The 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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The DUBLiN Lift

  1. 1. ARTICLE | facial aesthetics | Combining therapies for optimal outcomes in treating the ageing face: introducing the DUBLiN Facelift Patrick Treacy xxxxxx [AQ1: please provide an author image] ABSTRACT Objective radio frequency 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 UltraLase laser, The face is the area for which the majority of revolutionised with the development of PRP growth factors, Omnilux 633 nm light, patients seek cosmetic rejuvenation as the CO2 fractional laser skin resurfacing. This and neurotoxins. The technique is called convex lines of a youthful appearance tend procedure benefits from faster recovery the DUBLiN facelift as an acronym of the to flatten and droop as one grows older. The time, more precise control of ablation procedures involved: Dermaroller, UltraLase younger face is characterised by a balance depth, and reduced risk of post-procedural laser, Blood growth factors, Light (near-redDr Patrick Treacy is captured in the classic shape of the inverted problems. However, there have been cases 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 Doctors peels, dermal fillers, intense pulsed light and volume deficits resulting from the loss and Temail: he face, and particularly the eyes, is very barometer of a patient’s chronological and important for contact between humans, environmental age, and mastering the proper evaluation as these areas provide a window to the and execution of their aesthetic rejuvenation is rest of society with regard to a patient’s paramount for all cosmetic doctors. level of health, tiredness and emotional More recently, patients are seeking effective facial status, as well as interest in others4. Many rejuvenation procedures with less downtime and lowKeywords health professionals consider the periorbital area of the risks6. This change in attitude has been prompted by afractionalised laser resurfacing, face as the most important area of rejuvenation as realisation of both doctors and patients that the muchplatelet-rich plasma,microneedling, Omnilux 633 nm eye‑to-eye communication occurs in approximately hyped non-ablative methods were often subject tolight, neurotoxin 80% of all human interactions6. Both areas present a extravagant claims in terms of efficacy2–4. For many18 September 2012 |
  2. 2. ARTICLE | facial aesthetics | years, CO2 laser resurfacing was considered the ‘gold regeneration. The author used microneedling with low standard’ in treating photodamaged facial skin6–11. energy laser, and platelet rich plasma (PRP) to address Cutaneous laser resurfacing with a fractional (CO2) laser these issues. involves the vapourisation of the entire epidermis, as It is recognised that the most important rejuvenation well as a variable thickness of the dermis. Many process for photoaged skin is the collagen remodelling physicians stated that the ultrapulsed CO2 laser was the process, and dermal fibroblasts are known to have the most effective method of laser resurfacing12–13. most important function29. Rejuvenation of skin injury Photodamaged skin is the result of years of exposure to caused by UV light is a complex process that organically harmful ultraviolet light and is clinically demonstrated as involves cytokines interacting with a number of growth a gradual deterioration of cutaneous structure and factors and control proteins28. The procedures evaluated function. This results in the epidermis and upper included PRP, microneedling, and Omnilux 633 nm papillary dermis having a roughened surface texture, as near‑red light, with neurotoxins as an adjunct to low-level well as laxity, telangiectasias, wrinkles and variable fractional laser skin resurfacing. Cells in the epidermis degrees of skin pigmentation14–15. and dermis can be targeted by microneedling and Although ultrapulsed CO2 resurfacing lasers were near‑red light, resulting in fibroblast stimulation. Omnilux considered the best treatment option, they had many Revive™ (633 nm) therapy stimulates fibroblast activity, post-procedural problems16, 17, including prolonged leading to faster and more efficient collagen synthesis post‑operative recovery, pigmentary changes, and a high and extracellular matrix (ECM) proteins. It also increases incidence of acne flares and herpes simplex virus (HSV) cell vitality by increasing the production of cellular infection18, 19. Many patients complained of oedema, adenosine triphosphate (ATP) and stimulates the burning, and erythema that sometimes lasted for many contractile phase of the remodelling process producing months20, 21. The implied risks and long downtime made better lineated collagen30–33. Collagen induction therapy is many patients reluctant to accept this method of an aesthetic medical procedure that involves repeatedly treatment22, 23. More recently, fractional resurfacing lasers puncturing the skin with tiny, sterile needles. Typically, have addressed many of these earlier problems with this is done with a specialised instrument called a benefits of faster recovery time, more precise control of microneedling device. ablation depth, and reduced risk of post procedural Controlled studies have suggested that the application problems8. These lasers are extremely versatile, in that of autogenous PRP can enhance wound healing in both they can be used for the treatment of facial rhytides, acne animals and humans29. Five major growth factors such as scars, surgical scars, melasma and photodamaged skin, transforming growth factor (TGF), insulin-like growth and many have entered the market at the same time24. factor (IGF), platelet-derived growth factor (PDGF), With the advent of fractional laser skin resurfacing, the epidermal growth factor (EGF), and vascular endothelial number of completely ablative resurfacing cases has growth factor (VEGF) are known to be related to the declined for most practitioners. However, care should be wound-healing processes28. These growth factors are taken when treating sensitive areas such as the eyelids, released from platelets and the production of collagen upper neck, and especially the lower neck and chest, by and fibroblasts is stimulated by IGF, EGF, Interleukin-1 using lower energy and density, and scarring has been (IL‑1) and tumour necrosis factor (TNF)-α34, 35. In vivo noted in these areas25. Scarring after fractional CO2 laser studies report TGF-β to be the most stimulative growth therapy is considered mainly a result of overly-aggressive factor. PRP may be used for dermal augmentation and treatments and a lack of technical finesse. Physicians Sclafani observed aesthetic improvements of the have also recorded post‑operative infections leading to nasolabial fold in less than 2 weeks, and the results lasted scarring, although it is generally felt that these may be for up to 3 months28, 29. prevented by careful history-taking, vigilant post‑operative monitoring, and/or the use of prophylactic Research design and methods antibiotics26, 27. This multi-centre randomised study included 44 patients With regard to facial rejuvenation, CO2 laser light at a of skin types 1 and 2 aged between 39 and 68 years, 10 600 nm wavelength results in vaporisation with presenting with photoageing of the skin, 25 of whom thermal denaturation of type I collagen, collagen were women and 4 were men [AQ2: what about the shrinkage and later, collagen deposition. However, in remaining 15?]. The subjects presented with the typical very deep rhytides, acne scarring and severe elastotic hallmarks of chronological and photoageing, such as changes from sun damage, fractional CO2 therapy expression lines, rhytides, wrinkles, eyelid skin laxity, requires multiple treatments to achieve the same results dermatochalasis, lowered brows, lateral hooding, and as the older lasers28. A number of studies have evaluated prominent fat pads. All patients were subjected to a using different laser combinations in the same session in programme of skin tightening and neocollogenesis by order to improve collagen deposition, with a wider zone one of two methods: conventional fractional laser skin of fibroplasia6–9, 28. Owing to the inherent risks of fractional resurfacing (Group 1) or the DUBLiN Lift (Group 2). The laser skin resurfacing and its inability to deal with some mean patient age in Group 1 was 49 years (range 37– evidence of chronological ageing, it was advocated to 71 years) and in Group 2 was 55 years (range 41–76 years). here establish the clinical effectiveness of using a Fifteen patients underwent Lumenis ActiveFx™ with multi‑procedural approach to volumisation and collagen settings as (energy) 125 mJ and (rate) 19 w CPG 3/5/4.20 September 2012 |
  3. 3. | facial aesthetics | ARTICLETwenty-nine patients received the DUBLiN Lift, a three- also given to patients.phase combination of established treatments with The ActiveFX is a protocol of settings applied inmicroneedling, platelet growth hormones, near-red conjunction with an improved computer pattern633 nm light, and low-energy UltraLase fractional CO2 generator to the ultrapulsed CO2 laser (UltraPulselaser skin tightening. All patients received Dysport® in Encore, Lumenis Ltd). Technical differences betweenthree areas 1 week prior to the other treatments as an this non-sequential fractional device and the olderadjunct to the laser resurfacing. ultrapulsed CO2 include tissue bridges left between spots, The DUBLiN Lift was introduced as three phases over a resulting in faster healing time, and less thermal damageperiod of 3 weeks. Phase 1 included Dysport® at dilution to the basal cell membrane. The device has a smaller3.5 : 1 to three areas — glabellar, frontalis and periorbital. spot size (1300 mm rather than 2500 mm), resulting inPhase 2 introduced intense fibroblast stimulation and less post-procedure erythema.modification through microneedling, PRP growth factor The computer pattern generator lays down a randominduction, and near-red phototherapy. Phase 3 series of spots rather than a sequential sequenceadministered the low–level (CO2) UltraPulse laser at resulting in less overheating of the treated tissue. This100 mJ 14 w CPG 3/5/2, and adjunct near-red 633 nm application is termed ‘Cool Scan’, and was used withphototherapy. The study evaluated post-procedural every patient in the study.aesthetic results at 2 weeks, 4 weeks and 12 weeks. The The Traylife Kit (PRP) (Promoitalia Wellness Research)length of downtime, patient discomfort and adverse provides blood plasma enriched with a concentratedside‑effects were noted for each phase. source of autologous platelets that releases a number of Clinical assessment of patients in each group was growth factors and other cytokines that stimulate themade at 2 weeks, 1 month and 3 months post‑operatively healing of soft the presence of two aesthetic staff. The degree of Omnilux Revive™ (633 nm) (Photo Therapeutics, Inc.,improvement in photoageing was based on the degree of UK) stimulates fibroblast activity, leading to faster andre-epithelialisation rate, reduction of rhytides, reduction more efficient collagen synthesis and extracellularof tactile roughness, and loss of hyperpigmentation and matrix proteins.telangiectasias. The prolongation and severity of Dermaroller™ Collagen Induction Therapy (CIT)erythema as well as the presence of negative side-effects (AesthetiCare®, UK) is a minimally-invasive cosmetic(e.g. herpes) were also recorded. procedure that involves the use of a micro-needling The efficacy of treatment was evaluated using a device.variation of the five-point scale (Table 1) originally Scoring charts are presented in Tables 1–4.suggested by Dover et al36. Investigators and patientsevaluated efficacy using palpability assessments andchange from baseline score at 0, 6 and 12 weeks. A totalglobal score was recorded in each patient based on the Table 1 Patient treatment (positive) scoring chartaddition of points obtained from six photodamage Parameter 0 1 2 3 4variables. The degree of perceived improvement in Global score Area of Area of Area of Area of Area ofoverall aesthetic effect reflecting chronological age was roughness roughness roughness roughness roughnessassessed separately by patients and physicians using the x 0 x 1 x2 x3 x4Wrinkle Severity Rating Scale (WSRS) and the Global Fine lines None Rare Several Moderate ManyAesthetic Improvement Scale (GAIS). The WSRS is Pigmentary None Patchy Moderate Heavy Markedrecognised as a valid and reliable instrument for problems quantitative assessment of facial skin folds, with good Touch Even Rare Mild Moderate Severeinter- and intra-observer consistency5. Wrinkle severity is problems measured using a wrinkle severity rating scale with 1 Facial veins None Rare Several Moderate Severebeing absent and 5 being extreme. By allowing objective Coarse lines None Rare Several Moderate Manygrading of data, these proved useful clinical tools for Complexion Pink Pale Grey Slightly Distinctassessing the effectiveness of facial volumisation with yellow-grey yellow-greyPRP and microneedling–633.Interventions Table 2 Patient treatment (negative) scoring chartThe following treatment protocols were used for thisstudy: Lumenis ActiveFX CO2 laser, Traylife PRP, Omnilux Parameter 0 1 2 3 4633 nm red light, Dermaroller®, and Dysport®. All Erythema severity None Rare Several Moderate Severeparticipants received selective regional anaesthesia Infective outbreak None Rare Several Moderate Severeblocks with 2% lignocaine plus adrenaline, a topical (herpes/acne) combination anaesthetic of 23% lignocaine, and Crusting None Rare Several Moderate Severeprophylactic Valtrex 500 mg twice daily for 8  days. Pain of None Mild Tolerable Moderate SevereValium 5–10 mg stat was given as a pre-medication to procedure some patients. A post-procedural advice sheet and Improvement None Minimal Fair Good ExcellentNurofen or codeine with paracetamol — as required — was | September 2012 21
  4. 4. ARTICLE | facial aesthetics | into the buccal cavity with the needle directed Table 3 WSRS Patient scoring chart towards the infraorbital foramen ■■ Mental nerve block. 1 cc of 1–2% Lidocaine injected into5 Extreme Extremely deep and long folds, detrimental to facial appearance the mental foramen just above the bone level.4 Severe Very long and deep folds; prominent facial features; less than 2 mm visible3 Moderate Moderately deep folds; clear facial feature visible at normal Group 2: DUBLiN lift appearance, but not when stretched2 Mild Shallow but visible fold with a slight indentation; Phase 1 minor facial feature Dysport® treatment to three areas: glabellar, frontalis and1 Absent No visible nasolabial fold; continuous skin, injectable periorbital. implant alone Phase 2 (Week 2) Microneedling Table 4 Global Aesthetic Improvement Scale (GAIS) Topical anaesthesia: benzocaine 20%, Lidocaine Base 6%, and tetracaine 4%.Degree Description Each patient received Chiroxy cream post-procedure1 Exceptional improvement Excellent corrective result at week 12. No further to reduce erythema and inflammation. Tepid water was treatment required used to cleanse the face for the following 48 hours, and2 Very improved patient Marked improvement of appearance, but not completely optimal dried gently. It was recommended that make-up was not applied for 12 hours after the procedure. After the3 Improved patient Improvement of the appearance, better compared with the initial condition. Touch-up is advised procedure, a broad-spectrum UVA/UVB sunscreen with4 Unaltered patient The appearance substantially remains the same SPF 50 was recommended for use. compared with the original condition5 Worsened patient The appearance has worsened compared with the PRP preparation original condition 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 Group 1: fractional laser skin chloride). Withdraw platelets and mix with the DNA resurfacing Activator. Multiple injections (0.05–0.1 ml for a single injection) Phase 1 were applied to the intra/sub dermis using the Dysport® treatment to three areas: glabellar, frontalis and ‘multi‑pricking’ or retrograde linear techniques periorbital. Omnilux 633 nm LED Phase 2 (Week 2) This was applied for 20 minutes per session (126 J/cm2). Lumenis ActiveFX with settings (energy) 125 mJ (rate) 1 9w CPG 3/9/4 Phase 3 (Week 3) In the pre-laser procedure, the author typically prescribes Valium (Diazepam 5–10 mg orally) for anxiety, Low-level Ultralase administered 45 minutes before the procedure. Lumenis ActiveFX with settings (energy) 100 mJ rRate) For infection prophylaxis, Famvir (famciclovir) 750 mg 14 w CPG 3/5/2. daily or Valtrex (valcyclovir) 500 mg twice per day for 7 days, was prescribed for every patient starting 3 days Omnilux 633 nm LED before procedure. If the patient had a strong history of This was applied for 20 minutes per session (126 J/cm2). acne, By-Mycin (doxycycline 100 mg daily) or Keflex (cephalexin 500 mg twice per day) was prescribed for Histology 7  days, beginning on the day of surgery. Diflucan Skin biopsies were obtained from five of the patients (fluconazole 150 mg) was not routinely prescribed in any intra-operatively, before Phase 2 of the treatment, and at patient. 3  months post-operatively, and were performed to The patients were treated under topical and regional determine the amount of epidermal damage, subsequent anaesthesia. Topical anaesthesia comprised benzocaine inflammation, and new collagen synthesis. The extent of 20%, Lidocaine Base 6%, and tetracaine 4%). Regional neocollogenesis was compared with data on file for anaesthesia was three-fold: patients who had skin biopsies for laser resurfacing and ■■ Supraorbital and supratrochlear nerve block. The neurotoxin alone in 2007. Each 1 cm by 1 cm piece of skin supraorbital foramen was located and 1 cc of 1–2% was fixed with 10% formalin solution, neutral buffered. Lidocaine injected just above the bone laterally, with After treatment with polyester wax, the skin samples the needle directed medially, parallel to the brow and were sliced into 6 μm thicknesses. The sliced sections toward the nose were treated with haematoxylin and eosin statin (H&E) ■■ Infraorbital nerve block. 1 cc of 1–2% Lidocaine injected and Masson’s trichrome staining solutions. Through22 September 2012 |
  5. 5. | facial aesthetics | ARTICLEtissue evaluations, the thickness of the dermal layer and the ‘softer’ settings.presence of collagen fibres were observed. The thickness According to investigator-based WSRS and GAISof the dermal layer was calculated by measuring five assessments at 3 months after baseline, the DUBLiN liftdifferent sites from each section, and the mean value of was superior in 62% and 55.2% of patients respectively,the thickness of the dermal layer for each group was while fractional laser skin resurfacing was superior inused for the comparison. 33.3% and 34.4% of patients. (P < 0.0004). An ‘optimal’ cosmetic result was achieved in a higher percentage ofResults patients in Group 2 compared with Group 1.Over 3 months, 29 subjects (Group 2) were selected to Investigator-based and patient-based ratings usingcompare the effect of low energy fractional laser skin both the WSRS and GAIS indicated that the DUBLiN liftresurfacing with adjunctive treatments to conventional was more effective than conventional ablative laserablative laser resurfacing. These patients received a resurfacing in creating cosmetic correction to the lowerthree‑phase combination of established treatments with face. This resulted from the volumising effect of addingneurotoxin, microneedling, platelet growth hormones, PRP to the larger folds in this area. At 3 monthsnear-red 633 nm light, and low-energy Ultralase fractional post‑treatment, a higher proportion of patients showed aCO2 laser skin tightening over a 3-week period. Phase 1 greater than or equal to 1-grade improvement in WSRSincluded the administration of Dysport® neurotoxin to with DUBLiN Lift compared with fractional laser skinthe upper face. Phase 2 introduced fibroblast stimulation resurfacing. The author suspects the PRP may have afrom microneedling and PRP growth factor induction longer aesthetic effect when used in association withwith near-red phototherapy, and Phase 3 included microneedling and 633 nm light than previously noted27, 29.low‑level (CO2) UltraPulse laser with adjunct near-red However, the results were almost reversed whenever633 nm phototherapy. Results were compared to the periorbital rejuvenation was assessed alone, with almostreamining 15 patients (Group 1) who received fractional every patient (93%) favouring conventional fractionallaser skin resurfacing (125 mJ; 19 w CPG 3/5/4), and whose laser skin resurfacing. Investigator-based GAISdata was already on file. Patients in both groups were assessment of this region at 3 months after baselineadministered Dysport® neurotoxin 1 week prior to indicated that fractional resurfacing was superior in 93%treatment to complement and preserve the overall of patients, while the DUBLiN Lift was superior in 6.8% ofaesthetic effect. The study evaluated post-procedural patients (P = 0.0025).aesthetic results at baseline, 6 weeks and 12 weeks by Re-epithelialisation occurred in all laser-treated areasmeans of a scoring system based on Dover’s photoageing of both groups by day 7, and this appeared to be clinicallyscale, as well as using the WSRS and GAIS. similar for both procedures. Mean duration of erythema Histological results were obtained from both groups was 6.9 days after resurfacing (range 4–10 days) in Group 1showing the depth of laser penetration and consequential and 4.2 days in Group 2 (range 3–7 days). This appeared toformation of new collagen. All skin biopsies showed be in keeping with previous studies37. All patientsthermal coagulation of epidermis and superficial dermis reported having no ‘crusting’ effect remaining on theirin a depth ranging from 85 to 113 µ. The zone of residual face after 6 days. Residual erythema remained in onethermal (coagulative) damage was less in the Group 2 patient in Group 1 for a period of 14 days, but this waspatients, in whom less laser energy was used. The best minimal. Post-operative erythema was most intense inneocollogenesis results — at 3 months — were evident in the areas treated by with the ActiveFX at an energy levelGroup 1 where one patient NMG [AQ3: what does this above 125 mJ.signify?] (Image E) had evidence of effect at 700 µ. This The mean pain sensation [AQ5: how was this assessed?]was reflected in the patient’s skin, which continued to felt during the DUBLiN lift was 2.2 compared toimprove over the period. Owing to the variance in energy conventional fractional resurfacing treatment, whichof the CO2 laser in Group 1 and Group 2, it was expected was 3.4. The author noted that most patients did not feelthat the documented depth of histological ablation and much pain at all with the ActiveFX until the energy levelthermal effects would vary between them. Responses of crosses 100 mJ. No patient experienced any adverseaesthetic effect were evaluated at 6 and 12 weeks after reaction to laser skin resurfacing, except one case ofbaseline. herpetic infection in each group. (Group 1 6.6%; Group 2 The two methods appeared to produce different 3.4%). Both treatments were well tolerated. Clumping ofclinical improvement of lesions and rhytides. The global platelets occurred in 10% of patients treated with PRPscore [AQ4: are you referring to the GAIS? are the total for and the author felt that this was a result of thetables 1-4?] for photoageing for the DUBLiN lift improved concentration of solution used. In fact, anecdotalfrom 13.2 to 10.2 at day 30. This compared to 13.8 at evidence suggests that most cosmetic physicians arebaseline and 9.6 at day 30 for conventional FLRS alone. using PPP (platelet-poor plasma) in most areas of the face,The score for fine lines was the most significant reduction, rather than the higher concentrations used bydropping from 3.6 at baseline to 1.4 at day 30. The score for orthopaedic surgeons.reduction of coarse wrinkles (3.2 at baseline to 2.2 at6  weeks) was more difficult to interpret in this Conclusionsheterogeneous age grouping, with older patients Facial ageing is a consequence of many interactingrequiring the conventional ActiveFX settings rather than intrinsic and extrinsic factors. The most important of | September 2012 23
  6. 6. ARTICLE | facial aesthetics | 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 [AQ6: please state] References1. Raspaldo H. Volumizing effect of a new hyaluronic acid photodamage and photoprotection. J Am Acad Dermatol 27. 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  7. 7. | facial aesthetics | ARTICLE Further readingMatteo Tretti Clementoni a; Patrizia Gilardino a; Gabriele F. Muti a; preauricular and postauricular skin after high-energy, short-pulseDaniela Beretta b; Rossana Schianch. Non sequential fractional carbon dioxide laser. Arch Dermatol. 1996;132:425-428.ultrapulsed C02 resurfacing of photoaged skin. Journal of Cosmetic and Rubach BW, Schoenrock LD. Histological and clinical evaluation of facialLaser Therapy, Volume 9, Issue 4 2007 , pages 218 – 225 resurfacing using a carbon dioxide laser with the computer patternLask G, Keller G, Lowe N, Gormley D. Laser skin resurfacing with the generator. Arch Otolaryngol Head Neck Surg. 1997;123:929-934.SilkTouch flashscanner for facial rhytides. Dermatol Surg 1995;21:1021– Fitzpatrick RE, Tope WD, Goldman MP, Satur NM. Pulsed carbon dioxide1024. laser, trichloroacetic acid, baker-gordon phenol, and dermabrasion: aBernstein L, Kauvar A, Grossman M, Geronemus R. The short and long comparative clinical and histologic study of cutaneous resurfacing in aterm side effects of carbon dioxide laser resurfacing. Dermatol Surg porcine model. Arch Dermatol. 1996;132:469-471.1997;23:519–525. P Bonan, P Campolmi, G Cannarozzo, N Bruscino, A Bassi, S Betti, T Lotti.Alster TS. Side effects and complications of laser surgery. In: Alster TS. 1468-3083. 2011. 04034. Journal of the European Academy ofManual of Cutaneous Laser Techniques. Philadelphia: Lippinco, 2000 Dermatology and Venereology Eyelid skin tightening: a novel ‘Niche’ forBurkhardt BR, Maw R. Are more passes better? safety versus efficacy fractional CO2 rejuvenationwith the pulsed CO2 laser. Plast Reconstr Surg. 1997;99:1531-1534. G.F. Pierce, D. Brown, T.A. Mustoe Quantitative analysis of inflammatoryTreacy PJ. Article on fractionalised lasers Jan 2008 Health & Living cell influx, procollagen type I synthesis, and collagen cross-linking inMagazine incisional wounds: influence of PDGF-BB and TGF-beta 1 therapy J Lab Clin Med, 117 (1991), pp. 373–382David Goldberg, MD: Reduced Down-time Associated with NovelFractional UltraPulse CO2 Treatment (Active FX) as Compared to Mathew M. Avram, MD, JD,1,* Whitney D. Tope, MPhil, MD,2 Thomas Yu,Traditional Resurfacing P3115 -65th Annual American Academy of MD,3 Edward Szachowicz, MD, PhD,4 and J. Stuart Nelson, MD, PhD5Dermatology Meeting Hypertrophic Scarring of the Neck Following Ablative Fractional Carbon Dioxide Laser ResurfacingSmith KJ, Skelton HG, Graham JS, et al. Depth of morphologic skindamage and viability after one, two and three passes of a high-energy, Baez F and Reilly LR. The use of light-emitting diode therapy in theshort-pulse CO2 laser in pig skin. J Am Acad Dermatol. 1997;27:204-210. treatment of photoaged skin. Journal of Cosmetic Dermatology. 2007; 6: 189-194Fitzpatrick R, Ruiz-Esparaza J, Goldman M. The depth of thermalnecrosis using the CO2 laser. J Dermatol Surg Oncol. 1991;17:340-344. Lee SY, et al. A prospective, randomized, placebo-controlled, double- blinded, and split-face clinical study on LED phototherapy for skinTina S. Alster MD & Christopher A. Nanni MD Famciclovir Prophylaxis of rejuvenation: Clinical, profilometric, histologic, ultrastructural, andHerpes Simplex Virus Reactivation After Laser Skin Resurfacing biochemical evaluations and comparison of three different treatmentDermatol Surg Volume 25 Issue 3 Page 242-246, March 1999 settings. Journal of Photochemistry and Photobiology B. 2007; 88: 51-67Mario A. Trelles; Inés Allones Red light-emitting diode (LED) therapy Majid I (January 2009). Microneedling therapy in athrophic facial scars:accelerates wound healing post-blepharoplasty and periocular laser an objective assessment. J Cutan Aesthet Surg 2 (1): 26–30.ablative resurfacing Journal of Cosmetic and Laser Therapy: formerlyJournal of Cutaneous Laser Therapy, Volume 8, Issue 1, 2006, Pages 39 Doddaballapur S (July 2009). Microneedling with dermaroller J Cutan– 42 Aesthet Surg 2 (2): 110Kauvar ANB, Waldorf HA, Geronemus R. A histopathologic comparison Day DJ, Littler CM, Swift RW, Gottlieb S. The wrinkle severity rating scale:of char-free lasers. Dermatol Surg. 1996;22:343-348. a validation study Am J Clin Dermatol. 2004;5(1):49-52. Department of Dermatology, New York University Medical Center, New York, New YorkCotton J, Hood A, Gonin R, Beeson W, Hanke C. Histologic evaluation of 10021, USA | September 2012 25