Content uploaded by Desmond Brian Fernandes
Author content
All content in this area was uploaded by Desmond Brian Fernandes on May 09, 2020
Content may be subject to copyright.
Minimally Invasive Percutaneous Collagen Induction
Desmond Fernandes, MB, BCh, FRCS(Edin)
The Shirnel Clinic and Department of Plastic Reconstructive Surgery, University of Cape Town, 822 Fountain Medical Centre,
Heerengracht, Cape Town 8001, South Africa
We live in a time when more people are living to a
greater age than ever before. At the same time, there
is an accent on youth such that our patients are ask-
ing us to make them look as young as possible.
Obviously, surgery helps restructure the face into a
more youthful shape, but the old skin remains. Today,
many patients come before they need surgery,
searching for a rapid solution that will make them
look 10 years younger. How do we help our older
cosmetic patients or the much younger men and
women who want to prolong their tenure in a
youthful bracket?
This quest for younger-looking skin has spawned
many different topical techniques that share the same
principle of damaging the skin to cause fibrosis. The
fibrosis then causes tightening of the skin. Histori-
cally, skin peels were the first method of skin
rejuvenation. The principle of peeling is to destroy
the epidermis partially or almost completely to
damage the fibroblasts and dermal structures. This
damage then sets up an inflammatory response
proportional to the damage, which results in the
deposition of collagen. Peeling sacrifices the epider-
mis to achieve the desired result. The experience with
partial-depth burns misled many into believing that
the epidermis is a self-renewing organ that rapidly
grows over the damaged area, which is why peels
became progressively more destructive for the epi-
dermis (eg, the deep phenol peel) until the accumu-
lated problems forced clinicians to recognize that
smoother skin comes at a very heavy price for many
patients and also leads to a significant thinning of
the skin many years later. The proponents of peeling
looked only at the increase of collagen in the
papillary and reticular dermis but did not pay any
attention to the epidermis. The epidermis suffered by
becoming less undulating due to the destruction of
the dermal papillae and subsequent impaired nourish-
ment and, in turn resulted in a thinner epidermis with
fewer cells in the stratum spinosum than before
treatment. The stratum corneum is then less likely to
act as an efficient barrier, so it is not surprising that
many patients feel that their skin is too dry for years
after the treatment. Consequently, hydration of the
dermis also is affected.
Lighter peels (eg, Jessner’s and trichloracetic acid
(TCA)) were introduced, but the tightening of skin
was less effective. For some reason, which is difficult
to understand, clinicians in the late 1980s turned to
laser to destroy the epidermis even more thoroughly
to tighten the skin. We were told that laser would not
present the same problems as the heavy phenol peels
and that skin color and texture would be superior.
Smoothing skin is still most effectively done by CO
2
laser through the aggressive heat damage that is
caused. No other technique can match it, but at the
same time, CO
2
laser causes the most complications.
A significant problem is that deep treatments like this
stimulate fibrosis rather than new, naturally oriented
collagen formation. This fibrosis may result in a
much whiter reflectance from the dermis, giving the
skin an unnatural pallor. The sad fact is that several
years after the treatment, the collagen will be
1042-3699/05/$ – see front matter D2005 Elsevier Inc. All rights reserved.
doi:10.1016/j.coms.2004.09.004 oralmaxsurgery.theclinics.com
The author, a plastic and reconstructive surgeon practic-
ing in Cape Town, is the medical consultant for Environ
Cosmeceutics International and Vivida Closed Corporation
(c.c.), Cape Town, South Africa. Vivida c.c. is the
manufacturer of the Environ Roll-Cit. Dr. Fernandes has a
financial interest in both of these companies.
E-mail address: des@environ.co.za
Oral Maxillofacial Surg Clin N Am 17 (2005) 51 – 63
resorbed—as all scar collagen is—and fine wrinkles
will start to show as a result of the thin epidermis with
no dermal papillae. The impaired hydration of the
skin means that it is not as plump as it could be and
can look atrophic due to this excessive destruction.
Why destroy the epidermis to make the skin
smoother? The epidermis is an extremely complex,
highly specialized organ. It may be only 0.2 mm thick
but it is our sole protection from the environment.
We should never damage the epidermis unless the
risk of leaving the epidermis intact is greater than the
risk of removing it. Wrinkles are hardly a good ex-
cuse to destroy this wonderfully complex interface
that we have with the world. Whatever we do, we
should try to ensure that the basic normal architecture
of the skin is never altered. To rejuvenate facial skin
and really look young, we need a perfect epidermis
with natural dermal papillae, good hydration, normal
color, and normal resilience.
The problem with most treatments that are used is
that only the face can successfully be treated. In
addition, if the result after one treatment is inade-
quate, then a repeated treatment cannot easily be
done. Clinicians have concentrated on rejuvenating
the face, with the result that we get patients with a
younger-looking face but with older hands, arms,
and trunk. We need to treat not only the face but the
hands, arms, trunk, and legs. Laser, however, has
extremely limited indications for areas other than the
face. Laser treatment is not real rejuvenation and will
not satisfy patients who are looking for a more
complete rejuvenation.
This article is devoted to a technique that lends
itself to treatment of the face and the body to achieve
collagen induction. Although this technique may
seem new, we have had centuries of experience with
the technique of tattooing, but in this case, there is no
pigment used. There are now a growing number of
clinicians who believe that we can get closer to our
patients’ dreams of rejuvenation by pricking skin with
needles to get percutaneous collagen induction (PCI).
Principles of the needling technique
Orentreich and Orentreich [1] described ‘‘subci-
sion’’ as a way of building up connective tissue be-
neath retracted scars and wrinkles. The author [2],
simultaneously and independently, used a similar
technique to treat the upper lip by sticking a 15-gauge
needle into the skin and then tunneling under the
wrinkles in various directions, parallel to the skin
surface. The lip wrinkles were improved in many
cases, but the problem was that bleeding caused
severe and unacceptable bruising, which sometimes
resulted in hard nodules. Camirand and Doucet [3]
treated scars with a tattoo gun to ‘‘needle abrade’’
them. Although this technique can be used on ex-
tensive areas, it is laboriously slow and the holes in
the epidermis are too close and too shallow. These
techniques work because the needles break old col-
lagen strands in the most superficial layer of the
dermis that tether scars or wrinkles. It is presumed
that this process promotes removal of damaged col-
lagen and induces more collagen immediately under
the epidermis. The author believes that the standard
technique of tattooing is too superficial to give good
effects for thicker scars or for stimulating collage-
Fig. 1. Needling the face for refining wrinkles using the
special tool designed for PCI.
Fig. 2. Histologic section of skin showing puncture sites
where the needle has penetrated (arrows) and generally
divided cells from each other rather than cutting through the
cells. The tracts are curved, reflecting the path of the needle
as it rolls into and then out of the skin. The holes are about
four cells wide and will heal rapidly. Note that the epidermis
and particularly the stratum corneum is intact except for
these tiny holes (hematoxylin-eosin, original magnification
40).
fernandes52
nosis in the reticular dermis. Needles need to pene-
trate relatively deeply to stimulate the production of
elastin fibers oriented from the deep layers of the
dermis to the surface. Based on these principles, the
author designed a special tool for PCI [4] (Fig. 1).
Indications for needling
Indications for percutaneous collagen induction
1. To restore skin tightness in the early stages of
facial aging. This procedure is relatively minor
and can safely be recommended. Some patients
who are worried about cosmetic surgery may
be satisfied with simple PCI. The neck, arms,
abdomen, thighs, and areas between the breasts
and buttocks also can be treated. Upper-lip
creases can respond very well to needling
(Figs. 2– 4) but may give an even better result
when combined with fat grafts.
2. Fine wrinkles are an excellent indication for
needling of the skin.
3. Acne scarring—the skin becomes thicker and
the results are superior to dermabrasion.
4. To tighten skin after liposuction.
5. Stretch marks (Fig. 5).
6. Lax skin on the arms (Fig. 6) and abdomen
(Fig. 7).
7. Scars—if they are white, then they can become
more skin colored.
8. Hypertrophic burn scars—PCI can safely be
used in children and may avoid procedures to
release contractures.
Contraindications for percutaneous collagen
induction
1. Patients who have not pretreated their skin with
vitamin A.
2. Presence of skin cancers, warts, solar keratoses,
or any skin infection. The needles may
disseminate abnormal cells by implantation.
3. Active acne or herpes labialis infections in the
face or impetigo lesions anywhere on the body.
4. Patients on any anticoagulant therapy like
warfarin, heparin, and other oral anticoagu-
lants. The presence of these drugs may cause
excessive, uncontrolled bleeding. Patients pre-
viously on such treatment should have their
coagulation status checked before the treatment
to confirm that they have a normal clotting/
bleeding profile.
5. Many patients take aspirin daily for medical or
health reasons. The aspirin should be stopped at
least 3 days before the procedure.
6. Allergy to local anesthetic agents or general
anesthesia. These patients should be assessed
by a specialist anesthetist before treatment.
7. Patients on chemotherapy, high doses of
corticosteroids, or radiotherapy.
8. Patients with uncontrolled diabetes mellitus.
9. Patients with an extremely rare but severe form
of keloid scarring in which virtually every pin-
prick becomes a keloid. Patients often have
keloids on the palms of the hands or soles of
the feet.
Fig. 3. Histologic section shows that the needle tract
penetrates to a depth of about 1.5 to 2 mm through the
papillary dermis into the reticular dermis (hematoxylin-
eosin, original magnification 40).
Fig. 4. Appearance of the skin immediately after PCI. The
skin has been cleaned thoroughly and areas of cyanosis can
be seen.
minimally invasive percutaneous collagen induction 53
Preparing the skin
To achieve youthful skin, one needs the skin to be
functionally as young as possible. Most patients
coming for rejuvenation have photoaging and this
needs to be addressed before attempting any PCI.
Photoaging not only is due to the actual ultraviolet
damage of dermal tissues but also is the result of a
chronic deficiency of vitamin A. [5] The first step
toward skin health is to topically replace photo-
sensitive vitamin A [6] and the other antioxidants
vitamins C and E and carotenoids, which are nor-
mally lost on exposure to light. Vitamin A is utterly
essential for the normal physiology of skin and yet
it is destroyed by exposure to light so that it is
prevented from exerting its important influence on
skin and preserving collagen. Vitamin A is believed
to control between 350 to 1000 genes that control
normal function, proliferation, and differentiation of
cells. One cannot exaggerate the value of vitamin A
in a rejuvenation program for skin, especially with
PCI, because in this case, we are specifically trying to
stimulate cells to induce collagen to their maximum.
Vitamin A in physiologic doses will stimulate cell
growth, the release of growth factors, angiogenesis
[7], and the production of healthy new collagen. The
DNA effects of vitamin A interact in parallel with the
growth factors released by PCI. Adequate nourish-
ment of the skin with vitamin A (not necessarily as
Fig. 6. (Left image) Histology shows thigh skin before PCI. (Right image ) Six months after PCI, more collagen (pink ) and elastin
(brown) can be detected. Although difficult to estimate, there is at least 400% more collagen and elastin in the postprocedure
histology section (Giemsa, original magnification 40).
Fig. 5. This slide illustrates the ease with which Indian ink
passively penetrates the skin after needling. Skin was
removed from the upper eyelid and then later needled.
Following needling, Indian ink was applied to the surface
and allowed to dry before the specimen was placed in
formalin for histologic examination. Notice that the ink has
penetrated the papillary dermis. The lesson from this
procedure is that clinicians and patients must be cautious
about what is applied to the surface of the skin after needling.
fernandes54
retinoic acid but also as retinyl esters, retinal, or
retinaldehyde) will ensure that the metabolic pro-
cesses for collagen production will be maximized and
the skin will heal as rapidly as possible [8].
Vitamin C is similarly important for collagen
formation but is destroyed by exposure to blue light.
Both of these vitamins need to be replaced every day
so that the natural protection and repair of DNA can
be maintained. As a result, the skin will take on a
more youthful appearance. The addition of palmitoyl
pentapeptide or other similar peptides also will ensure
that better collagen will be formed. The use of a
special device for microneedling of the skin (Environ
Cosmetic Roll-Cit, Vivida c.c., Cape Town, South
Africa) will ensure that higher doses of the active
ingredients get into the skin. These chemicals,
however, cannot achieve really youthful skin because
the collagen immediately below the epidermis has
been destroyed by years of sun exposure and the
production of collagen in this area needs to be
stimulated by a more targeted technique.
Technique of percutaneous collagen induction
The skin is routinely prepared by using topical
vitamin A and C and antioxidants for at least 3 weeks,
but preferably for 3 months if the skin is very sun
damaged. If the stratum corneum is thickened and
rough, a series of mild TCA peels (2.5% – 5% TCA in
a special gel formulation) will get the surface of the
skin prepared for needling and maximize the result.
Under topical, local, or general anesthesia, the
skin is closely punctured with the special tool that
consists of a rolling barrel with needles at regular
intervals. By rolling backward and forward with
Fig. 8. Phase II of the inflammatory response, which is predominantly the stage of tissue proliferation. Monocytes, keratinocytes,
and fibroblasts continue to influence and be influenced by the release of growth factors. Keratinocytes stimulate growth of the
epidermis and release growth factors to promote collagen deposition by the fibroblasts. New blood vessels are created, and there
is a surge of matrix deposition. GAGs, glycosaminoglycans.
Fig. 7. Phase I of the inflammatory response showing the cascade of cytokines and growth factors following the initial injury of
needling. At this stage, neutrophils are the dominant leucocytes but are gradually replaced by monocytes, the dominant
leucocytes in phase II.
minimally invasive percutaneous collagen induction 55
some pressure in various directions one can achieve
an even distribution of the holes. The skin should be
needled as densely as possible. Usually, as the needle
holes get too close to each other, the needle ‘‘slips’’
into an established hole and so it seems impossible to
over treat the skin. For very superficial small scars, I
use a simple tattoo-artist’s gun as described by
Camirand and Doucet [3]. When using the tattoo-
artist’s machine, one has to be very careful not to
overtreat an area because the skin can then be
damaged because the needles plough their way
through the skin and may remove the epidermis.
The needles penetrate through the epidermis (Fig. 8)
but do not remove it, so the epidermis is only
punctured and will rapidly heal. The needle seems to
divide cells from each other rather than cutting
through the cells so that many cells are spared.
Because the needles are set in a roller, the needle
initially penetrates at an angle and then goes deeper
as the roller turns. Finally the needle is extracted at
the converse angle and therefore the tracts are curved,
reflecting the path of the needle as it rolls into and
then out of the skin. The epidermis and particularly
the stratum corneum remain intact, except for these
tiny holes, which are about four cells in diameter. The
needles penetrate about 1.5 to 2 mm into the dermis
(Fig. 9). Naturally, the skin bleeds for a short time,
but that soon stops. The skin develops multiple
microbruises in the dermis that initiate the complex
cascade of growth factors that eventually results in
collagen production (Fig. 10). After the bleeding
stops, there is a serous ooze that has to be removed
from the surface of the skin. Wet gauze swabs soak
up most of the serous ooze. As the skin swells, the
holes are closed, the edges of the epidermis are
approximated, and the ooze stops. Noxious chemi-
cals, however, may still penetrate the skin, so only
safe molecules should be used topically (Fig. 11).
After this serous leak has stopped, the skin is washed
thoroughly and then covered with vitamin A, C, and
Fig. 9. The final remodeling phase of healing after PCI, which takes many months. Collagen type III is converted into collagen
type I, and the skin becomes tighter. Blood supply is normalized, so the skin becomes smoother and has a natural color.
Fig. 10. Appearance of the skin 2 days after PCI.
Fig. 11. Appearance of the skin 5 days after PCI. Makeup
can be used from about the fourth to the fifth day with-
out problems.
fernandes56
E oil or cream (do not use ascorbic acid). The patient
is warned that they will look terribly red and bruised,
and they are encouraged to shower within a few hours
of the procedure, when they return home.
Why percutaneous collagen induction works
PCI results from the natural response to wounding
of the skin, even though the wound is minute and
mainly subcutaneous. A single needle prick through
the skin would cause an invisible response. It is
necessary to understand that when the needle pene-
trates into the skin, this injury, minute as it might
seem, causes some localized damage and bleeding
by rupturing fine blood vessels. Platelets are auto-
matically released and the normal process of inflam-
mation commences, even though the wound is
miniscule. A completely different picture emerges
when thousands or tens of thousands of fine pricks
are placed close to each other and one gets a field
effect, because the bleeding is virtually confluent.
This promotes the normal post-traumatic release of
growth factors and infiltration of fibroblasts. This
reaction is automatic and produces a surge of activity
that inevitably leads to the fibroblasts being
‘‘instructed’’ to produce more collagen and elastin.
The collagen is laid down in the upper dermis just
below the basal layer of the epidermis (Fig. 12).
It now becomes important to understand the
process of inflammation in detail. An excellent ref-
erence on this topic is the chapter ‘‘Wound Healing’’
by Falabela and Falanga in The Biology of the Skin
[9]. There are three phases in wound healing:
Phase I: inflammation, which starts immediately
after the injury
Phase II: proliferation (tissue formation), which
starts after about 5 days and lasts about 8 weeks
Phase III: tissue remodeling, from 8 weeks to
about 1 year
Phase I: initial injury
The inflammation phase starts when the needles
prick the skin and rupture blood vessels and blood
cells and serum gets into the surrounding tissue
(Fig. 13). Platelets are important in causing clotting
and releasing chemotactic factors, which cause an
invasion of other platelets, leucocytes, and fibro-
blasts. The leucocytes, particularly neutrophils, then
act on the damaged tissue to remove debris and kill
bacteria. After the platelets have been activated by
exposure to thrombin and collagen, they release
numerous cytokines. This process involves a complex
Fig. 12. Mirror image of the right eye of a patient who had
PCI of the lower-eyelid skin done in conjunction with an
upper blepharoplasty and lateral elevation of the eyebrow in
a scarless technique devised by the author. The left image
shows the right eyelid preoperatively and the right image
shows the eyelid 6 months postoperatively.
Fig. 13. (A) Upper lip before PCI showing lipstick tracking up the creases. (B) Fourteen months after one PCI treatment. No
fillers have been used.
minimally invasive percutaneous collagen induction 57
concatenation of numerous factors that are impor-
tant in (1) controlling the formation of a clot
(eg, fibrinogen, fibronectin, von Willebrand factor,
thrombospondin, ADP, and thromboxane); (2) in-
creasing vascular permeability, which then allows
the neutrophils to pass through the vessel walls and
enter the damaged area; (3) attracting neutrophils
and monocytes; and (4) recruiting fibroblasts into the
wounded area.
Of special interest in understanding the action of
PCI are the following:
1. Fibroblast growth factor: promotes not only
fibroblast proliferation but also epidermal pro-
liferation and stimulates the production of new
blood vessels. Vitamin A is an essential
regulator of differentiation of fibroblasts and
keratinocytes so adequate doses in the tissues
are required at this stage. In anticipation of the
interrupted blood supply, it should be ensured
that the highest-possible normal levels of
vitamin A are stored in the skin before PCI.
2. Platelet-derived growth factor: chemotactic for
fibroblasts and promotes their proliferation,
meaning that more collagen and elastin will
be made. The need for vitamin C at this stage
becomes crucial because without adequate
levels of this vitamin, proline and lysine cannot
be incorporated into collagen and the strands
will then be defective.
3. Transforming growth factor a(TGF-a): facili-
tates re-epithelialization. In the case of PCI,
re-epithelialization is not an important action.
4. Transforming growth factor b(TGF-b): a
powerful chemotactic agent for fibroblasts that
migrate into the wound about 48 hours after
injury and start producing collagen types I and
III, elastin, glycoseaminoglycans, and proteo-
glycans. Collagen type III is the dominant form
of collagen in the early wound-healing phase.
Again, this action is heavily dependent on
adequate doses of vitamin C. At the same time,
TGF-binhibits proteases that break down the
intercellular matrix.
5. Connective tissue activating peptide III: also
promotes the production of intercellular matrix.
Fibroblasts migrate into the area, and this surge
of activity inevitably leads to the production of
more collagen and more elastin. Vitamin A and
C again are important mediators of this action.
6. Neutrophil activating peptide-2: has a chemo-
tactic effect for neutrophils that then migrate
into the wounded area. Neutrophils are impor-
tant for killing bacteria and helping to debride
tissue but, in the case of PCI, their main action
is the release of cytokines that enhance the
effects of the platelet cytokines (eg, platelet-
derived growth factor and connective tissue
growth factor).
Phase II: the period for tissue proliferation
As time passes, probably about 5 days in the case
of PCI, neutrophils are replaced by monocytes
(Fig. 14). The monocytes differentiate into macro-
phages and phagocytose the decaying neutrophils.
They are very important for the later healing phases
because they remove cellular debris and release
several growth factors including platelet-derived
growth factor, fibroblast growth factor, TGF-b, and
TGF-a, which stimulate the migration and prolifera-
tion of fibroblasts and the production and modula-
tion of extracellular matrix. With PCI, there is only
extravasated blood and very little connective tissue
damage to be dealt with. Bacterial infection is rare,
but it has been noticed that when the needled area
gets infected, greater smoothing of skin may occur,
probably due to a heightened growth factor response.
In standard wounds, the inflammatory phase ends
after about 5 to 6 days, as proliferation and tissue
formation ensue. In these cases, the main cell is the
keratinocyte. Keratinocytes change in morphology
and become mobile to cover the gap in the basement
membrane. The changes include retraction of tono-
filaments and the dissolution of desmosomes and
hemidesmosomes so that the cells can migrate. Pe-
ripheral cytoplasmic actin filaments also are devel-
oped that ‘‘pull’’ keratinocytes together to close the
wound. These actin filaments, however, are not an
important factor in PCI because re-epithelialization,
or the closure of the needle holes, occurs within a
few hours after needling because the gap is so small.
Disruption of the basement membrane by PCI de-
stroys the lamina lucida and brings basal keratino-
cytes into direct contact with the underlying collagen,
which inactivates laminin and stimulates keratinocyte
migration. When the keratinocytes have joined
together, they start producing all the components to
re-establish the basement membrane with laminin
and collagen types IV and VII. A day or two after PCI,
the keratinocytes start proliferating and act more in
thickening the epidermis than in closing the defect.
Initially after PCI, the disruption of the blood
vessels causes a moderate amount of hypoxia. The
low oxygen tension stimulates the fibroblast to
produce more TGF-b, platelet-derived growth factor,
and endothelial growth factor. Procollagen mRNA
fernandes58
also is upregulated, but this cannot cause collagen
formation because oxygen is required (which only
occurs when re-vascularization occurs). Collagen
type III is the dominant form of collagen in the early
wound-healing phase and becomes maximal 5 to
7 days after injury. The longer the initial phase, the
greater the production of collagen type III.
If the injury extends deeper than the adnexal
structures, then myofibroblasts may contract the
wound considerably. Although the injury in skin
needling extends deeper than the adnexal structures,
because the epithelial wounds are simply cleft,
myofibroblast wound contraction may not play a part
in the healing.
A number of proteins and enzymes are important
for fibroplasia and angiogenesis that develop at the
same time. Anoxia, TGF-b, and fibroblast growth
factor and other growth factors play an important
part in angiogenesis. Fibroblasts release insulinlike
growth factor that is an important stimulant for
proliferation of fibroblasts themselves and endothelial
cells. Insulinlike growth factor is essential in neo-
vascularisation. Insulinlike growth factor or somato-
medin-C also is one of the main active agents for
growth hormone.
Integrins facilitate the interaction of the fibro-
blasts, endothelial cells, and keratinocytes.
Phase III – the process of tissue remodeling
Tissue remodeling continues for months after the
injury and is mainly done by the fibroblasts (Fig. 15).
By the fifth day after injury, the fibronectin matrix is
laid down along the axis in which fibroblasts are
aligned and in which collagen will be laid down.
TGF-band other growth factors play an important
part in the formation of this matrix. Collagen type III
is laid down in the upper dermis just below the basal
layer of the epidermis.
Collagen type III is gradually replaced by
collagen type I over a period of a year or more,
which gives increased tensile strength. The matrix
metalloproteinases (MMPs) are essential for the con-
version process. The various MMPs are generally
Fig. 15. Mirror image of the right side of the face
preoperatively (left image) and 4 months after whole face
needling (right image). The upper lip was initially needled
three times 2 years before, at monthly intervals. The lower
eyelid has been needled only once.
Fig. 14. (A) Before PCI. (B) One year after treatment of PCI.
minimally invasive percutaneous collagen induction 59
classed as MMP-1 (collagenases), MMP-2 (gelatin-
ases), and MMP-3 (stromelysins).
Care of the skin after percutaneous collagen
induction
Immediately after the treatment, the skin looks
bruised, but bleeding is minimal and there is only a
small ooze of serum that soon stops. The author
recommends soaking the skin with saline swabs for
an hour or two and then cleaning the skin thoroughly
with a Tea Tree Oil – based cleanser. The patient is
encouraged to use topical vitamin A and vitamin C as
a cream or an oil to promote better healing and
greater production of collagen. The addition of
peptides like palmitoyl pentapeptide could possibly
ensure even better results.
At home, the patient should stand under a shower
for a long time, allowing the water to soak into the
surface of the skin. Bathing is discouraged because of
potential contamination from drains and plugs.
Patients should be reminded to use only tepid water
because the skin will be more sensitive to heat. While
the water is running over the face or body, the pa-
tient should gently massage the treated skin until all
serum, blood, or oil is removed. The importance of
a thorough but gentle washing of the skin, a few
hours after the procedure, cannot be stressed enough.
The skin will feel tight and may look uncomfort-
able in a few cases. Most patients say that the skin is
a little sensitive but the major complaint is about the
bruising and swelling. The following day, the skin
looks less dramatic (Fig. 16) and by day 4 or 5, the
skin has returned to a moderate pink flush, which can
easily be concealed with makeup (Fig. 17). Men
usually seem to heal faster and are less bruised than
women. From day 3 or 4 onward, iontophoresis [10]
and low-frequency sonophoresis of vitamin A and C
could maximize the induction of healthy collagen.
Iontophoresis also tends to reduce the swelling of the
skin, which also helps the patient look better sooner.
Low-frequency sonophoresis can be used alone with-
out iontophoresis to enhance penetration of palmitoyl
pentapeptide or other peptides (eg, palmitoyl hexa-
peptide, copper peptides, and so forth), which
also may increase the creation of healthy collagen
and elastin.
After the skin has been needled, it becomes easier
to penetrate, and much higher doses of vitamin A
become available in the depth of the skin. Higher
doses of vitamin A may cause a retinoid reaction
Fig. 16. Mirror image of the right side of the face of a patient
previously treated with extensive silicon injections that
resulted in terrible wrinkling and sagging of her facial skin.
This wrinkling and sagging had improved with suction
aspiration and a face-lift. (Left image) One year after the
face-lift. The skin is still terribly wrinkled and sagging.
(Right image) The patient 1 year after PCI of the whole face
and a scarless malar lift without any skin excision.
Fig. 17. Mirror image of the right breast to show stretch marks before PCI (left image ) and 6 months after PCI (right image). The
stretch marks have become virtually invisible.
fernandes60
even though the milder forms of vitamin A (eg,
retinyl palmitate) are being used. This reaction will
aggravate the pink flush of the skin and also cause
dry, flaky skin. Needling may cause some slight
roughness of the skin surface for a few days, and this
condition is definitely worse when topical vitamin A
is used. The clinician should ignore this and urge the
patient to continue using the topical vitamin A.
Patients usually anticipate that their skin will get red
and do not complain much about that but become
concerned about the dryness. It should be remembered
that the skin has lost the important barrier function of
keeping the water inside the skin. Until this barrier
function is restored completely after a few days, the
skin will feel dry. A hydrating cream or even petro-
latum can be used to soothe the dry sensation.
When the patient has not cleaned the skin thor-
oughly, a fine scab may form on the surface. The
formation of scabs should be discouraged because
they may cause obstruction and the development of
simple milia or tiny pustules. Milia are uncommon but
when they occur, they should be treated by pricking
and draining. Tiny pustules are more common and
usually found in patients treated for acne scars. It is
important to open them early and make sure that the
skin has been cleaned thoroughly and that there is no
serous residue on the surface. When the pustules are
allowed to dry on the skin, they will form thin scabs
that effectively prevent the penetration of the vitamins
necessary for a successful treatment.
The patient should avoid direct sun exposure for
at least 10 days if possible and use a broad-brimmed
hat or scarf to protect the facial skin.
Patients may shocked when they look in the
mirror, but this procedure is a far less shocking
experience than laser resurfacing.
The treatment can be repeated a month later, but
the best interval between treatments is presently
unknown. If a clinician intends to achieve a smooth-
ing comparable to a laser resurfacing, then depending
on the original state, a patient may require three or
even four treatments. The results that are achieved are
not temporary but endure for many years. Again, it
should be emphasized that this progress is utterly
dependent on adequate nutrition for the skin.
Predicted appearance after percutaneous collagen
induction
1. Immediately after procedure: bleeding and
bruising
2. Five to 20 minutes after procedure: bleeding
stops quickly; serum oozes from the skin
3. Day 1: bruised and dark purple-red appearance
in light skin; puffy facial appearance; some
bruising, especially close to eyes and in thin-
skinned areas
4. Day 2: red-purple hue on light skin like a
moderate sun burn; bruising, if any, starts to
lighten; swelling may be worse on the second
day in many people, and most people are not
ready to be seen in public at this stage
5. Day 3: appearance still pink, with bruising
getting steadily lighter; swelling reduced;
some people ready to appear in public but
could be conspicuous
6. Day 4 to 6: minimal swelling; bruising will take
a few days to disappear; can use makeup;
patient can appear in public with confidence
with the use of makeup
7. Day 7: in most patients, very few signs are
visible of the procedure. Most patients should
beadvisedtostayoffworkforbetween
5 and10 days if they deal with people at work
and are sensitive about their own appearance
Fig. 18. Mirror image of the right arm shows wrinkling and loose skin prior to PCI (left image) and tighter skin 4 months after
one session of PCI (right image).
minimally invasive percutaneous collagen induction 61
Note about darker, pigmented skin
Most patients with dark, type IV and V skin will
not show the amount of bruising that Medical Roll-
Cit usually causes. The skin will appear puffy, and
bruising might be visible only in thin-skinned areas
such as around the eyes. Changes are a lot less visible
than in light-skinned individuals. Darker-skinned
patients should protect the skin from exposure to
sunlight and, if necessary, a zinc oxide paste should
be used to ensure ultraviolet light protection. A com-
plication many people fear is the risk of hyper-
pigmentation. Tattoos are rarely hyperpigmented,
even in darker-skinned people. The author has never
seen hyperpigmentation in patients with darker skins
(eg, African, Indian, Malaysian, Chinese, Mediterra-
nean) that have been needled.
Results of percutaneous collagen induction
PCI has been used with success for lower-eyelid
wrinkles (see Fig. 2), upper-lip lines (see Figs. 3
and 4), facial wrinkles (see Fig. 5;Fig. 18), and lax
photo-damaged skin on the arms (see Fig. 7),
abdomen (Fig. 19), and legs. It is also useful for
reducing the appearance of stretch marks (see Fig. 6)
so that they become almost invisible. It is particularly
useful for acne scars and post burn scars. The scars
will flatten and, after a few treatments, the mesh
marks of skin grafts will be less obvious.
Advantages of percutaneous collagen induction
1. PCI does not damage the skin. Histology has
shown that the skin is indistinguishable from
normal skin and that the epidermis may show
more dermal papillae.
2. Skin becomes thicker, with greater than a
400% increase in collagen deposition and
significantly more elastin (Fig. 6).
3. Any part of the body may be treated.
4. The healing phase is short.
5. Compared with laser resurfacing, it is less
expensive and the skin is healthier.
6. May be safely done in people with darker pig-
mented skin, without fear of hyperpigmentation.
7. The skin does not become sun sensitive.
8. Can be done on people who have had laser
resurfacing or have very thin skin.
9. Telangiectasia generally improves probably
because the vessels are ruptured in so many
places that they cannot be repaired.
10. The technique is easy to master using a new
tool that has been specially designed for the
procedure and does not necessarily have to be
done by a plastic surgeon or dermatologist.
11. PCI can even be done using topical anesthesia
for limited areas.
Disadvantages of percutaneous collagen induction
1. Exposure to blood. This procedure is relatively
bloody, much the same as dermabrasion.
2. Although PCI cannot achieve as intense a
deposition of collagen as laser resurfacing, the
treatment can be repeated to get even better
results that will last as long if not longer than
laser resurfacing.
3. Overaggressive needling may cause scarring,
particularly when using a tattoo gun. This
scarring does not seem to occur when using
the special barrel of needles.
4. Herpes simplex is an uncommon complication
and patients are instructed to use a topical
virocidal if they feel the tingling feeling typical
of herpes.
Summary
PCI is a simple technique and, with the right tool,
can thoroughly puncture any skin easily and quickly.
Although a single treatment may not give the
Fig. 19. Mirror image of the right side of the abdomen
before PCI (left image) and 4 months after PCI (right image )
showing smoothening of the abdominal skin. A second
session of PCI will smoothen the redundant skin.
fernandes62
smoothing that is seen with laser resurfacing, the
epidermis remains virtually normal. When the result
is not sufficient, treatment can be repeated. The
technique can be used on areas that are not suitable
for peeling or laser resurfacing.
References
[1] Orentreich DS, Orentreich N. Subcutaneous incision-
less (subcision) surgery for the correction of depressed
scars and wrinkles. Dermatol Surg 1995;21(6):543 – 9.
[2] Fernandes D. Upper lip line treatment. Paper pre-
sented at the ISAPS Conference. Taipei, Taiwan,
October 1996.
[3] Camirand A, Doucet J. Needle dermabrasion. Aesth
Plast Surg 1997;21(1):48– 51.
[4] Fernandes D. Skin needling as an alternative to laser.
Paper presented at the IPRAS Conference, San
Francisco, CA, June 1999.
[5] Fisher GJ, Wang ZQ, Datta SC, et al. Pathophysiology
of premature skin aging induced by ultraviolet light.
N Engl J Med 1997;337(20):1419– 28.
[6] Fisher GJ, Datta SC, Talwar HS, et al. Molecular basis
of sun-induced premature skin aging and retinoid
antagonism. Nature 1996;379(6563):335– 9.
[7] Diaz BV, Lenoir MC, Ladoux A, et al. Regulation
of vascular endothelial growth factor expression in
human keratinocytes by retinoids. J Biol Chem 2000;
275(1):642 – 50.
[8] Varani J, Fisher GJ, Kang S, et al. Molecular
mechanisms of intrinsic skin aging and retinoid-
induced repair and reversal. J Investig Dermatol Symp
Proc 1998;3(1):57 – 60.
[9] Falabella AF, Falanga V. Wound healing. In: Freinkel
RK, Woodley DT, editors. The biology of the skin.
New York: Parthenon Publishing Group; 2001.
p. 281 – 97.
[10] Schmidt JB, Binder M, Macheiner W, et al. New
treatment of atrophic acne scars by iontophoresis with
estriol and tretinoin. Int J Dermatol 1995;34(1):53 – 7.
minimally invasive percutaneous collagen induction 63
