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  • 1. Periorbital Rejuvenation The DUBLiN Method Dr. Patrick J. Treacy Medical Director Ailesbury Clinics Ltd
  • 2. The DUBLiN method uses different methods and technologies in order to activate fibroblasts and direct them towards neocollogenesis. It also uses low level pulsed lasers to reduce skin laxity, accelerate growth factors and cause tightening.
  • 3. The DUBLiN method incorporates D Dermaroller U Ultrapulse Laser B Blood Factors Li Light – 633nm N Neurotoxin
  • 4. PERIORBITAL AGEING Periorbital region is a immediate barometer of a patient’s chronological and environmental age. It tells its own history of ultraviolet light exposure and wish for aesthetic treatments
  • 5. PERIORBITAL AGEING Anatomical changes include laxity of the eyelid skin, prominent infra-orbital fat pads, hypertrophic orbicularis oculi muscle, and even descent of the forehead, eyebrows and mid-face
  • 6. PERIORBITAL AGEING Clinically photo-aged skin is wrinkled, blotchy and leathery. Eyelid laxity can cause both ectropion and entropion or eiphoria and laxity of the medial and lateral canthal tendon.
  • 7. PERIORBITAL AGEING A variety of dermatological treatments are available such as topical creams, neurotoxin, RioBlush © carboxytherapy, Polaris © RF-radiofrequency and SmartXide © and AFX © CO2 fractionalised resurfacing lasers.
  • 8. TACTILE ROUGHNESS SALLOW SKIN COARSE RHYTIDS FINE RYTHIDS THREAD VEINS PIGMENTATION TitlePHOTOAGEING
  • 9. WRINKLES ECTROPION ENTROPION FAT PROTRUSION EPIPHORIA SKIN LAXITY TitleAGEING
  • 10. FAT PROTRUSION SALLOW SKIN THREAD VEINS COARSE RYTHIDS FINE RHYTIDS PIGMENTATION TitleLASER
  • 11. WRINKLES TEAR TROUGH WRINKLES FAT PROTRUSION PIGMENTATION SKIN LAXITY TitleCOLLAGEN
  • 12. Keratinocyte GF Vascular Endothelial GF Fibroblast GF Transforming GF-B Connective Tissue GF Platelet Derived GF TitleCOLLAGEN
  • 13. Tissue Repair -FIBROBLASTS A fibroblast is a type of cell that synthesizes the extracellular matrix and collagen, the structural framework (stroma) for animal tissues, and plays a critical role in wound healing. Fibroblasts are the most common cells of connective tissue in animals.
  • 14. Tissue Repair -FIBROBLASTS The efficacy of certain growth factors in forming collagen and healing various injuries is the theoretical basis for the use of PRP in tissue repair. The platelets collected in PRP are activated by the addition of thrombin and calcium chloride. This induces the release of these factors from alpha granules.
  • 15. DERMAROLLER
  • 16. LiGHT 633nm Migrating cells exert forces against the substrate to move forward. These forces are part of the contraction phase of migration in which the rear of the cell is detached from the substrate and the body of the cell is moved forward.
  • 17. Near Red Light 633 Dermaroller Title Fibroblast Activation PHASE 1 PRP Growth Factor Signals
  • 18. Mouse fibroblasts are starved for serum factors like PDF and IGF-1. Then, serum is added back and time lapse inverted phase contrast images are taken every 1 sec. Watch the ears of a cell, at the tips of a thin blanket of cytoplasm called "lamellipodium". Blood Growth Factors
  • 19. Keratinocyte GF Vascular Endothelial GF Fibroblast GF Transforming GF-B Connective Tissue GF Platelet Derived GF TitleCOLLAGEN
  • 20. Near Red Light 633 Low level Laser Title Fibroblast Activation PHASE 2 AGERA Prolifersyn ®
  • 21. LOW LEVEL LASER Laser specialists non-sequential fractionalised CO2 laser ablation is the most effective modality for repairing photo damaged skin The benefits are more precise control of ablation depth, faster recovery time and reduced risk of post procedural problems
  • 22. Continuous vs Ultrapulse Comparative Split Face Study
  • 23. Perioral split face study showing the different skin eschar results from the two fractionalised lasers immediately after treatment
  • 24. ULTRAPULSE
  • 25. Objective Methods Results Conclusion 1 2 3 4 Conclusions
  • 26. • A clinical assessment of each patient regarding the overall level of photoageing was made initially and at 2 weeks, I month and 3 months postoperatively in the presence of two physicians. • Positive scoring was based on the degree of re-epithelialisation rate, reduction of rhytides, loss of hyperpigmentation and telangectasias and reduction of tactile roughness. • The prolongation and severity of erythema as well as the presence of negative side effects (such as herpes were also recorded by both the patient and the doctor). The degree of photoageing and the efficacy of treatment were evaluated using a five-point scale originally suggested . by Dover et al.
  • 27. Score 0 1 2 3 4 Fine Lines None Rare Several Moderate Many Pigment None Patchy Moderate Heavy Severe Facial Veins None Rare Several Heavy Severe Coarse Lines None Rare Several Moderate Many Efficacy of treatment + scoring system
  • 28. Score 0 1 2 3 4 Touch Even Rare Mild Moderate Severe Complexion Pink Pale Grey Partial Yellow Grey Distinct Yellow Grey Efficacy of treatment + scoring system
  • 29. prolonged postoperative recovery pigmentary changes erythema infection Although, ultrapulsed CO2 laser skin resurfacing was largely considered the best option for treatment of this type of photoaged facial skin, it also had certain post- procedural problems
  • 30. Score 0 1 2 3 4 Erythema None Rare Several Moderate Severe Crusting None Rare Several Moderate Severe Pain None Rare Several Moderate Severe Herpes None Rare Several Moderate Severe Efficacy of treatment - scoring system
  • 31. 5 daysImmediate Random
  • 32. Your Text here Your Text hereYour Text hereMETHOD • If the patient has a strong history of HSV, we initially prescribed Famvir (Famciclovir) 750mgs daily for 10 days or Valtrex (valcyclovir) 500 mg bd for 10 days starting three days before surgery. This was adjusted during the study to commence one week before and to be used for one week after. • If the patient has a strong history of acne, we prescribe an antibiotic ByMycin (Doxycycline 100mgs daily) Augmentin Duo, (Amoxil Clavulinic Acid) Keflex (Cephalexin 500 mg bd) for 7 days, starting the day of surgery). • If the patient has a strong history of frequent yeast infections, we prescribe Diflucan (Fluconazole 150mgs), starting on the 4th post-operative day and taken once orally every other day PROHPYLAXIS
  • 33. Your Text here Your Text hereYour Text hereMETHOD Topical Anaesthesia Anestop® : (Amethocaine; Propitocaine; Lignocaine) as topical anaesthetic to the entire facial area for 45mins. Astra Zeneca Regional Anaesthesia Typically, we gave regional anaesthesia during the procedure including •Supraorbital and Supratrochlear Nerve Block •Infraorbital Nerve Block •Mental Nerve Block ANAESTHESIA
  • 34. Biopsy Staining Histology Histology was performed to determine the amount of tissue ablation, residual thermal damage, inflammati on and neocollagenesis Lesion penetrative dimensions were assessed histologically using haematoxylin & eosin Skin biopsies were obtained from 5 patients intraoperatively from each side, after one laser pass, and at 3 months postop.
  • 35. Thermal effect at 100 µm seen histologically using haematoxylin & eosin © Patrick Treacy
  • 36. 3 months post © Patrick Treacy
  • 37. Patient CM : Right Eye SmartXide treated (Power) 30W Dot Mode Spacing 200 μm Scanning well Time 500 μS 2 passes under R eye with obvious reduction in rhytides and neocollagenesis
  • 38. • The two CO2 lasers (Lumenis ActiveFx Deka SmartXide) appeared to produce equivalent clinical improvement of lesions and rhytides. Re-epithelialisation occurred in all laser treated areas by both devices by day 7and this appeared to be similar for both lasers. Mean duration of reepithelialisation was 6.9 days after resurfacing (range, 4-10 days). • Residual erythema remained for a period of 14 days but this was minimal (mean decreased from 4.1 on day 3 to 0.9 at day 14). Postoperative erythema was most intense in the areas treated by SmartXide whenever the dwell time was increased up to 1ms. This effect was also noted with the ActiveFx at the energy level above 125Mj. RESULTS
  • 39. • All skin biopsies in this study show effect of thermal treatment with thermal coagulation of epidermis and superficial dermis in a depth ranging from 85 to 113 microns. This was similar in both lasers with the SmartXide consistently getting below 100 µm. Many studies show the zone of residual thermal (coagulative) damage can extend a further 20 to 120 µm, depending on the particular laser variables used
  • 40. This was particularly evident in Patient C where the thermal effect appears to be more diffuse than focal and the evidence of effect was still measured at 700 microns, although this reflected a vague diffuse thermal effect as compared with the more localized usual effect. Because the various CO2 lasers currently available differ in their biophysical properties, their documented depth of histological ablation and thermal effects vary BIOPSY Patient C
  • 41. • The global score for photoageing for both devices improved from 13.8 at baseline to 9.6 at Day 30. The score for fine lines was the most significant reduction dropping form 3.6 at baseline to 1.4 at Day 30. The score for sallowness was the most difficult to interpret at Day 30 as the patients still had some mild erythematous effect. Scores for reduction of coarse wrinkles (3.2 at baseline to 2.2 at Day 30) was also difficult to interpret in this heterogeneous age grouping with older patients requiring the deeper penetrating ‘harder’ MaxFx rather than the ‘softer’ ActiveFx and it is apparent that Lumenis are presently working on a combination therapy to solve this problem. RESULTS
  • 42. • If fractionalised laser skin resurfacing (FLSR) with minimal downtime is now considered the new method of softly treating patients for minor skin conditions such photoageing then the SmartXide DOT has cost advantages to the operator. It has yet to be established whether this will be in multiple sessions or not. If the physician requires to treat patients with deeper facial rhytides or other pathology in a one off session then the ActiveFx appears to have these advantages. CONCLUSION
  • 43. www.ailesburyclinic.ie