AESTHETIC

A review of plasma medicine

BY RUTH CROFFORD

The author investigates the efficacy and tolerability of plasma treatments and asks what the future might hold in this field.

lasma medicine, a new and Contraindications and clinical of the University of Modena revolutionary technology to considerations and Reggio Emilia. They utilised the aesthetics, utilises the physical Contraindications to the use of global aesthetic improvement scale Pprocess of sublimation for plasma devices include pregnancy and (GAIS), to measure patient satisfaction therapeutic purposes. breastfeeding, the use of isotretinoin, following a non-surgical . Non-surgical clinical applications of systemic illnesses, infection at the one hundred percent of patients reported plasma devices include, but are not limited treatment site, body dysmorphia and allergy an aesthetic improvement, from being to, skin tightening / lifting, non-surgical to any of the topical preparations utilised. ‘satisfied’, to proclaiming an ‘outstanding blepharoplasty, removal of tattoos, Patients with a known history of keloid result’. A further tool was used to assess semi-permanent make-up, xanthelasma, or hypertrophic scarring should also be dermatochalasis, this being the Wrinkle Severity Rating Scale by Waugh & Blitzer [7]. fibroma, lentigo, warts, verruca vulgaris and avoided despite the treatment being The study concludes that patients found a improvement in the appearance of recommended to treat scarring itself [4]. and stretch-marks. decrease in dermatochalasis, from which The provision of numerous applications Treating patients within aesthetics severe laxity became mild, minimal or completely absent [2]. under the umbrella of non-invasive The advantages for the medical professional Other studies have examined the effects microsurgery or ‘aesthetic surgery’, make include yielding high profits from single of plasma generation at a cellular level. plasma devices broadly appealing to a wide session treatments that in the majority Scarano et al. investigated the safety range of medical professionals, including of cases only require outpatient care and of plasma exeresis (non-surgical removal dermatologists, nurses, doctors, dentists extremely low running costs. (Once a device of excess skin) in animal tissues. A direct and surgeons. is purchased each treatment can cost as comparison was made with electro UK companies started to distribute little as £1 in consumables). In addition, surgical / radio scalpel therapy. Plasma plasma medicine devices to the aesthetic most of the treatments can be conducted generation was demonstrated to minimise market just over four years ago. In this with the use of a commonplace topical damage within connective tissues, enabling time much has been learnt in practical anaesthetic such as Lmx4 or Emla. faster healing, both in the immediate and experience. Patients are readily attracted to plasma the postoperative periods. The efficacy and tolerability of plasma treatments given that they provide a Regeneration of skin tissue, neo- treatments is investigated in this article, cheaper alternative to surgery and generally collagenesis, specifically the remodelling of to highlight potential improvements and much shorter recovery times. Non-surgical collagen Type III fibres has been proven by considerations within our practice. intervention alleviates the possible two recent case reports in human studies complications and fear of surgery, as well as [8,9]. Furthermore, Rossi et al. concluded The science of plasma medicine the cost. that plasma exeresis offers promising Plasma generation occurs when an The success of plasma devices in the remodelling effect on collagen and clinically electrical discharge exits the device tip and aesthetics arena has been largely due to the improved appearances for patients without enters the target area, in most cases the most advertised application which is the serious adverse events. The author recently electrode tip is close enough to the target rejuvenation of the periorbital region, the conducted a survey consisting of nine (skin) but never touches it. The first step is ‘non-surgical blepharoplasty’. The American questions to plasma operators on Facebook immediate tissue contraction and thermal Society for Aesthetic states entitled ‘Plasma complications in aesthetic disruption as an active plasma mechanism that blepharoplasty is today the fourth medicine’. The survey was developed to [1]. most demanded aesthetic treatment in ask the question ‘Are patients experiencing Secondly, the tissue is sublimed; a direct medicine and aesthetic surgery [2]. This postoperative side-effects?’ Thirty-seven transfer of the tissue from a solid form area is considered to be a principal aspect medical practitioners completed the to a gaseous state is created. The heat is of facial aesthetic appearance by patients survey, and a significant 64.9% answered absorbed by the tissue being targeted and is and is often primarily selected for facial ‘yes’ to having witnessed side-effects. not transferred to surrounding tissue or the rejuvenation [5]. As practitioners we are The most common immediate (short- subcutis [2]. Plasma induces a denaturation aware that the periorbital region is one of term) effects were swelling (83.3%) and of collagen and other proteins in the skin the first to show signs of ageing [6]. erythema (62.2%). Longer-term side-effects [1]. Therefore, what follows is a cascade of Recent clinical studies have focused included mild hyperpigmentation (35.1%) neo-collagenisation, the thermal effects primarily on the efficacy of treatment hypopigmentation (10.8%) and erythema stimulate disruption of dermal solar of non-surgical blepharoplasty: A study (24.3%). elastosis, fibroblast activation and migration on 50 patients who were suffering An advantage to selecting a plasma from the deeper dermis and cytokine dermatochalasis of the upper eyelids device with the separation of anodic and release, tissue is regenerated [1,3]. was conducted by the Department of cathodic energies – as a direct translation

The PMFA Journal | FEBRUARY/MARCH 2019 | VOL 6 NO 3 | www.thepmfajournal.com AESTHETIC NURSING

NO. OF QUESTIONS QUESTION DEVICE NAME VOTES PERCENTAGE 1. Which plasma device do you operate? Nano Plasma 2 5.4 Plexr 6 16.2 Jett Plasma 2 5.4 Plasma IQ 5 13.5 Plasma BT 4 10.8 Other 18 48.6 TOTAL 6 37 100 2. Which indication(s) do you use it for? USES VOTES PERCENTAGE

Nonsurgical blepharoplasty 36 97.3 Removal of skin tags 24 64.9 Reduction of lines- lower face 24 64.9 Reduction of lines - upper face 23 62.2 Removal of millia 15 40.5 Mini face-lifting 14 37.8 Removal of warts 12 32.4 Stretch marks 11 29.7 Removal of verucas 6 16.2 Periumbilical laxity 6 16.2 Tattoo removal or fading 4 10.8 Papulosa Nigra 4 10.8 Removal of 1 2.7

Other 4 10.8 TOTAL 37 184 100 3. How many plasma procedures to PROCEDURES PERFORMED VOTES PERCENTAGE date have you performed?

Less than 10 procedures 9 24.3 11 – 50 15 40.5 Over 50 6 16.2

Figure 1: The results of a Facebook survey project. into treatment, this technology reduces by participants indicates that more research Treatment of post inflammatory postoperative swelling and erythema. is required to explore both preparing hyperpigmentation The cathodic handpiece has an antibiotic patients skin adequately pre-treatment and My personal suggestion is that patients have effect which fights anaerobic bacteria, the consideration of using test-patching a thorough skin assessment followed by a and acts as a temporary vasoconstrictor, prior to plasma therapy. test patch in the area of intended treatment reducing oedema both during and after the The device is promoted for all Fitzpatrick (one month prior to the delivery of a full procedure. skin types, but there is currently no clear treatment). At this point a skin preparation As the manufacturers and distributors evidence-based pathway to preparing plan can be discussed and agreed upon. have become more successful, the various skin types for preventing In the absence of formal guidance accompanying training protocols have pigmentation. The author suggests a to prevent post inflammatory become more innovative and beneficial to comprehensive assessment tool being hyperpigmentation my clinical both professional and patient. However, as developed by key opinion leaders in the area recommendation is to use the NeoRetin the prevalence of plasma devices increases, of dermatology and medical aesthetics. range of cosmeceuticals from Aestheticare and the number of treatments escalates in When questioned, the Facebook survey as a pre-treatment protocol. This well- both aesthetic and surgical medicine, it is participants gave 21 different answers established company has clinical data to important to face the future and ask what in their support of how they would treat ensure NeoRetin has been specifically needs to be improved? hyperpigmentation following plasma designed to manage the risk of post- Analysis of the survey showed that, therapy. inflammatory hyperpigmentation (PIH) – even with small sample numbers of 37 Please note that this survey questioned skin developing areas of pigmentation after medical professionals, a resounding 94% of all practitioners who used a variety of procedures that cause skin inflammation practitioners called for more information plasma devices and thus it proves that, and redness, a risk particularly in skin types and protocols on the management of historically, manufacturers are currently 3-6. It does this by tackling every stage of plasma medicine complications. not providing practitioners with protocols the melanin production cycle. The incidence of side-effects (both on how to deliver post inflammatory The range also includes broad-spectrum immediate, short and long-term) reported hyperpigmentation care. UVA and UVB protection to defend the skin

The PMFA Journal | FEBRUARY/MARCH 2019 | VOL 6 NO 3 | www.thepmfajournal.com AESTHETIC NURSING

References 1. Pourazizi M, Abtahi-Naeini B. Plasma application in aesthetic medicine: clinical and physical aspects. J Surg Dermatol 2017;2(T1). http://DX.doi.org/10.18282/had.v2.it.1.140 2. Rossi E, Farnetani F, Trakatelli M, et al. Clinical and confocal microscopy study of plasma exeresis for non-surgical blepharoplasty of the upper eyelid: A pilot study. Dermatol Surg 2018;44(2):283-90. 3. Weltmann KD, von Woedtke T. Plasma medicine – current state of research and medical application 2016. Plasma Physics and Controlled Fusion 2017;59(1):014031. 4. King M. Focus on plasma: the application of plasma devices in aesthetic medicine. The PMFA Journal 2017;4(5):24-26. https://www.thepmfajournal.com/ features/post/focus-on-plasma-the-application-of- plasma-devices-in-aesthetic-medicine 5. Nguyen HT, Isaacowitz DM, Rubin PA. Age and fatigue related markers of human faces: an eye-tracking study. Ophthalmology 2009;116:355-60. 6. Lemke BN, Stasior OG. The anatomy of eyebrow ptosis. Figure 2: Upper blespharoplasty TX diagram. Arch Opthalmol 1982;100:981-6. 7. Waugh JM, Blitzer A. Wrinkle Severity Rating Scale from the negative effects of UV exposure, Regenerative facials with the Nano (methods and assessment scales for measuring wrinkle reduce the production of Reactive Oxygen Plasma are easy to perform, produce only severity). January 2013. Species and help to prevent any further warm heat sensations and will improve skin 8. Tsioumas GS, Vlachodimitropoulos D, Goutas N. Clinical melanin production. texture. and histological presentation after Plexr application, needle shaping (vibrance) and O.F.F. Pinnacle Med Med Post plasma treatment, patients in my When looking at the multiple applications Sci 2014;2:522-30. clinic receive inflammation defence serum of this technology within the field of 9. Gloustianou G, Safari M, Tsioumas GS, et al. Presentation from Bio Cosmedical (available through medicine it is perhaps pertinent to look at of old and new histological results after plasma exerices (plexr) application (regeneration of the skin tissue with Fusion GT) and Heliocare Mineral from the global economic burden of diseases such collagen 111). Pinnacle Med Med Sci 2016;3:983-90. Aestheticare. as acne and how plasma treatments can 10. Chutsirimongkol C, Boonyawan D, Polnikorn N, et al. The aim when undertaking non-surgical lessen that burden for the NHS in the UK Non-thermal plasma for acne treatment and aesthetic blepharoplasty treatment is to minimise and our patient populations. skin improvement. Plasma Medicine 2014;4(1-4):79-88. pain, oedema and the risk of PIH, therefore In the UK 3. 5 million annual visits are these treatments are delivered over three made to the GP surgery directly in relation sessions. Each appointment has an interval to concerns regarding acne [10]. Acne of two to four weeks. remains the most common skin condition This is the original Professor Fippi method in adolescence and can continue into which is far more tolerable than a one- adulthood. session treatment. In the past decade studies have proven AUTHOR Not much is reported regarding ineffective the safety and efficacy of plasma medicine or sub-optimal treatment results, however, in relatively small populations. However, I would like to put forward, as a practitioner further detailed studies are required, who has treated over 200 men and women with larger test groups to examine the with plasma medicine devices, I have most widespread practice of plasma medicine certainly had patients who believe that within healthcare that goes beyond the there is no improvement in dermatochalasis aesthetic and surgical and into mainstay GP with non-surgical blepharoplasty. practices. Furthermore, currently I have two Medical professionals in the aesthetics Ruth Crofford, RN, BSc (Hons) NIP, patients with long-term erythema following arena are reporting long-term side-effects Clinic Nurse, Lioness Medical. lower non-surgical blepharoplasty, now including hyperpigmentation and erythema. nearly 18 months following treatment. Aesthetic doctor Martyn King calls for Neither of these patients reported having continued education and training as this Declaration of competing interests: The author is a KOL / trainer for Fusion GT. any healing difficulties with previous trauma procedure can cause destruction to the or surgery, and both are Fitzpatrick skin type 1. epidermis and may even lead to scarring [4]. Besides the obvious potential for SECTION EDITOR So what does the future hold? dermatology and aesthetic skin conditions, Fusion GT have developed a set of the technology offers non-invasive and attachments for the Nano Plasma device selective targeting of biological tissues at which will enable a treatment termed a molecular level, meaning that it has a plasma peeling to be utilised. The various role in stimulation of tissue regeneration, shaped attachments include a smooth chronic wound care and new approaches to surface tool which allows painless, non- cancer therapy [10]. So the future of plasma ablative manoeuvres that encourage plasma medicine is very bright and we are very cellular detachment in the epidermis. fortunate to be part of that journey right Anna Baker, Such treatments will produce a mild to now, however, a stronger clinical evidence Aesthetic Nurse and Teaching Co-ordinator moderate skin-tightening effect and some base is required to ensure safe, predictable for Dalvi Humzah Aesthetic Clinical Training Courses. degree of facial contour change that have results with the emphasis on reducing and been evidenced in other plasma devices [10]. managing postoperative complications.

The PMFA Journal | FEBRUARY/MARCH 2019 | VOL 6 NO 3 | www.thepmfajournal.com