PRIME Supplement - Dr. Patrick Treacy

INTERNATIONAL JOURNAL OF AESTHETIC AND ANTI-AGEING MEDICINE
Special Supplement
Autumn 2014
DERMAL
FILLER
INDUCED
FACIAL ARTERY
OCCLUSION
BOTOX FOR
DEPRESSION
IS IT EFFECTIVE?
THE
DUBLIN
LIFT
TO TREAT THE
AGEING FACE

Register to PRIME
online for FREE
prime-journal.com
Why Register:
prime-journal.com
Access the latest PRIME articles as
soon as they are published
ONLINE FIRST
Peer-review articles, insightful analysis
and key data all in one place
ONE PLATFORM
Watch the latest videos
which interest you
DIGITAL CONTENT
Comment on articles, and review
the opinions of your peers
INTERACT
The PRIME website is maximised for
mobiles and tablets so you can
read it on the go
EASE OF USE

prime-journal.com 3
| CONTENTS
BOARD MEMBER SPECIALISM COUNTRY
Dr Claude Dalle Anti-ageing & aesth. medicine France
Dr Wilmar Accursio Endocrinology Brazil
Dr Firas Al-Niaimi Dermatology & laser surgery UK
Dr Ashraf Badawi Dermatology Egypt & Canada
Dr Janethy Balakrishnan Aesthetic & anti-ageing medicine Malaysia
Dr Lakhdar Belhaouari Plastic surgery France
Dr Anthony Benedetto Cosmetic Dermatology USA
Dr Philippe Berros Oculoplastic surgery Monaco
Dr Dario Bertossi Maxillofacial surgery Italy
Dr Pierre Bouhanna Dermatology – Hair surgery France
Dr Fahd Benslimane Plastic Surgery Morocco
Prof Wayne Carey Dermatology Canada
Dr Claude Chauchard Anti-ageing medicine France
Dr Christophe de Jaeger Geriatrics France
Dr Gerd Gauglitz Aesthetic Dermatology Germany
Prof Ilaria Ghersetich Dermatology Italy
Dr Kate Goldie Aesthetic Physician UK
Prof Eckart Haneke Dermatology Germany
Dr Steven Hopping Plastic surgery USA
Prof Andreas Katsambas Dermatology Greece
Dr Mario Krause Anti-ageing medicine Germany
Dr Marina Landau Dermatology Israel
BOARD MEMBER SPECIALISM COUNTRY
Dr Gustavo Leibaschoff Cosmetic Surgery USA
Dr Sohail Mansoor Dermatology UK
Prof Leonardo Marini Dermatology Italy
Dr Sly Nedic Aesthetic & anti-ageing medicine South Africa
Prof Daniel Pella Cardiology Slovakia
Dr Chariya Petchngaovilai Dermatology Thailand
Prof Ascanio Polimeni Neuro-endocrinology Italy
Dr Herve Raspaldo Facial plastic surgery France
Dr Christopher Rowland-Payne Dermatology UK
Dr Neil Sadick Dermatology USA
Dr Hema Sundaram Dermatology USA
Dr Pakpilai Thavisin Dermatology&Anti-ageingmedicine Thailand
Dr Patrick Treacy Aesthetic surgery Ireland
Dr Mario Trelles Plastic surgery Spain
Dr Ines Verner Dermatology Israel
Dr Octavio Viera Anti-ageing medicine Spain
Dr Jean-Luc Vigneron Aesthetic dermatology France
Prof Bernard Weber Genetics Luxembourg
Dr Sabine Zenker Dermatology Germany
Catherine Decuyper Industry expert & consultant France
Wendy Lewis Industry expert USA
Christophe Luino Industry expert & consultant France
PRIME JOURNAL EDITORIAL BOARD
International Journal of Aesthetic
and Anti-Ageing Medicine
Informa, Christchurch Court,
10–15 Newgate Street, London, EC1A 7AZ
www.prime-journal.com
ISSN 2159-8908 (print)
ISSN 2159-8916 (online)
Managing Editor Nicola Whyke
nicola.whyke@informa.com
Editor Balraj Juttla
balraj.juttla@informa.com
Art Director David ‘Spike’ McCormack
spike@spikedesigns.co.uk
Sales Manager Christopher Keeling
christopher.keeling@informa.com /
+44(0)2033773183
Business Development Manager NA Meg McNeel
meg.mcneel@informausa.com / +1 (212) 520 2745
Production Manager Jonathan Collard
jonathan.collard@informa.com
Graphic Designer Snehal Sanghani
snehal.sanghani@informa.com
Director of Audience Development NoraPastenkos
nora.pastenkos@informausa.com
Production & Ads Department
primeadverts@informa.com
Please send your manuscripts and press releases to:
balraj.juttla@informa.com
All submitted manuscripts are evaluated on the basis
of scientific quality, originality, appropriateness,
contribution to the field and style. Suitable
manuscripts are subject to peer-review. Manuscripts
and accompanying files should be prepared in
accordance with our Author Guidelines, which are
available via www.prime-journal.com.
All content © 2014 Informa UK Ltd
Images © Shutterstock.com, unless otherwise stated
For address changes, please contact Hallmark
Fulfillment: primeinternational@halldata.com
Original articles previously published in Prime
Journal, Europe edition
Subscription rates
UK £295 Europe €370 Rest of world US$490
PatrickTreacyconsiderstheconflicting
evidenceofbotulinumtoxinuseasatherapyfor
depression,andproposesthatitallcomesdown
towherethetoxinisinjected
THE‘BOTOX
PARADOX’:
IS IT EFFECTIVE
FOR DEPRESSION?
REVERSAL OF A
DERMAL FILLER
INDUCED
FACIAL ARTERY
OCCLUSION
PatrickTreacydiscussesthefactorstoconsider
toavoidadverseeventsaftertheuseofadermal
filleraswellasthebestmethodsoftreating
complications,includingsteroidsandhyaluronidase
PatrickTreacypresentsanovelmethodforfull
facialrejuvenation,whichcombinesanumber
oftreatmentstoobtainthemostoptimum
results
COMBINING THERAPIES
FOR THE AGEING FACE:
THE DUBLIN LIFT
10
14
4

REVERSAL OF A
DERMAL FILLER
INDUCEDFACIAL ARTERY OCCLUSION
PatrickTreacydiscussesthefactorstoconsidertoavoidadverse
eventsaftertheuseofadermalfilleraswellasthebestmethodsof
treatingcomplications,includingsteroidsandhyaluronidase
KEYWORDS
Localised adiposities, topical
slimming treatment, botanical
extracts, ultrasonography, in vivo
assessment
ABSTRACT
Soft tissue augmentation with
dermal fillers has become an
integral part of most aesthetic
practices. Fortunately, adverse
reactions are usually mild and
transient. However, significant
adverse events such as
vascular occlusion also occur.
Vascular compromise occurs
because of embolisation and/
or compression material into/
onto the vasculature. In this
article, the author theorises
that late onset vascular
occlusion may occur not
only due to embolisation but
because hyaluronic acid (HA)
expands due to its hydrophilic
action and compresses the
facial artery or its branches.
He proposes that intravenous
steroids should be added to the
accepted reversal protocol. His
goal is not to promote this as
a definitive measure but rather
to establish a discussion on
treatment protocols that may
be helpful to other physicians
in the future.
W
ITHIN THE PAST 15 YEARS,
facial soft-tissue augmentation
has become very popular in
aesthetic clinics around the
world. Although most
biodegradable-type products
are considered safe, adverse events do occur that are
time-limited. The products have been observed to
have severe, persistent, and recurrent complications.
Histological examinations in these cases, often show
the presence and persistence of the filler1
. Dermal filler
complications are divided into ‘early’ and ‘delayed’ in
terms of time of occurrence and ‘minor’ and ‘major’ in
terms of severity1, 2
. Minor complications occurring
immediately or hours to days after injection include
injection site reactions, such as bruising, erythema,
pain and tenderness, swelling, and itching. These
events usually resolve within a week without
sequelae3, 4
. Severe vascular adverse events have been
reported in the glabellar and nasolabial regions after
treatment with both biodegradable and non-
biodegradable injectable fillers5
.
Although rarely reported in the literature,
complications related to interrupted blood supply to
the nose can occur with nasolabial fold dermal
injection. The exact mechanism of this event is
unknown, however it is widely accepted that vascular
compromise is a function of compression and/or
embolisation of material into the vasculature. It has
PATRICK TREACY, Medical
Director, Ailesbury Clinics Ltd
and Ailesbury Hair Clinics Ltd,
Dublin, Cork, London, and
Middle East
email: ptreacy@gmail.com
been theorised that, as injected hyaluronic acid (HA)
expands because of its hydrophilic action, the facial
artery, angular artery, or its branches, become
compressed. the facial artery runs in an oblique
direction over the mandible toward the nasal sidewall.
It passes under the zygomaticus muscles, crossing the
nasolabial fold. It turns to run in the alar crease and
along the lateral nasal wall, where it terminates in the
angular artery, which continues toward the medial
orbital rim6
.
There are several important factors that may lessen
the occurrence of adverse events. Before injecting any
dermal filler, a thorough medical history including
medication (especially blood thinners), allergies, and
scarring history (e.g. tendency for keloids) should be
taken. The injector should be well trained in injection
technique and know which filler to implant at which
depth. Understanding the anatomy, limitations of the
filler and proper technique can reduce the risk of adverse
effects. When complications occur, the practitioner
should understand how to manage them from
observation to surgical intervention7
.
Preventing side-effects
The best way to handle side-effects is to prevent them8
.
For optimum outcomes, aesthetic physicians should
have: a detailed understanding of facial anatomy; the
individual characteristics of available fillers; their
indications, contraindications, benefits, and drawbacks;
and ways to prevent and avoid potential complications9
.
Hyaluronic acid dermal fillers are the most widely used
injectables to augment facial volume without surgery.
They are popular because of their ease of
administration, predictable effectiveness, good safety
profile, and quick patient recovery10
. Since its
reformulation in mid-1999, the biologically engineered
hyaluronic acid filler Restylane (Medicis
Pharmaceuticals, Scottsdale, AZ, USA) elicits less than
one allergic reaction in 1600 treatments. Skin
PEER-REVIEW | DERMATOLOGY |
4 prime-journal.com

Severe vascular
adverse events have been
reported in the glabellar and
nasolabial regions after
treatment with both
biodegradable and
non-biodegradable
injectable fillers.
prime-journal.com 5
| DERMATOLOGY | PEER-REVIEW

reactions, including granuloma formation with poly-
L-lactic acid (Sculptra/formerly New Fill, Dermik
Laboratories, Berwyn, PA, USA) is considerably less
likely if a greater dilution and deeper injection
technique are employed11
. Inflammatory nodules are
likely to be caused by a low-grade infection maintained
within a biofilm surrounding the hydrophobic silicone
gel and the combination gels. Aquamid gel may prevent
formation of a biofilm through its high water-binding
capacity, explaining why late inflammatory nodules
are not seen after injection of this polyacrylamide
hydrogel product11, 12
. All gels act as foreign bodies. Host
response ranges from a few macrophages to an intense
foreign-body reaction with fibrosis, depending on gel
type. For polymer gels the filling effect stems from their
volume. For combination gels it stems from the
intended host foreign-body reaction to the
microparticles. Infectious nodules must be treated with
antibiotics. Granulomas must be treated with a
combination of both steroids and antibiotics or
excision12
.
Case study
Patient was a 37-year-old woman who received HA
injection to the left nasolabial fold. She had an
uneventful procedure but reported back to the clinic
with an erythematous reaction and some pain in the
nasolabial and malar area the next day. In view of the
vascular compromise she was immediately treated
with 150 units of hyaluronidase and nitropaste to the
reticulated area. Because the patient presented 24
hours post-procedure she was given 100 mgs of
cortisone IV and commenced on 4 mgs of
Dexamethasone PO. It was also considered appropriate
to inject 0.2 mls of a dilute solution of 50%
dexamethasone 40 mgs/ml into the area where the
hyaluronic acid was initially injected.
The patient became hypotensive during treatment
and was temporarily referred to the emergency room
until stable. This was considered secondary to the
nitropaste gel. The hospital was willing to allow the
patient to come back to the clinic for further steroid
Figure 1 Images demonstrating
management of a patient over
7 days with impending necrosis
owing to complications
secondary to hyaluronic acid
dermal filler injection
Figure 2 Branching patterns of facial artery
ILA
SLA
IAA
LNA
FB
Branching patterns of facial artery according to its termination (ILA, inferior labial
artery; SLA, superior labial artery; IAA, inferior alar artery; LNA, lateral nasal artery;
FB, forehead branch
6 prime-journal.com

treatment and commencement of Chiroxy oxygenating
skin cream (Auriga international, Belgium). Chiroxy
oxygenating skin cream is designed to increase the
oxygen content of your skin by delivering O2
via
nanosomes. Her symptoms and signs disappeared
within a 5 day period and 2 weeks later there was no
evidence of any residual vascular deficit.
Discussion
For the moment, there is no ideal dermal filler as they
have widely varying properties, associated risks, and
injection requirements that contribute to adverse
events for the patient. The majority of adverse reactions
are mild and transient, such as bruising and oedema
secondary to trauma or the physical characteristics of
the material itself.
However, although serious adverse events are rare,
vascular complications either arterial or venous can
occur that are related to volume of filler used and the
technique of placement in the region of terminal
vessels. It is possible that injected HA expands because
of its hydrophilic action and the underlying facial artery,
angular artery, or its branches, become compressed.
This results in vascular compromise that can lead to
skin necrosis unless it is immediately treated. The
author proposes that intravenous steroids and anti-
histamines should be given to all these patients.
There are also issues related to the recent use of
adjunctive lidocaine in fillers that may make vessels
more exposed to accidental infiltration. Lidocaine
significantly decreases pain during injection and
post‑injection with corresponding increased patient
satisfaction13
. The efficacy and safety profile of the
original filler may be compromised.
Rare complications with HA fillers include vascular
compression during or after the event which results in
reticulation some hours later and the author postulates
the use of intravenous steroids in these patients. These
patients normally show no evidence of vascular
compromise during injection. The protocol outlined by
Glaich et al14
calls for a coherent, sequential treatment
for vascular compromise resulting from injections of
hyaluronic acids. This protocol elaborates a sequence
of events that use topical nitroglycerin, hyaluronidase,
and other modalities to minimise the damage from
impending necrosis. Other authors have also published
guidelines for the treatment of impending necrosis
following soft tissue augmentation following injections
of hyaluronic acid15,16
. Based upon the experience with
hyaluronic acid occlusion, treatment for particular
fillers that occlude vascular structures should seek to
increase blood flow to the affected areas. This may be
accomplished by decreasing pressure in the anatomic
compartment(usingcorticosteroidsandhyaluronidase),
increasing blood flow (with sildenafil or similar drugs,
aspirin, and nitroglycerin paste), and increasing the
oxygen content to the affected tissues (hyperbaric
oxygen)17
.
Regarding reversal of a hyaluronic acid induced
embolus, the author recommends starting at higher
Table 1
Author’s HLA
reversal protocol
Discontinue injection of
HLA immediately
Massage the affected area
immediately
Apply warm packs of gauze
to area (microwave)
Apply nitro-paste or 10 mgs
transderm-nitro patches
(Novartis) for a period of
up to 12 hours
Mix 300 units of hyalase
(0.2mls) with 0.2mls
(Wockhardt UK) of 2%
lidocaine (Astra Zeneca)
Inject hyalase in 5–6 lots of
75u to occluded area
Hydrocortisone 100mg
IV stat (if not an acute
ischaemic event)
Dexamethsone 4mgs daily
PO X 3/7 (if not an acute
ischaemic event)
Table 2 Typical complication progression after
accidental intra-arterial injection of hyaluronic acid
CLINICAL FINDINGS TIMING
Blanching: invariably immediate, usually seen during Lasting seconds to tens of
the actual injection seconds
Livedo pattern or immediate reactive hyperaemia Minutes: sometimes up to
if insufficient material injected to occlude the artery tens of minutes
Blue-black discolouration Tens of minutes to hours
Blister/bullae formation Hours to days
Skin breakdown, ulceration, demarcation, slough Days to weeks
Figure 3 Effects of a large filler bolus
Figure 4 Effects of a small filler bolus
When a large bolus of filler material enters a small- or
medium-sized vessel, the material may flow retrograde to the
blood flow’s normal direction after it has filled in the distal
segment, because there is nowhere else for the filler to go. If
the filler bypasses a tributary during its retrograde flow, it may
enter this particular pathway and be carried to distant areas.
This is probably the pathophysiology responsible for injury
sites distant to the original injection site
Usually carried
downstream by
blood flow. May
cause limited
obstruction that
can be bypassed
via abundant
collateral vessels.
The problem is
in a region with
restricted
collaterals (eg,
the glabellar
region). Effect
depends on the
presence or
absence of
enough
collateral
circulation in the
target tissues
Micro volume
of filler does
not
completely
obstruct
blood supply
Angular
artery
Distal
branches
Supratochlear artery
Dorsal nasal artery
Ophthalmic
artery
Facial artery
External
carotid artery
Internal
carotid artery
Distal
branches
Collateral
flow
Proximal
branches
For the
moment, there is
no ideal dermal
filler as they have
widely varying
properties,
associated risks,
and injection
requirements that
contribute to
adverse events for
the patient.
prime-journal.com 7

levels of hyalase, possibly in the region of 150 to
300 iu, and then treating repeatedly until the circulation
returns. Repeated treatment, massage, and the other
recommendations to promote vasodilation are
continued. It is probable as the material starts to break
down, it flows further downstream, where it probably
opens collateral vessels, or it can flow further past these
and obstruct a slightly different area. When it gets to the
precapillary arterioles, it gets permanently stuck, unless
it is bathed in more hyaluronidase (HYAL) and is
hydrolysed.
There are so many variables in a typical case that it is
impossible to be specific, since the manner of
manipulation of the area, the quantity and nature of the
filler within the vessel, and the actual location of the
emboli all factor into the equation. The absolute
quantity of hyaluronidase is probably irrelevant during
an acute event, it’s the results that count.
Declaration of interest None
Figures 1 © Dr Treacy, 3-4 original artwork © Claudio
De Lorenzi redrawn for Prime Journal © Kevin February
One of the most
significant adverse events
associated with injections
of soft tissue
augmentation products is
vascular occlusion
Vascular complications
with HA fillers include
embolism or compression
during or after the event
which results in
reticulation some hours
later
The author postulates
the use of higher doses of
Hyalase than the normal
protocols and the uses of
intravenous steroids in
these patients
Key points References
1. Lowe NJ, Maxwell CA, Patnaik R.
Adverse reactions to dermal fillers:
review. Dermatol Surg 2005; 31 (11 Pt
2): 1616–25
2. Gladstone HB, Cohen JL. Adverse
effects when injecting facial fillers.
Semin Cutan Med Surg 2007; 26(1):
34–9
3. Baumann LS, Shamban AT,
Juvederm vs. Zyplast Nasolabial Fold
Study Group, et al. Comparison of
smooth-gel hyaluronic acid dermal
fillers with cross-linked bovine
collagen: a multicenter, double-
masked, randomized, within-subject
study. Dermatol Surg 2007; 33 Suppl 2:
S128–35
4. Pinsky MA, Thomas JA, Murphy
DK, et al. Juvederm injectable gel: A
multicenter, double-blind, randomized
study of safety and effectiveness.
Poster presented at the American
Society for Aesthetic Plastic Surgery
Annual Meeting, New York, NY, April
19–24, 2007
5. Bachmann F, Erdmann R,
Hartmann V, Wiest L, Rzany B. The
spectrum of adverse reactions after
treatment with injectable fillers in the
glabellar region: results from the
Injectable Filler Safety Study Dermatol
Surg 2009; 35 Suppl 2: 1629–34
6. Grunebaum LD, Bogdan Allemann
I, Dayan S, Mandy S, Baumann L. The
Risk of Alar Necrosis Associated with
Dermal Filler Injection. Dermatol Surg
2009; 35 Suppl 2: 1635–40
7. Gladstone HB, Cohen JL. Adverse
effects when injecting facial fillers.
Semin Cutan Med Surg 2007; 26 (1):
34–9
8. Funt D, Pavicic T. Dermal fillers in
aesthetics: an overview of adverse
events and treatment approaches. Clin
Cosmet Investig Dermatol 2013; 6:
295–316
9. Andre P, Lowe NJ, Parc A, Clerici TH,
Zimmermann U. Adverse reactions to
dermal fillers: a review of European
experiences. J Cosmet Laser Ther
2005; 7 (3–4): 171–6
10. Christensen L, Breiting V, Janssen
M, Vuust J, Hogdall E. Adverse
reactions to injectable soft tissue
permanent fillers. Aesthetic Plast Surg
2005; 29(1): 34–48
11. Christensen L. Normal and
pathologic tissue reactions to soft
tissue gel fillers. Dermatol Surg 2007;
33 Suppl 2: S168–75
12. Lowe NJ, Maxwell A, Patnaik R.
Adverse Reactions to Dermal Fillers:
Review. Dermatologic Surgery 2005;
31(s4):1626–1633
13. Smith L, Cockerham K Hyaluronic
acid dermal fillers: can adjunctive
lidocaine improve patient satisfaction
without decreasing efficacy or
duration? Patient Prefer Adherence
2011; 5: 133–9
14. Glaich AS, Cohen JL, Goldberg LH.
Injection necrosis of the glabella:
protocol for prevention and treatment
after use of dermal fillers. Dermatol
Surg 2006; 32(2): 276–281
15. Hirsch RJ, Cohen JL, Carruthers JD.
Successful management of an unusual
presentation of impending necrosis
following a hyaluronic acid injection
embolus and a proposed algorithm for
management with hyaluronidase.
Dermatol Surg 2007; 33(3): 357–360
16. Dayan SH, Arkins JP, Mathison CC.
Management of impending necrosis
associated with soft tissue filler
injections. J Drugs Dermatol 2011;
10(9): 1007–1012
17. Beer K, Downie J, Beer J . A
treatment protocol for vascular
occlusion from particulate soft tissue
augmentation. J Clin Aesthet Dermatol
2012; 5(5): 44–7
It is probable as the
material starts to break
down, it flows further
downstream, where it
probably opens collateral
vessels, or it can flow further
past these and obstruct a
slightly different area.
8 prime-journal.com

3D Human Anatomy Regional Edition and Primal Interactive
Human are our most detailed and comprehensive series
covering the whole human body from head and neck to foot and
ankle - with everything in between!
Order today and receive your complimentary 10% discount,
remember to use the following code at the check out
PRIMALHARPIH14 or contact us today for details on our cost
eﬀective single user, group and corporate license options:
info@primalpictures.com.
Easily explore the human body in accurate and interactive 3D
layer by layer.
Save your valuable time preparing for consultations and
sourcing clear, accurate and royalty free images for your
reference, presenting and client interaction!
Capture the images you need to create engaging presentations
or to educate and reassure your clients.
Quick access to a huge library of additional slides, illustrations,
short movie clips and animations.
Enhance your practice today with the deﬁnitive
3D anatomy software from Primal Pictures
an informa businesswww.primalpictures.com

In 2003, Heckmann et al
published data suggesting that
treatment of the glabellar
region with botulinum toxin
could produce a change in
facial expression from angry,
sad, and fearful to happy, and
that this could impact on
emotional experience.

THE‘BOTOX
PARADOX’:
IS IT EFFECTIVE
FOR DEPRESSION?PatrickTreacyconsiderstheconflictingevidenceofbotulinum
toxinuseasatherapyfordepression,andproposesthatitall
comesdowntowherethetoxinisinjected
PATRICK TREACY is Medical
Director of Ailesbury Clinics
Ltd and Ailesbury Hair Clinics
Ltd; Chairman of the Irish
Association of Cosmetic
Doctors and Irish Regional
Representative of the British
Doctors; European Medical
Advisor to Network Lipolysis
and the UK’s largest cosmetic
website Consulti,ng Rooms. He
practices cosmetic medicine
in his clinics in Dublin, Cork,
London and the Middle East
A
RECENT ARTICLE
byClaireColeman1
,
published in the
UK’s Daily Mail
newspaper, has led
to much confusion
with regard to the role of BOTOX® in
treating or causing depression. The
article was based on a study led by
Dr Michael Lewis of the School of
Psychology, Cardiff, Wales, who
followed 25 people who had
received BOTOX treatment for facial
lines and examined the idea of facial
feedback — where the expressions
we make with our faces affect how
we feel — and found that many
women who have the treatment for
cosmetic purposes feel depressed
because they are no longer able to
smile properly.
Previous studies, however, have
found that the treatment of frown
lines left patients feeling less
depressed. In 2006, Dr Eric Finzi and
Dr Erika Wasserman reported in
Dermatologic Surgery that treating
clinically depressed patients with
BOTOX on their frown lines actually
reduced patients’ feelings of
depression2
. Depression affects over
120 million people globally, making it
oneoftheleadingcausesofdisability
in the world. Although there are a
number of effective treatments,
therapeutic response remains
unsatisfactory and depression can
develop into a chronic condition in a
considerable proportion of patients.
An economic treatment option that
could provide long intervals
between treatments, and that is safe,
would be very important to doctors.
So, what is the truth? Is there an
actual physiological reason to
explain the different results?
The ‘grief’ muscles
The story begins in 1872, when
Charles Darwin recognised that
negative emotions, such as anger,
fear, and sadness — all prevalent in
depression — are associated with
hyperactivity of the corrugator and
procerus muscles in the glabellar
region of the face. Darwin called
them the ‘grief muscles’ and
formulated a new theory, known as
the ‘facial feedback hypothesis’,
which implied a mutual interaction
between emotions and facial muscle
activity. He published his new theory
in The Expression of the Emotions in
Man and Animals, which concerns
the genetically determined aspects
of behaviour.
In this book, Darwin aimed to trace
the animal origins of human
characteristics, such as the
tightening of the muscles around the
eyes in anger and efforts of memory.
Darwinevensoughtouttheopinions
of eminent British psychiatrists in
preparation of the book, which forms
Darwin’s main contribution to
psychology. His theory implied a
mutual interaction between
emotions and facial muscle activity.
Research into this stayed there
during the great upheavals of both
World Wars, until the rising
popularityofBOTOXmadescientists
review his facial hypothesis.
In 2003, Heckmann et al3
published data suggesting that
treatment of the glabellar region
with botulinum toxin could produce
a change in facial expression from
angry, sad, and fearful to happy, and
that this could impact on emotional
experience. Many therapists argue
that patients who had been treated
in the glabellar area reported an
increase in emotional wellbeing and
reduced levels of fear and sadness
beyond what would be expected
from the cosmetic benefit alone.
In 1992, Larsen et al4
provided
evidence that voluntary contraction
of facial muscles could channel
emotions, which were conversely
expressed by activation of these
muscles. Hennenlotter et al5
went
one stage further and showed that
botulinum toxin treatment to the
| DEPRESSION | OPINION
prime-journal.com 11

OPINION | DEPRESSION |
12 prime-journal.com
glabellar area stopped the activation of
limbic brain regions normally seen during
voluntary contraction of the corrugator
and procerus muscles. This indicated that
feedback from the facial musculature in
this region in some way modulated the
processing of emotions. Many other
researchers continued on this track, with
Havas et al6
noting that the processing
time for sentences with negative affective
connotation was prolonged in women
after botulinum toxin treatment to the
glabellar, and Neal and Chartrand7
speculating that the treatment interfered
with the ability to decode the facial
expression of other people. This is where
things remained, until recently, when
some authors suggested that this capacity
to counteract negative emotions could be
put to some clinical use during the
treatment of depression.
Reducing symptoms
of depression
A seminal article by Finzi and
Wasserman2
postulated that botulinum
toxin injected into the glabellar reduced
the symptoms of depression. The authors
provided data from an open case series
of 10 female patients. The article
contained a footnote from editor Alastair
Carruthers, who stated that the report
must be considered anecdotal as there
were no appropriate methods of control
used. In addition, there were other
methodological weaknesses, including
limited follow-up, lack of randomisation,
the absence of blind evaluation, and in
particular, the small number of subjects
included. Many felt that the methodology
of evaluating depression should have
been more rigorous.
At the time, I noted by letter that
patients’ self-report of depressive
symptoms by administration of the BDI-II
(Beck Depression Inventory) introduced
a significant bias. This is of more concern
because of the potential for secondary
cosmetic gain. While the BDI-II is an
accepted method of evaluating an
individual’s level of symptoms over time,
self-report in isolation was not considered
an acceptable method of diagnosing
depression. It was concluded that in
order to ensure that patients’ psychiatric
symptoms are accurately classified, a
thorough psychiatric interview must
be conducted.
In 2012, the Psychiatric University
Hospital of the University of Basel,
Switzerland, and the Medical School
Hanover, Germany, conducted a
randomised, placebo-controlled,
double‑blind trial8
. The authors
hypothesised that facial psychomotor
features associated with depression are
not just epiphenomena, but integral
components of the disorder, and may be
targeted in its therapy. To explore whether
attenuation of these features produces
alleviation in the affective symptoms,
they conducted a randomised controlled
trial of botulinum toxin injection to the
glabellar region as an adjunctive
treatment of major depression. The study
was investigator-initiated and carried out
independently of any commercial entity.
Participants in the study were recruited
from local psychiatric outpatient units
and psychiatrists in private practice. In
order to avoid attracting candidates who
were primarily motivated by receiving
this treatment for cosmetic reasons,
botulinum toxin treatment was not
explicitly mentioned. Exclusion criteria
included psychotic symptoms, suicidal
tendency, and clinical severity requiring
immediate intervention. The same
injection scheme was applied as that of
the open case series2
. At each study visit,
participants were assessed using the
Hamilton Depression Rating Scale with
Atypical Depression Supplement
(SIGH‑ADS), the BDI self-rating
questionnaire, and the Clinical Global
Impressions (CGI) Scale. To conceal
Havas et al
noted that the
processing time for
sentences with
negative affective
connotation was
prolonged in
women after
botulinum toxin
treatment to the
glabellar.

References
1. Coleman C. Is Maria’s story
proof Botox can make you
depressed? London, UK: Daily Mail,
2013. http://tinyurl.com/bv2y3kr
(accessed 21 May 2013)
2. Finzi E, Wasserman E.
Treatment of depression with
botulinum toxin A: a case series.
Dermatol Surg 2006; 32(5): 645–9
3. Heckmann M, Teichmann B,
Schröder U, Sprengelmeyer R,
Ceballos-Baumann AO.
Pharmacologic denervation of
frown muscles enhances baseline
expression of happiness and
decreases baseline expression of
anger, sadness, and fear. J Am Acad
Dermatol 2003; 49(2): 213–6
4. Larsen RJ, Kasimatis M, Frey K.
Facilitating the furrowed brow: an
unobtrusive test of the facial
feedback hypothesis applied to
unpleasant affect. Cognition
Emotion 1992; 6: 321–38
5. Hennenlotter A, Dresel C,
Castrop F, Ceballos-Baumann AO,
Wohlschläger AM, Haslinger B. The
link between facial feedback and
neural activity within central
circuitries of emotion--new insights
from botulinum toxin-induced
denervation of frown muscles.
Cereb Cortex 2009; 19(3):537–42
6. Havas DA, Glenberg AM,
Gutowski KA, Lucarelli MJ,
Davidson RJ. Cosmetic use of
botulinum toxin-a affects
processing of emotional language.
Psychol Sci 2010; 21(7): 895–900
7. Neal DT, Chartrand TL.
Embodied emotion perception:
amplifying and dampening facial
feedback modulates emotion
perception accuracy. Soc Psychol
Personal Sci 2011; doi:
10.1177/1948550611406138
8. Wollmer MA, de Boer C, Kalak N
et al. Facing depression with
botulinum toxin: a randomized
controlled trial. J Psychiatr Res
2012; 46(5): 574–81
| DEPRESSION | OPINION
cosmetic changes from psychometric
raters, participants wore an opaque
surgical cap, which covered the glabella
and forehead during examinations.
The study concluded — for the first
time — that a single botulinum treatment of
the glabellar region with BOTOX could
reducethesymptomsofmajordepression.
This effect developed within a few weeks
and persisted until the end of the 16-week
follow-up period. The effect sizes in the
study were large and the response and
remission rates high. It is still unknown
how botulinum toxin actually reduces
depression and it is postulated that a
number of mechanisms may be involved.
As a result of the clinical data relating to
botulinum toxin treatment on emotional
perception, it is assumed that reduced
proprioceptive feedback from the
paralysed facial muscles is a relevant
mechanism of mood improvement.
As the authors did not include patients
who were cosmetically concerned about
their frown lines, it is unreasonable to
assume that an aesthetic benefit was the
major cause of mood improvement.
There is a small possibility of either
placebo effect or central pharmacological
botulinum toxin effects, including
possible pharmacodynamics or
pharmacokinetic interactions with
concomitant antidepressant therapy.
The ‘Botox Paradox’
So, who is correct? Does Botox reduce or
augment depression? How can the
findings of Dr Lewis be in complete
contrast to those of other researchers? I
believe that both are correct, and that the
answer to tise apparent medical paradox
lies with the original theories of Darwin.
Dr Lewis and colleagues found that
people treated for another muscle
(around the crows’ feet) left patients
feeling more depressed. This does not
contravene Darwin’s original hypotheses;
in fact it supports it. The muscles around
the eye are related to happiness and
smiling, and to restrict their movement
must interfere with the facial feedback
hypotheses in a converse way to those in
the glabellar area. We can only assume
that reduced proprioceptive feedback
from these paralysed facial muscles is a
relevant mechanism of mood
deterioration, and this is why they may
increase depression. Accordingly,
happiness can make you smile and
smiling can make you happy. It is obvious
that the facial musculature not only
expresses, but also regulates, mood states.
Botulinum toxin injection interferes with
the ‘facial feedback hypothesis’ originally
postulated by Darwin. (Perhaps it was my
sixth sense, but I never felt right about
totally removing crow’s feet around a
patient’s eyes.)
Conclusions
Thereisgrowingevidencethatbotulinum
toxin injection to the glabellar region may
be an effective, safe, and sustainable
intervention in the treatment of
depression. The reason for this has not
yet been fully evaluated, but we must
consider the concept that the facial
musculature not only expresses, but also
regulates, mood states. Owing to the
longer intervals between treatments, it
may also be an economic option, and the
safety and tolerability record of
botulinum toxin injections to the
glabellar region is excellent.
However, further studies are required,
including focus on muscles in the lower
sections of the face. It is possible that
treatment of the depressor angularis oris
and the mentalis muscles, for example,
may also have mood-elevating effects,
and may enhance the clinical effect of the
glabellar injection of botulinum toxin.
Modulation of mood states with
botulinum toxin may also be effective in
the treatment of other clinical conditions
involving negative emotions, like anxiety
disorders. There have also been recent
studies investigating the possibility of
botulinum toxin for bipolar disorder and
post-traumatic stress disorder (PTSD).
It is paramount to remember that
botulinum toxin to the glabellar region
may be an effective, safe, and sustainable
intervention in the treatment of
depression. The reason for this has not yet
been fully evaluated, but we must
consider the concept as depression
affects a huge number of people, making
it one of the leading causes of disability
worldwide.

PatrickTreacypresentsanovelmethodforfullfacial
rejuvenation,whichcombinesanumber
oftreatmentstoobtainthemostoptimumresults
KEYWORDS
fractionalised laser resurfacing,
platelet-rich plasma,
microneedling, Omnilux 633 nm
light, neurotoxin
Objective
The DUBLiN Lift: To establish the
clinical effectiveness of combining
five treatments in the rejuvenation of
the ageing face in an effort to increase
aesthetic effect, patient safety, and
reduce laser downtime.
The face is the area for which the majority
of patients seek cosmetic rejuvenation as
the convex lines of a youthful appearance
tend to flatten and droop as one grows
older. The younger face is characterised by
a balance captured in the classic shape of
the inverted triangle. The reversal of this
‘triangle of beauty’ as ageing proceeds
is considered generally less aesthetically
appealing1
. At present, a variety of different
dermatologic and volumising treatments
are available for facial rejuvenation. These
include chemical peels, dermal fillers,
intense pulsed light and radiofrequency
lasers, platelet-rich plasmas (PRP)
microneedling, microdermabrasion,
botulinum toxin injections, and laser
resurfacing. Each treatment has its own
relative beneﬁt, as well as risks2, 3
.
In recent years, facial rejuvenation
has been revolutionised with the
development of CO2
fractional laser skin
resurfacing. This procedure benefits
from faster recovery time, more precise
control of ablation depth, and reduced
risk of post-procedural problems.
However, there have been cases of
hypopigmentation, hypertrophic scars
and skin mottling, most often seen on
the face, neck and chest when the laser
parameters are used more aggressively4
.
Furthermore, the technique does not
attend to chronological ageing problems
such as volume deficits resulting from
the loss and repositioning of facial fat.
This article examines the possibility
of combining five established therapies
in an attempt to address these deficits.
The facial rejuvenating therapies include
microneedling, low-dose UltraPulse
laser, PRP growth factors, Omnilux
633 nm light, and neurotoxins. The
technique is called the DUBLiN facelift as
an acronym of the procedures involved:
Dermaroller, UltraPulse laser, Blood
growth factors, Light (near-red 633 nm),
and Neurotoxin.
The author compared this method
to fractional laser skin resurfacing with
regard to the reduction of photoageing
and overall aesthetic effect. Neurotoxin
was used in both arms of the study.
DR PATRICK TREACY is
Medical Director of Ailesbury
Clinics Ltd and Ailesbury Hair
Clinics Ltd; Chairman of the
Irish Association of Cosmetic
Doctors and Irish Regional
Representative of the British
Doctors; European Medical
Advisor to Network Lipolysis
and the UK’s largest cosmetic
website Consulting Rooms. He
practices cosmetic medicine
in his clinics in Dublin, Cork,
London and the Middle East
ABSTRACT
T
HE FACE, AND
particularly the eyes, is
very important for contact
between humans, as this
area provides a window to
the rest of society with
regard to a patient’s level of health,
tiredness and emotional status, as well as
interest in others4
. Many health
professionals consider the periorbital area
of the face as the most important area
of rejuvenation as eye‑to-eye
communication occurs in approximately
80% of all human interactions6
. Both areas
present a barometer of a patient’s
chronological and environmental age, and
mastering the proper evaluation and
execution of their aesthetic rejuvenation is
paramount for all cosmetic doctors.
More recently, patients are seeking
effective facial rejuvenation procedures
with less downtime and low risks7
. This
change in attitude has been prompted by
a realisation of both doctors and patients
that the much hyped non-ablative
methods were often subject to
extravagant claims in terms of efficacy2–4
.
For many years, CO2
laser resurfacing was
considered the ‘gold standard’ in treating
photodamaged facial skin6–11
. Cutaneous
laser resurfacing with a fractional (CO2
)
laser involves the vapourisation of the
entire epidermis, as well as a variable
thickness of the dermis. Many physicians
stated that the ultrapulsed CO2
laser was
the most effective method of laser
resurfacing12–13
. Photodamaged skin is the
result of years of exposure to harmful
ultraviolet light and is clinically
demonstrated as a gradual deterioration
of cutaneous structure and function. This
results in the epidermis and upper
papillary dermis having a roughened
surface texture, as well as laxity,
telangiectasias, wrinkles and variable
degrees of skin pigmentation14–15
.
Although ultrapulsed CO2
resurfacing
lasers were considered the best
COMBININGTHERAPIESFORTHEAGEINGFACE:
THE DUBLiN
LIFT
More
recently, patients
are seeking
effective facial
rejuvenation
procedures with
less downtime
and low risks.

noted in these areas25
. Scarring after fractional CO2
laser
therapy is considered mainly a result of overly-aggressive
treatments and a lack of technical finesse. Physicians
have also recorded post‑operative infections leading to
scarring, although it is generally felt that these may be
prevented by careful history-taking, vigilant
post‑operative monitoring, and/or the use of prophylactic
antibiotics26, 27
.
With regard to facial rejuvenation, CO2
laser light at a
10 600 nm wavelength results in vapourisation with
thermal denaturation of type I collagen, collagen
shrinkage and later, collagen deposition. However, in
very deep rhytides, acne scarring and severe elastotic
changes from sun damage, fractional CO2
therapy
requires multiple treatments to achieve the same results
as the older lasers28
. A number of studies have evaluated
using different laser combinations in the same session in
order to improve collagen deposition, with a wider zone
of ﬁbroplasia6–9, 28
. Owing to the inherent risks of fractional
laser skin resurfacing and its inability to deal with some
evidence of chronological ageing, it was advocated to
here establish the clinical effectiveness of using a
multi‑procedural approach to volumisation and collagen
regeneration. The author used microneedling with low
energy laser, and platelet rich plasma (PRP) to address
these issues.
Collagen remodelling and fibroblast
stimulation
It is recognised that the most important rejuvenation
process for photoaged skin is the collagen remodelling
process, and dermal fibroblasts are known to have the
most important function29
. Rejuvenation of skin injury
caused by UV light is a complex process that organically
involves cytokines interacting with a number of growth
factors and control proteins28
. The procedures evaluated
included PRP, microneedling, and Omnilux 633 nm
near‑red light, with neurotoxins as an adjunct to low-level
fractional laser skin resurfacing. Cells in the epidermis
and dermis can be targeted by microneedling and
Care should
be taken when
treating sensitive
areas such as the
eyelids, upper
neck, and
especially the
lower neck and
chest, by using
lower energy and
density, as scarring
has been noted in
these areas.
Figure 1 Omnilux 633 nm light
for fibroblast stimulation
Figure 2 Blood post-centrifuge, showing the platelet layer Figure 3 Injecting PRP in the periorbital area
treatment option, they had many post-procedural
problems16, 17
, including prolonged post‑operative
recovery, pigmentary changes, and a high incidence of
acne flares and herpes simplex virus (HSV) infection18, 19
.
Many patients complained of oedema, burning, and
erythema that sometimes lasted for many months20, 21
.
The implied risks and long downtime made many
patients reluctant to accept this method of treatment22, 23
.
More recently, fractional resurfacing lasers have
addressed many of these earlier problems with benefits
of faster recovery time, more precise control of ablation
depth, and reduced risk of post procedural problems8
.
These lasers are extremely versatile, in that they can be
used for the treatment of facial rhytides, acne scars,
surgical scars, melasma and photodamaged skin, and
many have entered the market at the same time24
.
With the advent of fractional laser skin resurfacing, the
number of completely ablative resurfacing cases has
declined for most practitioners. However, care should be
taken when treating sensitive areas such as the eyelids,
upper neck, and especially the lower neck and chest, by
using lower energy and density, as scarring has been

Patient histology Carbon dioxide laser ablative fractionalisation
near‑red light, resulting in fibroblast stimulation. Omnilux
Revive™ (633 nm) therapy stimulates fibroblast activity,
leading to faster and more efficient collagen synthesis
and extracellular matrix (ECM) proteins. It also increases
cell vitality by increasing the production of cellular
adenosine triphosphate (ATP) and stimulates the
contractile phase of the remodelling process producing
better lineated collagen30–33
. Collagen induction therapy is
an aesthetic medical procedure that involves repeatedly
Parameter 0 1 2 3 4
Global score Area of Area of Area of Area of Area of
roughness roughness roughness roughness roughness
x 0 x 1 x2 x3 x4
Fine lines None Rare Several Moderate Many
Pigmentary
None Patchy Moderate Heavy Marked
problems
Touch
Even Rare Mild Moderate Severe
problems
Facial veins None Rare Several Moderate Severe
Coarse lines None Rare Several Moderate Many
Complexion Pink Pale Grey Slightly Distinct
yellow-grey
Parameter 0 1 2 3 4
Erythema severity None Rare Several Moderate Severe
Infective outbreak
None Rare Several Moderate Severe(herpes/acne)
Crusting None Rare Several Moderate Severe
Pain of
None Mild Tolerable Moderate Severe
procedure
Improvement None Minimal Fair Good Excellent
Group 1 patient showing ablative
CO2
laser penetration to 118 nm.
Depth range 113 microns
Group 2 patient showing collagen
formation at 3 months, representing
a skin biopsy from a Group 2 patient
3 months post-treatment. Depth
range 118 microns
Group 2 patient at Phase 3. Depth
range 85 microns
Group 1 patient showing collagen
formation at 3 months. Depth range
700 microns
All skin biopsies show the effect of thermal treatment with thermal coagulation
of the epidermis and superficial dermis
puncturing the skin with tiny, sterile needles. Typically,
this is done with a specialised instrument called a
microneedling device.
Controlled studies have suggested that the application
of autogenous PRP can enhance wound healing in both
animals and humans29
. Five major growth factors such as
transforming growth factor (TGF), insulin-like growth factor
(IGF), platelet-derived growth factor (PDGF), epidermal
growth factor (EGF), and vascular endothelial growth
factor(VEGF)areknowntoberelatedtothewound-healing
processes28
. These growth factors are released from
platelets, and the production of collagen and fibroblasts is
stimulated by IGF, EGF, Interleukin-1 (IL‑1) and tumour
necrosis factor (TNF)-α34, 35
. In vivo studies report TGF-β to be
the most stimulative growth factor. PRP may be used for
dermal augmentation and Sclafani observed aesthetic
improvements of the nasolabial fold in less than 2 weeks,
and the results lasted for up to 3 months28, 29
.
Research design and methods
This multi-centre randomised study included 44 patients
of skin types 1 and 2 aged between 39 and 68 years,
presenting with photoageing of the skin, 37 of whom
were women and seven were men. The subjects
presented with the typical hallmarks of chronological
and photoageing, such as expression lines, rhytides,
wrinkles, eyelid skin laxity, dermatochalasis, lowered
brows, lateral hooding, and prominent fat pads. All
patients were subjected to a programme of skin
tightening and neocollagenesis by one of two methods:
conventional fractional laser skin resurfacing (Group 1) or
the DUBLiN Lift (Group 2). The mean patient age in Group
1 was 49 years (range 37–71 years) and in Group 2 was 55
years (range 41–76 years).
Fifteen patients underwent Lumenis ActiveFX™ with
settings as (energy) 125 mJ and (rate) 19 w CPG 3/5/4.
Twenty-nine patients received the DUBLiN Lift, a
three‑phase combination of established treatments with
microneedling, platelet growth hormones, near-red
633 nm light, and low-energy UltraPulse fractional CO2
Table 1 Patient treatment (positive) scoring chart
Table 2 Patient treatment (negative) scoring chart
yellow-grey

laser skin tightening. All patients received Dysport® in
three areas 1 week prior to the other treatments as an
adjunct to the laser resurfacing.
The DUBLiN Lift was introduced as three phases over a
period of 3 weeks. Phase 1 included Dysport® at dilution
3.5 : 1 to three areas — glabellar, frontalis and periorbital.
Phase 2 introduced intense fibroblast stimulation and
modification through microneedling, PRP growth factor
induction, and near-red phototherapy. Phase 3
administered the low–level (CO2
) UltraPulse laser at
100 mJ 14 w CPG 3/5/2, and adjunct near-red 633 nm
phototherapy. The study evaluated post-procedural
aesthetic results at 2 weeks, 4 weeks and 12 weeks. The
length of downtime, patient discomfort and adverse
side‑effects were noted for each phase.
Clinical assessment of patients in each group was
made at 2 weeks, 1 month and 3 months post‑operatively
in the presence of two aesthetic staff. The degree of
improvement in photoageing was based on the degree of
re-epithelialisation rate, reduction of rhytides, reduction
of tactile roughness, and loss of hyperpigmentation and
telangiectasias. The prolongation and severity of
erythema as well as the presence of negative side-effects
(e.g. herpes) were also recorded.
The efficacy of treatment was evaluated using a
variation of the five-point scale (Table 1) originally
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
DEGREE DESCRIPTION
5 Extreme Extremely deep and long folds, detrimental to facial appearance
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
appearance, but not when stretched
2 Mild Shallow but visible fold with a slight indentation;
minor facial feature
1 Absent No visible nasolabial fold; continuous skin, injectable
implant alone
DEGREE DESCRIPTION
1 Exceptional improvement Excellent corrective result at week 12. No further
treatment required
2 Very improved patient Marked improvement of appearance, but not
completely optimal
3 Improved patient Improvement of the appearance, better compared with
the initial condition. Touch-up is advised
4 Unaltered patient The appearance substantially remains the same
compared with the original condition
5 Worsened patient The appearance has worsened compared with the
original condition
global score was recorded in each patient based on the
addition of points obtained from six photodamage
variables. The degree of perceived improvement in
overall aesthetic effect reflecting chronological age was
assessed separately by patients and physicians using the
Wrinkle Severity Rating Scale (WSRS) and the Global
Aesthetic Improvement Scale (GAIS). The WSRS is
recognised as a valid and reliable instrument for
quantitative assessment of facial skin folds, with good
inter- and intra-observer consistency5
. Wrinkle severity is
measured using a wrinkle severity rating scale with 1
being absent and 5 being extreme. By allowing objective
grading of data, these proved useful clinical tools for
assessing the effectiveness of facial volumisation with
PRP and microneedling–633.
Interventions
The following treatment protocols were used for this study:
Lumenis ActiveFX CO2
laser, Traylife PRP, Omnilux 633 nm
red light, Dermaroller®, and Dysport®. All participants
received selective regional anaesthesia blocks with 2%
lignocaine plus adrenaline, a topical combination
anaesthetic of 23% lignocaine, and prophylactic Valtrex
500 mg twice daily for 8 days. Valium 5–10 mg stat was
given as a pre-medication to some patients. A post-
procedural advice sheet and Nurofen or codeine with
paracetamol — as required — was also given to patients.
Clinical assessment of patients in
each group was made at 2 weeks, 1
month and 3 months post‑operatively in
the presence of two aesthetic staff.
Table 3 Wrinkle Severity Rating Scale (WSRS) patient
scoring chart
Table 4 Global Aesthetic Improvement Scale (GAIS)
Figure 4 Patients before
(A, C) and after (B, D) the
DUBLiN Lift

■■ Infraorbital nerve block. 1 cc of 1–2% Lidocaine
injected into the buccal cavity with the needle
directed towards the infraorbital foramen
■■ Mental nerve block. 1 cc of 1–2% Lidocaine injected
into the mental foramen just above the bone level.
Group 2: DUBLiN lift
Phase 1
Dysport® treatment to three areas: glabellar, frontalis and
periorbital.
Phase 2 (Week 2)
Microneedling Topical anaesthesia: benzocaine 20%,
Lidocaine Base 6%, and tetracaine 4%.
Each patient received Chiroxy cream post-procedure
to reduce erythema and inflammation. Tepid water
Figure 5 Patient in differing
phases of DUBLiN Lift
The ActiveFX is a protocol of settings applied in
conjunction with an improved computer pattern
generator to the ultrapulsed CO2
laser (UltraPulse
ENCORE, Lumenis Ltd). Technical differences between
this non-sequential fractional device and the older
ultrapulsed CO2
include tissue bridges left between spots,
resulting in faster healing time, and less thermal damage
to the basal cell membrane. The device has a smaller
spot size (1300 mm rather than 2500 mm), resulting in
less post-procedure erythema.
The computer pattern generator lays down a random
series of spots rather than a sequential sequence
resulting in less overheating of the treated tissue. This
application is termed ‘Cool Scan’, and was used with
every patient in the study.
The Traylife Kit (PRP) (Promoitalia Wellness Research)
provides blood plasma enriched with a concentrated
source of autologous platelets that releases a number of
growth factors and other cytokines that stimulate the
healing of soft tissue.
Omnilux Revive™ (633 nm) (Photo Therapeutics, Inc.,
UK) stimulates fibroblast activity, leading to faster and
more efficient collagen synthesis and extracellular
matrix proteins.
Dermaroller™ Collagen Induction Therapy (CIT)
(AesthetiCare®, UK) is a minimally-invasive cosmetic
procedure that involves the use of a micro-needling
device.
Scoring charts are presented in Tables 1–4.
Group 1: fractional laser skin
resurfacing
Phase 1
Dysport® treatment to three areas: glabellar, frontalis and
periorbital.
Phase 2 (Week 2)
Lumenis ActiveFX with settings (energy) 125 mJ (rate)
1 9w CPG 3/9/4
In the pre-laser procedure, the author typically
prescribes Valium (Diazepam 5–10 mg orally) for anxiety,
administered 45 minutes before the procedure.
For infection prophylaxis, Famvir (famciclovir) 750 mg
daily or Valtrex (valcyclovir) 500 mg twice per day for 7
days, was prescribed for every patient starting 3 days
before procedure. If the patient had a strong history of
acne, By-Mycin (doxycycline 100 mg daily) or Keflex
(cephalexin 500 mg twice per day) was prescribed for
7 days, beginning on the day of surgery. Diflucan
(fluconazole 150 mg) was not routinely prescribed in any
patient.
The patients were treated under topical and regional
anaesthesia. Topical anaesthesia comprised benzocaine
20%, Lidocaine Base 6%, and tetracaine 4%. Regional
anaesthesia was three-fold:
■■ Supraorbital and supratrochlear nerve block. The
supraorbital foramen was located and 1 cc of 1–2%
Lidocaine injected just above the bone laterally, with
the needle directed medially, parallel to the brow and
toward the nose

was used to cleanse the face for the following 48 hours,
and dried gently. It was recommended that make-up was
not applied for 12 hours after the procedure. After the
procedure, a broad-spectrum UVA/UVB sunscreen with
SPF 50 was recommended for use.
PRP preparation 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 chloride). Withdraw platelets and
mix with the DNA Activator.
Multiple injections (0.05–0.1 ml for a single injection)
were applied to the intra/sub dermis using the
‘multi‑pricking’ or retrograde linear techniques
Omnilux 633 nm LED This was applied for 20 minutes
per session (126 J/cm2
).
Phase 3 (Week 3)
Low-level UltraPulse Lumenis ActiveFX with settings
(energy) 100 mJ (rate) 14 w CPG 3/5/2.
Omnilux 633 nm LED This was applied for 20 minutes
per session (126 J/cm2
).
Histology Skin biopsies were obtained
from five of the patients intra-operatively,
before Phase 2 of the treatment and at
3 months post-operatively, and were
performed to determine the amount of
epidermal damage, subsequent
inflammation, and new collagen synthesis.
The extent of neocollagenesis was
Figure 6 Cachexic patient
with volumisation post PRP/
DUBLiN Lift
compared with data on file for patients who had skin
biopsies for laser resurfacing and neurotoxin alone in
2007. Each 1 cm by 1 cm piece of skin was fixed with 10%
formalin solution, neutral buffered. After treatment with
polyester wax, the skin samples were sliced into 6 μm
thicknesses. The sliced sections were treated with
haematoxylin and eosin statin (H&E) and Masson’s
trichrome staining solutions. Through tissue evaluations,
thethicknessofthedermallayerandpresenceofcollagen
fibres were observed. The thickness of the dermal layer
was calculated by measuring five different sites from
each section, and the mean value of the thickness of the
dermallayerforeachgroupwasusedforthecomparison.
Results
Over 3 months, 29 subjects (Group 2) were selected to
compare the effect of low energy fractional laser skin
resurfacing with adjunctive treatments to conventional
ablative laser resurfacing. These patients received a
three‑phase combination of established treatments with
neurotoxin, microneedling, platelet growth hormones,
near-red633 nmlight,andlow-energyUltraPulsefractional
CO2
laser skin tightening over a 3-week period. Phase 1
included the administration of Dysport® neurotoxin to the
upper face. Phase 2 introduced fibroblast
stimulation from microneedling and PRP
growth factor induction with near-red
phototherapy, and Phase 3 included
low‑level (CO2
) UltraPulse laser with adjunct
near-red 633 nm phototherapy. Results were
compared to the remaining 15 patients
(Group 1) who received fractional laser skin
resurfacing (125 mJ; 19 w CPG 3/5/4), and
Over 3 months, 29 subjects
(Group 2) were selected to compare
the effect of low energy fractional
laser skin resurfacing with adjunctive
treatments to conventional ablative
laser resurfacing.

Investigator-based and patient-
based ratings using both the WSRS
and GAIS indicated that the DUBLiN
lift was more effective than
conventional ablative laser
resurfacing in creating cosmetic
correction to the lower face.
whose data was already on file. Patients in both groups
were administered Dysport® neurotoxin 1 week prior to
treatment to complement and preserve the overall
aesthetic effect. The study evaluated post-procedural
aesthetic results at baseline, 6 weeks and 12 weeks by
means of a scoring system based on Dover’s photoageing
scale, as well as using the WSRS and GAIS.
Histological results were obtained from both groups
showingthedepthoflaserpenetrationandconsequential
formation of new collagen. All skin biopsies showed
thermal coagulation of the epidermis and superficial
dermis in a depth ranging from 85 to 113 µ. The zone of
residual thermal (coagulative) damage was less in the
Group 2 patients, in whom less laser energy was used.
The best neocollagenesis results — at 3 months — were
evident in Group 1 where one patient had evidence of
effect at 700 µ. This was reflected in the patient’s skin,
which continued to improve over the period. Owing to
the variance in energy of the CO2
laser in Group 1 and
Group 2, it was expected that the documented depth of
histological ablation and thermal effects would vary
between them. Responses of aesthetic effect were
evaluated at 6 and 12 weeks after baseline.
The two methods appeared to produce different
clinical improvement of lesions and rhytides. The GAIS
for photoageing for the DUBLiN lift improved from 13.2 to
10.2 at day 30. This compared to 13.8 at baseline and 9.6 at
day 30 for conventional fractional laser skin resurfacing
alone. The score for fine lines was the most significant
reduction, dropping from 3.6 at baseline to 1.4 at day 30.
The score for reduction of coarse wrinkles (3.2 at baseline
to 2.2 at 6 weeks) was more difficult to interpret in this
heterogeneous age grouping, with older patients
requiring the conventional ActiveFX settings rather than
the ‘softer’ settings.
According to investigator-based WSRS and GAIS
assessments at 3 months after baseline, the DUBLiN lift
was superior in 62% and 55.2% of patients respectively,
while fractional laser skin resurfacing was superior in
33.3% and 34.4% of patients. (P < 0.0004). An ‘optimal’
cosmetic result was achieved in a higher percentage of
patients in Group 2 compared with Group 1.
Investigator-based and patient-based ratings using both
the WSRS and GAIS indicated that the DUBLiN lift was
moreeffectivethanconventionalablativelaserresurfacing
in creating cosmetic correction to the lower face. This
resulted from the volumising effect of adding
PRP to the larger folds in this area. At 3 months
post‑treatment, a higher proportion of patients
showed a greater than or equal to 1-grade
improvement in WSRS with the DUBLiN Lift
compared with fractional laser skin resurfacing.
The author suspects the PRP may have a longer
aesthetic effect when used in association with
microneedling and 633 nm light than previously
noted27, 29
. However, the results were almost
reversed whenever periorbital rejuvenation was
assessed alone, with almost every patient (93%)
favouring conventional fractional laser skin resurfacing.
Investigator-based GAIS assessment of this region at 3
months after baseline indicated that fractional resurfacing
was superior in 93% of patients, while the DUBLiN Lift was
superior in 6.8% of patients (P = 0.0025).
Objective results
Re-epithelialisation occurred in all
laser-treated areas of both groups by
day 7, and this appeared to be clinically
similar for both procedures. Mean
duration of erythema was 6.9 days
after resurfacing (range 4–10 days) in
Group 1 and 4.2 days in Group 2 (range
3–7 days). This appeared to be in
keeping with previous studies37
. All
patients reported having no ‘crusting’
effect remaining on their face after 6 days. Residual
erythema remained in one patient in Group 1 for a
Further reading
☛ Alster TS, Nanni CA. Famciclovir prophylaxis of herpes
simplex virus reactivation after laser skin resurfacing.
Dermatol Surg 1999; 25(3): 242–6
☛ Alster TS. Side effects and complications of laser
surgery. In: Alster TS. Manual of Cutaneous Laser
Techniques. Philadelphia: Lippinco, 2000
☛ Avram MM, Tope WD, Yu T, Szachowicz E, Nelson JS.
Hypertrophic scarring of the neck following ablative
fractional carbon dioxide laser resurfacing. Lasers Surg
med 2009; 41(3): 185–8
☛ Baez F, Reilly LR. The use of light-emitting diode
therapy in the treatment of photoaged skin. J Cosmet
Dermatol 2007; 6(3): 189–94
☛ Berlin AL, Hussain M, Phelps R, Goldberg DJ.
Treatment of photoaging with a very superficial Er:YAG
laser in combination with a broadband light source. J
Drugs Dermatol 2007; 6(11): 1114–8
☛ Bernstein LJ, Kauvar AN, Grossman MC, Geronemus
RG. The short- and long-term side effects of carbon
dioxide laser resurfacing. Dermatol Surg 1997; 23(7):
519–25
☛ Bonan P, Campolmi P, Cannarozzo G et al. Eyelid skin
tightening: a novel ‘Niche’ for fractional CO2
rejuvenation. J Eur Acad Dermatol Venereol 2012; 26(2):
186–93
☛ Burkhardt BR, Maw R. Are more passes better? safety
versus efficacy with the pulsed CO2 laser. Plast Reconstr
Surg 1997; 100(6): 1531–4
☛ Cotton J, Hood AF, Gonin R, Beeson WH, Hanke CW.
Histologic evaluation of preauricular and postauricular
skin after high-energy, short-pulse carbon dioxide laser.
Arch Dermatol 1996; 132(4): 425–8
☛ Day DJ, Littler CM, Swift RW, Gottlieb S. The
wrinkle severity rating scale: a validation study.
Am J Clin Dermatol 2004; 5(1): 49–52
☛ Doddaballapur S. Microneedling
with dermaroller. J Cutan Aesthet
Surg 2009; 2(2): 110–1
☛ Goldberg D. Reduced
Down-time Associated with Novel
Fractional UltraPulse CO2
Treatment (Active FX) as
Compared to Traditional
Resurfacing P3115. Presented at
the 65th Annual American
Academy of Dermatology
Meeting
☛ Fitzpatrick RE,
Ruiz-Esparaza J, Goldman
MP. The depth of thermal necrosis using the CO2 laser: a
comparison of superpulsed mode and conventional
mode. J Dermatol Surg Oncol 1991; 17(4): 340–4
☛ Fitzpatrick RE, Tope WD, Goldman MP, Satur NM.
Pulsed carbon dioxide laser, trichloroacetic acid,
Baker-Gordon phenol, and dermabrasion: a comparative
clinical and histologic study of cutaneous resurfacing in
a porcine model. Arch Dermatol 1996; 132(4): 469–71
☛ Kauvar ANB, Waldorf HA, Geronemus R. A
histopathologic comparison of char-free lasers.
Dermatol Surg 1996; 22: 343–8
☛ Lask G, Keller G, Lowe N, Gormley D. Laser skin
resurfacing with the SilkTouch flashscanner for facial
rhytides. Dermatol Surg 1995; 21(12): 1021–4
☛ Lee SY, Park KH, Choi JW et al. A prospective,
randomized, placebo-controlled, double-blinded, and
split-face clinical study on LED phototherapy for skin
rejuvenation: clinical, profilometric, histologic,
ultrastructural, and biochemical evaluations and
comparison of three different treatment settings. J
Photochem Photobiol B 2007; 88(1): 51–67
☛ Majid I. Microneedling therapy in atrophic facial scars:
an objective assessment. J Cutan Aesthet Surg 2009;
2(1): 26–30
☛ Pierce GF, Brown D, Mustoe TA. Quantitative analysis
of inflammatory cell influx, procollagen type I synthesis,
and collagen cross-linking in incisional wounds:
influence of PDGF-BB and TGF-beta 1 therapy J Lab Clin
Med 1991; 117(5): 373–82
☛ Rubach BW, Schoenrock LD. Histological and clinical
evaluation of facial resurfacing using a carbon dioxide
laser with the computer pattern generator. Arch
Otolaryngol Head Neck Surg 1997; 123(9): 929–34
☛ Smith KJ, Skelton HG, Graham JS, Hamilton TA,
Hackley BE Jr, Hurst CG. Depth of
morphologic skin damage and
viability after one, two and three
passes of a high-energy,
short-pulse CO2 (Tru-Pulse)
laser in pig skin. J Am Acad
Dermatol 1997; 37(2 Pt 1):
204–10
☛ Trelles MA, Allones I. Red
light-emitting diode (LED)
therapy accelerates wound
healing post-blepharoplasty
and periocular laser
ablative resurfacing. J
Cosmet Laser Ther 2006;
8(1): 39–42
ARTICLE | FACIAL AESTHETICS |

period of 14 days, but this
was minimal. Post-
operative erythema was
most intense in the areas
treated with the ActiveFX
at an energy level above
125 mJ.
The mean pain sensation (Table 2) felt during the
DUBLiN lift was 2.2 compared to conventional
fractional resurfacing treatment, which was 3.4.
The author noted that most patients did not
feel much pain at all with the ActiveFX
until the energy level crosses 100 mJ. No
patient experienced any adverse
reaction to laser skin resurfacing,
except one case of herpetic infection
in each group (Group 1 6.6%; Group 2
3.4%). Both treatments were well
tolerated. Clumping of platelets
occurred in 10% of patients treated
with PRP and the author felt that
thiswasaresultoftheconcentration
of solution used. In fact, anecdotal
evidence suggests that most
cosmetic physicians are using PPP
(platelet-poor plasma) in most areas of
the face, rather than the higher
concentrations used by orthopaedic
surgeons.
Conclusions
Facial ageing is a consequence of many interacting
intrinsic and extrinsic factors. The most important of
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 None
Figure images © Patrick Treacy
References
1. Raspaldo H. Volumizing effect
of a new hyaluronic acid
sub-dermal facial filler: a
retrospective analysis based on 102
cases. J Cosmet Laser Ther 2008;
10(3): 134–42
2. Cohen JL, Bar A. Fillers for Facial
Rejuvenation. In: Hirsch RJ, Cohen
JL, Sadick N. Aesthetic
Rejuvenation: A Regional
Approach. China: McGraw-Hill
Companies, 2009
3. Hirsch RJ. Dermal Fillers. In:
Sadick N, Moy R, Lawrence N.
Concise Manual of Cosmetic
Dermatologic Surgery. China:
McGraw-Hill Companies, 2008
4. Clementoni MT, Gilardino P, Muti
GF, Beretta D, Schianchi R.
Non-sequential fractional
ultrapulsed C02 resurfacing of
photoaged skin. J Cosmet Laser
Ther 2007; 9(4): 218–25
5. Rohrich RJ, Pessa JE. The fat
compartments of the face:
anatomy and clinical implications
for cosmetic surgery. Plast
Reconstr Surg 2007; 119(7): 2219–27
6. Sadick NS. Update on
non-ablative light therapy for
rejuvenation: a review. Lasers Surg
Med 2003; 32(2): 120–8
7. Williams EF 3rd, Dahiya R.
Review of nonablative laser
resurfacing modalities. Facial Plast
Surg Clin North Am 2004; 12(3):
305–10
8. Grema H, Greve B, Raulin C.
Facial rhytides — subsurfacing or
resurfacing? A review. Lasers Surg
Med 2003; 32(5): 405–12
9. Manuskiatti W, Fitzpatrick RE,
Goldman MP. Long-term
effectiveness and side effects of
carbon dioxide laser resurfacing
for photoaged facial skin. J Am
Acad Dermatol 1999; 40(3): 401–11
10. Fitzpatrick RE, Goldman MP,
Satur NM, Tope WD. Pulsed carbon
dioxide laser resurfacing of
photo-aged facial skin. Arch
Dermatol 1996; 132(4): 395–402
11. Hamilton MM. Carbon dioxide
laser resurfacing. Facial Plast Surg
Clin North Am 2004; 12(3): 289–95
12. Fitzpatrick RE. CO2 laser
resurfacing. Dermatol Clin 2001;
19(3): 443–51
13. Fitzpatrick RE. Maximizing
benefits and minimizing risk with
CO2 laser resurfacing. Dermatol
Clin 2002; 20(1): 77–86
14. Taylor CR, Stern RS, Leyden JJ,
Golchrest BA. Photoaging/
photodamage and
photoprotection. J Am Acad
Dermatol 1990; 22(1): 1–15
15. Lavker RM. Cutaneous aging:
chronological versus photoaging.
In: Gilchrest BA. Photodamage.
Cambridge, MA: Blackwell Science,
1995
16. Fife DJ, Fitzpatrick RE, Zachary
CB. Complications of fractional CO2
laser resurfacing: four cases. Lasers
Surg Med 2009; 41(3): 179–84
17. Nanni CA, Alster TS.
Complications of carbon dioxide
laser resurfacing. An evaluation of
500 patients. Dermatol Surg 1998;
24(3): 315–20
18. Alster T, Hirsch R. Single-pass
CO2 laser skin resurfacing of light
and dark skin: Extended experience
with 52 patients. J Cosmet Laser
Ther 2003; 5(1): 39–42
19. Alster TS. Cutaneous
resurfacing with CO2 and erbium:
YAG lasers: preoperative,
intraoperative, and postoperative
considerations. Plast Reconstr Surg
1999; 103(2): 619–32
20. Alster TS, Lupton JR. Treatment
of complications of laser skin
resurfacing. Arch Facial Plast Surg
2000; 2(4): 279–84
21. Sullivan SA, Dailey RA.
Complications of laser resurfacing
and their management. Ophthal
Plast Reconstr Surg 2000; 16(6):
417–26
22. Berwald C, Levy JL, Magalon G.
Complications of the resurfacing
laser: retrospective study of 749
patients. Ann Chir Plast Esthet
2004; 49(4): 360–5
23. Trelles MA, Mordon S, Svaasand
LO, Mellor TK, Rigau J, Garcia L. The
origin and role of erythema after
carbon dioxide laser resurfacing: a
clinical and histologic study.
Dermatol Surg 1998; 24(1): 25–9
24. Fitzpatrick RE, Rostan EF.
Reversal of photodamage with
topical growth factors: a pilot study.
J Cosmet Laser Ther 2003; 5(1):
25–34
25. Bjerring P.
Photorejuvenation — an overview.
Med Laser Appl 2004; 19: 186–95
26. Chapas AM, Brightman L, Sukal
S et al. Successful treatment of
acneiform scarring with CO2
ablative fractional resurfacing.
Lasers Surg Med 2008; 40(6): 381–6
27. Eppley BL, Pietrzak WS, Blanton
M. Platelet-rich plasma: a review of
biology and applications in plastic
surgery. Plast Reconstr Surg 2006;
118(6): 147e–159e
28. Sadick NS. A study to determine
the efficacy of a novel handheld
light-emitting diode device in the
treatment of photoaged skin. J
Cosmetic Dermatol 2008; 7(4):
263–7
29. Sclafani AP. Applications of
platelet-rich fibrin matrix in facial
plastic surgery. Facial Plast Surg
2009; 25(4): 270–6
30. Bhat J, Birch J, Whitehurst C,
Lanigan SW. A single-blinded
randomised controlled study to
determine the efficacy of Omnilux
Revive facial treatment in skin
rejuvenation. Lasers Med Sci 2005;
20(1): 6–10
31. Russell BA, Kellett N, Reilly LR. A
study to determine the efficacy of
combination LED light therapy (633
nm and 830 nm) in facial skin
rejuvenation. J Cosmet Laser Ther
2005; 7(3–4): 196–200
32. Kim JW. Clinical trial of
non-thermal 633nm Omnilux LED
array for renewal of photoaging:
Clinical Surface Profilometric
Results. Journal of the Korean
Society for Laser Medicine and
Surgery 2005; 9: 69–76
33. Fabbrocini G, De Vita V, Pastore
F et al. Collagen induction therapy
for the treatment of upper lip
wrinkles. J Dermatolog Treat 2012;
23(2): 144–52
34. Stebbins WG, Hanke CW.
Ablative fractional CO2 resurfacing
for photo aging of the hands: pilot
study of 10 pateints. Dermatol Ther
2011; 24(1): 62–70
35. Goldman MP, Marchell N,
Fitzpatrick RE. Laser skin
resurfacing of the face with a
combined CO2/Er: YAG laser.
Dermatol Surg 2000; 26(2): 102–4
36. Dover JS, Bhatia AC, Stewart B,
Arndt KA. Topical 5-aminolevulinic
acid combined with intense pulsed
light in the treatment of
photoaging. Arch Dermatol 2005;
141(10): 1247–52
37. Lowe NJ, Lask G, Griffin ME,
Maxwell A, Lowe P, Quilada F. Skin
resurfacing with the Ultrapulse
carbon dioxide laser. Observations
on 100 patients. Dermatol Surg
1995; 21(12): 1025–9
Facial ageing is a consequence of many interacting
intrinsic and extrinsic factors. The most important of these
include sun exposure or photoageing, and the intrinsic
changes associated with chronological ageing.

eventsIndustryeventsin2014–15
fortheaestheticand
anti-ageingmarket
24–25 OCTOBER 2014
2nd AMEC
Paris, France
www.euromedicom.com
19–21 NOVEMBER 2014
myRhinoplasty 2014
London, UK
www.aesculap-academia.co.uk
BAPRAS Winter Scientific
Meeting 2014
London, UK
http://tinyurl.com/p8nwkeg
BODY Conference &
Exhibition
London, UK
www.bodyconference.co.uk
29 JANUARY–1 FEBRUARY 2015
IMCAS Paris
Paris, France
www.imcas.com
5–8 MARCH 2015
12th EADV Spring
Symposium
Valencia, Spain
www.eadv.org
7–8 MARCH 2015
ACE 2015
London, UK
www.ace2014.co.uk
26–28 MARCH 2015
13th AMWC
Monte Carlo, Monaco
www.euromedicom.com
4–6 JUNE 2015
Beauty Through
Science
Stockholm, Sweden
www.beautythroughscience.com
6–10 JULY 2015
18th World congress IPRAS
Vienna, Austria
www.ipras.org
31 OCT–1 NOVEMBER 2014
3rd Marrakech World
Aesthetic Conference
Marrakech, Morocco
www.mwacongress.com
IMCAS India
Goa, India
www.imcas.com/en/india2014/congress
10th National Laser &
Cosmetic Medicine
Conference
Melbourne, Australia
www.dcconferences.com.au/lcmc2014/
1st AMWC
Latin America
Medellin, Colombia
www.euromedicom.com
EUROPE REST OF WORLDNORTH AMERICA
6–9 NOVEMBER 2014
QMP’s 10th
Aesthetic
Surgery Symposium
Chicago, Illinois
www.qmp.com
6–9 NOVEMBER 2014
ASDS Meeting
2014
San Diego,
California
www.asds.net
3–6 DECEMBER, 2014
Cosmetic Surgery
Forum
Las Vegas, NV
www.cosmeticsurgeryforum.com
4–6 DECEMBER, 2014
The Cutting Edge
2014
New York, NY
www.nypsf.org
| EVENTS

July/August 2014
Volume 4 ❙Issue 5
Farjo Hair Institute ❚Hair Restoration Market ❚Patient Testimonials ❚Product News ❚Events
ACNE AND
ACNE SCARS
ENERGY BASED
TREATMENTS
MALE BODY
IMPLANTS
MUSCULAR
ENHANCEMENT
ACNE IN
ADULT
WOMEN
CAUSES, TRIGGER
FACTORS AND
TREATMENT
OPTIONS
HAIRLOSS
withpolynucleotides
Treatingfemalehormonal
September 2014
Volume 4 ❙Issue 6
Hand Rejuvenation ❚ISAPS Surgical Relief Teams ❚AMEC Preview ❚Industry News ❚Events
Thefightagainst
SKINAGEING
Dietandnutraceutical
interventions
DERMAL
FILLER INDUCED
FACIAL ARTERY OCCLUSION
SUSPENDING
THREADS
FOR FACIAL REJUVENATION
A NEW TOPICAL
SLIMMING TREATMENT
CLINICAL EFFECTIVENESS
Has now been published for 4 years and has
received high acclaim from its thousands of
regular readers around the world for its unique
coverage of the latest news, features, reports,
and products in the field of aesthetic and
anti-ageing medicine.
➲PRIME will provide you with access to the best
peer-reviewed information available to keep you at
the cutting-edge of the industry.
➲PRIMEdraws on expertise from across the
aesthetic and anti-ageing medical market.
➲PRIME is the only publication to provide
comprehensive coverage of the global aesthetic
and anti-ageing disciplines.
➲PRIMEwill give you practical information and
case studies, enabling you to provide your patients
and clients with the latest techniques and best
possible care.
If you wish to receive PRIME in hard copy printed
format for the next 12 months please contact:
Brian Waller, Prime Journal, Informa Business
Information, Christchurch Court,
10–15 Newgate Street, London EC1A 7AZ, UK.
Email: brian.waller@informa.com
Subscription rates
UK £295 Europe €370 Rest of world US$490

PRIME Supplement - Dr. Patrick Treacy

Recommandé

Recommandé

Contenu connexe

Tendances

Tendances (20)

Similaire à PRIME Supplement - Dr. Patrick Treacy

Similaire à PRIME Supplement - Dr. Patrick Treacy (20)

Plus de Dr. Patrick J. Treacy

Plus de Dr. Patrick J. Treacy (20)

Dernier

Dernier (20)

PRIME Supplement - Dr. Patrick Treacy