TSI Micro-needling Training Manual by Jen

Conditions !" Common !" Skin # Acne Conditions Common Introducing Micro-needling # Hyperpigmentation Acne !" Skin # Rosacea Skin WhatCommon is Medical Skin Needling Hyperpigmentation Conditions Early History of Skin Abrasion # Skin Lesions (dermatalogical) Rosacea Common Skin Conditions Development of Needling Devices # !" # Acne Aging Skin (dermatalogical) Skin Lesions Conditions From Dermaroller to Micro-needling # !" # Hyperpigmentation Maintenance Aging Skin care

!" Common Skin

InnoPen Advantage # Rosacea # and Effect # Maintenance AcneIndications care # Skin Lesions (dermatalogical) How Micro-needling Works Hyperpigmentation # # Acne Aging Skin Rosacea Mechanism of Action # Acne # Hyperpigmentation Maintenance care Skin Lesions (dermatalogical) # Rosacea Histopathology Hyperpigmentation The Phases of Wound Healing # Skin Skin Lesions (dermatalogical) # Aging Rosacea Micro-needling Medical Specifications # care Aging Skin (dermatalogical) # Maintenance Skin Lesions Micro-needling Duty Cycle # Acne Maintenance # Aging Skin care Procedure # Hyperpigmentation # Maintenance care Prior to Treatment # Rosacea Treatment # Skin Lesions (dermatalogical) Needle Length Recommendations # AgingDirectional Skin Chart Additional Notes # Acne Maintenance care # Hyperpigmentation Contra Indications Patient Home Preparation # Rosacea # Skin Lesions (dermatalogical) # Aging Skin # Maintenance care

Conditions

Common Skin Conditions

The unique spring-loaded needle tip uses an automated, vibrating stamp-like motion that enhances results while offering a more controlled and safer method of treatment than other micro-needling devices. InnoPen’s disposable micro-needling tipcomes in sterilized individual packages that are easily replaced and loaded into the spring-automated device. The InnoPen tip has thirteen stainless steel micro-needles which can be adjusted from 0.25 to 2.5 mm, giving estheticians an innovative skin therapy system that is designed to cater to individual patient needs. InnoPen’s needle depth can be adjusted during the course of the procedure to accommodate different treatment areas, and can easily maneuver around facial contours and delicate features, such as the eyes, nose and mouth. InnoPen offers many advantages over leading competitors like IPL or fractional lasers; the unique automatic micro-needling function increases InnoPen’s effectiveness while causing less epidermal damage sometimes caused by excess heat and light based therapies. The InnoPen’s automated needling motion minimizes pain and discomfort, while better promoting an even absorption of topicals, such as PRP, hyaluronic acid and peptides into the skin which enhances overall results. The sloped, or curved, insertion of needles on a rolling fractional device can create damaging trenches in the epidermis leading to more bleeding, pain and recovery time. The stamping action of InnoPen’s vertical needles is not only effective in minimizing pain and bleeding, but also offers a safe, consistent treatment method that better rejuvenates the skin. InnoPen offers exceptional results, is cost effective, easy to use and has better precision and control than more expensive treatments.

What is Medical Skin Needling? Medical Skin Needling, also referred to as Collagen Induction Therapy (CIT) and Micro-Needling, is a relatively new concept being added to numerous aesthetic skin rejuvenation treatment options available such as Microdermabrasion, Microcurrent, Ultrasonic, laser resurfacing and chemical peels, all of which have come about since the mid 2000s. As with these treatments, micro-needling is aimed at stimulating the body’s own collagen production to tighten, lift and rejuvenate the skin, as well as reduce the appearance of fine lines and wrinkles, minimize pores, stretch marks, and scarring such as keloid, surgical and acne scars. It has also been successfully used for hair restoration in cases of alopecia.

The Early History of Skin Abraision Various treatment practices involving abrasive masks and alabaster to rejuvenate the skin can be traced back to ancient Egypt. These substances also include acids, poultices of minerals and plants and direct irritants such as fire and sandpaper-like materials.

In 1955, Norman and D. S. Orentreich used 18 or 20 gauge needles to perform minor surgical treatments aimed at treating scars and wrinkles using a tri-beveled hypodermic needle inserted under the defect to make subcuticular cuts. The principle of this procedure was to break the fibrotic strands that attach the scar to the underlying subcutaneous tissue. The depression is lifted by the releasing action of the procedure, as well as from connective tissue that forms during the course of normal wound healing.

Chemical peeling and skin abrasion procedures that are common today began in the early 20th century. German dermatologist Ernst L. F. Kromayer first documented controlled resurfacing abrasion of the skin in 1905. His technique involved the use of abrasives adhered to rotating wheels and rasps, which he used to treat acne scars, keratosis, and areas of hyperpigmentation. In the last century, there has been little advancement in the tools used for present day skin resurfacing.

The InnoPen is an unrivaled form of medical skin needling, also referred to as Collagen Induction Therapy (CIT) and micro-needling. The InnoPen is a relatively new concept being added to numerous aesthetic skin rejuvanation treatment options available such as microdermabrasion, micro-current, ultrasonic, laser resurfacing and chemical peels. As with these treatments, InnoPen is aimed at stimulating the body’s own collagen production to tighten, lift and rejuvenate the skin, as well as reduce the appearance of fine lines and wrinkles, minimize pores, stretch marks and scarring such as keloid, surgical and acne scars.

Despite the early use and success of skin abrasion, it did not gain recognized popularity until the early 1950s. Kurtin, a dermatologist at Mount Sinai Hospital in New York, presented the first series of patients who underwent skin abrasion with modified dental equipment in 1953. Kurtin described the use of high-speed rotary abraders, intra-operative freezing and a variety of abrasive end pieces.

Skin needling makes micro channels into the epidermis and dermis to release growth factors that promote scarless healing and the deposition of normal woven collagen rather than scar collagen. This is similar to fractional lasers, only without the negatives of loss of dermal papillae, potential destruction of melanocytes, abnormal collagen, coagulated vasculature and growth factors. A recent study on micro-needling published in 2010 from Dr. Aust M. C., “recorded 140% increase in epidermal thickness an increse in gene and protein expression of collagen I and Glycosaminoglycans and other factors.”

treatment that maximizes penetration of essential cell nutrients and maximizes release of growth factors associated with the positive aspects of wound healing simultaneously.” To accomplish healthy skin, the ideal skin rejuvenation treatment program needs to target three key cells (keratinocytes, melanocyte, firbroblast) and regulate their function. According to Dr. Setterfield, “Microneedling is the only treatment that respects all three main target cell types.” Additionally, Dr. Setterfield unequivocally has prescribed that needling, “or any other treatment modality for that matter, will always deliver inferior results if not combined with the building blocks of topical nutrients for the cell to work with.”

Dr. Lance Setterfield M.D., author of The Concise Guide to Dermal Needling, claims that, “Dermal Needling is the only rejuvenation

Development of Needling Devices Dr. Andre Camirand described his experience with skin needling in a 1997 publication in which he tattooed several patients who had facial hypochromic scars with a skin-color pigment. He found that after 1-2 years, melanin had replaced the areas of pigment and the appearance, color and texture showed substantial improvement. These results gave Camirand the idea that trepanation of scars with the tattoo gun was ultimately responsible for the improvement in the appearance of the scar. He then punctured scars without pigment, concluding that in doing so, he could break down the scar collagen, cause the realignment of fibrous tissue and stimulate melanogenesis. The results of repetitive sessions on scars were reported by Camirand to be impressive and presumably consistent, since all of his patients responded positively and showed aesthetic improvement from these treatments. Following these developments, Dr. Des Fernades introduced the first needling device, a small needle stamp, in 1966. He used it to induce collagen and as a regular treatment in his surgical practice.

In 2000, German inventor Horst Liebl trademarked the Dermaroller. Clinical Resolution Laboratory made some advances to the Dermaroller and released the new device to the public in 2004.

From Derma Rolling to Micro-needling

InnoPen vs. Dermaroller

*Sloped insertion of Dermaroller

*Vertical insertion of InnoPen

From Derma Rolling to InnoPen InnoPen Advantage

No cross infection ~ Disposable needles.

Easy to use.

Speed, faster than manual rolling.

Lower price of consumables.

Shorter treatment times.

Minimal side effects.

Adjustable needle depths.

Virtually no down time.

Less pain.

Easy to transport

Light-weight hand-piece.

Indications and Effect Wrinkles and Thin Skin Density HOW: Increased availability of cell nutrients and the triggering of the wound healing cascade brings platelets, fibroblasts, epithelial, endothelial and immune cells together to facilitate wound healing.

Hyperpigmentation HOW: The InnoPen increases availability of skin lightening actives, restores keratinocyte function and communication with melanocytes and optimizes pigment uptake, restores fibroblast function which normalizes signaling with melanocytes, normalizes melanogenesis and melanocyte differentiation and the other growth factors that support melanocytes in the epidermis. Unfortunately, melanocytes lie between most anti-aging treatment modalities and the targeted fibroblasts, and are often sacrificed in overzealous attempts to obtain greater results through aggressive injury. Melanocytes are in the basal layer of the epidermis and when damaged, hypo or hyperpigmentation results.

“Medical needling eliminates the risk of melanocyte heating injury and actually optimizes cell function, making it the ideal treatment for all skin types.” - Dr. Lance Setterfield M.D.

From Derma Rolling to InnoPen Indications and Effects (continued) Rosacea HOW: Stimulates epidermal growth factors which increases epidermal density and strengthens collagen in vessel walls and connective tissue that supports vessels. Increases platelet growth factors to help with inflammation, increases availability of cell nutrients and antioxidants, and helps with loss of adhesion and resiliency.

Scars HOW: Mechanical breakdown of existing scarring and allows for new and natural wound healing response to take place. An increase in growth factors responsible for remodeling occurs as a result.

Lax Skin HOW: Increased availability of cell nutrients and the triggering of the wound healing cascade brings platelets, fibroblasts, epithelial, endothelial and immune cells together to facilitate wound healing and epidermal growth.

UV Damage HOW: Increases availability of cell nutrients and attracts macrophages and immune system function to the damage area. Releases epidermal growth factors and releases glycoproteins that modulate the immune system.

Stretch Marks HOW: The epidermis is extremely thin and the underlying support is also atrophied. The ability to withstand thermal energy or heat related treatments without being burned or further injured is minimal. The micro-needling technology of the InnoPen allows for the increased synthesis and presence of epidermal growth factors and immune response triggers. This enables the opportunity for fibroblast proliferation and collagen formation and potential thickening.

How Micro-needling works

GROWTH FACTOR

FIBROBLAST PROLIFERATION

COLLAGEN INDUCTION

CLEANSE AND PREPARE INJURY ANESTHETIC STOPPING BLEEDING

ACTIVE INGREDIENTS

INFLAMMATION

INNOPEN TREATMENT ACTIVE INGREDIENTS

GROWTH FACTORS EMISSION

COOLING AND SOOTHING

FIBROBLAST CELL MULTIPLICATION

PROTECT COLLAGEN AND ELASTIN SYNTHESIS

Mechanism of Action PHASE I INJURY RELEASE OF GROWTH FACTORS EPIDERMAL GROWTH

BLEEDING AND PLATELET RELEASE

NEUTROPHILS

FIBROBLAST CHEMOTAXIS FIBROBLAST PROLIFERATION

MATRIX PRODUCTION

MONOCYTES

PHASE II TISSUE PROLIFERATION

CONTINUED RELEASE OF GROWTH FACTORS FROM FIBROBLASTS, KERATINOCYTES, AND MONOCYTES EPIDERMAL GROWTH

FIBROBLAST PROLIFERATION COLLAGEN III, IV, AND I ELASTIN PROTEOGLYCANS GAG’S ANGIOGENESIS

PHASE III FIBROPLASIA AND TISSUE REMODELING VASCULAR MATURATION

RELEASE OF GROWTH FACTORS COLLAGEN III

COLLAGEN I

Any treatment including an inflammatory and injury response, whether it be medical needling, tissue destruction using laser, microdermabrasion, physical surgery or by intense pulsed light therapy, requires the skin to recover via the mediation

Histopathology Clinical histologic studies found skin tissue that was micro-needled with 0.5 to 1.5 mm long needles (depending on facial skin thickness) revealed that micro-needling stimulated massive growth of elastin and collagen fibers (in some cases, up to 1000%). InnoPen uses eleven (33 gauge) needles in a stamping motion at a high rate of speed to cause microscopic trauma to the epidermis and dermis which then triggers the body’s natural wound healing process. Because the trauma is inconsequential, it allows for the repair of the tissue damage by way of regeneration, which is the replacement of lost cells by division of adjacent surviving cells. This requires an intact connective tissue framework as a foundation for the restoration of lost cells. In other words, the epidermal trauma is superficial enough to heal itself without creating unsightly scar tissue, yet deep enough to induce minimal inflammation, thereby stimulating fibroblasts to create collagen and elastin in the epidermis.

*Skin after vertical insertion of InnoPen

*Skin after sloped insertion of Dermaroller

*Histopathology

The Phases of Wound Healing

Inflammatory Phase (1-3 days) This response is the early phase of cell migration to remove debris and bacteria and stimulate the next proliferative phase.

Proliferative Phase (3-5 days) Includes angiogenesis to provide new blood vessel formation and supply oxygen required for new collagen formation. New collagen will be laid down and deposited with new tissue formation.

Fibroplastic Phase (5-20 days) New tissue formation instead of inflammatory response. Growth factors are released and fibroplasts release collagen.

Maturative Phase (28 days - 2 years) Collagens mature and stiffen and the matrix of new tissue shows 80% to full tensile strength.

Procedure Prior to Treatment Before the treatment, please have your patient observe the following:

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No Retin-A products or applications for 12 hours prior to treatment

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No Auto-immune therapies or products 12 hours prior to treatment.

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No prolonged sun exposure or sun burns to the treatment area 24 hours prior to treatment.

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Skin should be clean and make-up free.

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If an active or extreme breakout occurs before treatment, evaluate on a case by case basis.

Treatment 1. CLEANSING: Thoroughly cleanse the skin with a cleansing product appropriate for the type of skin that is being treated. For optimal results, it is advisable to remove dead cells of the stratum corneum with an exfoliating treatment such as microdermabrasion or a cleansing scrub. 2. APPLY ANESTHETIC OINTMENT ON THE TREATMENT REGION: It is important to read the user’s instructions of the anesthetic ointment prior to application to ensure proper use. Put on a sterile pair of gloves. Apply ointment to treatment area and leave on surface of skin for 20-30 minutes. For quicker results, occlude with plastic wrap for the duration of the waiting time if applicable to anesthetic ointment being used. Remove anesthetic ointment with gauze, followed bt a thoroughcleansing with an antiseptic antimicrobial wipe or solution. Most common compound formulas contain Benzocaine 20%, Lidocaine 6% and Tetracaine 6% in a Lipoderm base. This is a prescription only formula, so clinics not affiliated with a physician may need to source an Emla and Betacaine 5%. This lower percentage strength will not effectively allow for pain free deeper treatments. However, each patient will have different pain thresholds. A dental block can be used.

3. APPLY ACTIVE INGREDIENT: Uniformly apply hyaluronic acid. The numerous micro-holes created by the needles will favor deep penetration of the active ingredient into the skin. It is extremely important NOT to make contact with the patient’s skin and the product applicator to ensure sterility of the applicator and avoid contamination of the bottle.

4. TREATMENT: A. Re-glove. B. Wipe pen thoroughly with an alcohol wipe. C. Remove sterile needles from packaging and insert into the pen. D. Apply power source. E. Turn on speed level ring using the following levels: a. Face speed: 1 ~ 5 i. Thin, sensitive skin: 1 ~ 3 ii. Thick skin: 4 ~ 5 b. Body speed: 4 ~ 5

F. Choose the appropriate needle depth for the treatment using the following guidelines: MEDICAL MODEL Region Needle Depth* Thin Skin Thick Skin Forehead 0.25-0.5mm 05.-0.75mm Between Eyebrows 0.25-0.5mm 0.5-1.0mm Nose 0.25mm 0.5mm Eye Area 0.25mm 0.25mm Cheek Bone 0.5mm 0.5-1.0mm Cheek and Chin 0.5-1.0mm 1.0-2.0mm Lip Area 0.25mm 0.25mm Lips 0.25mm 0.25mm Facial Scarring 1.0-1.25mm 1.5-2.5mm Stretch Marks 1.0-1.5mm 1.5-2.5mm Surgical and Burn Scars 2.0-2.5mm 2.0-2.5mm *When using any needle depth greater than 2.0mm to treat scar treatments, stamp through the scar on the first pass before striping over it.

Procedure Needle Depth Recommendations

Treatment (continued) AESTHETIC MODEL Region Needle Depth* Thin Skin Thick Skin Forehead 0.25-0.5mm 05.-0.75mm Between Eyebrows 0.25-0.5mm 0.5mm Nose 0.25mm 0.5mm Eye Area 0.25mm 0.25mm Cheek Bone 0.5mm 0.5-1.0mm Cheek and Chin 0.5-1.0mm 1.0mm Lip Area 0.25mm 0.5-1.0mm Lips 0.25mm 0.25mm Scarring 1.0mm 1.0mm Stretch Marks 1.0mm 1.0mm G. Section the face into 5 areas: forehead, cheeks, chin, upper lip and nose. H. With free hand that is not holding the device, gently hold the skin taut. With the hand holding device, use a steady and slow treatment tempo. Use short stripe-like motions, much like a microdermabrasion treatment, lifting the needle tip between each stripe. AVOID using a snake-like pattern where you do not lift the hand-piece. a. First pass, while exerting a constant pressure, treat from bottom to top.

b. Second pass, while exerting a constant pressure, treat horizontally, working medial to laterally. c. Do not apply hard pressure and avoid treating very sensitive regions, such as the protuberant area of the eye area and/or irritated skin such as nodual and postual rosacea. It is possible to treat the perioccular areas of the eye, however, use caution and be sure to pull the skin under the eye taut with your free hand. DO NOT use a needle-depth over .25mm d. After treating the first section, i.e., forehead, cheek, etc., place the pen hand-piece device on a sterile surface and use a gauze pad to wipe the treated area to remove any blood. After wiping the treated area with a gauze pad, you must reglove. With new gloves and before touching the device, move to the next section and apply the HA-Boost. You may proceed to treat the new section as outlined above and repeat the instructions as before, being certain that re-gloving takes place after treating and cleaning of every single section. Following this step keeps the protocols compliant with the OSHA blood bourne pathogen certification criteria. It is suggested that you have this certification before using the InnoPen device.

I. Third pass (if needed), while exerting a constant pressure, treat in a diagonal direction, starting at the bottom of the face and work upward. Otherwise, spot treat problem areas such as deep wrinkles, stretch marks or scar tissue using a stamping motion.

Procedure Directional Chart

First Directionality

(Purple) Treat using the “striping technique” and follow the direction bottom to top. Start at the bottom of the movement and treat with upward strokes.

Second Directionality

(Blue) Making constant contact, start medially and work laterally from inside toward the outer face and then repeat starting from the inside to the outer face. This creates a “striping” movement which follows protocol.

Third Directionality

(Black) Outward and upward (when treating nose and upper lip on third pass use downward strokes as indicated in diagram above.

Treatment (continued) 5. COOLING, SOOTHING AND MOISTURIZING: A. After the entire treatment is complete, applyRecovery Serum to the treated area. Advise your client to apply this cream every 4 to 6 hours, for 48 to 72 hours following treatment. 6. POST-OPERATIVE TREATMENT: A. After the treatment, take precautions against sun exposure. Do not apply sunscreen for 12 hours after the treatment due to the skin’s channels being open for a period of time and due to the toxic nature of some sunscreens on the market. B. Do not apply make-up for at least 12 hours. C. Apply a light film forming substance such as Recovery Serum with a hyaluronic acid immediately post treatment. A short window of time exists to apply an active ingredient or serum. The micro injuries created have formed micro channels allowing product percutaneous absorption or trans delivery potential. In 2010, the research done in the Laser Physics Letters produced a study found that these channels close within about 10-15 minutes. See Laser Phys. Lett. reference. D. Needling may trigger a cold sore response in patients and a prophylaxis medication should be recommended to those who are prone to outbreaks.

7. HOME CARE: A. Wash the face thoroughly a few hours after treatment. Gently massage the face with tepid water (a shower can provide an easier ability to massage the face while washing at the same time), and remove all serum and other debris, such as dried blood. This will improve the appearance of the skin and also allow for better absorption of PHYTOBOOST serum. Minimal make-up may be applied the following day. B. For the first 1-3 days, the skin will be very dry and feel tight. Frequent use of serum will help alleviate this. C. After 2-3 days, patients can return to regular skin care products as soon as it is comfortable to do so. Vitamin A products are optimal and suggested. D. Avoid alcohol based toners for 10-14 days. E. Avoid direct sun exposure for at least 10 days if possible. F. Do not apply sunscreen the same day as treatment. Undesirable chemicals can penetrate if used in large amounts.

Treatment (continued) 8. RECOVERY TIMELINE: Day 1: Erythema and red appearance and severity will depend on how aggressive the treatment was performed. Day 2: A red hue or a pink hue persists like a moderate sunburn. Swelling may be more noticeable on the second day. Day 3: Skin can be pink or normal color. Swelling subsides.

Additional Notes * Immediate results can be seen after one treatment. For maximum results, administer a totla of 5-6 treatments.

STRETCH MARK THERAPY TREATMENTS 1. Treat the stretch marks using 3 passes.

SCAR THERAPY TREATMENTS Scar therapy treatments can require over 6 total treatments. Due to the aggressive trauma to the skin, 4-6 weeks between treatments is necessary. The treated area must be allowed the proper recovery time to avoid over-stimulation. Scars less than 6 months old can be treated more frequently. 1. Treat the scar using 3 passes. If the scarring is extremely dense or is a keloid scar, a fourth pass can be administered. 2. Change the direction of each pass following the protocol outlined above in H. For the third and fourth pass, use a stamping method. 3. Be aware that dense scarring can be very difficult to work. Therefore, instead of dragging the tip across the skin, use a stamping method, using a fractional protocol, as in laser therapy.

2. Change the direction of each pass following the protocol outlined above in H. For the third pass, treat diagonally. PRODUCT INFORMATION • • • • •

Products that are advisable to be used in combination with micro-needling are: Product(s) capable of stimulating collagen and elastin growth in the full dermal depth. Product(s) stimulating the regeneration of cells. Product(s) containing essential nutrients for the epidermis and dermis. Product(s) favoring blood circulation.

PRODUCTS THAT SHOULD NOT BE USED WITH MICRO-NEEDLING ARE: • •

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Vasoconstrictors. Do not apply chemical additives including HIGH-glycolic and hydroxy acids prior to treatment. Use of LOW-glycolic and hydroxy acids post treatment is approved. Avoid allergy causing materials. Avoid perfumes and artificial colorants.

OTHER PRECAUTIONS: (Examine the patient’s skin before treatment. The product can provoke serious side effects if not used by a skin care professional.) •

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Auto-immune therapies, Retin-A therapy or other hypersensitive skin treatments should be discontinued 12 hours prior to treatment. Extreme or active acne, rosacea or other inflamed conditions should not be treated. Open wounds, such as herpes, should be avoided. Client must take medication for 24 hours prior to treatment. If client is prone to facial outbreaks such as herpes, medication must be taken for 48 hours after treatment. InnoPen treatments should not be administered for 6 months after an Accutane regimen. Fitzpatrick III and above - use a zinc oxide paste to protect from sun exposure. It is important to warn patients with darker skin types that erythema associated with needling appears much darker. Post inflammatory hyperpigmentation is normal and will appear darker for possibly a few months before improving.

WARNINGS TO PROFESSIONAL USERS: • It is the responsibilty of the user to know the medical history of their patient prior to administering treatment. • Unseal the product tip just prior to treatment and make sure that the device does not touch other objects in order to avoid infection. • Aggrssive treatments are not necessarily more effective. • Do not use any product if the date of validity (expiration date) has expired, due to risk of infection.

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Qualified professionals should judge if the treatment is suitable for the physical/ skin condition of the patient. They must be able to decide the appropriate use of an anesthetic cream and select appropriate product(s) to use in combination with the treatment. Clinical use InnoPen is sold exclusively for medical or approved salon professional use. General sales to the public is expressly prohibited. InnoPen needles are sterile medical devices, specifically designed for single use, on a single patient. The needle must beused one time ONLY and then should be properly disposed in a sharps container. Under no circumstance should a needle tip be reused on multiple patients. Do not exert too strong a pressure when using the InnoPen. Use caution when treating the lips and eye contour (mainly the eyelids), as the skin is thinner in these particular areas. Do not use on children or animals. In the event of rash or allergic reaction or any other undesirable effect, discontinue use of the product immediately. Prior to use, be sure to check product for damage, proper seal and for term of validity (expiration date.) Drugs associated with photosensitivity - Needling does not increase photosensitivity and hyperpigmentation is one of the hardest things to treat, so it is very important to limit factors within our control to optimize results. Some common drugs and supplements can cause photosensitivity including antibiotics, antidepressants, diuretics, antihypertensive, anti-cholesterol agents, accutane and tretinoin and benzyl peroxide.

Contra Indications History of allergies - Patient may display urticaria (hives) due to the release of histamines if aggressive treatment is done on the thighs or abdomen. Results may lead to itching and could last for days. Rosacea - Safe for “vascular” but not pustular or nodular rosacea. Wait until the inflammation has settled. No need to delay other areas of concern such as peri-orbital lines that are outside the inflamed zone. Anti-coagulated patients - Patients on Coumadin and other anti-coagulants may present a challenge and the risks need to be balanced with the benefits. Do not justify discontinued treatment for potentially life threatening conditions in order to perform cosmetic treatments. Frequency of treatment - An enzyme responsible for remodeling excess collagen is collagenase and is peaked at day 14 after the treatement in response to injury. Additional treatments should not be done more than once per month. If treatments are administered before this time, it would ensure that collagenase is constantly peaked, thus having a negative effect. Botox and filler safety - Do not perform InnoPen within 48 hours of a botox treatment. Treatment before this period may affect the distribution of the botox beyond the injection site. Avoid InnoPen for two weeks after fillers to avoid an inflammatory reaction. IPL, Laser Fraxel, etc. - Micro-needling does not address all the problems encountered in aesthetic medicine. Vascular lesions and some pigmented lesions are better served through traditional treatments such as IPL, Laser and Fraxel, etc. The pro-fibrotic growth factors associated with the InnoPen would then allow for normal collagen formation. Pregnancy - Although dry needling with no products is safe, it is not typically recommended to treat pregnant patients. Diabetes - These patients are more prone to post treatment infection because wound healing is sometimes delayed. Keloid - This is not an absolute contra indication, but avoid treating any patients that are known to have kelooids on the palms and soles. Treatment with antihistamines for a few months after needling may be helpful to reduce and minimize the inflammatory response. Immune-suppressed patients - Proceed with caution, including topical creams such as Elidel (a cream that is prescribed to stop the immune system from producing eczema substances). The risk of secondary infection post treatment is increased.

POSSIBLE COMPLICATIONS • Cutaneous eruptions • Inflammation • Itching and burning sensations • Allergic reactions STORAGE • Store the device in a well-ventilated, room temperature area. • Keep the device out of the reach of children.

Patient Home Preperation Preparing the skin for this procedure will ensure optimum results. Healthy skin will respond better and results will last longer. Skin cells need nutrients for best function and a microneedling recommended anti-aging regime should include: • • • • • • • • • •

Oral supplements (omega 3, glucosamine and multivitamins) Cleanser and toners Topical vitamin A (avoid high doses) Topical vitamin C Topical antioxidants Topical copper peptides Topical growth factors Sunscreen HA-BOOST hyaluric acid PHYTO-BOOST phyto botanical

REFERENCES Aust MC, Reimers K, Kaplan HM, et al. Percutaneous Collagen Induction - RegeneratioPlace of Cicatrisaion? JPRAS - An Int’l Journal of Surgical Reconstruction, Received 19 May 2009; accepted 14 March 2010. Published online 22 April 2010. Setterfield, Lance M.D. The Concise Guide to Dermal Needling Medical Edition. New Zealand. Virtual Beauty Corporation, 2010. Print. Bal S, Kruithol AC, Liebel H, et al. In vivo visualization of microneedle conduits in human skin using laser scanning microscopy Laser Physics Letters, Laser Phys. Lt. 7, No. 3, 242-246 (2010)

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