Microcoring is a new and innovative minimally invasive method for systematically removing collimated cores of skin with scarless healing. It is currently FDA approved for the treatment of moderate to severe wrinkles in the mid to lower face. Other applications that have been explored include skin rejuvenation, skin tightening/lifting, pore size reduction, acne scar treatment, striae reduction, and scar revision. In contrast to energy-based devices designed to achieve similar outcomes, microcoring does not involve the use of thermal energy, conferring an enhanced safety profile. The safety and efficacy of microcoring technology highlight its promise for both aesthetic and reconstructive indications.
Key points
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Microcoring technology uses a systematic array of hollow hypodermic needles to remove skin safely and scarlessly.
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Current applications include rhytid reduction, skin tightening, skin rejuvenation, scar revision, pore size reduction, striae treatment, and acne scar treatment.
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Complications are minor and often transient, and include bleeding, erythema, dyspigmentation, infection, and ecchymoses.
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This technology does not generate thermal energy and is therefore theoretically safer in skin of color versus energy-based alternatives.
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Limitations of microcoring include insufficient core extraction and persistent erythema and edema.
Video content accompanies this article at http://www.advancesincosmeticsurgery.com .
Introduction: nature of the problem
Scarless skin remodeling, whether for aesthetic or reconstructive purposes, is an expanding multidisciplinary research and clinical frontier. One of the newest technologies is microcoring. The concept of microcoring originated from microcolumn skin grafting, which was shown to result in full thickness skin reconstitution [ ]. The realization that skin puncture with needle diameter less than 500 μm results in scarless healing led to the development of scarless skin remodeling with microcoring [ ].
For issues such as excessive skin laxity, surgery has historically served as the mainstay of treatment. Yet for many patients, surgery is not a reasonable option. Downsides of surgery include cost, prolonged recovery, peri/postoperative complications, or unsatisfactory results [ ]. Additionally, targeted cosmetic subunits are difficult to selectively treat with surgery.
The advent of minimally invasive technologies that induce wound healing, such as microneedling or fractional laser, has generated excitement about non-surgical interventions. Both microneedling and fractional laser deliver controlled tissue injury, inciting a healing response that promotes collagen production, skin rejuvenation, and overall skin restoration [ ]. However, the scope of indication for microneedling is narrow, and results are often subtle at best, which can be inadequate for many patients.
Fractional ablative lasers are commonly used, but their risk profile includes dyspigmentation, inflammation, burning, and scarring [ ]. Additionally, recovery following ablative treatments can be protracted and infection is a feared complication. These technologies also use thermal energy and heat, which has historically limited safe use in higher Fitzpatrick skin types [ ].
Microcoring uses a systematic array of hollow hypodermic needles to remove skin [ ]. In contrast to energy-based devices, microcoring does not produce thermal energy and therefore avoids thermal coagulation, theoretically resulting in faster core healing, as well as an enhanced safety profile.
Microcoring technology first came onto the market in mid-July 2021 with the introduction of Ellacor (Cytrellis Biosystems Inc., Woburn, MA). Founders, Dr William Ausen Jr and Dr Rox Anderson, brought forth this technology from vision to reality. This first-in-its-category device is approved by the FDA for treatment of rhytids on the mid-to-lower face [ ].
Initial data for microcoring are promising. Extraction of tissue cores leads to a significant increase in collagen production, restoring the structural integrity of the dermis [ ]. While not yet an FDA-approved indication, microcoring also leads to tissue contraction and tightening. Histology of treated skin in clinical trials confirmed absence of post-procedural scarring 90 days post-treatment [ ]. The effects of microcoring counteract the complex processes of photoaging and chronologic aging, such as decreased dermal thickness and disorientation of the dermal matrix resulting from upregulated matrix metalloproteinases, decreased collagen, and disrupted elastin fiber network.
While clinical trials to date have mostly focused on aesthetic indications, the applications for this technology are innumerable. Because of its safety and efficacy, in the right clinical context, microcoring offers an appealing alternative to current standard-of-care procedures used for similar purposes, including laser, microneedling, radiofrequency devices, and surgery.
The device and technology
Ellacor (Cytrellis Biosystems, Inc., Woburn, MA) is the first and only FDA-approved microcoring technology designed to treat moderate to severe rhytids on the mid-to-lower face in adults aged 22 or older with Fitzpatrick skin types I to IV. It should not be used on mucous membranes or within the bony rim.
The device has a reusable hand-held probe, which is composed of a systematic array of disposable hollow hypodermic needles. Disposable attachments, including the needle array with tubing and vacuum spacer flange, are secured into place. The operator uses a foot pedal to actuate the device after placing it at the treatment site. The needles penetrate the skin and are then retracted, extracting tissue cores which are aspirated by vacuum suction. Core aspiration is a key to the procedure, and makes it superior to other tissue removal treatments such as fractional lasers, where histologic studies show that defects are swiftly filled by microscopic epidermal necrotic debris, limiting final contraction and skin tightening [ ].
The treatments are carried out within a 1 cm 2 area without overlap. The extracted tissue cores are on the order of 400 μm, or a 27-gauge needle [ , ]. The lowest depth of needle penetration needed to ensure intact complete tissue coring should be used. Microcoring reaches depths of up to 3 to 5 mm [ ]. By way of comparison, carbon dioxide lasers reach depths of around 100 to 150 μm and Er:YAG lasers reach depths of 10 to 40 μm [ ]; however, pulse stacking can increase penetration depth [ ].
The Ellacor device offers multiple settings for tissue removal. A skin removal of 1% corresponds to 9 cores per square centimeter. Percentage removal settings range from 1% to 8%, and a higher percentage corresponds to a more aggressive treatment (1% = 9 cores; 3% = 24 cores; 6% = 36 cores; 7% = 51 cores; 8% = 60 cores). Core depth ranges from 0.0 to 4.0 mm, and is adjustable in 0.5 mm increments [ ]. Treatment durations, excluding preparation such as numbing, spanned from 15 to 30 minutes for the areas studied on the face; these authors have found that to be consistent with clinical practice [ ].
Surgical technique
Pre-operative planning
Pre-operative planning starts with patient selection. Patient-specific factors to consider include age, gender, body mass index, photodamage, current sun exposure, skin texture, and pertinent medications [ ]. Patients with a history of hypertrophic scarring or keloid formation, bleeding disorder, and active infection, acne, or rash overlying the treatment area should not be treated [ ].
Other important history includes past or recent surgery, trauma, scarring, and/or exogenous material (eg, silicone, fat, collagen) in the treatment area [ ]. Provider discretion must be used to determine candidacy for relative contraindications, which include chronic skin conditions (melasma, acne, scars), untreated drug or alcohol use disorder, immunosuppression, analgesic sensitivity, and bleeding disorders.
There are no current data to validate the safety of microcoring in pregnant and/or breastfeeding women; therefore, caution is advised.
Patient characteristics and contraindications
Ideal patients have moderate to severe facial laxity with or without rhytids. Importantly, patients with severe wrinkling or laxity are not optimal candidates. Discussion about benefits/risks and alternative procedures, including laser and surgical facelift, is vital ( Table 1 ). Patients must be aware of the approximately 1-week downtime, which may include ecchymoses, crusting, edema, and erythema [ ].
| Alternative intervention | Indication | Limitations | Complications |
|---|---|---|---|
| Topical retinoids | Fine wrinkling, dyschromia, skin retexturing | Sometimes poorly tolerated (redness, irritation, burning), can cause photosensitivity | Xerosis |
| Topical antioxidants (ie, vitamin C) | Skin rejuvenation | Poor skin penetration and poor chemical stability | Allergy or intolerance |
| Chemical peels | Skin retexturing | Requires indefinite serial treatments | Erythema, scarring, dyspigmentation |
| Botulinum toxin | Mild-to-moderate wrinkles | Immunogenicity over time, requires continued use for optimal results | Bruising, unintended paralysis (temporary) |
| Filler | Moderate-to-severe facial wrinkles and skin folds | Impermanent, can help to fill lines but cannot address excess skin or lax skin | Bruising, bleeding, swelling, Tyndall effect, nodularity, infection, hypersensitivity, necrosis, blindness |
| Microneedling | Skin rejuvenation | No notable skin tightening or skin surface area reduction | Transient erythema, post-inflammatory hyperpigmentation |
| Fractional ablative laser | Rhytids, photodamage, scarring, skin laxity, skin texture | Recovery time, cost, patient tolerance (ie, pain) | Dyspigmentation, inflammation, infection, scarring |
| Surgical facelift | Rhytids, skin laxity, skin redundancy | Invasiveness, cost, patient surgical candidacy, recovery time | Bleeding, edema, erythema, complications with anesthesia |
Contraindications are similar to other resurfacing procedures and include history of hypertrophic scarring or keloid formation, bleeding disorders, active infection, acne, or rash overlying treatment area [ ]. Relative contraindications include surgery at the treatment site within the past year, trauma, scarring, and/or exogenous material.
Dyspigmentation in skin of color is a greater concern with other energy-based devices than microcoring due to the heightened susceptibility to post-inflammatory pigment alteration. The increased melanin in darker skin types acts as a chromophore, absorbing additional energy from the laser [ ]. Clinical studies evaluating microcoring in skin of color are lacking [ ]. Theoretically, this device should be safe in skin of color, but further studies are needed.
The few clinical trials for microcoring to date have employed strict exclusion criteria, spanning dermatologic conditions (melasma, acne, scars) to special populations (pregnancy, breastfeeding, untreated drug or alcohol use disorder) to other past medical history (immunosuppression, analgesic sensitivity, bleeding disorders); therefore, safety and efficacy in these populations is uncertain [ ]. Individual devices may also have specific contraindications. For example, Ellacor is not recommended for use in patients who have an allergy to stainless steel or any of the topical, oral, or injected medications used during the procedure [ ].
Ellacor also recommends against use in patients with the following dermatologic and autoimmune conditions: keratosis, raised nevi, rosacea, melasma, active acne, cutaneous papules/nodules, active inflammatory lesions, dermatitis, psoriasis, cellulitis, urticarial folliculitis, acute inflammatory phase of scleroderma, rheumatoid arthritis, eczema, psoriasis, allergic dermatitis, collagen disorders, or lupus [ ].
Some medications, including blood thinners, chemotherapy, and high-dose corticosteroids should be considered when determining treatment safety. Shared decision-making with the patient, involving informed consent of associated risks, will also ensure appropriate screening. A summary of pre-procedure considerations is provided as Box 1 .
Pre-procedure considerations
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Ensure the patient does not have any contraindications.
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Any history of hyperpigmentation?
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Recent exposure to sun or tanning beds?
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Recent trauma or surgery to treatment area?
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History of active, chronic, or recurrent infection?
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History of active herpes simplex virus in the treatment area?
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Other medical conditions that may interfere with the treatment?
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Medications (oral, topical) which could affect the treatment, skin integrity, or healing process?
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Any over the counter or herbal supplements which could prolong healing or increase bleeding?
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Assess the skin: is it coarse, thin, fragile, or thick? This will help with determining treatment settings and setting appropriate, realistic patient expectations.
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Preparation, patient positioning, and anesthesia
Patients should be counseled on pre-procedure instructions ( Table 2 ). The day of the procedure, patient preparation begins with thorough facial cleansing. An antiseptic solution, such as isopropyl alcohol swabs or chlorhexidine wash, ensures a clean field. Patients should be in a supine position with their hair secured away from the treatment field with a hair net or cap.
| Pre-procedure instructions for patients | |
|---|---|
| 2 wk prior | Avoid any invasive or minimally invasive procedures in desired treatment area, including but not limited to skin surgery, laser therapy, microdermabrasion, chemical peels, etc. Avoid consuming blood thinning agents, such as aspirin, ibuprofen, vitamin E, fish oil, or grapeseed extract. If you are taking these under the direction of a physician, please consult with him or her first. |
| 1 day prior | Shave any excessive facial hair, such as beard or mustache. |
| Day of | Make sure the skin that will be treated is free of makeup, lotions, or other skin care products. |
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