This paper looks at the possibility of combining five established therapies in an attempt to address common concerns related to facial ageing. The therapies included microneedling, low dose Ultralase laser, (PRP) plasma rich protein growth factors, Omnilux 633 light and neurotoxins. The technique is called the DUBLiN face-lift as an acronym of the procedures involved. D Dermaroller U Ultralase Laser B Blood growth factors Li Light (near red 633) N Neurotoxin. The author compared this method to fractionalised laser skin resurfacing (FLSR) in terms of reduction of photoageing and overall aesthetic effect. Neurotoxin was used in both studies.

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Dr Treacy’s
CASEBOOK
Dr Patrick Treacy on combining therapies for optimal outcomes in treating the
ageing face: an introduction to the DUBLiN Facelift.
T
his paper looks at the possibility of combining five
established therapies in an attempt to address
common concerns related to facial ageing. The
therapies included microneedling, low dose
Ultralase laser, (PRP) plasma rich protein growth
factors, Omnilux 633 light and neurotoxins. The technique is
called the DUBLiN face-lift as an acronym of the procedures
involved. D Dermaroller U Ultralase Laser B Blood growth
factorsLi Light(nearred633) NNeurotoxin.
The author compared this method to fractionalised laser
skin resurfacing (FLSR) in terms of reduction of photo-
ageing and overall aesthetic effect. Neurotoxin was used in
bothstudies.
RESEARCH DESIGN AND METHODS
This multi-centre randomised study included 44 patients of
skin type I and II aged between 39 -68 years presenting with
photo-ageing of skin, 37 of whom were women and seven
weremen.
The subjects presented with the typical hall marks of
chronological and photo-ageing 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 neocollogenesis by one of two methods, conventional
FLSR or the DUBLiN Lift. 15 patients underwent Lumenis
ActiveFx withsettings(Energy) 125mJ(Rate) 19wCPG3/5/4.
29 patients received the DUBLiN Lift, a three phase
combination of established treatments with micro-needling,
platelet growth hormones, near-red 633nm light and low
energy ultralase fractional CO2 laser skin tightening. All
patients received Dysport®
in three areas one week prior to
theother treatmentsasanadjunctto thelaserresurfacing.
The DUBLiN Lift was introduced as three phases over a
period of three weeks. Phase I included Dysport®
at dilution
3.5:1 in 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 included low–level (CO2)
Ultrapulselaserwithsettings(Energy)100mJ(Rate)14wCPG
3/5/2 and adjunct near-red 633nm phototherapy. The study
evaluated post procedural aesthetic results at two weeks,
four weeks and twelve weeks. The length of downtime,
patient discomfort and adverse side effects were noted for
eachphase.
Clinicalassessmentofpatientsineachgroupingwasmade
at two weeks, I month and three months postoperatively
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 (such as
herpes)werealsorecorded.
Theefficacyoftreatmentwasevaluatedusingavariationof
thefive-pointscale(FigI)originallysuggestedbyDoveretal.1
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
photo-damagevariables.
The degree of perceived improvement in overall aesthetic
effect reflecting chronological age was assessed separately
by patients and physicians using the Wrinkle Severity Rating
ScaleandtheGlobalAestheticImprovementScale.TheWSRS
isrecognisedasavalidandreliableinstrumentforquantitative
assessment of facial skin folds, with good inter- and intra-
observer consistency.2
Wrinkle severity is measured by using
a wrinkle severity rating scale with one being absent and five
being extreme. By allowing objective grading of data, these
proved useful clinical tools for assessing the effectiveness of
facialvolumisationwithPRPandMN-633.
Dublin LIFT Herpes Simplex Dublin LIFT Injecting PRP3 Dublin LIFT NW Eye Before Dublin LIFT NW Eye After 2

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Interventions: Lumenis ActiveFx CO2 laser.
Traylife Protein Rich Plasma, Omnilux 633 diode
light. Dermaroller® and Dysport®. All participants
received selective regional anaesthesia blocks with
2% Lignocaine plus adrenaline, topical combination
anaesthetic of 23% lignocaine and prophylactic Valtrex
500 mg twice daily for eight days. Valium 5-10mgs mgs
stat was given as a pre-med to some patients. A post
procedural advice sheet and Neurofen or Codeine with
Paracetemol as required.
1. The ‘ActiveFx’ is a protocol of settings applied in
conjunction to an improved CPG (computer pattern
generator) to the ultrapulsed CO2 laser (Ultrapulse
Encore, Lumenis Ltd, Santa Clara, CA, USA). 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 small spot size (1300 mm
instead of 2500 mm) resulting in less post procedure
erythema.
The CPG 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 this feature was used with
every patient in the study.
2. Traylife Kit (Platelets Rich Plasma) PROMOITALIA
Wellness Research. The kit provides blood plasma
enriched with a concentrated source of autologous
platelets that releases several growth factors and
other cytokines that stimulate the healing of soft
tissue.
3. Omnilux reviveTM (633nm) stimulates fibroblast
activity, leading to faster and more efficient collagen
synthesis and ECM proteins. Photo Therapeutics,
Inc. Unit 1 Kingfisher House, Juniper Dr. London SW18
1TX United Kingdom
4. Dermaroller®
Collagen Induction Therapy (CIT) is a
minimally-invasive cosmetic procedure that involves
the use of a micro-needling device. These devices
come from many sources. AesthetiCare®
, Unit
124, Thorp Arch Estate, Wetherby, West Yorkshire
LS23 7BJ

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RESULTS
Over three months, 29 subjects (Group 2) were selected to
compare the effect of low energy FLRS (fractionalised laser
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 633nm light and low energy ultralase fractional
CO2 laser skin tightening over a three weekly period. Phase
I included the administration of Dysport neurotoxin in 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 633nm phototherapy.
Results were compared to 15 patients (Group 1) who received
FLSR at the level of settings (Energy) 125 mJ (Rate) 19w CPG
3/5/4 and whose data was already on file. Patients in both
groups were administered received Dysport®
neurotoxin
one week prior to treatment to complement and preserve
the aesthetic effect. The study evaluated post procedural
aesthetic results at baseline, six weeks and twelve weeks
by means of a scoring system based on Dover’s photoageing
scale as well as using the Wrinkle Severity Rating Scale and
theGlobal Aesthetic ImprovementScale.
Histologicalresultswereobtainedfrombothgroupsshowing
the depth of laser penetration and consequential formation of
new collagen. All skin biopsies showed thermal coagulation of
epidermis and superficial dermis in a depth ranging from 85 to
113 microns. The zone of residual thermal (coagulative) damage
was less in the Group 2 patients where less laser energy was
used.Thebestneocollogenesisresultsat3monthswereevident
in Group 1 where one patient (Image E) had evidence of effect
at 700 microns. This was reflected in the patient’s skin, which
continued to improve over the period. Because the variance in
energy of the CO2 laser in Group 1 and Group 2 it was expected
thatthedocumenteddepthofhistologicalablationandthermal
effectswouldvarybetweenthem.
Responsesofaestheticeffectwereevaluatedatsixand12
weeksafter baseline.
The two methods appeared to produce different clinical
improvement of lesions and rhytides. The GAIS global score
for photo-ageing for the DUBLiN lift improved from 13.2 to
10.2 at Day 30. This compared to 13.8 at baseline to 9.6 at day
30 for conventional FLRS alone. The score for fine lines was
the most significant reduction dropping form 3.6 at baseline
to1.4atDay30.Thescoreforreductionofcoarsewrinkles(3.2
at baseline to 2.2 at 6 weeks) was more difficult to interpret in
thisheterogeneousagegroupingwitholderpatientsrequiring
the conventional ActiveFx settings rather than the “softer”
ones.Accordingtoinvestigator-basedWrinkleSeverityRating
Scale and Global Aesthetic Improvement Scale assessments
at three months after baseline, DUBLIN Lift was superior
in 62.0 percent and 55.2 percent of patients, respectively,
whereasFLSRwassuperiorin33.3percentand34.4percentof
patients. (p 0.0004). “Optimal cosmetic result” was achieved
inahigherpercentageofpatientsinGroup2thanGroup1.
(Fig1)Patienttreatment(positive)scoringchart
Parameter 0 1 2 3 4
Erythema
Severity
None Rare Several Moderate Severe
Infective
Outbreak
(Herpes/Acne)
None Rare Several Moderate Severe
Crusting None Rare Several Moderate Severe
Painof
Procedure
None Mild Tolerable Moderate Severe
Improvement None Minimal Fair Good Excellent
(Fig3)WSRSPatientscoringchart
Degree Description
1Exceptionalimprovement Excellentcorrectiveresultatweek
12.Nofurthertreatmentrequired
2Veryimprovedpatient Marked improvement of
the appearance, but not
completely optimal.
3Improvedpatient Improvementoftheappearance
bettercomparedwiththeinitial
condition.Touch-upisadvised.
4Unalteredpatient Theappearancesubstantially
remainsthesamecomparedwith
theoriginalcondition.
5Worsenedpatient The appearance has worsened
compared with the original
condition.
(Fig2)Patienttreatment(negative)scoringchart
5 Extreme Extreme(extremelydeepandlongfolds,
detrimentaltofacialappearance)....
4 Severe Severe:verylonganddeepfolds;prominentfacial
features;lessthan2mmvisible
3 Moderate Moderate:moderatelydeepfolds;clearfacialfeature
visibleatnormalappearancebutnotwhenstretched
2 Mild Mild:Shallowbutvisiblefoldwithaslight
indentation;minorfacialfeature
1 Absent Absent:novisiblenasolabialfold;continuousskin
injectableimplantalone
Dublin LIFT 633 Light2
Dublin LIFT PRP1 EF3 EF3 EM4

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(Fig4)GlobalAestheticImprovementScale(GAIS)
GROUP1:FLRS GROUP2DUBLINLift
Phase1 NormalDysport®
treatmenttothreeareas.Glabellar,Frontalisand
Periorbital.
NormalDysport®
treatmenttothreeareas.
Glabellar,FrontalisandPeriorbital.
Phase2
(Week2)
LumenisActiveFxwithsettings(Energy)125mJ(Rate)19wCPG3/9/4
PreLaserProcedure:ForanxietywetypicallyprescribedValium
(Diazepam5–10mgpo)tobegiven45minutespriortotheprocedure.
Infection Prophylaxis: Famvir (Famciclovir) 750mgs daily or Valtrex
(valcyclovir) 500 mg bd for 7 days was prescribed for every patient
starting 3 days before procedure. If the patient had a strong history
of acne, ByMycin (Doxycycline 100mgs daily) or Keflex (Cephalexin
500 mg bd) was prescribed for 7 days, starting the day of surgery.
Diflucan (Fluconazole 150mgs) was not routinely prescribed in
any patient.
Anaesthesia: The patients were treated under topical and regional
anaesthesia.
• Topical Anaesthesia: (Benzocaine 20%, Lidocaine Base 6%
Tetracaine 4%) Receptura Apotheke Frankfurt am Main
• RegionalAnaesthesia
1)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, towards the nose.
2) InfraorbitalNerveBlock:1ccof1-2%Lidocaineinjectedintothebuccal
cavitywiththeneedledirectedtowardstheinfraorbitalforamen.
3)MentalNerveBlock:1ccof1-2%Lidocaineinjectedintothemental
foramenjustabovethebonelevel.
Microneedling: Topical Anaesthesia
Topical Anaesthesia: (Benzocaine 20%,
Lidocaine Base 6% Tetracaine 4%) Receptura
Apotheke Frankfurt am Main
Each patient received Chiroxy Cream
post procedure to reduce erythema and
inflammation. Tepid water was used to cleanse
face for the following 48 hours and dry 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 SPF50.
PRP preparation: Draw blood (4 ml per each
tube). Centrifuge tubes at 2000 rpms x 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 to 0.1 ml for single
injection) intra/sub dermis with multipricking
or retrograde linear technique
Omnilux633nmLED:20min/session(126J/cm2).
Phase3 LowLevelUltralase
LumenisActiveFxwithsettings(Energy)100mJ
(Rate)14wCPG3/5/2.
Omnilux633nmLED:20min/session(126J/cm2).
ActiveFx RE before treatment ActiveFx RE on Day 4 ActiveFx RE on Day 14 ActiveFx RE on Day 30
GROUP 1 PERIORBITAL RYTHIDES
Thepatientwasa53yoCaucasianmalewhopresentedwithbilateralperiorbitalrhytidesfortreatment.Hehadaprevious
poor response with fibroblast transplanting (Isolagen) into the area and he was an intermittent Botox user. The patient
wastreatedwiththeLumenisActiveFxwithsettings(Energy)100mJ(Rate)19wCPG3/5/4
Patient CM : The right eye was treated with the Lumenis ActiveFx with settings (Energy) 100 mJ (Rate) 125 Hz CPG 3/5/2.
withobviousreductioninrhytides
GROUP 2 NMG
The patient was a 39yo Caucasian female. She received PRP, microneedling, 633NM light and Dysport 35u bilaterally.
TheperiorbitalareawastreatedwiththeLumenisActiveFxwithsettings(Energy)100mJ(Rate)14wCPG3/5/2
R eye ActiveFx Day 1 ReyeActiveFxtreatedDay3 R eye ActiveFx Day 30 Day 2 Day 30
PatientNMG: (Rside)ActiveFxtreated(Energy)125mJ(Rate)19wCPG3/5/4

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HISTOLOGY
Laserpenetrationdepth113nm Newcollagenformationseenat700mm.
Laser penetration depth seen at 113 mm Laser penetration depth 85 mm
Image A Group 1 Patient PN
immediate post procedure
ImageCisGroup1PatientNMG
immediatepostprocedure
Image D Group 2 Patient MW
Three months post procedure
ImageBGroup2PatientMW
immediatepostPhase3procedure
ActiveFxtreated(Energy)100mJ9.4J/
cm2(Rate)125Hz18.8WCPG3/5/2/
Image E Group 1 NMG three months
post procedure
ActiveFxtreated(Energy)15-30W125mJ
9.4J/cm2(Rate)125Hz18.8WCPG3/5/2/
Investigator-based and patient-based ratings using both
WSRS and GAIS indicated that the DUBLIN Lift was more
effective than conventional ablative laser resurfacing in
creating cosmetic correction in the lower face. This resulted
from the volumising effect of adding PRP to the larger
folds in this area. At three months post-treatment, a higher
proportion of patients showed a or = 1-grade improvement
in Wrinkle Severity Rating Scale with DUBLIN Lift than
with FLSR. The author suspects the PRP may have a longer
aesthetic effect when used in association with NM and 633
light than has been previously noted.3-4 However the results
werealmostreversedwheneverperiorbitalrejuvenationwas
assessed alone with almost every patient (93%) favouring
conventional FLSR. Investigator-based Global Aesthetic
Improvement Scale assessment of this region at three
months after baseline indicated that FLSR was superior in
93.0 percent of patients, whereas DUBLiN Lift was superior
in6.8percentofpatients(p=0.0025).
Re-epithelialisation occurred in all laser treated areas by
both groups by day seven and this appeared to be clinically
similar for both procedures. Mean duration of erythema
was 6.9 days after resurfacing (range, four to 10 days) in
Group 1 and 4.2 days in Group 2 (range, three to seven days).
This appeared to be in keeping with previous studies.5
All
patients reported having no crusting effect remaining on
their face after six days. Residual erythema remained in one
patientinGroup1foraperiodof14daysbutthiswasminimal.
Postoperative erythema was most intense in the areas
treatedbywiththeActiveFxattheenergylevelabove125Mj.
COMPLICATIONS
G2 EK Dublin LIFT Before G2 EK Dublin LIFT After G2 EK Dublin LIFT Eye Before G2 EK Dublin LIFT Eye After

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Dr Patrick Treacy is chairman of the Irish Association of Cosmetic Doctors and Irish Regional Representative
of the British Association of Cosmetic Medicine. He is a fellow of the Royal Society of Medicine and
the Royal Society of Arts. (London) and chairman of the Ailesbury Humanitarian Foundation. He is on
the editorial boards of five international aesthetic and dermatology journals and has pioneered facial
endoprosthesis techniques for HIV facial lipodystrophy and radiosurgery thermocoagulation. He is on the
faculty for IMCAS Paris 2016, AMWC Monaco 2016, EAMWC Moscow 2016, AM Live London 2016, FACE
London 2016, AMEC Paris 2016, and RSM ICG London 2016. His awards include: ‘Best Professional Journalist
Ireland’ (2003);’Best Medical Clinic in Ireland’ (2005); Highly Commended ‘Best Aesthetic Clinic Ireland
UK (2008) (2009); Winner of the MyFaceMyBody ‘Best Innovative Technique’ facial aesthetics and hair
transplant (2012) (2013) and Winner AMEC Paris ‘Best Medical Case Facial Rejuvenation ‘2014’.
REFERENCES
1. Tina S. Alster MD Christopher A. Nanni MD Famciclovir Prophylaxis
of Herpes Simplex Virus Reactivation After Laser Skin Resurfacing
Dermatol Surg Volume 25 Issue 3 Page 242-246, March 1999
2. Rohrich RJ, Pessa JE: The fat compartments of the face: anatomy and
clinical implications for cosmetic surgery. Plast Reconstr Surg 2007,
119:2219-2227.
3. B.L. Eppley, W.S. Pietrzak, M. Blanton Platelet-rich plasma: a review of
biology and applications in plastic surgery Plast Reconstr Surg., 118 (2006
Nov), pp. 147e–159e
4. A.P. Sclafani Applications of platelet-rich fibrin matrix in facial plastic
surgery. Facial Plast Surg., 25 (2009 Nov), pp. 270–276
5. 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;21:1025–1029.
The mean pain sensation (Table 2) felt during the DUBLiN
Lift was 2.2 compared to conventional FLRS treatment at
3.4. We noted most patients did not really feel pain with the
ActiveFx until the proceduralists crosses 100mj. No patient
experienced any adverse reaction to laser skin resurfacing
except one case of herpetic infection in each group. (Group 1
was6.6%andGroup2was3.4%).
Both treatments were well tolerated. Clumping of
platelets occurred in 10% of patients treated with PRP and
the author felt that this was due to the concentration of
solutionused.Infact,anecdotalevidencesuggeststhatmost
cosmetic physicians are using PPP (platelet poor plasma) in
most areas of the face rather than the higher concentrations
used by orthopaedic surgeons. Mean patient age in Group 1
was 49.24 years (range, 37-71 years) and Group 2 was 54.86
(range, 41-76years).
CONCLUSIONS
The author presents a novel method of facial rejuvenation
that examines the possibility of 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. He concludes
that although fractionalised CO2 laser resurfacing is
recognised as the gold standard procedure for tissue
that has lost its elasticity it has adverse risks and does
not adequately address the problems associated with
chronological ageing. He addresses the requirement to
apply adjunct methods such as plasma rich platelets to
address nasolabial or marionette lines and volume deficits
resulting from the loss and repositioning of facial fat.
The author also establishes the benefit of using other
facial rejuvenating therapies including microneedling,
PRP growth factors, 633 nm light to limit the depth of
laser penetration and decrease the risk of scarring and
permanent pigmentary alteration. The novel technique
is called the DUBLiN facelift as an acronym of the
procedures involved: Dermaroller, UltraPulse laser, Blood
growth factors, Light (near-red 633 nm), and Neurotoxin.
The author has done this research independently and
receives no financial benefit from the companies who
providedthe materials forthe study.
Historical note. The author won the MyFaceMyBody
Awards for facial rejuvenation in London in 2012 for this
methodoffacialrejuvenation.Itwasrecognizedasoneofthe
first true combination therapies. Since this time it a modified
version of the treatment DBLi (using Dermaroller, Blood
Factors and Light) has become popular amongst nurses and
aestheticians who don’t have access to expensive lasers or
botulinumtoxin. AM