South African plastic surgeon Dr Des Fernandes talks the benefits of skin needling and its place in the future of skin rejuvenation.
Skin needling has come a long way since 1995 when it initially came onto the scene when Andre Camirand first published his experience about making scars less visible by ‘dry needling’ them.
When I extended the concept to rejuvenating skin in 1997, doctors ridiculed the idea that a simple pinprick could have such powers. Like Camirand, I started by using a tattoo artist’s device with a flat array of four needles that could penetrate 1-2mm into the skin. I had previously been trained by the doyen of tattoo artists so I could adapt that skill to safely needle patients’ faces, but I learned that intensive needling put the patients out of social circuit for up to 10 days and the procedure took a long time to do. I also noticed that thick scars didn’t change sufficiently. I reasoned that if one could use a roller with 3mm needles, one could needle deeper and probably faster and, because there would be fewer holes, the skin would return to a normal appearance sooner. Intensive treatments this way looked almost the same as using a tattoo gun, but the healing time was reduced to 5-7 days.
By 1999 I had a sufficient number of clinical results to make a presentation at the International Plastic, Reconstructive and Aesthetic Society conference in San Francisco. The lecture theatre was packed with standing room only and one prescient comment was that my lecture was the most provocative and exciting idea for the coming century.
I believed the clinical results indicated there was regeneration of tissue and, in particular, restoration of the normal lattice arrangement of the fibres in the dermis. Regeneration had never before been described as a result of any intervention and I ended up explaining this in a long interview on Channel 5 TV in the UK. The first publication of skin needling was in the Hot Topics section of Aesthetic Surgery Journal.
At that stage I presumed the reason for regeneration was from platelet-derived growth factors released after puncturing tiny vessels in the dermis. Almost at the same time Mark Ferguson in the UK was studying TGF-beta-3 in preventing the formation of scars. In time I realised that since TGF-beta-3 was released from platelets, it was the most likely cause of tissue regeneration and scar reduction when needling skin.
However, there was no proof of this until Matthias Aust took up the challenge to study skin needling and his team discovered that the release of the TGF-beta growth factors in simple wounding and in skin needling were diametrically different. In skin wounds, TGF-beta 1, 2 and 3 are all released but the TGF-beta-3 fades away within 24 hours and TGF-beta 1 and 2 persist for a week or two.
In skin needling the reverse situation applies and this has been confirmed in repeated tests: TGF-beta 3 persists at raised levels for up to two weeks whereas TGF-beta 1 and 2 fade away within 24 hours. This detail provoked the idea that needling again a week later would increase the effects of TGF-beta-3 and produce results superior to needling at longer intervals.
However, in order to do needling as intensively, we needed to fully anaesthetise the skin and that required sedation because it can be very uncomfortable just to get good anaesthesia of the face and neck. The question then arose about how to make needling easier for the patient and also make it less dramatic in appearance.
By using rollers with needles that protruded only 1.0mm we could do skin needling under simple topical anaesthesia. That made needling more accessible and because we worked less intensively the clinical and social sequelae would be easier to tolerate. I assumed that with an intensive needling one makes about five times more holes in the skin than we could by using topical anaesthesia, so I recommended six treatments done at weekly intervals.
After several months I realised that this regime produced results very similar to one intensive treatment but more conservatively minded people worried that frequent treatments would negate the benefits of needling. Indeed, some ‘authorities’ condemned weekly treatments even though they had no clinical evidence at all.
Aust and colleagues doubted that needling at weekly intervals had any value but fortunately researched this and discovered that needling at weekly intervals gave far superior results. They also showed without doubt that topical Vitamin A, and they used Environ vitamin ACE Oil in their studies, virtually doubled the benefits of needling.
There is no clinical doubt, and scientific investigation has proved, the best way to induce changes by needling is to use topical Vitamin A and repeat the needling within 7 days. I believe the reason for this is the concentrations of TGF-beta-3 build up to levels unattainable by even the most intensive needling because each needling experience adds to the previous levels of TGF-beta-3.
The challenge now is to optimise needling and I believe using well-selected peptides can enhance our results. My clinical research shows dramatically better results when I add a special cocktail of peptides. I believe we should not use growth factors themselves, but rather molecules that will induce the natural balance of growth factors. I am currently researching needling every second or third day and the indications are that this regime gives the greatest tightening of skin that I have ever seen.
Needling does something clinicians have craved for centuries: it causes regeneration and rejuvenation and we will learn to harness its powers more effectively in the coming
years.
