# Facial Anti-Aging Treatments with Soft Peeling and Microneedling Technique
## 2 Materials and Methods  
This multicenter uncontrolled experimental study recruited a population of healthy subjects of both sexes with advanced signs of photo- and chrono-aging (Glogau 3 and 4) [28], phototype 1 to 4 according to Fitzpatrik [29]. The study protocol was performed in accordance with the European Union GCP Standards of Clinical Practice and the ethical principles expressed in the Declaration of Helsinki [30]. A total 56 subjects between the ages of 42 and 73 (average 56.18) were treated: 38 women and 11 men completed the study and were evaluated at 30 and 60 days after treatment; 7 subjects were excluded from the study as they did not perform the check-up in the pre-established timing, and 3 subjects experienced an acute inflammatory pathology that led to the intake of medications, and therefore were not considered suitable for evaluation. These 3 subjects were excluded for follow up because two had a gastrointestinal infection (two sisters) and one had multiple extensive abrasions from falling off a motorcycle. The subjects were enrolled from 1 October 2019 to 31 October 2019. The study started on 1 November 2019 and ended on 28 February 2020. During the period from recruitment (one week before treatment) to the second and last evaluation (60 days after treatment), patients considered suitable for evaluation did not undergo any concomitant therapy, did not manifest any pathologies, and were not subjects of aesthetic treatments on the face. The recruitment of the candidates involved an initial interview to evaluate the criteria for inclusion and exclusion from the study. Inclusion criteria were aging signs classified in classes 3 (wrinkles present even at rest) and 4 (wrinkles everywhere) of the Glogau photo-aging scale, phototype from 1 to 4 according to the Fitzpatrick classification. General exclusion criteria excluded candidates who: were below the age of 18, were pregnant or breastfeeding, had known allergies to one or more of the active ingredients of the peeling, suffered from serious or skin-related autoimmune diseases, were experiencing acute infections, were in a state of immunosuppression, had hemorrhagic diathesis, required oral anticoagulant therapy, had platelet disorders, had a tendency to develop hypertrophic scars, keloids or skin inflammations, or had undergone any aesthetic treatments in the last 3 months (fillers, threads, peels, lasers, etc.). Specific exclusion criteria in the area to be treated were: ongoing acute pathologies (inflammation, burns, continuous solutions, acute dermatological lesions), infections (including herpetic reactivations) and skin tumors, and permanent implants or foreign bodies in the area to be treated. The doctor who recruited the suitable subject, after giving information about the study, then: (i) evaluated the facial features, (ii) filled in the facial wrinkle evaluation form assigning each type a value from 1 to 5 according to the scale of evaluation of [PERSON] [25] (Table 1), (iii) filled in the anamnestic form and the clinical data sheet, (iv) took the photos for the evaluation, and (v) collected the forms previously given to the patient (information sheet, informed consent, personal data management sheet). For microneedling, an automatic device consisting of a handpiece and a cartridge consisting of 6 sterile disposable stainless steel microneedles (maximum length 1.5 mm, 0.35 mm caliber) was used. The handpiece contained an engine that moved the cartridge needles and a needle depth gauge, allowing the user to control the penetration depth of the needle from 0 to 1.5 mm. The control unit allowed the user to adjust the needle stroke frequency from 100 to 150 Hz. Peppermint Peel-Intense (PMP) (Marc Medical srl, Cecina, Italy) was used for the soft peeling. PMP is a soft peel used exclusively for medical use, specifically for subjects with signs of photo- and chrono-aging.