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English Pages XIX, 347 [346] Year 2021
Percutaneous Collagen Induction With Microneedling A Step-by-Step Clinical Guide Emerson Lima Mariana Lima
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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 (eBook) https://doi.org/10.1007/978-3-030-57541-0 © 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
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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
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Contents
1 Fundamentals of Percutaneous Collagen Induction (PCI) with Needles������������������������������������������������������������������������������������������������������ 1 1.1 Percutaneous Needle Collagen Induction (PCI) Versus Ablative Procedures�������������������������������������������������������������� 1 1.2 Principles of the PCI Technique�������������������������������������������������������� 2 1.3 Characteristics of the PCI Technique������������������������������������������������ 5 1.4 PCI Advantages�������������������������������������������������������������������������������� 7 1.5 Disadvantages of PCI������������������������������������������������������������������������ 8 Sources������������������������������������������������������������������������������������������������������ 8 2 Classification and Characteristics of the Injury Provoked by PCI ���� 9 2.1 Level of the Injury and Its Relationship to the Length of the Needle������������������������������������������������������������������������ 9 2.2 Classification of Injury Level������������������������������������������������������������ 14 2.3 Final Considerations ������������������������������������������������������������������������ 15 Sources������������������������������������������������������������������������������������������������������ 17 3 Devices for PCI���������������������������������������������������������������������������������������� 19 3.1 Available Devices������������������������������������������������������������������������������ 20 3.1.1 Microneedle Rollers�������������������������������������������������������������� 20 3.1.2 Microneedle Pens������������������������������������������������������������������ 23 3.1.3 Microneedles Associated with Technologies������������������������ 24 3.2 Final Considerations ������������������������������������������������������������������������ 25 Sources������������������������������������������������������������������������������������������������������ 25 4 Pain Management in PCI: Analgesia and Anesthesia�������������������������� 27 César Romão 4.1 Local Anesthetics������������������������������������������������������������������������������ 27 4.1.1 Infiltrative Anesthesia ���������������������������������������������������������� 31 4.2 Tumescent Anesthesia���������������������������������������������������������������������� 32 4.2.1 Topical Anesthesia���������������������������������������������������������������� 35 4.2.2 TAC �������������������������������������������������������������������������������������� 37 xi
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4.2.3 LET �������������������������������������������������������������������������������������� 38 4.2.4 Dermomax® ������������������������������������������������������������������������ 38 4.2.5 Betacaine® LA �������������������������������������������������������������������� 38 4.2.6 Tetracaine 4%������������������������������������������������������������������������ 38 4.2.7 S-Caine Patch®�������������������������������������������������������������������� 39 4.2.8 Pliaglis® ������������������������������������������������������������������������������ 39 4.2.9 Toperma® ���������������������������������������������������������������������������� 39 4.2.10 Peripheral Nerve Blocks ������������������������������������������������������ 40 4.2.11 Blocking the Supraorbital and Supratrochlear Nerves���������� 41 4.2.12 Infraorbital Nerve Block ������������������������������������������������������ 41 4.2.13 Nasociliary Nerve Block������������������������������������������������������ 42 4.2.14 Lacrimal Nerve Block���������������������������������������������������������� 42 4.2.15 Zygomatic Nerve Block�������������������������������������������������������� 43 4.2.16 Mental Nerve Block�������������������������������������������������������������� 43 4.3 Local Anesthetic Intoxication ���������������������������������������������������������� 44 4.3.1 Special Features of Anesthesia for PCI�������������������������������� 46 Sources������������������������������������������������������������������������������������������������������ 46 5 Preparing the Skin for PCI and Postoperative Management�������������� 49 5.1 Skin Care That Favors Treatment ���������������������������������������������������� 51 5.2 Detailing the Guidelines for Moderate Injury���������������������������������� 52 5.3 Detail of the Guidelines for Deep Lesion ���������������������������������������� 54 5.4 Biocellulose in Post-procedure �������������������������������������������������������� 56 5.5 Closing Considerations �������������������������������������������������������������������� 57 Sources������������������������������������������������������������������������������������������������������ 57 6 Histopathological Evidences of the Percutaneous Collagen Induction with Microneedling������������������������������������������������ 59 Helio Miot 6.1 Introduction�������������������������������������������������������������������������������������� 59 6.2 Photoaging and Melasma������������������������������������������������������������������ 61 6.3 Acne and Stretch Mark Scars������������������������������������������������������������ 64 Sources������������������������������������������������������������������������������������������������������ 65 7 Managing Complications in PCI������������������������������������������������������������ 69 7.1 PCI Versus Ablative Interventions���������������������������������������������������� 69 7.2 Expected Reactions and Adverse Effects������������������������������������������ 70 7.2.1 Edema ���������������������������������������������������������������������������������� 70 7.2.2 Erythema ������������������������������������������������������������������������������ 73 7.2.3 Hematoma, Petechiae, and Purple���������������������������������������� 73 7.2.4 Crusts������������������������������������������������������������������������������������ 73 7.2.5 Post-inflammatory Hyperpigmentation�������������������������������� 74 7.2.6 Desquamation ���������������������������������������������������������������������� 74 7.2.7 Burning and Awareness�������������������������������������������������������� 74 7.2.8 Infections������������������������������������������������������������������������������ 75 7.2.9 Pain �������������������������������������������������������������������������������������� 75 7.2.10 Depressed or Elevated Scars ������������������������������������������������ 75 Sources������������������������������������������������������������������������������������������������������ 76
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8 PCI in Aging Skin������������������������������������������������������������������������������������ 77 8.1 PCI Fundamentals in Skin Aging������������������������������������������������������ 77 8.2 Applicability of PCI to Skin Aging�������������������������������������������������� 80 8.3 Thickness of Skin������������������������������������������������������������������������������ 80 8.4 Wrinkle Depth���������������������������������������������������������������������������������� 81 8.5 Flaccidity������������������������������������������������������������������������������������������ 81 8.6 Step-by-Step�������������������������������������������������������������������������������������� 82 8.6.1 Deep Injury �������������������������������������������������������������������������� 83 8.7 Methodological Sequence for Deep Injury �������������������������������������� 83 8.7.1 Moderate Injury�������������������������������������������������������������������� 85 8.8 Final Considerations ������������������������������������������������������������������������ 86 Sources������������������������������������������������������������������������������������������������������ 86 9 PCI in the Treatment of Melasma���������������������������������������������������������� 87 9.1 Lima Protocol������������������������������������������������������������������������������������ 88 9.2 Mechanism of Action������������������������������������������������������������������������ 90 9.2.1 Proposed Methodological Sequence ������������������������������������ 92 9.3 Final Considerations ������������������������������������������������������������������������ 97 Sources������������������������������������������������������������������������������������������������������ 97 10 PCI Correcting Post-inflammatory Hyperpigmentation �������������������� 99 10.1 Rational PCI in Post-inflammatory Hyperpigmentation (PIH) �������������������������������������������������������������� 99 10.2 Step by Step: Lima Protocol ���������������������������������������������������������� 101 10.3 Evaluation and Conduct������������������������������������������������������������������ 105 10.4 Final Considerations ���������������������������������������������������������������������� 107 Sources������������������������������������������������������������������������������������������������������ 107 11 Correcting Acne Scars Using PCI���������������������������������������������������������� 109 11.1 PCI Fundamentals in Acne Scars���������������������������������������������������� 109 11.2 Applicability of PCI on Acne Scars������������������������������������������������ 114 11.2.1 Skin Thickness�������������������������������������������������������������������� 114 11.2.2 Scar Characteristics������������������������������������������������������������ 115 11.2.3 Flaccidity and Needle Length �������������������������������������������� 115 11.2.4 Deep Injury ������������������������������������������������������������������������ 115 11.3 Step by Step������������������������������������������������������������������������������������ 117 11.4 Final Considerations ���������������������������������������������������������������������� 118 Sources������������������������������������������������������������������������������������������������������ 122 12 Correcting After Accident Scars Using PCI������������������������������������������ 123 12.1 Applicability of Needle Techniques������������������������������������������������ 126 12.1.1 Patient Assessment�������������������������������������������������������������� 126 12.1.2 Step by Step������������������������������������������������������������������������ 127 12.1.3 Complementary Techniques������������������������������������������������ 130 12.1.4 Complications �������������������������������������������������������������������� 130 12.2 Final Considerations ���������������������������������������������������������������������� 130 Sources������������������������������������������������������������������������������������������������������ 130
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13 Correcting Post-surgical Scar Using PCI���������������������������������������������� 133 13.1 PCI Fundamentals in Post-surgical Scars �������������������������������������� 133 13.2 Indications of PCI in Post-surgical Scars���������������������������������������� 134 13.2.1 Conduct ������������������������������������������������������������������������������ 135 13.3 Final Considerations ���������������������������������������������������������������������� 136 Sources������������������������������������������������������������������������������������������������������ 138 14 Correcting Post-burn Scar Using PCI���������������������������������������������������� 141 14.1 Rational Use of PCI in Post-burn Scars������������������������������������������ 142 14.2 Applicability of PCI to Post-burn Scars������������������������������������������ 145 14.3 Care in the Technical Execution ���������������������������������������������������� 147 14.4 Adverse Effects ������������������������������������������������������������������������������ 150 14.5 Closing Considerations ������������������������������������������������������������������ 150 Sources������������������������������������������������������������������������������������������������������ 150 15 Correcting High and Hypertrophic Scars with PCI ���������������������������� 153 15.1 PCI Fundamentals in High Scars���������������������������������������������������� 153 15.2 Applicability of PCI in High Scars ������������������������������������������������ 156 15.2.1 Methodological Sequence for the Approach���������������������� 156 15.3 Final Considerations ���������������������������������������������������������������������� 160 Sources������������������������������������������������������������������������������������������������������ 160 16 Correcting Stretch Marks Using PCI���������������������������������������������������� 163 16.1 Fundamentals in Stretch Marks������������������������������������������������������ 163 16.2 Applicability of PCI on Stretch Marks ������������������������������������������ 165 16.2.1 Stretch Marks Characteristic���������������������������������������������� 165 16.2.2 Needle Length�������������������������������������������������������������������� 166 16.2.3 Depth Injury������������������������������������������������������������������������ 167 16.2.4 Step by Step������������������������������������������������������������������������ 167 16.3 Final Considerations ���������������������������������������������������������������������� 169 Sources������������������������������������������������������������������������������������������������������ 171 17 Correcting Laxity and Cellulitis Using PCI������������������������������������������ 173 17.1 PCI in Gynoid Lipodystrophy (Cellulite) �������������������������������������� 173 17.2 PCI Fundamentals in Cellulite Treatment�������������������������������������� 176 17.3 Applicability of PCI in Cellulite ���������������������������������������������������� 178 17.3.1 Skin Thickness�������������������������������������������������������������������� 178 17.3.2 Cellulite Ratios ������������������������������������������������������������������ 178 17.3.3 Flaccidity and Needle Length �������������������������������������������� 178 17.3.4 Deep Injury ������������������������������������������������������������������������ 179 17.3.5 Step-by-Step������������������������������������������������������������������������ 179 17.3.6 Dressing Recommended by the Author After PCI�������������� 180 17.4 Final Considerations ���������������������������������������������������������������������� 183 Sources������������������������������������������������������������������������������������������������������ 183 18 PCI and Transcutaneous Drug Delivery������������������������������������������������ 185 18.1 Introduction������������������������������������������������������������������������������������ 185 18.2 Fundamentals of the Association of PCI to Drug Delivery������������ 186
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18.3 Indications and Contraindications�������������������������������������������������� 188 18.4 Pre- and Post-treatment Considerations������������������������������������������ 190 18.5 Final Considerations ���������������������������������������������������������������������� 192 Sources������������������������������������������������������������������������������������������������������ 193 19 PCI Associated with Fillers and Botulinum Toxin�������������������������������� 197 19.1 Rational Addition of Techniques���������������������������������������������������� 197 19.2 Association Protocols���������������������������������������������������������������������� 197 Sources������������������������������������������������������������������������������������������������������ 205 20 PCI in the Treatment of Alopecias���������������������������������������������������������� 207 20.1 PCI in the Treatment of Androgenetic Alopecia ���������������������������� 208 20.2 IPCA with Drug Delivery in the Treatment of Alopecia���������������� 210 20.3 Contraindications and Adverse Effects ������������������������������������������ 212 20.4 Therapeutic Proposal���������������������������������������������������������������������� 214 20.5 Conclusion�������������������������������������������������������������������������������������� 214 Sources������������������������������������������������������������������������������������������������������ 215 21 PCI in the Treatment of Scleroderma���������������������������������������������������� 219 21.1 Rational Use of PCI������������������������������������������������������������������������ 220 21.2 Treatment Protocol�������������������������������������������������������������������������� 223 21.3 Technical Aspects���������������������������������������������������������������������������� 225 21.4 Step-by-Step������������������������������������������������������������������������������������ 226 21.4.1 Asepsis and Anesthesia of the Area������������������������������������ 226 21.4.2 Evolution and Postoperative Care�������������������������������������� 226 21.4.3 Pain and Discomfort ���������������������������������������������������������� 227 21.5 Dermal Tunneling Indication���������������������������������������������������������� 228 Sources������������������������������������������������������������������������������������������������������ 233 22 PCI in the Hypochromias and Achromias �������������������������������������������� 235 22.1 Rational Use of PCI in Depigmented Lesions�������������������������������� 235 22.2 Step-by-Step������������������������������������������������������������������������������������ 240 22.2.1 Patient Selection������������������������������������������������������������������ 240 22.2.2 Instrumental������������������������������������������������������������������������ 241 22.2.3 Anesthesia �������������������������������������������������������������������������� 241 22.2.4 Transurgery ������������������������������������������������������������������������ 242 22.2.5 After Surgery���������������������������������������������������������������������� 243 22.2.6 Evolution���������������������������������������������������������������������������� 243 22.3 Final Considerations ���������������������������������������������������������������������� 244 Sources������������������������������������������������������������������������������������������������������ 244 23 PCI Associated with Intense Pulsed Light �������������������������������������������� 247 23.1 Why Associate Intense Pulsed Light with PCI? ���������������������������� 247 23.2 Step-by-Step������������������������������������������������������������������������������������ 248 23.3 Final Considerations ���������������������������������������������������������������������� 252 Sources������������������������������������������������������������������������������������������������������ 252
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24 PCI Associated with Peelings������������������������������������������������������������������ 255 24.1 PCI Fundamentals Associated with Peelings���������������������������������� 255 24.2 Prepare for the Procedure���������������������������������������������������������������� 257 24.3 Safety Profile and Origin of the Substances Used�������������������������� 265 24.3.1 Step-by-Step������������������������������������������������������������������������ 265 24.4 Final Considerations ���������������������������������������������������������������������� 267 Sources������������������������������������������������������������������������������������������������������ 267 25 Fundamentals of the Dermal Tunneling (DT): A Subcision™ Variant ���������������������������������������������������������������������������� 269 25.1 Introduction������������������������������������������������������������������������������������ 269 25.2 Principles and Technique of DT������������������������������������������������������ 270 25.2.1 Step-by-Step������������������������������������������������������������������������ 270 25.2.2 Advantages of DT �������������������������������������������������������������� 275 25.2.3 Disadvantages of DT���������������������������������������������������������� 276 25.3 Closing Considerations ������������������������������������������������������������������ 276 Sources������������������������������������������������������������������������������������������������������ 276 26 Dermal Tunneling in the Treatment of Depressed Scars���������������������� 279 26.1 Dermal Tunneling (DT) in Scars���������������������������������������������������� 279 26.1.1 Fundamentals of Dermal Tunneling in the Correction of Scars������������������������������������������������������������������������������������ 279 26.2 DT Foundations and Technique in Acne Scars ������������������������������ 281 26.2.1 Step-by-Step������������������������������������������������������������������������ 281 26.2.2 Evolution and Postoperative Care�������������������������������������� 283 Sources������������������������������������������������������������������������������������������������������ 287 27 Dermal Tunneling in the Treatment of Static Wrinkles and Grooves ���������������������������������������������������������������������������� 289 27.1 Fundamentals of Dermal Tunneling (DT) for the Treatment of Static Wrinkles���������������������������������������������������������� 289 27.1.1 Step-by-Step������������������������������������������������������������������������ 290 27.2 Evolution���������������������������������������������������������������������������������������� 294 27.3 Final Considerations ���������������������������������������������������������������������� 296 Sources������������������������������������������������������������������������������������������������������ 297 28 PCI Associated with Multi-needle Radiofrequency for the Treatment of Periorbital and Perioral Wrinkles and Laxity �������������� 299 28.1 Fundamental Concepts of Pulsed High-Frequency Electrosurgery �������������������������������������������������������������������������������� 299 28.2 Principles of Multi-needle Radiofrequency (MNR) ���������������������� 300 28.3 MNP in the Periorbital Region ������������������������������������������������������ 303 28.3.1 Step-by-Step������������������������������������������������������������������������ 304 28.4 MNR in Perioral Region ���������������������������������������������������������������� 307 28.4.1 Step-by-Step������������������������������������������������������������������������ 309 28.5 Final Considerations ���������������������������������������������������������������������� 314 Sources������������������������������������������������������������������������������������������������������ 317
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29 PCI Associated to Multineedle Radiofrequency for Treatment of Scars ���������������������������������������������������������������������������������� 319 29.1 Fundamentals of the Use of Multineedle Radiofrequency (MNR) in Scars���������������������������������������������������� 319 29.2 Applicability of MNR in Scars ������������������������������������������������������ 322 29.2.1 Step-by-Step������������������������������������������������������������������������ 323 29.3 Final Considerations ���������������������������������������������������������������������� 327 Sources������������������������������������������������������������������������������������������������������ 328 30 PCI on Ethnic Skin���������������������������������������������������������������������������������� 331 30.1 Introduction������������������������������������������������������������������������������������ 331 30.2 PCI�������������������������������������������������������������������������������������������������� 332 30.3 Radiofrequency Pulsed with Multi-needles������������������������������������ 334 Sources������������������������������������������������������������������������������������������������������ 339 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.
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Chapter 1
Fundamentals of Percutaneous Collagen Induction (PCI) with Needles
1.1 P ercutaneous Needle Collagen Induction (PCI) Versus 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
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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
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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.
0,25 mm
0,50 mm
1,00 mm
1,50 mm
1 Fundamentals of Percutaneous Collagen Induction (PCI) with Needles
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
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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.
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1 Fundamentals of Percutaneous Collagen Induction (PCI) with Needles
1.5 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 L evel of the Injury and Its Relationship to the Length 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
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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
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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 Devices for PCI
3.1.3 Microneedles Associated with Technologies 3.1.3.1 Electromagnetic Nonionizing Radiofrequency 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
25
3.2 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
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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
29
4.1 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