 2016;8(3):242–5.
26. Lima EA, Lima MA, Araújo CEC, Nakasawa YMM, Leal NC. Investigation on the use of 3%
and 5% retinoic acid in peeling solution as a drug delivery agent after percutaneous induction of collagen with needles (IPCA®): safety profile and application protocol. Surg Cosmet
Dermatol. 2018;10(1):21–6.
27. Lima EAV. Pulsed radiofrequency with multineedles: a therapeutic proposal for wrinkles, sagging, and periorbital pigmentation. Surg Cosmet Dermatol. 2015;7(3):223–6.
28. Lima EVA. Association of microneedling with phenol peeling: a new therapeutic approach for
sagging, wrinkles and acne scars on the face. Surg Cosmet Dermatol. 2015;7(4):328–31.
29. Lima EVA. Pulsed radiofrequency with multineedles for earlobe aging treatment. Surg Cosmet
Dermatol. 2016;8(4):307–10.
30. Lima EVA. Indução percutânea de colágeno com agulhas (IPCA®) associada a radiofrequência pulsada com multiagulhas (RFPM®) na condução de cicatrizes de acne deprimidas: protocolo de tratamento. Surg Cosmet Dermatol. 2017;9(3):234–6.
31. Lina F, Yue Z, Chao L, et al. Skin tissue repair materials from bacterial cellulose by a multilayer fermentation method. J Mater Chem. 2012;22:12349–57.
32. Nathan ST. Treatment of minor wounds from dermatologic procedures: a comparison of three
topical wound care ointments using a laser wound model. J Am Acad Dermatol. 2011;64:S8–15.
33. Orentreich DS, Orentreich N. Subcutaneous incisionless (subcision) surgery for the correction
of depressed scars and wrinkles. Dermatol Surg. 1995;21(6):543–9.
Chapter 23
PCI Associated with Intense Pulsed Light
23.1
Why Associate Intense Pulsed Light with PCI?
The accurate knowledge of the delivery potential of each intervention has aroused a
tendency to add procedures for its optimization. Added to this advantage, it is also
considered the less time spent by the patient when organizing for the procedure and
its recovery. It is important to remember that the anesthesia and preparation will
also be concentrated in a single time, validating the safety criteria. The ability of
percutaneous induction of collagen (PCI) with needles to produce whitening and
improvement of skin quality is already well studied. Figure 23.1 presents the end
point recommended for this purpose, a moderate injury. In parallel, intense pulsed
light (IPL) whitens melanoses and also improves the appearance of the skin. The
author then proposed the association of these two techniques for areas such as the
face, neck, and limbs. The first observations already presented, by the dermatological evaluation and perception of the patients, results superior to those of the
Fig. 23.1 (a) Colon of a patient after IPL (540 nm, 15 J/cm2, 15 ms). (b) Colon of the same patient
after performing PCI, with moderate injury
The Editor(s) (if applicable) and The Author(s), under exclusive license
to Springer Nature Switzerland AG 2021
E. Lima, M. Lima, Percutaneous Collagen Induction With Microneedling,
https://doi.org/10.1007/978-3-030-57541-0_23
247
248
23
PCI Associated with Intense Pulsed Light
procedures performed alone. Later, the author identified an advantage in the speed
of recovery of the skin, with elimination of the crusts in a smoother way and uniformity of skin color more quickly, when compared to the isolated use of IPL. In order
to further optimize its results, the author decided to add the well-known retinoic
acid. See the following protocol description. PCI has its effect well demonstrated on
scars. The author considers its introduction in the therapeutic arsenal of these lesions
a water divisor, regardless if they are depressed or elevated scars. The association of
IPL with PCI is chosen when dealing with recent high, neovascularized, or keloid
lesions. It has also been used by the author in cases of rosacea and in patients with
reactive skin who present an erythema beyond what is expected in the first 7 days
after PCI with deep injury.
23.2
Step-by-Step
For the treatment of photodane and scars, the protocol associating IPL with is suggested. Note the methodological sequence for each type of indication:
1. Topical anesthesia with 4% liposomal lidocaine, massaged over unsanitized skin
1 hour before intervention, in a quantity of up to 60 g for arms and hands and up
to 30 g for face and neck (see Lime Protocol in Chap. 10, PCI in Conducting
Post-Inflammatory Hyperpigmentation)
2. Hygiene of the area to be treated with 2% chlorhexidine degermant after 1 hour.
It is preferable to do the asepsis immediately before the PCI, after the IPL
3. LIP administration using the parameters recommended by the machine manufacturer, based on his experience. The principle is to look for wavelength, time
interval, and energy directed to the treatment of melanoses or neovascularization, depending on the indication. Figure 23.1 shows the neck of a patient after
IPL (540 nm, 15 J/cm2, 15 ms), and the performance of PCI in the same patient,
with moderate injury. Figure 23.2 presents a patient before and after 30 days of
this protocol, and Fig. 23.3 shows another patient treated by the same
Fig. 23.2 Colon of a patient before and after 30 days of this protocol
23.2 Step-by-Step
249
Fig. 23.3 Patient treated by the same methodological sequence recommended by the author
Fig. 23.4 Arms and hands treated in the same methodological sequence as the author
­ ethodological sequence recommended by the author. Figure 23.4 presents
m
arms and hands also treated in the same way. For the face, the end point is similar, as shown in Fig. 23.5a. The procedure was closed with a 5% retinoic acid
peel, toned (Fig. 23.5b)
4. The addition of retinoic acid to the procedure should be done immediately after
the PCI (moderate injury). Figure 23.6a shows a patient’s arm immediately after
IPL with PCI, and Fig. 23.6b shows the same area after peeling 5% retinoic acid.
Modest scaling can be observed in the evolution of this patient after 7 days
(Fig. 23.6c). The author’s proposal is to optimize results by performing three
techniques in a single time. This sequence can be performed on the face, neck,
250
23
PCI Associated with Intense Pulsed Light
Fig. 23.5 (a) Face with moderate injury end point. (b) The procedure was terminated with a 5%
retinoic acid peel, toned
Fig. 23.6 (a) Patient’s arm
immediately after IPL
association with PCI. (b)
Same arm after application
of 5% retinoic acid peel.
(c) 7-day evolution of
this patient
a
b
c
arms, and hands, with good results, as shown in Fig. 23.7a–d, in which a patient
is observed before and 30 days after a session
5. If retinoic acid peeling is not an option, serum bloody exudation is expected to
crystallize, and after 30–40 minutes, the physical filter is applied
23.2 Step-by-Step
251
a
b
c
d
Fig. 23.7 Pictures of patients before and 30 days after IPL; PCI and retinoic acid were associated
with the hands, arms, and face
252
23
PCI Associated with Intense Pulsed Light
6. Another alternative, when IPL is not available or there is intense photodane, is to
use 88% phenol, as guided in the protocol detailed in Chap. 25, PCI Associated
with Peelings. If this is the choice, phenol 88% is applied in a scored manner,
followed by PCI (moderate injury) and 5% retinoic acid peeling to finish
7. For treatment of potentially neovascularized scar, start with infiltrative anesthesia, followed by IPL and PCI (deep injury). When the lesions are hypertrophic or
keloid, the infiltration of triamcinolone can be added to the methodological
sequence, before performing PCI.
8. In the postoperative period, we recommend regenerating creams and/or silicone
gels and the introduction of lightening agents soon after reepithelialization, associated with sunscreen and direct sun exposure restriction. As there will be in this
proposal a deepithelialization of the treated area, it is necessary that all care be
taken to avoid complications and offer better results.
23.3
Final Considerations
In the author’s experience, these associations have been safe and offered good
results. The introduction of a technology immediately before IPCA® optimizes the
results in color, texture, and relief, as well as accelerates the delivery of results,
reducing risks of complication and downtime. Caution and attention in pre- and
postoperative should be emphasized, and only specialists who have mastery of the
techniques should perform them. The author has tested several ways to perform this
intervention and considers the previously suggested sequences the safest and most
reproducible.
Sources
1. Bagatin E, Hassun K, Talarico S. Revisão sistemática sobre peelings. Surg Cosmet Dermatol.
2009;1(1):37–46.
2. Bal SM, Caussian J, Pavel S, et al. In vivo assessment of safety of microneedle arrays in human
skin. Eur J Pharm Sci. 2008;35(3):193–202.
3. Fernandes D. Minimally invasive percutaneous collagen induction. Oral Maxillofac Surg Clin
North Am. 2006;17(1):51–63.
4. Fulton JE, Porumb S. Chemical peels – their place within the range of resurfacing techniques.
Am J Clin Dermatol. 2004;5(3):179–87.
5. Kadunc BV, Vanti AA. Avaliação da toxicidade sistêmica do fenol em peelings faciais. Surg
Cosmet Dermatol. 2009;1(1):10–4.
6. Lima EVA, Lima MMDA, Paixão MP, et al. Assessment of the effects of skin microneedling
as adjuvant therapy for facial melasma: a pilot study. BMC Dermatol. 2017;17:14.
7. Lima EA. Microneedling in facial recalcitrant melasma: report of a series of 22 cases. An Bras
Dermatol. 2015;90(6):919–21.
8. Lima EVA, et al. Induction of pigmentation through microneedling in stable localized vitiligo
patients. Dermatol Surg. 2020;46(13):434–5.
Sources
253
9. Lima EA. Microagulhamento em melasma facial recalcitrante: uma série de 22 casos. An Bras
Dermatol. 2015;90(6):917–9.
10. Lima EA, Lima M, Takano D. Microneedling experimental study and classification of the
resulting injury. Surg Cosmet Dermatol. 2013;5:110–4.
11. Lima EVA. Dermal tunneling: a proposed treatment for depressed scars. An Bras Dermatol.
2016;91(5):697–9.
12. Lima EVA. Indução percutânea de colágeno com agulhas em cicatrizes após acidentes automobilísticos: correção cosmética e funcional. Surg Cosmet Dermatol. 2017;9(2):127–9.
13. Lima EVA. Dermal tunneling (TD®): a therapeutic option for static glabellar wrinkles. Surg
Cosmet Dermatol. 2016;8(1):42–5.
14. Lima EVA. Pulsed radiofrequency with multineedles (RFPM®) in the treatment of atrophic
stretch marks. Surg Cosmet Dermatol. 2016;8(3):242–5.
15. Lima EA, Lima MA, Araújo CEC, Nakasawa YMM, Leal NC. Investigation on the use of 3%
and 5% retinoic acid in peeling solution as a drug delivery agent after percutaneous induction of collagen with needles (IPCA®): safety profile and application protocol. Surg Cosmet
Dermatol. 2018;10(1):21–6.
16. Lima EAV. Pulsed radiofrequency with multineedles: a therapeutic proposal for wrinkles, sagging, and periorbital pigmentation. Surg Cosmet Dermatol. 2015;7(3):223–6.
17. Lima EVA. Association of microneedling with phenol peeling: a new therapeutic approach for
sagging, wrinkles and acne scars on the face. Surg Cosmet Dermatol. 2015;7(4):328–31.
18. Lima EVA. Pulsed radiofrequency with multineedles for earlobe aging treatment. Surg Cosmet
Dermatol. 2016;8(4):307–10.
19. Lima EVA. Indução percutânea de colágeno com agulhas (IPCA®) associada a radiofrequência pulsada com multiagulhas (RFPM®) na condução de cicatrizes de acne deprimidas: protocolo de tratamento. Surg Cosmet Dermatol. 2017;9(3):234–6.
20. Lv YG, Liu J, Gao YH, et al. Modeling of transdermal drug delivery with a microneedle array.
J Micromech Microeng. 2006;16(11):151–4.
21. Nelson BR, Fader DJ, Gillard M, et al. Pilot histologic and ultrastructural study of the effects
of medium-depth chemical facial peels on dermal collagen in patients with actinically damaged skin. J Am Acad Dermatol. 1995;32(3):472–8.
22. Vandervoort L, Ludwig A. Microneedles for transdermal drug delivery; minireview. Front
Biosci. 2008;13(5):1711–5.
23. Vasconcelos NB, Figueira GM, Fonseca JCM. Estudo comparativo de hemifaces entre 2 peelings de fenol (fórmulas de Baker Gordon e de Hetter), para a correção de rítides faciais. Surg
Cosmet Dermatol. 2013;5(1):40–4.
Chapter 24
PCI Associated with Peelings
24.1
PCI Fundamentals Associated with Peelings
The beneficial role of peelings in the treatment of wrinkles, flaccidity, spots, and
scars has been widely studied. Evidence of increased collagen fibers types I and III
and restoration of elastic fibers, as well as remodeling of the dermis induced by a
caustic agent, are effects already described by some authors. The use of assets such
as retinoic acid, trichloroacetic acid, and phenol in variable concentrations provides
great benefits in isolation. Phenol has immediate caustic action, with the ability to
promote denaturation and coagulation of epidermal keratin proteins, achieving clinical results incomparable to other ablative techniques, but requires a recovery time
often incompatible with the routine of many patients (Fig. 24.1). Microneedles
promise a shorter recovery time. The goal of generating multiple micropunctures,
which result in inflammatory stimuli and collagen production, has been described as
percutaneous induction of collagen. Initially, there is loss of the integrity of the skin
barrier, targeting keratinocyte dissociation and release of cytokines, which result in
dermal vasodilation and keratinocyte migration to restore epidermal damage.
Fibroblasts and keratinocytes are stimulated, followed by the production of type
III collagen, elastin, glycosaminoglycans, and proteoglycans and the formation of
the fibronectin matrix, which allows the deposit of collagen just below the basal
layer of the epidermis. The literature consulted does not present any report on the
association of these two therapeutic conducts, which alone exhibit similar responses
to the same indications, probably because the use of microneedles is based on the
principle of partial preservation of the epidermis, which results only in perforation
and not in removal of the epidermis, as observed in ablative techniques such as peelings (Fig. 24.2). The author, who has been using this association for 6 years, has
observed that the addition of a medium peel with 35% trichloroacetic acid (TCA) or
88% phenol to the percutaneous induction of collagen with needles (PCI) causes a
faster recovery process, making it possible to return to work activities a little earlier,
The Editor(s) (if applicable) and The Author(s), under exclusive license
to Springer Nature Switzerland AG 2021
E. Lima, M. Lima, Percutaneous Collagen Induction With Microneedling,
https://doi.org/10.1007/978-3-030-57541-0_24
255
256
24
Fenol 88%
Fenol 88%
48 HOURS
72 HOURS
TCA 35%
Fenol 88%
TCA 35%
Fenol 88%
24 HOURS
5 DAYS
PCI Associated with Peelings
TCA 35%
TCA 35%
Fig. 24.1 Evolution of a patient treated with 88% phenol above the line of demarcation and with
35% TCA below the line of demarcation
24.2
257
Prepare for the Procedure
BEFORE
24 H POST-OPERATIVE
7 DAYS POST-OPERATIVE
Fig. 24.2 Evolution of a patient treated with PCI
and has observed a reduced incidence of adverse effects when compared to the isolated use of these caustics. Another practical evidence is the improvement of clinical
results achieved when the association of peeling and PCI is chosen compared to
those obtained with the latter alone.
24.2
Prepare for the Procedure
As we will have in this proposal a deepithelialization of the treated area, it is necessary that all care be taken to avoid complications and offer better results:
• Use of bleaching or depigmentation actives at least 30 days before the intervention: The skin that presents a lower amount of melanin will be less subject to
post-inflammatory hyperpigmentation. The intervention of an area that presents
uniformity of tone will be essential for an equal result in color, texture, and
brightness.
• Use of solar filter: Photoprotection is mandatory in the post-procedure, and prior
adaptation to a broad-spectrum solar filter with color should be a prerequisite for
intervention. The skin will be more sensitive to light and therefore more prone to
erythema and hyperpigmentation. It is important to advise on abstinence from
recreational sun exposure for a minimum period of 45–90 days such as beach,
pool, parks, mountains, soccer fields, and the like.
• Recovery period: Make sure the candidate is available to be absent from public
activities for at least 7–10 days. Indoor activities may occur without inconvenience. The proximity of the treatment to social events that require the patient’s
presence should be avoided. For safety, a minimum period of 3 months before
these appearances is recommended.
• Simple herpes preventive antiviral treatment: It is recommended to start antiviral
48 hours before the procedure and maintain until reepithelialization, an average
of 5–7 days. It is not considered safe to interrupt the antiviral before the integrity
of the keratinocyte is established, as it is a necessary condition for reducing susceptibility to infection. Usual doses are recommended.
258
24
PCI Associated with Peelings
Some substances lend themselves and have good cosmetic results with this
association.
Retinoic acid in concentrations of 3–5%. PCI is recommended immediately
before using topical anesthesia retinoic acid peeling. The use of needle roller or pen
with a length of 1.5 mm is indicated, with the objective of producing a moderate
injury (see Chap. 2, PCI Injury Level Classification and Its Applicability), capable
of permeating the active. The production of an intense bloody dew is not recommended, which would compromise the fixation of retinoic acid on the skin. After
application, the product should remain for 2 hours. If the patient’s history shows
greater reactive sensitivity to the active ingredient, this time can be shortened to
3 hours. A modest peeling will be initiated in the first 72 hours, however, without
compromising the patient’s labor activities. It is recommended to introduce sunscreen the following day and a lightener. Retinoid or derived can be introduced at
night, respecting the tolerance of each individual. The safety offered by the assets
used after the PCI has been discussed in workshops. Concentrations ranging from
3% to 5% have shown good cosmetic results with and without the addition of toning
agents. Research recently conducted by the author (Emerson Lima 2016) evaluated
the sterility of retinoic acid solutions from two handling pharmacies. The agents
were kept under the same conditions of use, concluding that both agents kept under
refrigeration and at room temperature and those used on the day of production and
30 days, 60 days, and 90 days after production showed safety related to the proliferation of bacteria. The author was also able to prove the sterility of these solutions
and their bactericidal power by adding the mentioned peeling solutions to the plates.
Thus, he was able to state in the study that even after partial loss of the skin barrier
with PCI, the addition of retinoic acid at 3% and 5% is safe. Figure 24.3 shows the
a
b
a
b
a
b
c
d
c
d
Fig. 24.3 Bacterial growth at the time of dilution (immediate) in the first and second hour. (a)
Staphylococcus aureus (A: bacterial growth in saline, B: bacterial growth in retinoic acid soon
after seeding, C: bacterial growth in retinoic acid 1 hour after seeding, D: bacterial growth in retinoic acid 2 hours after seeding). (b) Pseudomonas aeruginosa (A: bacterial growth in saline, B:
bacterial growth in retinoic acid soon after seeding, C: bacterial growth in retinoic acid 1 hour after
seeding, D: bacterial growth in retinoic acid 2 hours after seeding)
24.2
Prepare for the Procedure
259
a
b
c
d
Fig. 24.4 (a) Patient immediately after being submitted to moderate injury. (b) Patient after cleaning the skin with saline to demonstrate the even erythema of the area treated. (c) Patient immediately after application of tinted 5% retinoic acid solution. (d) Tinted 5% retinoic acid solution in
sterile container and brush recommended for the procedure
experiment. Figure 24.4 present a patient treated by the author protocol associating
PCI to retinoic acid 5%.
Trichloroacetic acid (TCA) in concentrations of 15–35%. An increase in safety
relative to adverse effects is observed with this association compared to the isolated
use of TCA. This association offers good results and a safety profile in the treatment
of flaccidity, rhytides, and photodanus on the face, as well as in shallow, depressed
scars on the face. It is recommended to apply the caustic before performing PCI; the
opposite can offer unpredictable results. For greater patient comfort, it is necessary
to perform infiltrative anesthesia of the entire area to be treated, associated or not
(depending on the need) with anesthetic blockade. The application of Jessner’s solution with semi-humid gauze before ACT is useful to seek the uniformity of frosting.
A needle length of 1.5–2.5 mm is used (author’s preference) after frosting is established, seeking a lesion from moderate to deep (see Chap. 2, PCI Injury Level
Classification and Its Applicability). The bleeding dew produced should reach a
homogeneous petechial pattern in the treated area, but this aspect is not observed at
the same intensity when compared to the area not treated by peeling. After finishing
the peeling PCI sequence of an area, we reproduce the same sequence in another
area of the face, commonly limiting the association to the genial and forehead
260
24
PCI Associated with Peelings
regions and complementing the treatment of the nasal, perioral, and periorbital dorsum with peeling only. We include dry gauze and Micropore®, maintaining the
dressing for 12 hours. The removal is done in the bath by the patient himself, when
a restorative cream is introduced. It is prudent not to use topical or systemic antibiotics. In addition to the fact that there is no scientific basis, such practice may contribute, as far as is known, to bacterial resistance, as well as probably induce
sensitization both to the active in use as a cross-reaction to similar agents, delaying
recovery. Skin regeneration occurs in 7–10 days and can be established before. The
resulting erythema is moderate and regresses progressively in 30 days on average.
A lightener or depigmentant can be introduced as soon as reepithelialization is
established and the patient tolerates its nocturnal use, always accompanied by a
broad-spectrum sunscreen, preferably with toning agent.
88% phenol. This solution, in this concentration, is capable of producing a
medium peel, and its association with PCI has presented, by the author’s experience, good results and safety profile. A recent study published by the author evaluated 28 patients diagnosed with wrinkles, flaccidity, or acne scars in the genial
regions treated with the association of 88% phenol peeling followed by PCI, following the same protocol: monitoring with recording of heart rate, oxygen saturation,
and blood pressure during the procedure and degreasing of the skin with liquid soap,
asepsis with chlorhexidine, and anesthetic blocking of infraorbital and mentonian
nerves, followed by infiltrative anesthesia with 2% lidocaine solution plus saline at
a ratio of 1:3 of the genian region, respecting the maximum dose of anesthetic
according to the patient’s weight. 88% phenol was applied with gauze until solid
bleaching was obtained, immediately followed by PCI with 2.5 mm long needles.
Shuttle movements were performed until uniform bloody dew was obtained. The
contralateral genial region was treated with the same technique. The procedure was
finished with a gauze dressing removed after 24 hours at home, during bathing, followed by the use of skin regenerator three times a day. Figures 24.5, 24.6, 24.7,
24.8, 24.9, 24.10, 24.11, 24.12, 24.13, and 24.14 demonstrate the post-procedure
evolution.
Fifteen days after the intervention, all patients were examined and asked to
answer a questionnaire about the period after the procedure. We tried to identify
expected effects such as erythema, edema, or other complications such as post-­
inflammatory hyperpigmentation or infections. During this visit, all patients were
instructed to use industrialized depigmentant (retinoic acid 0.05% + hydroquinone
4% + fluocinolone acetonide 0.01%), alternating it with skin regenerator for 15 days
and toned, industrialized, and SPF 50+ sunscreen. Afterwards, the use of depigmentant was oriented every night, which was done with good tolerability. The clinical
evaluation (according to the scale with the categories very good, good, reasonable,
and bad) and the photographic evaluation (with the same digital camera immediately before and 3 months after the procedure) were performed by the investigator
3 months after the procedure, when questionnaires of satisfaction with the results
were also applied to the patients. Among the 27 patients treated, 12 had only wrinkles and flaccidity, 5 had only acne scars, and 10 had wrinkles, flaccidity, and acne
scars. The phototype of the patients varied from I to III, according to Fitzpatrick’s
24.2
Prepare for the Procedure
261
a
b
24 hours
48 hours
c
72 hours
d
4 Days
e
5 Days
Fig. 24.5 Postoperative evolution of the association of 88% phenol with PCI. (a) 24 hours, (b)
48 hours, (c) 72 hours, (d) 4 days, and (e) 5 days
Fig. 24.6 Acne scar patient treated with the association of 88% phenol and PCI
classification. In the clinical evaluation and by photographs, the author considered
the results from good to very good. In the satisfaction questionnaire, 100% of the
patients reported being satisfied with the results. All informed that they would submit to the intervention again, if necessary. The degree of pain and discomfort during
262
24
PCI Associated with Peelings
Fig. 24.7 Acne scar patient treated with the association of 88% phenol and PCI
Fig. 24.8 Photoaging patient treated with the association of 88% phenol and PCI
Fig. 24.9 Photoaging patient treated with the association of 88% phenol and PCI
the procedure was considered tolerable by the patients. The heart rate, oxygen saturation, and blood pressure records had little oscillation during the intervention. The
return to work activities varied from 7 to 10 days. Moderate edema and erythema
persisted during the period that oscillated from 25 to 35 days, being well covered by
the use of toned sunscreen. Moderate post-inflammatory hyperpigmentation was
24.2
Prepare for the Procedure
263
Fig. 24.10 Photoaging patient treated with the association of 88% phenol and PCI
Fig. 24.11 Photoaging patient treated with the association of 88% phenol and PCI
Fig. 24.12 Photoaging patient treated with the association of 88% phenol and PCI
observed in 7 of the 28 patients and was reverted with depigmentation within
30–45 days. It was also considered that all 28 patients treated were responsive to the
technique used and that they would repeat the same procedure in other cases with
similar indication. Thirteen of the 28 patients evaluated are already with 24 months
of follow-up after the procedure and have satisfactory maintenance of the results. It
264
24
PCI Associated with Peelings
Fig. 24.13 Patient treated with 88% phenol in association with PCI for wrinkles, flaccidity, and
melanoses, after 90 days
Fig. 24.14 Patient treated with 88% phenol in association with PCI for wrinkles and sagging,
after 90 days
24.3 Safety Profile and Origin of the Substances Used
265
was observed that the recovery time with the 88% phenol applied alone is longer
when compared to its association with PCI, besides the substantial improvement in
the latter proposal.
We suggest avoiding the association of peeling with PCI in:
• Melasma or in the individual with a tendency to post-inflammatory hyperpigmentation previously observed: Unlike the safety offered with PCI as an isolated
technique, the addition of a Caucasian may worsen the melasma and increase
sensitization to light; great caution should be taken.
• Reactive, erythematous, telangiectasia exuberant skin, with rosacea or in the
most allergic ones: In these cases, only PCI is indicated. In cases where there is
substantial photodane associated with melasma, toned retinoic acid peeling can
be used, ending the intervention with PCI (moderate injury).
• Patients who are not willing to be absent from the sun in their routines.
• Patient with phototypes between IV and VI according to Fitzpatrick, because
they are more subject to post-inflammatory hyperpigmentation, often surprising
even with superficial peelings. It is worth remembering that the PCI substantially
enhances the intervention.
24.3
Safety Profile and Origin of the Substances Used
It is essential to certify the good origin of the solutions used in these interventions,
as well as their conservation and shelf life. Attention should be paid to the quality of
the substrates used, which directly affects the results. The label must clearly contain
the contents of the container, avoiding exchanges or confusion at the time of use.
24.3.1
Step-by-Step
• Patient assessment. The applicability of PCI associated with peelings should be
reserved for phototypes I to III. It is not recommended for higher phototypes,
subject to post-inflammatory hyperpigmentation, which may be transitory or
long-lasting. The preparation is mandatory, and the less melanin the treated skin
is providing, the lower the risk of darkening. Therefore, the use of depigmentant
and sunscreen 30 days before the intervention is recommended.
• Instrumental. The author prefers the use of a roll with an average of 192 needles
of 2.5 mm in length. The treatment should be performed in a procedure room
carefully prepared for a surgical intervention and by a trained and qualified professional. It is essential not to trivialize these safety criteria, which range from
the use of sterile gloves and sterile surgical fields to an environment that follows
strict disinfection standards.
266
24
PCI Associated with Peelings
• Asepsis and anesthesia of the area. After antisepsis with 2% chlorhexidine, it is
suggested the association of anesthetic blocking of the infraorbital and mentonian nerves and complement with 2% lidocaine solution without 1:2 vasoconstrictor 0.9% saline, respecting the maximum dose of the active agent allowed (see
Chap. 4, Analgesia and Anesthesia). The addition of bicarbonate in order to offer
more comfort, reducing burning, is optional.
• Peeling. Both 35% TCA and 88% phenol are applied seeking the conventional
frosting of the intervention. We do not recommend the use of these actives after
the PCI. The author considers this proposal unsafe and likely to trigger variable
adverse effects such as discromias and dystrophic scars. It is emphasized that
first the peeling is performed and then, at the same time, the use of the needle
roller. In the case of 5% retinoic acid peeling, after moderate injury and the formation of a biological dressing installed 30–40 minutes after the intervention,
resulting from the crystallization of serosanguinolent exudation, the active is
applied.
• Transurgical. The use of the microneedle roller in this association happens following the same methodology proposed for the PCI isolated technique. The
treatment with the caustic chosen for the peel should be performed immediately
before the use of the microneedles. Once the peeling is completed, after infiltrative anesthesia, the instruments are rolled, forming parallel and adjacent strips of
micropunctures, which intersect diagonally, seeking to achieve a uniform purple
color with thousands of microperforations. The surface is usually rigid due to
anesthetic infiltration and the presence of caustic, which facilitates the rolling of
the instrument. Substantial reduction of bleeding is observed in the following
10–20 minutes, giving rise to a serous exudation that progressively regresses in
the first 6–8 hours.
• Post-immediate surgery. The exudation is exuberant; therefore the dressing
should be performed with sterile gauze in large quantities and microporated
adhesive, without the addition of any wetting agent. The author does not recommend, as in previous guidelines, topical or systemic antibiotic therapy.
• Evolution and postoperative care. The edema observed the day after the intervention is substantial. Aiming at the patient’s comfort and postoperative practicality,
it is recommended that the dressing be removed at home, when the treated area
should be sanitized with liquid soap with low detergency potential, avoiding sensitization. After this practice, it is recommended to use a regenerating balm until
reepithelialization, an average of 5–7 days, when lightening creams and sunscreen can be used. Light restriction should be targeted. If the dermatologist
wishes to use a filler as hyaluronic acid, it is recommended that this intervention
be programmed for at least 30 days after this treatment, making sure that the
edema has completely receded. The application of botulinum toxin, in the
author’s practice, is safe after 15 days of this intervention. The application of
botulinum toxin should not be performed at the same surgical time. Adverse
effects can occur in the validity of the edema, by increasing the diffusion of the
toxin’s action halo, reaching muscle fibers alien to the proposal.
Sources
267
• Complications. The prevention of adverse effects is dependent on preoperative
care and transoperative and mandatory attention in the postoperative. It should
continue until the total spontaneous removal of crusts and regression of edema,
hematomas, and erythema, because the patient will be subject to hyperpigmentation post-inflammatory. Persistent erythema can also occur, but it is easily controlled with the use of sunscreen and night silicone gel, in order to maintain
hydration and avoid pruritus or excoriations.
• Pain and discomfort. Despite causing deep injury, the association of medium
peel with PCI does not cause postoperative pain. If the complaint settles after
48 hours of intervention, secondary infection should be considered.
• Prophylaxis for herpes. As this is an intervention that uses caustic substance,
resulting in deepithelialization of the treated area, it is mandatory to introduce
the anti-herpetic. The ablative intervention removes the epidermis completely
and, consequently, allows infection by an opportunistic organism that may install
itself with the loss of keratinocyte integrity. Therefore, it is recommended to
introduce the preventive treatment in the usual doses and interrupt it only after
reepithelialization, when the keratinocyte will be intact.
24.4
Final Considerations
In the author’s experience, the peeling and PCI association has been safe and provided good results. The introduction of caustic immediately before PCI optimizes
results under conditions of sagging, deep wrinkles, and acne scars. Caution and
attention in preoperative and postoperative should be accentuated, and only dermatologists who have mastery of both techniques should perform them. The author has
tested several ways to perform this intervention and considers the previously suggested methodological sequence the safest and most reproducible.
Sources
1. Bagatin E, Hassun K, Talarico S. Revisão sistemática sobre peelings. Surg Cosmet Dermatol.
2009;1(1):37–46.
2. Bal SM, Caussian J, Pavel S, et al. In vivo assessment of safety of microneedle arrays in human
skin. Eur J Pharm Sci. 2008;35(3):193–202.
3. Fernandes D. Minimally invasive percutaneous collagen induction. Oral Maxillofac Surg Clin
North Am. 2006;17(1):51–63.
4. Fulton JE, Porumb S. Chemical peels – their place within the range of resurfacing techniques.
Am J Clin Dermatol. 2004;5(3):179–87.
5. Kadunc BV, Vanti AA. Avaliação da toxicidade sistêmica do fenol em peelings faciais. Surg
Cosmet Dermatol. 2009;1(1):10–4.
6. Lima EVA, Lima MMDA, Paixão MP, et al. Assessment of the effects of skin microneedling
as adjuvant therapy for facial melasma: a pilot study. BMC Dermatol. 2017;17:1–6.
268
24
PCI Associated with Peelings
7. Lima EA. Microneedling in facial recalcitrant melasma: report of a series of 22 cases. An Bras
Dermatol. 2015;90(6):919–21.
8. Lima EVA, et al. Induction of pigmentation through microneedling in stable localized vitiligo
patients. Dermatol Surg. 2020;46(13):434–5.
9. Lima EA. Microagulhamento em melasma facial recalcitrante: uma série de 22 casos. Na Bras
Dermatol. 2015;90(6):917–9.
10. Lima EA, Lima M, Takano D. Microneedling experimental study and classification of the
resulting injury. Surg Cosmet Dermatol. 2013;5:110–4.
11. Lima EVA. Dermal tunneling: a proposed treatment for depressed scars. An Bras Dermatol.
2016;91(5):697–9.
12. Lima EVA. Indução percutânea de colágeno com agulhas em cicatrizes após acidentes automobilísticos: correção cosmética e funcional. Surg Cosmet Dermatol. 2017;9(2):127–9.
13. Lima EVA. Dermal tunneling (TD®): a therapeutic option for static glabellar wrinkles. Surg
Cosmet Dermatol. 2016;8(1):42–5.
14. Lima EVA. Pulsed radiofrequency with multineedles (RFPM®) in the treatment of atrophic
stretch marks. Surg Cosmet Dermatol. 2016;8(3):242–5.
15. Lima EA, Lima MA, Araújo CEC, Nakasawa YMM, Leal NC. Investigation on the use of 3%
and 5% retinoic acid in peeling solution as a drug delivery agent after percutaneous induction of collagen with needles (IPCA®): safety profile and application protocol. Surg Cosmet
Dermatol. 2018;10(1):21–6.
16. Lima EAV. Pulsed radiofrequency with multineedles: a therapeutic proposal for wrinkles, sagging, and periorbital pigmentation. Surg Cosmet Dermatol. 2015;7(3):223–6.
17. Lima EVA. Association of microneedling with phenol peeling: a new therapeutic approach for
sagging, wrinkles and acne scars on the face. Surg Cosmet Dermatol. 2015;7(4):328–31.
18. Lima EVA. Pulsed radiofrequency with multineedles for earlobe aging treatment. Surg Cosmet
Dermatol. 2016;8(4):307–10.
19. Lima EVA. Indução percutânea de colágeno com agulhas (IPCA®) associada a radiofrequência pulsada com multiagulhas (RFPM®) na condução de cicatrizes de acne deprimidas: protocolo de tratamento. Surg Cosmet Dermatol. 2017;9(3):234–6.
20. Lv YG, Liu J, Gao YH, et al. Modeling of transdermal drug delivery with a microneedle array.
J Micromech Microeng. 2006;16(11):151–4.
21. Nelson BR, Fader DJ, Gillard M, et al. Pilot histologic and ultrastructural study of the effects
of medium-depth chemical facial peels on dermal collagen in patients with actinically damaged skin. J Am Acad Dermatol. 1995;32(3):472–8.
22. Vandervoort L, Ludwig A. Microneedles for transdermal drug delivery; minireview. Front
Biosci. 2008;13(5):1711–5.
23. Vasconcelos NB, Figueira GM, Fonseca JCM. Estudo comparativo de hemifaces entre 2 peelings de fenol (fórmulas de Baker Gordon e de Hetter), para a correção de rítides faciais. Surg
Cosmet Dermatol. 2013;5(1):40–4.
Chapter 25
Fundamentals of the Dermal Tunneling
(DT): A Subcision™ Variant
25.1
Introduction
The use of needles for cosmetic interventions is increasingly gaining ground and
consolidating within the dermatologist’s therapeutic arsenal. Orentreich and
Orentreich were the first to report the use of needles with the objective of stimulating the production of collagen in the treatment of depressed scars and wrinkles, a
technique widespread under the name of Subcision™. Their studies were confirmed
by other authors, who were based on the same precept: rupture and removal of the
damaged subepidermal collagen, followed by substitution by new collagen and
elastin fibers (Fig. 25.1). The change in color, texture, elasticity, and uniformity of
the skin surface in the presence of scars is secondary to inflammatory changes
affecting the epidermis, dermis, and hypodermis en bloc or alone, and these sites are
targeted by techniques that use needles. Needles with particular characteristics have
been used by different authors in their procedures, among them 19 G, 20 G, 21 G,
and 18 G 1.5 Nokor, presenting particular technical advantages in their experiments.
In gynoid lipodystrophy, Hexsel and Mazzuco’s investigations also document the
use of needles for cosmetic correction. Adverse effects can be evidenced in the
immediate post-procedure, such as edema, hematoma, pain, or late, such as post-­
inflammatory hyperpigmentation, hypercorrection of treated depression and fibrotic
nodules. Complications can be avoided or well managed when the intervention is
performed by an experienced and discerning professional. Dermal tunneling (DT)
proposes the release of fibrotic beams in the dermis and the dermosubcutaneous
transition into depressed scars, with the use of a new instrument and guided by an
easy to perform methodology.
The Editor(s) (if applicable) and The Author(s), under exclusive license
to Springer Nature Switzerland AG 2021
E. Lima, M. Lima, Percutaneous Collagen Induction With Microneedling,
https://doi.org/10.1007/978-3-030-57541-0_25
269
270
25
Fundamentals of the Dermal Tunneling (DT): A Subcision™ Variant
Fig. 25.1 Rupture of fibrotic bars and release of skin observed in Subcision™
25.2
Principles and Technique of DT
Proposed by dermatologist Emerson Lima (2017), DT was presented to the scientific community for the first time in lectures that took place at the 70th Congress of
the Brazilian Society of Dermatology (2015, São Paulo). The technique offers its
own methodology, a result of the author’s 17-year experience with needles for cosmetic therapeutic corrections. The step-by-step of the technique will be
described below.
25.2.1
Step-by-Step
• Instrumental. The instrument used to perform the DT is a sterile suction needle,
1.20 × 25 mm 18 G × 1″ (Fig. 25.2). The treatment should be performed in a
procedure room carefully prepared for surgical intervention and by a qualified
and trained professional. After endorsing some possibilities of intervening with
this instrument in dozens of patients, considering the reproduction of the method
by trained specialists, the author elaborated a methodological sequence that is
easy to apply and with limited risks of adverse effects.
• First step. Initially, the area to be treated is marked with brilliant green or similar
resistant to the actives used in antisepsis, in order to carry out the marking maintenance. The design used to guide the intervention depends on the injury to be
treated. In the face of a depressed lesion, a tracing of four straight lines is made
at the extremities, forming a rhombus, which must contemplate the depression(s)
in its entirety or even the delineation of a triangle or pyramid that follows the
same precepts (Fig. 25.3).
25.2
Principles and Technique of DT
271
Fig. 25.2 18 G suction
needle used to perform DT
• Hygienization and anesthesia of the area. Then antisepsis is performed with 2%
chlorhexidine and anesthesia with 2% lidocaine without vasoconstrictor at the
four corners of the rhombus or at the apex of the geometric design created.
Usually there is no need to anesthetize the whole area contained in the drawing;
however, if discomfort of the patient is observed, the anesthesia should include
the whole area to be treated.
• Following the proposed design. The 18 G suction needle is introduced through a
transpidermal route into the depth of the dermal/dermosubcutaneous plane, making a canalicular path with the consequent rupture of the existing fibrotic beams,
creating linear tunnels within the altered dermis. The movements performed by
the needle are inbound and outbound, starting from the vertices (named, for
didactic reasons, from A) to the center of the rhomboid (named B) (see Fig. 25.3)
272
25
STEP 1
A
Fundamentals of the Dermal Tunneling (DT): A Subcision™ Variant
A
B
STEP 3
A
A
A
A
B
A
A
A
A
STEP 2
A
STEP 4
A
A
A
B
A
A
Fig. 25.3 Methodology proposed for DT. The movement of the needle is from the vertex (A) to
the center (B) of the diamond
or their equivalences. The next tunnel is formed following the same precept,
immediately adjacent to the previous one; for this, the introduction of the needle
is done in the same orifice, which results in the creation of several horizontal
hematic columns arranged in parallel. The same procedure is performed from the
other three vertices, so that the columns intersect, until the whole area is detached
or treated. The basic design can be halved or quartered, depending on the injury
to be treated. It can also be duplicated if the area is extensive (Fig. 25.4).
• Transurgery. In the treated region, an important hematoma is observed. The holes
which made it possible to introduce the suction needle present substantial bleeding, due to the size of the instrument, but it is a limited condition. Commonly,
compression with sterile cotton facilitates hemostasis, which is established in a
few minutes. As the cutting potential of the instruments used in this case is limited (18 G suction needle), we observed that the trauma is less intense when
compared to the instruments previously proposed for Subcision™. There is no
need to suture the holes; healing occurs by second intention, since it is a solution
of continuity of less than 1 mm (Fig. 25.5).
• Post-immediate surgery. Containing bleeding, it is recommended to occlude the
region treated with gauze and Micropore®, performing a conventional dressing,
without the use of any topical asset. Topical or systemic antibiotic therapy is also
not indicated, nor cryotherapy or compresses. It is preferable that the accommodation of the hematoma and the resulting inflammatory response follow its natural course (Fig. 25.5).
25.2
Principles and Technique of DT
273
A
B
Agulha de
aspiração
Fig. 25.4 Pyramid design for the treatment of static wrinkles
• Evolution and postoperative care. It is recommended to remove the dressing in
the first 12–24 hours, to sanitize the area with water and soap with good detergency power. There is no need to keep the area occluded by dressing. The following day, the application of a broad-spectrum toned sunscreen will begin,
accompanied by recommendations for restriction of exposure to lights. The
edema on the following day is often more intense when compared to the
­immediate postoperative period, although the absorption of the infiltrated anesthetic has already established itself. This edema is progressive until the first
48–72 hours of the intervention, when it starts to regress (Fig. 25.6). Around the
fifth to seventh day, involuntary hematomas persist, but the edema is quite modest. During this period, photoprotection is mandatory. Nodes may appear, and
274
25
Fundamentals of the Dermal Tunneling (DT): A Subcision™ Variant
Fig. 25.5 Edema observed in the immediate postoperative period
Fig. 25.6 Daily evolution of edema and hematoma of a patient after the intervention
their resolution is completed within 30 days on average. According to the author’s
practice, the patient will be able to return to his laborative activities when the
treated region is visible, as in the face, around the seventh postoperative day. The
return to public coexistence may occur if the treated area is covered on the following day (Fig. 25.7).
Despite the many proposals currently available, the treatment of depressed scars,
static wrinkles, and gynoid lipodystrophy remains a major challenge. DT is a new
25.2
Principles and Technique of DT
275
Fig. 25.7 Patient treated with DT after 30 days of intervention
surgical approach for the treatment of these lesions, in an attempt to optimize the
results observed with the already existing techniques of detachment, standardizing
an intervention methodology that can be reproduced by other doctors and applied to
many patients. One can conclude in relation to DT:
• Following the methodology described above, the author has considered an effective treatment in depressed scars, deep wrinkles, and gynoid lipodystrophy.
• The results were promising and compatible with the expectations of the author
and the patients, which allow us to suggest the inclusion of the proposed methodology in the therapeutic arsenal of depressed scars.
• The pain and discomfort in the intraoperative and postoperative reported by
patients were compatible with what was expected for procedures like this.
• The absence of postoperative complications stimulates to treat other patients.
It is suggested the evaluation of the technique in other groups to confirm the
results and conclusions presented here.
25.2.2
Advantages of DT
• The procedure allows the release of fibrotic beams and stimulates the production
of collagen without removing the epidermis, which favors the improvement of
texture and coloring of the treated area.
• The recovery and absorption time of the hematoma formed is usually shorter
when compared to the techniques previously proposed for detachment, substantially reducing the risk of adverse effects when compared.
• The skin becomes more resistant, losing the characteristic friable aspect of the
scar tissue, resembling the natural tissue, before the aggression that resulted in
the injury.
276
25
Fundamentals of the Dermal Tunneling (DT): A Subcision™ Variant
• It is indicated for all skin types and colors and can be used not only on the face
but also in areas of lower concentration of sebaceous glands, such as the neck,
burn scars, legs, and buttock, when you want to treat gynoid lipodystrophy.
• It has a low cost when compared to procedures that require high investment
technologies.
25.2.3
Disadvantages of DT
• It is a technical-dependent procedure and requires specialized training and indepth knowledge of the skin and lesions to be addressed, as well as the ability to
treat possible complications.
• It requires time away from labor activities, when in an exposed area, such as the
face, which can vary from 5 to 7 days.
• The hematoma that forms after the intervention is slowly reabsorbed and may be
accompanied by pain. It requires restriction of exposure to light and disciplined
use of sunscreen.
• It requires a careful evaluation of the patient by the doctor and a therapeutic proposal compatible with the possible results to be achieved, avoiding false
expectations.
25.3
Closing Considerations
DT is an innovative and safe treatment that can be used in a wide range of indications if the objective is to release fibrotic beams and stimulate collagen production,
acting as another weapon in the dermatologist’s therapeutic arsenal.
Sources
1. Al-Dhalimi MA, Arnoos AA. Subcision for treatment of rolling acne scars in Iraqi patients: a
clinical study. J Cosmet Dermatol. 2012;11:144–50.
2. AlGhamdi KM. A better way to hold a Nokor needle during subcision. Dermatol Surg.
2008;34:378–9.
3. Aust MC. Percutaneous collagen induction therapy: an alternative treatment for scars, wrinkles, and skin laxity. Plast Reconstr Surg. 2008;121(4):1421–9.
4. Bal SM, Caussian J, Pavel S, et al. In vivo assessment of safety of microneedle arrays in human
skin. Eur J Pharm Sci. 2008;35(3):193–202.
5. Camirand A, Doucet J. Needle dermabrasion. Aesthet Plast Surg. 1997;21(1):48–51.
6. Fabroccini G, Fardella N. Acne scar treatment using skin needling. Clin Exp Dermatol.
2009;34(8):874–9.
7. Fernandes D, Massimo S. Combating photoaging with percutaneous collagen induction. Clin
Dermatol. 2008;26(2):192–9.
Sources
277
8. Goodman GJ. Postacne scaring: a review of its pathophysiology and treatment. Dermatol Surg.
2000;26:857–71.
9. Hexsel DM, Mazzuco R. Subcision: a treatment for cellulite. Int J Dermatol. 2000;39:539–44.
10. Lima EVA, Lima MMDA, Paixão MP, et al. Assessment of the effects of skin microneedling
as adjuvant therapy for facial melasma: a pilot study. BMC Dermatol. 2017;17:1–6.
11. Lima EA. Microneedling in facial recalcitrant melasma: report of a series of 22 cases. An Bras
Dermatol. 2015;90(6):919–21.
12. Lima EVA, et al. Induction of pigmentation through microneedling in stable localized Vitiligo
patients. Dermatol Surg. 2020;46(13):434–5.
13. Lima EA. Microagulhamento em melasma facial recalcitrante: uma série de 22 casos. Na Bras
Dermatol. 2015;90(6):917–9.
14. Lima EA, Lima M, Takano D. Microneedling experimental study and classification of the
resulting injury. Surg Cosmet Dermatol. 2013;5:110–4.
15. Lima EVA. Dermal tunneling: a proposed treatment for depressed scars. An Bras Dermatol.
2016;91(5):697–9.
16. Lima EVA. Indução percutânea de colágeno com agulhas em cicatrizes após acidentes automobilísticos: correção cosmética e funcional. Surg Cosmet Dermatol. 2017;9(2):127–9.
17. Lima EVA. Dermal Tunneling (TD®): a therapeutic option for static glabellar wrinkles. Surg
Cosmet Dermatol. 2016;8(1):42–5.
18. Lima EVA. Pulsed radiofrequency with multineedles (RFPM®) in the treatment of atrophic
stretch marks. Surg Cosmet Dermatol. 2016;8(3):242–5.
19. Lima EA, Lima MA, Araújo CEC, Nakasawa YMM, Leal NC. Investigation on the use of 3%
and 5% retinoic acid in peeling solution as a drug delivery agent after percutaneous induction of collagen with needles (IPCA®): safety profile and application protocol. Surg Cosmet
Dermatol. 2018;10(1):21–6.
20. Lima EAV. Pulsed radiofrequency with multineedles: a therapeutic proposal for wrinkles, sagging, and periorbital pigmentation. Surg Cosmet Dermatol. 2015;7(3):223–6.
21. Lima EVA. Association of microneedling with phenol peeling: a new therapeutic approach for
sagging, wrinkles and acne scars on the face. Surg Cosmet Dermatol. 2015;7(4):328–31.
22. Lima EVA. Pulsed radiofrequency with multineedles for earlobe aging treatment. Surg Cosmet
Dermatol. 2016;8(4):307–10.
23. Lima EVA. Indução percutânea de colágeno com agulhas (IPCA®) associada a radiofrequência pulsada com multiagulhas (RFPM®) na condução de cicatrizes de acne deprimidas: protocolo de tratamento. Surg Cosmet Dermatol. 2017;9(3):234–6.
24. Orentreich DS, Orentreich N. Subcutaneous incisionless (subcision) surgery for the correction
of depressed scars and wrinkles. Dermatol Surg. 1995;21(6):543–9.
Chapter 26
Dermal Tunneling in the Treatment
of Depressed Scars
26.1
26.1.1
Dermal Tunneling (DT) in Scars
undamentals of Dermal Tunneling in the Correction
F
of Scars
Scars are a challenge in dermatological practice, even in view of the wide therapeutic arsenal currently available for this approach. Brazil is a fertile ground for the
development of new techniques due to the dermatological surgeon’s well-known
creativity, the ethnic plurality that forces us to be aware of the adverse effects resulting from aggressive interventions, and the architectural polymorphism of the scars
that causes us to study more and more (Fig. 26.1; see, in Chap. 12, PCI in Acne
Scars, the classification of acne scars, based on their shape and characteristics).
The use of needles for cosmetic interventions is increasingly gaining ground and
consolidating within the dermatologist’s therapeutic arsenal. Orentreich and
Orentreich were the first to report the use of needles with the objective of stimulating the production of collagen in the treatment of depressed scars and wrinkles, a
technique widespread under the name of Subcision™, followed by other authors
who presented adaptations to the technique, with needle variation and approach. As
already mentioned in previous chapters, dermal tunneling (DT) was inspired by this
detachment technique and guided by its principles of fibrotic beam rupture and collagen production stimulus. For this, the methodology and instruments themselves
required the TD® denomination to characterize this new approach. Post-acne
inflammatory scars are a frequent complaint, which presents itself as a great challenge, even in the face of all the therapeutic options offered by qualified dermatologists. For 17 years of treating acne scars, the author of this work uses the technique
of detachment with needles in depressed scars, offering acceptable cosmetic results
(Fig. 26.2), but the standardization of results and prevention of adverse effects, with
a safer postoperative, guided him to the development of DT.
The Editor(s) (if applicable) and The Author(s), under exclusive license
to Springer Nature Switzerland AG 2021
E. Lima, M. Lima, Percutaneous Collagen Induction With Microneedling,
https://doi.org/10.1007/978-3-030-57541-0_26
279
280
26 Dermal Tunneling in the Treatment of Depressed Scars
Fig. 26.1 Architectural polymorphism of acne scars
Fig. 26.2 Patients with depressed acne scars and lipodystrophy treated with Subcision™
26.2 DT Foundations and Technique in Acne Scars
281
Fig. 26.3 Patient with depressed acne scars and lipodystrophy, 60 days after being treated with DT
26.2
DT Foundations and Technique in Acne Scars
The technique offers its own methodology to be followed, seeking standardization,
with the objective of presenting results, as far as possible, predictable. It is indicated
for facial lipodystrophy, often observed in patients after cystic acne. The typical
flaccidity of the genian region and the wrinkles resulting from this excess skin are
improved by the technique (Fig. 26.3).
DT has precise indication in distensible and non-distensible depressed scars. The
latter are detached, often requiring complementary interventions to alleviate the
irregular surface of the raised scar. See the step-by-step of the technique below.
26.2.1
Step-by-Step
• Instrumental. The instrument used to perform the DT is a sterile suction needle,
1.20 × 25 mm 18 G × 1″. The treatment must be performed in a procedure room
carefully prepared for surgical intervention and by a qualified and trained professional. After endorsing some possibilities of intervening with this instrument in
dozens of patients, considering the reproduction of the method by trained specialists, the author elaborated a methodological sequence of easy application and
with limited risks of adverse effects.
• First step. Initially, the area to be treated is marked with brilliant green or similar
resistant to the actives used in antisepsis, with the objective of maintaining the
marking. The design used to guide the intervention depends on the injury to be
treated. In front of a depressed scar, a tracing of four straight lines is made at the
extremities, forming a rhombus, which must contemplate the depression(s) in its
entirety. In the case of acne scars on the face, there is often a need to create more
than one lozenge in each genial region until all scars are contained (Fig. 26.4).
282
26 Dermal Tunneling in the Treatment of Depressed Scars
Fig. 26.4 Patient under dynamic evaluation (smiling), showing flaccidity. Planning of DT for correction of lipodystrophy after cystic treatment and 60 days after treatment
• Cleaning and anesthesia of the area. Then, antisepsis is performed with 2%
chlorhexidine and anesthesia with 2% lidocaine without vasoconstrictor in the
four vertices of the rhombus. Usually there is no need to anesthetize the whole
area contained in the drawing; however, if discomfort of the patient is observed,
the anesthesia should include the whole area to be treated.
• Follow the proposed design. The 18 G suction needle is introduced through a
transpidermal route into the depth of the dermal plane, making a canalicular path
with the consequent rupture of the existing fibrotic beams, creating linear tunnels
within the altered dermis. The needle movements are inbound and outbound,
starting from the vertices (named, for didactic reasons, from A) to the center of
the rhomboid (called B) (see Fig. 25.3, in Chap. 25, Principles of Dermal
Tunneling) or their equivalences. The next tunnel is formed following the same
precept, immediately adjacent to the previous one; for this, the needle is introduced in the same hole, which results in the creation of several horizontal hematic
columns arranged in parallel. The same procedure is performed from the other
three vertices, so that the columns intersect until the whole area is detached or
treated. The basic design can be halved depending on the injury to be treated. It
can also be duplicated if the area is extensive.
• Transoperative. In the treated region, an important hematoma is observed. The
holes that made it possible to introduce the suction needle present substantial
bleeding, due to the size of the instrument, but it is a limited condition. Commonly,
26.2 DT Foundations and Technique in Acne Scars
283
compression with sterile cotton facilitates hemostasis, which is ­established in a
few minutes. As the cutting potential of the instruments used in this case is limited (18 G suction needle), we observed that the trauma is less intense when
compared to that caused by the instruments previously proposed for Subcision™.
There is no need to suture the holes; the healing happens by second intention,
since it is a solution of continuity of less than 1 mm.
• Immediate postoperative. Containing the bleeding, it is recommended to occlude
the region treated with gauze and Micropore®, performing a conventional dressing, without the need to use any topical asset. Topical or systemic antibiotic
therapy is not indicated either, since it is a clean procedure, according to the Food
and Drug Administration (FDA) recommendations. Cryotherapy or hot compresses are also not indicated. It is preferable that the accommodation of the
hematoma and the inflammatory response resulting from its presence follow its
natural course. There is also no need for preventive antiviral treatment for the
reactivation of simple herpes; since this is a technique that does not result in
deepithelialization, the epidermis is preserved.
26.2.2
Evolution and Postoperative Care
It is recommended to remove the dressing in the first 12–24 hours, in order to sanitize the area, with water and soap with good detergency power. There is no need to
keep the area occluded by dressing. The following day, the application of a broad-­
spectrum toned sunscreen is started, accompanied by the recommendations of
restriction to light exposure. The edema on the following day is often more intense
when compared to the immediate postoperative period, although the absorption of
the infiltrated anesthetic has already established itself. This edema is progressive
until the first 48–72 hours of intervention, when it starts to regress. Around the fifth
to seventh day, the bruises persist in involution, but the edema is quite modest.
During all this period, the photoprotection is mandatory. Nodules may appear, and
their resolution is completed within 30 days on average. According to the author’s
practice, the patient will be able to return to his casual activities when the treated
region is visible, as on the face, around the seventh postoperative day. The return to
public coexistence may happen the following day if the treated area is covered.
One can conclude regarding DT in acne scars:
• The results were promising and compatible with the expectations of the author
and patients, which allow us to suggest the inclusion of the methodology proposed in the therapeutic arsenal of acne scars. The author also observed improvement in the quality and tone of the skin, probably as a result of collagen stimulus
resulting from the manipulation of the dermis, reorganizing its structure.
284
26 Dermal Tunneling in the Treatment of Depressed Scars
• The edema observed in the postoperative period is a limiting factor. It is recommended not to perform the intervention close to social events assumed by the
patient or when there is a need to return to labor activities in less than 7 days.
• The pain and discomfort in the intraoperative and postoperative reported by
patients were compatible with what was expected for procedures like these. In
the postoperative period, no pain has been observed. If it occurs within 48 hours,
be aware of secondary infection. The author’s practice has not demonstrated such
complication.
• Post-inflammatory hyperpigmentation has not been seen as a complication, since
the epidermis is preserved during the intervention; however, the use of retinoic
acid with or without bleaching actives can be recommended already on the fifth
postoperative day, seeking to optimize results.
• It is essential that the operator has a thorough knowledge of the skin as well as
being trained to perform DT and able to treat possible complications (Figs. 26.5,
26.6, and 26.7). Figures 26.8, 26.9, and 26.10 present patients treated with DT.
Fig. 26.5 Patient with depressed scars and face groove after 60 days of performing DT
26.2 DT Foundations and Technique in Acne Scars
285
a
b
c
Fig. 26.6 Patient with depressed acne scars and lipodystrophy treated with DT. (a) Right. (b)
Front. (c) Left
286
26 Dermal Tunneling in the Treatment of Depressed Scars
Fig. 26.7 Patient with depressed acne scars and lipodystrophy treated with DT
Fig. 26.8 Patient with mental scar treated with DT
Fig. 26.9 Patient with depressed acne scars and lipodystrophy treated with DT
Sources
287
Fig. 26.10 Patient with malar scar treated with DT
Sources
1. Al-Dhalimi MA, Arnoos AA. Subcision for treatment of rolling acne scars in Iraqi patients: a
clinical study. J Cosmet Dermatol. 2012;11:144–50.
2. AlGhamdi KM. A better way to hold a Nokor needle during subcision. Dermatol Surg.
2008;34:378–9.
3. Aust MC. Percutaneous collagen induction therapy: an alternative treatment for scars, wrinkles, and skin laxity. Plast Reconstr Surg. 2008;121(4):1421–9.
4. Bal SM, Caussian J, Pavel S, et al. In vivo assessment of safety of microneedle arrays in human
skin. Eur J Pharm Sci. 2008;35(3):193–202.
5. Camirand A, Doucet J. Needle dermabrasion. Aesthet Plast Surg. 1997;21(1):48–51.
6. Fabroccini G, Fardella N. Acne scar treatment using skin needling. Clin Exp Dermatol.
2009;34(8):874–9.
7. Fernandes D, Massimo S. Combating photoaging with percutaneous collagen induction. Clin
Dermatol. 2008;26(2):192–9.
8. Goodman GJ. Postacne scaring: a review of its pathophysiology and treatment. Dermatol Surg.
2000;26:857–71.
9. Hexsel DM, Mazzuco R. Subcision: a treatment for cellulite. Int J Dermatol. 2000;39:539–44.
10. Lima EA. Microagulhamento em melasma facial recalcitrante: uma série de 22 casos. Na Bras
Dermatol. 2015;90(6):917–9.
11. Lima EA, Lima M, Takano D. Microneedling experimental study and classification of the
resulting injury. Surg Cosmet Dermatol. 2013;5:110–4.
12. Lima EA. Microneedling in facial recalcitrant melasma: report of a series of 22 cases. An Bras
Dermatol. 2015;90(6):919–21.
13. Lima EVA, Lima MMDA, Paixão MP, et al. Assessment of the effects of skin microneedling
as adjuvant therapy for facial melasma: a pilot study. BMC Dermatol. 2017;17:1–6.
14. Lima EVA. Dermal tunneling: a proposed treatment for depressed scars. An Bras Dermatol.
2016;91(5):697–9.
15. Lima EVA. Indução percutânea de colágeno com agulhas em cicatrizes após acidentes automobilísticos: correção cosmética e funcional. Surg Cosmet Dermatol. 2017;9(2):127–9.
16. Lima EVA. Dermal tunneling (TD®): a therapeutic option for static glabellar wrinkles. Surg
Cosmet Dermatol. 2016;8(1):42–5.
17. Lima EVA. Pulsed radiofrequency with multineedles (RFPM®) in the treatment of atrophic
stretch marks. Surg Cosmet Dermatol. 2016;8(3):242–5.
288
26 Dermal Tunneling in the Treatment of Depressed Scars
18. Lima EVA, et al. Induction of pigmentation through microneedling in stable localized vitiligo
patients. Dermatol Surg. 2020;46(13):434–5.
19. Lima EA, Lima MA, Araújo CEC, Nakasawa YMM, Leal NC. Investigation on the use of 3%
and 5% retinoic acid in peeling solution as a drug delivery agent after percutaneous ­induction
of collagen with needles (IPCA®): safety profile and application protocol. Surg Cosmet
Dermatol. 2018;10(1):21–6.
20. Lima EVA. Pulsed radiofrequency with multineedles: a therapeutic proposal for wrinkles, sagging, and periorbital pigmentation. Surg Cosmet Dermatol. 2015;7(3):223–6.
21. Lima EVA. Association of microneedling with phenol peeling: a new therapeutic approach for
sagging, wrinkles and acne scars on the face. Surg Cosmet Dermatol. 2015;7(4):328–31.
22. Lima EVA. Pulsed radiofrequency with multineedles for earlobe aging treatment. Surg Cosmet
Dermatol. 2016;8(4):307–10.
23. Lima EVA. Indução percutânea de colágeno com agulhas (IPCA®) associada a radiofrequência pulsada com multiagulhas (RFPM®) na condução de cicatrizes de acne deprimidas: protocolo de tratamento. Surg Cosmet Dermatol. 2017;9(3):234–6.
24. Orentreich DS, Orentreich N. Subcutaneous incisionless (subcision) surgery for the correction
of depressed scars and wrinkles. Dermatol Surg. 1995;21(6):543–9.
Chapter 27
Dermal Tunneling in the Treatment
of Static Wrinkles and Grooves
27.1
undamentals of Dermal Tunneling (DT)
F
for the Treatment of Static Wrinkles
The presence of wrinkles in regions such as the forehead, glabella, and middle and
lower third of the face, even when there is no active contracture of the corresponding musculature, characterizes static lines, which are usually more difficult to attenuate. These wrinkles become more evident when the individual has thick or oily
skin, which leads this lesion to a scar condition, difficult to be reversed. The deeper
and older the wrinkles, the more frustrating attempts at correction become, resulting
in a therapeutic challenge (Fig. 27.1). The use of botulinum toxin offers good results
in dynamic wrinkles, especially on the upper third of the face, but the response is
unsatisfactory when we encounter deep static wrinkles. Dermal fillers, such as hyaluronic acid, offer good results in association with botulinum toxin in cases where
the skin is thinner or when fibrotic beams have not yet been installed. In these cases,
there is a prior need to release the bottom of these wrinkles attached to the fibrotic
beams, so that the last proposed association can achieve its objectives. According to
the author’s experience, when this release is neglected, the incarceration of the filler
will be observed, interspersed with the fibrosis mentioned, consequently leading to
undesirable cosmetic results. The subcutaneous incision, or Subincision™, has also
been proposed for the treatment of these creases. Initially described by Orentreich
and Orentreich in 1995, it is based on the rupture of fibrotic beams and the triggering of an inflammatory response, with bleeding, which culminates in neocollagenesis. As was done for scars (see Chap. 26), it was also proposed to perform dermal
tunneling (DT) for the correction of static wrinkles. The treatment is based on the
release of the wrinkle bottom and its consequent filling by blood, which results in
fibrin deposit and production a new collagen, making the wrinkle shallower and
offering cosmetic improved smooth skin surface. Cosmetic improvement is even
The Editor(s) (if applicable) and The Author(s), under exclusive license
to Springer Nature Switzerland AG 2021
E. Lima, M. Lima, Percutaneous Collagen Induction With Microneedling,
https://doi.org/10.1007/978-3-030-57541-0_27
289
290
27 Dermal Tunneling in the Treatment of Static Wrinkles and Grooves
Fig. 27.1 Deep static wrinkles that present a therapeutic challenge
Fig. 27.2 Patient with static forehead wrinkles treated with the association of DT and botulinum toxin
better evidenced when botulinum toxin is applied in combination. Figure 27.2
shows the association of DT with botulinum toxin.
27.1.1
Step-by-Step
• Patient assessment. The wrinkles to be addressed should be static. Normally,
wrinkles poorly responded to the application of botulinum toxin and those
resulted from skin flaccidity. These depressions appear due to the aging process
or consumption of dermis and fat pad in acne, photoaging, and posture addiction.
It does not matter the thickness of the skin, if thinner or thicker, as is the case of
individuals with oily skin or the color of the patient. The treatment presents a
versatility of safety capable of performance in all skin types, especially considering that the epidermis is preserved, there is no deepithelialization, and, consequently, the risk of post-inflammatory hyperpigmentation is reduced.
• How to proceed with the intervention. DT uses a sterile suction needle,
1.20 × 25 mm 18 G × 1″ (see Chap. 26).
• First step. Initially, the area to be treated is marked with brilliant green. A pyramid or triangle-shaped drawing is performed for glabellar wrinkles, with the
27.1 Fundamentals of Dermal Tunneling (DT) for the Treatment of Static Wrinkles
Fig. 27.3 Methodology
proposed for the treatment
of linear static
wrinkles with DT
291
A
Sterile suction needle
1.20 × 25 mm 18 G × 1”
B
apex facing up (craniocaudal axis) and base positioned between the eyebrows
with an acute angle of 10 °–30 °, depending on the extent of the lesion (Fig. 27.3).
The dashed line should contemplate the entire crease. In the labiogenic or mentogenian grooves, this is done in a similar way.
• Antisepsis and anesthesia of the area. Antisepsis is performed with 2%
chlorhexidine and anesthesia with 2% lidocaine without vasoconstrictor in the
four corners of the rhombus. Usually there is no need to anesthetize the whole
rhomboid; however, if discomfort is observed, the anesthesia should include
the whole area.
• Follow the proposed design. The 18 G suction needle is introduced through a
transpidermal route into the depth of the dermal plane, making a canalicular path
with consequent rupture of the existing fibrotic beams, creating linear tunnels
292
27 Dermal Tunneling in the Treatment of Static Wrinkles and Grooves
within the altered dermis. The movements performed by the needle are inbound
and outbound, starting from the apex of the triangle to the base. The next tunnel
is formed following the same precept, immediately adjacent to the previous one;
for this, the needle is introduced in the same hole, which results in the creation
of an average of four horizontal hematic columns arranged in parallel or even
single columns when dealing with static wrinkles of the forehead (Fig. 27.4).
• Transurgical. In the treated region, an important hematoma is observed
(Fig. 27.5). The holes that made it possible to introduce the suction needle present substantial bleeding, by the caliber of the instrument, mainly in the glabella
region, which is a limited condition (Fig. 27.6). Commonly, compression with
Fig. 27.4 Immediate postoperative of a patient treated with DT for correction of static wrinkles of
the forehead
Fig. 27.5 Patient
evolution after DT. Before
the procedure (a),
immediate postoperative
after glabella treatment (b),
and 30 days after the
intervention (c)
a
b
c
27.1 Fundamentals of Dermal Tunneling (DT) for the Treatment of Static Wrinkles
Fig. 27.6 Postoperative
90 days after treatment of
glabella static
wrinkle with DT
293
a
b
sterile cotton facilitates hemostasis, which is established in a few minutes. As the
cutting potential of the instruments used in this case is limited (18 G suction
needle), it can be observed that the trauma is less intense when compared to that
caused by the instruments previously proposed for Subcision™. There is no need
to suture the holes; the healing happens by second intention, since it is a solution
of continuity of less than 1 mm.
• Post-immediate surgery. The bleeding is modified and easily contained. Gauze is
rarely used for the dressing, which must be done with several layers of
Micropore®. Topical or systemic antibiotic therapy is not indicated. It is a clean
procedure, and according to the Food and Drug Administration (FDA) rules, this
precaution is unnecessary. Figure 27.7 presents a patient treated with
DT. Cryotherapy or hot compresses are also not indicated. It is preferable that the
accommodation of the hematoma and the inflammatory response resulting from
its presence follow its natural course (Fig. 27.8).
• Postoperative care (see Chap. 29, Dermal Tunneling (DT) in Scars).
294
27 Dermal Tunneling in the Treatment of Static Wrinkles and Grooves
Figs. 27.7 Postoperative
90 days after treatment of
the static glabellar wrinkle
with TD®. (Personal file of
the author)
a
b
c
Fig. 27.8 Patient evolution after DT. Before the procedure (a), immediate postoperative (b), and
90 days after the treatment of the labiogenic groove and the menthrogenic groove with DT (c)
27.2
Evolution
It can be observed that despite the use of good fillers available on the market, as well
as techniques and technologies to stimulate collagen in regions marked by rhytides,
the deeper wrinkles still present themselves as a challenge in the dermatologist’s
therapeutic practice. DT is a new surgical approach for the treatment of these
lesions, in an attempt to optimize the results observed with the botulinum toxin,
whose action on dynamic wrinkles remains the gold standard treatment. In cases
where this association is chosen, it is recommended to:
• Perform the DT for releases of static creases in the glabella and forehead as the
first stage of treatment, following the methodology described above. When the
botulinum toxin is initially performed and reaches its purpose of relaxing the
frontal and corrugated muscles of the eyebrows, the drainage of the edema and
the reabsorption of the hematoma may be delayed, causing discomfort and may
compromise the results.
27.2 Evolution
295
• Wait for the resorption of the hematoma and the involution of the edema before
programming the application of the botulinum toxin. This period varies from 15
to 30 days. Do not apply the botulinum toxin during the period of edema, which
may cause migration of the product and increase the halo of diffusion, which
may trigger relaxation of unforeseen muscles and asymmetry of results.
• Do not perform DT and application of botulinum toxin at the same surgical time.
Adverse effects may occur for the same reasons as above
• In some cases, when the wrinkle is old and deeper, there may be a need for more
than one intervention. For this purpose, it is recommended to wait 30 days
between the performance of a DT and another. Respecting the period of total
regression of the edema, the application of the botulinum toxin is programmed.
When DT is associated with a filler, it is recommended to:
• Initially perform the DT, observing the regression of the edema and hematoma,
and then, in a second time, proceed with the deposition of a filler. It is suggested
to perform both techniques at the same time only in cases of treatment of the
genial region, when the loss of volume is substantial and the risk of overcorrection is not considered. However, it is more prudent to wait a while
• Respect the average time, considered safe by the author, to avoid hypercorrections or hypocorrections, between the performance of the DT and the filling
deposition, when dealing with the perioral regions, periorbital or the upper third
of the face, is 30 days. The acute inflammation will have given space to the maturation of the collagen, and the use of this agent can optimize the results
• Note that performing these interventions two times also provides the security to
evaluate the results achieved by DT and if the permanence, even if partial, of the
initial injury is still evident, one should intervene again, respecting the period of
30 days. Figures 27.9 and 27.10 show two patients treated with DT to attenuate
the nasogenic and menthrogenic sulcus, respectively, in two sessions.
­Figure 27.11 shows the evolution of one patient 90 days and 12 months after
treatment, showing results maintained without any additional treatment.
Fig. 27.9 Patient treated with DT for attenuation of the nasogenic grove in two sessions
296
27 Dermal Tunneling in the Treatment of Static Wrinkles and Grooves
Fig. 27.10 Patient treated with DT for attenuation of the menthrogenic grove in two sessions
Fig. 27.11 Evolution of a patient 90 days and 12 months after treatment, showing maintained
results without any additional treatment
27.3
Final Considerations
DT is a safe treatment for static wrinkles, offering good results, and can be optimized when associated with other techniques. Training is fundamental, since it is a
technical-dependent intervention, and the learning curve must be respected.
Sources
297
Sources
1. AlGhamdi KM. A better way to hold a Nokor needle during subcision. Dermatol Surg.
2008;34:378–9.
2. Almeida ART, Marques ERMC, Kadunc BV. Rugas glabelares: estudo piloto dos padrões de
contração. Surg Cosmet Dermatol. 2010;2(1):23–8.
3. Balighi K, Robati RM, Moslehi H, et al. Subcision in acne scar with and without subdermal
implant: a clinical trial. J Eur Acad Dermatol Venereol. 2008;22:707–11.
4. Dubina M, Tung R, Bototin D, et al. Treatment of forehead/glabellar rhytide complex with
combination of botulinum toxin and hyaluronic acid versus botulinum toxin a injection alone:
a split face, rather-blinded, randomized control trial. J Cosmet Dermatol. 2013;12(4):261–6.
5. Hexsel DM, Mazzuco R. Subcision: a treatment for cellulite. Int J Dermatol. 2000;39:539–44.
6. Hexsel DM, Mazzuco R. Subcision: uma alternativa cirúrgica para a lipodistrofia ginóide
(celulite) e outras alterações no relevo corporal. An Br Dermatol. 1997;72:1.
7. Kim HS, Kim C, Cho H. A study on glabellar wrinkle patterns in Koreans. J Eur Acad Dermatol
Venereol. 2014;28(10):1332–9.
8. Lima EA. Microagulhamento em melasma facial recalcitrante: uma série de 22 casos. Na Bras
Dermatol. 2015;90(6):917–9.
9. Lima EA, Lima M, Takano D. Microneedling experimental study and classification of the
resulting injury. Surg Cosmet Dermatol. 2013;5:110–4.
10. Lima EA. Microneedling in facial recalcitrant melasma: report of a series of 22 cases. An Bras
Dermatol. 2015;90(6):919–21.
11. Lima EVA, Lima MMDA, Paixão MP, et al. Assessment of the effects of skin microneedling
as adjuvant therapy for facial melasma: a pilot study. BMC Dermatol. 2017;17:1–6.
12. Lima EVA. Dermal tunneling: a proposed treatment for depressed scars. An Bras Dermatol.
2016a;91(5):697–9.
13. Lima EVA. Indução percutânea de colágeno com agulhas em cicatrizes após acidentes automobilísticos: correção cosmética e funcional. Surg Cosmet Dermatol. 2017a;9(2):127–9.
14. Lima EVA. Dermal tunneling (TD®): a therapeutic option for static glabellar wrinkles. Surg
Cosmet Dermatol. 2016b;8(1):42–5.
15. Lima EVA. Pulsed radiofrequency with multineedles (RFPM®) in the treatment of atrophic
stretch marks. Surg Cosmet Dermatol. 2016c;8(3):242–5.
16. Lima EVA, et al. Induction of pigmentation through microneedling in stable localized vitiligo
patients. Dermatol Surg. 2020;46(13):434–5.
17. Lima EA, Lima MA, Araújo CEC, Nakasawa YMM, Leal NC. Investigation on the use of 3%
and 5% retinoic acid in peeling solution as a drug delivery agent after percutaneous induction of collagen with needles (IPCA®): safety profile and application protocol. Surg Cosmet
Dermatol. 2018;10(1):21–6.
18. Lima EAV. Pulsed radiofrequency with multineedles: a therapeutic proposal for wrinkles, sagging, and periorbital pigmentation. Surg Cosmet Dermatol. 2015c;7(3):223–6.
19. Lima EVA. Association of microneedling with phenol peeling: a new therapeutic approach for
sagging, wrinkles and acne scars on the face. Surg Cosmet Dermatol. 2015d;7(4):328–31.
20. Lima EVA. Pulsed radiofrequency with multineedles for earlobe aging treatment. Surg Cosmet
Dermatol. 2016d;8(4):307–10.
21. Lima EVA. Indução percutânea de colágeno com agulhas (IPCA®) associada a radiofrequência pulsada com multiagulhas (RFPM®) na condução de cicatrizes de acne deprimidas: protocolo de tratamento. Surg Cosmet Dermatol. 2017b;9(3):234–6.
22. Orentreich DS, Orentreich N. Subcutaneous incisionless (subcision) surgery for correction of
depressed scars and wrinkles. Dermatol Surg. 1995;21(6):543–9.
Chapter 28
PCI Associated with Multi-needle
Radiofrequency for the Treatment
of Periorbital and Perioral Wrinkles
and Laxity
28.1
undamental Concepts of Pulsed
F
High-Frequency Electrosurgery
Electrosurgery (radio electrosurgery) is a process of cutting and coagulation of tissue using a high-frequency alternating current. It is important to emphasize that
high-frequency electrosurgery is a completely different physical process from cauterization. In cauterization, the passive transfer of heat from a hot object to the tissue
takes place with an increase in temperature, evaporation of intracellular water, and
denaturation of proteins, resulting in cell death. In contrast, in high-frequency electrosurgery (cutting and coagulation), a high-frequency current passes through the
tissue, leading to a faster temperature increase than in cauterization, which results
in intracellular boiling (temperature above 100 °C), determining expansion and rupture of cell membranes (cellular implosion), a phenomenon known as vaporization.
Because these processes are so similar, it is important to not be confused between
thermal cauterization and high-frequency electrosurgery. In the latter, there is a passage of a high-frequency current through an organic tissue in order to obtain a specific surgical effect such as cutting or coagulation.
An electrosurgery device is composed of a current generating unit and two electrodes: one active (better known as pen) and one dispersive (better known as plate).
The current generated flows from the device to the body of the patient (by the active
electrode) and returns to the device (by the dispersion electrode). The addition of a
pulser to this circuit aims to intercalate the electric current between the device and
the pedal (high-frequency pulsed electrosurgery). The pulser interrupts the current
in predetermined cycles (5–64 times per second). The higher the pulse, the greater
the amount of current interruptions that will hit the tissue in the same amount of
time and vice versa. It is important to respect the thermal relaxation time of the skin.
This time is necessary for the fabric to cool 50% of the temperature reached soon
after the passage of current. In this way, the thermal effect is controlled, lowering
The Editor(s) (if applicable) and The Author(s), under exclusive license
to Springer Nature Switzerland AG 2021
E. Lima, M. Lima, Percutaneous Collagen Induction With Microneedling,
https://doi.org/10.1007/978-3-030-57541-0_28
299
300
28
PCI Associated with Multi-needle Radiofrequency for the Treatment of Periorbital…
Fig. 28.1 Electrodes named Lima 8, Lima 4, and Lima 2
the cell temperature and preventing heat from damaging adjacent tissues (lateral
heat propagation). In current models, the pulser is built into a pulse and fractionation unit. The thermal effect is strongly attenuated when working with pulsed current. The pulsed radio frequency device we have experience with is the Wavetronic
5000® (ISO 13485:2016 EC certificate: CE 652850, Fig. 28.1). It enables the selection of two forms of pulsed radio frequency: pulsed and single pulse. In pulsed
form, pulsed current remains active while the pedal is activated. In single pulse
form, a single shot of selected energy occurs. The protocols described in this and the
next chapter use the Wavetronic® 5000 device in single pulse and power condition
(Watts) in CUT. For this purpose, Brazilian dermatologist Emerson Lima (2013)
designed electrodes with very fine multi-needles and 2.0 mm in length multi-needle
radiofrequency (MNR), seeking to offer more delicate results with a lower risk of
complications.
28.2
Principles of Multi-needle Radiofrequency (MNR)
By using an electrode consisting of a series of eight needles 0.1 mm thick and
2.0 mm long, we will equally divide by eight the energy selected for contact. With
the proper configuration of the device, we can realize eight columns of 0.1 mm per
shot, with a depth of 2.0 mm. Thus it is plausible the epidermal restitution is in an
integral form and mechanical and thermal dermal stimulus, producing tissue retraction and synthesis of collagen. To treat smaller areas, electrodes consisting of eight
needles, four needles, and two needles are used. These electrodes were named Lima
8, Lima 4, and Lima 2, respectively (Fig. 28.1), referencing the creator of these tips,
28.2 Principles of Multi-needle Radiofrequency (MNR)
301
Brazilian dermatologist Dr. Emerson Lima. This tool comes with the proposal to
optimize the collagenic stimulus offered by the needles, adding to the intervention
a high pulsed energy current. Figures 28.2, 28.3, 28.4, and 28.5 show schematically
how these electrodes act when penetrating the skin.
Figure 28.6 shows the Lima 8 electrode indicated for eyelid rejuvenation.
Figure 28.7 presents a Lima 8 electrode with 100× increase.
Figs. 28.2, 28.3, 28.4, and 28.5 Schematic of how these electrodes act when penetrating the skin,
creating channels to stimulate the collagen production
Fig. 28.6 The Lima 8 electrode indicated for eyelid rejuvenation
302
28
PCI Associated with Multi-needle Radiofrequency for the Treatment of Periorbital…
Fig. 28.7 The Lima 8
electrode with 100×
increase
Fig. 28.8 Large, uneven holes caused by epilepilation electrode, showing lack of uniformity of
treatment and substantial injury to the epidermis
The multi-needle radiofrequency (MNR) technique has its applicability on periorbital skin excess and flaccidity, periorbital hyperpigmentation, static facial wrinkles, acne scars, superficial skin flaccidity, xanthelasma, syringoma, surgical scars,
and stretch marks, among others. The electrodes Lima with multi-Agulhas were
idealized with the objective of preserving the epidermis to the maximum, causing
minimal injury to the layer of the skin and taking the greatest stimulus to the dermis.
Before the development of these electrodes with fine and delicate needles, the
author could not standardize his stimuli, and the injury caused was very coarse and
irregular (Fig. 28.8), increasing the risks of scarring and post-inflammatory
28.3 MNP in the Periorbital Region
a
303
b
Fig. 28.9 (a) Horizontal cut of the eyelid treated with MNR. Cavity ellipsoid at dermis level
showing diameter outrageous caused by one of the needles in the Lima 8 electrode. (b) Vertical cut
of the eyelid treated with MNR. See continuity solution of the epidermis and papillary and reticular
dermis demonstrating the depth reached by the Lima 8 electrode (Hematoxylin and eosin [HE]
200×). (Courtesy of Dr. Nilceo Michalany)
hyperpigmentation. The histopathological examination presented in Fig. 28.9 illustrates the injury caused by one of the needles of the Lima 8 electrode that goes
beyond the epidermis and extends to the deep dermis. In the periorbital region, the
needle reaches the orbicular muscle leading to a contraction, resulting in the containment of modest pockets of fat.
28.3
MNP in the Periorbital Region
The use of high-frequency randomized fractional energy triggered on the skin
results in dermal regeneration at the papillary-reticular interface through the stimulation of fibroblasts with consequent synthesis of collagen and elastic fibers, as well
as epidermal regeneration produced by the migration of keratinocytes. MNP proposes an innovative approach to skin rejuvenation, based on subablative energy, by
means of electrodes made up of several needles, connected to a radio electrosurgery
apparatus. This technique, performed in a precise and punctuated manner, does not
compromise the tissue adjacent to the vaporized microdots and causes significant
tissue impact, which makes it possible to stimulate the new collagen. The electrodes
Lima are sterile and disposable and, as they are very delicate, are often completely
damaged at the end of the intervention. We do not recommend reuse even if resterilized. A recent clinical study (Emerson Lima 2015) evaluated the efficacy of MNR
in rejuvenating the periorbital region. Twelve women and seven men with aging of
the periorbital region were evaluated and treated in the outpatient clinic.
The photographic documentation was made with the same digital camera in
identical environmental conditions, immediately before and 1 month after single
intervention. The methodology followed the step-by-step description above. The
304
28
PCI Associated with Multi-needle Radiofrequency for the Treatment of Periorbital…
patients in this group were treated with the device in CUT, with power 30 and active
in 30 ms, using the Lima 8 electrode and performing only one step, avoiding overlap. The outer limits of the eyelid aesthetic unit were obeyed. In the upper eyelid,
the procedure was performed up to the groove of the eyelid and in the lower eyelid
up to 2 mm from the ciliary edge. After the procedure, the patients received a bandage with microporated adhesive tape, which was removed the next day. For the
post-operative period, the use of a skin regeneratorl) 2 times/day and industrialized
sunscreen with SPF 60. The patients’ phototype varied from II to IV according to
Fitzpatrick’s classification. All patients reported satisfaction with the results. In the
comparative evaluation of the photographs of the previous and after procedure periods, performed by two independent dermatologists, the rate of improvement was
50%, good, in four patients; 75%, very good, in eight patients; and 100%, excellent,
in seven patients. Pain during the treatment was considered tolerable, with tissue
regeneration between 5 and 7 days, with a return to labor activities after significant
reduction of edema and hematomas resulting from infiltrative anesthesia. No infections, acromias, ectropies, or unaesthetic scars were observed in this group.
Mild to moderate post-inflammatory hyperpigmentation was observed after
10–15 days of treatment in 11 of 19 patients and resolved within 20–30 days with
the use of bleaching formulations. Below are the steps and peculiarities to be
considered.
Characteristics of the periorbital region. We consider the patient of choice for
this intervention to be the one who has a modest skin surplus, in the presence of
flaccidity and static wrinkles. Young individuals have also benefited from the whitening intervention in this region. The author has had a good experience even in high
phototypes, which he does not consider a limitation for its applicability. When we
are faced with pigmented lesions, with a lot of melanin, preparation is essential in
order to avoid post-inflammatory hyperpigmentation. The choice of the lightener is
at the discretion of the specialist doctor, as well as the patient’s tolerability.
28.3.1
Step-by-Step
Dermatologist Emerson Lima (2015) developed a protocol based on his investigations in animal skin and human skin, later proven in the results obtained in treating
flaccidity, wrinkles, and scars. The protocol uses the Wavetronic 5000® (ISO
13485:2016 EC certificate: CE 652850) connected in the CUT function (power),
single pulse mode (time interval), with a power of 30 W and active in 30 ms:
• Attach the Lima 8 electrode to the pen electrode of the device (pen).
• Asepsis with 2% chlorhexidine.
• Infiltrative anesthesia with lidocaine 2% with epinephrine in small areas or anesthetic solution (lidocaine 2% without epinephrine 10 ml + 20 ml saline + 8.4%
3 ml sodium bicarbonate) for larger areas.
28.3 MNP in the Periorbital Region
305
• Gently place the Lima 8 electrode on the skin, and activate the pedal so that the
multi-needles penetrate 2.0 mm through the corneal, epidermis layer, reaching
the dermis. In the periorbital area, the electrode touches the orbicular muscle.
The intensity of the results from the point of view of tissue retraction will be
proportional to the density of the microchannels produced by the multi-needles.
The closer the holes are to each other, the better the results will be, and also the
greater the thermal effect accumulated per area of tissue treated. This density of
holes is proportional to the edema, bleeding, and recovery time of the toothed
area. Therefore, caution is recommended while the operator is gaining experience and attention to the responsiveness of each patient. The area should be dry.
When the humidity is intense, there is an increase in the skin’s resistance to the
penetration of microneedles. Therefore, it is recommended to dry the region, drying the bleeding and exuldating several times during the procedure.
• The “tighter” the web of the holes, the greater the stimulus of PCI, but also the
greater the probability of complications such as hypercromias and microulcerizations. The ideal safe spacing is about 1 mm between one row of microperforations and another. You should never overlap the stimulus with the microneedles.
A single shot to produce a row of microperforations. The overlap will produce
fissures in the skin and may result in unaesthetic scars. During the procedure, if
the needles are difficult to perforate, they should be cleaned very carefully with
gauze wet in saline solution or delicate brush. The sequencing for each nomination will be reported in the following chapters. This technique has been used in
the treatment of the periorbital and perioral regions, linear static wrinkles, flaccidity, depressed and dystrophic scars, and stretch marks, among other
indications.
• Hygiene of the electrodes should be performed to remove residues that may
compromise the quality of the procedure or result in complications. It is recommended to use a little wet cotton in saline solution, and with the appliance turned
on and the pedal on, pass the needles gently over the cotton until cleaned.
• Immediate postoperative. The dressing is made with sterile Micropore®, without
the addition of any humectant. Topical or systemic antibiotic therapy is not indicated. It is a clean procedure, and according to the Food and Drug Administration
(FDA) regulations, this precaution is unnecessary. Cryotherapy or hot compresses are recommended on the following days. The use of topical or systemic
corticotherapy is not recommended to contain the expected effects of the selflimited inflammatory process. Figure 28.10 shows the immediate postoperative
period and after 5 days, respectively.
• Postoperative evolution and care. Remove the dressing with the aid of water and
soap the following day when the use of a regenerating balm is recommended on
average for 5–7 days. Whitening creams and broad-spectrum sunscreen can be
used after reepithelialization. Light restriction should be targeted. Edema and
hematoma in the following days are substantial (Fig. 28.11). In the author’s practice, the patient will be able to return to his/her working activities 5–7 days after
306
28
PCI Associated with Multi-needle Radiofrequency for the Treatment of Periorbital…
Figs. 28.10 Immediate
postoperative period and
after 5 days, respectively
Fig. 28.11 Edema and
hematoma in the following
days are substantial
the intervention. There’s no need for bandages after. If there is still some exudation left, you can keep it by replacing it. Figure 28.12 shows the evolution of the
hematoma on the seventh postoperative day. In Fig. 28.13, observe the improvement of wrinkles and sagging skin in the periorbital region before and after
30 days. Figures 28.14, 28.15, 28.16, and 28.17 present patients treated by MNR
after 60 days.
28.4
MNR in Perioral Region
307
Fig. 28.12 Evolution of the hematoma on the seventh postoperative day
Fig. 28.13 Improvement of wrinkles and sagging skin in the periorbital region before and
after 30 days
28.4
MNR in Perioral Region
The intrinsic and extrinsic aging process offers the face a considerable reduction in
volume. Bone resorption, muscle mass reduction, fat redistribution, ligament laxity,
and skin are observed, which, as an envelope, cover all this structure, become loose
and lax, and result in leftovers, flaccidity, and fine, deep wrinkles. The dermis and
epidermis also suffer from degeneration tune and further accentuate the resulting
aspect of time and oxidative stress. Ablative treatments such as medium and deep
chemical peelings provide undeniable stimulus in collagen production, which
results in attenuation of wrinkles, flaccidity, improved texture, brightness, and coloring of the skin surface, in addition to substantial attenuation of the photodanum.
Very good results are also observed with the association of peelings to surgical
abrasion-chemabrasion. Figures 28.18, 28.19, and 28.20 show results obtained from
the association of abrasion with a caustic asset or one of the techniques alone.
However, as mentioned in Chap. 1, the recovery of these procedures is long and
results in a more light sensitive tissue, subject to hyperpigmentation after
308
28
PCI Associated with Multi-needle Radiofrequency for the Treatment of Periorbital…
inflammatory and photosensitivity, in addition to the risk of complications such as
hypertrophic scarring, persistent erythema, and dyschromias. In order to preserve
the epidermis, MNR offers the proposal of causing a fractional injury to the skin,
making it possible that the integrity of the microregion adjacent to the trauma
remains intact, favoring a shorter recovery time and reduced risk of complications,
as already mentioned in previous chapters. Static wrinkles are often a challenge
Figs. 28.14, 28.15, 28.16, and 28.17 Patients treated by MNR after 60 days
28.4
MNR in Perioral Region
309
Fig. 28.14, 28.15, 28.16, and 28.17 (continued)
because of their depth and rigidity. MNR brings a proposal to stimulate the production of collagen, without causing deepithelialization. The epidermis and dermis are
punctured by the Lima multi-needles associated with pulsed radio frequency. In this
way, even deep wrinkles resulting from the evolution of elastosis in photoaged skin,
which often behave as deep scars difficult to be treated by the techniques described
above, are improved. Figure 28.21 presents a patient before and immediately after
MNR, while Fig. 28.22 shows the MNR response to deep wrinkles 30 days after the
intervention. Also in the thinner and flaccid skin, a substantial cosmetic gain is
observed with MNR, for the same reasons already presented here. We are facing an
intervention that aims to rectify the surface of the skin, correcting tissue rhytides
and laxity, replacing damaged dermis and epidermis with a new tissue. Additionally,
we observed a potential of MNR to loosen the bottom of shallow and deep wrinkles,
as well as volumerizar the region that lost support with the aging process. This technique uses authorial methodology and specific electrodes, namely, Lima 8, Lima 4,
or Lima 2. The choice of the ideal electrode depends on the length and width of the
wrinkles to be addressed. Figures 28.23 and 28.24 present deep grooves of patients
treated by MNR after 45 days. Figure 28.25 presents the improvement of fine wrinkles after a single session of MNR.
28.4.1
Step-by-Step
• The skin needs to be prepared: Follow the guidelines presented in previous chapters. In older individuals, the more elastic the skin, the greater the evidence of
resistance. Thick and seborrheic skin presents deeper wrinkles, consequently
requiring more interventions. We recommend that the electrode rests on the
310
28
PCI Associated with Multi-needle Radiofrequency for the Treatment of Periorbital…
Figs. 28.18, 28.19, and 28.20 Results obtained from the association of abrasion with TCA 35%
Fig. 28.21 Patient before and immediately after MNR
28.4
MNR in Perioral Region
Fig. 28.22 MNR response to deep wrinkles 30 days after the intervention
Figs. 28.23 and 28.24 Deep grooves of patients treated by MNR after 45 days
311
312
28
PCI Associated with Multi-needle Radiofrequency for the Treatment of Periorbital…
Fig. 28.25 Improvement of fine wrinkles after a single session of MNR
•
•
•
•
•
•
•
patient’s skin at a 90 ° angle, without pressure. The force damages the multi-­
needles, which are very delicate.
The treatment must be performed in a procedure room carefully prepared for a
surgical intervention and by a trained and qualified professional. It is essential
not to trivialize these safety criteria, which range from the use of sterile gloves
and the affixing of sterile surgical drapes to an environment that follows strict
disinfection standards.
The demarcation of the wrinkles to be treated may be necessary, avoiding distortion of the area after the anesthetic infiltration
Use infiltrative anesthesia. We suggest a 2% lidocaine solution without a 1:1
vasoconstrictor of 0.9% saline, avoiding exceeding the maximum dose allowed
(see Chap. 4, Analgesia and Anesthesia)
After cleaning with 2% chlorhexidine and the Wavetronic 5000 connected in
CUT and single pulse, with power 30 and active in 30 ms, the tip of Lima 8, Lima
4, or Lima 2 is positioned perpendicular to the wrinkles to be treated, usually
parallel to those lesions. The area should be fully covered by multi-needles. The
bleeding is modest, but it happens. After 10 minutes of the end of the intervention, a significant reduction in bleeding can already be observed, leading to a
serous exudation that gradually regresses in the first 4 hours.
After the procedure, the patients receive a bandage with microporated adhesive
tape, which will be removed the next day. Usually it is not necessary to use
gauzes, but if the exudation is substantial, they are added directly on the skin.
The following day, the dressing is removed, and it is recommended the use of
regenerating cream 2× a day until the seventh day of post-procedure when sunscreen and whitening creams can be introduced. Figures 28.26, 28.27, 28.28, and
28.29 present good improvement in deep groove of patients after 90 days of two
sessions of MNR.
Complementary techniques: If the dermatologist wishes to use a filler as hyaluronic acid, we recommend that this intervention be scheduled for at least
15 days after the MNR, making sure that the edema has completely receded. The
application of botulinum toxin in the author’s practice is safe already after
28.4
MNR in Perioral Region
313
Figs. 28.26, 28.27, 28.28, and 28.29 Good improvement in deep groove of patients after 90 days
of 2 sessions MNR
314
28
PCI Associated with Multi-needle Radiofrequency for the Treatment of Periorbital…
Fig. 28.26, 28.27, 28.28, and 28.29 (continued)
15 days of this intervention. Do not apply the botulinum toxin at the same surgical time. Adverse effects may occur during the edema, due to the increased diffusion of the toxin’s action halo, reaching muscle fiber alien to the proposal. The
association of DT and PCI can happen at the same surgical time, if the patient has
indication
• Complications: Infrequent as long as proper care is taken in skin preparation and
attention is paid to postoperative recommendations rigorously. Post-­inflammatory
hyperpigmentation has been the most common complaint.
Figures 28.30, 28.31, 28.32, 28.33, and 28.34 show results of patients treated
with MNR for the correction of static wrinkles and neck laxity.
28.5
Final Considerations
The aging of the periorbital region is a frequent complaint among patients seeking
to improve their appearance. Minimally invasive procedures, such as filling with
hyaluronic acid, application of botulinum toxin, and use of laser with bleaching and
rejuvenating potential, have their limitations, especially when they show leftover
skin, flaccidity, and static wrinkles. Surgical correction of excess skin is often not
well accepted by patients, especially the youngest. In cases where we are faced with
modest skin leftovers, flaccidity, and wrinkles, the use of a method that favors the
28.5 Final Considerations
315
replacement of the damaged collagen by the photodanum with new collagen seems
to substantially improve the appearance of this region. MNP, a methodology developed and studied in detail recently, using specific electrodes, based on results
observed in the last 4 years using already available electrodes, has offered, in the
author’s experience, very satisfactory results. That way, we conclude that:
• MNR is a promising therapeutic proposal for periorbital rejuvenation, especially
when there is no indication or desire for conventional surgery and when thin,
flaccid, and wrinkled skin is the most prominent complaint. The results obtained
Figs. 28.30, 28.31, 28.32, 28.33, and 28.34 Patients treated with MNR for the correction of static
wrinkles and neck laxity
316
28
PCI Associated with Multi-needle Radiofrequency for the Treatment of Periorbital…
Fig. 28.30, 28.31, 28.32, 28.33, and 28.34 (continued)
can be reproduced using the methodology and electrodes described in this chapter. The few adverse effects observed encouraged the author to recommend the
inclusion of this new proposal in the broad therapeutic arsenal already available
for interventions in this region.
The proposed treatments for deep wrinkles commonly offer modest results, and
it is difficult to correct this complaint with isolated techniques. The use of interventions that do not produce a complete deepithelialization has been gaining more and
more space, for safety and recovery time. In addition to the botulinum toxin and
fillers, we propose the association of MNR. The author concludes that:
• MNR is a promising therapeutic proposal for the treatment of various types and
shapes of wrinkles.
• A thorough knowledge of these lesions is essential so that the indication alone or
in association with the technique offers good results.
• The rapid return to activities and the few adverse effects observed encouraged
the author to recommend the inclusion of this new proposal in the broad therapeutic arsenal already available for interventions in this region
Sources
317
• Post-inflammatory hyperpigmentation, although reversible, deserves special
attention, and here it is always a recommended skin preparation before intervention and care after treatment.
Sources
1. Aust MC. Percutaneous collagen induction therapy: an alternative treatment for scars, wrinkles, and skin laxity. Plast Reconstr Surg. 2008;121(4):1421–9.
2. Bal SM, Caussian J, Pavel S, Bouwstra JA. In vivo assessment of safety of microneedle arrays
in human skin. Eur J Pharm Sci. 2008;35(3):193–202.
3. Brody HJ. Trichloracetic acid application in chemical peeling, operative techniques. Plast
Reconstr Surg. 1995;2(2):127–8.
4. Bagatin E, Hassun K, Talarico S. Revisão sistemática sobre peelings. Surg Cosmet Dermatol.
2009;1(1):37–46.
5. Bravo BS, Rocha CR, Bastos JT, et al. Comprehensive treatment of periorbital region with
hyaluronic acid. J Clin Aesthet Dermatol. 2015;8(6):30–5.
6. Camirand A, Doucet J. Needle dermabrasion. Aesthet Plast Surg. 1997;21(1):48–51.
7. Cohen KI, Diegelmann RF, Lindbland WJ. Wound healing: biochemical and clinical aspects.
Philadelphia: WB Saunders Co; 1992.
8. Fathi R, Pfeiffer M, Tsoukas M. Minimally invasive eyelid care in dermatology: medical, laser,
and cosmetic therapies. Clin Dermatol. 2015;33(2):207–16.
9. Fioramonti P, Fallico N, Parisi P, et al. Periorbital area rejuvenation using carbon dioxide
therapy. J Cosmet Dermatol. 2012;11(3):223–8.
10. Fabroccini G, Fardella N. Acne scar treatment using skin needling. Clin Exp Dermatol.
2009;34(8):874–9.
11. Fernandes D. Minimally invasive percutaneous collagen induction. Oral Maxillofac Surg Clin
North Am. 2006;17(1):51–63.
12. Fernandes D, Massimo S. Combating photoaging with percutaneous collagen induction. Clin
Dermatol. 2008;26(2):192–9.
13. Lima EA. Microagulhamento em melasma facial recalcitrante: uma série de 22 casos. Na Bras
Dermatol. 2015;90(6):917–9.
14. Lima EA, Lima M, Takano D. Microneedling experimental study and classification of the
resulting injury. Surg Cosmet Dermatol. 2013;5:110–4.
15. Lima EA. Microneedling in facial recalcitrant melasma: report of a series of 22 cases. An Bras
Dermatol. 2015;90(6):919–21.
16. Lima EVA, Lima MMDA, Paixão MP, et al. Assessment of the effects of skin microneedling
as adjuvant therapy for facial melasma: a pilot study. BMC Dermatol. 2017;17:1–6.
17. Lima EVA. Dermal tunneling: a proposed treatment for depressed scars. An Bras Dermatol.
2016;91(5):697–9.
18. Lima EVA. Indução percutânea de colágeno com agulhas em cicatrizes após acidentes automobilísticos: correção cosmética e funcional. Surg Cosmet Dermatol. 2017;9(2):127–9.
19. Lima EVA. Dermal Tunneling (TD®): a therapeutic option for static glabellar wrinkles. Surg
Cosmet Dermatol. 2016;8(1):42–5.
20. Lima EVA. Pulsed radiofrequency with multineedles (RFPM®) in the treatment of atrophic
stretch marks. Surg Cosmet Dermatol. 2016;8(3):242–5.
21. Lima EVA, et al. Induction of pigmentation through microneedling in stable localized Vitiligo
patients. Dermatol Surg. 2020;46(13):434–5.
22. Lima EA, Lima MA, Araújo CEC, Nakasawa YMM, Leal NC. Investigation on the use of 3%
and 5% retinoic acid in peeling solution as a drug delivery agent after percutaneous induc-
318
23.
24.
25.
26.
27.
28
PCI Associated with Multi-needle Radiofrequency for the Treatment of Periorbital…
tion of collagen with needles (IPCA®): safety profile and application protocol. Surg Cosmet
Dermatol. 2018;10(1):21–6.
Lima EAV. Pulsed radiofrequency with multineedles: a therapeutic proposal for wrinkles, sagging, and periorbital pigmentation. Surg Cosmet Dermatol. 2015;7(3):223–6.
Lima EVA. Association of microneedling with phenol peeling: a new therapeutic approach for
sagging, wrinkles and acne scars on the face. Surg Cosmet Dermatol. 2015;7(4):328–31.
Lima EVA. Pulsed radiofrequency with multineedles for earlobe aging treatment. Surg Cosmet
Dermatol. 2016;8(4):307–10.
Lima EVA. Indução percutânea de colágeno com agulhas (IPCA®) associada a radiofrequência pulsada com multiagulhas (RFPM®) na condução de cicatrizes de acne deprimidas: protocolo de tratamento. Surg Cosmet Dermatol. 2017;9(3):234–6.
Orentreich DS, Orentreich N. Subcutaneous incisionless (subcision) surgery for the correction
of depressed scars and wrinkles. Dermatol Surg. 1995;21(6):543–9.
Chapter 29
PCI Associated to Multineedle
Radiofrequency for Treatment of Scars
29.1
undamentals of the Use of Multineedle
F
Radiofrequency (MNR) in Scars
Scarring lesions can result from inflammatory processes, accidents, surgeries, and
present varied characteristics, which contemplate both changes in color and change
in skin texture, as well as compromising the revelation and distortion by retraction.
Cystic acne often results in scars that are difficult to treat. The consumption of the
dermis and hypodermis, as well as the deterioration of the epidermis resulting from
the destructive action of inflammatory cytokines, often leads to depressed, elevated
dystrophic lesions, loss of pigment, and hyperpigmentation, in addition to flaccidity
and development of superficial and deep rhytides (Fig. 29.1). This polymorphism,
commonly observed in severe and prolonged post-inflammatory acne patients, presents itself as a therapeutic challenge. To this end, there is a need to particularly
evaluate these lesions, examining their architecture and directing the most specific
intervention option to the correction of each healing unit. See classification by
Bogdana Kadunc and Ada Trindade (2013).
We often observe the need to associate techniques in the same individual, to aim
the optimization of results. We consider surgical interventions such as Subcision®,
micrografts, shavings, excisions, and ablative techniques often necessary for the
most severe cases. Figures 29.2, 29.3, and 29.4 present patients treated with these
interventions. Ablative treatments such as chemical peelings and light technologies,
as referenced in previous chapters, offer a collagen stimulus at the expense of
removing the epidermis. Multineedle radiofrequency (MNR) proposes a neocollagenesis with preservation of this noble structure.
Even the widest and deepest scars will respond to microneedles, considering that
the more superficial and narrower they are, the better the therapeutic result obtained.
High scars will also respond to MNR, as well as dystrophic, flat, and dyschromic
scars. The degree of improvement is also variable and depends on the severity of
The Editor(s) (if applicable) and The Author(s), under exclusive license
to Springer Nature Switzerland AG 2021
E. Lima, M. Lima, Percutaneous Collagen Induction With Microneedling,
https://doi.org/10.1007/978-3-030-57541-0_29
319
320
29
PCI Associated to Multineedle Radiofrequency for Treatment of Scars
Fig. 29.1 Three patients who had accentuated acne scars by the natural process of aging
Fig. 29.2 Patient with non-distinguishable depressed acne scars treated with phenol 88% scored
in two sessions with interval of 30 days
these injuries. Roughly speaking, we can compare this rupture to that which would
occur with the release of cords that produce the “capitonê” aspect as a pillow.
Similar to what occurs with Subcision®, which acts in windshield movements, or
the proposal of dermal tunneling (DT), which acts in shuttle movements, PCI and
MNR needle epidermis and dermis, leading to partial destruction of fibrosis of the
treated area. In older individuals, intrinsic aging and photodanus worsen the appearance of scars. Added to the laxity and the redistribution of fat on the face, there is an
accentuation of the unaesthetic aspect. It should be reported that even when the
patient is submitted to procedures that remove skin leftovers, attenuating flaccidity,
and wrinkles, the resulting skin must offer a good appearance, and this translates
into tissue renewal, the result of an intervention based on neocollagenesis and
neoangiogenesis.
Despite volumerizing the region consumed by previous inflammation, the fillers
cannot achieve good results, since there is a need to intervene particularly in each
29.1 Fundamentals of the Use of Multineedle Radiofrequency (MNR) in Scars
321
Fig. 29.3 Patient with shallow depressed acne scars treated with surgical abrasion
Fig. 29.4 Patient with acne dystrophic scars treated with micrografting
scars before. In the presence of the fibrotic beams, the filler will be incarcerated, not
fulfilling its role with excellence, and may offer an unnatural aspect to the treated
region. Therefore, the author guides the use of MNR associated or not with PCI and/
or DT as an initial step in the approach to acne scars, regardless of characteristics
and architectural scar classification. The author’s 20-year experience in the treatment of acne scars is accompanied by experiments with radiofrequency apparatus
and epilation needle in depressed scars, intuitively.
Figure 29.5 presents a patient treated in this way in 2006. It is worth noting that
the device currently available for this purpose, using a single pulse randomized
energy fractionation, offers much more security and more predictable and better
results.
322
29
PCI Associated to Multineedle Radiofrequency for Treatment of Scars
Fig. 29.5 Patient treated with radiofrequency randomized to correct depressed scars
29.2
Applicability of MNR in Scars
We are facing an intervention that aims to regenerate traumatized skin, replacing
damaged dermis and epidermis with new tissue. Additionally, we observed a potential of MNR to release fibrotic cords that traction vertically or horizontally to adjacent skin. Thus the healthy edges of the skin that border the scars will be released,
offering in some cases a functional gain to the region. MNR has its own methodology and instruments, designed by dermatologist Emerson Lima, who has been
studying radiofrequency for over 20 years and has developed an authorial sequential, using specific electrodes. The use of the electrodes Lima 8, Lima 4, or Lima 2
is necessary for the execution of MNR (see Chap. 28). The choice of one will
depend on the architectural pattern of the scar to be treated. These electrodes consist
of 2.0 mm needles, which go beyond the epidermis and also act on the dermis,
where the damage is installed. In Fig. 29.6 observe a patient with undistinguishable
29.2
Applicability of MNR in Scars
323
Fig. 29.6 Patient with undistinguishable depressed acne scars before and after an MNR session,
showing superficialization of the lesions
a
b
c
Fig. 29.7 Before (a) and the patient’s evolution after 30 days (b) (area still violated) and after
90 days, (c) with the maturation of the new collagen produced
depressed acne scars before and after an MNR session, showing superficialization
of the lesions (Fig. 29.7).
29.2.1
Step-by-Step
The following is a methodological sequence based on our experience and previous
evaluations in an attempt to standardize and reproduce results.
• Patient assessment. The scars should be evaluated for their architectural features.
The scars that best respond to MNR are the depressed ones. Those undistinguishable, difficult to improve, also respond well to the stimulus with MNR. It is mandatory the preparation with lighteners and sunscreen. The wider and deeper the
scar, the more modest the response. The choice of the electrodes Lima 2, Lima 4,
or Lima 8 depends on the shape and characteristic of the lesion. Rigidity and
coloring are also limiting factors of response. In older individuals, the more
324
•
•
•
•
•
•
29
PCI Associated to Multineedle Radiofrequency for Treatment of Scars
e­ lastotic the skin, the greater the evidence of resistance. We recommend that the
electro rests on the patient’s skin at a 90 ° angle, without pressure. Commonly,
facial lesions are more responsive to MNR when compared to those found on the
chest or back; the latter need more interventions, and more cautiously, to offer
the same result as the former. The procedure should be performed in a surgical
environment and with all the safety measures recommended in previous chapters.
Instrumental. In order to make MNR effective safely and with predictable results,
it is mandatory to use the FRAXX device and the Lima 2, 4, or 8 tips. No other
type of electrode or the use of these electrodes in other machines is recommended, which may offer serious risks of complications. The MNR technique, as
already mentioned, has been exhaustively tested by the author, who considers it
reproducible as long as it follows this sequence.
Demarcation of the scars to be addressed. If they are not clearly visible with the
light of the environment or the aid of surgical focus, it is suggested to mark with
a white pencil all the way, avoiding losing the limits after the infiltrative
anesthesia.
Anesthesia. Topical anesthesia is poorly tolerated. The use of infiltrative anaesthesia is recommended. Here we suggest a solution of lidocaine 2% 1:1 of saline
0.9%, avoiding exceeding the maximum dose allowed (see Chap. 4, “Analgesia
and Anesthesia”).
Systematic procedure. After cleaning with 2% chlorhexidine and anesthesia of
the lesions, the FRAXX device is used in CUT and single pulse, with an average
power of 30 W and active in 30 ms. When the injuries are less than 2.5 mm, it is
recommended to position the Lima 2 tip. Wider lesions may benefit from the
Lima 4 electrode. Linear scars should preferably be treated with the Lima 8 electrode. It is recommended to perform only one pass, avoiding overlap, and, for
this, micropunctures with an average distance of 1 mm from one hole to the other
are performed. The area should be fully contemplated by the needles. The bleeding is modest, but it happens. After 10 minutes of the end of the intervention, a
significant reduction in bleeding can already be observed, which gives rise to a
serous exudation that gradually regresses in the first 4 hours.
Immediate postoperative. After the procedure there is no need to use gauze; the
patients receive a bandage with microporated adhesive tape, removed the next
day. Topical or systemic antibiotics are not recommended. For the postoperative
period, the use of skin regenerator two times/day and industrialized sunscreen
with SPF 60 is recommended. Cryotherapy or hot compresses are not indicated.
We prefer that the accommodation of the bruises and the inflammatory response
resulting from their presence follow their natural course. Nor is the use of topical
or systemic corticotherapy recommended to contain the expected effects of the
self-limited inflammatory process. It is recommended to propose a second or
third intervention only after assessing the lesions at least 30 days after the first
approach. It is considered 90 days an ideal period to propose the next session.
Use of lightening creams. It is recommended after reepithelialization which
takes place within 24–48 hours of intervention. Varies from 2 to 7 days, ­depending
29.2
•
•
•
•
•
Applicability of MNR in Scars
325
on the type of scar treated. That is why close monitoring by the dermatologist,
knowledgeable and qualified for this type of evolution, is crucial.
Postoperative evolution and care. The dressing can be removed at home by the
patient himself, wetting him in the shower the same day or the next day, when the
treated area can be sanitized with liquid soap with low detergency potential,
avoiding sensitization. When the area treated is limited, it is possible to apply
sunscreen already on the first day, without the need for a regenerating balm.
When ample, it is recommended to add this adjuvant until reepithelialization.
Lightening creams can be used already in the first days, depending on the
patient’s tolerance. The light restriction is oriented. Edema and hematoma in the
post-procedural healthy days are moderate. In the author’s practice, the patient
will be able to return to his laboratory activities around the fifth postoperative
day, but some patients already return in the first 24 hours, mainly if the treated
area is covered. Figures 29.8, 29.9, 29.10, 29.11, and 29.12 show patients
treated by MNR.
Complementary techniques. If the dermatologist wishes to use a filler as hyaluronic acid, we recommend that this intervention be scheduled for at least
15 days after the MNR, making sure that the edema has completely receded. The
application of botulinum toxin in the author’s practice is safe already after
15 days of this intervention. Do not apply the botulinum toxin at the same surgical time. Adverse effects may occur during the edema, due to the increased diffusion of the toxin’s action halo, reaching muscle fibers alien to the proposal.
The association with DT and PCI can happen at the same surgical time, if the
patient has indication.
Complications. They are much more related to expected effects such as edema,
bruising, transient post-inflammatory hyperpigmentation, and transient erythema. Taking due care in the preparation of the skin, establishing the attention
to the postoperative recommendations with rigor, the MNR presents itself, for
acne scars, as a safe and reproducible technique, provided that the operator is
duly qualified and trained.
Pain and discomfort. The post-op is quiet. The author’s experience ensures that
pain is not a common complaint and, if present, should warn of secondary infection especially if installed after 48 hours of intervention. Commonly there is no
need for analgesic or anti-inflammatory postoperative, but if there is a complaint
of discomfort, without any other aggravating factor, dipyrone 1 g is recommended every 6 hours.
Prophylaxis for herpes. It is not routinely recommended, as it is not an ablative
intervention, which removes the epidermis completely and consequently allows
infection by an organism that needs the keratinocyte integrity to proliferate.
However, in cases where the frequent and recalcitrant character of the viral infection is identified, we consider it mandatory, taking into account mainly surgical stress.
326
29
PCI Associated to Multineedle Radiofrequency for Treatment of Scars
Figs. 29.8, 29.9, 29.10, 29.11, and 29.12 Patients treated by a single session of MNR after 90 days
29.3 Final Considerations
327
Fig. 29.8, 29.9, 29.10, 29.11, and 29.12 (continued)
29.3
Final Considerations
The wide therapeutic arsenal currently available for the treatment of scars has
enabled the association of techniques seeking the optimization of results. The use of
interventions that do not generate complete deepithelialization has been gaining
more and more space, for safety and recovery time. We propose MNR for the treatment of scars, a methodology developed and studied in detail over the last year,
using specific electrodes, based on results obtained in the treatment of periorbital
aging, stretch marks, and wrinkles. The author concludes that:
• MNR is a promising therapeutic proposal for the treatment of various forms of
scarring
• A thorough knowledge of these lesions is essential so that the indication alone or
in association with the technique offers the cosmetic results obtained by the author
• In the author’s conception, the results achieved can be reproduced using the
methodology and the electrodes presented here with precision
• The rapid return to activities and the few adverse effects observed in the evaluated group encouraged the author to recommend the inclusion of this new
328
29
PCI Associated to Multineedle Radiofrequency for Treatment of Scars
p­ roposal in the broad therapeutic arsenal already available for interventions in
this region
• Post-inflammatory hyperpigmentation, although reversible, deserves special
attention and the author always recommends preparing the skin before the intervention with lighteners and resuming it soon after the reepithelialization is
established
• The procedure requires training and is technical-dependent. The operator must
be properly enabled and have all the basic knowledge necessary to guarantee the
excellence of the results.
Sources
1. Aust MC. Percutaneous collagen induction therapy: an alternative treatment for scars, wrinkles, and skin laxity. Plast Reconstr Surg. 2008;121(4):1421–9.
2. Bal SM, Caussian J, Pavel S, Bouwstra JA. In vivo assessment of safety of microneedle arrays
in human skin. Eur J Pharm Sci. 2008;35(3):193–202.
3. Brody HJ. Trichloroacetic acid application in chemical peeling, operative techniques. Plast
Reconstr Surg. 1995;2(2):127–8.
4. Camirand A, Doucet J. Needle dermabrasion. Aesthet Plast Surg. 1997;21(1):48–51.
5. Cohen KI, Diegelmann RF, Lindbland WJ. Wound healing: biochemical and clinical aspects.
Philadelphia: WB Saunders Co; 1992.
6. Fabroccini G, Fardella N. Acne scar treatment using skin needling. Clin Exp Dermatol.
2009;34(8):874–9.
7. Fernandes D, Massimo S. Combating photoaging with percutaneous collagen induction. Clin
Dermatol. 2008;26(2):192–9.
8. Fernandes D. Minimally invasive percutaneous collagen induction. Oral Maxillofac Surg Clin
North Am. 2006;17(1):51–63.
9. Lima EVA, Lima MMDA, Paixão MP, et al. Assessment of the effects of skin microneedling
as adjuvant therapy for facial melasma: a pilot study. BMC Dermatol. 2017;17:1–6.
10. Lima EA. Microneedling in facial recalcitrant melasma: report of a series of 22 cases. An Bras
Dermatol. 2015;90(6):919–21.
11. Lima EVA, et al. Induction of pigmentation through microneedling in stable localized vitiligo
patients. Dermatol Surg. 2020;46(13):434–5.
12. Lima EA. Microagulhamento em melasma facial recalcitrante: uma série de 22 casos. Na Bras
Dermatol. 2015;90(6):917–9.
13. Lima EA, Lima M, Takano D. Microneedling experimental study and classification of the
resulting injury. Surg Cosmet Dermatol. 2013;5:110–4.
14. Lima EVA. Dermal tunneling: a proposed treatment for depressed scars. An Bras Dermatol.
2016;91(5):697–9.
15. Lima EVA. Indução percutânea de colágeno com agulhas em cicatrizes após acidentes automobilísticos: correção cosmética e funcional. Surg Cosmet Dermatol. 2017;9(2):127–9.
16. Lima EVA. Dermal tunneling (TD®): a therapeutic option for static glabellar wrinkles. Surg
Cosmet Dermatol. 2016;8(1):42–5.
17. Lima EVA. Pulsed radiofrequency with multineedles (RFPM®) in the treatment of atrophic
stretch marks. Surg Cosmet Dermatol. 2016;8(3):242–5.
18. Lima EA, Lima MA, Araújo CEC, Nakasawa YMM, Leal NC. Investigation on the use of 3%
and 5% retinoic acid in peeling solution as a drug delivery agent after percutaneous induction of collagen with needles (IPCA®): safety profile and application protocol. Surg Cosmet
Dermatol. 2018;10(1):21–6.
Sources
329
19. Lima EAV. Pulsed radiofrequency with multineedles: a therapeutic proposal for wrinkles, sagging, and periorbital pigmentation. Surg Cosmet Dermatol. 2015;7(3):223–6.
20. Lima EVA. Association of microneedling with phenol peeling: a new therapeutic approach for
sagging, wrinkles and acne scars on the face. Surg Cosmet Dermatol. 2015;7(4):328–31.
21. Lima EVA. Pulsed radiofrequency with multineedles for earlobe aging treatment. Surg Cosmet
Dermatol. 2016;8(4):307–10.
22. Lima EVA. Indução percutânea de colágeno com agulhas (IPCA®) associada a radiofrequência pulsada com multiagulhas (RFPM®) na condução de cicatrizes de acne deprimidas: protocolo de tratamento. Surg Cosmet Dermatol. 2017;9(3):234–6.
23. Orentreich DS, Orentreich N. Subcutaneous incisionless (subcision) surgery for the correction
of depressed scars and wrinkles. Dermatol Surg. 1995;21(6):543–9.
Chapter 30
PCI on Ethnic Skin
30.1
Introduction
Melanin is the major determinant of skin color; its concentration of melanosomes in
dark skins is as much as double compared to light skins. There is also an increase in
tyrosinase activity, producing more melanin and presenting a particular response to
ultraviolet (UV) exposure.
When an intervention is made in Afrodescendant patients, the most significant
difference in relation to Caucasians, for example, corresponds to the amount of
melanin. This peculiarity of ethnic skin requires special attention from the dermatologist when choosing a treatment for scars, stretch marks, cellulite, wrinkles, flaccidity, and bleaching of spots, as well as extra care in the preparation, during
treatment and post-procedure, in order to avoid complications. It is worth noting
that in a mixed country like Brazil, where the majority of the population is ethnically diverse, interventions will always be subject to unexpected effects, even on
skins considered less susceptible to complications.
Not even the most traditional classification of phototypes idealized by Thomas
Fitzpatrick (I to VI) meets the range of ethnic differences that exists in Brazil.
Therefore, procedures that preserve the melanin reservoir of the skin – the epidermis – are considered to offer less risk of adverse effects. Ablative procedures that
completely remove the epidermis commonly offer greater risks of dyschromias and
scars to the ethnic skin and should be evaluated very carefully. This warning is also
valid for technologies with lights.
Current interventions seek fractional skin damage, allowing the integrity of the
microregion adjacent to the trauma to remain intact, which favors a shorter recovery
time and a lower risk of complications. The fractional CO2 laser comprises an
example of this proposal; however, due to the heating it offers, it is still subject to
dyschromias.
The Editor(s) (if applicable) and The Author(s), under exclusive license
to Springer Nature Switzerland AG 2021
E. Lima, M. Lima, Percutaneous Collagen Induction With Microneedling,
https://doi.org/10.1007/978-3-030-57541-0_30
331
332
30.2
30
PCI on Ethnic Skin
PCI
The percutaneous induction of collagen with needles presents a proposal to stimulate the production of collagen, without causing the deepithelialization observed in
ablative techniques and without the heating of lights. The epidermis and dermis are
perforated but not removed. Figure 30.1 presents a patient with non-distinguishable
depressed scars, difficult to manage, treated with a single session of PCI, with deep
injury (Emerson Lima Classification 2013). Figure 30.2 shows the same patient,
4 years after the intervention, showing the maintenance of results.
a
b
Fig. 30.1 Patient before (a) and after 30 days of PCI treatment (b)
a
b
Fig. 30.2 Patient before (a) and after 4 years of PCI (b) treatment
30.2 PCI
333
Deep wrinkles resulting from the evolution of elastosis in photoaged skin, which
often behave as deep scars difficult to treat, can also be improved by needles.
Microneedles break the stiffness and stiffness often seen in deep static wrinkles,
such as those in the perioral, periorbital, and forehead regions, especially in individuals with thick, seborrheic skin, as well as in smokers.
In cases of scarring lesions, these needles promote micropunctures at the bottom
of the scars, modifying their surface and destructuring the abnormal collagen, which
favors neovascularization and neoangiogenesis, in the same way as microneedles.
The depressed scars, even the widest and deepest, will respond to the needles.
However, the more superficial and narrower, the better the therapeutic result
obtained.
The detachment of the bottom of scars and deeper wrinkles may sometimes
require the combination of other interventions. Dermal tunneling (DT) proposes the
rupture of fibrotic cords, also with epidermal preservation. This technique is a variant of Subcision™, which uses its own instruments and methodology. Figures 30.3
and 30.4 present patients treated by single session of DT for stretch marks and acne
scar, respectively.
High scars also respond to PCI. The degree of improvement is variable and
depends on the severity of the lesions, i.e., the higher the degree of cosmetic gain.
In such cases, cautiously associating intense pulsed light (IPL) and PCI can improve
the results, as well as using injectable corticosteroids, in the same surgical act,
immediately before proceeding with PCI and IPL. Figure 30.5 demonstrates this
association in a patient with periareolar keloid injury. It is also possible to perform
tangential excision prior to PCI. Figure 30.6 shows patients who benefited from PCI
alone for scarring, melasma, and post-inflammatory hyperpigmentation.
Fig. 30.3 Patient before
and after PCI treatment for
old stretch marks
334
30
PCI on Ethnic Skin
Fig. 30.4 Patient before and after PCI treatment for acne scar
a
b
Fig. 30.5 Patient before and after association of PCI and IPL in periareolar keloid injury
30.3
Radiofrequency Pulsed with Multi-needles
Associating radiofrequency with microneedles has proven effective on ethnic skin.
Despite the increased risk of dyschromias from heating, the fractionation of pulsed
energy offered by the technique has made good safety possible. The darkening during the healing evolution is reverted in a short time with the help of lightening
creams. Figure 30.7 presents an afro-descending patient before, in the immediate
postoperative period and 60 days after multi-needle radiofrequency (MNR) to treat
neck flaccidity, and Fig. 30.8 shows a patient 45 days after if they are unique to MNR.
In MNR electrodes of 100 μ of diameter and 2 mm of depth are used, coupled to
the Wavetronic 5000 device, in the single pulse function, with power from 30 to
45 W (in cut) and active in 30 to 45 ms. The electrodes designed by Emerson Lima
may have two, four, or eight needles, named Lima 2, Lima 4, and Lima 8, respectively (Fig. 30.9). Figure 30.10 presents patients with periorbital flaccidity and
hyperpigmentation treated with MNR.
30.3 Radiofrequency Pulsed with Multi-needles
335
a
b
c
d
e
f
Fig. 30.6 (a–j) Patient before and after treatment with PCI
336
30
g
h
i
j
PCI on Ethnic Skin
Fig. 30.6 (continued)
To perform the techniques mentioned, a sequential method was included in previous chapters, detailing the appropriate environment for intervention, anesthesia,
instruments, and care during preparation, during the procedure, and postoperatively.
Figure 30.11 presents the before of a patient who has had lipodystrophy and acne
and melasma scars for more than 30 years and the result after 45 days of an PCI and
DT session. Figure 30.12 shows the before and after of a patient treated with MNR
for dystrophic scars.
337
30.3 Radiofrequency Pulsed with Multi-needles
a
b
c
Fig. 30.7 (a) Patient before intervention presenting with neck flaccidity. (b) Immediate postoperative. (c) Result after 60 days of MNR
a
b
Fig. 30.8 Patient before (a) and after (b) single session MNR
Fig. 30.9 Lima electrodes
338
30
a
b
c
d
e
f
PCI on Ethnic Skin
Fig. 30.10 (a–f) Before and after patients with periorbital flaccidity and hyperpigmentation
treated with MNR
339
Sources
a
b
Fig. 30.11 Patient before (a) and after (b) the association of DT and PCI
Fig. 30.12 Patient before and after MNR treatment for dystrophic scars
Sources
1. Aust MC. Percutaneous collagen induction therapy (PCI) – an alternative treatment for scars.
Wrinkles Skin Laxity. Plast Reconstr Surg. 2008;121(4):1421–9.
2. Bal SM, Caussian J, Pavel S, Bouwstra JA. In vivo assessment of safety of microneedle arrays
in human skin. Eur J Pharm Sci. 2008;35(3):193–202.
3. Brody HJ. Trichloroacetic acid application in chemical peeling, operative techniques. Plast
Reconstr Surg. 1995;2(2):127–8.
4. Camirand A, Doucet J. Needle dermabrasion. Aesthet Plast Surg. 1997;21(1):48–51.
5. Cohen KI, Diegelmann RF, Lindbland WJ. Wound healing: biochemical and clinical aspects.
Philadelphia: W.B. Saunders Co; 1992.
6. Fabroccini G, Fardella N. Acne scar treatment using skin needling. Clin Exp Dermatol.
2009;34(8):874–9.
7. Fernandes D, Massimo S. Combating photoaging with percutaneous collagen induction. Clin
Dermatol. 2008;26(2):192–9.
8. Fernandes D. Minimally invasive percutaneous collagen induction. Oral Maxillofac Surg Clin
North Am. 2006;17(1):51–63.
340
30
PCI on Ethnic Skin
9. Lima EVA, Lima MMDA, Paixão MP, et al. Assessment of the effects of skin microneedling
as adjuvant therapy for facial melasma: a pilot study. BMC Dermatol. 2017;17:1–6.
10. Lima EA. Microneedling in facial recalcitrant melasma: report of a series of 22 cases. An Bras
Dermatol. 2015;90(6):919–21.
11. Lima EVA, et al. Induction of pigmentation through microneedling in stable localized vitiligo
patients. Dermatol Surg. 2020;46(13):434–5.
12. Lima EA. Microagulhamento em melasma facial recalcitrante: uma série de 22 casos. Na Bras
Dermatol. 2015;90(6):917–9.
13. Lima EA, Lima M, Takano D. Microneedling experimental study and classification of the
resulting injury. Surg Cosmet Dermatol. 2013;5:110–4.
14. Lima EVA. Dermal tunneling: a proposed treatment for depressed scars. An Bras Dermatol.
2016;91(5):697–9.
15. Lima EVA. Indução percutânea de colágeno com agulhas em cicatrizes após acidentes automobilísticos: correção cosmética e funcional. Surg Cosmet Dermatol. 2017;9(2):127–9.
16. Lima EVA. Dermal Tunneling (TD®): a therapeutic option for static glabellar wrinkles. Surg
Cosmet Dermatol. 2016;8(1):42–5.
17. Lima EVA. Pulsed radiofrequency with multineedles (RFPM®) in the treatment of atrophic
stretch marks. Surg Cosmet Dermatol. 2016;8(3):242–5.
18. Lima EA, Lima MA, Araújo CEC, Nakasawa YMM, Leal NC. Investigation on the use of 3%
and 5% retinoic acid in peeling solution as a drug delivery agent after percutaneous induction of collagen with needles (IPCA®): safety profile and application protocol. Surg Cosmet
Dermatol. 2018;10(1):21–6.
19. Lima EAV. Pulsed radiofrequency with multineedles: a therapeutic proposal for wrinkles, sagging, and periorbital pigmentation. Surg Cosmet Dermatol. 2015;7(3):223–6.
20. Lima EVA. Association of microneedling with phenol peeling: a new therapeutic approach for
sagging, wrinkles and acne scars on the face. Surg Cosmet Dermatol. 2015;7(4):328–31.
21. Lima EVA. Pulsed radiofrequency with multineedles for earlobe aging treatment. Surg Cosmet
Dermatol. 2016;8(4):307–10.
22. Lima EVA. Indução percutânea de colágeno com agulhas (IPCA®) associada a radiofrequência pulsada com multiagulhas (RFPM®) na condução de cicatrizes de acne deprimidas: protocolo de tratamento. Surg Cosmet Dermatol. 2017;9(3):234–6.
23. Orentreich DS, Orentreich N. Subcutaneous incisionless (subcision) surgery for the correction
of depressed scars and wrinkles. Dermatol Surg. 1995;21(6):6543–9.
Index
A
Abdomen retractile scar, 137
Ablative techniques, 133
Accident scars, 123, 125, 126
architectural polymorphism of post-­
accident scars, 123
atrophic and acromatic scars, 129
complementary techniques, 130
complications, 130
evolution, 129
needle techniques
dynamic assessment, 127
instrumental, 127
patient assessment, 126
static evaluation, 126
transoperative, 127
periorbital scar secondary to motorcycle
accident, 129
post immediate surgery, 128
supercilium, scar on, 129
transoperative for post-mastoplasty scar
correction, 128
Achromias
anesthesia, 241, 242
evaluation, 243
instruments, 241
patient selection, 240, 241
transurgery, 242, 243
after surgery, 243
Acne scars, 60, 64, 65, 109, 113, 114, 116,
200, 261, 262, 320, 334
applicability of PCI
deep injury, 115, 116, 119
flaccidity and needle length, 115
scar characteristics, 115
skin thickness, 114, 115
complementary techniques, 117, 120
complications, 118
dermal tunneling (DT), 281, 283, 284
immediate post-operative, 117
instrumental, 117
morphological classification of, 109
patient assessment, 117
PCI, 113
postoperative care, 117
and stretch marks scars, 64, 65
surgical abrasion, 110–112
Adequate anamnesis, 50
Aging skin
applicability of PCI, 80
deep injury, 83
asepsis and anesthesia of the
area, 84
complementary techniques, 85
complications, 85
evolution and post-operative care, 84
instruments, 83
patient assessment, 83
post immediate surgery, 84
prophylaxis for herpes, 85
transerperative, 84
flaccidity, 81, 82
moderate injury, 85
PCI fundamentals in, 77–81
skin thickness, 80, 81
wrinkle depth, 81, 82
The Editor(s) (if applicable) and The Author(s), under exclusive license
to Springer Nature Switzerland AG 2021
E. Lima, M. Lima, Percutaneous Collagen Induction With Microneedling,
https://doi.org/10.1007/978-3-030-57541-0
341
342
Alopecia
androgenetic, 208, 209
contraindications and adverse effects,
212, 214
IPCA with drug delivery, 210–214
therapeutic proposal, 214
Aminoamides, 28
Aminoesters, 28
Aminolevulinic acid (ALA), 189
Androgenetic alopecia, PCI, 208–211
Anesthetic group, 29
Anesthetics, in local infiltration, 32
Antisepsis, 228
Architectural polymorphism of acne scars,
141, 280
Arm scar, 135
Ascorbyltetraisopalmitate, 52
Asepsis, 117, 127, 135, 147, 179
Atrophic, buttock acromial stretch marks, 165
Atrophic stretch marks, 164, 169
B
Bacterial infection, 75
Basal membrane restructuring (PAS), 92
β-catenine, 209
Beta tissue growth factor (TGF-β), 1
Betacaine® LA, 38
Biocellulose, 54, 56
Biostimulator, 200, 202, 203
Bone eminence, 12
Botulinum toxin, 133, 198, 199, 201–204, 290
Breast scar, 134
Bundles of collagen, 92
Burning and awareness, 74, 75
C
Calcium hydroxyapatite, 201
Carboxytherapy, 65
Cellulitis, 173
assepsis and anesthesia, 179
buttocks and thighs affected by, 175
cellulite ratios, 178
classification of, 176
complementary techniques, 180
complications, 180
deep injury, 179
etiopathogeny, 175, 176
evolution and postoperative care, 180
flaccidity and needle length, 178
grade IV, 181–183
immediate postoperative, 180
Index
instrumental, 179
pain and discomfort, 181
patient assessment, 179
PCI fundamentals in treatment, 176, 177
preferential location of, 174
prophylaxis for herpes, 182
skin thickness, 178
Subcision™, 175, 177
transoperative, 180
Cervical keloid scar, 154
Chronic eczematization, 142
Cosmetic gain, 124
Cosmetic scar improvement, 124
Crusts, 73, 74
Cryosurgery, 153
Cryotherapy, 229
Cystic acne, 109
D
Damaged dermal collagen, 142
Deep injury, 83, 115, 116, 119, 145, 156, 167
asepsis and anesthesia of the area, 84
complementary techniques, 85
complications, 85
evolution and post-operative care, 84
instruments, 83
patient assessment, 83
post immediate surgery, 84
prophylaxis for herpes, 85
transerperative, 84
Deep static wrinkles, 290
Deep wrinkles, 81, 333
Deepithelialization, 70, 142, 176, 283
Depigmented lesions, rational use of PCI
in, 235–238
Depressed acne scars, 323
managing complications in PCI, 75
Dermal tunneling (DT), 113, 119, 125, 133,
143, 155, 179, 228, 229, 231, 320,
333, 339
acne scars, 281, 283, 284
advantages, 275
depressed scars, 284–286
cleaning and anesthesia of the area, 282
evolution and postoperative care, 283
immediate post-operative, 283
instrument, 281
transoperative, 282
disadvantages, 276
evolution and postoperative care, 273
for static wrinkles treatment, 289, 295, 296
antisepsis and anesthesia of area, 291
Index
evaluation, 294, 295
patient assessment, 290
post immediate surgery, 293, 294
transurgical, 292, 293
instrumental, 270
pain and discomfort, 275
post immediate surgery, 272
principles and technique of, 270
in scars, 279
transurgery, 272
Dermaroller™, 19
Dermatoscopy, 190
Dermomax®, 38
Desepithelialization, 142, 164
Desquamation, 74
Destructure fibrosis, 154
Devices for PCI, 19, 20
electromagnetic non-ionising
radiofrequency, 24
micro-needle rollers, 20–23
Diffuse skin scleroderma, 219
Dorsal nasal tumor, 137
Drug delivery, 99
Dyschromia, 72, 111, 113
E
Edema, 70, 71, 149, 227, 284, 306
Elastosis, 11
Electromagnetic non-ionising
radiofrequency, 24
Electrosurgery, 299
Elevated breast scar, 158
Elevated cervical scars, 159
Elevated scar, 158
Elevated scar in abdominal, 160
Elevated shoulder scar, 159
EMLA®, 37, 39
Epidermal keratinocytes, 188
Epilepilation electrode, 302
Epinephrine, 30
Erythema, 73
Ethnic skin, PCI on, 331–334
MNR, 334, 336, 339
Eyelid rejuvenation, 301
F
Facial acne scars, 65, 137
Female pattern hair loss-FPHL, 209
Fibroblasts, 255
Fibrosis, 12
Fitzpatrick's classification, 261, 304
343
Flaccidity, 81, 82, 115, 178
Fluid anhydrous serum, 192
Forehead scar, 138
Fractionated radiofrequency (RF)
microneedle, 24
G
Gel regenerator, 117
Glabella wrinkles, 82
Granulocyte and macrophage colony-­
stimulating factor (GM-CSF), 3
Growth factor release, 208
Gynoid lipodystrophy, 173, 269, 274–276
H
Hematoma, 149, 227, 231, 306, 307
Hematoma, petechiae and purple, 73
Hematoxylin and eosin (H&E), 60
High scar, 153, 154, 319, 333
complications, 157
deep injury, 156
evolution and postoperative care, 157
postoperative care, 157
scar characteristics, 156
transoperative, 156
Human embryonic stem cell drug delivery
(HESC-EPC CM), 188
Hyaluronic acid, 199
Hydroxyapatite/polylactic acid, 200
Hygienization, 54, 271
Hypercromias, 305
Hyperpigmented scar, 89, 90, 100, 101
Hypochromia
anesthesia, 241, 242
evaluation, 243
instrument, 241
patient selection, 240, 241
transurgery, 242, 243
after surgery, 243
I
Immunomodulators, 236
Infections, 75
Infiltration, 13
Infiltrative anesthesia, 31–33
Inflammatory process, 197
Inframammary and breast hypertrophic
scar, 11
Infraorbital nerve block, 41–42
Intense photodane, 252
344
Intense pulsed light (IPL), 247–252
Intrinsic and extrinsic aging process, 307
IPCA®, 126, 147, 150, 156, 157
Isolated and non-isolated micro-needles, 24
Isomorphic response, 236
K
Keloid management, 153
Keloid scars, 155
Keratinocytes, 187, 207, 255
Ki67 immunomarker, 91, 93
Köebner phenomenon, 212
L
Labiogenic groove, 291, 294
Lacrimal nerve block, 42–43
Laparotomy scar patient, 128
Latanoprost, 236
Lidocaine, 30, 34, 38
Lidocaine intoxication, 30
Light needles, 142
Lime electrode, 337
Lima 2 electrode, 300
Lima 4 electrode, 300
Lima 8 electrode, 300, 301, 304, 305
Lima protocol, 88–91, 96, 97, 101–104, 191,
236, 237
Limited skin scleroderma, 219
Lipodystrophy, 200
Liposomal encapsulation, 241
Liposomal encapsulation of lidocaine, 38
Liposomal lidocaine, 38, 242
Local anesthetics, 27–30, 35
chemical structure, 28
in clinical practice, 28
Lupus alopecia, 215
M
Malar scar, 287
Mammoplasty scar, 135
Managing complications in PCI
burning and awareness, 74, 75
crusts, 73, 74
depressed/elevated scars, 75
desquamation, 74
edema, 70, 71
erythema, 73
expected reactions and adverse effects, 70
hematoma, petechiae and purple, 73
infections, 75
Index
pain, 75
PCI vs. ablative interventions, 69–71
post inflammatory hyperpigmentation, 74
Masson Fontana method, 100
Mature melanosomes, 88
Mechanical stimulation, 185, 207
Melanin, 331
Melanogenesis, 91
Melasma, 60–64, 71, 87, 88, 236, 265
in different areas and phototypes, 87
histopathological examination, 88
Lima protocol, 88–91
mechanism of action, 90, 91
methodological sequence
asepsis and anesthesia of area, 93
complications, 96
immediate postoperative, 94
instrumental, 93
pain and discomfort, 97
patient assessment, 92
post-operative evolution and care, 96
prophylaxis for herpes, 97
transoperative, 94
treatment of, 88
Melasma recalcitrant after Lima Protocol
treatment, 102
Mental nerve block, 43–44
Mental scar, 286
Menthrogenic groove, 294, 296
Mentogenian grooves, 291
Mentonian, 44
Mesotherapy, 19, 189
Methylaminolevulinate (MAL), 189
Micro perforations, 207
Microchannels, 185, 207
Micro-needle pens, 23
Micro-needle rollers, 20–23
Microneedle stimulation, 4
Microneedles, 2, 19, 21
Microperforations, 3, 305
Micropore®, 54, 84, 117, 148, 169, 260,
272, 283
Micropunctures, 3, 4, 156, 165, 175, 177, 208,
236, 255, 333
Minimally invasive procedures, 314
Minoxidil, 190, 209, 212
Moderate injury, 85
Moderate post-inflammatory
hyperpigmentation, 262, 304
Multi-needle radiofrequency (MNR), 197,
200, 225, 310–312
complementary techniques, 312
complications, 314
Index
correction of static wrinkles and neck
laxity, 315
ethnic skin, 334, 336, 339
evolution of hematoma, 307
good improvement, 313
hygiene of electrodes, 305
immediate postoperative period, 305, 306
infiltrative anaesthesia, 312
Lima 8 electrode, 304, 305
in perioral region, 307, 309
in periorbital region, 303, 304
post-operative evolution and care, 305
principles, 300, 302, 303
in scars, 319–322
anesthesia, 324
applicability, 322, 323
complementary techniques, 325
complications, 325
demarcation of scars, 324
immediate postoperative, 324
instrumental, 324
lightening creams, 324
pain and discomfort, 325
patient assessment, 323
post-operative evolution and care, 325
prophylaxis for herpes, 325
systematic procedure, 324
skin needs, 309
N
Nasociliary nerve block, 42
Neoangiogenesis, 112, 113, 154, 165
Neocollagenesis, 54, 60, 289, 319
Neocollagenosis, 113, 142
Neovascularized scar, 252
Nerve fibers, 29, 30
Non-ablative fractionated lasers, 142
Normotrophic scars, 157
Nose scar, 138
P
Pain
definition of, 27
and discomfort, 227
managing complications in PCI, 75
Pain management in PCI
ambulatory procedures, 27
ambulatory setting, 27
anesthesia for PCI, 46
anesthetic group, 29
epinephrine, 30
345
infiltrative anesthesia, 31–33
lidocaine intoxication, 30
local acid pH, 31
local anesthetics, 27–30
nerve fibers, 29, 30
peripheral nerve blocks, 40–46
topical anesthesia, 35–37, 39
tumescent anesthesia, 32–34
vasoconstriction, 31
Painful procedure, 13
Papillary dermis, 188
Patient before and after, 120
Peelings, 262–265
assepsis and anesthesia of the area, 266
bacterial growth at the time of dilution, 258
bleaching or depigmentation actives, 257
complications, 267
evolution and postoperative care, 266
instrumental, 265
pain and discomfort, 267
patient assessment, 265
PCI fundamentals with, 255–257
post immediate surgery, 266
postoperative evolution, 261
prophylaxis for herpes, 267
recovery period, 257
retinoic acid, 258
simple herpes preventive antiviral
treatment, 257
solar filter, 257
transurgical, 266
trichloroacetic acid (TCA), 259
Percutaneous needle collagen induction (PCI),
10–12, 16, 17, 25, 105, 119, 185
vs. ablative interventions, 1, 2, 69–71
advantages, 7
bone eminence, 12
characterization of, 5–7
classification
of injury level, 14
intensity of injury, 15
deep bleeding affecting reticular
dermis, 14
different needle lengths, 10
disadvantages, 8
elastosis, 11
fibrosis and scars, 12
flaccidity, 9
live pig skin, 13
maturation, 4
microneedling, histopathological
evidences of, 59
acne and stretch marks scars, 64, 65
Index
346
Percutaneous needle collagen induction (cont.)
immediate microneedle induced tissue
damage, 59
melasma, 61–64
photoaging, 61–64
needle passage path associated with
bleeding, 15
needles with lengths, 13
papillary dermis restricted surface
bleeding, 14
principles of, 2–4
healing, 4
injury, 3
skin thickness, 9
thickness of adipose cushion, 12
vector of force and its intensity, 9
Percutaneous collagen induction with needles
(IPCA®), 19
Percutaneous Needle-Induced Collagen
(IPCA) skin microneedling, 59
Periareolar keloid injury, 334
Periorbital flaccidity and
hyperpigmentation, 338
Peripheral nerve blocks, 40–46
Persistent erythema, 72, 73, 111
Pharmacokinetics, 33
Photoaging, 61–64
Photodane, 248
Photodynamic therapy (PDT) treatment, 189
Photoprotection, 273
Physical methods, 212
Platelet-derived growth factors (PDGF), 209
Platelet-rich plasma (PRP), 212
Pliaglis®, 39
Polychromy, 147
Post-acne conglobata hyperpigmentation, 106
Post-acne inflammatory scars, 279
Post burn scar, 141
adverse effects, 150
applicability of PCI, 145–147
care in technical execution, 147–149
rational use of PCI, 142–144
Post-inflammatory hyperpigmentation (PIH),
61, 69, 74, 99, 100, 111, 127, 134,
179, 284
evaluation and conduct
complications, 105
instrumental, 105
pain and discomfort, 105
patient assessment, 105
prophylaxis for herpes, 105
Lima protocol, 101–104
Post-surgical scars, 133, 134, 136
indications of PCI, 134
instrumental, 135
transurgery, 135, 136
Prilocaine, 34, 44
Pulsed high-frequency electrosurgery,
299, 300
R
Radiofrequency pulsed with multi-­
needles, 334
Recalcitrant melasma, 101
Reepithelialization, 52, 54, 61, 260
Residual erythema, 60
Retinoic acid, 250, 258
Retractile neck scar, 71
Robotic microneedle, 24
Rupture of fibrotic bars, 270
S
S-Caine Patch®, 39
Scar characteristics, 115, 156
Schiff (PAS) periodic acid, 62
Scleroderma, 219
asepsis and anesthesia of area, 226
dermal tunneling (DT), 228, 229, 231
evolution and postoperative care, 226, 227
pathognomonic aspect of the face, 219
pathophysiological mechanisms, 219
patient affected by, 220
rational use of PCI, 220, 222
healing, second phase, 220
injury, first phase, 220
maturation, third phase, 222
technical aspects, 225
treatment protocol, 223, 228
Serosanguinolent exudation, 191
Shoulder scar, 136
Skin aging, see Aging skin
Skin preparation for PCI and postoperative
management, 49, 50
biocellulose, 56
guidelines for deep lesion, 54–56
guidelines for moderate injury, 53, 54
skin care, 51
soap for sensitive skin, 51
sunscreen, 51
topical retinoic acid and alpha-hydroxy
acid (AHA), 52
vitamin C, 52
whitenings, 52
Skin thickness, 80, 81, 178
Index
Solar filter, 257
Static forehead wrinkles, 290
Static wrinkles treatment, DT, 289, 295, 296
antisepsis and anesthesia of area, 291
evaluation, 294, 295
patient assessment, 290
post immediate surgery, 293, 294
transurgical, 292, 293
Stretch marks
area anesthesia, 167
characteristic, 165, 166
deep injury, 167
evolution and care in postoperative, 169
fundamental of, 163–165
instrumental, 167
needle length, 166
patient preparation, 167
postoperative, 169
transoperative, 167–169
Subcision™, 2, 19, 20, 80, 109, 113, 124, 143,
174, 177, 180, 183, 220, 269, 270,
279, 283, 293, 319, 333
Subincision™, 289
Submentonian scar, 12
Substantial edema, 72
Substantial erythema, 111
Sun protection factor (SPF), 102
Sunscreen, 51
Supraorbital and supratrochlear
nerves, 41
Systemic corticotherapy, 50, 128
Systemic intoxication, 44
T
Tacrolimus, 236, 237
Telangiectasis, 61
TGF-COPY3, 222
Toperma®, 39–40
Topical anesthesia, 31, 35–37, 39
Topical corticosteroid, 157
Topical retinoic acid and alpha-hydroxy acid
(AHA), 52
Topical/systemic antibiotics, 56
347
Topical/systemic corticotherapy, 54, 148,
180, 324
Topical tretinoin, 164
Transcutaneous drug delivery, 186
contraindications, 188–190
hollow, with central lumen, 188
indications, 188–190
needle coated with substance, 187
needles dissolve, 187
penetration of active ingredients into the
skin, 186
physical (active) methods, 187
pre and post-treatment
considerations, 190–193
solid needless, 187
Transdermal drug delivery system, 185
Transient erythema, 149
Transpidermal penetration, 187
Transpidermal water loss (TEWL), 191
Triamcinolone, 145, 156, 190, 209
Triamcinolone infiltration, 154
Trichloroacetic acid (TCA), 255, 259
Tumescent anesthesia, 32–34
V
Vaporization, 299
Vasoconstriction, 31
Vitamin C, 52
W
Wavetronic 5000®, 300, 304
Whitenings, 52
Wnt proteins, 209
Wrinkle depth, 81, 82
X
Xerose, 142
Z
Zygomatic nerve block, 43