Introduction
Micro-needling mesotherapy is an innovative technique used in cosmetology and aesthetic medicine. The procedure uses special devices with needles that create small punctures in the skin, stimulating the repair processes. The procedure aims to improve the appearance of the skin by stimulating the production of structural proteins, such as collagen and elastin, as well as glycosaminoglycans. Micro-needling also enhances the transport of various substances through the skin as it bypasses the stratum corneum and deposits them directly in the deeper layers of the epidermis. Additionally, micro-needling removes the keratinised epidermis and leftover sebum around hair follicles [1]. Due to its effectiveness in improving skin condition and minimal invasiveness, this method has gained widespread recognition among both practitioners and patients. Additionally, during the procedure, large skin blood vessels are not damaged, which minimises the risk of complications such as hematomas and bruising and significantly shortens the recovery period after the procedure [2–4].
Treatment technique
The procedure uses special devices: dermapen and dermaroller. The dermapen is equipped with a single-use sterile tip called a cartridge, containing thin needles of appropriate thickness and length. Cartridges also vary in the number of needles, ranging from 9 to 36 needles arranged in rows. The device is electrically powered and equipped with a battery. The more needles, the more micro-injuries are created in the skin during the procedure. The longer the needles, the deeper they penetrate into the skin. Needle length is automatically adjusted and can be regulated depending on the area being treated during the procedure. The needles are positioned at a 90-degree angle to the skin surface during the micro-needling procedure. The procedure is performed using sliding movements or the so-called “stamping” technique, which involves applying and lifting the device from the skin [3, 5].
The dermaroller is a sterile, single-use device consisting of a plastic handle ending in a roller with several rows of needles. All the needles are of the same length. The needle length in the dermaroller is fixed and cannot be adjusted. The principle of the dermaroller’s action involves rolling it over the skin, creating micro-punctures. Vertical, horizontal and diagonal movements are performed. The needles are positioned at different angles relative to the skin during puncturing, which reduces the precision of the procedure [3, 5].
An appropriate needle length is used depending on the indications. For treating acne scars and other types of scars, needles with a length of 1.5–2 mm are typically used. For reducing wrinkles, needles with a length of 0.5 mm or 1.0 mm are most commonly used. With needle lengths up to 0.5 mm, the procedure is practically painless and the intensity of pain increases as the needle penetration depth increases. Additionally, the perception of pain also depends on the thickness of the epidermis and dermis [3].
Additionally, the needle length should be adjusted according to the area where the procedure is being performed. The skin on the forehead, around the lower eyelids and on the bridge of the nose is punctured to a slightly shallower depth, using needles with a length of 0.5 to 1.0 mm. On the cheeks and chin, the skin is punctured a bit deeper, using needles with a length to 1.5 mm. In general, thicker or more fibrous skin can be treated with deeper needles, so oily skin will be punctured at a greater depth compared to normal skin [2].
Applications of micro-needling
The procedure is most commonly performed to counteract the skin’s ageing process, including reducing fine lines, as well as to improve the overall elasticity and firmness of the skin [5–7].
El-Domyati et al. evaluated the effectiveness of micro-needling in eliminating signs of photo-ageing; treatments were performed around the eyes and on the forehead. Patients were advised to apply a topical antibiotic with fusidic acid for 24 h after the procedure to minimise the risk of infection at the treatment site. In addition, photo-protection with SPF 30, or higher, was recommended. Photographs were taken before each treatment and 3 months after treatment. In addition, skin samples were taken at the beginning of the study, again after 1 month and then again after 3 months. Samples were stained with haematoxylin and eosin, using the Verhoeff-van Gieson method for elastin fibre analysis and picrosirius red for newly synthesised collagen. An immune-peroxidase technique was used to examine total elastin and type I and III collagen. Immunofluorescence was used to detect type VII collagen and tropoelastin. Histometric assessments were performed using computer software. In all the participants, a reduction in wrinkle depth and an improvement in skin texture were observed. Histological studies showed an increase in epidermal thickness, enhanced production of tropoelastin, collagen types I, III, and VII, as well as a reduction in elastin levels [8].
Other indications include scars – primarily acne scars. This leads to a reduction in their depth and an improvement in skin texture [4, 9]. Several studies have shown the effectiveness of micro-needling mesotherapy in treating scars.
Von Dalwig-Nolda and Ablon conducted a study on patients with atrophic acne scars. All subjects had rolling scars, 42 subjects had ice-pick scars and 55 had boxcar scars. The average treatment time was 15.7 min. The severity of scarring was assessed using the Goodman and Baron Scale prior to and 3 months after the study. Improvements in facial acne scars were noted regardless of severity [10].
In turn, El-Domyati et al. performed a series of micro-needle mesotherapy treatments on a group of people with atrophic acne scars. Patients were ordered to apply a topical antibiotic with fusidic acid for 24 h after surgery to eliminate the risk of surgical field infection. Until the erythema subsided, the subjects were to apply a moisturiser and use photoprotection with an SPF rating of at least 30. Skin sections were taken for biopsy before the study, during the course of the study, more specifically after 1 month, i.e. after 2 treatments and then 3 months after the start of the study. Histopathological examinations were carried out using standard haematoxylin and eosin, the Verhoeff-van Gieson method for elastin fibre analysis and picrosirius red for newly synthesised collagen. An immune-peroxidase technique was used to assess type I and III collagen, as well as total elastin. Immunofluorescence was used to detect type VII collagen and tropoelastin. All histometric assessments were conducted using computer software. The authors reported a flattening of acne scars and a significant increase in the synthesis of tropoelastin, collagen type I, III, and VII, as well as newly synthesised collagen, while the total elastin significantly decreased after the treatment. Furthermore, a significant increase in epidermal thickness was observed [11].
Mesotherapy contributes to the improvement of hair follicle condition and stimulates the growth of new hair by activating stem cells and growth factors. Therefore, it is commonly used in the treatment of hair loss. Kumar et al. confirm the beneficial effects of micro-needling in the treatment of androgenic alopecia. The participants were divided into two groups. In group 1, a series of micro-needling mesotherapy treatments were performed over a period of 12 weeks. Additionally, a 5% minoxidil solution was applied twice a day. In group 2, the treatment was limited to the application of a 5% minoxidil solution twice a day for 12 weeks. Before and after the therapy, trichoscopic images were taken. It was shown that the combination of minoxidil with micro-needling is more effective than using these treatments separately [12].
Bao et al. conducted a study on patients with androgenetic alopecia. The subjects were divided into three groups. In group 1, a 5% minoxidil solution was applied twice daily for a period of 24 weeks. In group 2, a series of micro-needling treatments were performed. In group 3, micro-needling was performed according to the same schedule, in combination with the twice daily application of a 5% minoxidil solution. Changes in hair density and diameter were assessed every 3 weeks before and after treatment and patients were monitored for 6 months after the treatment ended. All three groups showed a significant increase in non-hair follicle density, with the highest increase observed in group 3. Ninety percent of participants treated with minoxidil alone experienced a relapse of hair loss, and all newly grown hair fell out, whereas, in the group treated with micro-needling and the group combining micro-needling with minoxidil, the newly grown hair remained well-maintained [13]. The summary of studies on the applications of micro-needling is presented in Table 1.
Table 1
Summary of studies on the applications of micro-needling
Immunological component
During mesotherapy treatment, controlled inflammation is induced in the skin through intensive puncturing with very fine needles of different lengths that come into contact with the skin [14]. Additionally, micro-needling creates microscopic gaps between blood vessels just beneath the epidermis layer [15, 16]. This influences the release of platelets and stimulates the production of collagen, elastin and growth factors, including platelet-derived growth factor (PDGF), transforming growth factor (TGF), fibroblast growth factor-2 (FGF-2), and epidermal growth factor (EGF) [17]. The micro-needling procedure typically lasts for several minutes, but its performance triggers a series of skin reactions, including processes in which immune system cells are involved, such as the influx of neutrophils and macrophages, which, due to their phagocytic properties, cleanse the site of micro-injury from potential contaminants and bacteria [16]. The next stage involves the formation of tissue composed of fibroblasts, collagen and hyaluronic acid. It has been shown that the presence of collagen type III determines the extensibility of the regenerating tissue. This process occurs simultaneously with neocollagenesis (the formation of new collagen). This causes the skin to be better oxygenated. During the extracellular matrix remodelling phase, it continues to undergo transformation. Initially, type III collagen is primarily synthesised, but it gradually transforms into type I collagen. The skin becomes thicker and more durable, regaining its normal colour and texture [18, 19].
Pre-treatment preparation
The procedure begins with a consultation with a specialist to assess the condition of the skin and discuss the client’s expectations for the treatment. Before starting the micro-needling procedure, it is necessary to rule out any contraindications in the patient. Contraindications include active acne, herpes and other infections at the treatment site, a tendency to develop keloid scars and any disruption of the skin’s continuity in the treatment area. Pregnant and breastfeeding women, as well as patients with cancer, are excluded from the procedure. Before the procedure, certain medications should not be taken, such as antibiotics, NSAIDs and glucocorticoids. The procedure is contraindicated for individuals allergic to nickel, which is present in the needles, as well as to the active substances contained in the ampoules introduced into the skin [2].
Next, the skin should be properly prepared by removing makeup, followed by cleansing and disinfecting. Additionally, local anaesthesia in the form of an ointment can be applied to minimise pain and discomfort during the procedure. After about 15 to 45 min, the anaesthetic ointment is removed from the skin and the procedure can begin [6].
The first step is to apply the appropriate mesotherapy cocktail according to the indications, followed by performing micro-needling on the selected areas of the skin. When starting the procedure, one hand stretches the skin, while the other hand manipulates the device. The procedure typically lasts from 15 to 20 min. Immediately after the procedure, the skin is swollen, reddened and tender, which may persist for a few hours. The patient is likely to experience a slight burning and itching sensation. Small bruises and mild peeling of the epidermis may occur. Micro-needling is a procedure that does not carry the risk of scarring or the development of post-inflammatory hyperpigmentation. Post-treatment effects can be visible after the first session, but they are most often noticeable only after a series of treatments. The final effects are not visible immediately as the process of collagen formation continues for about 3–6 months after the therapy is completed [3].
Post-treatment care
Immediately after the procedure, the skin is hypersensitive and excessively reactive, which is why it requires proper post-treatment care. Regenerating and moisturising products should be used, along with sun protection, preferably with creams containing an SPF 50. For at least a week after the procedure, exfoliating products should not be used. For 24 h after the procedure and preferably for 2–3 days, it is not recommended to apply makeup. It is important to reduce the risk of bacterial infection by not touching the skin at the site of the procedure and avoiding contact with animals [6]. Other post-procedure recommendations involve lifestyle modifications. For 24 h after the procedure, it is recommended to avoid consuming alcohol and engaging in intense physical activity. It is advised not to expose the skin to extreme temperatures, including using a sauna, after the procedure. Due to the irritating effect of chlorine, it is recommended to avoid swimming in a pool after the procedure.
Post-treatment complications
Complications after the procedure are very rare. Typical, expected side effects include pain during the procedure, which is minimised by the application of local anaesthetics, however, despite their use, patients may still experience discomfort. Other potential side effects include erythema, irritation, and mild swelling. These symptoms may last for several hours or a few days after the procedure [7, 20, 21].
Other relatively rare side effects include: reactivation of the herpes simplex virus, local skin infection, allergic contact dermatitis to the nickel present in the needles, allergic reactions to the ingredients of the cocktails used in mesotherapy, hyperpigmentation [7, 21].
Conclusions
Micro-needling mesotherapy is highly popular due to its wide range of applications and minimal invasiveness. Additionally, the quick recovery time allows patients to return to their daily activities immediately. Micro-needling mesotherapy can be applied to various areas, including the face, neck, décolletage and body. The practitioner has the ability to personalise the procedure to the individual needs of the skin by adjusting the products used during micro-needling. These aspects have made micro-needling a widely performed procedure.
