Combining therapies
for optimal outcomes
in treating the ageing
face:introducing the
DUBLiN Facelift
months20, 21
. The implied risks and long downtime made
many patients reluctant to accept this method of
treatment22, 23
three‑phase combination of established treatments with
microneedling, platelet growth hormones, near-red
633 nm light, and...
change from baseline score at 0, 6 and 12 weeks. A total
global score was recorded in each patient based on the
addition o...
towards the infraorbital foramen
■■ Mental nerve block. 1 cc of 1–2% Lidocaine injected into
the mental foramen just above...
presence of collagen fibres were observed. The thickness
of the dermal layer was calculated by measuring five
different si...
was superior in 62% and 55.2% of patients respectively,
while fractional laser skin resurfacing was superior in
33.3% and ...
1.	 Raspaldo H. Volumizing effect of a new hyaluronic acid
sub-dermal facial filler: a retrospective analysis b...
Further reading
Alster TS, Nanni CA. Famciclovir prophylaxis of
herpes simplex virus reactivation after laser
skin resurfa...
'Multi Procedural Approach to Facial Rejuvenation'
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'Multi Procedural Approach to Facial Rejuvenation'


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Article looks at 'Multi Procedural Approach to Facial Rejuvenation' as it combines Microneedling, Omnilux 633 Phototherapy, Blood group factors injection to stimulate neocollagenesis within facial area.

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'Multi Procedural Approach to Facial Rejuvenation'

  1. 1. Combining therapies for optimal outcomes in treating the ageing face:introducing the DUBLiN Facelift 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 Association of Cosmetic 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 email: 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 ARTICLE | facial aesthetics | 18 September 2012 |
  2. 2. 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 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 Figure 1 xxxxxxxx Figure 2 xxxxxxxx Figure 3 xxxxxxxx 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 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 ARTICLE | facial aesthetics | 20 September 2012 |
  3. 3. three‑phase combination of established treatments with microneedling, platelet growth hormones, near-red 633 nm light, and low-energy UltraPulse fractional CO2 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 energy laser, and platelet rich plasma (PRP) to address these issues. 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 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 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) are known to be related to the wound-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 Table 1 Patient treatment (positive) scoring chart 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 yellow-grey Table 2 Patient treatment (negative) scoring chart 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 | facial aesthetics | ARTICLE |September 2012 21
  4. 4. change from baseline score at 0, 6 and 12 weeks. A total 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. 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 ■■ Infraorbital nerve block. 1 cc of 1–2% Lidocaine injected into the buccal cavity with the needle directed Table 3 Wrinkle Severity Rating Scale (WSRS) patient scoring chart 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 Table 4 Global Aesthetic Improvement Scale (GAIS) 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 ARTICLE | facial aesthetics | 22 September 2012 |
  5. 5. 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 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 rRate) 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 determinetheamountofepidermaldamage,subsequent inflammation, and new collagen synthesis. The extent of neocollogenesis was 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, the thickness of the dermal layer and | facial aesthetics | ARTICLE |September 2012 23 A B C Figure 4 xxxxxxx
  6. 6. presence of collagen 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 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 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 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 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 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 Figure 5 xxxxxx A B C D ARTICLE | facial aesthetics | 24 September 2012 |
  7. 7. 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 more effective than conventional ablative laser resurfacing 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 microneedlingand633 nmlightthanpreviouslynoted27, 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). 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 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 A B C Figure 6 xxxxx 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 this was a result of the concentration 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 | facial aesthetics | ARTICLE |September 2012 25
  8. 8. 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 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 Patient images ©Patrick Treacy ARTICLE | facial aesthetics | 26 September 2012 |
  9. 9. 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 | facial aesthetics | ARTICLE |September 2012 27