Dublin Lift by Patrick Treacy

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It concludes that although fractionalised CO2 laser resurfacing is recognised as the gold standard procedure for tissue that has lost its elasticityit has adverse risks and does not adequately address …

It concludes that although fractionalised CO2 laser resurfacing is recognised as the gold standard procedure for tissue that has lost its elasticityit has adverse risks and does not adequately address the problems associated with chronological aging. He addresses the requirement to apply adjunct methods such as plasma rich platelets to address nasolabial or marionette lines and volume deficits resulting from the loss and repositioning of facial fat. It establishes the benefit of using other facial rejuvenating therapies including microneedling, PRP growth factors, 633 nm light to limit the depth of laser penetration and decrease the risk of scarring and permanent pigmentary alteration. The novel 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.

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  • 1. ARTICLE | facial aesthetics | Combining therapies for optimal outcomes in treating the ageing face: introducing the DUBLiN Facelift Patrick Treacy presents a novel method for full facial rejuvenation, which combines a number of treatments to obtain the most optimum results ABSTRACT Objective radiofrequency 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 UltraPulse laser, The face is the area for which the majority of revolutionised with the development of PRP growth factors, Omnilux 633 nm patients seek cosmetic rejuvenation as the CO2 fractional laser skin resurfacing. This light, and neurotoxins. The technique is convex lines of a youthful appearance tend procedure benefits from faster recovery called the DUBLiN facelift as an acronym to flatten and droop as one grows older. The time, more precise control of ablation of the procedures involved: Dermaroller, younger face is characterised by a balance depth, and reduced risk of post-procedural UltraPulse laser, Blood growth factors, LightDr Patrick Treacy is captured in the classic shape of the inverted problems. However, there have been cases (near-red 633 nm), and Neurotoxin.Medical Director of Ailesbury triangle. The reversal of this ‘triangle of of hypopigmentation, hypertrophic scarsClinics Ltd and Ailesbury Hair beauty’ as ageing proceeds is considered and skin mottling, most often seen on The author compared this method toClinics Ltd; Chairman of the generally less aesthetically appealing1. At the face, neck and chest when the laser fractional laser skin resurfacing with regardIrish Association of Cosmetic present, a variety of different dermatologic parameters are used more aggressively4. to the reduction of photoageing and overallDoctors and Irish Regional and volumising treatments are available for Furthermore, the technique does not attend aesthetic effect. Neurotoxin was used inRepresentative of the British facial rejuvenation. These include chemical to chronological ageing problems such as both arms of the study.Association of Cosmetic peels, dermal fillers, intense pulsed light and volume deficits resulting from the loss andDoctors; European Medical TAdvisor to Network Lipolysisand the UK’s largest cosmeticwebsite Consulting Rooms. He he face, and particularly the eyes, is very a patient’s chronological and environmental age, andpractices cosmetic medicine important for contact between humans, mastering the proper evaluation and execution of theirin his clinics in Dublin, Cork,London and the Middle East as this area provides a window to the rest aesthetic rejuvenation is paramount for all cosmetic of society with regard to a patient’s level doctors.email: ptreacy@gmail.com of health, tiredness and emotional status, More recently, patients are seeking effective facial as well as interest in others4. Many health rejuvenation procedures with less downtime and lowKeywords professionals consider the periorbital area of the face as risks7. This change in attitude has been prompted by afractionalised laser resurfacing, the most important area of rejuvenation as eye‑to-eye realisation of both doctors and patients that the muchplatelet-rich plasma,microneedling, Omnilux 633 nm communication occurs in approximately 80% of all hyped non-ablative methods were often subject tolight, neurotoxin human interactions6. Both areas present a barometer of extravagant claims in terms of efficacy2–4. For many18 September 2012 | prime-journal.com
  • 2. ARTICLE | facial aesthetics |Figure 1 xxxxxxxx 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, and scarring has been 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 years, CO2 laser resurfacing was considered the ‘gold have also recorded post‑operative infections leading to standard’ in treating photodamaged facial skin6–11. scarring, although it is generally felt that these may be Cutaneous laser resurfacing with a fractional (CO2) laser prevented by careful history-taking, vigilant involves the vapourisation of the entire epidermis, as post‑operative monitoring, and/or the use of prophylactic well as a variable thickness of the dermis. Many antibiotics26, 27. physicians stated that the ultrapulsed CO2 laser was the With regard to facial rejuvenation, CO2 laser light at a most effective method of laser resurfacing12–13. 10 600 nm wavelength results in vapourisation with Photodamaged skin is the result of years of exposure to thermal denaturation of type I collagen, collagen harmful ultraviolet light and is clinically demonstrated as shrinkage and later, collagen deposition. However, in a gradual deterioration of cutaneous structure and very deep rhytides, acne scarring and severe elastotic function. This results in the epidermis and upper changes from sun damage, fractional CO2 therapy papillary dermis having a roughened surface texture, as requires multiple treatments to achieve the same results well as laxity, telangiectasias, wrinkles and variable as the older lasers28. A number of studies have evaluated degrees of skin pigmentation14–15. using different laser combinations in the same session in Although ultrapulsed CO2 resurfacing lasers were order to improve collagen deposition, with a wider zone considered the best treatment option, they had many of fibroplasia6–9, 28. Owing to the inherent risks of fractional post-procedural problems16, 17, including prolonged laser skin resurfacing and its inability to deal with some post‑operative recovery, pigmentary changes, and a high evidence of chronological ageing, it was advocated to incidence of acne flares and herpes simplex virus (HSV) here establish the clinical effectiveness of using a infection18, 19. Many patients complained of oedema, multi‑procedural approach to volumisation and collagen burning, and erythema that sometimes lasted for many regeneration. The author used microneedling with low Figure 2 xxxxxxxx Figure 3 xxxxxxxx20 September 2012 | prime-journal.com
  • 3. | facial aesthetics | ARTICLEenergy laser, and platelet rich plasma (PRP) to address three‑phase combination of established treatments withthese issues. microneedling, platelet growth hormones, near-red It is recognised that the most important rejuvenation 633 nm light, and low-energy UltraPulse fractional CO2process for photoaged skin is the collagen remodelling laser skin tightening. All patients received Dysport® inprocess, and dermal fibroblasts are known to have the three areas 1 week prior to the other treatments as anmost important function29. Rejuvenation of skin injury adjunct to the laser resurfacing.caused by UV light is a complex process that organically The DUBLiN Lift was introduced as three phases over ainvolves cytokines interacting with a number of growth period of 3 weeks. Phase 1 included Dysport® at dilutionfactors and control proteins28. The procedures evaluated 3.5 : 1 to three areas — glabellar, frontalis and periorbital.included PRP, microneedling, and Omnilux 633 nm Phase 2 introduced intense fibroblast stimulation andnear‑red light, with neurotoxins as an adjunct to low-level modification through microneedling, PRP growth factorfractional laser skin resurfacing. Cells in the epidermis induction, and near-red phototherapy. Phase 3and dermis can be targeted by microneedling and administered the low–level (CO2) UltraPulse laser atnear‑red light, resulting in fibroblast stimulation. Omnilux 100 mJ 14 w CPG 3/5/2, and adjunct near-red 633 nmRevive™ (633 nm) therapy stimulates fibroblast activity, phototherapy. The study evaluated post-proceduralleading to faster and more efficient collagen synthesis aesthetic results at 2 weeks, 4 weeks and 12 weeks. Theand extracellular matrix (ECM) proteins. It also increases length of downtime, patient discomfort and adversecell vitality by increasing the production of cellular side‑effects were noted for each phase.adenosine triphosphate (ATP) and stimulates the Clinical assessment of patients in each group wascontractile phase of the remodelling process producing made at 2 weeks, 1 month and 3 months post‑operativelybetter lineated collagen30–33. Collagen induction therapy is in the presence of two aesthetic staff. The degree ofan aesthetic medical procedure that involves repeatedly improvement in photoageing was based on the degree ofpuncturing the skin with tiny, sterile needles. Typically, re-epithelialisation rate, reduction of rhytides, reductionthis is done with a specialised instrument called a of tactile roughness, and loss of hyperpigmentation andmicroneedling device. telangiectasias. The prolongation and severity of Controlled studies have suggested that the application erythema as well as the presence of negative side-effectsof autogenous PRP can enhance wound healing in both (e.g. herpes) were also recorded.animals and humans29. Five major growth factors such as The efficacy of treatment was evaluated using atransforming growth factor (TGF), insulin-like growth variation of the five-point scale (Table 1) originallyfactor (IGF), platelet-derived growth factor (PDGF), suggested by Dover et al36. Investigators and patientsepidermal growth factor (EGF), and vascular endothelial evaluated efficacy using palpability assessments andgrowth factor (VEGF) are known to be related to thewound-healing processes28. These growth factors arereleased from platelets, and the production of collagen Table 1 Patient treatment (positive) scoring chartand fibroblasts is stimulated by IGF, EGF, Interleukin-1 Parameter 0 1 2 3 4(IL‑1) and tumour necrosis factor (TNF)-α34, 35. In vivo Global score Area of Area of Area of Area of Area ofstudies report TGF-β to be the most stimulative growth roughness roughness roughness roughness roughnessfactor. PRP may be used for dermal augmentation and x 0 x 1 x2 x3 x4Sclafani observed aesthetic improvements of the Fine lines None Rare Several Moderate Manynasolabial fold in less than 2 weeks, and the results lasted Pigmentary None Patchy Moderate Heavy Markedfor up to 3 months28, 29. problems Touch Even Rare Mild Moderate SevereResearch design and methods problems This multi-centre randomised study included 44 patients Facial veins None Rare Several Moderate Severeof skin types 1 and 2 aged between 39 and 68 years, Coarse lines None Rare Several Moderate Manypresenting with photoageing of the skin, 37 of whom Complexion Pink Pale Grey Slightly Distinctwere women and seven were men. The subjects yellow-grey yellow-greypresented with the typical hallmarks of chronologicaland photoageing, such as expression lines, rhytides,wrinkles, eyelid skin laxity, dermatochalasis, lowered Table 2 Patient treatment (negative) scoring chartbrows, lateral hooding, and prominent fat pads. Allpatients were subjected to a programme of skin Parameter 0 1 2 3 4tightening and neocollagenesis by one of two methods: Erythema severity None Rare Several Moderate Severeconventional fractional laser skin resurfacing (Group 1) or Infective outbreak None Rare Several Moderate Severethe DUBLiN Lift (Group 2). The mean patient age in Group (herpes/acne) 1 was 49 years (range 37–71 years) and in Group 2 was 55 Crusting None Rare Several Moderate Severeyears (range 41–76 years). Pain of None Mild Tolerable Moderate Severe Fifteen patients underwent Lumenis ActiveFx™ with procedure settings as (energy) 125 mJ and (rate) 19 w CPG 3/5/4. Improvement None Minimal Fair Good ExcellentTwenty-nine patients received the DUBLiN Lift, a prime-journal.com | September 2012 21
  • 4. ARTICLE | facial aesthetics | Encore, Lumenis Ltd). Technical differences between Table 3 Wrinkle Severity Rating Scale (WSRS) this non-sequential fractional device and the older patient scoring chart ultrapulsed CO2 include tissue bridges left between spots, resulting in faster healing time, and less thermal damage5 Extreme Extremely deep and long folds, detrimental to facial appearance to the basal cell membrane. The device has a smaller4 Severe Very long and deep folds; prominent facial features; less than spot size (1300 mm rather than 2500 mm), resulting in 2 mm visible less post-procedure erythema.3 Moderate Moderately deep folds; clear facial feature visible at normal The computer pattern generator lays down a random appearance, but not when stretched series of spots rather than a sequential sequence2 Mild Shallow but visible fold with a slight indentation; resulting in less overheating of the treated tissue. This minor facial feature application is termed ‘Cool Scan’, and was used with1 Absent No visible nasolabial fold; continuous skin, injectable every patient in the study. implant alone The Traylife Kit (PRP) (Promoitalia Wellness Research) provides blood plasma enriched with a concentrated Table 4 Global Aesthetic Improvement Scale (GAIS) source of autologous platelets that releases a number of growth factors and other cytokines that stimulate theDegree Description healing of soft tissue.1 Exceptional improvement Excellent corrective result at week 12. No further Omnilux Revive™ (633 nm) (Photo Therapeutics, Inc., treatment required UK) stimulates fibroblast activity, leading to faster and2 Very improved patient Marked improvement of appearance, but not more efficient collagen synthesis and extracellular completely optimal matrix proteins.3 Improved patient Improvement of the appearance, better compared with Dermaroller™ Collagen Induction Therapy (CIT) the initial condition. Touch-up is advised (AesthetiCare®, UK) is a minimally-invasive cosmetic4 Unaltered patient The appearance substantially remains the same procedure that involves the use of a micro-needling compared with the original condition device.5 Worsened patient The appearance has worsened compared with the Scoring charts are presented in Tables 1–4. original condition Group 1: fractional laser skin change from baseline score at 0, 6 and 12 weeks. A total resurfacing global score was recorded in each patient based on the addition of points obtained from six photodamage Phase 1 variables. The degree of perceived improvement in Dysport® treatment to three areas: glabellar, frontalis and overall aesthetic effect reflecting chronological age was periorbital. assessed separately by patients and physicians using the Wrinkle Severity Rating Scale (WSRS) and the Global Phase 2 (Week 2) Aesthetic Improvement Scale (GAIS). The WSRS is Lumenis ActiveFX with settings (energy) 125 mJ (rate) recognised as a valid and reliable instrument for 1 9w CPG 3/9/4 quantitative assessment of facial skin folds, with good In the pre-laser procedure, the author typically inter- and intra-observer consistency5. Wrinkle severity is prescribes Valium (Diazepam 5–10 mg orally) for anxiety, measured using a wrinkle severity rating scale with 1 administered 45 minutes before the procedure. being absent and 5 being extreme. By allowing objective For infection prophylaxis, Famvir (famciclovir) 750 mg grading of data, these proved useful clinical tools for daily or Valtrex (valcyclovir) 500 mg twice per day for 7 assessing the effectiveness of facial volumisation with days, was prescribed for every patient starting 3 days PRP and microneedling–633. before procedure. If the patient had a strong history of acne, By-Mycin (doxycycline 100 mg daily) or Keflex Interventions (cephalexin 500 mg twice per day) was prescribed for The following treatment protocols were used for this 7  days, beginning on the day of surgery. Diflucan study: Lumenis ActiveFX CO2 laser, Traylife PRP, Omnilux (fluconazole 150 mg) was not routinely prescribed in any 633 nm red light, Dermaroller®, and Dysport®. All patient. participants received selective regional anaesthesia The patients were treated under topical and regional blocks with 2% lignocaine plus adrenaline, a topical anaesthesia. Topical anaesthesia comprised benzocaine combination anaesthetic of 23% lignocaine, and 20%, Lidocaine Base 6%, and tetracaine 4%. Regional prophylactic Valtrex 500 mg twice daily for 8  days. anaesthesia was three-fold: Valium 5–10 mg stat was given as a pre-medication to ■■ Supraorbital and supratrochlear nerve block. The some patients. A post-procedural advice sheet and supraorbital foramen was located and 1 cc of 1–2% Nurofen or codeine with paracetamol — as required — was Lidocaine injected just above the bone laterally, with also given to patients. the needle directed medially, parallel to the brow and The ActiveFX is a protocol of settings applied in toward the nose conjunction with an improved computer pattern ■■ Infraorbital nerve block. 1 cc of 1–2% Lidocaine injected generator to the ultrapulsed CO2 laser (UltraPulse into the buccal cavity with the needle directed22 September 2012 | prime-journal.com
  • 5. | facial aesthetics | ARTICLE towards the infraorbital foramen■■ Mental nerve block. 1 cc of 1–2% Lidocaine injected into A B the mental foramen just above the bone level.Group 2: DUBLiN liftPhase 1Dysport® treatment to three areas: glabellar, frontalis andperiorbital.Phase 2 (Week 2)MicroneedlingTopical anaesthesia: benzocaine 20%, Lidocaine Base 6%,and tetracaine 4%. Each patient received Chiroxy cream post-procedureto reduce erythema and inflammation. Tepid water wasused to cleanse the face for the following 48 hours, anddried gently. It was recommended that make-up was notapplied for 12 hours after the procedure. After theprocedure, a broad-spectrum UVA/UVB sunscreen withSPF 50 was recommended for use. CPRP preparationDraw blood (4 ml for each tube), then centrifuge tubes at2000 rpm for 5 minutes. Take the syringe, insert theneedle and withdraw 0.5 ml DNA Activator (10% calciumchloride). Withdraw platelets and mix with the DNAActivator. 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 techniquesOmnilux 633 nm LEDThis was applied for 20 minutes per session (126 J/cm2).Phase 3 (Week 3)Low-level UltraPulseLumenis ActiveFX with settings (energy) 100 mJ rRate)14 w CPG 3/5/2.Omnilux 633 nm LEDThis was applied for 20 minutes per session (126 J/cm2).HistologySkin biopsies were obtained from five of the patientsintra-operatively, before Phase 2 of the treatment and at3  months post-operatively, and were performed todetermine the amount of epidermal damage, subsequentinflammation, and new collagen synthesis. The extent ofneocollogenesis was compared with data on file forpatients who had skin biopsies for laser resurfacing andneurotoxin alone in 2007. Each 1 cm by 1 cm piece of skinwas fixed with 10% formalin solution, neutral buffered.After treatment with polyester wax, the skin sampleswere sliced into 6 μm thicknesses. The sliced sectionswere treated with haematoxylin and eosin statin (H&E)and Masson’s trichrome staining solutions. Throughtissue evaluations, the thickness of the dermal layer and Figure 4 xxxxxxx prime-journal.com | September 2012 23
  • 6. ARTICLE | facial aesthetics | Figure 5 xxxxxx presence of collagen fibres were observed. The thickness of the dermal layer was calculated by measuring five A different sites from each section, and the mean value of the thickness of the dermal layer for each group was used for the comparison. 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-red 633 nm light, and low-energy UltraPulse fractional CO2 laser skin tightening over a 3-week period. Phase 1 included the administration of Dysport® neurotoxin to the upper face. Phase 2 introduced B 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 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 showing the depth of laser penetration and consequential formation of new collagen. All skin biopsies showed C 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 neocollogenesis 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 D 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 lift24 September 2012 | prime-journal.com
  • 7. | facial aesthetics | ARTICLE B Awas superior in 62% and 55.2% of patients respectively,while fractional laser skin resurfacing was superior in C33.3% and 34.4% of patients. (P < 0.0004). An ‘optimal’cosmetic result was achieved in a higher percentage ofpatients in Group 2 compared with Group 1. Investigator-based and patient-based ratings usingboth the WSRS and GAIS indicated that the DUBLiN liftwas more effective than conventional ablative laserresurfacing in creating cosmetic correction to the lowerface. This resulted from the volumising effect of addingPRP to the larger folds in this area. At 3 monthspost‑treatment, a higher proportion of patients showed agreater than or equal to 1-grade improvement in WSRSwith the DUBLiN Lift compared with fractional laser skinresurfacing. The author suspects the PRP may have alonger aesthetic effect when used in association withmicroneedling and 633 nm light than previously noted27, 29.However, the results were almost reversed wheneverperiorbital rejuvenation was assessed alone, with almostevery patient (93%) favouring conventional fractional Figure 6 xxxxxlaser skin resurfacing. Investigator-based GAISassessment of this region at 3 months after baselineindicated that fractional resurfacing was superior in 93% resurfacing treatment, which was 3.4. The author notedof patients, while the DUBLiN Lift was superior in 6.8% of that most patients did not feel much pain at all with thepatients (P = 0.0025). ActiveFX until the energy level crosses 100 mJ. No patient Re-epithelialisation occurred in all laser-treated areas experienced any adverse reaction to laser skinof both groups by day 7, and this appeared to be clinically resurfacing, except one case of herpetic infection in eachsimilar for both procedures. Mean duration of erythema group (Group 1 6.6%; Group 2 3.4%). Both treatments werewas 6.9 days after resurfacing (range 4–10 days) in Group 1 well tolerated. Clumping of platelets occurred in 10% ofand 4.2 days in Group 2 (range 3–7 days). This appeared to patients treated with PRP and the author felt that this wasbe in keeping with previous studies37. All patients a result of the concentration of solution used. In fact,reported having no ‘crusting’ effect remaining on their anecdotal evidence suggests that most cosmeticface after 6 days. Residual erythema remained in one physicians are using PPP (platelet-poor plasma) in mostpatient in Group 1 for a period of 14 days, but this was areas of the face, rather than the higher concentrationsminimal. Post-operative erythema was most intense in used by orthopaedic surgeons.the areas treated with the ActiveFX at an energy levelabove 125 mJ. Conclusions The mean pain sensation (Table  2) felt during the Facial ageing is a consequence of many interactingDUBLiN lift was 2.2 compared to conventional fractional intrinsic and extrinsic factors. The most important of prime-journal.com | September 2012 25
  • 8. ARTICLE | facial aesthetics |these include sun exposure or photoageing, and theintrinsic changes associated with chronological ageing.Over time, the muscles of facial expression producedynamic and static facial lines and folds. Laserresurfacing has long been recognised as a skinrejuvenation procedure for tissue that has lost itselasticity and become less able to resist stretching.However, despite the advent of newer fractionalisedlasers, it has adverse risks and does not adequatelyaddress the problems associated with chronologicalageing as gravity exerts its toll on the facial structures. It isimportant to apply supplementary methods, such asdermal fillers or PRP, to address nasolabial or marionettelines and volume deficits resulting from the loss andrepositioning of facial fat.Declaration of interest none Patient images ©Patrick Treacy References 1. Raspaldo H. Volumizing effect of a new hyaluronic acid 1990; 22(1): 1–15 review of biology and applications in plastic surgery. 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  • 9. | facial aesthetics | ARTICLE Further readingAlster TS, Nanni CA. Famciclovir prophylaxis of CW. Histologic evaluation of preauricular and 1021–4herpes simplex virus reactivation after laser postauricular skin after high-energy, short- Lee SY, Park KH, Choi JW et al. A prospective,skin resurfacing. Dermatol Surg 1999; 25(3): pulse carbon dioxide laser. Arch Dermatol randomized, placebo-controlled, double-242–6 1996; 132(4): 425–8 blinded, and split-face clinical study on LEDAlster TS. Side effects and complications of Day DJ, Littler CM, Swift RW, Gottlieb S. The phototherapy for skin rejuvenation: clinical,laser surgery. In: Alster TS. Manual of wrinkle severity rating scale: a validation profilometric, histologic, ultrastructural, andCutaneous Laser Techniques. Philadelphia: study. Am J Clin Dermatol 2004; 5(1): 49–52 biochemical evaluations and comparison ofLippinco, 2000 Doddaballapur S. Microneedling with three different treatment settings. JAvram MM, Tope WD, Yu T, Szachowicz E, dermaroller. J Cutan Aesthet Surg 2009; 2(2): Photochem Photobiol B 2007; 88(1): 51–67Nelson JS. Hypertrophic scarring of the neck 110–1 Majid I. Microneedling therapy in atrophicfollowing ablative fractional carbon dioxide Goldberg D. Reduced Down-time Associated facial scars: an objective assessment. J Cutanlaser resurfacing. Lasers Surg med 2009; 41(3): with Novel Fractional UltraPulse CO2 Aesthet Surg 2009; 2(1): 26–30185–8 Treatment (Active FX) as Compared to Pierce GF, Brown D, Mustoe TA. QuantitativeBaez F, Reilly LR. The use of light-emitting Traditional Resurfacing P3115. Presented at the analysis of inflammatory cell influx,diode therapy in the treatment of photoaged 65th Annual American Academy of procollagen type I synthesis, and collagenskin. J Cosmet Dermatol 2007; 6(3): 189–94 Dermatology Meeting cross-linking in incisional wounds: influence ofBerlin AL, Hussain M, Phelps R, Goldberg DJ. Fitzpatrick RE, Ruiz-Esparaza J, Goldman MP. PDGF-BB and TGF-beta 1 therapy J Lab Clin MedTreatment of photoaging with a very The depth of thermal necrosis using the CO2 1991; 117(5): 373–82superficial Er:YAG laser in combination with a laser: a comparison of superpulsed mode and Rubach BW, Schoenrock LD. Histological andbroadband light source. J Drugs Dermatol conventional mode. J Dermatol Surg Oncol clinical evaluation of facial resurfacing using a2007; 6(11): 1114–8 1991; 17(4): 340–4 carbon dioxide laser with the computerBernstein LJ, Kauvar AN, Grossman MC, Fitzpatrick RE, Tope WD, Goldman MP, Satur pattern generator. Arch Otolaryngol HeadGeronemus RG. The short- and long-term side NM. Pulsed carbon dioxide laser, Neck Surg 1997; 123(9): 929–34effects of carbon dioxide laser resurfacing. trichloroacetic acid, Baker-Gordon phenol, and Smith KJ, Skelton HG, Graham JS, Hamilton TA,Dermatol Surg 1997; 23(7): 519–25 dermabrasion: a comparative clinical and Hackley BE Jr, Hurst CG. Depth of morphologicBonan P, Campolmi P, Cannarozzo G et al. histologic study of cutaneous resurfacing in a skin damage and viability after one, two andEyelid skin tightening: a novel ‘Niche’ for porcine model. Arch Dermatol 1996; 132(4): three passes of a high-energy, short-pulse CO2fractional CO2 rejuvenation. J Eur Acad 469–71 (Tru-Pulse) laser in pig skin. J Am AcadDermatol Venereol 2012; 26(2): 186–93 Kauvar ANB, Waldorf HA, Geronemus R. A Dermatol 1997; 37(2 Pt 1): 204–10Burkhardt BR, Maw R. Are more passes better? histopathologic comparison of char-free Trelles MA, Allones I. Red light-emitting diodesafety versus efficacy with the pulsed CO2 lasers. Dermatol Surg 1996; 22: 343–8 (LED) therapy accelerates wound healinglaser. Plast Reconstr Surg 1997; 100(6): 1531–4 Lask G, Keller G, Lowe N, Gormley D. Laser skin post-blepharoplasty and periocular laser resurfacing with the SilkTouch flashscanner for ablative resurfacing. J Cosmet Laser TherCotton J, Hood AF, Gonin R, Beeson WH, Hanke 2006; 8(1): 39–42 facial rhytides. Dermatol Surg 1995; 21(12): prime-journal.com | September 2012 27