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ARTICLE | facial aesthetics                                |


    Combining therapies
  for optimal outcomes
  in treating the ageing
   face: introducing the
      DUBLiN Facelift
                                                                Patrick Treacy xxxxxx

 [AQ1: please provide an author image]




                                    ABSTRACT
                                    Objective                                         radio frequency lasers, platelet-rich plasmas   repositioning of facial fat.
                                    The DUBLiN Lift: To establish the clinical        (PRP) microneedling, microdermabrasion,
                                    effectiveness of combining five treatments        botulinum toxin injections, and laser           This article examines the possibility of
                                    in the rejuvenation of the ageing face in an      resurfacing. Each treatment has its own         combining five established therapies
                                    effort to increase aesthetic effect, patient      relative benefit, as well as risks2, 3.          in an attempt to address these deficits.
                                    safety, and reduce laser downtime.                                                                The facial rejuvenating therapies include
                                                                                      In recent years, facial rejuvenation has been   microneedling, low-dose UltraLase laser,
                                    The face is the area for which the majority of    revolutionised with the development of          PRP growth factors, Omnilux 633 nm light,
                                    patients seek cosmetic rejuvenation as the        CO2 fractional laser skin resurfacing. This     and neurotoxins. The technique is called
                                    convex lines of a youthful appearance tend        procedure benefits from faster recovery         the DUBLiN facelift as an acronym of the
                                    to flatten and droop as one grows older. The      time, more precise control of ablation          procedures involved: Dermaroller, UltraLase
                                    younger face is characterised by a balance        depth, and reduced risk of post-procedural      laser, Blood growth factors, Light (near-red
Dr Patrick Treacy is                captured in the classic shape of the inverted     problems. However, there have been cases        633 nm), and Neurotoxin.
Medical Director of Ailesbury       triangle. The reversal of this ‘triangle of       of hypopigmentation, hypertrophic scars
Clinics Ltd and Ailesbury Hair      beauty’ as ageing proceeds is considered          and skin mottling, most often seen on           The author compared this method to
Clinics Ltd; Chairman of the        generally less aesthetically appealing1. At       the face, neck and chest when the laser         fractional laser skin resurfacing with regard
Irish Association of Cosmetic       present, a variety of different dermatologic      parameters are used more aggressively4.         to the reduction of photoageing and overall
Doctors; and Irish Regional         and volumising treatments are available for       Furthermore, the technique does not attend      aesthetic effect. Neurotoxin was used in
Representative of the British       facial rejuvenation. These include chemical       to chronological ageing problems such as        both arms of the study.
Association of Cosmetic Doctors     peels, dermal fillers, intense pulsed light and   volume deficits resulting from the loss and




                                    T
email: ptreacy@gmail.com
                                                   he face, and particularly the eyes, is very                barometer of a patient’s chronological and
                                                   important for contact between humans,                      environmental age, and mastering the proper evaluation
                                                   as these areas provide a window to the                     and execution of their aesthetic rejuvenation is
                                                   rest of society with regard to a patient’s                 paramount for all cosmetic doctors.
                                                   level of health, tiredness and emotional                      More recently, patients are seeking effective facial
                                                   status, as well as interest in others4. Many               rejuvenation procedures with less downtime and low
Keywords                            health professionals consider the periorbital area of the                 risks6. This change in attitude has been prompted by a
fractionalised laser resurfacing,   face as the most important area of rejuvenation as                        realisation of both doctors and patients that the much
platelet-rich plasma,
microneedling, Omnilux 633 nm       eye‑to-eye communication occurs in approximately                          hyped non-ablative methods were often subject to
light, neurotoxin                   80% of all human interactions6. Both areas present a                      extravagant claims in terms of efficacy2–4. For many


18      September 2012 | prime-journal.com
ARTICLE | facial aesthetics             |

                    years, CO2 laser resurfacing was considered the ‘gold              regeneration. The author used microneedling with low
                    standard’ in treating photodamaged facial skin6–11.                energy laser, and platelet rich plasma (PRP) to address
                    Cutaneous laser resurfacing with a fractional (CO2) laser          these issues.
                    involves the vapourisation of the entire epidermis, as                It is recognised that the most important rejuvenation
                    well as a variable thickness of the dermis. Many                   process for photoaged skin is the collagen remodelling
                    physicians stated that the ultrapulsed CO2 laser was the           process, and dermal fibroblasts are known to have the
                    most effective method of laser resurfacing12–13.                   most important function29. Rejuvenation of skin injury
                    Photodamaged skin is the result of years of exposure to            caused by UV light is a complex process that organically
                    harmful ultraviolet light and is clinically demonstrated as        involves cytokines interacting with a number of growth
                    a gradual deterioration of cutaneous structure and                 factors and control proteins28. The procedures evaluated
                    function. This results in the epidermis and upper                  included PRP, microneedling, and Omnilux 633 nm
                    papillary dermis having a roughened surface texture, as            near‑red light, with neurotoxins as an adjunct to low-level
                    well as laxity, telangiectasias, wrinkles and variable             fractional laser skin resurfacing. Cells in the epidermis
                    degrees of skin pigmentation14–15.                                 and dermis can be targeted by microneedling and
                       Although ultrapulsed CO2 resurfacing lasers were                near‑red light, resulting in fibroblast stimulation. Omnilux
                    considered the best treatment option, they had many                Revive™ (633 nm) therapy stimulates fibroblast activity,
                    post-procedural problems16, 17, including prolonged                leading to faster and more efficient collagen synthesis
                    post‑operative recovery, pigmentary changes, and a high            and extracellular matrix (ECM) proteins. It also increases
                    incidence of acne flares and herpes simplex virus (HSV)            cell vitality by increasing the production of cellular
                    infection18, 19. Many patients complained of oedema,               adenosine triphosphate (ATP) and stimulates the
                    burning, and erythema that sometimes lasted for many               contractile phase of the remodelling process producing
                    months20, 21. The implied risks and long downtime made             better lineated collagen30–33. Collagen induction therapy is
                    many patients reluctant to accept this method of                   an aesthetic medical procedure that involves repeatedly
                    treatment22, 23. More recently, fractional resurfacing lasers      puncturing the skin with tiny, sterile needles. Typically,
                    have addressed many of these earlier problems with                 this is done with a specialised instrument called a
                    benefits of faster recovery time, more precise control of          microneedling device.
                    ablation depth, and reduced risk of post procedural                   Controlled studies have suggested that the application
                    problems8. These lasers are extremely versatile, in that           of autogenous PRP can enhance wound healing in both
                    they can be used for the treatment of facial rhytides, acne        animals and humans29. Five major growth factors such as
                    scars, surgical scars, melasma and photodamaged skin,              transforming growth factor (TGF), insulin-like growth
                    and many have entered the market at the same time24.               factor (IGF), platelet-derived growth factor (PDGF),
                       With the advent of fractional laser skin resurfacing, the       epidermal growth factor (EGF), and vascular endothelial
                    number of completely ablative resurfacing cases has                growth factor (VEGF) are known to be related to the
                    declined for most practitioners. However, care should be           wound-healing processes28. These growth factors are
                    taken when treating sensitive areas such as the eyelids,           released from platelets and the production of collagen
                    upper neck, and especially the lower neck and chest, by            and fibroblasts is stimulated by IGF, EGF, Interleukin-1
                    using lower energy and density, and scarring has been              (IL‑1) and tumour necrosis factor (TNF)-α34, 35. In vivo
                    noted in these areas25. Scarring after fractional CO2 laser        studies report TGF-β to be the most stimulative growth
                    therapy is considered mainly a result of overly-aggressive         factor. PRP may be used for dermal augmentation and
                    treatments and a lack of technical finesse. Physicians             Sclafani observed aesthetic improvements of the
                    have also recorded post‑operative infections leading to            nasolabial fold in less than 2 weeks, and the results lasted
                    scarring, although it is generally felt that these may be          for up to 3 months28, 29.
                    prevented          by   careful     history-taking,     vigilant
                    post‑operative monitoring, and/or the use of prophylactic          Research design and methods
                    antibiotics26, 27.                                                 This multi-centre randomised study included 44 patients
                       With regard to facial rejuvenation, CO2 laser light at a        of skin types 1 and 2 aged between 39 and 68 years,
                    10 600 nm wavelength results in vaporisation with                  presenting with photoageing of the skin, 25 of whom
                    thermal denaturation of type I collagen, collagen                  were women and 4 were men [AQ2: what about the
                    shrinkage and later, collagen deposition. However, in              remaining 15?]. The subjects presented with the typical
                    very deep rhytides, acne scarring and severe elastotic             hallmarks of chronological and photoageing, such as
                    changes from sun damage, fractional CO2 therapy                    expression lines, rhytides, wrinkles, eyelid skin laxity,
                    requires multiple treatments to achieve the same results           dermatochalasis, lowered brows, lateral hooding, and
                    as the older lasers28. A number of studies have evaluated          prominent fat pads. All patients were subjected to a
                    using different laser combinations in the same session in          programme of skin tightening and neocollogenesis by
                    order to improve collagen deposition, with a wider zone            one of two methods: conventional fractional laser skin
                    of fibroplasia6–9, 28. Owing to the inherent risks of fractional    resurfacing (Group 1) or the DUBLiN Lift (Group 2). The
                    laser skin resurfacing and its inability to deal with some         mean patient age in Group 1 was 49 years (range 37–
                    evidence of chronological ageing, it was advocated to              71 years) and in Group 2 was 55 years (range 41–76 years).
                    here establish the clinical effectiveness of using a                  Fifteen patients underwent Lumenis ActiveFx™ with
                    multi‑procedural approach to volumisation and collagen             settings as (energy) 125 mJ and (rate) 19 w CPG 3/5/4.


20   September 2012 | prime-journal.com
| facial aesthetics | ARTICLE

Twenty-nine patients received the DUBLiN Lift, a three-                                        also given to patients.
phase combination of established treatments with                                                  The ActiveFX is a protocol of settings applied in
microneedling, platelet growth hormones, near-red                                              conjunction with an improved computer pattern
633 nm light, and low-energy UltraLase fractional CO2                                          generator to the ultrapulsed CO2 laser (UltraPulse
laser skin tightening. All patients received Dysport® in                                       Encore, Lumenis Ltd). Technical differences between
three areas 1 week prior to the other treatments as an                                         this non-sequential fractional device and the older
adjunct to the laser resurfacing.                                                              ultrapulsed CO2 include tissue bridges left between spots,
   The DUBLiN Lift was introduced as three phases over a                                       resulting in faster healing time, and less thermal damage
period of 3 weeks. Phase 1 included Dysport® at dilution                                       to the basal cell membrane. The device has a smaller
3.5 : 1 to three areas — glabellar, frontalis and periorbital.                                 spot size (1300 mm rather than 2500 mm), resulting in
Phase 2 introduced intense fibroblast stimulation and                                          less post-procedure erythema.
modification through microneedling, PRP growth factor                                             The computer pattern generator lays down a random
induction, and near-red phototherapy. Phase 3                                                  series of spots rather than a sequential sequence
administered the low–level (CO2) UltraPulse laser at                                           resulting in less overheating of the treated tissue. This
100 mJ 14 w CPG 3/5/2, and adjunct near-red 633 nm                                             application is termed ‘Cool Scan’, and was used with
phototherapy. The study evaluated post-procedural                                              every patient in the study.
aesthetic results at 2 weeks, 4 weeks and 12 weeks. The                                           The Traylife Kit (PRP) (Promoitalia Wellness Research)
length of downtime, patient discomfort and adverse                                             provides blood plasma enriched with a concentrated
side‑effects were noted for each phase.                                                        source of autologous platelets that releases a number of
   Clinical assessment of patients in each group was                                           growth factors and other cytokines that stimulate the
made at 2 weeks, 1 month and 3 months post‑operatively                                         healing of soft tissue.
in the presence of two aesthetic staff. The degree of                                             Omnilux Revive™ (633 nm) (Photo Therapeutics, Inc.,
improvement in photoageing was based on the degree of                                          UK) stimulates fibroblast activity, leading to faster and
re-epithelialisation rate, reduction of rhytides, reduction                                    more efficient collagen synthesis and extracellular
of tactile roughness, and loss of hyperpigmentation and                                        matrix proteins.
telangiectasias. The prolongation and severity of                                                 Dermaroller™ Collagen Induction Therapy (CIT)
erythema as well as the presence of negative side-effects                                      (AesthetiCare®, UK) is a minimally-invasive cosmetic
(e.g. herpes) were also recorded.                                                              procedure that involves the use of a micro-needling
   The efficacy of treatment was evaluated using a                                             device.
variation of the five-point scale (Table 1) originally                                            Scoring charts are presented in Tables 1–4.
suggested by Dover et al36. Investigators and patients
evaluated efficacy using palpability assessments and
change from baseline score at 0, 6 and 12 weeks. A total
global score was recorded in each patient based on the
                                                                     Table 1 Patient treatment (positive) scoring chart
addition of points obtained from six photodamage                 Parameter 	    0	          1	         2	                    3	             4
variables. The degree of perceived improvement in
                                                                 Global score	  Area of 	   Area of 	  Area of	              Area of	       Area of
overall aesthetic effect reflecting chronological age was        	              roughness 	 roughness	 roughness	            roughness	     roughness
assessed separately by patients and physicians using the         	              x 0	        x 1	       x2	                   x3	            x4
Wrinkle Severity Rating Scale (WSRS) and the Global              Fine lines 	   None	       Rare 	     Several 	             Moderate	      Many
Aesthetic Improvement Scale (GAIS). The WSRS is                  Pigmentary	    None 	      Patchy	    Moderate	             Heavy	         Marked
recognised as a valid and reliable instrument for                problems	
quantitative assessment of facial skin folds, with good          Touch 	        Even 	      Rare 	     Mild 	                Moderate 	     Severe
inter- and intra-observer consistency5. Wrinkle severity is      problems	
measured using a wrinkle severity rating scale with 1            Facial veins 	 None 	      Rare 	     Several 	             Moderate 	     Severe
being absent and 5 being extreme. By allowing objective          Coarse lines 	 None	       Rare	      Several	              Moderate	      Many
grading of data, these proved useful clinical tools for          Complexion	    Pink 	      Pale	      Grey 	                Slightly	      Distinct
assessing the effectiveness of facial volumisation with          				                                                        yellow-grey	   yellow-grey
PRP and microneedling–633.

Interventions                                                        Table 2 Patient treatment (negative) scoring chart
The following treatment protocols were used for this
study: Lumenis ActiveFX CO2 laser, Traylife PRP, Omnilux         Parameter	           0	          1	           2	            3	         4
633 nm red light, Dermaroller®, and Dysport®. All                Erythema severity 	 None 	       Rare 	       Several 	     Moderate 	 Severe
participants received selective regional anaesthesia             Infective outbreak 	 None 	      Rare 	       Several 	     Moderate 	 Severe
blocks with 2% lignocaine plus adrenaline, a topical             (herpes/acne)	
combination anaesthetic of 23% lignocaine, and                   Crusting 	           None 	      Rare 	       Several 	     Moderate 	 Severe
prophylactic Valtrex 500 mg twice daily for 8  days.             Pain of	             None 	      Mild 	       Tolerable 	   Moderate 	 Severe
Valium 5–10 mg stat was given as a pre-medication to             procedure 	
some patients. A post-procedural advice sheet and                Improvement 	        None 	      Minimal 	    Fair 	        Good 	         Excellent
Nurofen or codeine with paracetamol — as required — was


                                                                                               prime-journal.com | September 2012                         21
ARTICLE | facial aesthetics                     |

                                                                                               into the buccal cavity with the needle directed
     Table 3 WSRS Patient scoring chart                                                        towards the infraorbital foramen
                                                                                            ■■ Mental nerve block. 1 cc of 1–2% Lidocaine injected into
5	 Extreme 	           Extremely deep and long folds, detrimental to facial appearance
                                                                                               the mental foramen just above the bone level.
4	 Severe 	            Very long and deep folds; prominent facial features; less than
		                     2 mm visible
3	 Moderate	           Moderately deep folds; clear facial feature visible at normal
                                                                                            Group 2: DUBLiN lift
		                     appearance, but not when stretched
2	 Mild	               Shallow but visible fold with a slight indentation;                  Phase 1
		                     minor facial feature                                                 Dysport® treatment to three areas: glabellar, frontalis and
1	 Absent 	            No visible nasolabial fold; continuous skin, injectable              periorbital.
		                     implant alone
                                                                                            Phase 2 (Week 2)

                                                                                            Microneedling
     Table 4 Global Aesthetic Improvement Scale (GAIS)                                      Topical anaesthesia: benzocaine 20%, Lidocaine Base 6%,
                                                                                            and tetracaine 4%.
Degree	                        Description
                                                                                               Each patient received Chiroxy cream post-procedure
1 Exceptional improvement	     Excellent corrective result at week 12. No further           to reduce erythema and inflammation. Tepid water was
	                              treatment required
                                                                                            used to cleanse the face for the following 48 hours, and
2 Very improved patient	       Marked improvement of appearance, but not
	                              completely optimal                                           dried gently. It was recommended that make-up was not
                                                                                            applied for 12 hours after the procedure. After the
3 Improved patient	            Improvement of the appearance, better compared with
	                              the initial condition. Touch-up is advised                   procedure, a broad-spectrum UVA/UVB sunscreen with
4 Unaltered patient	           The appearance substantially remains the same                SPF 50 was recommended for use.
	                              compared with the original condition
5 Worsened patient	            The appearance has worsened compared with the                PRP preparation
	                              original condition                                           Draw blood (4 ml for each tube), then centrifuge tubes at
                                                                                            2000 rpm for 5 minutes. Take the syringe, insert the
                                                                                            needle and withdraw 0.5 ml DNA Activator (10% calcium
                             Group 1: fractional laser skin                                 chloride). Withdraw platelets and mix with the DNA
                             resurfacing                                                    Activator.
                                                                                              Multiple injections (0.05–0.1 ml for a single injection)
                             Phase 1                                                        were applied to the intra/sub dermis using the
                             Dysport® treatment to three areas: glabellar, frontalis and    ‘multi‑pricking’ or retrograde linear techniques
                             periorbital.
                                                                                            Omnilux 633 nm LED
                             Phase 2 (Week 2)                                               This was applied for 20 minutes per session (126 J/cm2).
                             Lumenis ActiveFX with settings (energy) 125 mJ (rate)
                             1 9w CPG 3/9/4                                                 Phase 3 (Week 3)
                                In the pre-laser procedure, the author typically
                             prescribes Valium (Diazepam 5–10 mg orally) for anxiety,       Low-level Ultralase
                             administered 45 minutes before the procedure.                  Lumenis ActiveFX with settings (energy) 100 mJ rRate)
                                For infection prophylaxis, Famvir (famciclovir) 750 mg      14 w CPG 3/5/2.
                             daily or Valtrex (valcyclovir) 500 mg twice per day for 7
                             days, was prescribed for every patient starting 3 days         Omnilux 633 nm LED
                             before procedure. If the patient had a strong history of       This was applied for 20 minutes per session (126 J/cm2).
                             acne, By-Mycin (doxycycline 100 mg daily) or Keflex
                             (cephalexin 500 mg twice per day) was prescribed for           Histology
                             7  days, beginning on the day of surgery. Diflucan             Skin biopsies were obtained from five of the patients
                             (fluconazole 150 mg) was not routinely prescribed in any       intra-operatively, before Phase 2 of the treatment, and at
                             patient.                                                       3  months post-operatively, and were performed to
                                The patients were treated under topical and regional        determine the amount of epidermal damage, subsequent
                             anaesthesia. Topical anaesthesia comprised benzocaine          inflammation, and new collagen synthesis. The extent of
                             20%, Lidocaine Base 6%, and tetracaine 4%). Regional           neocollogenesis was compared with data on file for
                             anaesthesia was three-fold:                                    patients who had skin biopsies for laser resurfacing and
                             ■■ Supraorbital and supratrochlear nerve block. The            neurotoxin alone in 2007. Each 1 cm by 1 cm piece of skin
                                 supraorbital foramen was located and 1 cc of 1–2%          was fixed with 10% formalin solution, neutral buffered.
                                 Lidocaine injected just above the bone laterally, with     After treatment with polyester wax, the skin samples
                                 the needle directed medially, parallel to the brow and     were sliced into 6 μm thicknesses. The sliced sections
                                 toward the nose                                            were treated with haematoxylin and eosin statin (H&E)
                             ■■ Infraorbital nerve block. 1 cc of 1–2% Lidocaine injected   and Masson’s trichrome staining solutions. Through


22   September 2012 | prime-journal.com
| facial aesthetics | ARTICLE

tissue evaluations, the thickness of the dermal layer and       the ‘softer’ settings.
presence of collagen fibres were observed. The thickness           According to investigator-based WSRS and GAIS
of the dermal layer was calculated by measuring five            assessments at 3 months after baseline, the DUBLiN lift
different sites from each section, and the mean value of        was superior in 62% and 55.2% of patients respectively,
the thickness of the dermal layer for each group was            while fractional laser skin resurfacing was superior in
used for the comparison.                                        33.3% and 34.4% of patients. (P < 0.0004). An ‘optimal’
                                                                cosmetic result was achieved in a higher percentage of
Results                                                         patients in Group 2 compared with Group 1.
Over 3 months, 29 subjects (Group 2) were selected to              Investigator-based and patient-based ratings using
compare the effect of low energy fractional laser skin          both the WSRS and GAIS indicated that the DUBLiN lift
resurfacing with adjunctive treatments to conventional          was more effective than conventional ablative laser
ablative laser resurfacing. These patients received a           resurfacing in creating cosmetic correction to the lower
three‑phase combination of established treatments with          face. This resulted from the volumising effect of adding
neurotoxin, microneedling, platelet growth hormones,            PRP to the larger folds in this area. At 3 months
near-red 633 nm light, and low-energy Ultralase fractional      post‑treatment, a higher proportion of patients showed a
CO2 laser skin tightening over a 3-week period. Phase 1         greater than or equal to 1-grade improvement in WSRS
included the administration of Dysport® neurotoxin to           with DUBLiN Lift compared with fractional laser skin
the upper face. Phase 2 introduced fibroblast stimulation       resurfacing. The author suspects the PRP may have a
from microneedling and PRP growth factor induction              longer aesthetic effect when used in association with
with near-red phototherapy, and Phase 3 included                microneedling and 633 nm light than previously noted27, 29.
low‑level (CO2) UltraPulse laser with adjunct near-red          However, the results were almost reversed whenever
633 nm phototherapy. Results were compared to the               periorbital rejuvenation was assessed alone, with almost
reamining 15 patients (Group 1) who received fractional         every patient (93%) favouring conventional fractional
laser skin resurfacing (125 mJ; 19 w CPG 3/5/4), and whose      laser skin resurfacing. Investigator-based GAIS
data was already on file. Patients in both groups were          assessment of this region at 3 months after baseline
administered Dysport® neurotoxin 1 week prior to                indicated that fractional resurfacing was superior in 93%
treatment to complement and preserve the overall                of patients, while the DUBLiN Lift was superior in 6.8% of
aesthetic effect. The study evaluated post-procedural           patients (P = 0.0025).
aesthetic results at baseline, 6 weeks and 12 weeks by             Re-epithelialisation occurred in all laser-treated areas
means of a scoring system based on Dover’s photoageing          of both groups by day 7, and this appeared to be clinically
scale, as well as using the WSRS and GAIS.                      similar for both procedures. Mean duration of erythema
   Histological results were obtained from both groups          was 6.9 days after resurfacing (range 4–10 days) in Group 1
showing the depth of laser penetration and consequential        and 4.2 days in Group 2 (range 3–7 days). This appeared to
formation of new collagen. All skin biopsies showed             be in keeping with previous studies37. All patients
thermal coagulation of epidermis and superficial dermis         reported having no ‘crusting’ effect remaining on their
in a depth ranging from 85 to 113 µ. The zone of residual       face after 6 days. Residual erythema remained in one
thermal (coagulative) damage was less in the Group 2            patient in Group 1 for a period of 14 days, but this was
patients, in whom less laser energy was used. The best          minimal. Post-operative erythema was most intense in
neocollogenesis results — at 3 months — were evident in         the areas treated by with the ActiveFX at an energy level
Group 1 where one patient NMG [AQ3: what does this              above 125 mJ.
signify?] (Image E) had evidence of effect at 700 µ. This          The mean pain sensation [AQ5: how was this assessed?]
was reflected in the patient’s skin, which continued to         felt during the DUBLiN lift was 2.2 compared to
improve over the period. Owing to the variance in energy        conventional fractional resurfacing treatment, which
of the CO2 laser in Group 1 and Group 2, it was expected        was 3.4. The author noted that most patients did not feel
that the documented depth of histological ablation and          much pain at all with the ActiveFX until the energy level
thermal effects would vary between them. Responses of           crosses 100 mJ. No patient experienced any adverse
aesthetic effect were evaluated at 6 and 12 weeks after         reaction to laser skin resurfacing, except one case of
baseline.                                                       herpetic infection in each group. (Group 1 6.6%; Group 2
   The two methods appeared to produce different                3.4%). Both treatments were well tolerated. Clumping of
clinical improvement of lesions and rhytides. The global        platelets occurred in 10% of patients treated with PRP
score [AQ4: are you referring to the GAIS? are the total for    and the author felt that this was a result of the
tables 1-4?] for photoageing for the DUBLiN lift improved       concentration of solution used. In fact, anecdotal
from 13.2 to 10.2 at day 30. This compared to 13.8 at           evidence suggests that most cosmetic physicians are
baseline and 9.6 at day 30 for conventional FLRS alone.         using PPP (platelet-poor plasma) in most areas of the face,
The score for fine lines was the most significant reduction,    rather than the higher concentrations used by
dropping from 3.6 at baseline to 1.4 at day 30. The score for   orthopaedic surgeons.
reduction of coarse wrinkles (3.2 at baseline to 2.2 at
6  weeks) was more difficult to interpret in this               Conclusions
heterogeneous age grouping, with older patients                 Facial ageing is a consequence of many interacting
requiring the conventional ActiveFX settings rather than        intrinsic and extrinsic factors. The most important of


                                                                                              prime-journal.com | September 2012   23
ARTICLE | facial aesthetics                                        |

                                       these include sun exposure or photoageing, and the
                                       intrinsic changes associated with chronological ageing.
                                       Over time, the muscles of facial expression produce
                                       dynamic and static facial lines and folds. Laser
                                       resurfacing has long been recognised as a skin
                                       rejuvenation procedure for tissue that has lost its
                                       elasticity and become less able to resist stretching.
                                       However, despite the advent of newer fractionalised
                                       lasers, it has adverse risks and does not adequately
                                       address the problems associated with chronological
                                       ageing as gravity exerts its toll on the facial structures. It is
                                       important to apply supplementary methods, such as
                                       dermal fillers or PRP, to address nasolabial or marionette
                                       lines and volume deficits resulting from the loss and
                                       repositioning of facial fat.

                                       Declaration of interest [AQ6: please state]	




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photoaging with a very superficial Er:YAG laser in combination         1998; 24(3): 315–20                                                  Omnilux Revive facial treatment in skin rejuvenation. Lasers
with a broadband light source. J Drugs Dermatol 2007; 6(11):           18.	 Alster T, Hirsch R. Single-pass CO2 laser skin resurfacing of   Med Sci 2005; 20(1): 6–10
1114–8                                                                 light and dark skin: Extended experience with 52 patients. J         31.	 Russell BA, Kellett N, Reilly LR. A study to determine the
5.	 Rohrich RJ, Pessa JE. The fat compartments of the face:            Cosmet Laser Ther 2003; 5(1): 39–42                                  efficacy of combination LED light therapy (633 nm and 830
anatomy and clinical implications for cosmetic surgery. Plast          19.	 Alster TS. Cutaneous resurfacing with CO2 and erbium: YAG       nm) in facial skin rejuvenation. J Cosmet Laser Ther 2005;
Reconstr Surg 2007; 119(7): 2219–27                                    lasers: preoperative, intraoperative, and postoperative              7(3–4): 196–200
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rejuvenation: a review. Lasers Surg Med 2003; 32(2): 120–8             20.	Alster TS, Lupton JR. Treatment of complications of laser        array for renewal of photoaging: Clinical Surface Profilometric
7.	 Williams EF 3rd, Dahiya R. Review of nonablative laser             skin resurfacing. Arch Facial Plast Surg 2000; 2(4): 279–84          Results. Journal of the Korean Society for Laser Medicine and
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24     September 2012 | prime-journal.com
| facial aesthetics | ARTICLE

    Further reading
Matteo Tretti Clementoni a; Patrizia Gilardino a; Gabriele F. Muti a;        preauricular and postauricular skin after high-energy, short-pulse
Daniela Beretta b; Rossana Schianch. Non sequential fractional               carbon dioxide laser. Arch Dermatol. 1996;132:425-428.
ultrapulsed C02 resurfacing of photoaged skin. Journal of Cosmetic and       Rubach BW, Schoenrock LD. Histological and clinical evaluation of facial
Laser Therapy, Volume 9, Issue 4 2007 , pages 218 – 225                      resurfacing using a carbon dioxide laser with the computer pattern
Lask G, Keller G, Lowe N, Gormley D. Laser skin resurfacing with the         generator. Arch Otolaryngol Head Neck Surg. 1997;123:929-934.
SilkTouch flashscanner for facial rhytides. Dermatol Surg 1995;21:1021–      Fitzpatrick RE, Tope WD, Goldman MP, Satur NM. Pulsed carbon dioxide
1024.                                                                        laser, trichloroacetic acid, baker-gordon phenol, and dermabrasion: a
Bernstein L, Kauvar A, Grossman M, Geronemus R. The short and long           comparative clinical and histologic study of cutaneous resurfacing in a
term side effects of carbon dioxide laser resurfacing. Dermatol Surg         porcine model. Arch Dermatol. 1996;132:469-471.
1997;23:519–525.                                                             P Bonan, P Campolmi, G Cannarozzo, N Bruscino, A Bassi, S Betti, T Lotti.
Alster TS. Side effects and complications of laser surgery. In: Alster TS.   1468-3083. 2011. 04034. Journal of the European Academy of
Manual of Cutaneous Laser Techniques. Philadelphia: Lippinco, 2000           Dermatology and Venereology Eyelid skin tightening: a novel ‘Niche’ for
Burkhardt BR, Maw R. Are more passes better? safety versus efficacy          fractional CO2 rejuvenation
with the pulsed CO2 laser. Plast Reconstr Surg. 1997;99:1531-1534.           G.F. Pierce, D. Brown, T.A. Mustoe Quantitative analysis of inflammatory
Treacy PJ. Article on fractionalised lasers Jan 2008 Health & Living         cell influx, procollagen type I synthesis, and collagen cross-linking in
Magazine www.hlaw.ie                                                         incisional wounds: influence of PDGF-BB and TGF-beta 1 therapy J Lab
                                                                             Clin Med, 117 (1991), pp. 373–382
David Goldberg, MD: Reduced Down-time Associated with Novel
Fractional UltraPulse CO2 Treatment (Active FX) as Compared to               Mathew M. Avram, MD, JD,1,* Whitney D. Tope, MPhil, MD,2 Thomas Yu,
Traditional Resurfacing P3115 -65th Annual American Academy of               MD,3 Edward Szachowicz, MD, PhD,4 and J. Stuart Nelson, MD, PhD5
Dermatology Meeting                                                          Hypertrophic Scarring of the Neck Following Ablative Fractional Carbon
                                                                             Dioxide Laser Resurfacing
Smith KJ, Skelton HG, Graham JS, et al. Depth of morphologic skin
damage and viability after one, two and three passes of a high-energy,       Baez F and Reilly LR. The use of light-emitting diode therapy in the
short-pulse CO2 laser in pig skin. J Am Acad Dermatol. 1997;27:204-210.      treatment of photoaged skin. Journal of Cosmetic Dermatology. 2007; 6:
                                                                             189-194
Fitzpatrick R, Ruiz-Esparaza J, Goldman M. The depth of thermal
necrosis using the CO2 laser. J Dermatol Surg Oncol. 1991;17:340-344.        Lee SY, et al. A prospective, randomized, placebo-controlled, double-
                                                                             blinded, and split-face clinical study on LED phototherapy for skin
Tina S. Alster MD & Christopher A. Nanni MD Famciclovir Prophylaxis of       rejuvenation: Clinical, profilometric, histologic, ultrastructural, and
Herpes Simplex Virus Reactivation After Laser Skin Resurfacing               biochemical evaluations and comparison of three different treatment
Dermatol Surg Volume 25 Issue 3 Page 242-246, March 1999                     settings. Journal of Photochemistry and Photobiology B. 2007; 88: 51-67
Mario A. Trelles; Inés Allones Red light-emitting diode (LED) therapy        Majid I (January 2009). Microneedling therapy in athrophic facial scars:
accelerates wound healing post-blepharoplasty and periocular laser           an objective assessment. J Cutan Aesthet Surg 2 (1): 26–30.
ablative resurfacing Journal of Cosmetic and Laser Therapy: formerly
Journal of Cutaneous Laser Therapy, Volume 8, Issue 1, 2006, Pages 39        Doddaballapur S (July 2009). Microneedling with dermaroller J Cutan
– 42                                                                         Aesthet Surg 2 (2): 110
Kauvar ANB, Waldorf HA, Geronemus R. A histopathologic comparison            Day DJ, Littler CM, Swift RW, Gottlieb S. The wrinkle severity rating scale:
of char-free lasers. Dermatol Surg. 1996;22:343-348.                         a validation study Am J Clin Dermatol. 2004;5(1):49-52. Department of
                                                                             Dermatology, New York University Medical Center, New York, New York
Cotton J, Hood A, Gonin R, Beeson W, Hanke C. Histologic evaluation of       10021, USA




                                                                                            prime-journal.com | September 2012                        25

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The DUBLiN Lift

  • 1. ARTICLE | facial aesthetics | Combining therapies for optimal outcomes in treating the ageing face: introducing the DUBLiN Facelift Patrick Treacy xxxxxx [AQ1: please provide an author image] ABSTRACT Objective radio frequency lasers, platelet-rich plasmas repositioning of facial fat. The DUBLiN Lift: To establish the clinical (PRP) microneedling, microdermabrasion, effectiveness of combining five treatments botulinum toxin injections, and laser This article examines the possibility of in the rejuvenation of the ageing face in an resurfacing. Each treatment has its own combining five established therapies effort to increase aesthetic effect, patient relative benefit, as well as risks2, 3. in an attempt to address these deficits. safety, and reduce laser downtime. The facial rejuvenating therapies include In recent years, facial rejuvenation has been microneedling, low-dose UltraLase laser, The face is the area for which the majority of revolutionised with the development of PRP growth factors, Omnilux 633 nm light, patients seek cosmetic rejuvenation as the CO2 fractional laser skin resurfacing. This and neurotoxins. The technique is called convex lines of a youthful appearance tend procedure benefits from faster recovery the DUBLiN facelift as an acronym of the to flatten and droop as one grows older. The time, more precise control of ablation procedures involved: Dermaroller, UltraLase younger face is characterised by a balance depth, and reduced risk of post-procedural laser, Blood growth factors, Light (near-red Dr Patrick Treacy is captured in the classic shape of the inverted problems. However, there have been cases 633 nm), and Neurotoxin. Medical Director of Ailesbury triangle. The reversal of this ‘triangle of of hypopigmentation, hypertrophic scars Clinics Ltd and Ailesbury Hair beauty’ as ageing proceeds is considered and skin mottling, most often seen on The author compared this method to Clinics Ltd; Chairman of the generally less aesthetically appealing1. At the face, neck and chest when the laser fractional laser skin resurfacing with regard Irish Association of Cosmetic present, a variety of different dermatologic parameters are used more aggressively4. to the reduction of photoageing and overall Doctors; and Irish Regional and volumising treatments are available for Furthermore, the technique does not attend aesthetic effect. Neurotoxin was used in Representative of the British facial rejuvenation. These include chemical to chronological ageing problems such as both arms of the study. Association of Cosmetic Doctors peels, dermal fillers, intense pulsed light and volume deficits resulting from the loss and T email: ptreacy@gmail.com he face, and particularly the eyes, is very barometer of a patient’s chronological and important for contact between humans, environmental age, and mastering the proper evaluation as these areas provide a window to the and execution of their aesthetic rejuvenation is rest of society with regard to a patient’s paramount for all cosmetic doctors. level of health, tiredness and emotional More recently, patients are seeking effective facial status, as well as interest in others4. Many rejuvenation procedures with less downtime and low Keywords health professionals consider the periorbital area of the risks6. This change in attitude has been prompted by a fractionalised laser resurfacing, face as the most important area of rejuvenation as realisation of both doctors and patients that the much platelet-rich plasma, microneedling, Omnilux 633 nm eye‑to-eye communication occurs in approximately hyped non-ablative methods were often subject to light, neurotoxin 80% of all human interactions6. Both areas present a extravagant claims in terms of efficacy2–4. For many 18 September 2012 | prime-journal.com
  • 2. ARTICLE | facial aesthetics | years, CO2 laser resurfacing was considered the ‘gold regeneration. The author used microneedling with low standard’ in treating photodamaged facial skin6–11. energy laser, and platelet rich plasma (PRP) to address Cutaneous laser resurfacing with a fractional (CO2) laser these issues. involves the vapourisation of the entire epidermis, as It is recognised that the most important rejuvenation well as a variable thickness of the dermis. Many process for photoaged skin is the collagen remodelling physicians stated that the ultrapulsed CO2 laser was the process, and dermal fibroblasts are known to have the most effective method of laser resurfacing12–13. most important function29. Rejuvenation of skin injury Photodamaged skin is the result of years of exposure to caused by UV light is a complex process that organically harmful ultraviolet light and is clinically demonstrated as involves cytokines interacting with a number of growth a gradual deterioration of cutaneous structure and factors and control proteins28. The procedures evaluated function. This results in the epidermis and upper included PRP, microneedling, and Omnilux 633 nm papillary dermis having a roughened surface texture, as near‑red light, with neurotoxins as an adjunct to low-level well as laxity, telangiectasias, wrinkles and variable fractional laser skin resurfacing. Cells in the epidermis degrees of skin pigmentation14–15. and dermis can be targeted by microneedling and Although ultrapulsed CO2 resurfacing lasers were near‑red light, resulting in fibroblast stimulation. Omnilux considered the best treatment option, they had many Revive™ (633 nm) therapy stimulates fibroblast activity, post-procedural problems16, 17, including prolonged leading to faster and more efficient collagen synthesis post‑operative recovery, pigmentary changes, and a high and extracellular matrix (ECM) proteins. It also increases incidence of acne flares and herpes simplex virus (HSV) cell vitality by increasing the production of cellular infection18, 19. Many patients complained of oedema, adenosine triphosphate (ATP) and stimulates the burning, and erythema that sometimes lasted for many contractile phase of the remodelling process producing months20, 21. The implied risks and long downtime made better lineated collagen30–33. Collagen induction therapy is many patients reluctant to accept this method of an aesthetic medical procedure that involves repeatedly treatment22, 23. More recently, fractional resurfacing lasers puncturing the skin with tiny, sterile needles. Typically, have addressed many of these earlier problems with this is done with a specialised instrument called a benefits of faster recovery time, more precise control of microneedling device. ablation depth, and reduced risk of post procedural Controlled studies have suggested that the application problems8. These lasers are extremely versatile, in that of autogenous PRP can enhance wound healing in both they can be used for the treatment of facial rhytides, acne animals and humans29. Five major growth factors such as scars, surgical scars, melasma and photodamaged skin, transforming growth factor (TGF), insulin-like growth and many have entered the market at the same time24. factor (IGF), platelet-derived growth factor (PDGF), With the advent of fractional laser skin resurfacing, the epidermal growth factor (EGF), and vascular endothelial number of completely ablative resurfacing cases has growth factor (VEGF) are known to be related to the declined for most practitioners. However, care should be wound-healing processes28. These growth factors are taken when treating sensitive areas such as the eyelids, released from platelets and the production of collagen upper neck, and especially the lower neck and chest, by and fibroblasts is stimulated by IGF, EGF, Interleukin-1 using lower energy and density, and scarring has been (IL‑1) and tumour necrosis factor (TNF)-α34, 35. In vivo noted in these areas25. Scarring after fractional CO2 laser studies report TGF-β to be the most stimulative growth therapy is considered mainly a result of overly-aggressive factor. PRP may be used for dermal augmentation and treatments and a lack of technical finesse. Physicians Sclafani observed aesthetic improvements of the have also recorded post‑operative infections leading to nasolabial fold in less than 2 weeks, and the results lasted scarring, although it is generally felt that these may be for up to 3 months28, 29. prevented by careful history-taking, vigilant post‑operative monitoring, and/or the use of prophylactic Research design and methods antibiotics26, 27. This multi-centre randomised study included 44 patients With regard to facial rejuvenation, CO2 laser light at a of skin types 1 and 2 aged between 39 and 68 years, 10 600 nm wavelength results in vaporisation with presenting with photoageing of the skin, 25 of whom thermal denaturation of type I collagen, collagen were women and 4 were men [AQ2: what about the shrinkage and later, collagen deposition. However, in remaining 15?]. The subjects presented with the typical very deep rhytides, acne scarring and severe elastotic hallmarks of chronological and photoageing, such as changes from sun damage, fractional CO2 therapy expression lines, rhytides, wrinkles, eyelid skin laxity, requires multiple treatments to achieve the same results dermatochalasis, lowered brows, lateral hooding, and as the older lasers28. A number of studies have evaluated prominent fat pads. All patients were subjected to a using different laser combinations in the same session in programme of skin tightening and neocollogenesis by order to improve collagen deposition, with a wider zone one of two methods: conventional fractional laser skin of fibroplasia6–9, 28. Owing to the inherent risks of fractional resurfacing (Group 1) or the DUBLiN Lift (Group 2). The laser skin resurfacing and its inability to deal with some mean patient age in Group 1 was 49 years (range 37– evidence of chronological ageing, it was advocated to 71 years) and in Group 2 was 55 years (range 41–76 years). here establish the clinical effectiveness of using a Fifteen patients underwent Lumenis ActiveFx™ with multi‑procedural approach to volumisation and collagen settings as (energy) 125 mJ and (rate) 19 w CPG 3/5/4. 20 September 2012 | prime-journal.com
  • 3. | facial aesthetics | ARTICLE Twenty-nine patients received the DUBLiN Lift, a three- also given to patients. phase combination of established treatments with The ActiveFX is a protocol of settings applied in microneedling, platelet growth hormones, near-red conjunction with an improved computer pattern 633 nm light, and low-energy UltraLase fractional CO2 generator to the ultrapulsed CO2 laser (UltraPulse laser skin tightening. All patients received Dysport® in Encore, Lumenis Ltd). Technical differences between three areas 1 week prior to the other treatments as an this non-sequential fractional device and the older adjunct to the laser resurfacing. ultrapulsed CO2 include tissue bridges left between spots, The DUBLiN Lift was introduced as three phases over a resulting in faster healing time, and less thermal damage period of 3 weeks. Phase 1 included Dysport® at dilution to the basal cell membrane. The device has a smaller 3.5 : 1 to three areas — glabellar, frontalis and periorbital. spot size (1300 mm rather than 2500 mm), resulting in Phase 2 introduced intense fibroblast stimulation and less post-procedure erythema. modification through microneedling, PRP growth factor The computer pattern generator lays down a random induction, and near-red phototherapy. Phase 3 series of spots rather than a sequential sequence administered the low–level (CO2) UltraPulse laser at resulting in less overheating of the treated tissue. This 100 mJ 14 w CPG 3/5/2, and adjunct near-red 633 nm application is termed ‘Cool Scan’, and was used with phototherapy. The study evaluated post-procedural every patient in the study. aesthetic results at 2 weeks, 4 weeks and 12 weeks. The The Traylife Kit (PRP) (Promoitalia Wellness Research) length of downtime, patient discomfort and adverse provides blood plasma enriched with a concentrated side‑effects were noted for each phase. source of autologous platelets that releases a number of Clinical assessment of patients in each group was growth factors and other cytokines that stimulate the made at 2 weeks, 1 month and 3 months post‑operatively healing of soft tissue. in the presence of two aesthetic staff. The degree of Omnilux Revive™ (633 nm) (Photo Therapeutics, Inc., improvement in photoageing was based on the degree of UK) stimulates fibroblast activity, leading to faster and re-epithelialisation rate, reduction of rhytides, reduction more efficient collagen synthesis and extracellular of tactile roughness, and loss of hyperpigmentation and matrix proteins. telangiectasias. The prolongation and severity of Dermaroller™ Collagen Induction Therapy (CIT) erythema as well as the presence of negative side-effects (AesthetiCare®, UK) is a minimally-invasive cosmetic (e.g. herpes) were also recorded. procedure that involves the use of a micro-needling The efficacy of treatment was evaluated using a device. variation of the five-point scale (Table 1) originally Scoring charts are presented in Tables 1–4. suggested by Dover et al36. Investigators and patients evaluated efficacy using palpability assessments and change from baseline score at 0, 6 and 12 weeks. A total global score was recorded in each patient based on the Table 1 Patient treatment (positive) scoring chart addition of points obtained from six photodamage Parameter 0 1 2 3 4 variables. The degree of perceived improvement in Global score Area of Area of Area of Area of Area of overall aesthetic effect reflecting chronological age was roughness roughness roughness roughness roughness assessed separately by patients and physicians using the x 0 x 1 x2 x3 x4 Wrinkle Severity Rating Scale (WSRS) and the Global Fine lines None Rare Several Moderate Many Aesthetic Improvement Scale (GAIS). The WSRS is Pigmentary None Patchy Moderate Heavy Marked recognised as a valid and reliable instrument for problems quantitative assessment of facial skin folds, with good Touch Even Rare Mild Moderate Severe inter- and intra-observer consistency5. Wrinkle severity is problems measured using a wrinkle severity rating scale with 1 Facial veins None Rare Several Moderate Severe being absent and 5 being extreme. By allowing objective Coarse lines None Rare Several Moderate Many grading of data, these proved useful clinical tools for Complexion Pink Pale Grey Slightly Distinct assessing the effectiveness of facial volumisation with yellow-grey yellow-grey PRP and microneedling–633. Interventions Table 2 Patient treatment (negative) scoring chart The following treatment protocols were used for this study: Lumenis ActiveFX CO2 laser, Traylife PRP, Omnilux Parameter 0 1 2 3 4 633 nm red light, Dermaroller®, and Dysport®. All Erythema severity None Rare Several Moderate Severe participants received selective regional anaesthesia Infective outbreak None Rare Several Moderate Severe blocks with 2% lignocaine plus adrenaline, a topical (herpes/acne) combination anaesthetic of 23% lignocaine, and Crusting None Rare Several Moderate Severe prophylactic Valtrex 500 mg twice daily for 8  days. Pain of None Mild Tolerable Moderate Severe Valium 5–10 mg stat was given as a pre-medication to procedure some patients. A post-procedural advice sheet and Improvement None Minimal Fair Good Excellent Nurofen or codeine with paracetamol — as required — was prime-journal.com | September 2012 21
  • 4. ARTICLE | facial aesthetics | into the buccal cavity with the needle directed Table 3 WSRS Patient scoring chart towards the infraorbital foramen ■■ Mental nerve block. 1 cc of 1–2% Lidocaine injected into 5 Extreme Extremely deep and long folds, detrimental to facial appearance the mental foramen just above the bone level. 4 Severe Very long and deep folds; prominent facial features; less than 2 mm visible 3 Moderate Moderately deep folds; clear facial feature visible at normal Group 2: DUBLiN lift appearance, but not when stretched 2 Mild Shallow but visible fold with a slight indentation; Phase 1 minor facial feature Dysport® treatment to three areas: glabellar, frontalis and 1 Absent No visible nasolabial fold; continuous skin, injectable periorbital. implant alone Phase 2 (Week 2) Microneedling Table 4 Global Aesthetic Improvement Scale (GAIS) Topical anaesthesia: benzocaine 20%, Lidocaine Base 6%, and tetracaine 4%. Degree Description Each patient received Chiroxy cream post-procedure 1 Exceptional improvement Excellent corrective result at week 12. No further to reduce erythema and inflammation. Tepid water was treatment required used to cleanse the face for the following 48 hours, and 2 Very improved patient Marked improvement of appearance, but not completely optimal dried gently. It was recommended that make-up was not applied for 12 hours after the procedure. After the 3 Improved patient Improvement of the appearance, better compared with the initial condition. Touch-up is advised procedure, a broad-spectrum UVA/UVB sunscreen with 4 Unaltered patient The appearance substantially remains the same SPF 50 was recommended for use. compared with the original condition 5 Worsened patient The appearance has worsened compared with the PRP preparation original condition Draw blood (4 ml for each tube), then centrifuge tubes at 2000 rpm for 5 minutes. Take the syringe, insert the needle and withdraw 0.5 ml DNA Activator (10% calcium Group 1: fractional laser skin chloride). Withdraw platelets and mix with the DNA resurfacing Activator. Multiple injections (0.05–0.1 ml for a single injection) Phase 1 were applied to the intra/sub dermis using the Dysport® treatment to three areas: glabellar, frontalis and ‘multi‑pricking’ or retrograde linear techniques periorbital. Omnilux 633 nm LED Phase 2 (Week 2) This was applied for 20 minutes per session (126 J/cm2). Lumenis ActiveFX with settings (energy) 125 mJ (rate) 1 9w CPG 3/9/4 Phase 3 (Week 3) In the pre-laser procedure, the author typically prescribes Valium (Diazepam 5–10 mg orally) for anxiety, Low-level Ultralase administered 45 minutes before the procedure. Lumenis ActiveFX with settings (energy) 100 mJ rRate) For infection prophylaxis, Famvir (famciclovir) 750 mg 14 w CPG 3/5/2. daily or Valtrex (valcyclovir) 500 mg twice per day for 7 days, was prescribed for every patient starting 3 days Omnilux 633 nm LED before procedure. If the patient had a strong history of This was applied for 20 minutes per session (126 J/cm2). acne, By-Mycin (doxycycline 100 mg daily) or Keflex (cephalexin 500 mg twice per day) was prescribed for Histology 7  days, beginning on the day of surgery. Diflucan Skin biopsies were obtained from five of the patients (fluconazole 150 mg) was not routinely prescribed in any intra-operatively, before Phase 2 of the treatment, and at patient. 3  months post-operatively, and were performed to The patients were treated under topical and regional determine the amount of epidermal damage, subsequent anaesthesia. Topical anaesthesia comprised benzocaine inflammation, and new collagen synthesis. The extent of 20%, Lidocaine Base 6%, and tetracaine 4%). Regional neocollogenesis was compared with data on file for anaesthesia was three-fold: patients who had skin biopsies for laser resurfacing and ■■ Supraorbital and supratrochlear nerve block. The neurotoxin alone in 2007. Each 1 cm by 1 cm piece of skin supraorbital foramen was located and 1 cc of 1–2% was fixed with 10% formalin solution, neutral buffered. Lidocaine injected just above the bone laterally, with After treatment with polyester wax, the skin samples the needle directed medially, parallel to the brow and were sliced into 6 μm thicknesses. The sliced sections toward the nose were treated with haematoxylin and eosin statin (H&E) ■■ Infraorbital nerve block. 1 cc of 1–2% Lidocaine injected and Masson’s trichrome staining solutions. Through 22 September 2012 | prime-journal.com
  • 5. | facial aesthetics | ARTICLE tissue evaluations, the thickness of the dermal layer and the ‘softer’ settings. presence of collagen fibres were observed. The thickness According to investigator-based WSRS and GAIS of the dermal layer was calculated by measuring five assessments at 3 months after baseline, the DUBLiN lift different sites from each section, and the mean value of was superior in 62% and 55.2% of patients respectively, the thickness of the dermal layer for each group was while fractional laser skin resurfacing was superior in used for the comparison. 33.3% and 34.4% of patients. (P < 0.0004). An ‘optimal’ cosmetic result was achieved in a higher percentage of Results patients in Group 2 compared with Group 1. Over 3 months, 29 subjects (Group 2) were selected to Investigator-based and patient-based ratings using compare the effect of low energy fractional laser skin both the WSRS and GAIS indicated that the DUBLiN lift resurfacing with adjunctive treatments to conventional was more effective than conventional ablative laser ablative laser resurfacing. These patients received a resurfacing in creating cosmetic correction to the lower three‑phase combination of established treatments with face. This resulted from the volumising effect of adding neurotoxin, microneedling, platelet growth hormones, PRP to the larger folds in this area. At 3 months near-red 633 nm light, and low-energy Ultralase fractional post‑treatment, a higher proportion of patients showed a CO2 laser skin tightening over a 3-week period. Phase 1 greater than or equal to 1-grade improvement in WSRS included the administration of Dysport® neurotoxin to with DUBLiN Lift compared with fractional laser skin the upper face. Phase 2 introduced fibroblast stimulation resurfacing. The author suspects the PRP may have a from microneedling and PRP growth factor induction longer aesthetic effect when used in association with with near-red phototherapy, and Phase 3 included microneedling and 633 nm light than previously noted27, 29. low‑level (CO2) UltraPulse laser with adjunct near-red However, the results were almost reversed whenever 633 nm phototherapy. Results were compared to the periorbital rejuvenation was assessed alone, with almost reamining 15 patients (Group 1) who received fractional every patient (93%) favouring conventional fractional laser skin resurfacing (125 mJ; 19 w CPG 3/5/4), and whose laser skin resurfacing. Investigator-based GAIS data was already on file. Patients in both groups were assessment of this region at 3 months after baseline administered Dysport® neurotoxin 1 week prior to indicated that fractional resurfacing was superior in 93% treatment to complement and preserve the overall of patients, while the DUBLiN Lift was superior in 6.8% of aesthetic effect. The study evaluated post-procedural patients (P = 0.0025). aesthetic results at baseline, 6 weeks and 12 weeks by Re-epithelialisation occurred in all laser-treated areas means of a scoring system based on Dover’s photoageing of both groups by day 7, and this appeared to be clinically scale, as well as using the WSRS and GAIS. similar for both procedures. Mean duration of erythema Histological results were obtained from both groups was 6.9 days after resurfacing (range 4–10 days) in Group 1 showing the depth of laser penetration and consequential and 4.2 days in Group 2 (range 3–7 days). This appeared to formation of new collagen. All skin biopsies showed be in keeping with previous studies37. All patients thermal coagulation of epidermis and superficial dermis reported having no ‘crusting’ effect remaining on their in a depth ranging from 85 to 113 µ. The zone of residual face after 6 days. Residual erythema remained in one thermal (coagulative) damage was less in the Group 2 patient in Group 1 for a period of 14 days, but this was patients, in whom less laser energy was used. The best minimal. Post-operative erythema was most intense in neocollogenesis results — at 3 months — were evident in the areas treated by with the ActiveFX at an energy level Group 1 where one patient NMG [AQ3: what does this above 125 mJ. signify?] (Image E) had evidence of effect at 700 µ. This The mean pain sensation [AQ5: how was this assessed?] was reflected in the patient’s skin, which continued to felt during the DUBLiN lift was 2.2 compared to improve over the period. Owing to the variance in energy conventional fractional resurfacing treatment, which of the CO2 laser in Group 1 and Group 2, it was expected was 3.4. The author noted that most patients did not feel that the documented depth of histological ablation and much pain at all with the ActiveFX until the energy level thermal effects would vary between them. Responses of crosses 100 mJ. No patient experienced any adverse aesthetic effect were evaluated at 6 and 12 weeks after reaction to laser skin resurfacing, except one case of baseline. herpetic infection in each group. (Group 1 6.6%; Group 2 The two methods appeared to produce different 3.4%). Both treatments were well tolerated. Clumping of clinical improvement of lesions and rhytides. The global platelets occurred in 10% of patients treated with PRP score [AQ4: are you referring to the GAIS? are the total for and the author felt that this was a result of the tables 1-4?] for photoageing for the DUBLiN lift improved concentration of solution used. In fact, anecdotal from 13.2 to 10.2 at day 30. This compared to 13.8 at evidence suggests that most cosmetic physicians are baseline and 9.6 at day 30 for conventional FLRS alone. using PPP (platelet-poor plasma) in most areas of the face, The score for fine lines was the most significant reduction, rather than the higher concentrations used by dropping from 3.6 at baseline to 1.4 at day 30. The score for orthopaedic surgeons. reduction of coarse wrinkles (3.2 at baseline to 2.2 at 6  weeks) was more difficult to interpret in this Conclusions heterogeneous age grouping, with older patients Facial ageing is a consequence of many interacting requiring the conventional ActiveFX settings rather than intrinsic and extrinsic factors. The most important of prime-journal.com | September 2012 23
  • 6. ARTICLE | facial aesthetics | these include sun exposure or photoageing, and the intrinsic changes associated with chronological ageing. Over time, the muscles of facial expression produce dynamic and static facial lines and folds. Laser resurfacing has long been recognised as a skin rejuvenation procedure for tissue that has lost its elasticity and become less able to resist stretching. However, despite the advent of newer fractionalised lasers, it has adverse risks and does not adequately address the problems associated with chronological ageing as gravity exerts its toll on the facial structures. It is important to apply supplementary methods, such as dermal fillers or PRP, to address nasolabial or marionette lines and volume deficits resulting from the loss and repositioning of facial fat. Declaration of interest [AQ6: please state] References 1. Raspaldo H. Volumizing effect of a new hyaluronic acid photodamage and photoprotection. J Am Acad Dermatol 27. 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  • 7. | facial aesthetics | ARTICLE Further reading Matteo Tretti Clementoni a; Patrizia Gilardino a; Gabriele F. Muti a; preauricular and postauricular skin after high-energy, short-pulse Daniela Beretta b; Rossana Schianch. Non sequential fractional carbon dioxide laser. Arch Dermatol. 1996;132:425-428. ultrapulsed C02 resurfacing of photoaged skin. Journal of Cosmetic and Rubach BW, Schoenrock LD. Histological and clinical evaluation of facial Laser Therapy, Volume 9, Issue 4 2007 , pages 218 – 225 resurfacing using a carbon dioxide laser with the computer pattern Lask G, Keller G, Lowe N, Gormley D. Laser skin resurfacing with the generator. Arch Otolaryngol Head Neck Surg. 1997;123:929-934. SilkTouch flashscanner for facial rhytides. Dermatol Surg 1995;21:1021– Fitzpatrick RE, Tope WD, Goldman MP, Satur NM. Pulsed carbon dioxide 1024. laser, trichloroacetic acid, baker-gordon phenol, and dermabrasion: a Bernstein L, Kauvar A, Grossman M, Geronemus R. The short and long comparative clinical and histologic study of cutaneous resurfacing in a term side effects of carbon dioxide laser resurfacing. Dermatol Surg porcine model. Arch Dermatol. 1996;132:469-471. 1997;23:519–525. P Bonan, P Campolmi, G Cannarozzo, N Bruscino, A Bassi, S Betti, T Lotti. Alster TS. Side effects and complications of laser surgery. In: Alster TS. 1468-3083. 2011. 04034. Journal of the European Academy of Manual of Cutaneous Laser Techniques. Philadelphia: Lippinco, 2000 Dermatology and Venereology Eyelid skin tightening: a novel ‘Niche’ for Burkhardt BR, Maw R. Are more passes better? safety versus efficacy fractional CO2 rejuvenation with the pulsed CO2 laser. Plast Reconstr Surg. 1997;99:1531-1534. G.F. Pierce, D. Brown, T.A. Mustoe Quantitative analysis of inflammatory Treacy PJ. Article on fractionalised lasers Jan 2008 Health & Living cell influx, procollagen type I synthesis, and collagen cross-linking in Magazine www.hlaw.ie incisional wounds: influence of PDGF-BB and TGF-beta 1 therapy J Lab Clin Med, 117 (1991), pp. 373–382 David Goldberg, MD: Reduced Down-time Associated with Novel Fractional UltraPulse CO2 Treatment (Active FX) as Compared to Mathew M. Avram, MD, JD,1,* Whitney D. Tope, MPhil, MD,2 Thomas Yu, Traditional Resurfacing P3115 -65th Annual American Academy of MD,3 Edward Szachowicz, MD, PhD,4 and J. Stuart Nelson, MD, PhD5 Dermatology Meeting Hypertrophic Scarring of the Neck Following Ablative Fractional Carbon Dioxide Laser Resurfacing Smith KJ, Skelton HG, Graham JS, et al. Depth of morphologic skin damage and viability after one, two and three passes of a high-energy, Baez F and Reilly LR. The use of light-emitting diode therapy in the short-pulse CO2 laser in pig skin. J Am Acad Dermatol. 1997;27:204-210. treatment of photoaged skin. Journal of Cosmetic Dermatology. 2007; 6: 189-194 Fitzpatrick R, Ruiz-Esparaza J, Goldman M. The depth of thermal necrosis using the CO2 laser. J Dermatol Surg Oncol. 1991;17:340-344. Lee SY, et al. A prospective, randomized, placebo-controlled, double- blinded, and split-face clinical study on LED phototherapy for skin Tina S. Alster MD & Christopher A. Nanni MD Famciclovir Prophylaxis of rejuvenation: Clinical, profilometric, histologic, ultrastructural, and Herpes Simplex Virus Reactivation After Laser Skin Resurfacing biochemical evaluations and comparison of three different treatment Dermatol Surg Volume 25 Issue 3 Page 242-246, March 1999 settings. Journal of Photochemistry and Photobiology B. 2007; 88: 51-67 Mario A. Trelles; Inés Allones Red light-emitting diode (LED) therapy Majid I (January 2009). Microneedling therapy in athrophic facial scars: accelerates wound healing post-blepharoplasty and periocular laser an objective assessment. J Cutan Aesthet Surg 2 (1): 26–30. ablative resurfacing Journal of Cosmetic and Laser Therapy: formerly Journal of Cutaneous Laser Therapy, Volume 8, Issue 1, 2006, Pages 39 Doddaballapur S (July 2009). Microneedling with dermaroller J Cutan – 42 Aesthet Surg 2 (2): 110 Kauvar ANB, Waldorf HA, Geronemus R. A histopathologic comparison Day DJ, Littler CM, Swift RW, Gottlieb S. The wrinkle severity rating scale: of char-free lasers. Dermatol Surg. 1996;22:343-348. a validation study Am J Clin Dermatol. 2004;5(1):49-52. Department of Dermatology, New York University Medical Center, New York, New York Cotton J, Hood A, Gonin R, Beeson W, Hanke C. Histologic evaluation of 10021, USA prime-journal.com | September 2012 25