'Multi Procedural Approach to Facial Rejuvenation'

Combining therapies
for optimal outcomes
in treating the ageing
face:introducing the
DUBLiN Facelift
PatrickTreacypresentsanovelmethodforfullfacial
rejuvenation,whichcombinesanumber
oftreatmentstoobtainthemostoptimumresults
Keywords
fractionalised laser resurfacing,
platelet-rich plasma,
microneedling, Omnilux 633 nm
light, neurotoxin
Objective
The DUBLiN Lift: To establish the clinical
effectiveness of combining five treatments
in the rejuvenation of the ageing face in an
effort to increase aesthetic effect, patient
safety, and reduce laser downtime.
The face is the area for which the majority of
patients seek cosmetic rejuvenation as the
convex lines of a youthful appearance tend
to flatten and droop as one grows older. The
younger face is characterised by a balance
captured in the classic shape of the inverted
triangle. The reversal of this ‘triangle of
beauty’ as ageing proceeds is considered
generally less aesthetically appealing1
. At
present, a variety of different dermatologic
and volumising treatments are available for
facial rejuvenation. These include chemical
peels, dermal fillers, intense pulsed light and
radiofrequency lasers, platelet-rich plasmas
(PRP) microneedling, microdermabrasion,
botulinum toxin injections, and laser
resurfacing. Each treatment has its own
relative beneﬁt, as well as risks2, 3
.
In recent years, facial rejuvenation has been
revolutionised with the development of
CO2
fractional laser skin resurfacing. This
procedure benefits from faster recovery
time, more precise control of ablation
depth, and reduced risk of post-procedural
problems. However, there have been cases
of hypopigmentation, hypertrophic scars
and skin mottling, most often seen on
the face, neck and chest when the laser
parameters are used more aggressively4
.
Furthermore, the technique does not attend
to chronological ageing problems such as
volume deficits resulting from the loss and
repositioning of facial fat.
This article examines the possibility of
combining five established therapies
in an attempt to address these deficits.
The facial rejuvenating therapies include
microneedling, low-dose UltraPulse laser,
PRP growth factors, Omnilux 633 nm
light, and neurotoxins. The technique is
called the DUBLiN facelift as an acronym
of the procedures involved: Dermaroller,
UltraPulse laser, Blood growth factors, Light
(near-red 633 nm), and Neurotoxin.
The author compared this method to
fractional laser skin resurfacing with regard
to the reduction of photoageing and overall
aesthetic effect. Neurotoxin was used in
both arms of the study.
Dr Patrick Treacy is
Medical Director of Ailesbury
Clinics Ltd and Ailesbury Hair
Clinics Ltd; Chairman of the
Irish Association of Cosmetic
Doctors and Irish Regional
Representative of the British
Association of Cosmetic
Doctors; European Medical
Advisor to Network Lipolysis
and the UK’s largest cosmetic
website Consulting Rooms. He
practices cosmetic medicine
in his clinics in Dublin, Cork,
London and the Middle East
email: ptreacy@gmail.com
ABSTRACT
T
he face, and particularly the eyes, is very
important for contact between humans,
as this area provides a window to the rest
of society with regard to a patient’s level
of health, tiredness and emotional status,
as well as interest in others4
. Many health
professionals consider the periorbital area of the face as
the most important area of rejuvenation as eye‑to-eye
communication occurs in approximately 80% of all
human interactions6
. Both areas present a barometer of
a patient’s chronological and environmental age, and
mastering the proper evaluation and execution of their
aesthetic rejuvenation is paramount for all cosmetic
doctors.
More recently, patients are seeking effective facial
rejuvenation procedures with less downtime and low
risks7
. This change in attitude has been prompted by a
realisation of both doctors and patients that the much
hyped non-ablative methods were often subject to
extravagant claims in terms of efficacy2–4
. For many
ARTICLE | facial aesthetics |
18 September 2012 |prime-journal.com

months20, 21
. The implied risks and long downtime made
many patients reluctant to accept this method of
treatment22, 23
. More recently, fractional resurfacing lasers
have addressed many of these earlier problems with
benefits of faster recovery time, more precise control of
ablation depth, and reduced risk of post procedural
problems8
. These lasers are extremely versatile, in that
they can be used for the treatment of facial rhytides, acne
scars, surgical scars, melasma and photodamaged skin,
and many have entered the market at the same time24
.
With the advent of fractional laser skin resurfacing, the
number of completely ablative resurfacing cases has
declined for most practitioners. However, care should be
taken when treating sensitive areas such as the eyelids,
upper neck, and especially the lower neck and chest, by
using lower energy and density, and scarring has been
noted in these areas25
. Scarring after fractional CO2
laser
therapy is considered mainly a result of overly-aggressive
treatments and a lack of technical finesse. Physicians
have also recorded post‑operative infections leading to
scarring, although it is generally felt that these may be
prevented by careful history-taking, vigilant
post‑operative monitoring, and/or the use of prophylactic
antibiotics26, 27
.
With regard to facial rejuvenation, CO2
laser light at a
10 600 nm wavelength results in vapourisation with
thermal denaturation of type I collagen, collagen
shrinkage and later, collagen deposition. However, in
very deep rhytides, acne scarring and severe elastotic
changes from sun damage, fractional CO2
therapy
requires multiple treatments to achieve the same results
as the older lasers28
. A number of studies have evaluated
using different laser combinations in the same session in
order to improve collagen deposition, with a wider zone
of ﬁbroplasia6–9, 28
. Owing to the inherent risks of fractional
laser skin resurfacing and its inability to deal with some
evidence of chronological ageing, it was advocated to
here establish the clinical effectiveness of using a
multi‑procedural approach to volumisation and collagen
regeneration. The author used microneedling with low
Figure 1 xxxxxxxx
Figure 2 xxxxxxxx Figure 3 xxxxxxxx
years, CO2
laser resurfacing was considered the ‘gold
standard’ in treating photodamaged facial skin6–11
.
Cutaneous laser resurfacing with a fractional (CO2
) laser
involves the vapourisation of the entire epidermis, as
well as a variable thickness of the dermis. Many
physicians stated that the ultrapulsed CO2
laser was the
most effective method of laser resurfacing12–13
.
Photodamaged skin is the result of years of exposure to
harmful ultraviolet light and is clinically demonstrated as
a gradual deterioration of cutaneous structure and
function. This results in the epidermis and upper
papillary dermis having a roughened surface texture, as
well as laxity, telangiectasias, wrinkles and variable
degrees of skin pigmentation14–15
.
Although ultrapulsed CO2
resurfacing lasers were
considered the best treatment option, they had many
post-procedural problems16, 17
, including prolonged
post‑operative recovery, pigmentary changes, and a high
incidence of acne flares and herpes simplex virus (HSV)
infection18, 19
. Many patients complained of oedema,
burning, and erythema that sometimes lasted for many

three‑phase combination of established treatments with
microneedling, platelet growth hormones, near-red
633 nm light, and low-energy UltraPulse fractional CO2
laser skin tightening. All patients received Dysport® in
three areas 1 week prior to the other treatments as an
adjunct to the laser resurfacing.
The DUBLiN Lift was introduced as three phases over a
period of 3 weeks. Phase 1 included Dysport® at dilution
3.5 : 1 to three areas — glabellar, frontalis and periorbital.
Phase 2 introduced intense fibroblast stimulation and
modification through microneedling, PRP growth factor
induction, and near-red phototherapy. Phase 3
administered the low–level (CO2
) UltraPulse laser at
100 mJ 14 w CPG 3/5/2, and adjunct near-red 633 nm
phototherapy. The study evaluated post-procedural
aesthetic results at 2 weeks, 4 weeks and 12 weeks. The
length of downtime, patient discomfort and adverse
side‑effects were noted for each phase.
Clinical assessment of patients in each group was
made at 2 weeks, 1 month and 3 months post‑operatively
in the presence of two aesthetic staff. The degree of
improvement in photoageing was based on the degree of
re-epithelialisation rate, reduction of rhytides, reduction
of tactile roughness, and loss of hyperpigmentation and
telangiectasias. The prolongation and severity of
erythema as well as the presence of negative side-effects
(e.g. herpes) were also recorded.
The efficacy of treatment was evaluated using a
variation of the five-point scale (Table 1) originally
suggested by Dover et al36
. Investigators and patients
evaluated efficacy using palpability assessments and
energy laser, and platelet rich plasma (PRP) to address
these issues.
It is recognised that the most important rejuvenation
process for photoaged skin is the collagen remodelling
process, and dermal fibroblasts are known to have the
most important function29
. Rejuvenation of skin injury
caused by UV light is a complex process that organically
involves cytokines interacting with a number of growth
factors and control proteins28
. The procedures evaluated
included PRP, microneedling, and Omnilux 633 nm
near‑red light, with neurotoxins as an adjunct to low-level
fractional laser skin resurfacing. Cells in the epidermis
and dermis can be targeted by microneedling and
near‑red light, resulting in fibroblast stimulation. Omnilux
Revive™ (633 nm) therapy stimulates fibroblast activity,
leading to faster and more efficient collagen synthesis
and extracellular matrix (ECM) proteins. It also increases
cell vitality by increasing the production of cellular
adenosine triphosphate (ATP) and stimulates the
contractile phase of the remodelling process producing
better lineated collagen30–33
. Collagen induction therapy is
an aesthetic medical procedure that involves repeatedly
puncturing the skin with tiny, sterile needles. Typically,
this is done with a specialised instrument called a
microneedling device.
Controlled studies have suggested that the application
of autogenous PRP can enhance wound healing in both
animals and humans29
. Five major growth factors such as
transforming growth factor (TGF), insulin-like growth
factor (IGF), platelet-derived growth factor (PDGF),
epidermal growth factor (EGF), and vascular endothelial
growth factor (VEGF) are known to be related to the
wound-healing processes28
. These growth factors are
released from platelets, and the production of collagen
and fibroblasts is stimulated by IGF, EGF, Interleukin-1
(IL‑1) and tumour necrosis factor (TNF)-α34, 35
. In vivo
studies report TGF-β to be the most stimulative growth
factor. PRP may be used for dermal augmentation and
Sclafani observed aesthetic improvements of the
nasolabial fold in less than 2 weeks, and the results lasted
for up to 3 months28, 29
.
Research design and methods
This multi-centre randomised study included 44 patients
of skin types 1 and 2 aged between 39 and 68 years,
presenting with photoageing of the skin, 37 of whom
were women and seven were men. The subjects
presented with the typical hallmarks of chronological
and photoageing, such as expression lines, rhytides,
wrinkles, eyelid skin laxity, dermatochalasis, lowered
brows, lateral hooding, and prominent fat pads. All
patients were subjected to a programme of skin
tightening and neocollagenesis by one of two methods:
conventional fractional laser skin resurfacing (Group 1) or
the DUBLiN Lift (Group 2). The mean patient age in Group
1 was 49 years (range 37–71 years) and in Group 2 was 55
years (range 41–76 years).
Fifteen patients underwent Lumenis ActiveFx™ with
settings as (energy) 125 mJ and (rate) 19 w CPG 3/5/4.
Twenty-nine patients received the DUBLiN Lift, a
Table 1 Patient treatment (positive) scoring chart
Parameter 0 1 2 3 4
Global score Area of Area of Area of Area of Area of
roughness roughness roughness roughness roughness
x 0 x 1 x2 x3 x4
Fine lines None Rare Several Moderate Many
Pigmentary None Patchy Moderate Heavy Marked
problems
Touch Even Rare Mild Moderate Severe
problems
Facial veins None Rare Several Moderate Severe
Coarse lines None Rare Several Moderate Many
Complexion Pink Pale Grey Slightly Distinct
yellow-grey yellow-grey
Table 2 Patient treatment (negative) scoring chart
Parameter 0 1 2 3 4
Erythema severity None Rare Several Moderate Severe
Infective outbreak None Rare Several Moderate Severe
(herpes/acne)
Crusting None Rare Several Moderate Severe
Pain of None Mild Tolerable Moderate Severe
procedure
Improvement None Minimal Fair Good Excellent
| facial aesthetics | ARTICLE
prime-journal.com |September 2012 21

change from baseline score at 0, 6 and 12 weeks. A total
global score was recorded in each patient based on the
addition of points obtained from six photodamage
variables. The degree of perceived improvement in
overall aesthetic effect reflecting chronological age was
assessed separately by patients and physicians using the
Wrinkle Severity Rating Scale (WSRS) and the Global
Aesthetic Improvement Scale (GAIS). The WSRS is
recognised as a valid and reliable instrument for
quantitative assessment of facial skin folds, with good
inter- and intra-observer consistency5
. Wrinkle severity is
measured using a wrinkle severity rating scale with 1
being absent and 5 being extreme. By allowing objective
grading of data, these proved useful clinical tools for
assessing the effectiveness of facial volumisation with
PRP and microneedling–633.
Interventions
The following treatment protocols were used for this
study: Lumenis ActiveFX CO2
laser, Traylife PRP, Omnilux
633 nm red light, Dermaroller®, and Dysport®. All
participants received selective regional anaesthesia
blocks with 2% lignocaine plus adrenaline, a topical
combination anaesthetic of 23% lignocaine, and
prophylactic Valtrex 500 mg twice daily for 8 days.
Valium 5–10 mg stat was given as a pre-medication to
some patients. A post-procedural advice sheet and
Nurofen or codeine with paracetamol — as required — was
also given to patients.
The ActiveFX is a protocol of settings applied in
conjunction with an improved computer pattern
generator to the ultrapulsed CO2
laser (UltraPulse
Encore, Lumenis Ltd). Technical differences between
this non-sequential fractional device and the older
ultrapulsed CO2
include tissue bridges left between spots,
resulting in faster healing time, and less thermal damage
to the basal cell membrane. The device has a smaller
spot size (1300 mm rather than 2500 mm), resulting in
less post-procedure erythema.
The computer pattern generator lays down a random
series of spots rather than a sequential sequence
resulting in less overheating of the treated tissue. This
application is termed ‘Cool Scan’, and was used with
every patient in the study.
The Traylife Kit (PRP) (Promoitalia Wellness Research)
provides blood plasma enriched with a concentrated
source of autologous platelets that releases a number of
growth factors and other cytokines that stimulate the
healing of soft tissue.
Omnilux Revive™ (633 nm) (Photo Therapeutics, Inc.,
UK) stimulates fibroblast activity, leading to faster and
more efficient collagen synthesis and extracellular
matrix proteins.
Dermaroller™ Collagen Induction Therapy (CIT)
(AesthetiCare®, UK) is a minimally-invasive cosmetic
procedure that involves the use of a micro-needling
device.
Scoring charts are presented in Tables 1–4.
Group 1: fractional laser skin
resurfacing
Phase 1
Dysport® treatment to three areas: glabellar, frontalis and
periorbital.
Phase 2 (Week 2)
Lumenis ActiveFX with settings (energy) 125 mJ (rate)
1 9w CPG 3/9/4
In the pre-laser procedure, the author typically
prescribes Valium (Diazepam 5–10 mg orally) for anxiety,
administered 45 minutes before the procedure.
For infection prophylaxis, Famvir (famciclovir) 750 mg
daily or Valtrex (valcyclovir) 500 mg twice per day for 7
days, was prescribed for every patient starting 3 days
before procedure. If the patient had a strong history of
acne, By-Mycin (doxycycline 100 mg daily) or Keflex
(cephalexin 500 mg twice per day) was prescribed for
7 days, beginning on the day of surgery. Diflucan
(fluconazole 150 mg) was not routinely prescribed in any
patient.
The patients were treated under topical and regional
anaesthesia. Topical anaesthesia comprised benzocaine
20%, Lidocaine Base 6%, and tetracaine 4%. Regional
anaesthesia was three-fold:
■■ Supraorbital and supratrochlear nerve block. The
supraorbital foramen was located and 1 cc of 1–2%
Lidocaine injected just above the bone laterally, with
the needle directed medially, parallel to the brow and
toward the nose
■■ Infraorbital nerve block. 1 cc of 1–2% Lidocaine injected
into the buccal cavity with the needle directed
Table 3 Wrinkle Severity Rating Scale (WSRS)
patient scoring chart
5 Extreme Extremely deep and long folds, detrimental to facial appearance
4 Severe Very long and deep folds; prominent facial features; less than
2 mm visible
3 Moderate Moderately deep folds; clear facial feature visible at normal
appearance, but not when stretched
2 Mild Shallow but visible fold with a slight indentation;
minor facial feature
1 Absent No visible nasolabial fold; continuous skin, injectable
implant alone
Table 4 Global Aesthetic Improvement Scale (GAIS)
Degree Description
1 Exceptional improvement Excellent corrective result at week 12. No further
treatment required
2 Very improved patient Marked improvement of appearance, but not
completely optimal
3 Improved patient Improvement of the appearance, better compared with
the initial condition. Touch-up is advised
4 Unaltered patient The appearance substantially remains the same
compared with the original condition
5 Worsened patient The appearance has worsened compared with the
original condition

towards the infraorbital foramen
■■ Mental nerve block. 1 cc of 1–2% Lidocaine injected into
the mental foramen just above the bone level.
Group 2: DUBLiN lift
Phase 1
Dysport® treatment to three areas: glabellar, frontalis and
periorbital.
Phase 2 (Week 2)
Microneedling
Topical anaesthesia: benzocaine 20%, Lidocaine Base 6%,
and tetracaine 4%.
Each patient received Chiroxy cream post-procedure
to reduce erythema and inflammation. Tepid water was
used to cleanse the face for the following 48 hours, and
dried gently. It was recommended that make-up was not
applied for 12 hours after the procedure. After the
procedure, a broad-spectrum UVA/UVB sunscreen with
SPF 50 was recommended for use.
PRP preparation
Draw blood (4 ml for each tube), then centrifuge tubes at
2000 rpm for 5 minutes. Take the syringe, insert the
needle and withdraw 0.5 ml DNA Activator (10% calcium
chloride). Withdraw platelets and mix with the DNA
Activator.
Multiple injections (0.05–0.1 ml for a single injection)
were applied to the intra/sub dermis using the
‘multi‑pricking’ or retrograde linear techniques
Omnilux 633 nm LED
This was applied for 20 minutes per session (126 J/cm2
).
Phase 3 (Week 3)
Low-level UltraPulse
Lumenis ActiveFX with settings (energy) 100 mJ rRate)
14 w CPG 3/5/2.
Omnilux 633 nm LED
This was applied for 20 minutes per session (126 J/cm2
).
Histology
Skin biopsies were obtained from five of the patients
intra-operatively, before Phase 2 of the treatment and at
3 months post-operatively, and were performed to
determinetheamountofepidermaldamage,subsequent
inflammation, and new collagen synthesis. The extent of
neocollogenesis was compared with data on file for
patients who had skin biopsies for laser resurfacing and
neurotoxin alone in 2007. Each 1 cm by 1 cm piece of skin
was fixed with 10% formalin solution, neutral buffered.
After treatment with polyester wax, the skin samples
were sliced into 6 μm thicknesses. The sliced sections
were treated with haematoxylin and eosin statin (H&E)
and Masson’s trichrome staining solutions. Through
tissue evaluations, the thickness of the dermal layer and
A B
C
Figure 4 xxxxxxx

presence of collagen fibres were observed. The thickness
of the dermal layer was calculated by measuring five
different sites from each section, and the mean value of
the thickness of the dermal layer for each group was
used for the comparison.
Results
Over 3 months, 29 subjects (Group 2) were selected to
compare the effect of low energy fractional laser skin
resurfacing with adjunctive treatments to conventional
ablative laser resurfacing. These patients received a
three‑phase combination of established treatments with
neurotoxin, microneedling, platelet growth hormones,
near-red 633 nm light, and low-energy UltraPulse
fractional CO2
laser skin tightening over a 3-week period.
Phase 1 included the administration of Dysport®
neurotoxin to the upper face. Phase 2 introduced
fibroblast stimulation from microneedling and PRP
growth factor induction with near-red phototherapy, and
Phase 3 included low‑level (CO2
) UltraPulse laser with
adjunct near-red 633 nm phototherapy. Results were
compared to the remaining 15 patients (Group 1) who
received fractional laser skin resurfacing (125 mJ; 19 w
CPG 3/5/4), and whose data was already on file. Patients in
both groups were administered Dysport® neurotoxin 1
week prior to treatment to complement and preserve the
overall aesthetic effect. The study evaluated post-
procedural aesthetic results at baseline, 6 weeks and 12
weeks by means of a scoring system based on Dover’s
photoageing scale, as well as using the WSRS and GAIS.
Histological results were obtained from both groups
showingthedepthoflaserpenetrationandconsequential
formation of new collagen. All skin biopsies showed
thermal coagulation of the epidermis and superficial
dermis in a depth ranging from 85 to 113 µ. The zone of
residual thermal (coagulative) damage was less in the
Group 2 patients, in whom less laser energy was used.
The best neocollogenesis results — at 3 months — were
evident in Group 1 where one patient had evidence of
effect at 700 µ. This was reflected in the patient’s skin,
which continued to improve over the period. Owing to
the variance in energy of the CO2
laser in Group 1 and
Group 2, it was expected that the documented depth of
histological ablation and thermal effects would vary
between them. Responses of aesthetic effect were
evaluated at 6 and 12 weeks after baseline.
The two methods appeared to produce different
clinical improvement of lesions and rhytides. The GAIS
for photoageing for the DUBLiN lift improved from 13.2 to
10.2 at day 30. This compared to 13.8 at baseline and 9.6 at
day 30 for conventional fractional laser skin resurfacing
alone. The score for fine lines was the most significant
reduction, dropping from 3.6 at baseline to 1.4 at day 30.
The score for reduction of coarse wrinkles (3.2 at baseline
to 2.2 at 6 weeks) was more difficult to interpret in this
heterogeneous age grouping, with older patients
requiring the conventional ActiveFX settings rather than
the ‘softer’ settings.
According to investigator-based WSRS and GAIS
assessments at 3 months after baseline, the DUBLiN lift
Figure 5 xxxxxx
A
B
C
D

was superior in 62% and 55.2% of patients respectively,
while fractional laser skin resurfacing was superior in
33.3% and 34.4% of patients. (P < 0.0004). An ‘optimal’
cosmetic result was achieved in a higher percentage of
patients in Group 2 compared with Group 1.
Investigator-based and patient-based ratings using
both the WSRS and GAIS indicated that the DUBLiN lift
was more effective than conventional ablative laser
resurfacing in creating cosmetic correction to the lower
face. This resulted from the volumising effect of adding
PRP to the larger folds in this area. At 3 months
post‑treatment, a higher proportion of patients showed a
greater than or equal to 1-grade improvement in WSRS
with the DUBLiN Lift compared with fractional laser skin
resurfacing. The author suspects the PRP may have a
longer aesthetic effect when used in association with
microneedlingand633 nmlightthanpreviouslynoted27, 29
.
However, the results were almost reversed whenever
periorbital rejuvenation was assessed alone, with almost
every patient (93%) favouring conventional fractional
laser skin resurfacing. Investigator-based GAIS
assessment of this region at 3 months after baseline
indicated that fractional resurfacing was superior in 93%
of patients, while the DUBLiN Lift was superior in 6.8% of
patients (P = 0.0025).
Re-epithelialisation occurred in all laser-treated areas
of both groups by day 7, and this appeared to be clinically
similar for both procedures. Mean duration of erythema
was 6.9 days after resurfacing (range 4–10 days) in Group 1
and 4.2 days in Group 2 (range 3–7 days). This appeared to
be in keeping with previous studies37
. All patients
reported having no ‘crusting’ effect remaining on their
face after 6 days. Residual erythema remained in one
patient in Group 1 for a period of 14 days, but this was
minimal. Post-operative erythema was most intense in
the areas treated with the ActiveFX at an energy level
above 125 mJ.
The mean pain sensation (Table 2) felt during the
DUBLiN lift was 2.2 compared to conventional fractional
A
B
C
Figure 6 xxxxx
resurfacing treatment, which was 3.4. The author noted
that most patients did not feel much pain at all with the
ActiveFX until the energy level crosses 100 mJ. No patient
experienced any adverse reaction to laser skin
resurfacing, except one case of herpetic infection in each
group (Group 1 6.6%; Group 2 3.4%). Both treatments were
well tolerated. Clumping of platelets occurred in 10% of
patients treated with PRP and the author felt that this was
a result of the concentration of solution used. In fact,
anecdotal evidence suggests that most cosmetic
physicians are using PPP (platelet-poor plasma) in most
areas of the face, rather than the higher concentrations
used by orthopaedic surgeons.
Conclusions
Facial ageing is a consequence of many interacting
intrinsic and extrinsic factors. The most important of

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these include sun exposure or photoageing, and the
intrinsic changes associated with chronological ageing.
Over time, the muscles of facial expression produce
dynamic and static facial lines and folds. Laser
resurfacing has long been recognised as a skin
rejuvenation procedure for tissue that has lost its
elasticity and become less able to resist stretching.
However, despite the advent of newer fractionalised
lasers, it has adverse risks and does not adequately
address the problems associated with chronological
ageing as gravity exerts its toll on the facial structures. It is
important to apply supplementary methods, such as
dermal fillers or PRP, to address nasolabial or marionette
lines and volume deficits resulting from the loss and
repositioning of facial fat.
Declaration of interest none
Patient images ©Patrick Treacy

Further reading
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