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ARTICLE | FACIAL AESTHETICS                        |                                                                      ...
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| FACIAL AESTHETICS | ARTICLE                                                                            generator to the ...
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Dublin Lift
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Dublin Lift

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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.


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Dublin Lift

  1. 1. ARTICLE | facial aesthetics | Combining therapies for the ageing face: the DUBLiN lift Patrick Treacy presents a novel method for full facialPrime Downloaded from informahealthcare.com by 109.255.10.181 on 10/08/12 rejuvenation, which combines a number of treatments to obtain the most optimum results ABSTRACT Objective ‘triangle of beauty’ as ageing proceeds resurfacing. This procedure benefits in an attempt to address these deficits. The DUBLiN Lift: To establish the is considered generally less aesthetically from faster recovery time, more precise The facial rejuvenating therapies include clinical effectiveness of combining appealing1. At present, a variety of different control of ablation depth, and reduced microneedling, low-dose UltraPulse For personal use only. five treatments in the rejuvenation of dermatologic and volumising treatments risk of post-procedural problems. laser, PRP growth factors, Omnilux the ageing face in an effort to increase are available for facial rejuvenation. These However, there have been cases of 633 nm light, and neurotoxins. The aesthetic effect, patient safety, and include chemical peels, dermal fillers, hypopigmentation, hypertrophic scars technique is called the DUBLiN facelift as reduce laser downtime. intense pulsed light and radiofrequency and skin mottling, most often seen on an acronym of the procedures involved: lasers, platelet-rich plasmas (PRP) the face, neck and chest when the laser Dermaroller, UltraPulse laser, Blood The face is the area for which the majority microneedling, microdermabrasion, parameters are used more aggressively4. growth factors, Light (near-red 633 nm), of patients seek cosmetic rejuvenation as botulinum toxin injections, and laser Furthermore, the technique does not and Neurotoxin. the convex lines of a youthful appearance resurfacing. Each treatment has its own attend to chronological ageing problems The author compared this method tend to flatten and droop as one grows relative benefit, as well as risks2, 3. such as volume deficits resulting from to fractional laser skin resurfacing with older. The younger face is characterised by In recent years, facial rejuvenation the loss and repositioning of facial fat. regard to the reduction of photoageing a balance captured in the classic shape of has been revolutionised with the This article examines the possibility and overall aesthetic effect. Neurotoxin the inverted triangle. The reversal of this development of CO2 fractional laser skin of combining five established therapies was used in both arms of the study. T he face, and particularly that the much hyped non-ablative the eyes, is very important methods were often subject to More for contact between extravagant claims in terms of efficacy2–4. recently, patients humans, as this area For many years, CO2 laser resurfacing was are seeking provides a window to the considered the ‘gold standard’ in treating effective facial rest of society with regard photodamaged facial skin6–11. Cutaneous to a patient’s level of health, tiredness and laser resurfacing with a fractional (CO2) rejuvenation emotional status, as well as interest in laser involves the vapourisation of the procedures with others4. Many health professionals entire epidermis, as well as a variable less downtime consider the periorbital area of the thickness of the dermis. Many physicians face as the most important area stated that the ultrapulsed CO2 laser was and low risks. Dr Patrick Treacy is of rejuvenation as eye‑to-eye the most effective method of laser Medical Director of Ailesbury communication occurs in approximately resurfacing12–13. Photodamaged skin is the Clinics Ltd and Ailesbury Hair Clinics Ltd; Chairman of the 80% of all human interactions6. Both result of years of exposure to harmful Irish Association of Cosmetic areas present a barometer of a patient’s ultraviolet light and is clinically Doctors and Irish Regional chronological and environmental age, demonstrated as a gradual deterioration Representative of the British Association of Cosmetic and mastering the proper evaluation and of cutaneous structure and function. This Doctors; European Medical execution of their aesthetic rejuvenation results in the epidermis and upper Advisor to Network Lipolysis and the UK’s largest cosmetic is paramount for all cosmetic doctors. papillary dermis having a roughened website Consulting Rooms. He More recently, patients are seeking surface texture, as well as laxity, practices cosmetic medicine effective facial rejuvenation procedures telangiectasias, wrinkles and variable Keywords in his clinics in Dublin, Cork, fractionalised laser resurfacing, London and the Middle East with less downtime and low risks7. This degrees of skin pigmentation14–15. platelet-rich plasma, change in attitude has been prompted by Although ultrapulsed CO2 resurfacing microneedling, Omnilux 633 nm email: ptreacy@gmail.com a realisation of both doctors and patients lasers were considered the best light, neurotoxin 20 ❚ October 2012 | prime-journal.com
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  4. 4. | facial aesthetics | ARTICLE using lower energy and density, as 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 evaluatedPrime Downloaded from informahealthcare.com by 109.255.10.181 on 10/08/12 using different laser combinations in the same session in treatment option, they had many post-procedural Figure 1 Omnilux 633 nm light order to improve collagen deposition, with a wider zone problems16, 17, including prolonged post‑operative for fibroblast stimulation of fibroplasia6–9, 28. Owing to the inherent risks of fractional recovery, pigmentary changes, and a high incidence of laser skin resurfacing and its inability to deal with some acne flares and herpes simplex virus (HSV) infection18, 19. evidence of chronological ageing, it was advocated to Many patients complained of oedema, burning, and here establish the clinical effectiveness of using a erythema that sometimes lasted for many months20, 21. Care should multi‑procedural approach to volumisation and collagen The implied risks and long downtime made many be taken when regeneration. The author used microneedling with low patients reluctant to accept this method of treatment22, 23. treating sensitive energy laser, and platelet rich plasma (PRP) to address For personal use only. More recently, fractional resurfacing lasers have areas such as the these issues. addressed many of these earlier problems with benefits of faster recovery time, more precise control of ablation eyelids, upper Collagen remodelling and fibroblast depth, and reduced risk of post procedural problems8. neck, and stimulation These lasers are extremely versatile, in that they can be especially the It is recognised that the most important rejuvenation used for the treatment of facial rhytides, acne scars, process for photoaged skin is the collagen remodelling surgical scars, melasma and photodamaged skin, and lower neck and process, and dermal fibroblasts are known to have the many have entered the market at the same time24. chest, by using most important function . Rejuvenation of skin injury 29 With the advent of fractional laser skin resurfacing, the lower energy and caused by UV light is a complex process that organically number of completely ablative resurfacing cases has density, as scarring involves cytokines interacting with a number of growth declined for most practitioners. However, care should be factors and control proteins . The procedures evaluated 28 taken when treating sensitive areas such as the eyelids, has been noted in included PRP, microneedling, and Omnilux 633 nm upper neck, and especially the lower neck and chest, by these areas. near‑red light, with neurotoxins as an adjunct to low- Figure 2 Blood post-centrifuge, showing the platelet layer Figure 3 Injecting PRP in the periorbital area prime-journal.com | October 2012 ❚ 23
  5. 5. ARTICLE | FACIAL AESTHETICS | puncturing the skin with tiny, sterile needles. Typically, Table 1 Patient treatment (positive) scoring chart this is done with a specialised instrument called a Parameter 0 1 2 3 4 microneedling device. Controlled studies have suggested that the application Global score Area of Area of Area of Area of Area of roughness roughness roughness roughness roughness of autogenous PRP can enhance wound healing in both x0 x1 x2 x3 x4 animals and humans29. Five major growth factors such as Fine lines None Rare Several Moderate Many transforming growth factor (TGF), insulin-like growth factor Pigmentary (IGF), platelet-derived growth factor (PDGF), epidermal None Patchy Moderate Heavy Marked growth factor (EGF), and vascular endothelial growth problems Touch factor (VEGF) are known to be related to the wound-healing Even Rare Mild Moderate Severe problems processes28. These growth factors are released from Facial veins None Rare Several Moderate Severe platelets, and the production of collagen and fibroblasts is Coarse lines None Rare Several Moderate Many stimulated by IGF, EGF, Interleukin-1 (IL-1) and tumour Complexion Pink Pale Grey Slightly Distinct necrosis factor (TNF)-α34, 35. In vivo studies report TGF-β to be yellow-grey yellow-grey 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,Prime Downloaded from informahealthcare.com by 109.255.10.181 on 10/08/12 Table 2 Patient treatment (negative) scoring chart and the results lasted for up to 3 months28, 29. Parameter 0 1 2 3 4 Research design and methods Erythema severity None Rare Several Moderate Severe This multi-centre randomised study included 44 patients Infective outbreak of skin types 1 and 2 aged between 39 and 68 years, (herpes/acne) None Rare Several Moderate Severe presenting with photoageing of the skin, 37 of whom Crusting None Rare Several Moderate Severe were women and seven were men. The subjects Pain of presented with the typical hallmarks of chronological None Mild Tolerable Moderate Severe procedure and photoageing, such as expression lines, rhytides, For personal use only. Improvement None Minimal Fair Good Excellent wrinkles, eyelid skin laxity, dermatochalasis, lowered brows, lateral hooding, and prominent fat pads. All patients were subjected to a programme of skin level fractional laser skin resurfacing. Cells in the tightening and neocollagenesis by one of two methods: epidermis and dermis can be targeted by microneedling conventional fractional laser skin resurfacing (Group 1) or and near-red light, resulting in fibroblast stimulation. the DUBLiN Lift (Group 2). The mean patient age in Group Omnilux Revive™ (633 nm) therapy stimulates fibroblast 1 was 49 years (range 37–71 years) and in Group 2 was 55 activity, leading to faster and more efficient collagen years (range 41–76 years). synthesis and extracellular matrix (ECM) proteins. It also Fifteen patients underwent Lumenis ActiveFX™ with increases cell vitality by increasing the production of settings as (energy) 125 mJ and (rate) 19 w CPG 3/5/4. cellular adenosine triphosphate (ATP) and stimulates the Twenty-nine patients received the DUBLiN Lift, a contractile phase of the remodelling process producing three-phase combination of established treatments with better lineated collagen30–33. Collagen induction therapy is microneedling, platelet growth hormones, near-red an aesthetic medical procedure that involves repeatedly 633 nm light, and low-energy UltraPulse fractional CO2 Patient histology Carbon dioxide laser ablative fractionalisation All skin biopsies show the effect of thermal treatment with thermal coagulation of the epidermis and superficial dermis Group 1 patient showing ablative Group 2 patient at Phase 3. Depth Group 1 patient showing collagen Group 2 patient showing collagen CO2 laser penetration to 118 nm. range 85 microns formation at 3 months. Depth range formation at 3 months, representing Depth range 113 microns 700 microns a skin biopsy from a Group 2 patient 3 months post-treatment. Depth range 118 microns 24 October 2012 | prime-journal.com
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  7. 7. ARTICLE | FACIAL AESTHETICS | Clinical assessment of patients in Table 3 Wrinkle Severity Rating Scale (WSRS) each group was made at 2 weeks, 1 patient scoring chart month and 3 months post-operatively in DEGREE DESCRIPTION the presence of two aesthetic staff. 5 Extreme Extremely deep and long folds, detrimental to facial appearance 4 Severe Very long and deep folds; prominent facial features; less than variables. The degree of perceived improvement in 2 mm visible overall aesthetic effect reflecting chronological age was 3 Moderate Moderately deep folds; clear facial feature visible at normal assessed separately by patients and physicians using the appearance, but not when stretched Wrinkle Severity Rating Scale (WSRS) and the Global 2 Mild Shallow but visible fold with a slight indentation; Aesthetic Improvement Scale (GAIS). The WSRS is minor facial feature recognised as a valid and reliable instrument for 1 Absent No visible nasolabial fold; continuous skin, injectable implant alone 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 Table 4 Global Aesthetic Improvement Scale (GAIS) being absent and 5 being extreme. By allowing objective grading of data, these proved useful clinical tools forPrime Downloaded from informahealthcare.com by 109.255.10.181 on 10/08/12 DEGREE DESCRIPTION assessing the effectiveness of facial volumisation with 1 Exceptional improvement Excellent corrective result at week 12. No further PRP and microneedling–633. treatment required 2 Very improved patient Marked improvement of appearance, but not Interventions completely optimal The following treatment protocols were used for this 3 Improved patient Improvement of the appearance, better compared with study: Lumenis ActiveFX CO2 laser, Traylife PRP, Omnilux the initial condition. Touch-up is advised 633 nm red light, Dermaroller®, and Dysport®. All 4 Unaltered patient The appearance substantially remains the same participants received selective regional anaesthesia compared with the original condition blocks with 2% lignocaine plus adrenaline, a topical For personal use only. 5 Worsened patient The appearance has worsened compared with the original condition 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 laser skin tightening. All patients received Dysport® in some patients. A post-procedural advice sheet and three areas 1 week prior to the other treatments as an Nurofen or codeine with paracetamol — as required — was adjunct to the laser resurfacing. Figure 4 Patients before also given to patients. The DUBLiN Lift was introduced as three phases over a (A, C) and after (B, D) the The ActiveFX is a protocol of settings applied in period of 3 weeks. Phase 1 included Dysport® at dilution DUBLiN Lift conjunction with an improved computer pattern 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 global score was recorded in each patient based on the addition of points obtained from six photodamage 26 October 2012 | prime-journal.com
  8. 8. | FACIAL AESTHETICS | ARTICLE 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 thePrime Downloaded from informahealthcare.com by 109.255.10.181 on 10/08/12 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) Figure 5 Patient in difering f directed towards the infraorbital foramen (AesthetiCare®, UK) is a minimally-invasive cosmetic phases of DUBLiN Lift Mental nerve block. 1 cc of 1–2% Lidocaine injected procedure that involves the use of a micro-needling into the mental foramen just above the bone level. device. For personal use only. Scoring charts are presented in Tables 1–4. Group 2: DUBLiN lift Phase 1 Group 1: fractional laser skin Dysport® treatment to three areas: glabellar, frontalis and resurfacing periorbital. Phase 1 Dysport® treatment to three areas: glabellar, frontalis and Phase 2 (Week 2) periorbital. Microneedling Topical anaesthesia: benzocaine 20%, Lidocaine Base 6%, and tetracaine 4%. Phase 2 (Week 2) Each patient received Chiroxy cream post-procedure Lumenis ActiveFX with settings (energy) 125 mJ (rate) to reduce erythema and inflammation. Tepid water was 1 9w CPG 3/9/4 used to cleanse the face for the following 48 hours, and In the pre-laser procedure, the author typically dried gently. It was recommended that make-up was 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 prime-journal.com | October 2012 27
  9. 9. ARTICLE | FACIAL AESTHETICS | not applied for 12 hours after the procedure. After the Figure 6 Cachexic patient 2007. Each 1 cm by 1 cm piece of skin was fixed with 10% procedure, a broad-spectrum UVA/UVB sunscreen with with volumisation post PRP/ formalin solution, neutral buffered. After treatment with DUBLiN Lift SPF 50 was recommended for use. polyester wax, the skin samples were sliced into 6 µmPrime Downloaded from informahealthcare.com by 109.255.10.181 on 10/08/12 thicknesses. The sliced sections were treated with PRP preparation Draw blood (4 ml for each tube), then haematoxylin and eosin statin (H&E) and Masson’s centrifuge tubes at 2000 rpm for 5 minutes. Take the trichrome staining solutions. Through tissue evaluations, syringe, insert the needle and withdraw 0.5 ml DNA the thickness of the dermal layer and presence of collagen Activator (10% calcium chloride). Withdraw platelets and fibres were observed. The thickness of the dermal layer mix with the DNA Activator. was calculated by measuring five different sites from Multiple injections (0.05–0.1 ml for a single injection) each section, and the mean value of the thickness of the were applied to the intra/sub dermis using the dermal layer for each group was used for the comparison. ‘multi-pricking’ or retrograde linear techniques For personal use only. Results Omnilux 633 nm LED This was applied for 20 minutes Over 3 months, 29 subjects (Group 2) were selected to per session (126 J/cm2). compare the effect of low energy fractional laser skin resurfacing with adjunctive treatments to conventional Phase 3 (Week 3) ablative laser resurfacing. These patients received a Low-level UltraPulse Lumenis ActiveFX with settings three-phase combination of established treatments with (energy) 100 mJ (rate) 14 w CPG 3/5/2. neurotoxin, microneedling, platelet growth hormones, near-red 633 nm light, and low-energy UltraPulse fractional Omnilux 633 nm LED This was applied for 20 minutes CO2 laser skin tightening over a 3-week period. Phase 1 per session (126 J/cm2). included the administration of Dysport® neurotoxin to the upper face. Phase 2 introduced fibroblast stimulation from Histology Skin biopsies were obtained from five of the microneedling and PRP growth factor induction with patients intra-operatively, before Phase 2 of near-red phototherapy, and Phase 3 included the treatment and at 3 months post- low-level (CO2) UltraPulse laser with adjunct operatively, and were performed to Over 3 months, 29 subjects near-red 633 nm phototherapy. Results were determine the amount of epidermal (Group 2) were selected to compare compared to the remaining 15 patients damage, subsequent inflammation, and the effect of low energy fractional (Group 1) who received fractional laser skin new collagen synthesis. The extent of laser skin resurfacing with adjunctive resurfacing (125 mJ; 19 w CPG 3/5/4), and neocollagenesis was compared with data whose data was already on file. Patients in on file for patients who had skin biopsies for treatments to conventional ablative both groups were administered Dysport® laser resurfacing and neurotoxin alone in laser resurfacing. neurotoxin 1 week prior to treatment to 28 October 2012 | prime-journal.com
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  11. 11. ARTICLE | facial aesthetics | 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 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 orPrime Downloaded from informahealthcare.com by 109.255.10.181 on 10/08/12 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%) Facial ageing is a consequence of many interacting favouring conventional fractional laser skin resurfacing. Investigator-based GAIS assessment of this region at 3 intrinsic and extrinsic factors. The most important of these For personal use only. months after baseline indicated that fractional resurfacing include sun exposure or photoageing, and the intrinsic was superior in 93% of patients, while the DUBLiN Lift was changes associated with chronological ageing. superior in 6.8% of patients (P = 0.0025). complement and preserve the overall aesthetic effect. Objective results The study evaluated post-procedural aesthetic results at Re-epithelialisation occurred in all laser-treated areas of baseline, 6 weeks and 12 weeks by means of a scoring both groups by day 7, and this appeared to be clinically system based on Dover’s photoageing scale, as well as similar for both procedures. Mean duration of erythema using the WSRS and GAIS. was 6.9 days after resurfacing (range 4–10 days) in Group 1 Histological results were obtained from both groups and 4.2 days in Group 2 (range 3–7 days). This appeared to showing the depth of laser penetration and consequential be in keeping with previous studies37. All patients reported formation of new collagen. All skin biopsies showed having no ‘crusting’ effect remaining on their face after 6 thermal coagulation of the epidermis and superficial days. Residual erythema remained in one patient in Group dermis in a depth ranging from 85 to 113 µ. The zone of 1 for a period of 14 days, but this was minimal. Post- residual thermal (coagulative) damage was less in the operative erythema was most intense in the areas treated Group 2 patients, in whom less laser energy was used. with the ActiveFX at an energy level above 125 mJ. 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, References which continued to improve over the period. Owing to 1. Raspaldo H. Volumizing 2007; 9(4): 218–25 of carbon dioxide laser effect of a new hyaluronic 5. Rohrich RJ, Pessa JE. The resurfacing for photoaged the variance in energy of the CO2 laser in Group 1 and acid sub-dermal facial filler: a fat compartments of the facial skin. J Am Acad retrospective analysis based face: anatomy and clinical Dermatol 1999; 40(3): 401–11 Group 2, it was expected that the documented depth of on 102 cases. J Cosmet Laser implications for cosmetic 10. Fitzpatrick RE, Goldman Ther 2008; 10(3): 134–42 surgery. Plast Reconstr Surg MP, Satur NM, Tope WD. histological ablation and thermal effects would vary 2. Cohen JL, Bar A. Fillers for 2007; 119(7): 2219–27 Pulsed carbon dioxide laser between them. Responses of aesthetic effect were Facial Rejuvenation. In: Hirsch RJ, Cohen JL, Sadick 6. Sadick NS. Update on resurfacing of photo-aged facial skin. Arch Dermatol non-ablative light therapy for evaluated at 6 and 12 weeks after baseline. N. Aesthetic Rejuvenation: A rejuvenation: a review. 1996; 132(4): 395–402 Regional Approach. China: Lasers Surg Med 2003; 32(2): 11. Hamilton MM. Carbon The two methods appeared to produce different McGraw-Hill Companies, 120–8 dioxide laser resurfacing. 2009 Facial Plast Surg Clin North clinical improvement of lesions and rhytides. The GAIS 3. Hirsch RJ. Dermal Fillers. 7. Williams EF 3rd, Dahiya R. Review of nonablative laser Am 2004; 12(3): 289–95 for photoageing for the DUBLiN lift improved from 13.2 to In: Sadick N, Moy R, Lawrence resurfacing modalities. Facial 12. Fitzpatrick RE. CO2 laser N. Concise Manual of Plast Surg Clin North Am resurfacing. Dermatol Clin 10.2 at day 30. This compared to 13.8 at baseline and 9.6 at Cosmetic Dermatologic 2004; 12(3): 305–10 2001; 19(3): 443–51 Surgery. China: McGraw-Hill 8. Grema H, Greve B, Raulin 13. Fitzpatrick RE. day 30 for conventional fractional laser skin resurfacing Companies, 2008 C. Facial Maximizing benefits and 4. 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