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Controlled trauma

Fletcher_Controlled_Trauma

Controlled trauma

Ms Leslie Fletcher explains a new patented technique in which controlled trauma stimulates new collagen

ArqueDerma is a patented technique that I developed for injecting hyaluronic acid and dermal filers into the dermis, using a modest subcuticular undermining effect with the needle that releases the dermal attachments. The separated, redundant tissue is then collected, redirected and stabilised upward.

Approach
There are three differentiating principles of the ArqueDerma technique, which simultaneously address the three signs of ageing: volume loss, redundant tissue and deteriorated skin.

The first principle is the ‘lost and found’ principle. ArqueDerma utilises the patient’s own tissue to replace and redirect into a hollow area. This also covers the second principle, the ‘less is more’ principle that addresses the patient’s redundant tissue. Instead of filling the hollow tissue in the face, we redirect and move the patient’s own redundant tissue into that area of hollow. The third principle is the ‘neocollagenesis principle’, which addresses deteriorated skin tissue. With a bit of undermining, a controlled injury induces wound healing. The controlled trauma injection technique increases collagen synthesis and has a long-term anti-ageing effect on the quality of the skin.

We use cannulas a lot in the USA—probably not as much as in the UK—but the whole point of a cannula is to create less trauma in the patient’s tissue. Sometimes a little bit of trauma can be good for establishing long-lasting results. Results can improve with time as the body creates collagen to stimulate and fill lines, even after the product has gone.

A patient with solar elastosis—ingrained etching that is crosshatched around the face—is hard to treat with fillers. I don’t have any lasers in my office, but this type of patient would definitely be a CO2 candidate, using the principle of heat causing some trauma and stimulating collagens. I don’t have that at my disposal, so I have developed a technique that uses hyaluronic acid injectables to produce a similar result to CO2 lasering on skin tissue. These results have shown the durability of endogenous neocollagenesis. Without reinjection, results are noticeable even years post treatment when the product is gone. What’s left is the body’s own collagen made in response to the trauma.

Comparison
There are various techniques used today that offer their own advantages. Conventional bolusing is very atraumatic; you go in, you place the product in and you come out. There’s not a lot of fanning, or movement with that needle.

Another method is threading and fanning with a cannula, which creates collagen just by passing the instrument through the tissue. It does create a neocollagenesis, but using a needle ups the ante, as it is a sharp instrument that will cut through and create more controlled trauma.

To up the ante even more, you can put increased tension on the needle when you’re in the tissue, splaying the needle to create undermining and subcision. It increases the neocollagenesis result, producing a longer-lasting result. The least amount of trauma that you produce for your patient, the least amount of neocollagenesis, the more trauma you can create the more organised neocollagenesis you will create.

Controlled trauma
The term subcision was trademarked by Dr Orentreich, a New York dermatologist, in 1994. His technique was developed for acne scars and he used an 18-gauge needle to break up the adhesions from their dermal attachments and pop the scar forward. He used no product, just a simple modality of needling and he had 97% patient satisfaction rate for the correction of defects. The concepts of using subcision to break up the attachments of the contour abnormalities to release the surface from deeper tissues is similar in ArqueDerma. However, it’s not using an 18-gauge needle as a separate treatment modality. ArqueDerma uses the injecting needle when placing the HA to create neocollagenesis and separate tissue, to create a pocket which keeps the tissue elevated until the collagen has a chance to form. So in this technique, the HA is actually used as a liquid glue as opposed to a filler.

In Dr Orentreich’s work he speaks about the blood being a place-holder that holds the space open until the new collagen has a chance to form. With bruising that is gone within two to three weeks. I feel that it’s better to leave a little product behind—the hyaluronic acid (HA) is there to hydrate the area and is also used as a space-holder or a potential separator to hold the tissue in place until the body has a chance to form its own collagen. This happens around four to six weeks later.

Collagen
Photoaged, aged or damaged skin has collapsed fibroblasts, because there is a decrease in healthy collagen putting pressure or tension on them. This creates a self-perpetuating cycle of degrading or fragmenting of its own natural collagen.

Fragmented collagen is detrimental to the growth of new collagen because it takes up space. We want to get rid of as much of the fragmented collagen as possible before we can start building the long, healthy collagen fibrils. Healthy, intact collagen attaches to the fibroblast and signals for it to stimulate even more collagen. We want full, intact collagen as much as we can under the skin because it holds the tissue up. It gives the skin an armature or a place to hold and suspend the area so that you’re not getting skin laxity.

If you imagine a bowl of cooked spaghetti noodles; you’d pour out the water, and put the spaghetti on your countertop and put a paper towel on top of that. The paper towel will drape nicely over the cooked spaghetti noodles. But, if you take tiny, thin, chopped-up noodles, boil it, pour that on your countertop and put a paper towel on top, the paper towel’s won’t drape very well—it’s not going to be very supportive.

Where you place the hyaluronic acid it swells due to the product’s hydrophilic nature—holding 1,000 times its weight in water. As the product swells, it puts pressure up against the fibroblasts, which signals those fibroblasts to create their own collagen.

The ArqueDerma technique places the HA in small, vectored strands, creating a synthesis of collagen, a breaking-down of old collagen, and a building-up of the new collagen over  a larger area. You’re actually putting it throughout the whole face and having that same neocollagenesis process happening over a larger surface area.

Every day our skin is in a process of ageing. We’re exposed to the sun, which releases matrix metalloproteinases (MMPs)—a proteinase that breaks down collagen. It breaks down those long spaghetti strands into tiny strands, which aren’t supportive for the skin tissue, and it also takes up space from longer ones forming. When longer strands can’t form, they can’t put pressure against the fibroblasts and the fibroblasts cannot create more collagen. It’s a cycle of ageing that occurs all day every day.

To reduce ageing we have to do something to interrupt that cycle, and there are many things that we can do to stimulate the collagen including chemical peels and dermal injury with laser, needles or micro-needling. If you use microneedling, you create a change in the cycle when you are rolling, so when you’re injecting you can also change the cycle with your injecting needle, to increase creation of more collagen.

An inflammatory phase occurs, where there is an increase of MMPs that break up unhealthy, broken collagen strands. It attacks these fragments first because they’re smaller. It breaks them down and macrophages them out and once they’re washed out space is created for healthy collagen to form.

Growth factors are also released which stimulate the fibroblasts to produce more collagen. The long, healthy collagen strands put pressure up against the fibroblasts to create more collagen. It’s a good thing to have this cycle change because we need to increase our amount of collagen production since we lose 1% of collagen a year after the age of 30.

We have to do something to make up for this lost collagen, and it takes a lot of product to fill up what we’ve lost. What we can do though is stimulate the body’s own collagen which is free and use that as an adjunct to dermal fillers.

The healing phase
The inflammatory phase is the first three days—platelets release growth factors, neutrophils and macrophages are pulled into the wound, fibroblasts begin to be pulled into the wound and endothelial cells start to proliferate.

Next there are three to 28 days of proliferation, or the fibroblastic phase. The keratinocytes and fibroblasts get involved and start producing more growth factors, which will move on to the synthesis of the extracellular matrix, and new capillaries form so there is also neo-vascularisation.

Last is the remodeling phase, which lasts between 28 days and two years. It’s a continuation of growing collagen and the fibroblasts promote remodeling by producing extracellular matrix MMPs. This is an ongoing process lasting two years, and then after the two year period, the new collagen that’s been produced in the body has been speculated to last between four and seven years. Your patients aren’t going to perceive this as a treatment that will last for four to seven years, so I try not to quote that, because then they’re going to get upset at seven years if they don’t look like they did the day they left the office. The lift might be gone after a couple of years and patients do need to be re-injected to get that elevation of the tissue that they had initially. What does happen is the skin deterioration has changed over time—that lasts several years. I have no problem telling patients their results will last them two to four years.

Perceived disadvantages
There might be some perceived disadvantages with this technique. One might wonder how creating trauma affects your patients – do they bruise? The answer is yes, most of the time they do. However, I take the time to educate my patients ahead of time on the advantages of the bruising and how that leaves the patient with some extra stimulation. Patients do get excited about it to the point where if they don’t bruise, they’ll call me and say, “Wait a minute, I thought you said I was going to bruise! Does this mean the technique won’t work?”

The patients are very aware that there is social downtime. This is much more of a procedure than a basic fill, but I definitely like to give them the advantages. Some may say there’s an increased risk of occlusion over a cannula. This isn’t really the case, because you’re delivering micro-amounts, well under 0.1ml, sometimes less than 0.05ml with each pass and you’re always moving your needle—a moving needle is a safe needle.

Another possible perceived disadvantage is the potential to have a decrease in sales because you use less product and patients take a lot longer to come back—this is just not the case. We’ve done a lot of follow with the people who take our courses and have been licensed in this technique, and their filler sales go up between 200% to 300% within the first few months. That’s due to word-of-mouth referrals because the results are so great. Additionally, the patients may spend a little extra money at their initial appointment to get the initial lift completed.

Ms Leslie Fletcher is an Aesthetic Nurse Injector. She owns an international training company, InjectAbility Institute where she licenses out the ArqueDerma technique. E: info@arquederma.com

Author: bodylanguage

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