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

© COPYRIGHT 2013 BELLUS MEDICAL LLC. ALL RIGHTS RESERVED.

Advanced Microneedling Training

Today’s Agenda

Goals of Skin RejuvenationThe Science of MicroneedlingMicroneedling Compared to Other Popular Therapies

BreakMicroneedling + TopicalsHow Does Microneedling Affect Common Skin Conditions

Synergistic Treatment Modalities to MicroneedlingBasic Protocols/Advanced Protocol WorkshopPackaging Treatments

How Does Medical Needling Work?

• 0.5mm – 3.0mm

• Uses very fine, surgical stainless steel needles to make channels into the epidermis and dermis to release growth factors

• Promotes scarless healing and deposition of normal woven collagen rather than scar collagen

• Similar to Fraxel, without the negative loss of dermal papillae, potential destruction of melanocytes, abnormal collagen, coagulated growth factors

• Allows 80% more product into the skin (compared to 7-10% normally)

1 . 1 5

1 . 1 0

Collagen Induction Therapy

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

Microinjuries allow for release of serum containing cytokines and growth factor*

1 . 1 9

Phases of Wound Repair

Wrinkles

Thin skin

Hyperpigmentation

Rosacea

Loss of Resiliency

Premature aging

Scars

Epidermal density and strength

Lax skin

UV damage

Stretch marks

Hair restoration

Most Effective Uses of Dermal Needling

1 . 1 6

Features of Healthy Skin

� Soft, compact stratum corneum, with strong skin barrier

� Dense spinosum layer with consistent, strong cell-to-cell adhesion

� Even color, with melanocytes that distribute melanin uniformly

� Resilience

� Dermis rich with collagen and elastin fibers

� Good dermal and epidermal hydration: Extracellular matrix rich with glycosaminoglycans

1 . 3

The Three Layers of the Skin

1 . 4

Key Goals of Skin Rejuvenation

1 Optimize cell function- supply skin cells with essential building blocks through oral nutrition, topical ingredients, and vigorous exercise to increase blood flow and encourage lymphatic system. Tell the cells what to do with release of growth factors ( causes cells to differentiate ,proliferate, grow) and cytokines (signaling molecules released by cells to assist in communication)

2 Preserve integrity of the epidermis- provides natural barrier against pathogens, UV radiation, and free radicals

3 Strengthen dermal/epidermal junction-prevents flattening of dermal/epidermal junction ,which presents as wrinkles

4 Preserve dermal papillae-facilitates exchange of oxygen nutrients, and waste products between epidermis and dermis. Provides strength between dermal/epidermal junction to prevent wrinkles

5 Break down scar tissue- allows epidermis to lay flat

6 Release epidermal growth factors

7 Increase natural collagen: transforming growth factor ß3 (TGF-ß3)

8 Induce regenerative healing

1 . 5

Optimize Cell Function

1 Keratinocyte -Epidermis is 90% keratinocytes; to improve epidermal density, stimulate proper keratinization (smoothness) and produce a strong compact barrier function; “Until recently, the keratinocyte, which as considered less important than the fibroblast in creating healthy skin, was abused shamelessly with a variety of ablative treatments. New research, however, suggests the humble keratinocyte is responsible for releasing several key growth factors that conduct the orchestra of cells beneath it to facilitate ideal skin rejuvenation.”

2 Melanocyte- Ensures even skin color

3 Fibroblast- to stimulate collagen, elastin and glycosaminoglycans(GAGS) for firm, tight hydrated skin

1 . 6

Optimizing the Keratinocytes

� Basic epidermal topical requirements:

Omega 3Omega 6CeramideSqualenesSphingolipidPhospholipid

1 . 7

Epidermal Cell Requirements

Omega 3• Kiwifuit seed oil• Lecithin• Hemp see oil• Flax seed oil• Camelina oil

Omega 6• Hemp seed oil• Borage oil• Evening Primrose oil• Rice bran oil

Ceramide• Yeast (pichia anomala extract)• Wheat extracts

Squalenes• Rice bran oil• Olive oil

Sphingolipid• Yeast (pichia anamola extract)

Phospholipid• Lecithin

Optimizing the Melanocyte

Unfortunately, melanocytes lie between most anti-aging treatment modalities and the

targeted fibroblasts, and are often sacrificed in overzealous attempts to obtain greater injury

through aggressive injury.


1 . 9


5 intervention points:

• Block UV radiation

• Block Melanin Stimulating Hormone (MSH) before it stimulates the keratinocytes and melanocytes

• Inhibit tyrosinase, the enzyme needed to form melanin in the melanosome

• Interfere with L-Dopa, the building blocks for pigment in the melanosomes

• Interfere with transfer of pigment from the melanosome to the keratinocyte

1 . 8

Product Ingredients Affecting Melanogenesis*

Active Ingredient MSH Tyrosinase Pigment Granule

MelanosomeTransfer

Magnesium ascorbyl phosphate

Ascorbyl tetra isopalmitate

Niacinamide

Arbutin

Azelaic acid

Paper mulberry

Aloesin

Glabridin

Glucosamine

Ascorbic acid*Florence Barrett-Hill. Secretions. Cosmetic Chemistry.

Compounds Affecting Melanogenesis*

Compounds MSH Tyrosinase Pigment Granule

MelanosomeTransfer

Lumixyl

Melanostat

Sulforawhite

Whitesphere

Lightocean *Florence Barrett-Hill. Secretions. Cosmetic Chemistry.

Ingredients TO AVOID* with microneedling

Substance MSH Tyrosinase Pigment Granule

MelanosomeTransfer

Kojic Acid**

Hydroquinone*** *Florence Barrett-Hill. Secretions. Cosmetic Chemistry.**Banned in some countries. May cause dermatitis long term.***Banned is some countries. Potential carcinogenic effect.

Medical Needling eliminates the risk of melanocyte heat injury and actually optimizes cell function, making it the ideal treatment for all skin types.

Lance Setterfield, Dermal Needling, Medical Edition, 2010

Optimizing the Fibroblast

Requires injury to stimulate:

• chemical peels• Levulan and photodynamic therapy• IPL• Thermage• Fraxel• CO2• Laser

Ingredients for Optimal Fibroblast FunctionAids in

Collagen Synthesis

Aids inGAG

Synthesis

PreventsOxidative

Stress

PreventsLipid

Peroxidation

Growth Factors

Magnesium ascorbyl phosphate

Ascorbyl tetra isopalmitate

Retinyl palmitate

Retinol

Copper peptides

Beta-carotene

DMAE

Hyaluronic Acid*Florence Barrett Hill. Secretions, Cosmetic Chemistry 2009**all above have antioxidant and anti-inflammatory properties and can be used on compromised and high-risk skins excepts retinol.

Ingredients for Optimal Fibroblast Function

Aids inCollagen Synthesis

Aids inGAG

Synthesis

PreventsOxidative

Stress

PreventsLipid

Peroxidation

Glucosamine

Super dismutase oxide

Resveratrol (Bioflavanoid)

Matrixyl®

Amino acid Proline

Amino acid Lysine

Ascorbic acid

Zinc

Calcium

*Florence Barrett Hill. Secretions, Cosmetic Chemistry 2009

Questions?


1 Optimize cell function

2 Preserve integrity of the epidermis

3 Strengthen dermal/epidermal junction

4 Preserve dermal papillae

5 Break down scar tissue




1 . 5

Preserve the Epidermis

• Epidermis is complex, highly specialized organ

• 0.2mm thick

• Only protection from the environment


Traditional Ablative Therapies

• Damage the skin to cause fibrosis of the papillary dermis• Epidermis thinned• Dermal papillae destroyed• Severe changes in dermis


Resultant Collagen from Ablative Therapies:

• Parallel (scar) orientation rather than normal, lattice network

• Scar collagen will be resorbed by the body over time – all scar collagen is

• Fine wrinkles will be visible due to thinned epidermis and lack of dermal papillae

1 . 1 1


*Abd El-Aal NH, et al. J Dermatol 2012;57:181-6

What does old vs. young skin look like?*

Biopsy of young skin showing thick bundles of collagen bundles.

Biopsy of aged skin showing thin and loose collagen fibers (Masson- Trichrome ×100).

1 . 1 2

Collagen Induction TherapyCIT Promotes deposition of fresh new collagen without scar formation*

Left, before CIT. Right, six months after CIT, more collagen (pink) and elastin (brown) can be detected. Estimated > 400% more collagen and improved epidermal/dermal thickness*Fernandes, D. OralLMaxillofacial Surg Clin 2005; 17:51-63

1 . 1 3

Increased Dermal ThicknessBefore After

Patient had an increase in dermal thickness after 5 months. Dermal thickness increased from 1.91 mm to 2.41 mm.Moon, HS et. al; Department of Dermatology, Eulji University School of Medicine

Creation of microchannels in the skin with minimal damage to epidermis*

� Microchannels are open for a short time, which allows for more efficient penetration of topicals

� Minimal damage to tissue equals minimal downtime

1 . 1 4

Microchannel Formation

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










1 . 5

The Three Layers of the Skin

1 . 4

Preserve the dermal papillae

• Exchanges oxygen, nutrients, and waste products between the epidermis and dermis

• Provides strength between the epidermis and dermis to prevent the deterioration and separation of the dermal/epidermal junction, which presents as wrinkles










1 . 5

Break Down Scar Tissue

Allows the epidermis to lift and lay flat, eliminating any shadowing

1 . 1 0


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

Microinjuries allow for release of serum containing cytokines and growth factor*










1 . 5

Induce Regenerative Healing

• Collagen forms from the base upwards

• Opposite of Regenerative Healing is “Cicatricial healing”: leaves a scar when the formation of new connecting tissue overlies a wound

Microneedling Meets All Goals

Optimize cell function

Preserve integrity of the epidermis

Strengthen dermal/epidermal junction

Preserve dermal papillae

Break down scar tissue

Release epidermal growth factors

Increase natural collagen: transforming growth factor ß3 (TGF-ß3)

Induce regenerative healing

1 . 1 0

Ablative vs. Non-Ablative Treatments

1 . 1 1

Comparison with Other Treatments

1 . 2 0

Introducing SkinPen2013: SkinPen modernizes microneedling

• Stainless steel, cordless design• Single, use disposable Advanced Microneedle Cartridge• Minimizes epidermal destruction while delivering over

1400 microchannels per second• Ideal for clinical practice

� Fine lines or moderate wrinkles

� Diminished skin texture, tone and color

1 . 8

� Atrophic acne scars� Stretch marks� Traumatic scars� Photo aging

Topicals + Microneedling

The secret to successful rejuvenation is to provide all the necessary building blocks for optimum

results. Needling and all other treatment modalities, used alone, are not effective. They sap the cell of

resources needed to rebuild and repair.

Lance Setterfield, Dermal Needling, 2010.

Dr. Des Fernandes – Topical A & C

Pre-treats patients with topical A and C three weeks to three month prior to needling.

• Vitamin A is essential for the normal physiology of the skin and for collagen preservation; maximizes collagen production and the

skin will heal as rapidly as possible

• Vitamin C needs to replaced daily to ensure for natural protection and repair of DNA; essential for the production of normal collagen

1 . 1 7

Recovery of skin barrier function following microneedling treatment as measured by transepidermal water loss (TEWL)

Microchannel Characteristics

Figure from: The AAPS Journal, Vol. 13, No. 3, September 2011

1 . 1 8

I N T A C T S K I N

6 H O U R S

1 2 H O U R S

0 H O U R S

8 H O U R S

1 8 H O U R S

4 H O U R S

1 0 H O U R S

2 4 H O U R S

Calcein imaging to study closure of microchannels formed by 0.7 mm microneedles.

Channels closed by 18 hours post treatment, showing thereversible nature of the channels.

Figure from: The AAPS Journal, Vol. 13, No. 3, September 2011

Microchannel Characteristics


1 . 1 5

*Figure from: The AAPS Journal, Vol. 13, No. 3, September 2011

For dermal rollers, the number of microchannelsincreases as a function of the number of passes made

1 pass 3 passes 5 passes 10 passes 15 passes


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

For SkinPen, the number of microchannels depends on how quickly

you move the SkinPen across the surface of the skin.

► Needles cycle at 142 Hz or 142 “stamps”/second, potentially creating 1704 microchannels/second when moving the skin pen

► Slower movement at a rate of 1 cm/second, you can create roughly 4858 microchannels/ cm2 of skin*

► Faster movement at a rate of 3 cm/second, you can create roughly 1621 microchannels/ cm2 of skin*

► The SkinPen produces significantly more microchannels with one pass than created by a dermal rollers after many passes!

1 . 1 6

Plast Surg Int. ID 15824. Epub 2011 Apr 7

M I C R O N E E D L I N G + D E P I G M E N T I N G S E R U M

D E P I G M E N T I N G S E R U M A L O N E

B E F O R E A F T E R 2 M O N T H S

Microneedling has been

shown to enhance pen-

etration of a depigmenting

serum in a 20-subject study

for treatment of melasma.

Microneedling +

depigmenting serum:Mean MASI score of 19.1

at baselineMean MASI score of

14.4 (P < .001) at 1 monthMean MASI score

9.2 (P < .001) at 2

monthsDepigmenting serum alone:Mean MASI score of

20.4 at baselineMean MASI score of

17.4 (P < .05) at 1 monthMean MASI score of

13.3 (P < .05) at 2 months

Enhancement of Topical Penetration

3 . 3 6

Recommended Needle Depth

Needle depth is contingent on:

� Thickness of dermis in area to be treated:

The dermis of the face is variable, typically no deeper than 1.5 mm

Dermis in other areas of the body may be thicker or thinner, with the dermis of the back typically the thickest (~3 mm)

� Reason for Treatment:

Facial rejuvenation for improvement of skin texture of fine lines will require less penetration

Improvement of scar tissue will require a more aggressive treatment and therefore deeper penetration

Fabbrocini G, et al.. J Dermatolog Treat. 2012 Dec 8. [Epub ahead of print].

3 . 4

Recommended Needle Depth

Plast Reconstr Surg. 2005 May;115(6):1769-73

Average Skin Thickness Measurements

Site

AVG ABC

Upper lip Lower lip

Philtrum

Chin

Upper eyelid Lower

eyelid

Forehead

Right cheek

0.83 ± 0.17

0.82 ± 0.15

0.83 ± 0.10

1.15 ± 0.11

0.38 ± 0.09

0.82 ± 0.21

1.03 ± 0.15

1.07 ± 0.09

Site AVG ABC

Left cheek

Malar eminence

Submental

Nasal tip

Nasal dorsum

Right neck

Left neck

1.17 ± 0.08

1.05 ± 0.45

0.89 ± 0.19

1.22 ± 0.15

1.15 ± 0.11

0.52 ± 0.23

0.54 ± 0.20

3 . 5

QUESTIONS?

After three weeks. One localized area treatment using a 2.0mm needle.

Photos courtesy of the Women’s Centre for Excellence

Before After

After three weeks. One localized area treatment using a 2.0mm needle.

Photos courtesy of the Women’s Centre for Excellence

After

After one treatment. First pass at 0.5 mm; second pass at 1.0 mm.

Before

Photos courtesy of Dr. Ken Oleszek, LaFontaine Aesthetics

After

After one treatment. First pass at 0.5 mm; second pass at 1.0 mm.

Before

Photos courtesy of Dr. Ken Oleszek, LaFontaine Aesthetics

After

Four weeks after one treatment. Three passes at 1.0 mm.

Photos courtesy of Dr. Christie Matter, North Texas Dermatology

Before After

Before

Photos courtesy of Spectacular Skin

After

After one treatment.

Before After

After one treatment.Photos courtesy of Spectacular Skin

Before After

After one treatment.

Photos courtesy of Spectacular Skin

Why Bellus Medical?

• Ongoing Advanced Training at no cost to our Practice Partners

• Skinpen.com specifically educates the patient and easily drives them into your practice Skinpen.com drove over 3,000 into our partner practices in October!

• Referral program rewards you with cash or needles the same day your referral purchases SkinPen

• Social media team dedicated to connecting with your practice and your patients to educate on microneedling and draw interest to SkinPen

Why SkinPen?

• Stainless steel, cordless design

• The most advanced microneedle cartridge on the market:

Bio-Sleeve technology eliminates cross-contamination and protect the pen

12 medical grade steel, 32 gauge needles to reduce epidermal destruction for superior results and positive patient experience

Exhaust port to reduce suction and risk of broken capillaries

QUESTIONS?

Basic Protocols

3 . 6

Atrophic Scarring

Indication: Improved appearance of atrophic scarring Treatment Frequency: 3–6 treatments at monthly intervals

1 Prepare the affected area by applying preferred anesthetic and sterilization protocols.

2 Apply HA Peptide Gel provided in kit to treatment area.

3 Set the SkinPen depth to 1.5-2 mm depending on skin thickness.

4 Begin treatment of the affected area with an initial pass consisting of small circular movements in an outward and down direction until the entire area is covered. Use your free hand to keep the skin taut.

continued

3 . 3 5

Atrophic Scarring continued

5 This should be followed by two linear passes, one verticaland one horizontal, both of which cover the entire affected area.

For deep scarring, the skin should be stretched perpendicular to the direction of the pass to ensure proper skin penetration at the scar base.

A stamping motion can be used to provide extra penetration to deep scars.

6 Wipe off any pinpoint bleeding and rinse the skin with sterile saline solution.

7 (Optional) Place serum containing vitamin E and Vitamin C over treated area.

8 Wrap an ice pack with sterile gauze and place against the treated area for 5 minutes.

3 . 3 5

Improvement in Atrophic Scars

� 34 of 36 patients achieved a reduction in scar severity by one or two grades.*

� More than 80% of patients assessed their treatment as “excellent” on a 10-point scale.*

*J Cutan Aesthet Surg. 2009 Jan; 2(1):26–30

B E F O R E A F T E R 3 – 4 T R E A T M E N T S

AC

NE

S

CA

R

PO

X

SC

AR

3 . 3 4

3 . 3 7

Hyperpigmentation

Indication: Improved appearance of hyperpigmentation Treatment Frequency: 2-4 treatments at bi-monthly intervals

1 Prepare the affected area by applying preferred anesthetic and sterilization protocols.

2 Apply HA Peptide Gel provided in kit to treatment area.

3 Set the SkinPen depth to 0.75-1.5 mm depending on skin thickness.

4 Begin treatment of the affected area with an initial pass consisting of small circular movements in an outward and down direction until the entire area is covered. Use your free hand to keep the skin taut.

continued

3 . 3 9

Hyperpigmentation continued

5 This should be followed by two linear passes, one vertical and one horizontal, both of which cover the entire affected area.


7 Place depigmenting serum over treated area.


3 . 3 8

Hyperpigmentation continued

5 This should be followed by two linear passes, one vertical and one horizontal, both of which cover the entire affected area.


7 Place depigmenting serum over treated area.


Advanced Protocol Workshop

• SkinPen + Vitamin A, C, E = overall collagen production

• HydraFacial + SkinPen = red carpet ready, hydrated, not downtime collagen remodeling

• Perfect Peel + SkinPen = melasma/hyperpigmentation

• VI Peel + SkinPen = acne/melasma

• Nectifirm + Botox + SkinPen = neck tightening

• Exillis/Radiofrequency + SkinPen = face/neck tightening

SkinPen + Hydrafacialred carpet ready hydration no downtime collagen remodeling

1. Cleanse with Active 4 Cleanser2. Degrease with alcohol or acetone3. Apply topical numbing for 30-45 minutes occluding with plastic wrap4. Remove plastic wrap and topical with alcohol or acetone5. Apply hyaluronic acid to treatment area, start SkinPen treatment

following face graph for appropriate depth on each area.6. Wash area with Active 4 Cleanser7. Start Hydrafacial treatment using all steps including red LED at the end

of the treatment8. After red LED, use 2-4 pumps of the Antiox serum followed by the Pure

Moist and a tinted SPF.

SkinPen + Perfect Peel

1. Cleanse with Active 4 Cleanser2. Degrease with alcohol or acetone3. Apply topical numbing for 30-45 minutes occluding with plastic wrap4. Remove plastic wrap and topical with alcohol or acetone5. Apply hyaluronic acid to treatment area, start SkinPen treatment

following face graph6. Wash area with Active 4 Cleanser7. Degrease with alcohol or acetone8. Apply vaseline or aquaphor to the corner of the eyes, nouth and nose

prior to applying peel9. Pour Perfect Peel in measuring cup and use the 4x4 gauze pads that

come with the peel and saturate in the peel solution

SkinPen + Perfect Peel cont’d

10. Apply the first pass to the treatment area and wait 60 seconds, then apply the second pass vigorously rubbing on the area. Use all of the peel solution.

11. Patient will feel a mild to moderate burning sensation, provide a hand held fan for patient comfort.

12. No products can be applied to the skin the first day, not even sunblock.13. Sleep with the peel on overnight. The next morning, wash skin with

gentle cleanser, pat dry and apply the first towelette vigorously rubbing into skin. Apply a broad spectrum UVA/UVB block SPF. That evening, 1 hour before bed, wash your skin and apply the second towelette vigoroursly rubbing into skin.

14. On day 3, start using the post op cream and apply as needed. If itching occurs before day 3, start using the post op cream at that time.

Protocol Workshop

• SkinPen as maintenance between Fraxel Laser in peri oral and crows feet areas

• The Power of Three: SkinPen + Filler + Neurotoxin for overall rejuvenation

• Kiss Your Lip Lines Goodbye: SkinPen + Filler + Neurotoxin in lower face

SkinPen + Radio FrequencyBody Treatment

1. Cleanse area2. Perform SkinPen Treatment using 1.5 to 2.5 depth on body3. Wipe area with wet 4x4 gauze pads4. Use baby oil or grape seed oil and treat area following the

recommended parameters for the area you are treating5. When finished, wipe off gel and massage the area with body cream for

1-2 minutes6. Encourage patients to stay hydrated drinking a gallon of water the day

of treatment and throughout the duration of the treatments7. Suggest home care of Resolution MD Cellulite system and apply to the

treated areas twice a day to maintain results and help smooth the appearance of uneven skin and/or cellulite

8. Treatments can be done in a series with re-treatment every 7-10 days. Maintenance minimum 3 times per year.

THANK YOU!!

Documents

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