Dr Patrick Treacy on combining therapies for optimal outcomes in treating the ageing face: an introduction to the DUBLiN Facelift

58 Aesthetic Medicine • March 2016

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Dr Patrick Treacy on combining therapies for optimal outcomes in treating the ageing face: an introduction to the DUBLiN Facelift.

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 photo-ageing and overall aesthetic effect. Neurotoxin was used in both studies.

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 were men.

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 with settings (Energy) 125 mJ (Rate) 19w CPG 3/5/4.

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 the other treatments as an adjunct to the laser resurfacing.

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) Ultrapulse laser with settings (Energy) 100 mJ (Rate) 14w CPG 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 each phase.

Clinical assessment of patients in each grouping was made 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) were also recorded.

The efficacy of treatment was evaluated using a variation of the five-point scale (Fig I) originally suggested by Dover et al.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-damage 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 and the Global Aesthetic Improvement Scale. The WSRS is recognised as a valid and reliable instrument for quantitative 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 facial volumisation with PRP and MN-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




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 the Global Aesthetic Improvement Scale.

Histological results were obtained from both groups showing 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. The best neocollogenesis results at 3 months were evident 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 that the documented depth of histological ablation and thermal effects would vary between them.

Responses of aesthetic effect were evaluated at six and 12 weeks after 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 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” ones. According to investigator-based Wrinkle Severity Rating 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, whereas FLSR was superior in 33.3 percent and 34.4 percent of patients. (p < 0.0004). “Optimal cosmetic result” was achieved in a higher percentage of patients in Group 2 than Group 1.

(Fig 1) Patient treatment (positive) scoring chart Parameter 0 1 2 3 4Erythema Severity

None Rare Several Moderate Severe

InfectiveOutbreak (Herpes/Acne)

None Rare Several Moderate Severe

Crusting None Rare Several Moderate Severe Pain ofProcedure

None Mild Tolerable Moderate Severe

Improvement None Minimal Fair Good Excellent

(Fig 3) WSRS Patient scoring chart Degree Description1 Exceptional improvement Excellent corrective result at week

12. No further treatment required

2 Very improved patient Marked improvement of the 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.

(Fig 2) Patient treatment (negative) scoring chart 5 Extreme Extreme (extremely deep and long folds,

detrimental to facial appearance). ...4 Severe Severe: very long and deep folds; prominent facial

features; less than 2 mm visible3 Moderate Moderate: moderately deep folds; clear facial feature

visible at normal appearance but not when stretched

2 Mild Mild: Shallow but visible fold with a slight indentation; minor facial feature

1 Absent Absent: no visible nasolabial fold; continuous skin injectable implant alone

Dublin LIFT 633 Light2

Dublin LIFT PRP1 EF3 EF3 EM4


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(Fig 4) Global Aesthetic Improvement Scale (GAIS) GROUP 1: FLRS GROUP 2 DUBLIN Lift

Phase 1 Normal Dysport® treatment to three areas. Glabellar, Frontalis and Periorbital.

Normal Dysport® treatment to three areas. Glabellar, Frontalis and Periorbital.

Phase 2 (Week 2)

Lumenis ActiveFx with settings (Energy) 125 mJ (Rate) 19w CPG 3/9/4

Pre Laser Procedure: For anxiety we typically prescribed Valium (Diazepam5–10 mg po) to be given 45 minutes prior to the procedure.

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

• Regional Anaesthesia 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) Infraorbital Nerve Block: 1 cc of 1-2% Lidocaine injected into the buccal cavity with the needle directed towards the infraorbital foramen.

3) Mental Nerve Block: 1 cc of 1-2% Lidocaine injected into the mental foramen just above the bone level.

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

Omnilux 633 nm LED: 20 min/session (126 J/cm2).

Phase 3 Low Level Ultralase Lumenis ActiveFx with settings (Energy) 100 mJ (Rate) 14w CPG 3/5/2.Omnilux 633 nm LED: 20 min/session (126 J/cm2).

ActiveFx RE before treatment ActiveFx RE on Day 4 ActiveFx RE on Day 14 ActiveFx RE on Day 30

GROUP 1 PERIORBITAL RYTHIDES The patient was a 53yo Caucasian male who presented with bilateral periorbital rhytides for treatment. He had a previous poor response with fibroblast transplanting (Isolagen) into the area and he was an intermittent Botox user. The patient was treated with the Lumenis ActiveFx with settings (Energy) 100 mJ (Rate) 19w CPG 3/5/4

Patient CM : The right eye was treated with the Lumenis ActiveFx with settings (Energy) 100 mJ (Rate) 125 Hz CPG 3/5/2. with obvious reduction in rhytides

GROUP 2 NMG The patient was a 39yo Caucasian female. She received PRP, microneedling, 633NM light and Dysport 35u bilaterally. The periorbital area was treated with the Lumenis ActiveFx with settings (Energy) 100 mJ (Rate) 14w CPG 3/5/2

R eye ActiveFx Day 1 R eye ActiveFx treated Day 3 R eye ActiveFx Day 30 Day 2 Day 30

Patient NMG : (R side) ActiveFx treated (Energy) 125 mJ (Rate) 19w CPG 3/5/4




HISTOLOGY

Laser penetration depth 113 nm New collagen formation seen at 700 mm.

Laser penetration depth seen at 113 mm Laser penetration depth 85 mm

Image A Group 1 Patient PN immediate post procedure

Image C is Group 1 Patient NMG immediate post procedure

Image D Group 2 Patient MW Three months post procedure

Image B Group 2 Patient MW immediate post Phase 3 procedureActiveFx treated (Energy) 100 mJ 9.4J/cm2 (Rate) 125 Hz 18.8W CPG 3/5/2/

Image E Group 1 NMG three months post procedure ActiveFx treated (Energy) 15-30W 125 mJ 9.4J/cm2 (Rate) 125 Hz 18.8W CPG 3/5/2/

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 were almost reversed whenever periorbital rejuvenation was 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 in 6.8 percent of patients (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 patient in Group 1 for a period of 14 days but this was minimal. Postoperative erythema was most intense in the areas treated by with the ActiveFx at the energy level above 125Mj.

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 was 6.6% and Group 2 was 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 due to 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. Mean patient age in Group 1 was 49.24 years (range, 37-71 years) and Group 2 was 54.86 (range, 41-76 years).

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 provided the materials for the study.

Historical note. The author won the MyFaceMyBody Awards for facial rejuvenation in London in 2012 for this method of facial rejuvenation. It was recognized as one of the 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 botulinum toxin. AM

Health & Medicine

Dr Patrick Treacy on combining therapies for optimal outcomes in treating the ageing face: an introduction to the DUBLiN Facelift