Stemming from the use of hypodermic needles to treat wrinkles and scars, in 1997, Des Fernandes, MBBCh, developed the first stamping device to induce collagen production. Today the treatment is known as microneedling, and even though it suffered a setback during the Covid-19 pandemic with restrictions on elective aesthetic procedures, it is making a strong return.
According to a report published in Transparency Market Research, microneedling is forecasted to grow at a compound annual growth rate (CAGR) of 7.9% to reach a market value of $1.1 billion by 2031, thanks to a rise in demand for cosmetic treatments, along with developments in technology.1
Physiology of Microneedling
Controlled micro-injuries caused by microneedling initiate a wound healing cascade resulting in an increased production of connective tissue growth factors while leaving the epidermis undamaged. A fibronectin matrix forms approximately five days after treatment, leaving the skin tighter and more youthful. One retrospective analysis found that skin treated with four sessions one month apart increased collagen and elastin deposition up to 400%.2
As well as being a popular treatment for collagen induction therapy, microneedling enhances the delivery of topicals by creating micro-channels in the skin that allow for deeper penetration into the dermis, making this treatment a staple in many cosmetic practices and medspas. Despite these advancements and benefits, microneedling continues to boast a low cost of entry for aesthetic practices, physicians, patients and clients.
Trends in Microneedling Treatment Protocols
Facial plastic surgeon Steven Weiner, MD, laid down his scalpel in 2005 and now focuses on non-invasive cosmetic treatments at The Aesthetic Clinique in Santa Rosa 
Beach, Fla. In Dr. Weiner’s opinion, radiofrequency (RF) microneedling provides a superior treatment compared to standard microneedling. “RF microneedling gives much better results for tightening and acne scars than microneedling,” he shared. “The RF causes coagulation leading to greater collagen and elastin production.”
According to Suneel Chilukuri, MD, director of cosmetic surgery at Refresh Dermatology (Houston, Texas), RF microneedling technology can also be used to treat acne. “RF microneedling is a great option for early intervention for scarring while the resolution of acne is occurring. It is extremely safe, and you can use it on all skin types,” he said. “We use it on patients with active acne, including pustular and cystic acne, and see a tremendous reduction in the size of the sebaceous glands. By decreasing the size of the sebaceous gland with an external device producing heat, there is less oil production, so it is a very cost-effective mechanism for decreasing acne,” he added.
Christine Petti, MD, a plastic surgeon from Torrance, Calif., uses innovative treatments for nonsurgical skin tightening and is also a fan of RF microneedling. “One of my favorite RF microneedling protocols is to aggressively treat smile and marionette lines, jawline, submental laxity and nec
klace lines. For these problem areas I try to stack the depth and maintain the RF level and time (milliseconds). By stacking, I mean varying the depth from 2.5 mm to 3.0 mm to 3.2 mm to create a ‘column’ of dermal injury and thereby an inflammatory response that will result in a pillar of collagenesis to support and thicken the skin in the treated areas. The results I have seen in my patients are a smoothing and filling in of these smile lines, such that it appears that they had dermal filler treatments,” she emphasized.
Varying treatment depth has allowed J.D. McCoy, ND, founder of Contour Medical (Gilbert, Ariz.), to treat his patients more aggressively with improved comfort. “Historically, I would only be able to treat about 1 mm or deeper,” he said. “I use a device that allows me to treat very superficially on the first pass to target pigment in the superficial facial membrane for collagen stimulation and to desensitize the skin. After superficially treating the patient’s skin, I go back and do a deeper pass with much more comfort.”
Dr. McCoy is able to also treat the neck and jowl, historically a challenge for non-invasive cosmetic treatments. “There has been an evolution in the technology and RF microneedling is a necessity for me, at least for the neck and jowl,” he reported. “The key is going deep enough to target the fibro-septal network and deliver enough energy for effe
ctive tissue coagulation. I have seen the most coagulation and the most shrinkage from using the Sylfirm X, a dual-wave RF microneedling device from BENEV (Mission Viejo, Calif.), with a non-insulated needle for clean energy delivery. I often do one side first and show my patients the difference, because the results are impressive,” he explained.
Plastic and reconstructive surgeon Erez Dayan, MD, medical director at Avance Plastic Surgery Institute (Reno, Nev.), called attention to studies that are currently looking at protocols comparing different microneedling and outcomes. At least one study showed that RF microneedling is an effective tool for physicians to achieve tissue retraction compared to energy-based devices alone.3 “It will be interesting to see how the histologic outcomes compare in terms of collagen remodeling and regeneration,” Dr. Dayan indicated.
Combination and Specialized Treatments
Dr. Chilukuri combines RF microneedling with other treatments for his signature neck lift. “We
first use RF microneedling followed by the 1927 thulium laser to get results similar to surgery.” Along with the neck lift, Dr. Chilukuri has great success with treating smile lines around the eyes using a treatment he calls a C-Lift. “We do two or three treatment sessions spaced about four to six weeks apart using the Sylfirm X for significant results. When the patient smiles, the eye lines do not crinkle because this method thickens the dermis.”
Dr. Day
an mainly uses microneedling to improve surgical and traumatic scars, and in combination with platelet-rich plasma (PRP) for facial rejuvenation. “We have seen faster recovery and improved results with microneedling and PRP,” he shared. “But one of my favorite combination treatments is microneedling with medium depth chemical peels (35% TCA with Jessner’s solution). This is a powerful yet safe anti-aging treatment to correct fine lines and wrinkles of the face and neck.”
According to Dr. McCoy, combining microneedling with certain injectables can provide comfort with enhanced results. “I do combination therapy using bio-stimulant filler to volumize and stimulate collagen from the inside out and microneedling to treat skin from the outside in,” he shared. “I do this in a single appointment because products like Sculptra (Galderma) or Bellafill (Suneva) have numbing agents in them, so I will inject those first to get a good numb
ing of the area to make microneedling more comfortable and then do the microneedling over the top in the same visit.”
Additionally, Dr. McCoy uses dual wave RF microneedling to treat difficult melasma and pigment issues that could historically only be treated with laser. “Ethnic skin types are also difficult to treat with laser as safety becomes a concern. However, patients that might not be good candidates for laser-based treatment typically are good candidates for RF microneedling. This is a breakthrough as darker skin types typically do not have as many options on the laser-based side, but with the microneedling we can treat all skin types.”
Updated Microneedling Technologies
The Secret PROTM from Cutera® (
Brisbane, Calif.) is an innovative and versatile device that can treat skin texture, pore size and stimulate collagen production for all skin types. With a fractional CO2 laser for skin resurfacing, along with RF microneedling to initiate hemostasis and coagulation for deep dermal remodeling, the Secret PRO delivers exceptional results and a superior experience. “There is little downtime associated with the RF microneedling on the Secret PRO, so many patients use this as a ‘weekend treatment,’” explained Michael Somenek, MD, a facial plastic surgeon in Washington, D.C. “As someone who has used many RF microneedling devices, this has one of the best ergonomic handpieces, making it easy to use, and patients are comfortable with how the device delivers the microneedles. The user can adjust the settings, including the depth and more importantly, the RF time, which can really maximize results.”
H. William Song, MD, of Omni Aesthetics MedSpa (Santa Monica, Calif.) prefers the Rejuvapen NXT® by Refine USA (Jacksonville Beach, Fla.). “The powerful motor and ergonomic design make this device stand out from similar devices on t
he market,” he expressed. “We recommend regular microneedling with Rejuvapen NXT to every patient in our practice because it is safe, and it works.” The Rejuvapen NXT is an FDA-cleared microneedling device that treats facial wrinkles as it provides flexibility to customize treatments for optimal results. The innovative design features plug-in power for consistent speed and patented disposable tips to improve procedure safety while eliminating suction and clogging during treatment. The device has been clinically proven to deliver safe, effective and reliable results for patients of all skin types and aging severity.
Agnes RF from Agnes (Torrance, Calif.) incorporates RF energy for tissue coagulation and electrothermolysis, with micro-insulated needles to penetrate the skin at specific points while distributing RF energy at precise temperatures to generate a tissue response without damaging the epidermis. Jack Zamora, MD, a facial plastic surgeon based in Denver, Colo., uses the Agnes RF as the foundation for his non-invasive facial sculpting. “Agnes allows us to deliver powerful levels of RF energy to coagulate subdermal tissue in the safest way possible,” he said. “We use other RF microneedling devices for more superficial treatments; however, for deep yet non-invasive treatments, nothing delivers a visible arc plasma effect in the subdermal space like Agnes.”
According to Dr. Zamora, the larger insulated needles can deliver visible and palpable skin contraction outcomes. He also uses it to enhance some surgical procedures, including difficult-to-treat jowls.
SkinPen by Crown Aesthetics (Dallas, Texas) is the ideal gateway technology to help physicians grow their practice. It delivers dramatic rejuvenation results in a quick, comfortable and affordable procedure that patients love. As the first FDA-cleared microneedling device, SkinPen Precision is now cleared to improve the appearance of neck wrinkles and facial acne scars. Engineered and manufactured in the U.S., with over 90 validation studies ensuring quality, safety and performance, SkinPen Precision sets a standard in microneedling.
“We have used the SkinPen Precision device for several years and keep getting positive feedback from our patients,” said board-certified plastic surgeon Gregory Buford, MD (Lone Tree, Colo.). “It provides optimal outcomes with less tissue damage than some of its competitors so downtime is minimized while results are optimized. We also see less drag with it than with other devices which equates to less collateral tissue damage and downtime.”
Clinicians at Esthetic Medical (Scottsdale, Ariz.) have created SkinStylus® Sterlock, an affordable FDA-cleared microneedling system built by practitioners for practitioners.
This device features a revolutionary patented SteriStamp® and SteriTip®, non-absorbent sterile applicator for PRP and microneedling.
Gretchen Frieling, MD, dermatologist and CEO of G Face MD in Wellesley, Mass., explained how SkinStylus works. “The small microneedles penetrate the skin at varying depths to stimulate collagen formation gently and gradually,” she advised. “Patients with acne scarring and post-inflammatory hyperpigmentation can achieve significant softening and correction of the scars and pigment.” The SkinStylus can be used both cordless and corded and offers three different cartridge options including a revolutionary 36 pin HiLo cartridge offering three times the treatment efficiency of other systems.
With prejuvenation in mind, dermatologist Tonya McLeod, MD (Charlotte, N.C.), combines her microneedling treatments with PRX Derm Perfection from Love Beauty Pro & Medical (Woburn, Mass.). This innovative regenerative clinical aesthetic treatment combines the effects of hydrogen peroxide, 33% TCA and kojic acid.
“I use this as an anti-aging defense for prejuvenation and a rejuvenating skin tightening treatment. I also incorporate PRX to treat stretch marks, skin laxity on the face, upper arms and legs, especially after significant weight loss or aging,” Dr. McLeod reported. “With PRX, I can offer options for spring and summer treatments and increased possibilities for cosmetic treatments in skin type IV-V.” PRX is a no-downtime, no-photosensitivity treatment that is safe for all skin types and targets aging skin, texture, laxity, wrinkles and dull skin for complete rejuvenation of the face and body.
Adjunctive Topicals
EMC Pharma (Maryland Heights, Mo.) focuses on innovative and cost-effective medications and incorporates their exclusive hypochlorous acid (HOCI) into their products. Michael Gold, MD, founder of Gold Skin Care Center (Nashville, Tenn.) u
ses the company’s Lasercyn and Celacyn Scar Gel with HOCI to eradicate bacteria, reduce inflammation and pruritus, break down biofilm and increase oxygenation.
“Lasercyn is one of the most stable hypochlorous acid products on the market and one of the go-to technologies for prepping the skin before all of the procedures we do, whether RF microneedling, microneedling, or any laser or injectable procedure. HOCl kills virtually everything on contact and is safe to use anywhere and on anyone,” Dr. Gold reported. “Celacyn uses a specialized drug delivery along with silicones to improve scars, and studies have demonstrated its effectiveness. When using this product during a procedure, I am assuring that my patient will not have any major potential inflammatory pathogens – before, during or after. There is nothing else on the market that does this,” he added.
Topicals for post-microneedling 
can significantly improve patient outcomes, as demonstrated by AnteAGE MD® Brightening Solution from AnteAGE (Irvine, Calif.). This topical adjunct can be safely applied to the skin after microneedling to treat stubborn pigmentation and stop new discoloration from forming by blocking all seven pathways to melanogenesis. According to Alexis Stephens, MD, at Parkland Dermatology, AnteAGE MD Brightening Solution can help take patients’ microneedling results to the next level. “It improves results of treatment for discoloration and dramatically cuts down on the number of sessions needed by allowing patients to achieve an even skin tone much faster. Incorporating this solution also improved the clinic workflow by allowing me to use just one serum per session.”
Recovery dramatically affects the patient experience, and take-home treatments can help improve results. The Epionce Essential Recovery Kit® is an all-in-one take-home kit for post-procedure barrier repair. It is clinically proven to reduce erythema and transepidermal water loss (TEWL) post-treatment and to reduce 95.5% of Malassezia yeast in 30 seconds. Carl Thornfeldt, MD, founder and CEO of Epionce in Boise, Idaho, uses microneedling combined with superficial chemical peels, RF or LED for anti-aging to reverse photodamage in the skin and for acne. He explained the importance of managing the patient’s healing with the all-in-one approach of the Epionce kit. “The Epionce Essential Recovery Kit provides all of the key functions for proper healing: semio
cclusion, hydration, accelerating epidermal and barrier repair and preventing microbial infection, and it is the only post-procedure kit documented to statistically improve signs of photo-aging four weeks after the procedure compared to standard acetic acid soaks and a lanolin-based ointment regimen.”
Protocols for Improved Results and Complication Avoidance
In Dr. McCoy’s practice, awareness of the patient environment is part of preparation, while pre- and post-procedure therapies are an important aspect of patient comfort and outcomes. “I try to be mindful of the patient’s environment, including their hydration status and electrolyte balance,” he explained. “I am in the middle of Arizona, so most patients are dehydrated. Ensuring they are sufficiently hydrated can greatly improve the results and comfort during treatment,” he explained. While Dr. McCoy is careful to screen his patients; he takes advantage of the numbing effects of certain injectables as part of his pre-procedure treatment; and he also applies topical exosomes post-procedure to help speed healing.
As with any medical treatment, microneedling can have its complications. According to Dr. Weiner, complications from microneedling are rare; however, an area over-treated with too many passes may develop post-inflammatory hyperpigme
ntation (PIH). He also warns that prolonged swelling or redness can occur. Patients can have reactions to topicals applied immediately after treatment because some are not meant to penetrate deeply into the skin, which may lead to granuloma and infections.
Dr. Weiner explained that specific pre- and post-treatment protocols can help avoid complications. “I use sterile gloves, I clean the skin with alcohol and Hipiclens prior to treatment, and then again post-procedure with gauze soaked with hypochlorous acid,” he shared. “I use ultrasound to measure skin thickness prior to all RF microneedling treatments. This allows for exact placement of the needles to the deepest part of the dermis (the area of maximum collagen and elastin creation) and avoids going into the subcutaneous fat, which can lead to fat loss in rare cases. I do not go shallower than 1.5 mm in skin types IV-VI.”
Emerging Treatment Protocols
Owing to these and other pi
oneering practitioners looking for ways to create a nonsurgical facelift, microneedling has evolved past the stage of only treating fine lines. “I am aware that industry research is working to develop techniques that will enable physicians to deliver special pharmacological agents into the dermis with microneedling to effect even more rapid and dramatic collagenesis,” Dr. Petti inferred. “Also, stem cell infusion into the dermis shows promise for achieving the fountain of youth effect, where the dermis is replenished with young cells that can maintain the youthful appearance of the skin.”
Innovative technology is sparking a revolution in microneedling, and progressing interest in nonsurgical therapies, creating a bright future not only for this technology and treatment, but the world of aesthetics as a whole.
References:
1. Microneedling Market (Technique: Manual and Automated; Product: Dermapen, Dermaroller, RF Microneedling Devices, and Others; Material: Silicon, Titanium, Stainless Steel, Polymers, and Others; Application: Skin Rejuvenation, Scarring, Acne, Wrinkles, and Others; and End-user: Hospitals, Dermatology Clinics, Homecare Settings, and Others) - Global Industry Analysis, Size, Share, Growth, Trends, and Forecast, 2021-2031
2. .Litchman G, Nair PA, Badri T, et al. Microneedling. [Updated 2022 May 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https:// www.ncbi.nlm.nih.gov/books/NBK459344/
3. Dayan E, Chia C, Burns AJ, Theodorou S. Adjustable Depth Fractional Radiofrequency Combined with Bipolar Radiofrequency: A Minimally Invasive Combination Treatment for Skin Laxity. Aesthet Surg J. 2019 Apr 8;39(Suppl_3):S112-S119. doi: 10.1093
