Advances in Cosmetic Surgery 2 (2019) 47–53

ADVANCES IN COSMETIC SURGERY

Microneedling
Shilpi Khetarpal, MDa,*, Jonathan Soh, MDb, Mara Weinstein Velez, MDb,
Adele Haimovic, MDc
a
Cleveland Clinic Foundation, 9500 Euclid Avenue, A61, Cleveland, OH 44195, USA; bUniversity of Rochester Medical Center, 601 Elmwood
Avenue, Rochester, NY 14642, USA; cThe Ronald O. Perelman Department of Dermatology, New York University Langone Health, 530 First
Avenue, Suite 7R, New York City, NY, 10016, USA

KEYWORDS
 Microneedling  Scars  Facial rejuvenation  Percutaneous collagen induction

KEY POINTS
 Microneedling is safe in all skin types given it does not use heat, therefore does not have a chromophore.
 Microneedling can be used to treat scars and facial rejuvenation and as a transdermal drug delivery system.
 Microneedling is an effective procedure with a low side-effect profile and minimal downtime and is well tolerated.

Video content accompanies this article at http://www.advancesincosmeticsurgery.com.

BACKGROUND Doucet [2] used a tattoo gun without ink to puncture

Microneedling, also referred to as percutaneous
collagen induction (PCI) therapy, has gained significant
popularity in dermatology. With a wide array of appli-
cations, including scar treatment, improvement of
pigmentary alteration, skin rejuvenation, and as a trans-
dermal drug delivery system, microneedling is a valu-
able therapeutic option. Microneedling is an effective
procedure with a low side-effect profile and minimal
downtime and is well tolerated.
The concept was first described by Orentreich and
Orentreich in 1995 [1], who described subcision for
the treatment of scars and wrinkles. In their article,
they hypothesize that in addition to releasing fibrous at-
tachments, controlled trauma from a hypodermic nee-
dle triggers a wound healing response and connective
tissue production and subsequently improves
depressed sites [1]. A few years later, Camirand and
wounds with 9 needles or 12 needles at high speed
They reported significant improvement in achromic, hy-
pertrophic, and undesirable scars.
MECHANISM OF ACTION
Microneedling is believed to stimulate the wound heal-
ing cascade and promote new collagen deposition
without significant damage to the overlying epidermis.
Physical trauma from the penetration of the needle
through the stratum corneum creates microchannels
with minimal damage to the epidermis. This controlled
skin injury induces dermal regeneration. The wound
healing cascade in the dermis is triggered, and multiple
growth factors are released, including fibroblast growth
factor, platelet-derived growth factor, and transforming
growth factor (TGF)-a and TGF-b [3], leading to the

Disclosure statement: The authors have nothing to disclose.

*Corresponding author. Cleveland Clinic Foundation, 9500 Euclid Avenue, A61, Cleveland, OH 44195. E-mail address: Shil-
pikhetarpal@gmail.com

https://doi.org/10.1016/j.yacs.2019.02.003 www.advancesincosmeticsurgery.com
2542-4327/19/ © 2019 Elsevier Inc. All rights reserved. 47
48 Khetarpal et al
proliferation and migration of fibroblasts [4]. Neovas-
cularization and neocollagenesis ensue. Tissue remodel-
ing occurs over the subsequent weeks to months [4].
Initially a fibronectin matrix forms and allows for the
deposition of collagen type III. The type III collagen is
eventually replaced by type I collagen [5]. This remodel-
ing process results in skin tightening and scar reduction.
Aust and colleagues [6] performed histologic exami-
nation of 20 patients treated with microneedling and re-
ported normal stratum corneum, thickened epidermis
(stratum granulosum), and normal rete ridges. Elastica
staining demonstrated an increase in elastic fiber
deposition and van Gieson staining demonstrated an
increase in collagen deposition at 6 months postopera-
tively [6]. Aust and colleagues [7] went on to show that
PCI can lead to skin regeneration without scar forma-
tion. TGF-b is essential for fibrotic scar formation.
TGF-b1 and TGF-b2 promote a fibrotic response
whereas TGF-b3 is believed to promote scarless wound
healing [8]. They reported an initial increase in TGF-b1
and TGF-b2 after PCI followed by a significant down-
regulation. This contrasts with TGF-b3, which was up-
regulated 2 weeks after PCI and did not down-regulate
at weeks 4 and 8 [7]. This may partially explain why
microneedling can promote skin rejuvenation and
improve texture without triggering scar formation.
MICRONEEDLING INSTRUMENTS
The first microneedling device described in the literature
was by Fernandes [9]. Fernandes created a cylindrical-
shaped tool with many needles that was designed to be
rolled back and forth on the skin until pinpoint bleeding
was achieved [9]. This device is similar to the modern-
day dermaroller. Today, there are numerous micronee-
dling devices commercially available varying based on
needle length, needle number, and automation. More
superficial devices, with needle lengths less than
0.15 mm, can be purchased for home use whereas deeper
devices, with needle lengths ranging from 0.1 mm to
3.5 mm, are designed to be used in a medical facility.
The automated devices are pen-shaped and allow needle
penetration depths to be easily adjusted. Choice of nee-
dle length varies depending on the location treated.
Another advantage of electronic pens is their disposable
needle tips, which decrease risk of infection and allow for
the treatment of small areas [5]. Many dermarollers, in
contrast to the automated devices, need to be disposed
of after each use and are difficult to use in small areas,
such as the upper lip and around the eyes [3].
In addition to traditional microneedling devices,
companies are now combining microneedling with
radiofrequency and light-emitting diodes to treat scar-
ring, wrinkles, and skin laxity. With fractional radiofre-
quency microneedling, there are insulated needles that
on skin penetration release radiofrequency currents
that lead to dermal remodeling and neocollagenesis [3].
Microneedling devices also have been shown an
effective method of drug delivery. In some scenarios,
the needles pierce the skin and then a drug is applied
topically to the skin and is able to penetrate through
the broken skin barrier. There also are microneedling
pens with hollow needles that allow the medication
to be delivered directly into the dermis [10]. Care
must be taken when choosing which topical agents
are used because certain medications are not designed
to be delivered directly into the skin because hypersen-
sitivity reactions have been reported [11].
PROCEDURE
Microneedling is an office-based procedure. Prior to the
procedure, the skin should be washed with a gentle
cleanser. A topical anesthetic, such as eutectic mixture
of lidocaine and prilocaine or 30% lidocaine, is applied
to the skin for approximately 30 minutes prior to the
procedure. After removing the topical anesthetic with
a dry gauze, the skin should be cleansed thoroughly
with alcohol to decrease the risk of any infection.
The treatment area often is divided into zones and
the needle depth varies depending on the location
treated. A lubricant, such as a hyaluronic acid gel or
platelet-rich plasma (PRP), is used to allow the device
to gently glide over the skin. Each zone is treated with a
combination of a circular motions, linear horizontal,
or vertical strokes. For deeper scars and rhytids, a
stamping technique may be used. It is important not
to dwell in 1 spot for too long and avoid using exces-
sive pressure [12]. Once the procedure is completed,
the skin is cleansed with a wet gauze, and hyaluronic
acid gel is applied. Frequent moisturization and sun-
screen application is important for the days after the
procedure (Video 1).
CONTRAINDICATIONS AND TREATMENT
CONSIDERATIONS
Contraindications to microneedling include
 Active infection, such as herpes labialis, warts, or
bacterial infections
 Significant keloid predisposition
 Immunosuppression
 Blood dyscrasias

Individuals with a history of herpes labialis should
be treated with prophylactic oral antivirals. Although
not a contraindication, the authors do not recommend
performing microneedling and botulinum toxin in the
same area on the same day to decrease risk of unwanted
toxin diffusion [5]. The authors also do not recommend
treatment of individuals with a suntan due to increased
risk of postinflammatory hyperpigmentation (PIH).
ADVERSE EVENTS
Microneedling is associated with a low rate of adverse
events Expected side effects include post-treatment ery-
thema, edema, and mild peeling. These usually resolve
within 2 days to 3 days. Less common adverse events
include reactivation of herpes, hypersensitivity reac-
tions [13], and worsening of acne. Although PIH has
been reported [14], it is uncommon. Microneedling is
believed a safe treatment of patients with skin of color
[15]. Permanent tram-track scarring has been reported
but it has been suggested that this was due to improper
technique and excessive pressure [16].
MICRONEEDLING AND REJUVENATION
Microneedling has proved a targeted and safe option for
facial rejuvenation [12,17,18]. Skin aging is the mani-
festation of dyspigmentation, rhytids, loss of elasticity,
and collagen. Cumulative intrinsic and extrinsic pres-
sures remodel the extracellular and cellular components
of the skin. The microneedling ability to mechanically
stimulate the dermis while sparing trauma to the
epidermis allows for the neogenesis of collagen and
elastin. This reorganization of dermal architecture is
what is clinically perceived as skin rejuvenation.
Rejuvenation has been characterized by both subjec-
tive and objective measures. Subjective scales, such as
the Wrinkle Severity Rating Scale, Global Aesthetic
Improvement Scale, and patient satisfaction scales, help
quantify changes in skin quality [19]. Objective measures
of rejuvenation include histologic examination (collagen,
elastin, tropoelastin, fibroblasts, fibrillin, and epidermal
thickness), ultrasound measurements, silicone relief im-
pressions, and anatomic structural measurements.
Microneedling triggers a proinflammatory and sub-
sequent collagen and elastin remodeling cascade by dis-
rupting dermal collagen and scar tethering. Adjustable
needle lengths (0.5–3 mm) can deliver a drug or induce
a mechanical injury anywhere from the stratum cor-
neum down to the papillary dermis. In addition to
depth control, microneedling minimally disrupts the
epidermal barrier and melanocyte density along the
Microneedling 49
dermal-epidermal junction [20]. By preserving native
epidermis and dermal-epidermal melanocytes, micro-
needling mitigates the risk of PIH, hypopigmentation,
infection, scarring, and milia.
Microneedling is a useful alternative to traditional
skin resurfacing procedures in patients with darker
skin types (Fitzpatrick IV–VI). Dermabrasion, chemical
peels, and lasers have been associated with prolonged
recovery periods and adverse events in patients with
darker skin [15]. In preclinical models, Aust and col-
leagues [21] showed a decrease in melanocyte-
stimulating hormone (MC1R) expression and no
change in melanocyte quantity after PCI therapy.
Microneedling has been examined for wrinkle reduc-
tion of the face and neck. Fabbroccini and colleagues
[22] studied the effect of 2 microneedling sessions on
perioral upper lip rhytids in 10 female subjects. Using
photography (wrinkle depth) and silicon microrelief
impressions, they demonstrated a 2.3-fold reduction
in wrinkle severity (Wrinkle Severity Rating Scale)
and a 33% decrease in skin irregularity (silicone
impressions).
In 2011, Fabbroccini and colleagues [23] used
microneedling to treat aging neck skin in 8 patients
over a span of 2 treatments. The group showed a 90%
improvement in lesion severity using the Global
Aesthetic Improvement Scale, Wrinkle Severity Rating
Scale, photographic and ultrasound imaging, and sili-
cone rubber impressions. Ultrasound demonstrated a
24% average reduction in rhytid depth and an average
0.45-mm increase in skin thickness (Fig. 1).
Histologic changes associated with rejuvenation also
have been described after microneedling. Aust and col-
leagues [21] demonstrated an increase of collagen and
elastin deposition in 20 patients, 6 months after a
microneedling procedure. At 1 year, patients were noted
to have 40% thickening of the stratum spinosum [22].
El-Domyati and colleagues [24] treated 10 patients
(Fitzpatrick III, Fitzpatrick IV, Glogau classes II–III)
with 6 microneedling sessions at 2-week intervals. Pa-
tients were evaluated with standard photographs and
skin biopsy (at baseline, 1 month, and 3 months after
first treatment). The investigators reported noticeable
clinical improvement of photoaged skin. Histometery
was used to quantify levels of collagen types I, III, IV,
elastin, and tropoelastin within the skin biopsies. The
group noted a significant increase in collagen (I, III,
and VII) and tropoelastin compared with baseline.
Elastin was significantly decreased from baseline. These
findings indicate that it can take 6 weeks to 8 weeks
from initiation of treatment to achieve clinically
apparent results from dermal collagen production.
50 Khetarpal et al
FIG. 1 Before (left) and after (right) 2 microneedling treatments for perioral rhytids done 2 weeks apart at a
depth of 2 mm.
Therefore, microneedling skin rejuvenation should be
performed in a series of 3 to 6 biweekly sessions to
achieve optimal improvement [5].
Microneedling can promote rejuvenation through
transdermal drug delivery. Pre-procedural and concur-
rent treatment regimens include microneedling with
topical agents like vitamins A and C, PRP, hyaluronic
acid, and embryonic stem cells. In cases of exogenous
supplementation, side effects like granuloma forma-
tion secondary to allergic hypersensitivity have been
reported and should be considered [11]. Patients
should be counseled to use only what is recommended
by the physician as a postprocedural regimen. Lee and
colleagues [25] conducted a randomized controlled,
split-face study with 25 patients using microneedling
(0.25 mm) with and without human embryonic
stem cells–endothelial precursor cells (hESCs-EPCs).
After 5 treatments at 2-week intervals, physician global
assessments for pigment and wrinkle improvement
were significantly higher in those with the hESCs-
EPCs and microneedling versus those with micronee-
dling alone. Patient satisfaction scores also were re-
ported higher in the hESCs-EPCs with microneedling
group.
In a split-face study, Sundaram and colleagues [26]
found that patients treated with microneedling fol-
lowed by a topical cross-linked hyaluronic acid formu-
lation had improvement in skin moisture, tone,
radiance, texture, uniformity, and global appearance.
These were quantified by standardized topographic im-
aging and biometrical measures. Patients were more
satisfied with the appearance of the treated versus un-
treated hemiface 28 days after the procedure.
Microneedling has also shown effective when com-
bined with other treatment modalities to improve facial
rhytids and skin laxity. Clementoni and Munavalli [27]
used high-intensity focused radiofrequency with
microneedling to treat 33 patients with skin laxity of
the lower face and neck. Six months after treatment
(3 treatments once per month, 3 passes per treatment),
there was a significant decrease in the cervicomental
and gnathion angles (primary endpoint); 81.8% of pa-
tients had moderate or higher improvement based on
blinded global assessments and 87% of patients self-
reported that they were very satisfied with the results.
Although most of the research on microneedling
has been conducted with respect to improving acne
scars, microneedling with chemical peels has also
proved to rejuvenate light and dark skin. Sharad [28]
demonstrated significant improvement in superficial
and deep acne scars as well as improvement in skin
texture and PIH after microneedling with glycolic
acid. Sixty patients with atrophic box scars or rolling
acne scars with PIH were randomized to either micro-
needling alone or microneedling with 35% glycolic
acid once every 6 weeks for 5 total sessions. Those
with combination therapy had significant improve-
ment in skin texture and postacne pigmentation [28].
In a similar study, patients undergoing microneedling
(weeks 0, 6, and 12) with 70% glycolic acid peels
(weeks 3, 9, and 15) had a larger improvement in
skin texture (based on visual analog scale) than pa-
tients undergoing microneedling alone [29]. Improve-
ments in atrophic acne scars also have been found after
combination therapy with 15% trichloroacetic acid
(TCA) [30]. EL-Domyati and colleagues [31] found sig-
nificant increases in epidermal thickness, collagen
bundle organization, and neogenesis after micronee-
dling with 15% TCA.
Kontochristopoulos and colleagues [32] performed
microneedling with 10% TCA on 13 patients with peri-
orbital hyperpigmentation (melanosis). After 1 treat-
ment of microneedling followed by TCA application
to the infraorbital area, nearly all patients had

significant improvement (fair, good, or excellent) by
physician and patient global assessments. There was
no recurrence at 4-month follow-up.
Combination microneedling therapy with PRP
also has led to improvement of atrophic acne scars
[33–35]. Extrapolation from this and similar studies
suggests that combination therapy with PRP may be a
useful tool for rejuvenation.
Microneedling has shown promising results with
respect to facial rejuvenation. Studies thus far have
documented clinical and histologic changes that help
improve wrinkles and skin laxity. Its minimal invasive-
ness lends itself to a favorable safety profile. Micronee-
dling can be considered a useful tool for rejuvenation
and one that mitigates risk of hyperpigmentation and
patient down time. Microneedling can be used safely
and effectively alone or in combination with additional
agents or treatment modalities.
MICRONEEDLING AND SCARS
Microneedling is an alternative therapy that can be used
to improve the appearance of scars. It initially was used
for skin rejuvenation, and it is now used for a wide va-
riety of indications, but most of the literature focuses on
acne scarring. The extent of acne scarring is related to the
severity of preceding inflammation, stage and nature of
treatment, extent of local manipulation, and individual
predisposition to scarring. Although most of the litera-
ture has focused on acne scars, microneedling has been
using in other types of scarring, including varicella,
burns, and striae, and post-surgical scars. Microneedling
is a minimally invasive procedure involving superficial
and controlled puncturing of the skin by rolling with
fine needles [3]. The microinjuries cause a wound heal-
ing cascade with release of various growth factors,
including platelet-derived growth factor, TGF-a and
TGF-b, connective tissue growth factor, and fibroblast
growth factor. This process helps breakdown old hard-
ened scar tissue and allows tissue to revascularize. Neo-
vascularization and neocollagenesis are initiated by
migration and growth of fibroblasts. After 5 days of
injury, a fibronectin matrix forms that determines the
deposition of collagen. Histologic examination of skin
treated with 4 microneedling sessions 4 weeks apart
shows up to 400% increase in collagen and elastin
6 months after the last treatment. Additionally, collagen
bundles have a normal lattice pattern rather than the
parallel pattern seen in scar tissue [35]. Results after
each treatment are not seen immediately, because new
collagen continues to be produced for 3 months to
6 months after each treatment; the final outcome of
Microneedling 51
each treatment is seen after 6 months. It is recommen-
ded that 4 sessions to 6 sessions are done for a signifi-
cant improvement when treating all types of scars.
Microneedling can be combined with other tech-
niques to yield better results. These include trans-
dermal drug delivery, chemical peels, and energy
devices. There are various commercially available de-
vices that have small microneedles (0.5–3 mm long
and 0.1–0.25 mm in diameter) that break collagen
bundles in the superficial layer of the dermis that
contribute to scars. This leads to induction of more
collagen beneath the epidermis [36]. The microneedles
create small wounds in the epidermis, which enhance
the delivery of drugs across the skin barrier because it
bypasses the stratum corneum and delivers the drug
directly in the vascularized dermis. Laser-assisted
drug delivery, however, seems more effective. An
advantage of microneedling over laser is a lower risk
of PIH. Other techniques that damage the epidermis
have a high risk of PIH, but microneedling is an
exception.
Microneedling also has been combined with PRP to
enhance outcomes when treating acne scars. PRP is an
autologous concentration of platelets in a small vol-
ume of plasma. The plasma is rich in platelets, stem
cells, and growth factors, which stimulate skin to
produce more collagen. These platelets also enhance
tissue regeneration and promote healing by the release
of numerous growth factors from their a-granules. One
study compared 35 subjects with atrophic acne scars
who received 4 monthly microneedling sessions with
and without PRP for facial acne scarring. The right
face received microneedling alone, whereas the left
side of the face received microneedling followed
by the topical application of PRP [34]. A dermaroller
was used with 192 titanium needles at a depth of
1.5 mm until an endpoint of uniform pinpoint
bleeding was achieved. Assessments were done at
6 months after the last treatment using the Goodman
and Baron global acne scarring scale. There was signif-
icant improvement on both sides of the face, but
the side treated with microneedling and PRP had
higher patient satisfaction compared with the side
treated with microneedling alone. Additionally, there
was significantly less erythema and edema post-
microneedling on the side treated with PRP, leading
to less downtime overall. A split-face study of 50 pa-
tients with acne scars were treated with microneedling
of the full face, followed by topical and intradermal
injection of PRP or distilled water [37]. The side treated
with PRP had greater improvement, faster healing
shown by decreased edema and erythema after
52 Khetarpal et al
2 days, and increased collagen and epidermal thickness
on histology. Another study by Chawla [38] using
microneedling with either vitamin C or PRP for acne
scarring showed patients were more satisfied with
PRP than vitamin C. A study comparing microneedling
to nonablative fractional erbium 1340-nm laser for
acne scarring showed no statistical difference between
the 2 groups 6 months after 3 monthly sessions [39].
There was, however, a higher rate of PIH (13.6%) in
the laser group. Other studies have examined micro-
needling with other topical agents, including glycolic
acid and TCA, which enhanced microneedling results,
leading to greater improvement in acne scars compared
with microneedling alone. It is believed that these
topical agents are delivered directly to the dermis, given
the microneedles facilitated deeper penetration into
the skin, bypassing epidermal damage to stimulate
collagen and elastin formation [40].
Microneedling has gained popularity in treating
striae distensae. Several studies have compared micro-
needling to other modalities, including fractional abla-
tive CO2 laser resurfacing and microdermabrasion
[41,42]. In both studies, patients were randomized to
receive 3 monthly microneedling sessions. Patient
satisfaction was higher in the microneedling group,
and increased collagen, fibroblasts, and epidermal
thickness was seen in all the microneedling treated
specimens. Side effects of the areas treated with micro-
needling included mild pain, erythema, and spotty
bleeding.
As for burn scars, mouse models have shown that 4
monthly microneedling session lead to an increase in
type III collagen and increased mean epidermal thick-
ness up to 140% [43]. The results continued to
improve with repeated treatments. Mouse models
who had second-degree burns showed improvement
in epidermal thickening and normalization of dermal
collagen and elastin up to 12 months after each micro-
needling session.
Microneedling has recently gained popularity given
it is simple, inexpensive, safe, and effective technique.
Given it lacks heat and a chromophore target, micro-
needling has an excellent safety profile in all skin
types. It has a decreased risk of infection, photosensi-
tivity, and postinflammatory dyspigmentation given
it does not deliver heat to the skin. Providers should
be cautious not to apply excess pressure during treat-
ment, because reports of tram track scarring have
been observed [16]. It can be used for a wide variety
of indications, including transdermal drug delivery,
facial rejeuvenation, and improvement in the appear-
ance of scars.
SUPPLEMENTARY DATA
Supplementary data related to this article can be found
online at https://doi.org/10.1016/j.yacs.2019.02.003.
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