Periorbital Rejuvenation

The DUBLiN Method

Dr. Patrick J. TreacyMedical DirectorAilesbury Clinics Ltd

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

PERIORBITAL AGEING

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

PERIORBITAL 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

PERIORBITAL AGEING

Clinically photo-aged skin is wrinkled, blotchy and leathery. Eyelid laxity can cause both ectropion and entropion or eiphoria and laxity of the medial and lateral canthal tendon.

PERIORBITAL AGEING

A variety of dermatological treatments are available such as topical creams, neurotoxin, RioBlush © carboxytherapy, Polaris © RF-radiofrequency and SmartXide © and AFX © CO2 fractionalised resurfacing lasers.

TACTILEROUGHNESS

TACTILEROUGHNESS

SALLOW SKINSALLOW SKIN COARSE

RHYTIDS

COARSE RHYTIDS

FINE RYTHIDS

FINE RYTHIDS

THREAD VEINSTHREAD VEINS PIGMENTATION

PIGMENTATION

TitleTitlePHOTOAGEING

WRINKLESWRINKLES

ECTROPION ECTROPION ENTROPION

ENTROPION

FATPROTRUSION

FATPROTRUSION

EPIPHORIA EPIPHORIA SKIN LAXITY

SKIN LAXITY

TitleTitleAGEING

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

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

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.

Tissue Repair -FIBROBLASTS

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.

DERMAROLLER

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

Mouse fibroblasts are starved for serum factors like PDF and IGF-1. Then, serum is added back and time lapse inverted phase contrast images are taken every 1 sec. Watch the ears of a cell, at the tips of a thin blanket of cytoplasm called "lamellipodium".

Blood Growth Factors

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

Near Red Light 633Near Red Light 633

Low level Laser Low level Laser

TitleTitleFibroblast Activation

PHASE 2

 AGERA Prolifersyn ®

LOW LEVEL 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

Continuous vs Ultrapulse

Comparative Split Face Study

Perioral split face study showing the different skin eschar results from the two fractionalised lasers immediately after treatment

ULTRAPULSE

Objective

Methods

Results

Conclusion

11

22

33

44 Conclusions

• A clinical assessment of each patient regarding the overall level of photoageing was made initially and at 2 weeks, I month and 3 months postoperatively in the presence of two physicians.

• Positive scoring was based on the degree of re-epithelialisation rate, reduction of rhytides, loss of hyperpigmentation and telangectasias and reduction of tactile roughness.

• The prolongation and severity of erythema as well as the presence of negative side effects (such as herpes were also recorded by both the patient and the doctor). The degree of photoageing and the efficacy of treatment were evaluated using a five-point scale originally suggested . by Dover et al.

Score 0 1 2 3 4

Fine Lines None Rare Several Moderate Many

Pigment None Patchy Moderate Heavy Severe

Facial Veins None Rare Several Heavy Severe

Coarse Lines None Rare Several Moderate Many

Efficacy of treatment + scoring system

Score 0 1 2 3 4

Touch Even Rare Mild Moderate Severe

Complexion Pink Pale Grey

Partial

Yellow

Grey

Distinct

Yellow

Grey

Efficacy of treatment + scoring system

prolonged postoperative

recovery

pigmentary changes

erythema

infection

Although, ultrapulsed CO2 laser skin resurfacing was largely considered the best option for treatment of this type of photoaged facial skin, it also had certain

post- procedural problems

Score 0 1 2 3 4

Erythema None Rare Several Moderate Severe

Crusting None Rare Several Moderate Severe

Pain None Rare Several Moderate Severe

Herpes None Rare Several Moderate Severe

Efficacy of treatment - scoring system

5 daysImmediate

Random

Your Text here Your Text hereYour Text hereMETHOD

• If the patient has a strong history of HSV, we initially prescribed Famvir (Famciclovir) 750mgs daily for 10 days or Valtrex (valcyclovir) 500 mg bd for 10 days starting three days before surgery. This was adjusted during the study to commence one week before and to be used for one week after.

• If the patient has a strong history of acne, we prescribe an antibiotic ByMycin (Doxycycline 100mgs daily) Augmentin Duo, (Amoxil Clavulinic Acid) Keflex (Cephalexin 500 mg bd) for 7 days, starting the day of surgery).

• If the patient has a strong history of frequent yeast infections, we prescribe Diflucan (Fluconazole 150mgs), starting on the 4th post-operative day and taken once orally every other day

PROHPYLAXIS

Your Text here Your Text hereYour Text hereMETHOD

Topical Anaesthesia

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

ANAESTHESIA

BiopsyBiopsy StainingStaining HistologyHistology

Histology was performed to determine the amount of tissue ablation, residual thermal damage, inflammation and neocollagenesis

Histology was performed to determine the amount of tissue ablation, residual thermal damage, inflammation and neocollagenesis

Lesion penetrative dimensions were assessed histologically using haematoxylin & eosin

Lesion penetrative dimensions were assessed histologically using haematoxylin & eosin

Skin biopsies were obtained from 5 patients intraoperatively from each side, after one laser pass, and at 3 months postop.

Skin biopsies were obtained from 5 patients intraoperatively from each side, after one laser pass, and at 3 months postop.

Thermal effect at 100 µm seen histologically using haematoxylin & eosin

© Patrick Treacy

3 months post © Patrick Treacy

• Patient CM : Right Eye SmartXide treated (Power) 30W Dot Mode Spacing 200 μm Scanning well Time 500 μS 2 passes under R eye with obvious reduction in rhytides and neocollagenesis

• The two CO2 lasers (Lumenis ActiveFx Deka SmartXide) appeared to produce equivalent clinical improvement of lesions and rhytides. Re-epithelialisation occurred in all laser treated areas by both devices by day 7and this appeared to be similar for both lasers. Mean duration of reepithelialisation was 6.9 days after resurfacing (range, 4-10 days).

• Residual erythema remained for a period of 14 days but this was minimal (mean decreased from 4.1 on day 3 to 0.9 at day 14). Postoperative erythema was most intense in the areas treated by SmartXide whenever the dwell time was increased up to 1ms. This effect was also noted with the ActiveFx at the energy level above 125Mj.

RESULTS

• All skin biopsies in this study show effect of thermal treatment with thermal coagulation of epidermis and superficial dermis in a depth ranging from 85 to 113 microns. This was similar in both lasers with the SmartXide 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

• The global score for photoageing for both devices improved from 13.8 at baseline to 9.6 at Day 30. The score for fine lines was the most significant reduction dropping form 3.6 at baseline to 1.4 at Day 30. The score for sallowness was the most difficult to interpret at Day 30 as the patients still had some mild erythematous effect. Scores for reduction of coarse wrinkles (3.2 at baseline to 2.2 at Day 30) was also difficult to interpret in this heterogeneous age grouping with older patients requiring the deeper penetrating ‘harder’ MaxFx rather than the ‘softer’ ActiveFx and it is apparent that Lumenis are presently working on a combination therapy to solve this problem.

RESULTS

• If fractionalised laser skin resurfacing (FLSR) with minimal downtime is now considered the new method of softly treating patients for minor skin conditions such photoageing then the SmartXide DOT has cost advantages to the operator. It has yet to be established whether this will be in multiple sessions or not. If the physician requires to treat patients with deeper facial rhytides or other pathology in a one off session then the ActiveFx appears to have these advantages.

CONCLUSION

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