Table 2

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.

Table 3

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.

Figure 4

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 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

Table 4

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 (rate) 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 determine the amount of epidermal damage, subsequent inflammation, and new collagen synthesis. The extent of neocollagenesis 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 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.