Dublin Lift

ARTICLE | facial aesthetics |

Combining therapies for the ageing face:

the DUBLiN
lift Patrick Treacy presents a novel method for full facial
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rejuvenation, which combines a number
of treatments to obtain the most optimum results
ABSTRACT
Objective ‘triangle of beauty’ as ageing proceeds resurfacing. This procedure benefits in an attempt to address these deficits.
The DUBLiN Lift: To establish the is considered generally less aesthetically from faster recovery time, more precise The facial rejuvenating therapies include
clinical effectiveness of combining appealing1. At present, a variety of different control of ablation depth, and reduced microneedling, low-dose UltraPulse
For personal use only.

five treatments in the rejuvenation of dermatologic and volumising treatments risk of post-procedural problems. laser, PRP growth factors, Omnilux
the ageing face in an effort to increase are available for facial rejuvenation. These However, there have been cases of 633 nm light, and neurotoxins. The
aesthetic effect, patient safety, and include chemical peels, dermal fillers, hypopigmentation, hypertrophic scars technique is called the DUBLiN facelift as
reduce laser downtime. intense pulsed light and radiofrequency and skin mottling, most often seen on an acronym of the procedures involved:
lasers, platelet-rich plasmas (PRP) the face, neck and chest when the laser Dermaroller, UltraPulse laser, Blood
The face is the area for which the majority microneedling, microdermabrasion, parameters are used more aggressively4. growth factors, Light (near-red 633 nm),
of patients seek cosmetic rejuvenation as botulinum toxin injections, and laser Furthermore, the technique does not and Neurotoxin.
the convex lines of a youthful appearance resurfacing. Each treatment has its own attend to chronological ageing problems The author compared this method
tend to flatten and droop as one grows relative beneﬁt, as well as risks2, 3. such as volume deficits resulting from to fractional laser skin resurfacing with
older. The younger face is characterised by In recent years, facial rejuvenation the loss and repositioning of facial fat. regard to the reduction of photoageing
a balance captured in the classic shape of has been revolutionised with the This article examines the possibility and overall aesthetic effect. Neurotoxin
the inverted triangle. The reversal of this development of CO2 fractional laser skin of combining five established therapies was used in both arms of the study.

T
he face, and particularly that the much hyped non-ablative
the eyes, is very important methods were often subject to
More
for contact between extravagant claims in terms of efficacy2–4. recently, patients
humans, as this area For many years, CO2 laser resurfacing was are seeking
provides a window to the considered the ‘gold standard’ in treating
effective facial
rest of society with regard photodamaged facial skin6–11. Cutaneous
to a patient’s level of health, tiredness and laser resurfacing with a fractional (CO2) rejuvenation
emotional status, as well as interest in laser involves the vapourisation of the procedures with
others4. Many health professionals entire epidermis, as well as a variable less downtime
consider the periorbital area of the thickness of the dermis. Many physicians
face as the most important area stated that the ultrapulsed CO2 laser was
and low risks.
Dr Patrick Treacy is of rejuvenation as eye‑to-eye the most effective method of laser
Medical Director of Ailesbury communication occurs in approximately resurfacing12–13. Photodamaged skin is the
Clinics Ltd and Ailesbury Hair
Clinics Ltd; Chairman of the 80% of all human interactions6. Both result of years of exposure to harmful
Irish Association of Cosmetic areas present a barometer of a patient’s ultraviolet light and is clinically
Doctors and Irish Regional chronological and environmental age, demonstrated as a gradual deterioration
Representative of the British
Association of Cosmetic and mastering the proper evaluation and of cutaneous structure and function. This
Doctors; European Medical execution of their aesthetic rejuvenation results in the epidermis and upper
Advisor to Network Lipolysis
and the UK’s largest cosmetic
is paramount for all cosmetic doctors. papillary dermis having a roughened
website Consulting Rooms. He More recently, patients are seeking surface texture, as well as laxity,
practices cosmetic medicine effective facial rejuvenation procedures telangiectasias, wrinkles and variable Keywords
in his clinics in Dublin, Cork, fractionalised laser resurfacing,
London and the Middle East with less downtime and low risks7. This degrees of skin pigmentation14–15.
platelet-rich plasma,
change in attitude has been prompted by Although ultrapulsed CO2 resurfacing microneedling, Omnilux 633 nm
email: ptreacy@gmail.com a realisation of both doctors and patients lasers were considered the best light, neurotoxin

20

❚ October 2012 | prime-journal.com

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| facial aesthetics | ARTICLE

using lower energy and density, as scarring has been
noted in these areas25. Scarring after fractional CO2 laser
therapy is considered mainly a result of overly-aggressive
treatments and a lack of technical finesse. Physicians
have also recorded post‑operative infections leading to
scarring, although it is generally felt that these may be
prevented by careful history-taking, vigilant
post‑operative monitoring, and/or the use of prophylactic
antibiotics26, 27.
With regard to facial rejuvenation, CO2 laser light at a
10 600 nm wavelength results in vapourisation with
thermal denaturation of type I collagen, collagen
shrinkage and later, collagen deposition. However, in
very deep rhytides, acne scarring and severe elastotic
changes from sun damage, fractional CO2 therapy
requires multiple treatments to achieve the same results
as the older lasers28. A number of studies have evaluated

using different laser combinations in the same session in
treatment option, they had many post-procedural Figure 1 Omnilux 633 nm light order to improve collagen deposition, with a wider zone
problems16, 17, including prolonged post‑operative for fibroblast stimulation of ﬁbroplasia6–9, 28. Owing to the inherent risks of fractional
recovery, pigmentary changes, and a high incidence of laser skin resurfacing and its inability to deal with some
acne flares and herpes simplex virus (HSV) infection18, 19. evidence of chronological ageing, it was advocated to
Many patients complained of oedema, burning, and here establish the clinical effectiveness of using a
erythema that sometimes lasted for many months20, 21.
Care should multi‑procedural approach to volumisation and collagen
The implied risks and long downtime made many be taken when regeneration. The author used microneedling with low
patients reluctant to accept this method of treatment22, 23. treating sensitive energy laser, and platelet rich plasma (PRP) to address

More recently, fractional resurfacing lasers have areas such as the these issues.
addressed many of these earlier problems with benefits
of faster recovery time, more precise control of ablation eyelids, upper Collagen remodelling and fibroblast
depth, and reduced risk of post procedural problems8. neck, and stimulation
These lasers are extremely versatile, in that they can be especially the It is recognised that the most important rejuvenation
used for the treatment of facial rhytides, acne scars, process for photoaged skin is the collagen remodelling
surgical scars, melasma and photodamaged skin, and
lower neck and process, and dermal fibroblasts are known to have the
many have entered the market at the same time24. chest, by using most important function . Rejuvenation of skin injury
29

With the advent of fractional laser skin resurfacing, the lower energy and caused by UV light is a complex process that organically
number of completely ablative resurfacing cases has
density, as scarring involves cytokines interacting with a number of growth
declined for most practitioners. However, care should be factors and control proteins . The procedures evaluated
28

taken when treating sensitive areas such as the eyelids, has been noted in included PRP, microneedling, and Omnilux 633 nm
upper neck, and especially the lower neck and chest, by these areas. near‑red light, with neurotoxins as an adjunct to low-

Figure 2 Blood post-centrifuge, showing the platelet layer Figure 3 Injecting PRP in the periorbital area

prime-journal.com | October 2012

❚ 23

ARTICLE | FACIAL AESTHETICS |

puncturing the skin with tiny, sterile needles. Typically,
Table 1 Patient treatment (positive) scoring chart this is done with a specialised instrument called a
Parameter 0 1 2 3 4 microneedling device.
Controlled studies have suggested that the application
Global score Area of Area of Area of Area of Area of
roughness roughness roughness roughness roughness of autogenous PRP can enhance wound healing in both
x0 x1 x2 x3 x4 animals and humans29. Five major growth factors such as
Fine lines None Rare Several Moderate Many transforming growth factor (TGF), insulin-like growth factor
Pigmentary (IGF), platelet-derived growth factor (PDGF), epidermal
None Patchy Moderate Heavy Marked growth factor (EGF), and vascular endothelial growth
problems
Touch factor (VEGF) are known to be related to the wound-healing
Even Rare Mild Moderate Severe
problems processes28. These growth factors are released from
Facial veins None Rare Several Moderate Severe platelets, and the production of collagen and fibroblasts is
Coarse lines None Rare Several Moderate Many stimulated by IGF, EGF, Interleukin-1 (IL-1) and tumour
Complexion Pink Pale Grey Slightly Distinct necrosis factor (TNF)-α34, 35. In vivo studies report TGF-β to be
yellow-grey yellow-grey the most stimulative growth factor. PRP may be used for
dermal augmentation and Sclafani observed aesthetic
improvements of the nasolabial fold in less than 2 weeks,

Table 2 Patient treatment (negative) scoring chart and the results lasted for up to 3 months28, 29.

Parameter 0 1 2 3 4 Research design and methods
Erythema severity None Rare Several Moderate Severe This multi-centre randomised study included 44 patients
Infective outbreak of skin types 1 and 2 aged between 39 and 68 years,
(herpes/acne) None Rare Several Moderate Severe presenting with photoageing of the skin, 37 of whom
Crusting None Rare Several Moderate Severe were women and seven were men. The subjects
Pain of presented with the typical hallmarks of chronological
None Mild Tolerable Moderate Severe
procedure and photoageing, such as expression lines, rhytides,

Improvement None Minimal Fair Good Excellent wrinkles, eyelid skin laxity, dermatochalasis, lowered
brows, lateral hooding, and prominent fat pads. All
patients were subjected to a programme of skin
level fractional laser skin resurfacing. Cells in the tightening and neocollagenesis by one of two methods:
epidermis and dermis can be targeted by microneedling conventional fractional laser skin resurfacing (Group 1) or
and near-red light, resulting in fibroblast stimulation. the DUBLiN Lift (Group 2). The mean patient age in Group
Omnilux Revive™ (633 nm) therapy stimulates fibroblast 1 was 49 years (range 37–71 years) and in Group 2 was 55
activity, leading to faster and more efficient collagen years (range 41–76 years).
synthesis and extracellular matrix (ECM) proteins. It also Fifteen patients underwent Lumenis ActiveFX™ with
increases cell vitality by increasing the production of settings as (energy) 125 mJ and (rate) 19 w CPG 3/5/4.
cellular adenosine triphosphate (ATP) and stimulates the Twenty-nine patients received the DUBLiN Lift, a
contractile phase of the remodelling process producing three-phase combination of established treatments with
better lineated collagen30–33. Collagen induction therapy is microneedling, platelet growth hormones, near-red
an aesthetic medical procedure that involves repeatedly 633 nm light, and low-energy UltraPulse fractional CO2

Patient histology Carbon dioxide laser ablative fractionalisation
All skin biopsies show the effect of thermal treatment with thermal coagulation
of the epidermis and superficial dermis

Group 1 patient showing ablative Group 2 patient at Phase 3. Depth Group 1 patient showing collagen Group 2 patient showing collagen
CO2 laser penetration to 118 nm. range 85 microns formation at 3 months. Depth range formation at 3 months, representing
Depth range 113 microns 700 microns a skin biopsy from a Group 2 patient
3 months post-treatment. Depth
range 118 microns

24 October 2012 | prime-journal.com


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Clinical assessment of patients in
Table 3 Wrinkle Severity Rating Scale (WSRS)
each group was made at 2 weeks, 1
patient scoring chart month and 3 months post-operatively in
DEGREE DESCRIPTION the presence of two aesthetic staff.
5 Extreme Extremely deep and long folds, detrimental to facial appearance
4 Severe Very long and deep folds; prominent facial features; less than variables. The degree of perceived improvement in
2 mm visible overall aesthetic effect reflecting chronological age was
3 Moderate Moderately deep folds; clear facial feature visible at normal assessed separately by patients and physicians using the
appearance, but not when stretched
Wrinkle Severity Rating Scale (WSRS) and the Global
2 Mild Shallow but visible fold with a slight indentation;
Aesthetic Improvement Scale (GAIS). The WSRS is
minor facial feature
recognised as a valid and reliable instrument for
1 Absent No visible nasolabial fold; continuous skin, injectable
implant alone quantitative assessment of facial skin folds, with good
inter- and intra-observer consistency5. Wrinkle severity is
measured using a wrinkle severity rating scale with 1
Table 4 Global Aesthetic Improvement Scale (GAIS) being absent and 5 being extreme. By allowing objective
grading of data, these proved useful clinical tools for

DEGREE DESCRIPTION assessing the effectiveness of facial volumisation with
1 Exceptional improvement Excellent corrective result at week 12. No further PRP and microneedling–633.
treatment required
2 Very improved patient Marked improvement of appearance, but not Interventions
completely optimal The following treatment protocols were used for this
3 Improved patient Improvement of the appearance, better compared with study: Lumenis ActiveFX CO2 laser, Traylife PRP, Omnilux
the initial condition. Touch-up is advised
633 nm red light, Dermaroller®, and Dysport®. All
4 Unaltered patient The appearance substantially remains the same participants received selective regional anaesthesia
compared with the original condition
blocks with 2% lignocaine plus adrenaline, a topical

5 Worsened patient The appearance has worsened compared with the
original condition
combination anaesthetic of 23% lignocaine, and
prophylactic Valtrex 500 mg twice daily for 8 days.
Valium 5–10 mg stat was given as a pre-medication to
laser skin tightening. All patients received Dysport® in some patients. A post-procedural advice sheet and
three areas 1 week prior to the other treatments as an Nurofen or codeine with paracetamol — as required — was
adjunct to the laser resurfacing. Figure 4 Patients before
also given to patients.
The DUBLiN Lift was introduced as three phases over a (A, C) and after (B, D) the The ActiveFX is a protocol of settings applied in
period of 3 weeks. Phase 1 included Dysport® at dilution DUBLiN Lift conjunction with an improved computer pattern
3.5 : 1 to three areas — glabellar, frontalis and periorbital.
Phase 2 introduced intense fibroblast stimulation and
modification through microneedling, PRP growth factor
induction, and near-red phototherapy. Phase 3
administered the low–level (CO2) UltraPulse laser at
100 mJ 14 w CPG 3/5/2, and adjunct near-red 633 nm
phototherapy. The study evaluated post-procedural
aesthetic results at 2 weeks, 4 weeks and 12 weeks. The
length of downtime, patient discomfort and adverse
side-effects were noted for each phase.
Clinical assessment of patients in each group was
made at 2 weeks, 1 month and 3 months post-operatively
in the presence of two aesthetic staff. The degree of
improvement in photoageing was based on the degree of
re-epithelialisation rate, reduction of rhytides, reduction
of tactile roughness, and loss of hyperpigmentation and
telangiectasias. The prolongation and severity of
erythema as well as the presence of negative side-effects
(e.g. herpes) were also recorded.
The efficacy of treatment was evaluated using a
variation of the five-point scale (Table 1) originally
suggested by Dover et al36. Investigators and patients
evaluated efficacy using palpability assessments and
change from baseline score at 0, 6 and 12 weeks. A total
global score was recorded in each patient based on the
addition of points obtained from six photodamage


| FACIAL AESTHETICS | ARTICLE

generator to the ultrapulsed CO2 laser (UltraPulse
ENCORE, Lumenis Ltd). Technical differences between
this non-sequential fractional device and the older
ultrapulsed CO2 include tissue bridges left between spots,
resulting in faster healing time, and less thermal damage
to the basal cell membrane. The device has a smaller
spot size (1300 mm rather than 2500 mm), resulting in
less post-procedure erythema.
The computer pattern generator lays down a random
series of spots rather than a sequential sequence
resulting in less overheating of the treated tissue. This
application is termed ‘Cool Scan’, and was used with
every patient in the study.
The Traylife Kit (PRP) (Promoitalia Wellness Research)
provides blood plasma enriched with a concentrated
source of autologous platelets that releases a number of
growth factors and other cytokines that stimulate 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) Figure 5 Patient in difering
f directed towards the infraorbital foramen
(AesthetiCare®, UK) is a minimally-invasive cosmetic phases of DUBLiN Lift Mental nerve block. 1 cc of 1–2% Lidocaine injected
procedure that involves the use of a micro-needling into the mental foramen just above the bone level.
device.

Scoring charts are presented in Tables 1–4. Group 2: DUBLiN lift
Phase 1
Group 1: fractional laser skin Dysport® treatment to three areas: glabellar, frontalis and
resurfacing periorbital.
Phase 1
Dysport® treatment to three areas: glabellar, frontalis and Phase 2 (Week 2)
periorbital. Microneedling Topical anaesthesia: benzocaine 20%,
Lidocaine Base 6%, and tetracaine 4%.
Phase 2 (Week 2) Each patient received Chiroxy cream post-procedure
Lumenis ActiveFX with settings (energy) 125 mJ (rate) to reduce erythema and inflammation. Tepid water was
1 9w CPG 3/9/4 used to cleanse the face for the following 48 hours, and
In the pre-laser procedure, the author typically dried gently. It was recommended that make-up was
prescribes Valium (Diazepam 5–10 mg orally) for anxiety,
administered 45 minutes before the procedure.
For infection prophylaxis, Famvir (famciclovir) 750 mg
daily or Valtrex (valcyclovir) 500 mg twice per day for 7
days, was prescribed for every patient starting 3 days
before procedure. If the patient had a strong history of
acne, By-Mycin (doxycycline 100 mg daily) or Keflex
(cephalexin 500 mg twice per day) was prescribed for
7 days, beginning on the day of surgery. Diflucan
(fluconazole 150 mg) was not routinely prescribed in any
patient.
The patients were treated under topical and regional
anaesthesia. Topical anaesthesia comprised benzocaine
20%, Lidocaine Base 6%, and tetracaine 4%. Regional
anaesthesia was three-fold:
Supraorbital and supratrochlear nerve block. The
supraorbital foramen was located and 1 cc of 1–2%
Lidocaine injected just above the bone laterally, with
the needle directed medially, parallel to the brow and
toward the nose
Infraorbital nerve block. 1 cc of 1–2% Lidocaine
injected into the buccal cavity with the needle

prime-journal.com | October 2012 27


not applied for 12 hours after the procedure. After the Figure 6 Cachexic patient 2007. Each 1 cm by 1 cm piece of skin was fixed with 10%
procedure, a broad-spectrum UVA/UVB sunscreen with with volumisation post PRP/ formalin solution, neutral buffered. After treatment with
DUBLiN Lift
SPF 50 was recommended for use. polyester wax, the skin samples were sliced into 6 µm

thicknesses. The sliced sections were treated with
PRP preparation Draw blood (4 ml for each tube), then haematoxylin and eosin statin (H&E) and Masson’s
centrifuge tubes at 2000 rpm for 5 minutes. Take the trichrome staining solutions. Through tissue evaluations,
syringe, insert the needle and withdraw 0.5 ml DNA the thickness of the dermal layer and presence of collagen
Activator (10% calcium chloride). Withdraw platelets and fibres were observed. The thickness of the dermal layer
mix with the DNA Activator. was calculated by measuring five different sites from
Multiple injections (0.05–0.1 ml for a single injection) each section, and the mean value of the thickness of the
were applied to the intra/sub dermis using the dermal layer for each group was used for the comparison.
‘multi-pricking’ or retrograde linear techniques

Results
Omnilux 633 nm LED This was applied for 20 minutes Over 3 months, 29 subjects (Group 2) were selected to
per session (126 J/cm2). compare the effect of low energy fractional laser skin
resurfacing with adjunctive treatments to conventional
Phase 3 (Week 3) ablative laser resurfacing. These patients received a
Low-level UltraPulse Lumenis ActiveFX with settings three-phase combination of established treatments with
(energy) 100 mJ (rate) 14 w CPG 3/5/2. neurotoxin, microneedling, platelet growth hormones,
near-red 633 nm light, and low-energy UltraPulse fractional
Omnilux 633 nm LED This was applied for 20 minutes CO2 laser skin tightening over a 3-week period. Phase 1
per session (126 J/cm2). included the administration of Dysport® neurotoxin to the
upper face. Phase 2 introduced fibroblast stimulation from
Histology Skin biopsies were obtained from five of the microneedling and PRP growth factor induction with
patients intra-operatively, before Phase 2 of near-red phototherapy, and Phase 3 included
the treatment and at 3 months post- low-level (CO2) UltraPulse laser with adjunct
operatively, and were performed to
Over 3 months, 29 subjects near-red 633 nm phototherapy. Results were
determine the amount of epidermal (Group 2) were selected to compare compared to the remaining 15 patients
damage, subsequent inflammation, and the effect of low energy fractional (Group 1) who received fractional laser skin
new collagen synthesis. The extent of
laser skin resurfacing with adjunctive resurfacing (125 mJ; 19 w CPG 3/5/4), and
neocollagenesis was compared with data whose data was already on file. Patients in
on file for patients who had skin biopsies for treatments to conventional ablative both groups were administered Dysport®
laser resurfacing and neurotoxin alone in laser resurfacing. neurotoxin 1 week prior to treatment to


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ARTICLE | facial aesthetics |

heterogeneous age grouping, with older patients
requiring the conventional ActiveFX settings rather than
the ‘softer’ settings.
According to investigator-based WSRS and GAIS
assessments at 3 months after baseline, the DUBLiN lift
was superior in 62% and 55.2% of patients respectively,
while fractional laser skin resurfacing was superior in
33.3% and 34.4% of patients. (P < 0.0004). An ‘optimal’
cosmetic result was achieved in a higher percentage of
patients in Group 2 compared with Group 1.
Investigator-based and patient-based ratings using both
the WSRS and GAIS indicated that the DUBLiN lift was
more effective than conventional ablative laser resurfacing
in creating cosmetic correction to the lower face. This
resulted from the volumising effect of adding PRP to the
larger folds in this area. At 3 months post‑treatment, a
higher proportion of patients showed a greater than 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 microneedling and
633 nm light than previously noted27, 29. However, the results
were almost reversed whenever periorbital rejuvenation
was assessed alone, with almost every patient (93%)
Facial ageing is a consequence of many interacting favouring conventional fractional laser skin resurfacing.
Investigator-based GAIS assessment of this region at 3
intrinsic and extrinsic factors. The most important of these

months after baseline indicated that fractional resurfacing
include sun exposure or photoageing, and the intrinsic was superior in 93% of patients, while the DUBLiN Lift was
changes associated with chronological ageing. superior in 6.8% of patients (P = 0.0025).

complement and preserve the overall aesthetic effect. Objective results
The study evaluated post-procedural aesthetic results at Re-epithelialisation occurred in all laser-treated areas of
baseline, 6 weeks and 12 weeks by means of a scoring both groups by day 7, and this appeared to be clinically
system based on Dover’s photoageing scale, as well as similar for both procedures. Mean duration of erythema
using the WSRS and GAIS. was 6.9 days after resurfacing (range 4–10 days) in Group 1
Histological results were obtained from both groups and 4.2 days in Group 2 (range 3–7 days). This appeared to
showing the depth of laser penetration and consequential be in keeping with previous studies37. All patients reported
formation of new collagen. All skin biopsies showed having no ‘crusting’ effect remaining on their face after 6
thermal coagulation of the epidermis and superficial days. Residual erythema remained in one patient in Group
dermis in a depth ranging from 85 to 113 µ. The zone of 1 for a period of 14 days, but this was minimal. Post-
residual thermal (coagulative) damage was less in the operative erythema was most intense in the areas treated
Group 2 patients, in whom less laser energy was used. with the ActiveFX at an energy level above 125 mJ.
The best neocollagenesis results — at 3 months — were
evident in Group 1 where one patient had evidence of
effect at 700 µ. This was reflected in the patient’s skin,
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30

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