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 showing the depth of laser penetration and consequential formation of new collagen. All skin biopsies showed thermal coagulation of the epidermis and superficial dermis in a depth ranging from 85 to 113µ. The zone of residual thermal (coagulative) damage was less in the Group 2 patients, in whom less laser energy was used. The best neocollagenesis results — at 3 months — were evident in Group 1 where one patient had evidence of effect at 700µ. 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.

Figure 4 Patients before (A, C) and after (B, D) the DUBLiN Lift

Figure 4 Patients before (A, C) and after (B, D) the DUBLiN Lift

The two methods appeared to produce different clinical improvement of lesions and rhytides. The GAISfor 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 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%) 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).

Objective results

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.

Figure 5 Cachexic patient with volumisation post PRP/DUBLiN Lift

Figure 5 Cachexic patient with volumisation post PRP/DUBLiN Lift

The mean pain sensation (Table 2) felt during the DUBLiN lift was 2.2 compared to conventional fractional 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 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.