What is injectable skin biostimulation?

Cutaneous biostimulation involves the intradermal-subcutaneous injection of pharmacological substances that stimulate tissue regeneration: thanks to their action, the skin becomes more hydrated, cells renew more quickly, and the production of collagen and elastin increases.

The main indications for this therapy are dehydration, aging, and photoaging. Normally, biostimulation is included in a skin management program established after a dermocosmetological check-up according to Bartoletti and Ramette, which includes the at-home application of specific cosmetics, the possible use of ambulatory chemical peels (which further stimulate cellular renewal), and the potential use of fillers.

The results that can be achieved depend a lot on individual response, and their duration varies depending on the severity of the starting situation and lifestyle factors (for example, avoiding sun exposure and consistently using sun protection can increase the effectiveness of the treatment over time). In any case, biostimulation, like all cyclic treatments, should be continued with monthly maintenance sessions after a cycle of close sessions.

Even if there are no episodes of allergy in the clinical history, in rare cases, a reaction to the injected substance can occur; furthermore, this treatment is contraindicated in individuals with coagulation disorders and certain conditions such as autoimmune diseases.

The most commonly used active ingredients for biostimulation, either alone or combined, include:

• Hyaluronic acid: Hydrates the skin, has free radical scavenging activity, improves the cohesion of the superficial skin layer, and its metabolism;
• Polydioxyribonucleotides: These are chains of fractions of nucleic acids, DNA, which are the foundation of all the body's activities. They have the property of increasing the functional capacity of fibroblasts, the cells that produce collagen and elastin, substances present in youthful skin that change in quantity and quality over time;
• Amino acids that are precursors of collagen: Collagen is the most common structural protein in the body; essential amino acids that constitute it, when injected into the dermis, stimulate its local production. This helps counteract the decrease in collagen that would lead to skin sagging over time.

Generally, it takes about 20 minutes to perform biostimulation, but there can be some variability. The level of pain experienced depends on individual sensitivity and the treated areas, and it is usually very tolerable. After the therapy, there may be some erythema (redness), mild and transient swelling (which typically resolves in about 30 minutes), and slight bleeding. Small bruises may also appear but will spontaneously disappear within a few days. In the days following biostimulation, sun exposure or UV lamps should be avoided, and sunscreen should always be applied. In the days immediately before and after the treatment, all procedures that could irritate the skin in any way should be avoided (waxing, electrolysis, exfoliating masks, laser hair removal, etc.).

Many facial irregularities can be improved with dermal fillers, also known as "filler" substances. When injected into the skin, they can create volumes or restore them if they have diminished over time. They can also fill in grooves and wrinkles, such as nasolabial folds, labiomental lines, or periocular and lip contour wrinkles.

The Bartoletti Cavalieri Associated Medical Practice is part of the National Consensus Conference on fillers, and in accordance with official guidelines on the use of fillers, it does not use permanent fillers and strongly discourages patients from requesting them.

The Italian Society of Aesthetic Medicine (SIME), of which Dr. Bartoletti is the President, has been one of the most active proponents at the Ministry of Health for guidelines on the safe use of fillers. Therefore, at our studio, only absorbable fillers are used, and permanent substances are not used.

Hyaluronic Acid

It is a natural constituent of human connective tissues. It has a very large molecule of a polysaccharide nature and plays important roles in the skin, including providing volume, firmness, and tone, thanks to its ability to bind a significant amount of water molecules (up to 100 times its dry weight).

Its presence in the skin decreases with aging, contributing to the decline in the mechanical properties of the skin.

One characteristic of hyaluronic acid filler is its ability to integrate well into tissues. Additionally, even when injected in small quantities, it binds a lot of water and tends to occupy a significant amount of space, making it a good "volume expander." Cells have the tools to metabolize the injected hyaluronic acid, which gradually disappears, breaking down into its components, which are harmless and reusable.
The hyaluronic acid available in the market today is of bacterial synthesis and exhibits excellent biocompatibility, which minimizes the possibility of allergic reactions. Thanks to its gel formulation, it's possible to achieve very natural results in filling wrinkles, creases, and depressions, as well as in volumetric augmentation of areas like cheeks and lips.

Depending on the density and structure of the filler used, the duration of corrections varies from a minimum of 4-6 months for fluid products and superficial corrections to a maximum of 12 months for more substantial products and deep corrections. Some factors, such as cigarette smoking and intense sun exposure, can accelerate the absorption, and the speed of absorption is linked to individual biochemical characteristics, overall health, and the patient's lifestyle.

Some pathological conditions require careful consideration on how appropriate the treatment can be. These include dermatopathies, inflammatory conditions of any nature present in the areas to be treated, certain autoimmune diseases, and all systemic conditions of a certain severity.

Like any injection, even when the treatment is correctly performed, unwanted reactions can occur: transient erythema (redness), mild and transient swelling, slight bleeding or small hematomas with swelling and bruising, local pain (lasting for a few hours), localized infections.

Other side effects are related to the biological activity of hyaluronic acid: some patients have experienced persistent swelling and erythema in the injection areas for over 24-48 hours, which in the treatment of the lips, in exceptional cases, can last up to 7 days. Mostly, these are localized phenomena that disappear spontaneously; in sporadic situations, the use of specific pharmacological support may be required. Rarely, palpable hardening or granularity in the implant area can occur, always transient. Isolated cases of abscess-like, sterile swellings have also been described, occurring 3-4 weeks after the implant, with spontaneous regression in 6-8 weeks.

Calcium Hydroxyapatite

Calcium hydroxyapatite is a unique filler approved by the FDA (Food and Drug Administration) in the United States for the correction of moderate to severe facial folds and wrinkles. In Europe, Radiesse filler is CE certified for plastic and reconstructive surgery, including the augmentation of the intradermal and subcutaneous soft tissue of the facial area.
The filler consists of 30% synthetic microspheres of calcium hydroxyapatite suspended in an aqueous gel solution (70%). These microspheres are composed of calcium and phosphate ions, substances also naturally present in epidermal tissue. Therefore, it is a 100% biocompatible product that does not require prior allergy testing.
During the injection, the gel in which the calcium hydroxyapatite microspheres are immersed provides an immediate corrective and filling action. Then, over the course of several months, the gel is degraded by macrophages, while the hydroxyapatite particles remain, and new collagen is synthesized around them. The duration of the implant is generally longer than that of other absorbable fillers, ranging from 12 to 18 months on average.
Calcium hydroxyapatite is mainly indicated for volumetric definition in facial areas where volume is provided by bony prominences, such as the cheekbones and jawline. You may experience slight discomfort during the injection, and for a few hours after the treatment, there may be mild local tenderness. Small bruises may appear in the treated areas, but they typically disappear within a week.

Poly-L-lactic Acid

Poly-L-lactic acid (PLLA) is a synthetic, biodegradable, immunologically inert, and absorbable polymer. Its action involves increasing dermal volume through neo-collagenesis (increased collagen production). The microparticles it is composed of, when injected with a fine needle into the subdermal layer, slowly degrade over the next 12-30 months until complete absorption, stimulating the surrounding tissue to produce new collagen. This slow and progressive collagen production increases the volume of atrophic areas. 
To achieve satisfactory results, patients with minor defects typically require 2-3 sessions, while those with more severe alterations may need 5 or 6. To maintain the results obtained from a treatment cycle, a touch-up is necessary every 8-12 months.

Rhinofiller

"Rhinofiller" is a technique that allows for nose reshaping and can serve as an alternative to traditional surgical rhinoplasty. It involves the injection of a specific filler into certain areas of the nose to harmonize its shape, correct asymmetries, and address humps, including those resulting from trauma. It is also possible to treat the nasal bridge to soften the curve or the nasolabial angle to correct the appearance of a drooping tip. These are minimal volume changes, but they can significantly impact the optical perception of the face, allowing for significant nose remodeling in some cases or making subtle and imperceptible modifications in others. A single session is usually sufficient for immediate results, which is a significant advantage compared to the invasiveness of surgical intervention and its lengthy post-operative recovery period.

Botulinum Toxin is a medical treatment first used in the 90s to treat expression wrinkles between the eyebrows. Thanks to the naturality of its results and the wide margin of safety which characterize it, it has quickly gained popularity between both doctors and patients.

The “Studio Medico Associato Bartoletti” (Associated Bartoletti Medical Practice), is a Reference Center known for treatments using botulinum toxing. 

Its use in Aesthetic Medicine is authorized by both the strict U.S. FDA and European regulatory bodies. The current method used is accepted by the scientific community and allows for achieving results with an optimal compromise between duration and naturalness.

From a technical standpoint, botulinum toxin, a neurotoxin produced by the bacterium Clostridium botulinum, is a drug that, when injected into a muscle, has the ability to reduce its contraction. This effect has a fairly constant duration of about 3-4 months, after which the muscle returns to its initial condition, with no residual effects. The therapeutic utility of this toxin is well-documented in conditions characterized by muscle hypercontraction (such as spasticity, strabismus, blepharospasm, or hemifacial spasm) and glandular hypersecretion disorders like hyperhidrosis. In Aesthetic Medicine, botulinum toxin is used to correct facial expression wrinkles (especially those in the upper third of the face: periocular, glabellar, and forehead wrinkles). The muscle-relaxing action of botulinum toxin makes wrinkles less noticeable and prevents their worsening, extending the duration of fillers, whose corrective effect is reduced by the contraction of local muscles that accelerate their degradation.
Over time, accumulated experience has shown us that the most striking result of this therapy is not the disappearance of wrinkles but the constant improvement in the person's facial expression, making them appear serene and rested.

The treatment involves intramuscular injections of a small amount of toxin, using a very fine needle, in the periocular region, forehead, and between the eyebrows. It can be performed 2 to 3 times a year, depending on individual needs.

It's important, on the day of the treatment, to avoid massaging the upper third of the face, bending down, wearing a helmet, or engaging in physical activities.

The effect of the toxin is not immediate but becomes noticeable after 3-4 days and fully defined after about 10 days. After this period, a follow-up visit is usually scheduled to correct any asymmetries.

Thanks to the natural result achievable, the ability to treat imperfections that cannot be corrected in other ways, its safety margin (the widest in Aesthetic Medicine), and the absolute safety of the drug, botulinum toxin has become, especially in recent years, a popular choice in the field of aesthetic medicine.

Botulinum Toxin Treatment For Hyperhidrosis

Sweating is a physiological phenomenon regulated by our autonomic nervous system. When it occurs excessively in certain areas of the body, it's referred to as hyperhidrosis.

Hyperhidrosis can be primary or secondary. Primary hyperhidrosis is the most common form, and its cause is unknown. It can be triggered by emotional factors. Secondary hyperhidrosis is associated with certain medical conditions or organ dysfunctions such as obesity, infections, malignant neoplasms, thyroid disorders, diabetes mellitus, and other endocrine diseases, as well as neurological problems.

Hyperhidrosis most frequently affects the hands (palmar hyperhidrosis) but can also occur in other areas of the body like the armpits or feet. The degree of sweating varies and can be severe, sometimes leading to dripping sweat. In some cases, excessive sweating can also be malodorous, referred to as bromhidrosis.

From a relational perspective, hyperhidrosis can cause embarrassment and have a negative impact on one's psychological well-being, especially in severe cases. The condition typically begins in adolescence and often persists throughout life, affecting social interactions negatively.

Antiperspirants containing aluminum chloride are often used topically to treat hyperhidrosis, but the results are not always satisfactory.

Botulinum toxin, which has been used for this purpose for several years now, can reduce excessive sweating by inhibiting sweat glands. The treatment has no contraindications or side effects. Botulinum toxin is injected subcutaneously using micro-injections spaced approximately 1.5 cm apart on the palms of the hands, soles of the feet, or in the armpits, sometimes with the use of local anesthesia. The effect becomes noticeable within two or three days and lasts for several months before gradually wearing off. On average, the inhibition of sweat glands persists for about 8 months. When the effect diminishes, the treatment can be repeated.

It is a novel methodology primarily employed for "skin tightening," which involves compacting and reshaping the skin. Additionally, it addresses any excess fat that may be present in the treated area, promoting its removal.

The procedure is minimally invasive and is executed using particularly fine optical laser fibers that are inserted directly beneath the skin, without cuts or incisions. The laser fiber heats the soft tissues it encounters, elevating the subcutaneous structures to a high temperature: adipose lobules are partially dissolved, blood vessels coagulate, and fibrous tissues contract and remodel.

Methodology and Protocols

The areas typically treated using this approach encompass those of the face, neck, and body where skin laxity and excess adiposity are present.

One or two sessions per year are envisaged, contingent upon the extent of the area and the tissue's structure. The therapy is minimally invasive and necessitates the use of small quantities of local anesthetic. Following the initial application, a moderate and localized edema may develop, which, upon initial examination, might not manifest the skin tightening or reduction in adipose mass, traits observable once the edema has subsided. The final result ought to be appraised no earlier than three months.

Risks and Contraindications

The treatment is safe, yet individual responses vary, making it impossible to quantify in advance the extent and duration of the outcome, nor the number of sessions required to achieve it.
During and following the procedure, aesthetic and/or functional discomfort of varying durations may arise (redness, swelling, bruising, hematoma, ulceration, abrasion, pain, "popcorn" effect, etc.). Other issues are exceedingly rare (skin burns of varying degrees due to an individual response, potential alterations in sensitivity or temporary nerve damage).

The following individuals should not undergo treatment: those with skin wounds, abrasions, or localized skin conditions in the area that needs to be treated; individuals with spastic paralysis; individuals with thrombosis and/or thrombophlebitis; individuals with serious health conditions; and pregnant women.

The micro-reinjection of autologous adipose tissue is an important technological advancement made possible by the use of new single-use materials whose characteristics have been certified through years of experimentation.
Microlipofilling involves a real auto-transplant of adipose cells by reinjecting fat taken from the patient themselves. Thanks to special, very small cannulas, it's possible to extract and reinject micro-particles of fat with an approximate diameter of 0.5 mm, each containing several hundred cells.

The indications in reparative and reconstructive surgery are:

• Filling of post-traumatic tissue depressions.
• Improvement of skin trophism in scar lesions of any nature, especially burns, radiodermatitis, lesions from scleroderma...
• Aesthetic indications: volumizing effect, especially in the cheek area, nasolabial folds, lips, temples...; filling and reduction of facial wrinkles.

This technique can be used alone or in combination with another cosmetic surgery treatment, especially neck lifts and facelifts.
After a thorough clinical and photographic analysis of the areas to be treated, the precise amount of adipose tissue needed and the regions for injection will be determined. The procedure is usually performed under local anesthesia and can be done either as a day surgery or in an outpatient setting.

The Surgery

In the preoperative phase, the donor areas are identified: the area below the navel, hips, the inner surface of the knees, back...
The entry points of the cannula and the extraction sites are anesthetized with Xylocaine combined with adrenaline, and then the collection of adipose tissue can begin. This collection is done manually with a 10 cc syringe and very gentle suction force; typically, 4 to 6 syringes are collected, and the adipose tissue is isolated. It is then centrifuged to separate the anesthesia fluid from the micro-islands of adipose tissue.
The re-injection can begin after local anesthesia and the creation of access points through which micro-cannulas will be introduced to inject the adipose tissue in all directions and on all planes. The micro-islands of adipose tissue will act as grafts and remain stable over time, improving the quality of the skin.
In the post-operative course, there is no pain, minimal swelling, and usually only a few bruises appear. The result stabilizes after 2 months, and follow-up appointments will be scheduled at 2 and 6 months after the procedure. Micro-reinjection of autologous adipose tissue is a real surgical intervention. It will be necessary to ensure that there are no contraindications for the use of local anesthesia, and the risk of infection appears to be minimal. Over-correction and the injection of an excessive volume of adipose tissue should be avoided. In summary, micro-reinjection of autologous adipose tissue is a new technique made possible by the use of highly efficient cannulas that have the advantage of being single-use.

The Plexr is a medical device used in various fields, including dermatology, aesthetic medicine, gynecology, and dentistry. The instrument ionizes the air between its handpiece and the epidermis, generating a micro-plasma beam. Upon contact with the epidermis, the plasma sublimates the corneocytes, changing them from a solid to a gaseous state, resulting in the renewal of the epidermis. Some of the energy reaches the dermis, stimulating the production of new collagen and promoting the reorganization of existing collagen fibers.

In dermatology and aesthetic medicine, plasma technology allows for the treatment of various skin lesions and aesthetic issues, such as hyperkeratosis, warts, fibromas, xanthelasma, pigmentation spots, angiomas, and scars.

Plexr therapy is generally well-tolerated. Treated areas may experience redness and swelling, which typically resolve within a couple of days, forming small scabs that will naturally fall off in about a week on the face and 15 days on the body. It is essential to apply high-protection sunscreen during the recovery period.

The number of sessions varies depending on the condition or aesthetic concern being treated, typically ranging from one to three sessions spaced 30-45 days apart.

Intense pulsed light (IPL) is a procedure that utilizes a source of pulsed light energy, which, unlike lasers, is non-coherent, non-collimated, and covers a broad spectrum of wavelengths. Due to these attributes, even though it isn't precisely a laser, it finds extensive use in fields ranging from cutaneous vascular lesions to pigment disorders, even in the treatment of hirsutism and hypertrichosis.

The technology upon which it is founded allows the operator to select the appropriate wavelength and parameters tailored to the pigmented lesion being treated. This choice takes into account its depth and location, whether the lesion is composed of melanin or hemoglobin. The light energy is absorbed solely by the target being aimed at, raising its temperature to the point of causing fragmentation and subsequently eliminating the lesion.

By addressing the effects of cutaneous photoaging on the face, neck, décolletage, and back of hands, IPL technology enables rapid, effective, non-invasive photorejuvenation with minimal side effects. Pulsed light penetrates deeply into the structure of the skin's collagen, and thanks to its wide spectrum of wavelengths, it concurrently acts upon a broad range of conditions. This includes pigmented lesions, photoaging, rosacea, and flushing—a flexibility that is unmatched by conventional monochromatic lasers.

Main indications of pulsed light

• Non-ablative cutaneous photorejuvenation to treat photoaging damage, promoting neocollagen deposition, enhancing texture, and reducing dilated follicular ostia.
• Pigmentation disorders: hyperpigmentation, sunspots, etc.
• Vascular lesions: rosacea, flushing, couperose, ruby angiomas, etc.
• Progressively permanent hair removal.

Preparation for the Treatment

Assessment of the individual's phototype, lesion type, and its predominant component (vascular or pigmented), aided by a cutaneous check-up.
In the 4 weeks prior to the treatment and the 3 following weeks, it is imperative to avoid exposure to sunlight and/or UVA lamps. Additionally, for at least two months prior to the treatment, medications or substances that heighten skin sensitivity to light should not be taken.

The Treatment:

Light energy is emitted through a specialized handpiece in a series of electronically controlled pulses, tailored to the patient's skin characteristics and the type of lesion or condition being treated. This approach enables the light to selectively target the desired area, leaving the healthy or normally pigmented skin unchanged and undamaged.

During the initial visit, the doctor performs a test to identify the most suitable wavelength for the specific case. The duration of the treatment varies based on the dimensions of the targeted area and the type of intervention, generally spanning from 30 to 60 minutes. The number of sessions also varies according to the aesthetic concern being addressed—typically 4 to 6 sessions for photorejuvenation, and at least 5 sessions for significant hair density reduction.

The therapy isn't notably painful and therefore doesn't require anesthesia; the application of a cold gel alleviates the sensation of slight tingling, followed by warmth, which is felt briefly and recedes swiftly.

IPL therapy is contraindicated in the following cases: pregnancy, suspicious skin lesions in the regions to be treated, impaired wound healing, the use of vitamin A or isotretinoin, and epilepsy.

Post-Treatment Period and Contraindications:

• Treated hyperchromia may darken in the initial days post-session, lasting approximately 10-15 days.
• Small crusts appear where vessels were treated (8-10 days).
• Minor edema is present (lasting 24 hours) as well as moderate erythema (1-3 days).
• Following the treatment, soothing creams will be applied. Sunscreen is essential before exposing the treated area to sunlight to prevent hyperpigmentation.

Intense Pulsed Light therapy is not advised in the following cases: pregnancy, suspicious skin lesions in the regions to be treated, impaired healing, consumption of vitamin A or isotretinoin, epilepsy.

IPL for Hair Removal

Pulsed light technology can be employed for hair removal. The light emitted from the device is selectively absorbed by the hair shaft, causing carbonization of the hair and its root. Epilation refers to a procedure that isn't permanent but yields long-lasting results; however, maintenance sessions are still required.

The outcome is deemed satisfactory if a hair thinning of 70-80% is achieved; the remaining 20-30% transforms into fine fuzz (vellus hair). Success rates vary depending on the phototype and treated areas. For instance, fair skin with dark hair responds more effectively, while certain regions such as the back of the hands or fingers might not respond at all.
IPL has no effect on white, red, and blonde hairs as its target is melanin; the more pigmented the hair, the more it will be affected. In individuals with even mild endocrine dysfunctions or those undergoing cortisone or hormonal treatments (e.g., contraceptive pills), treated hairs can regrow or new ones may appear. Consequently, while this treatment proves effective for most individuals, there's no prior guarantee of success.

Pre and Post Intense Pulsed Light Treatment Guidelines

The treatment is conducted over several weekly sessions (on average 6-8), followed by one or two maintenance sessions annually.
In the 4-6 weeks leading up to the treatment, waxing and/or tweezing should be avoided, and hair should not be bleached. However, shaving is permissible up to 3 days before the treatment.

In the 2 days prior to the session and in the days following it, the use of a loofah glove, at-home peeling with exfoliating creams, as well as the use of perfumes or alcohol-based tonics must be avoided. Throughout the month leading up to and during the treatment phases, sun exposure and tanning lamps must be avoided, and the application of self-tanning creams should be suspended. Saunas, steam baths, or exposure to any other sources of heat should also be refrained from during the entire treatment period.

After IPL therapy, the skin may become more or less intensely red, and this redness may persist for at least 1-5 days. Pinpoint areas of swelling and edema may also appear at the level of hair follicles. This simply the result of hair follicles being damaged due to the explosion of the hair within the follicle itself. This mechanism is the basis of permanent hair removal and indicates the successful outcome of the therapy.

After the treatment, it's important to use total sun protection. If you are undergoing antibiotic and/or anti-acne therapy or taking other medications, you should inform your doctor during the evaluation visit so that they can establish the correct start date for the treatment.

Contraindications and Side Effects

The treatment with Intense Pulsed Light (IPL) is not recommended in the following cases: pregnancy, suspected skin lesions in the areas that need to be treated, wound healing disorders, intake of vitamin A or isotretinoin, epilepsy.

Intense Pulsed Light (IPL) treatment can have some common side effects, including transient erythema (redness), tenderness, itching, swelling, and transient hyperpigmentation. There is also a possibility of hyperpigmentation or hypopigmentation occurring if the treated areas are not adequately protected from sunlight.

The quality of clinical outcomes from the treatment cannot be evaluated in advance, nor can precise guarantees be provided about the achievable results, as individual conditions are essential in determining the patient's clinical response.

Laser technology is effective in treating and removing certain pigmented lesions, such as freckles or age-related spots. Most of these spots are not typically dangerous and are primarily caused by sun exposure. Their dark color results from a significant buildup of melanin in a specific area of the skin.

"Laser resurfacing with Erbium-YAG" is a surgical method used to improve facial wrinkles and treat skin imperfections such as post-acne scars. The Erbium-YAG laser emits an intense beam of light that instantly vaporizes tissues and the skin, with selective action on the targeted area and minimal impact on surrounding tissues.

Ultrapulse CO2 laser resurfacing is a surgical technique used to improve facial wrinkles and treat skin imperfections such as post-acne scars. The CO2 laser emits an intense beam of light that instantly heats and vaporizes tissues and skin. This action is so precise and selective at the point of laser impact that the surrounding tissue is only mildly affected.