Multiprocedural Synchronous Facial Rejuvenation

Introducing the DUBLiN method

Dr. Patrick J. TreacyMedical DirectorAilesbury Clinics Ltd

PHOTOAGEING

Photoageing refers to the damage that is done to the skin from prolonged exposure, over a person's lifetime, to UV radiation. Most of the skin changes that occur as we get older are accelerated by sun exposure. Examples of skin changes from photoageing include:

PERIORBITAL AGEING

The periorbital region is a immediate barometer of a patient’s chronological and environmental age. It tells its own history of ultraviolet light exposure and the wish for aesthetic rejuvenation treatments

SKIN CANCERSKIN CANCER

SALLOW SKINSALLOW SKIN COARSE

RHYTIDS

COARSE RHYTIDS

FINE RYTHIDS

FINE RYTHIDS

THREAD VEINSTHREAD VEINS PIGMENTATION

PIGMENTATION

TitleTitlePHOTOAGEING

CHRONOLOGICAL AGEING

Anatomical changes include laxity of the eyelid skin, prominent infra-orbital fat pads, hypertrophic orbicularis oculi muscle, and even descent of the forehead, eyebrows and mid-face

WRINKLESWRINKLES

ECTROPION ECTROPION ENTROPION

ENTROPION

FATPROTRUSION

FATPROTRUSION

EPIPHORA EPIPHORA SKIN LAXITY

SKIN LAXITY

TitleTitleCHRONOAGEING

Treating Facial Ageing

A great variety of stand alone facial rejuvenation treatments are presently available including Botox©,Dermaroller©, RioBlush©,Radiofrequency Devices Syneron Polaris©RF, Thermage© InfraRed Titan©, CO2 fractionalised resurfacing AFX© SmartXide© Fraxel Repair©,

PERIORBITAL AGEING

A variety of novel periorbital rejuvenation treatments are available such as retinol topical creams, Dermaroller ©, Botox ©, Thermage ©, Fraxel ©, RioBlush ©, Polaris © RF, SmartXide ©, AFX © CO2 fractionalised resurfacing

WHY LASER RESURFACING?

Thermal effect at 100 µm seen histologically using haematoxylin & eosin

Treacy Dublin

3 months post

WRINKLESWRINKLES

TEAR TROUGH TEAR TROUGH WRINKLES

WRINKLES

FATPROTRUSION

FATPROTRUSION

PIGMENTATION PIGMENTATION SKIN LAXITY

SKIN LAXITY

TitleTitleCOLLAGEN

FAT PROTRUSION

FAT PROTRUSION

SALLOW SKINSALLOW SKIN THREAD VEINS

THREAD VEINS

COARSE RYTHIDS

COARSE RYTHIDS

FINERHYTIDS

FINERHYTIDS

PIGMENTATIONPIGMENTATION

TitleTitlePositive

CO2 FRSL

• Patient CM 2 passes under R eye with obvious reduction in rhytides and neocollogenesis

MarionetteLines

MarionetteLines

Eyebrow HeightEyebrow Height Youthful Look

Youthful Look

Nasolabial Lines

Nasolabial Lines

CheekAugmentation

CheekAugmentation

Volume loss Volume loss

TitleTitleNegative

CO2 FRSL

New Collagen

Fibroblast Stimulatio

n

CO2 Laser

Botox

Although, many feel that ultrapulsed fractionalised

CO2 laser skin resurfacing is the best treatment option for photo aged facial skin, could we improve on this

modality.

ULTRAPULSE

CONSULTATION

PROPHYLAXIS

PROCEDURE

Conclusion

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22

33

44 DUBLIN

CONSULTATION

CONSULTATION

PROPHYLAXIS

PROCEDURE

Conclusion

11

22

33

44 DUBLIN

Your Text here Your Text hereYour Text hereMETHOD• Every patient being treated in the perioral area is given Valtrex (valcyclovir) 500 mg bd for 8 days starting three days before surgery. This is increased if there is a break out of Herpes.

• If the patient has active acne, we prescribe ByMycin (Doxycycline) 100mgs for 7 days, starting one day prior to procedure.

• If the patient has evidence of prolonged erythema we prescribe Lamasil 250mgs for one week.

PROHPYLAXIS

Herpetic Infection post laser resurfacing

CONSULTATION

PROPHYLAXIS

PROCEDURE

Conclusion

11

22

33

44 DUBLIN

PROCEDURE

Your Text here Your Text hereYour Text hereMETHOD

Topical Anaesthesia

BLT ® : (Amethocaine; Propitocaine; Lignocaine) as topical anaesthetic to the entire facial area for 45mins.  Regional Anaesthesia  Typically, we gave regional anaesthesia during the procedure including  •Supraorbital and Supratrochlear Nerve Block•Infraorbital Nerve Block •Mental Nerve Block

ANAESTHESIA

Active Fx Settings

• Patient CM 2 passes under R eye with obvious reduction in rhytides and neocollogenesis

• All skin biopsies in this study show effect of thermal treatment with thermal coagulation of epidermis and superficial dermis consistently getting below 100 µm. Many studies show the zone of residual thermal (coagulative) damage can extend a further 20 to 120 µm, depending on the particular laser variables used

This was particularly evident in Patient C where the thermal effect appears to be more diffuse than focal and the evidence of effect was still measured at 700 microns, although this reflected a vague diffuse thermal effect as compared with the more localized usual effect. Because the various CO2 lasers currently available differ in their biophysical properties, their documented depth of histological ablation and thermal effects vary

BIOPSY

Patient C

New Collagen

Fibroblast Stimulatio

n

CO2 Laser

Botox

Although, many feel that ultrapulsed fractionalised

CO2 laser skin resurfacing is the best treatment option for photo aged facial skin, could we improve on this

modality.

FAT PROTRUSION

FAT PROTRUSION

SALLOW SKINSALLOW SKIN THREAD VEINS

THREAD VEINS

COARSE RYTHIDS

COARSE RYTHIDS

FINERHYTIDS

FINERHYTIDS

PIGMENTATIONPIGMENTATION

TitleTitleLASER

WRINKLESWRINKLES

TEAR TROUGH TEAR TROUGH WRINKLES

WRINKLES

FATPROTRUSION

FATPROTRUSION

PIGMENTATION PIGMENTATION SKIN LAXITY

SKIN LAXITY

TitleTitleCOLLAGEN

The DUBLiN method uses different methods and technologies in order to activate fibroblasts and direct them towards neocollogenesis. It also uses low level pulsed lasers to reduce skin laxity, accelerate growth factors and cause tightening.

The DUBLiN method incorporates

D Dermaroller

U Ultrapulse Laser

B Blood Factors

Li Light – 633nm

N Neurotoxin

Tissue Repair -FIBROBLASTS

A fibroblast is a type of cell that synthesizes the extracellular matrix and collagen, the structural framework (stroma) for animal tissues, and plays a critical role in wound healing. Fibroblasts are the most common cells of connective

tissue in animals.

DERMAROLLER

ULTRALASE LASER

Laser specialists non-sequential fractionalised CO2 laser ablation is the most effective modality for repairing photo damaged skin

The benefits are more precise control of ablation depth, faster recovery time and reduced risk of post procedural problems

Keratinocyte GF Keratinocyte GF

Vascular Endothelial GFVascular Endothelial GF Fibroblast GF

Fibroblast GF

Transforming GF-BTransforming GF-B

Connective Tissue GF Connective Tissue GF

Platelet Derived GFPlatelet Derived GF

TitleTitleCOLLAGEN

BLOOD FACTORS

Tissue Repair –GROWTH FACTORS

Platelet Rich Plasma, also known as PRP is a component of whole blood that contains a concentrated amount of growth factors. This video describes the basic science of injecting PRP.

Tissue Repair –Platelet Rich Plasma

The efficacy of certain growth factors in forming collagen and healing various injuries is the theoretical basis for the use of PRP in tissue repair. The platelets collected in PRP are activated by the addition of thrombin and calcium chloride. This induces the release of these factors from alpha granules.

LiGHT 633nm

Migrating cells exert forces against the substrate to move forward. These forces are part of the contraction phase of migration in which the rear of the cell is detached from the substrate and the body of the cell is moved forward.

LiGHT 633nm

Migrating cells exert forces against the substrate to move forward. These forces are part of the contraction phase of migration in which the rear of the cell is detached from the substrate and the body of the cell is moved forward.

Near Red Light 633Near Red Light 633

Dermaroller Dermaroller

TitleTitleFibroblast Activation

PHASE 1

PRP Growth Factor Signals

Near Red Light 633Near Red Light 633

Post NTa Post NTa

TitleTitleCollagen

Synthesis

PHASE 2

Co2 Laser

Induction of FIBROBLASTS

A fibroblast is a type of cell that synthesizes the extracellular matrix and collagen, the structural framework (stroma) for animal tissues, and plays a critical role in wound healing. Fibroblasts are the most common cells of connective

tissue in animals.

Comparative study over three months

• Over 3 months, 15 patients (Group 1) received FLSR at normal settings

• Results were compared to 29 patients (Group 2) received low energy FLRS + adjunctive treatments

• Both group received BTXA one week prior to other treatments

Group 2 received a 3-phase combination

multi-rejuvenation technique over 3 weeks.

• Phase I included Dysport® at dilution 3.5:1 in 3 areas

• 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.

Near Red Light 633Near Red Light 633

Dermaroller Dermaroller

TitleTitleFibroblast Generation

PHASE 2 multi-combination technique

PRP Growth Factor Signals

Near Red Light 633Near Red Light 633

Dermaroller Dermaroller

TitleTitleFibroblast Activation

PHASE 2a fibroblast activation

PRP Growth Factor Signals

Near Red Light 633Near Red Light 633

Dermaroller Dermaroller

TitleTitleFibroblast

Stimulation

PHASE 2b fibroblast stimulation

PRP Growth Factor Signals

DERMAROLLER

Keratinocyte GF Keratinocyte GF

Vascular Endothelial GFVascular Endothelial GF Fibroblast GF

Fibroblast GF

Transforming GF-BTransforming GF-B

Connective Tissue GF Connective Tissue GF

Platelet Derived GFPlatelet Derived GF

TitleTitleCOLLAGEN

BLOOD FACTORS

GROWTH FACTORS

The efficacy of certain growth factors in forming collagen and healing various injuries is the theoretical basis for the use of PRP in tissue repair. The platelets collected in PRP are activated by the addition of thrombin and calcium chloride. This induces the release of these factors from alpha granules

LiGHT 633nm

Migrating cells exert forces against the substrate to move forward. These forces are part of the contraction phase of migration in which the rear of the cell is detached from the substrate and the body of the cell is moved forward.

Near Red Light 633Near Red Light 633

Post NTa Post NTa

TitleTitleCollagen

Synthesis

PHASE 2

Co2 Laser

ULTRALASE LASER

Laser specialists non-sequential fractionalised CO2 laser ablation is the most effective modality for repairing photo damaged skin

The benefits are more precise control of ablation depth, faster recovery time and reduced risk of post procedural problems

Patient A

Patient B

Patient C

Patient D

www.ailesburyclinic.ie

WSRS = Wrinkle Severity Rating Scale

5 Extreme Extremely deep and long folds, detrimental to facial appearance.

2-4mm Visible V-shaped fold when stretched

Unlikely to have satisfactory correction with injectable implant alone.

4 Severe Very long and deep folds; prominent facial feature.

Less than 2mm visible fold when stretched.

Significant improvement is expected from injectable implant.

3 Moderate Moderately deep folds.

Clear facial feature visible at normal appearance but not when stretched.

Excellent correction is expected from injectable implant.

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

Implant is expected to produce a slight improvement in appearance.

1 Absent No visible fold, continuous skin line.

GAIS = Global Aesthetic Improvement Scale

5 Very Much Improved Optimal cosmetic result for the implant in this patient.

4 Much Improved Marked improvement in appearance but not completely optimal for this patient. A touch-up would slightly improve the result.

3 Improved Obvious improvement in appearance from the initial condition, but a touch-up or re-treatment is indicated.

2 No Change The appearance is essentially the same as the original condition.

1 Worse The appearance is worse than the original condition.

DUBLIN Lift Periorbital Area

Dover Photoageing Scale

Wrinkle Severity Rating Scale

% Patient satisfaction

BTX

Wrinkle Severity Rating Scale

% Patient satisfaction

PRP

www.ailesburyclinic.ie