Percutaneous collagen induction–regeneration in place of cicatrisation?

Study of different pre-treatments in the comparison of the efficacy of photodynamic therapy for moderate to severe acne vulgaris

OBJECTIVE

To evaluate the efficacy of CO2 fractional laser and microneedling pretreatment combined with ALA-PDT for moderate-to-severe acne, aiming to optimize clinical treatment.

METHODS

Patients were randomly divided into three groups: Group A (CO2 fractional laser + ALA-PDT), Group B (microneedling + ALA-PDT), and Group C (ALA-PDT). Each group underwent photodynamic therapy once a week for 3 weeks. Efficacy was assessed at the end of the 4th week, and recurrence was assessed at the end of the 12th week.

RESULTS

A total of 150 patients with moderate to severe acne were included in this study, with 50 patients in each group. Four weeks after the end of treatment, the effective rates were 88 % for Group A, 62 % for Group B, and 36 % for Group C. Statistically significant differences were found between the groups (P < 0.05), with Group A showing superior efficacy compared to Group B (P < 0.05). No serious systemic or local adverse reactions were observed in any group. No recurrence was seen in any group 12 weeks after the end of treatment, and some patients continued to show improvement in skin lesions over time.

CONCLUSION

Both the CO2 fractional laser group and the microneedling group improved the efficacy of photodynamic therapy for moderate to severe acne compared to the control group, with the CO2 fractional laser group demonstrating better efficacy and fewer adverse effects.

Preconditioning Strategies for Improving the Outcome of Fat Grafting

Autologous fat grafting is a common procedure in plastic, reconstructive, and aesthetic surgery. However, it is frequently associated with an unpredictable resorption rate of the graft depending on the engraftment kinetics. This, in turn, is determined by the interaction of the grafted adipose tissue with the tissue at the recipient site. Accordingly, preconditioning strategies have been developed following the principle of exposing these tissues in the pretransplantation phase to stimuli inducing endogenous protective and regenerative cellular adaptations, such as the upregulation of stress-response genes or the release of cytokines and growth factors. As summarized in the present review, these stimuli include hypoxia, dietary restriction, local mechanical stress, heat, and exposure to fractional carbon dioxide laser. Preclinical studies show that they promote cell viability, adipogenesis, and angiogenesis, while reducing inflammation, fibrosis, and cyst formation, resulting in a higher survival rate and quality of fat grafts in different experimental settings. Hence, preconditioning represents a promising approach to improve the outcome of fat grafting in future clinical practice. For this purpose, it is necessary to establish standardized preconditioning protocols for specific clinical applications that are efficient, safe, and easy to implement into routine procedures.

Micro-needling versus acellular dermal matrix in RT1 gingival recession coverage: A randomized clinical trial

AIMS

This randomized trial assessed for the first time the efficacy of coronally advanced flap (CAF) followed by micro-needling (MN) in contrast to CAF with acellular dermal matrix (ADM) on gingival thickness (GT, primary outcome), keratinized tissue width (KTW), clinical attachment level (CAL), probing depth (PD), recession depth (RD), recession width (RW), recession reduction (Rec-Red), complete root coverage (CRC) and percentage of root coverage (all secondary outcomes) in management of RT1 gingival recession in patients with thin gingival phenotype.

METHODS

A total of 24 patients (n = 24) with a thin gingival phenotype and single RT1 gingival recession in the aesthetic zone were randomly allocated to test- (CAF + MN; n = 12) or control group (CAF + ADM; n = 12). All clinical parameters were evaluated at baseline, 3 and 6 months.

RESULTS

Both groups independently demonstrated significant gain in GT, RW, RD, CAL, PD, Rec-Red, CRC and percentage of root coverage, with reduced PI and BOP (p < .05) at 3 and 6 months, without intergroup differences (p > .05). At 6 months, KTW gain was significantly higher in CAF + MN (5.08 ± 0.9 mm) than in CAF + ADM-group (4.25 ± 1.06 mm; p < .05). Stepwise linear regression model with GT as dependent variable showed that base-line GT was the only statistically significant predictor for GT with a direct correlation between base-line GT and GT after 6 months.

CONCLUSION

CAF followed by MN could represent a promising graft-less approach for increasing gingival thickness, comparable to CAF with ADM, with superior keratinized tissue width improvement, in the treatment of RT1 recession defects in patients with thin gingival phenotype.

The Combination of Bioactive Herbal Compounds with Biomaterials for Regenerative Medicine

Regenerative medicine aims to restore the function of diseased or damaged tissues and organs by cell therapy, gene therapy, and tissue engineering, along with the adjunctive application of bioactive molecules. Traditional bioactive molecules, such as growth factors and cytokines, have shown great potential in the regulation of cellular and tissue behavior, but have the disadvantages of limited source, high cost, short half-life, and side effects. In recent years, herbal compounds extracted from natural plants/herbs have gained increasing attention. This is not only because herbal compounds are easily obtained, inexpensive, mostly safe, and reliable, but also owing to their excellent effects, including anti-inflammatory, antibacterial, antioxidative, proangiogenic behavior and ability to promote stem cell differentiation. Such effects also play important roles in the processes related to tissue regeneration. Furthermore, the moieties of the herbal compounds can form physical or chemical bonds with the scaffolds, which contributes to improved mechanical strength and stability of the scaffolds. Thus, the incorporation of herbal compounds as bioactive molecules in biomaterials is a promising direction for future regenerative medicine applications. Herein, an overview on the use of bioactive herbal compounds combined with different biomaterial scaffolds for regenerative medicine application is presented. We first introduce the classification, structures, and properties of different herbal bioactive components and then provide a comprehensive survey on the use of bioactive herbal compounds to engineer scaffolds for tissue repair/regeneration of skin, cartilage, bone, neural, and heart tissues. Finally, we highlight the challenges and prospects for the future development of herbal scaffolds toward clinical translation. Overall, it is believed that the combination of bioactive herbal compounds with biomaterials could be a promising perspective for the next generation of regenerative medicine.

Radiofrequency Microneedling: Technology, Devices, and Indications in the Modern Plastic Surgery Practice

Background

Since the initial invention of microneedling, advancements have been made to improve the desired effects. The addition of radiofrequency to microneedling devices was developed within the past decade as a way to induce thermal injury and increase dermal heating to enhance the dermal wound healing cascade.

Objectives

With an overabundance of literature and mainstream media focused on microneedling and radiofrequency microneedling, this review aims to focus on the available high-quality evidence.

Methods

A comprehensive review of the literature was performed across PubMed (National Institutes of Health, Bethesda, MD) and Embase (Elsevier, Amsterdam, the Netherlands) databases. Attention was focused on manuscripts that provided objective data with respect to clinical application, innovation, anatomy, and physiology.

Results

Optimal outcomes are achieved when needle depth is targeted to the reticular dermis. Needle depth should reflect the relative differences in epidermal and dermal thickness throughout the face. A depth of at least 1.5 mm should be used for the forehead and temporal skin, 1.0 mm for the malar region, 2.0 mm (maximum depth for radiofrequency microneedling) for the nasal side walls, 0.5 mm for the perioral skin, and 1.5 mm for the neck. Deeper settings can be used with care to provide some fat reduction in the submentum.

Conclusions

The authors find herein that radiofrequency microneedling is a safe adjunctive tool to surgical aesthetic procedures. The addition of radiofrequency poses an advance over traditional microneedling devices for skin tightening, with improvements in both safety and efficacy over time.

Level of Evidence 5

Going below and beyond the surface: Microneedle structure, materials, drugs, fabrication, and applications for wound healing and tissue regeneration

Microneedle, as a novel drug delivery system, has attracted widespread attention due to its non-invasiveness, painless and simple administration, controllable drug delivery, and diverse cargo loading capacity. Although microneedles are initially designed to penetrate stratum corneum of skin for transdermal drug delivery, they, recently, have been used to promote wound healing and regeneration of diverse tissues and organs and the results are promising. Despite there are reviews about microneedles, few of them focus on wound healing and tissue regeneration. Here, we review the recent advances of microneedles in this field. We first give an overview of microneedle system in terms of its potential cargos (e.g., small molecules, macromolecules, nucleic acids, nanoparticles, extracellular vesicle, cells), structural designs (e.g., multidrug structures, adhesive structures), material selection, and drug release mechanisms. Then we briefly summarize different microneedle fabrication methods, including their advantages and limitations. We finally summarize the recent progress of microneedle-assisted wound healing and tissue regeneration (e.g., skin, cardiac, bone, tendon, ocular, vascular, oral, hair, spinal cord, and uterine tissues). We expect that our article would serve as a guideline for readers to design their microneedle systems according to different applications, including material selection, drug selection, and structure design, for achieving better healing and regeneration efficacy.

Periorbital rejuvenation in the clinic: A state-of-the-art review

Objective

To provide an overview of the various treatment options available in the clinic to achieve periorbital rejuvenation.

Data Sources

Literature review and expert opinion.

Conclusions

Periorbital rejuvenation in the clinic can be accomplished through a variety of treatment modalities, including topical therapies, skin resurfacing, and fillers and injectables. Furthermore, some surgical approaches, such as upper blepharoplasties, ptosis, and brow lifts, can be performed in the clinic under local anesthesia with only mild oral sedation. However, the successful execution of such procedures depends on proper patient selection and maximizing patient comfort.

Microneedling-Associated Procedures to Enhance Facial Rejuvenation

Microneedling, also referred to as percutaneous collagen induction therapy, uses small needles to create mechanical injury to the skin, stimulating the wound-healing cascade and new collagen formation. Compared with other skin resurfacing techniques, microneedling preserves the epidermis and is nonablative, therefore reducing inflammation, downtime, and risk of dyspigmentation. In addition to increasing collagen production in fibroblasts, microneedling also helps normalize cell function of keratinocytes and melanocytes and can be used to increase absorption of topical medications, growth factors, or deliver radiofrequency directly to the dermis. The benefits of microneedling, associated procedures, indications for use, technical considerations, and potential complications are discussed.

Injectable Platelet-Rich Fibrin and Microneedling—A Non-Surgical Approach for Gingival Augmentation: A Randomized Controlled Clinical Trial

Aim:

The present study aimed to assess the efficacy of combining microneedling (MN) and injectable platelet-rich fibrin (i-PRF) administration with i-PRF alone in augmenting the thickness of gingiva to manage thin periodontal phenotype.

Methodology:

The clinical trial involved 36 patients who were diagnosed with thin periodontal phenotype. They were randomized under two groups: MN + i-PRF versus i-PRF alone, carried out as a split-mouth trial. One quadrant was treated only with i-PRF delivery through the gingival sulcus, while the contralateral side was treated with MN and i-PRF in 3 sessions at 10-day intervals. The primary parameter measured was the thickness of the gingiva, at baseline and 3 months following therapy. Statistical analysis was performed using the Mann-Whitney U test. Wilcoxon’s signed ranking test for inter-group and intra-group analysis, respectively.

Results:

The study results showed a significantly greater increase in gingival thickness (GT) in sites where both MN and i-PRF injection was done, compared to i-PRF alone, with a p value of .04.

Conclusion:

Both treatment modalities showed improvement in GT, being a minimally invasive alternative for mucogingival surgery. Adjunctive MN was found to be more beneficial than i-PRF alone. However, further research should be carried out to address the drawbacks of the study and for a better understanding of this novel approach.

Thermal imprinting during embryogenesis modifies skin repair in juvenile European sea bass (Dicentrarchus labrax)

Fish skin is a multifunctional tissue that develops during embryogenesis, a developmental stage highly susceptible to epigenetic marks. In this study, the impact of egg incubation temperature on the regeneration of a cutaneous wound caused by scale removal in juvenile European sea bass was evaluated. Sea bass eggs were incubated at 11, 13.5 and 16 °C until hatching and then were reared at a common temperature until 9 months when the skin was damaged and sampled at 0, 1 and 3 days after scale removal and compared to the intact skin from the other flank. Skin damage elicited an immediate significant (p < 0.001) up-regulation of pcna in fish from eggs incubated at higher temperatures. In fish from eggs incubated at 11 °C there was a significant (p < 0.001) up-regulation of krt2 compared to fish from higher thermal backgrounds 1 day after skin damage. Damaged epidermis was regenerated after 3 days in all fish irrespective of the thermal background, but in fish from eggs incubated at 11 °C the epidermis was significantly (p < 0.01) thinner compared to other groups, had less goblet cells and less melanomacrophages. The thickness of the dermis increased during regeneration of wounded skin irrespective of the thermal background and by 3 days was significantly (p < 0.01) thicker than the dermis from the intact flank. The expression of genes for ECM remodelling (mmp9, colXα, col1α1, sparc, and angptl2b) and innate immunity (lyg1, lalba, sod1, csf-1r and pparγ) changed during regeneration but were not affected by egg thermal regime. Overall, the results indicate that thermal imprinting of eggs modifies the damage-repair response in juvenile sea bass skin.

A systematic review of the comparison between needling (RF-needling, meso-needling, and micro-needling) and ablative fractional lasers (CO2, erbium YAG) in the treatment of atrophic and hypertrophic scars

The aim of this study is to compare needling (RF-needling, meso-needling, micro-needling) and ablative fractional lasers (CO2, erbium-YAG) in the treatment of atrophic and hypertrophic scars in a systematic review. The database was searched, and 10 articles were selected that were relevant in terms of content, topic, and purpose and met the inclusion criteria. Of all the articles reviewed in this study, there were 2 randomized split-face trials (20%), 1 controlled nonrandomized trial (10%), 1 controlled randomized phase III clinical trial (10%), 1 prospective trial (10%), 1 prospective nonrandomized open-label trial (10%), and 1 randomized comparative trial (10%), with the type of study not reported in 3 articles. We used Endnote X8 to review the articles and extract data. After review, the studies were analyzed and categorized. No statistically significant difference was found between the two methods, laser and micro-needling, in the treatment of atrophic and hypertrophic scars in 60% of the articles studied, and both showed significant improvement (70% or more improvement to complete response). Significant improvement was noted in 20% of the studies reviewed for the laser and micro-needling treatment methods. The results of this study show that needling and ablative fractional lasers are tolerable and safe procedures with no significant difference in the treatment of skin scars in sixty percent of the studies.

Utilization of ex vivo tissue model to study skin regeneration following microneedle stimuli

Microneedling is a popular skin resurfacing and rejuvenation procedure. In order to develop better adjunct products for consumers, there is a scientific need to establish greater understanding of the mechanism in which microneedling stimulates regeneration within skin. The purpose of this study is to develop a physiologically relevant ex vivo tissue model which closely mimics the actual microneedling procedure to elucidate its mechanism of action. In this study, human ex vivo skin was subjected to microneedling treatment and cultured for 6 days. Histological analysis demonstrated that the ex vivo skin was able to heal from microneedling injury throughout the culture period. Microneedling treatment stimulated proliferation and barrier renewal of the skin. The procedure also increased the levels of inflammatory cytokines and angiogenic growth factors in a dynamic and time dependent fashion. The tissue demonstrated hallmark signs of epidermal regeneration through morphological and molecular changes after the treatment. This is one of the first works to date that utilizes microneedled ex vivo skin to demonstrate its regenerative behavior. Our model recapitulates the main features of the microneedling treatment and enables the evaluation of future cosmetic active ingredients used in conjunction with microneedling.

Microneedling Outcomes in Early Post-Surgical Scars

BACKGROUND

Scars are a vexing sequela of surgery. Microneedling, also known as Minimally Invasive Percutaneous Collagen Induction (MIPCI), has demonstrated impressive improvements in chronic acne scars; however, no evidence exists for treating post-surgical scars during active wound healing. The purpose of this study was to demonstrate the utility and safe use of MIPCI in acute post-surgical scars.

METHODS

Twenty-five subjects who underwent surgery had scars treated with 3 treatments of MIPCI in the postoperative period. Scar assessment was measured by Vancouver Scar Scale (VSS), Patient & Observer Scar Assessment Scale (POSAS) and Global Aesthetic Improvement Scale (GAIS) after each of the 3 treatments and at final 2 month follow up.

RESULTS

Patients had positive improvement in VSS, POSAS and GAIS at 16-week post treatment initiation evaluation compared to initial measurement (p value<0.001). No statistically significant differences were noted when comparing the age of the patient, location of scars or Fitzpatrick Phototype Scales between patients. However, when comparing patients who began treatment early (week 6 to 7 post-op) to those who began treatment late (week 13 to 16 postop), there was a statistically significant difference in the POSAS group (p value <0.04).

CONCLUSIONS

Post-surgical scars treated with MIPCI in the maturation and remodeling phase had no adverse outcomes. Interestingly, our data shows treatment initiated early in the maturation phase (6-7 weeks post-op) while natural collagen formation was tapering off demonstrated improved aesthetic outcomes compared to treatments initiated late in the maturation phase (13-16wk post-op).

Non-Invasive and Surgical Modalities for Scar Management: A Clinical Algorithm

Scars can lead to aesthetic and functional impairments. The treatment of scars requires meticulous planning and an individually adapted therapeutic strategy. A conceptual algorithm for scar treatment makes everyday clinical work easier for the practitioner and offers more safety for the patient. Based on a retrospective analysis of 1427 patients who presented for treatment of a variety of scars, we developed an algorithm for scar management and treatment. The treatments are presented using case descriptions. Additionally, an electronic search of MEDLINE, EMBASE, and ClinicalTrials.gov databases was performed utilizing combinations of relevant medical subject headings for "scar treatment", "hypertrophic scar treatment" and "keloid treatment". Reference lists of relevant articles and reviews were hand-searched for additional reports. Observed outcomes included: conservative scar therapy, minimally invasive scar therapy, and surgical scar therapy using local, regional and free flaps. With this work, we provide an algorithm for safe scar treatment. For better understanding, we have described a clinical case for each algorithm modality.

Transdermal Drug Delivery in the Pig Skin

Transdermal delivery can be accomplished through various mechanisms including formulation optimization, epidermal stratum corneum barrier disruption, or directly by removing the stratum corneum layer. Microneedling, electroporation, a combination of both and also the intradermal injection known as mesotherapy have proved efficacy in epidermal-barrier disruption. Here we analyzed the effects of these methods of epidermal-barrier disruption in the structure of the skin and the absorption of four compounds with different characteristics and properties (ketoprofen, biotin, caffein, and procaine). Swine skin (Pietrain x Durox) was used as a human analogue, both having similar structure and pharmacological release. They were biopsied at different intervals, up to 2 weeks after application. High-pressure liquid chromatography and brightfield microscopy were performed, conducting a biometric analysis and measuring histological structure and vascular status. The performed experiments led to different results in the function of the studied molecules: ketoprofen and biotin had the best concentrations with intradermal injections, while delivery methods for obtaining procaine and caffein maximum concentrations changed on the basis of the lapsed time. The studied techniques did not produce significant histological alterations after their application, except for an observed increase in Langerhans cells and melanocytes after applying electroporation, and an epidermal thinning after using microneedles, with variable results regarding dermal thickness. Although all the studied barrier disruptors can accomplish transdermal delivery, the best disruptor is dependent on the particular molecule.

Dissolving microneedle rollers for rapid transdermal drug delivery

Dissolving microneedle patch (DMNP) is a minimally invasive and painless self-administration device. However, due to skin deformation, it is difficult to apply it on the large areas of skin or curved skin as the patch size increased for DMNP. Here, we propose a polyvinyl alcohol (PVA)-based dissolving microneedle roller (DMNR) device that can be used for delivering drugs rapidly on the large surface areas or curved skin and does not need to be attached on the skin all the time during drug delivery. The hypoglycemic effect of insulin-loaded DMNRs for transdermal delivery of insulin was studied on the type 1 diabetic rat models. It was found that the insulin-loaded DMNR has an immediate and effective hypoglycemic effect that the blood glucose level reduced below to 50% of original blood glucose at 1 h after DMNRs administrated.

Double-blind, randomized controlled trial comparing the use of microneedling alone versus chemical peeling alone versus a combination of microneedling and chemical peeling in the treatment of atrophic post-acne scars. An assessment of clinical effectiveness and patients' quality-of-life

Introduction

Acne vulgaris is a common, chronic disease. One of the most commonly encountered complications of acne is permanent atrophic scarring. Treatment of atrophic scars includes fillers, dermabrasion, laser resurfacing, microneedling and peelings and it is often difficult to treat. In our double-blind randomized controlled trial (RCT), we investigated the synergistic effect of microneedling with the application of trichloroacetic acid, kojic acid and hydrogen peroxide in the treatment of atrophic acne scars.

Aim

To assess the clinical effectiveness and patients' quality-of-life (HRQoL) after three types of atrophic post-acne scar treatment, namely microneedling alone (MN) vs chemical peeling alone (CP) vs. a combination of microneedling and chemical peeling (MN + CP).

Material and methods

A total of 120 patients were enrolled into the study following strict inclusion/exclusion criteria and randomized into the three treatment groups - MN, CP (a combination of trichloroacetic acid, kojic acid and hydrogen peroxide), and MN + CP. According to a preapproved protocol, each patient underwent four treatment sessions, each spread 20 days apart. Both pre- and post-treatment clinical status (using the Goodman-Baron scale; two expert raters blinded to the treatment used) and patients' HRQoL (using the Dermatology Life Quality Index) were assessed.

Results

During the 5-month recruitment period, a total of 120 patients were approached and agreed to take part in the study (94 females - 78.3% and 26 males) (mean age of 30.14 ±3.64 years; range: 18-45 years). Only in the MN + CP group there was a statistically significant improvement according to the G-B scale post-treatment (2.87 ±0.83 vs. 2.03 ±1.16 respectively; p = 0.0005). Patients in all three treatment groups experienced a statistically significant improvement in their HRQoL post-treatment (all p's < 0.05).

Conclusions

A combination of microneedling and chemical peeling produces the best, objectively measured effects in the treatment of atrophic post-acne scars. All examined treatments, even if not producing a clinically significant treatment outcome, improve patients' HRQoL.

Applications of microneedling for various dermatologic indications with a special focus on pigmentary disorders: A comprehensive review study

Microneedling can accelerate skin repair through numerous complex processes triggered by micro-injuries it produces on the skin surface with very thin needles. The current growth in the application of microneedling in the treatment of cutaneous diseases can be explained by its numerous effects on the skin as reported in the literature. Despite the numerous studies conducted on the application of microneedling in the treatment of skin lesions, its effects on pigmented skin lesions have remained relatively unexplored. The present review comprises an examination of the evidence for the application of microneedling in skin diseases in general and a comprehensive review of the applications of microneedling in pigmentation disorders. The review involved a search of all clinical studies, including trials, case reports, and case series, in the databases MEDLINE/PubMed and Google Scholar using the following keywords: "microneedling," "dermal needling," "percutaneous collagen induction," "skin needling," "dermaroller," and "dermatology disorder." Pertinent data were extracted from all relevant articles published from 1990 to April 2021, and focused on the application of microneedling in the treatment of pigmented skin lesions. Despite the limited number of available studies, evidence suggests the effectiveness and safety of microneedling in treating vitiligo, melasma, and periorbital hypermelanosis. It is noteworthy that the combination of any type of non-aggressive needing technique with other effective therapies (especially topical agents and mesotherapy) yields more promising therapeutic results than single therapy for melasma, dark cycles, and vitiligo as the prototype of pigmentary disorders. However, single needling therapy is significantly effective, too.

A Single-Center Trial to Evaluate the Efficacy and Tolerability of Four Microneedling Treatments on Fine Lines and Wrinkles of Facial and Neck Skin in Subjects With Fitzpatrick Skin Types I-IV: An Objective Assessment Using Noninvasive Devices and 0.33-mm Microbiopsies

BACKGROUND

Although ablative techniques are the standard of care for the treatment of fine lines and wrinkles, microneedling offers a minimally invasive alternative.

OBJECTIVES

The purpose of this study was to assess the efficacy of microneedling on facial and neck fine lines and wrinkles.

METHODS

Thirty-five subjects between 44 and 65 years old with Fitzpatrick skin types I to IV received 4 monthly microneedling treatments over the face and neck. Subjects returned 1 and 3 months posttreatment. At every visit, high-resolution ultrasonography and optical coherence tomography were performed, and transepidermal water loss and skin elasticity were measured. Microbiopsies (0.33 mm) were collected pretreatment, before the fourth treatment and 3 months posttreatment.

RESULTS

Thirty-two subjects (30 females, 2 males) completed all 7 visits. Facial dermal and epidermal density increased 101.86% and 19.28%, respectively, from baseline at 3 months posttreatment. Facial elasticity increased 28.2% from baseline at 3 months posttreatment. Facial attenuation coefficient increased 15.65% and 17.33% at 1 and 3 months posttreatment, respectively. At study completion, blood flow at a depth of 300 µm decreased 25.8% in the face and 42.3% in the neck. Relative collagen type III and elastin gene expression was statistically higher 3 months posttreatment. However, total elastin protein levels were unchanged from baseline values. Dermal muscle formation was observed in 58% of biopsies extracted 3 months posttreatment compared with 15.3% at baseline.

CONCLUSIONS

The results illustrate the effects of microneedling treatments. Noninvasive measurements and biopsy data showed changes in skin architecture and collagen/elastin gene expression, suggesting skin rejuvenation, with new extracellular matrix production and muscle formation.

LEVEL OF EVIDENCE: 3

A Combined Approach for Fast Nanofat Microneedling

Background

Lipofilling is currently a fundamental component of rhytidoplasty and fat harvesting has become a common procedure. Tonnard introduced the concept of nanofat grafting, a revolutionary milestone, in which adipocytes are mechanically separated from the stromal vascular fraction and the latter is injected, adding the possibility of cellular therapies to the surgical field. Later, Verpaele et al. published a report using a new device to apply this nanofat in a uniform manner, which they termed nanofat needling. The device has 24 microneedles of 1.5 mm length and is applied as a stamp, in a tapping motion. The same manufacturer offers a similar model with 64 microneedles, 1.0 mm length, and available as a roller.

Objectives

We sought to evaluate the combination of the above-mentioned microneedling devices to achieve faster nanofat delivery.

Materials and Methods

A prospective evaluation of patients undergoing a combined nanofat microneedling approach for skin rejuvenation and scar revision, using both a stamp device as well as a roller, was performed in a private practice setting, from January 2019 to January 2020. Patient satisfaction, complications, and surgical time were evaluated.

Results

We applied this combination treatment to over 100 treatment areas in 86 patients over a 12-month period, with a short operative time, no increase in complications, consistent results, and good patient satisfaction.

Conclusions

We recommend the use of this new device in association with the original one, in order to decrease the procedure time. We designate this strategy "fast nanofat microneedling."

Microneedling: Percutaneous Collagen Induction (PCI) Therapy for Management of Scars and Photoaged Skin-Scientific Evidence and Review of the Literature

Demand for safe, less aggressive and cost-efficient treatment modality to improve skin quality and appearance following scarring or photoaging is increasing steadily. A treatment modality that preserves the epidermis while promoting regeneration rather than cicatrization would be ideal. Percutaneous collagen induction (PCI) therapy or microneedling is claimed to approach this ideal objective. The current comprehensive literature review is intended to analyze the scientific basis supporting this therapeutic modality and to evaluate the efficacy of PCI microneedling therapy versus no treatment of patients with photoaged skin and scars of various etiologies on aesthetic skin rejuvenation, skin tightening and scar quality in prospective, retrospective and experimental studies. Twenty-five published studies were identified and included in this review. Four publications are experimental animal studies; most clinical reports are case series or small cohort non-randomized studies or trials lacking methodological unity with a heterogenous mix of scars, wrinkles and skin laxity being treated. The majority are studies about management of scars of various etiologies while only 4 specifically investigated the effect of PCI on wrinkles and aging skin. One study compared burn scar erythema in the treated area to the untreated area, and 5 studies included histologic evaluation of biopsies. Despite PCI promising therapeutic benefits and its increasing cosmetic applications, the current literature review unfortunately revealed a limited number of high-quality studies mostly experimental. Data and conclusions of clinical studies must be carefully interpreted before translating the evidence presented into clinical recommendations. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Microneedle systems as medical devices for esthetical treatments: A risk assessment approach

BACKGROUND

Microneedling devices are being used as a surgical technique without a clear regulatory category. They can become dangerous considering that these kind of devices can easily be bought and used by nonqualified people.

AIMS

Our aim has been to demonstrate that microneedling devices used in dermatological surgery are Medical Devices according to the current regulations.

PATIENTS/METHODS

After a thorough review in the European Union and USA medical device classification, we consider microneedling systems as Class II (US) or IIa (EU).

RESULTS

Therefore, they must follow the regulations established for medical devices. A risk assessment has also been made, in which the technical and scientific deficiencies in their design and manufacturing have been recognized in addition to including compulsory information for the regulatory agencies and most importantly for the final user.

CONCLUSION

It can be concluded that microneedling is an interesting tool in dermatology although more information related to its safety needs to be submitted. In addition, its use by nonprofessional people does not guarantee the safety of the user.

Effects of Percutaneous Collagen Induction Therapy Associated with Hyaluronic Acid on Inflammatory Response, Oxidative Stress, and Collagen Production

Percutaneous collagen induction (PCI) is an alternative treatment for skin dysfunctions, it aims to stimulate collagen production by encouraging normal wound healing that occurs after any trauma by inducing microlesions; also it may be potentiated with the association with drugs such as hyaluronic acid (HA). Our objective was to evaluate the effects of PCI associated with hyaluronic acid (0.9%) on inflammatory process, oxidative stress, and collagen production in rat epidermis. For the study, 36 adult Wistar rats were randomly divided into 6 groups (n = 6): Control; PCI 0.5; PCI 1.0; HA; PCI 0.5 + HA; and PCI 1.0 + HA. The animals were anesthetized, trichotomized, and the application of therapies was performed once; After 7 days, the animals were euthanized for removal of the skin region. Levels of pro-inflammatory (IL1, IL6, TNFα), anti-inflammatory (IL4 and IL10) cytokines and growth factors (FGF, TGFβ) were evaluated, besides oxidative stress parameters and histological analysis. In combination groups, there is a decrease in TNFα compared with the control and PCI groups in contrast to a significant increase in anti-inflammatory cytokines and growth factors. Oxidant and oxidative damage levels showed a significant decrease in PCI + HA groups in relation to PCI groups while antioxidant defense increased in PCI + HA groups compared with the control group. The number of fibroblasts was increased in the PCI 1.0 group in relation to the control, HA, and PCI 0.5. The number of blood vessels and collagen area was increased in groups PCI and PCI + HA compared with the HA group. We conclude that the combination of PCI with HA is able to accelerate the acute inflammatory process, reducing its deleterious effects and anticipating the chronic response, contributing to tissue repair.

Effects of microneedle length and duration of preconditioning on random pattern skin flaps in rats

To date, the surgical delay of skin flaps is the most common and reliable method that increases skin flap survival. In this study, we aimed to increase skin flap viability using preconditioning by microneedling. Seventy-two Sprague Dawley rats were randomly divided into control, surgical flap delay (SFD), and four microneedling groups (7 or 14 days of preconditioning with 0.5 mm or 1 mm needles). Modified McFarlane flaps were raised on the back of rats. In Group I, a caudal pedicled skin flap was raised and the flap survival rate was assessed on postoperative day 14. In the SFD group, a bipedicled flap was created and after 14 days of surgical delay, all skin flaps were raised. In the microneedling groups, 0.5 mm or 1 mm needles were used for 7 or 14 days. The flap survival rates of all microneedling and SFD groups were significantly higher than the control group. The plasma levels of vascular endothelial growth factor (VEGF) did not significantly differ between groups, but the VEGF level of skin samples in the SFD group was higher than the control group. The vessel counts of all microneedling and SFD groups were statistically higher than the control group in all skin samples taken before raising the flaps, but skin samples taken 14 days after raising the skin flap did not show any difference between groups. We showed that preconditioning by microneedling can be used to improve the viability of critical ischemic skin flaps at a level similar to surgical delay.

Lung Surfactant Accelerates Skin Wound Healing: A Translational Study with a Randomized Clinical Phase I Study

Lung surfactants are used for reducing alveolar surface tension in preterm infants to ease breathing. Phospholipid films with surfactant proteins regulate the activity of alveolar macrophages and reduce inflammation. Aberrant skin wound healing is characterized by persistent inflammation. The aim of the study was to investigate if lung surfactant can promote wound healing. Preclinical wound models, e.g. cell scratch assays and full-thickness excisional wounds in mice, and a randomized, phase I clinical trial in healthy human volunteers using a suction blister model were used to study the effect of the commercially available bovine lung surfactant on skin wound repair. Lung surfactant increased migration of keratinocytes in a concentration-dependent manner with no effect on fibroblasts. Significantly reduced expression levels were found for pro-inflammatory and pro-fibrotic genes in murine wounds. Because of these beneficial effects in preclinical experiments, a clinical phase I study was initiated to monitor safety and tolerability of surfactant when applied topically onto human wounds and normal skin. No adverse effects were observed. Subepidermal wounds healed significantly faster with surfactant compared to control. Our study provides lung surfactant as a strong candidate for innovative treatment of chronic skin wounds and as additive for treatment of burn wounds to reduce inflammation and prevent excessive scarring.

Injectable platelet-rich fibrin and microneedling for gingival augmentation in thin periodontal phenotype: A randomized controlled clinical trial

AIM

The aim of this present study was to evaluate the effect of gingival thickness (GT) and keratinized tissue width (KTW) using injectable platelet-rich fibrin (i-PRF) alone and with microneedling (MN) in individuals with thin periodontal phenotypes.

MATERIALS AND METHODS

In this split-mouth study, 33 systemically healthy patients with thin periodontal phenotypes were randomly treated with MN + i-PRF and i-PRF. I-PRF was injected on one side, and MN + i-PRF was performed on the other side of the same patient at 4 sessions with 10-day intervals. Clinical periodontal measurements, GT and KTW were assessed before the treatment and every month for six months after the final injection.

RESULTS

After the evaluation of GT between the groups, a statistically significant difference was found in MN + i-PRF group at the sixth month. In the intra-group comparisons, a statistically significant increase in GT was observed within both i-PRF [from 0.43 mm ± 0.14 to 0.62 mm ± 0.11 (p < .001)] and MN + i-PRF [from 0.4 mm ± 0.14 to 0.66 mm ± 0.12 (p < .001)] groups at the sixth month.

CONCLUSIONS

In individuals with thin periodontal phenotypes, standalone i-PRF and i-PRF with MN may have an influence in increasing GT. The results suggest that application of i-PRF and MN may be a first step of non-surgical method for increasing gingival thickness.

The Preparation of the Recipient Site in Fat Grafting: A Comprehensive Review of the Preclinical Evidence

BACKGROUND

Several methods to prepare the recipient site in fat grafting have been proposed in recent decades. However, to date, these procedures have never been reviewed exhaustively. The purpose of the present study is to provide a comprehensive overview of the different techniques to prepare the recipient site for fat grafting as they were investigated in preclinical studies, with resulting outcomes and underlying mechanisms of action.

METHODS

The PubMed/MEDLINE database was queried to search for preclinical investigations on the preparation of the recipient site in fat grafting using the following algorithm: ((recipient site) AND (fat grafting) OR (lipofilling) OR (lipograft)). A priori criteria were applied to review the resulting articles.

RESULTS

Thirteen animal studies met inclusion criteria. Overall, five techniques were identified: external volume expansion, implantation of alloplastic material (silicone sheets), administration of cell-proliferation factors (i.e., vascular endothelial growth factor, adipose tissue-derived stromal vascular fraction, and interleukin-8), ischemia, and microneedling. A positive effect on cellular activity (cell proliferation and angiogenesis) was demonstrated by all studies and achieved with all techniques. Seven of the eight authors who examined this aspect reported enhancement of fat graft survival.

CONCLUSIONS

Improvement of fat grafting surgical outcomes is documented preclinically using different recipient-site preparation techniques, particularly through enhancement of vascularization and soft-tissue expansion. This understanding will lead to further clinical research, especially for those cases where improvement of the recipient site is recommended, such as contracted scars or preirradiated tissues.

Percutaneous collagen induction (microneedling) for the management of non-atrophic scars: literature review

INTRODUCTION

Percutaneous collagen induction (PCI) or needling techniques are increasingly popular in the reconstructive and aesthetic arena. The underlying mechanisms of action rest on producing a pattern of non-ablative and non-confluent puncture wound pattern to the dermis with a resulting regenerative effect to the skin.

METHODS

A detailed English literature review was conducted using PubMed Medline, Embase and Web of Science; the manuscripts were appraised and classified according to level of evidence as well risk of bias. Results are presented in descending order of evidence for non-atrophic scars.

DISCUSSION

On the basis of level 1 evidence currently available, the combination of needling and silicone gel can improve the short-term pliability, height and vascularity of hypertrophic and keloid scars. According to level 2 evidence, needling alongside spray keratinocytes can produce a statistically significant improvement to patient/observer scar ratings and improve pigmentation in hypopigmented burn scars at 12-month follow-up. Results from mixed cohort studies also point towards needling having a beneficial effect on fat graft retention. Level 3 data suggest that needling can render significant resurfacing effects to both mature and actively hypertrophic burn scars at 12-month follow-up based on objective scar scales; furthermore, favourable histological changes are seen, including better collagen alignment in the dermis and increased epidermal thickness.

CONCLUSION

Needling techniques are promising adjuncts to non-atrophic scar management. Further research with long-term follow-up and comparative design protocols incorporating other resurfacing modalities is warranted before the exact value of needling is delineated in scar management protocols.

Medical Needling: Effect on Skin Erythema of Hypertrophic Burn Scars

Background Burn scars frequently tend to have pathological discolorations, which is manifested in the development of persistent erythema. Affected people suffer from psychological and physiological issues when they are restricted or rejected in their daily life. In this context, medical needling seems to be an efficient therapy for erythematous scars with a relatively low-risk rate of postoperative complications. Study research has already shown significant improvements in the scar quality with reference to the parameters "moisture and transepidermal water loss." Clinical data is up-to-date and provides an innovative therapy outcome of scar treatment with medical needling. Objective The aim of our study was to examine the influence of medical needling on the pathological and persistent erythema of hypertrophic burn scars. By means of reliable measurement methods, we were able to prove positive and sustainable outcomes for normal and healthy skin. The patient cohort included 20 patients with an average age of 34.63 years. Our examinations involved scars that were at least two years old and had healed by secondary intent. Every scar showed the pathological values of persistent erythema according to the participation requirements. Methods For the practical implementation of medical needling or percutaneous collagen induction (PCI), we used a roller covered with needles of 3 mm length. The needling device is rolled over the scar alternatively in a vertical, horizontal, and diagonal orientation. Multiple micro-wounds at a close distance cause intradermal bleeding, which evokes modified skin regeneration provoked by the effects of medical needling. Every patient has been followed up for 12 months postoperatively. Further on, valid results have been evaluated objectively as well as subjectively by the patient and observer. Results Our study has shown that persistent erythema of hypertrophic scars can be considered as an indication of PCI. The needling procedure influences vascularization by stimulating angiogenesis in the post-needling wound healing cascade. As the method is based on percutaneous collagen induction, the synthesis of collagen improves the vital thickness of the epidermis, which is directly associated with less transparency. Examined scars showed a significant reduction of erythema and were less reddened after treatment. Based on the outcomes of objective measurements, medical needling achieves a normalization of the skin color and an adjustment to healthy skin after repetitive treatments. Conclusion Medical needling seems to be a suitable therapy approach for treating erythematous, hypertrophic burn scars.

Photobiomodulation mechanisms in the kinetics of the wound healing process in rats

OBJECTIVES

The healing process of cutaneous lesions is considered a complex event divided into distinct and overlapping phases, which responds satisfactorily to photobiomodulation (PBM). PBM is indicated as a therapeutic resource capable of assisting tissue repair. The present study aimed to analyze the kinetics of cutaneous wounds healing process after application of the GaAlAs laser for treating wounds on the dorsum of rats.

MATERIALS AND METHODS

This study was approved by the Animal Ethics Committee of UFSCar. The animals were divided into 2 groups (n = 10); control group (CG) used 0.9% saline solution and the laser group (LG) used GaAlAs, 670 nm continuous pulse, 30 mW power, 14.28 J/cm² energy density, irradiating 1 point per wound for 30s, totaling 15 consecutive days of treatment. Samples were collected on the 4th, 11th and 16th days for histological analysis of HE, Picrosirius-Red, immunohistochemistry (Collagen1, TNF-α, VEGF). Statistical analyzes used the one-way ANOVA test for intra and inter group evaluations, and the Tukey post-test. Level of significance was set at p < 0.05.

RESULTS

The histopathological analysis (HE) showed a statistically significant difference for lower values of inflammatory infiltrate in LG versus CG on the 16th day; and for the increase of collagen in the 11th and 16th days of treatment. There was a statistically significant difference in the increase of VEGF on the 11th day for LG; decrease of TNF-α on the 4th and 11th day for LG, and increase of collagen type 1 on the 4th and 16th days for LG. The birefringence analysis of the percentage of collagen fibers presented on the 11th day of treatment revealed a greater quantity and significant statistical difference. Collagen fibers showed improved organization and arrangement on the 11th day for LG.

CONCLUSION

Our results show that PBM is effective in helping the kinetics of the cutaneous wound healing process in rats and promotes the necessary stimuli for the satisfactory evolution of healing process, ultimately leading to structurally desirable tissue.

Modern trends in lipomodeling

Lipomodeling is the process of relocating autologous fat to change the shape, volume, consistency, and profile of tissues, with the aim of reconstructing, rejuvenating, and regenerating body features. There have been several important advancements in lipomodeling procedures during the last thirty years. Four clinical steps are important for the success of engraftment: fat harvesting, fat processing, fat reinjection, and preconditioning of the recipient site. With the discovery of adipose derived stem cells and dedifferentiated cells, fat cells become a major tool of regenerative medicine. This article reviews recent trends in lipomodeling trying to understand most of the issues in this field.

Stem cell regenerative potential for plastic and reconstructive surgery

Stem cells represent heterogeneous population of undifferentiated cells with unique characteristics of long term self renewal and plasticity. Moreover, they are capable of active migration to diseased tissues, secretion of different bioactive molecules, and they have immunosuppressive potential as well. They occur in all tissues through life and are involved in process of embryogenesis and regeneration. During last decades stem cells attracted significant attention in each field of medicine, including plastic and reconstructive surgery. The main goal of the present review article is to present and discuss the potential of stem cells and to provide information about their safe utilization in chronic wounds and fistulae healing, scar management, breast reconstruction, as well as in bone, tendon and peripheral nerve regeneration.

Platelet-rich plasma and hyaluronic acid - an efficient biostimulation method for face rejuvenation

BACKGROUND

Cosmetic applications of platelet-rich plasma (PRP) are new, and reports are scarce and dispersed in the literature. There are a variety of commercially available kits and injection techniques, and the number and intervals of injections vary. New investigations should focus on developing a standardized procedure for PRP preparation and application methods to augment its efficacy and potency.

OBJECTIVES

In this report, we aim to provide data and commentary to assist and add to current guidelines.

METHODS

A series of 94 female patients with varying degrees of facial aging signs were treated with PRP and hyaluronic acid (HA). Mean age was 53.0 ± 5.6. The mean injection number was 3.6 ± 2.0. Platelet-poor and platelet- rich plasma parts were mixed with 0.5 cc %3.5 hyaluronic acid and 0.5 cc procaine and injected with a 30G, 13-mm needle into deep dermis and hypodermis. Patients were asked to rate their personal satisfaction with their skin texture, pigmentation, and sagging. In addition, the overall results were rated by three independent physicians and the patients themselves. The outcomes were peer-reviewed, and correlations between the degree of the aesthetic scores and the number of injections were explored.

RESULTS

There was a statistically significant difference in general appearance, skin firmness-sagging and skin texture according to the patients' before and after applications of PRP. A statistically significant correlation was found between the number of injections and overall satisfaction.

CONCLUSIONS

Compared to the baseline, the PRP and HA injections provided clinically visible and statistically significant improvement on facial skin. The improvements were more remarkable as the injection numbers increased.

Combination of medical needling and non-cultured autologous skin cell transplantation (ReNovaCell) for repigmentation of hypopigmented burn scars

Burn scars remain a serious physical and psychological problem for the affected people. Clinical studies as well as basic scientific research have shown that medical needling can significantly increase the quality of burn scars with comparatively low risk and stress for the patient with regards to skin elasticity, moisture, erythema and transepidermal water loss. However, medical needling has no influence on repigmentation of large hypopigmented scars. The goal of this study is to evaluate whether two established methods - needling (for improvement of scar quality) and non-cultured autologous skin cell suspension (for repigmentation) - can be successfully combined. Twenty subjects with mean age of 33 years (6-60 years) with scars from deep second and third degree burns have been treated. The average treated surface area was 94cm² (15-250cm²) and was focused on prominent areas such as the face, neck, chest and arm. Percutaneous collagen induction or "medical needling" was performed using a roller covered with 3mm long needles. The roller is vertically, horizontally and diagonally rolled over the scar, inducing microtrauma. Then, non-cultured autologous skin cell suspension (NCASCS) was produced and applied using the ReNovaCell Autologous Cell Harvesting Device (Avita Medical), according to the manufacturer's instructions. The patients were followed 12 months postoperatively. Pigmentation changes were measured objectively, as well as with patient and observer ratings. Patient satisfaction/preference was also obtained. Taken together, the pigmentation ratings and objective measures indicate individual improvement in 17 of the study participants. The melanin increases seen 12 months after NCASCS treatment are statistically significant. Medical needling in combination with NCASCS shows promise for repigmentation of burn cars.

Novel use of a flowable collagen-glycosaminoglycan matrix (Integra™ Flowable Wound Matrix) combined with percutaneous cannula scar tissue release in treatment of post-burn malfunction of the hand--A preliminary 6 month follow-up

INTRODUCTION

Long-term function following severe burns to the hand may be poor secondary to scar adhesions to the underlying tendons, webspaces, and joints. In this pilot study, we report the feasibility of applying a pasty dermal matrix combined with percutaneous cannula teno- and adhesiolysis.

PATIENTS AND METHODS

In this 6 month follow-up pilot study, we included eight hands in five patients with hand burns undergoing minimal-invasive, percutaneous cannula adhesiolysis and injection of INTEGRA™ Flowable Wound Matrix for a pilot study of this new concept. The flowable collagen-glycosaminoglycan wound matrix (FCGWM) was applied with a buttoned 2mm cannula to induce formation of a neo-gliding plane. Post treatment follow-up was performed to assess active range of motion (AROM), grip strength, Disabilities of the Arm, Shoulder and Hand (DASH) score, Vancouver Scar Scale (VSS) and quality of life Short-Form (SF)-36 questionnaire.

RESULTS

No complications were detected associated with the treatment of FCGWM injection. The mean improvement (AROM) at 6 months was 30.6° for digits 2-5. The improvement in the DASH score was a mean of 9 points out of 100. The VSS improved by a mean of 2 points out of 14.

DISCUSSION

The study demonstrates the feasibility and safety of percutaneous FCGWM for dermal augmentation after burn. Results from this pilot study show improvements in AROM for digits 2-5, functional scores from the patient's perspective (DASH) and scar quality (VSS). The flowable form of established INTEGRA™ wound matrix offers the advantage of minimal-invasive injection after scar release in the post-burned hand with a reduction in the risk of postsurgical re-scarring.

Microneedling as a successful treatment for alopecia X in two Pomeranian siblings

BACKGROUND

Alopecia X (hair cycle arrest) is a relatively frequent hair growth disorder in Pomeranians and several other breeds, characterized by symmetrical, noninflammatory alopecia without systemic signs. The cause and pathogenesis remain unknown. Previously reported treatments with various topical and systemic drugs have been variably successful.

HYPOTHESIS

We hypothesized that superficial mechanical skin trauma applied with a microneedling device would induce long-term hair regrowth at treated sites.

ANIMALS

Two neutered female Pomeranian siblings with histologically confirmed alopecia X. Previous treatments with deslorelin, melatonin and topical minoxidil had failed to produce significant hair regrowth.

METHODS

The dogs were anaesthetized and the skin was punctured with a microneedling device. Dogs were followed over a period of 12 months.

RESULTS

Five weeks after microneedling hair regrowth started, followed by a reduction in hyperpigmentation of affected skin. After 12 weeks there was a 90% improvement in coat coverage at previously alopecic areas. Twelve months after the procedure, coat conditions remained stable. No adverse effects were noted.

CONCLUSIONS AND CLINICAL IMPORTANCE

This is the first report of microneedling to induce hair regrowth in dogs affected by alopecia X. Long-term studies with microneedling in a larger number of dogs with alopecia X will need to be performed to confirm these preliminary results and to further evaluate if hair-regrowth is permanent.

Microneedle applications in improving skin appearance

Microneedles (MNs) are micron-sized, minimally invasive devices that breach the outermost layer of the skin, the stratum corneum (SC), creating transient, aqueous pores in the skin and facilitating the transport of therapeutic molecules into the epidermis. Following many years of extensive research in the area of MN-mediated trans- and intra-dermal drug delivery, MNs are now being exploited in the cosmeceutical industry as a means of disrupting skin cell architecture, inducing elastin and collagen expression and deposition. They are also being used as vehicles to deliver cosmeceutic molecules across the skin, in addition to their use in combinatorial treatments with topical agents or light sources. This review explores the chronology of microneedling methodologies, which has led to the emergence of MN devices, now extensively used in cosmeceutical applications. Recent developments in therapeutic molecule and peptide delivery to the skin via MN platforms are addressed and some commercially available MN devices are described. Important safety and regulatory considerations relating to MN usage are addressed, as are studies relating to public perception of MN, as these will undoubtedly influence the acceptance of MN products as they progress towards commercialisation.