While the majority of my patients are women, micro-needling works equally well in men. It is, I am convinced, an excellent strategy for men who want to keep their skin from adding years to their looks as a men's magazine would put it. Yet, still only about 5% of patients who cross the doorstep of my clinic belong to the male gender... Yes, micro-needling is still very much under men’s radar. However, I believe micro-needling is especially well-positioned to meet the cosmetic needs of well-informed, down-to-earth men who want to take control over an essential aspect of their masculinity, their face. The anecdote below is one that made my conviction even stronger. 

A few months ago, I treated a male patient who had an original take on micro-needling and was willing to elaborate on his views beyond the questionnaire I use to capture patient information and feedback. What that particular patient confided in me was truly enlightening. Like opening a window into a patient's mind, I was able to see what inner workings were at play and understand what logical steps had led a patient to push the door of the building at 433 N Camden Drive, Beverly Hills. The 50 year-old patient was in the field of medical devices and throughout his career, had developed a good understanding of how tissues heal after surgery, which share similarities with how skin can repair and remodel itself after micro-needling. By chance, he had run across articles on Micro-needling in the professional healthcare press. Intrigued and wanting to read more, he’d gone onto the pubMed website, searched articles and had consequently built his own conviction that the technique was legitimate, with substantial evidence showing safety and efficacy. 

The gentleman had a business-like style about him, someone pragmatic enough to understand that a series of (relatively) simple procedures could help him dramatically improve his facial skin and retain a youthful appearance. Because he was not my typical patient, I asked him if he would be willing to have me share his thoughts on the treatment, which he accepted. Below is a list he came back with. The language is of course not one I would use myself to describe certain scientific details but this is how he expressed it himself, so here it is in its raw unedited format:

I wanted an easy, natural and highly effective way to improve my skin appearance fast. Natural for me means non-surgical, non-destructive of skin layers (lasers were out), and not requiring the injection of any synthetic material or pharma product (Botox and collagen injections out).

I was especially concerned by the aspect of my neck that had aged much more than the skin on my face. I’d read that micro-needling was particularly effective for that area. 

I have come to see micro-needling the same way I see dental cleaning. To maintain healthy gums and teeth, an outside mechanical intervention is required provided by a hygienist. Without it, the body is unable to eliminate the hardened plaque from our teeth along with stains and tartar that regular brushing and flossing are not able to remove. Similarly, there is no automatic process in our body that is going to help us maintain a healthy and youth-looking skin, remove pigmentation or minimize scar tissue. For that, an outside intervention is required to trigger the production of certain types of collagen that are going to remodel our skin from under the surface. And the best way to achieve this effect, as I learned doing my research, is micro-needling.

I like the fact that there is a positive cumulative effect with each additional micro-needling treatment: because the remodeling happening in the skin after a treatment happens over a period of more than 10 months, there is a benefit in triggering collagen production at regular intervals. To make the most of this, I'm planning to come twice a year for treatment (similar to a dental cleaning session...).

My main concern with the procedure was...pain. Was I going to lose face by not being able to withstand the discomfort caused by the needling? Was I going to rip the single-use gown and rush out of the patient chair? Turns out, I apparently did quite well and Dr. Franck Joly was able to treat every area of the face and neck he had meant to. Again, I will revert to the same teeth cleaning analogy: sometimes unpleasant, mostly no sweat, but absolutely worth doing!

An added benefit for me was to surprise my wife, friends and family by showing the facial rejuvenation effects and telling of my experience with the intriguing procedure of micro-needling. Going for micro-needling was definitely an instance of getting out of my comfort zone, but as it often happens when we do so, I’m really glad I did!

After receiving this compelling feedback, I consulted with the patient again and clarified what current evidence actually says about the optimal frequency of micro-needling treatments. One way micro-needling treatments are at odds with the teeth cleaning analogy, is that an initial series of 3 to 6 sessions are recommended to jumpstart the collagen-inducing process and generate fast and long-lasting effects. This initial series can be completed within a few months. In fact, the latest studies from Dr Des Fernandes, the pioneer of micro-needling, are showing that the closer the treatments, the better the results. Dr Fernandes is now recommending 6 treatments within 6 weeks. This can be challenging for patients with active social and professional lives so I usually advise 2 to 3 weeks in between treatments for the initial series. Once the initial series is completed, I suggest giving it a break for a few months before considering more treatments. However, most of my patients decide to continue these treatments on a monthly basis to maintain results and keep the rejuvenation process going. Please remember that since the effect of medical micro-needling is based on stimulating the body’s own regeneration mechanisms, it takes time before the results become visible. Therefore, you should not expect the desired skin improvement outcome to happen immediately. Within 3-6 weeks after the treatment, the quality of your skin will show improvements. A few more months will be needed for the natural renewal processes to achieve its full effect. To go back to the patient’s plan of visiting me every 6 months, yes absolutely, but if fast results are expected, a series of 3 to 6 initial treatments performed in a minimal amount of time is also highly recommended!

Origin of micro-needling and how it works

To best explain how micro-needling works, it is a good idea to look at the history of the technique and how it evolved over time. In the mid-1990s, South African world-renowned plastic surgeon Dr. Des Fernandes found that an effective way to remove scars was to manually needle them. The technique was so efficacious and reproducible that another team, at the same time, was actually using a tattoo gun to treat scars! The principle behind the treatment was that needles were inserted to break down the dermal collagen bonds that are tethering scars at the surface of the skin. Think about a cushion with a button in the middle. A depression is created on the surface of the material and centered around the button in the middle. Remove the stitch that creates a tension where the button is placed and the cushion regains a flat appearance. This is in essence what micro-needling aims at doing when used to manage scars. Of course, the physiological mechanism making this possible is quite complex. What we know is that when micro-needles are inserted in the dermis, the resulting "miniature" wounds and bleeding trigger a natural healing cascade, resulting in dermal remodeling and skin resurfacing. 

Micro-needling is thus all about harnessing the body's power to self-repair. We humans may not have the incredible capacity to regenerate a whole arm as the octopus does (I recently watched the amazing documentary The Octopus My Teacher...), but our skin is still able to perform dramatic self-rejuvenation. If micro-needling produced such beneficial effects on scars, why not use the same techniques to improve the aspect of "normal" skin or skin with natural aging signs? Following this train of thought, Dr. Fernandes developed a roller, to create precise micro punctures and offer micro-needling to a wider audience of patients. Percutaneous collagen induction (PCI) -the professional term we use when speaking about medical micro-needling- was born. 

A roller contains multiple fine needles, typically 1 to 3.00 mm in length, situated on a barrel and rolled onto the skin to create numerous punctures into the outermost layer of the epidermis and dermis (Depending on the length of the needles the papillary or the deeper reticular dermis can be reached). The micro wounds initiate the release of growth factors, triggering collagen and elastin formation in the dermis. The added benefit is that the collagen generated from this technique is the highest quality of collagen found in the skin known as “embryonic” collagen.  Today, micro-needling is commonly used in the treatment of acne, scars, facial rejuvenation, and dyspigmentation. New research keeps being published adding to the body of evidence supporting the safety and efficacy of micro-needling. As a young clinician, I had the amazing privilege to find myself on the team of Dr. Des Fernandes in Cape Town, absorbing best practices directly from the master himself. Since then, I have developed my own medical needling practices, adding new techniques derived from “Constitutional Cosmetic Acupuncture”. I uncovered a surprising synergistic effect combining medical needling and “Constitutional Cosmetic Acupuncture”, a technique I have pioneered and started to teach other clinicians.

In a next post, I will tell you about the line of medical grade skin care treatments I have been promoting and using personally for the past 20 years, also a creation from my mentor Dr. Fernandes and a very essential part of the treatment I offer my patients. 

Platelet-mediated Percutaneous Collagen Induction (PCI) through micro-needling the skin:

A minimally-invasive treatment for burn; acne scarring, and facial; body rejuvenation

Franck AC Joly, LAc MTOM DiplOM 1 and Hilton M Kaplan, MBBCh FCSSA PhD 2

1 Franck Joly Acupuncture Cosmetique, Beverly Hills, CA

2 Rutgers University, New Brunswick, NJ

Percutaneous Collagen Induction (PCI), also known as Collagen Induction Therapy (CIT), is a highly innovative skin rejuvenation technique that was pioneered by Dr. Des Fernandes in the 1990’s and has now become a worldwide phenomenon. 1-6 Numerous methods exist today to revise scars, tighten skin and target photoaging, such as laser re-surfacing and deep peeling. Yet these treatments are ablative, injuring the skin and subsequently leading to fibrosis of the papillary dermis. 7 Although this may tighten the skin and improve scars, it is destructive to the epidermis. Importantly, the basement membrane is replaced with a flattened dermo-epidermal junction, that no longer has robust dermal papillae and is thinner than before, with poor integrity.

Even fractional treatments, which attempt to minimize this side-effect, result in a coagulated tissue zone that is 3-8 times larger than the ablated area. 8 This type of necrotic tissue is a stimulus for a cicatricial wound healing response, rather than a regenerative one. 7,8 The ideal treatment should do exactly the opposite, by rather improving tissue quality and building up any scarred areas to the level of normal skin, in a natural way. 9

PCI achieves this by creating thousands of tiny needle-pricks in the superficial dermis with virtually no tissue destruction. Aust, et al. have demonstrated an associated upregulation of TGF-B3, 6 which has been shown to stimulate regenerative, as opposed to cicatricial, wound-healing. 10,11 This process results in a confluent sheet of the patient’s own high-quality collagen being laid down in their skin. Furthermore, the procedure effectively breaks down and allows reorganization of scar tissue. This is achieved in a manner similar to subscision or needle trepanation of scars, 12 but with PCI this is now feasible over large areas. As there is no stripping of the stratum corneum, nor any deep inflammatory response, this technique maintains full photo protection and is suited to all skin types, all body areas, and without restriction to aesthetic units. 3

Since the effect of PCI is based on stimulating the body’s own (endogenous) regenerative mechanisms, results become visible over the normal wound healing time course. Within 3-6 weeks, skin quality improves noticeably, and over the next 1-2 months the natural renewal achieves full effect. PCI can be repeated, provided that the skin is given enough time to regenerate between treatments. To achieve maximum improvement, a course of up to six treatments is recommended, under topical anesthesia. These may be carried out as frequently as every 1-2 weeks, to monthly. Once the skin has fully recovered, after about 3-6 months, subsequent courses may be conducted.

PCI has to cause bleeding, to ensure sufficient platelet release will trigger the desired regenerative processes.

Bleeding, followed by some bruising over the first few days, are necessary effects which must be achieved deliberately. The capillary damage and platelet activation mediates a powerful wound healing response which results in fibroblasts laying down the patient’s own collagen and elastin. PCI is performed using very fine needles (30 gauge). Bleeding stops by the time the treatment is finished, and the tiny pin-pricks close up within hours.

This is similar to tattooing, and causes about the same degree of temporary discomfort. Post-operatively, the skin appears erythematous and slightly swollen for a few days. This looks like a moderate sunburn or mild abrasion, although the skin has not been abraded. During the acute healing phase, patients appear tired, and after about a week their skin returns to appearing normal.

As effective PCI depends on activation and the subsequent natural course of the skin’s wound healing and regenerative mechanisms, these processes can be further stimulated by topical vitamins. Products that contain high levels of vitamin A and C have been found to be beneficial both clinically 9 and pre-clinically, 6 when applied daily peri-operatively and for several months post-operatively. This is an important part of a successful PCI regimen.

Considering vitamin A, the medical literature is virtually confined to retinoic acid and retinol, which have harsh topical effects. 13,14 However, there are a number of effective forms of vitamin A which are more gentle than retinoic acid, and yet display similar efficacy. Over 80% of vitamin A in the skin is stored in the retinyl ester form (e.g., acetates and palmitates). 15,16 Esterases convert these into retinol, which oxidizes into retinoic acid, as needed within the skin. These forms of vitamin A are therefore recommended for a biomimetic approach which is more gentle (allowing for higher doses), and highly effective.

When considering vitamin C, an analogous strategy can be employed. Ascorbic acid can be too harsh for patients to use, and so stabilized, fat-soluble forms of vitamin C may be used instead (e.g., ascorbyl tetra-isopalmitate, which is esterolysed into ascorbic acid by esterases).

Because of the fundamental importance of vitamins A, C, E and other antioxidants, including hyaluronic acid and amino-peptides, a skin care regimen should include a cocktail of these to be effective. When combined with such an intelligent topical skin care strategy, PCI proves to be a simple and fast option for safely treating wrinkles and scars, and tightening skin naturally.

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alternative treatment for scars, wrinkles, and skin laxity. Plast Reconstr Surg. 2008;121(4):1421-1429.

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