Dublin Lift by Patrick Treacy

ARTICLE | facial aesthetics |

Combining therapies
for optimal outcomes
in treating the ageing
face: introducing the
DUBLiN Facelift
Patrick Treacy presents a novel method for full facial
rejuvenation, which combines a number
of treatments to obtain the most optimum results

ABSTRACT
Objective radiofrequency lasers, platelet-rich plasmas repositioning of facial fat.
The DUBLiN Lift: To establish the clinical (PRP) microneedling, microdermabrasion,
effectiveness of combining five treatments botulinum toxin injections, and laser This article examines the possibility of
in the rejuvenation of the ageing face in an resurfacing. Each treatment has its own combining five established therapies
effort to increase aesthetic effect, patient relative beneﬁt, as well as risks2, 3. in an attempt to address these deficits.
safety, and reduce laser downtime. The facial rejuvenating therapies include
In recent years, facial rejuvenation has been microneedling, low-dose UltraPulse laser,
The face is the area for which the majority of revolutionised with the development of PRP growth factors, Omnilux 633 nm
patients seek cosmetic rejuvenation as the CO2 fractional laser skin resurfacing. This light, and neurotoxins. The technique is
convex lines of a youthful appearance tend procedure benefits from faster recovery called the DUBLiN facelift as an acronym
to flatten and droop as one grows older. The time, more precise control of ablation of the procedures involved: Dermaroller,
younger face is characterised by a balance depth, and reduced risk of post-procedural UltraPulse laser, Blood growth factors, Light
Dr Patrick Treacy is captured in the classic shape of the inverted problems. However, there have been cases (near-red 633 nm), and Neurotoxin.
Medical Director of Ailesbury triangle. The reversal of this ‘triangle of of hypopigmentation, hypertrophic scars
Clinics Ltd and Ailesbury Hair beauty’ as ageing proceeds is considered and skin mottling, most often seen on The author compared this method to
Clinics Ltd; Chairman of the generally less aesthetically appealing1. At the face, neck and chest when the laser fractional laser skin resurfacing with regard
Irish Association of Cosmetic present, a variety of different dermatologic parameters are used more aggressively4. to the reduction of photoageing and overall
Doctors and Irish Regional and volumising treatments are available for Furthermore, the technique does not attend aesthetic effect. Neurotoxin was used in
Representative of the British facial rejuvenation. These include chemical to chronological ageing problems such as both arms of the study.
Association of Cosmetic peels, dermal fillers, intense pulsed light and volume deficits resulting from the loss and
Doctors; European Medical

T
Advisor to Network Lipolysis
and the UK’s largest cosmetic
website Consulting Rooms. He he face, and particularly the eyes, is very a patient’s chronological and environmental age, and
practices cosmetic medicine important for contact between humans, mastering the proper evaluation and execution of their
in his clinics in Dublin, Cork,
London and the Middle East as this area provides a window to the rest aesthetic rejuvenation is paramount for all cosmetic
of society with regard to a patient’s level doctors.
email: ptreacy@gmail.com of health, tiredness and emotional status, More recently, patients are seeking effective facial
as well as interest in others4. Many health rejuvenation procedures with less downtime and low
Keywords professionals consider the periorbital area of the face as risks7. This change in attitude has been prompted by a
fractionalised laser resurfacing, the most important area of rejuvenation as eye‑to-eye realisation of both doctors and patients that the much
platelet-rich plasma,
microneedling, Omnilux 633 nm communication occurs in approximately 80% of all hyped non-ablative methods were often subject to
light, neurotoxin human interactions6. Both areas present a barometer of extravagant claims in terms of efficacy2–4. For many

18 September 2012 | prime-journal.com


Figure 1 xxxxxxxx months20, 21. The implied risks and long downtime made
many patients reluctant to accept this method of
treatment22, 23. More recently, fractional resurfacing lasers
have addressed many of these earlier problems with
benefits of faster recovery time, more precise control of
ablation depth, and reduced risk of post procedural
problems8. These lasers are extremely versatile, in that
they can be used for the treatment of facial rhytides, acne
scars, surgical scars, melasma and photodamaged skin,
and many have entered the market at the same time24.
With the advent of fractional laser skin resurfacing, the
number of completely ablative resurfacing cases has
declined for most practitioners. However, care should be
taken when treating sensitive areas such as the eyelids,
upper neck, and especially the lower neck and chest, by
using lower energy and density, and 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
years, CO2 laser resurfacing was considered the ‘gold have also recorded post‑operative infections leading to
standard’ in treating photodamaged facial skin6–11. scarring, although it is generally felt that these may be
Cutaneous laser resurfacing with a fractional (CO2) laser prevented by careful history-taking, vigilant
involves the vapourisation of the entire epidermis, as post‑operative monitoring, and/or the use of prophylactic
well as a variable thickness of the dermis. Many antibiotics26, 27.
physicians stated that the ultrapulsed CO2 laser was the With regard to facial rejuvenation, CO2 laser light at a
most effective method of laser resurfacing12–13. 10 600 nm wavelength results in vapourisation with
Photodamaged skin is the result of years of exposure to thermal denaturation of type I collagen, collagen
harmful ultraviolet light and is clinically demonstrated as shrinkage and later, collagen deposition. However, in
a gradual deterioration of cutaneous structure and very deep rhytides, acne scarring and severe elastotic
function. This results in the epidermis and upper changes from sun damage, fractional CO2 therapy
papillary dermis having a roughened surface texture, as requires multiple treatments to achieve the same results
well as laxity, telangiectasias, wrinkles and variable as the older lasers28. A number of studies have evaluated
degrees of skin pigmentation14–15. using different laser combinations in the same session in
Although ultrapulsed CO2 resurfacing lasers were order to improve collagen deposition, with a wider zone
considered the best treatment option, they had many of ﬁbroplasia6–9, 28. Owing to the inherent risks of fractional
post-procedural problems16, 17, including prolonged laser skin resurfacing and its inability to deal with some
post‑operative recovery, pigmentary changes, and a high evidence of chronological ageing, it was advocated to
incidence of acne flares and herpes simplex virus (HSV) here establish the clinical effectiveness of using a
infection18, 19. Many patients complained of oedema, multi‑procedural approach to volumisation and collagen
burning, and erythema that sometimes lasted for many regeneration. The author used microneedling with low

Figure 2 xxxxxxxx Figure 3 xxxxxxxx


| facial aesthetics | ARTICLE

energy laser, and platelet rich plasma (PRP) to address three‑phase combination of established treatments with
these issues. microneedling, platelet growth hormones, near-red
It is recognised that the most important rejuvenation 633 nm light, and low-energy UltraPulse fractional CO2
process for photoaged skin is the collagen remodelling laser skin tightening. All patients received Dysport® in
process, and dermal fibroblasts are known to have the three areas 1 week prior to the other treatments as an
most important function29. Rejuvenation of skin injury adjunct to the laser resurfacing.
caused by UV light is a complex process that organically The DUBLiN Lift was introduced as three phases over a
involves cytokines interacting with a number of growth period of 3 weeks. Phase 1 included Dysport® at dilution
factors and control proteins28. The procedures evaluated 3.5 : 1 to three areas — glabellar, frontalis and periorbital.
included PRP, microneedling, and Omnilux 633 nm Phase 2 introduced intense fibroblast stimulation and
near‑red light, with neurotoxins as an adjunct to low-level modification through microneedling, PRP growth factor
fractional laser skin resurfacing. Cells in the epidermis induction, and near-red phototherapy. Phase 3
and dermis can be targeted by microneedling and administered the low–level (CO2) UltraPulse laser at
near‑red light, resulting in fibroblast stimulation. Omnilux 100 mJ 14 w CPG 3/5/2, and adjunct near-red 633 nm
Revive™ (633 nm) therapy stimulates fibroblast activity, phototherapy. The study evaluated post-procedural
leading to faster and more efficient collagen synthesis aesthetic results at 2 weeks, 4 weeks and 12 weeks. The
and extracellular matrix (ECM) proteins. It also increases length of downtime, patient discomfort and adverse
cell vitality by increasing the production of cellular side‑effects were noted for each phase.
adenosine triphosphate (ATP) and stimulates the Clinical assessment of patients in each group was
contractile phase of the remodelling process producing made at 2 weeks, 1 month and 3 months post‑operatively
better lineated collagen30–33. Collagen induction therapy is in the presence of two aesthetic staff. The degree of
an aesthetic medical procedure that involves repeatedly improvement in photoageing was based on the degree of
puncturing the skin with tiny, sterile needles. Typically, re-epithelialisation rate, reduction of rhytides, reduction
this is done with a specialised instrument called a of tactile roughness, and loss of hyperpigmentation and
microneedling device. telangiectasias. The prolongation and severity of
Controlled studies have suggested that the application erythema as well as the presence of negative side-effects
of autogenous PRP can enhance wound healing in both (e.g. herpes) were also recorded.
animals and humans29. Five major growth factors such as The efficacy of treatment was evaluated using a
transforming growth factor (TGF), insulin-like growth variation of the five-point scale (Table 1) originally
factor (IGF), platelet-derived growth factor (PDGF), suggested by Dover et al36. Investigators and patients
epidermal growth factor (EGF), and vascular endothelial evaluated efficacy using palpability assessments and
growth factor (VEGF) are known to be related to the
wound-healing processes28. These growth factors are
released from platelets, and the production of collagen
Table 1 Patient treatment (positive) scoring chart
and fibroblasts is stimulated by IGF, EGF, Interleukin-1 Parameter 0 1 2 3 4
(IL‑1) and tumour necrosis factor (TNF)-α34, 35. In vivo
Global score Area of Area of Area of Area of Area of
studies report TGF-β to be the most stimulative growth roughness roughness roughness roughness roughness
factor. PRP may be used for dermal augmentation and x 0 x 1 x2 x3 x4
Sclafani observed aesthetic improvements of the Fine lines None Rare Several Moderate Many
nasolabial fold in less than 2 weeks, and the results lasted Pigmentary None Patchy Moderate Heavy Marked
for up to 3 months28, 29. problems
Touch Even Rare Mild Moderate Severe
Research design and methods problems
This multi-centre randomised study included 44 patients Facial veins None Rare Several Moderate Severe
of skin types 1 and 2 aged between 39 and 68 years, Coarse lines None Rare Several Moderate Many
presenting with photoageing of the skin, 37 of whom Complexion Pink Pale Grey Slightly Distinct
were women and seven were men. The subjects yellow-grey yellow-grey
presented with the typical hallmarks of chronological
and photoageing, such as expression lines, rhytides,
wrinkles, eyelid skin laxity, dermatochalasis, lowered Table 2 Patient treatment (negative) scoring chart
brows, lateral hooding, and prominent fat pads. All
patients were subjected to a programme of skin Parameter 0 1 2 3 4
tightening and neocollagenesis by one of two methods: Erythema severity None Rare Several Moderate Severe
conventional fractional laser skin resurfacing (Group 1) or Infective outbreak None Rare Several Moderate Severe
the DUBLiN Lift (Group 2). The mean patient age in Group (herpes/acne)
1 was 49 years (range 37–71 years) and in Group 2 was 55 Crusting None Rare Several Moderate Severe
years (range 41–76 years). Pain of None Mild Tolerable Moderate Severe
Fifteen patients underwent Lumenis ActiveFx™ with procedure
settings as (energy) 125 mJ and (rate) 19 w CPG 3/5/4. Improvement None Minimal Fair Good Excellent
Twenty-nine patients received the DUBLiN Lift, a

prime-journal.com | September 2012 21


Encore, Lumenis Ltd). Technical differences between
Table 3 Wrinkle Severity Rating Scale (WSRS) this non-sequential fractional device and the older
patient scoring chart ultrapulsed CO2 include tissue bridges left between spots,
resulting in faster healing time, and less thermal damage
5 Extreme Extremely deep and long folds, detrimental to facial appearance to the basal cell membrane. The device has a smaller
4 Severe Very long and deep folds; prominent facial features; less than spot size (1300 mm rather than 2500 mm), resulting in
2 mm visible less post-procedure erythema.
3 Moderate Moderately deep folds; clear facial feature visible at normal The computer pattern generator lays down a random
appearance, but not when stretched series of spots rather than a sequential sequence
2 Mild Shallow but visible fold with a slight indentation; resulting in less overheating of the treated tissue. This
minor facial feature
application is termed ‘Cool Scan’, and was used with
1 Absent No visible nasolabial fold; continuous skin, injectable every patient in the study.
implant alone
The Traylife Kit (PRP) (Promoitalia Wellness Research)
provides blood plasma enriched with a concentrated
Table 4 Global Aesthetic Improvement Scale (GAIS) source of autologous platelets that releases a number of
growth factors and other cytokines that stimulate the
Degree Description healing of soft tissue.
1 Exceptional improvement Excellent corrective result at week 12. No further Omnilux Revive™ (633 nm) (Photo Therapeutics, Inc.,
treatment required UK) stimulates fibroblast activity, leading to faster and
2 Very improved patient Marked improvement of appearance, but not more efficient collagen synthesis and extracellular
completely optimal matrix proteins.
3 Improved patient Improvement of the appearance, better compared with Dermaroller™ Collagen Induction Therapy (CIT)
the initial condition. Touch-up is advised (AesthetiCare®, UK) is a minimally-invasive cosmetic
4 Unaltered patient The appearance substantially remains the same procedure that involves the use of a micro-needling
compared with the original condition device.
5 Worsened patient The appearance has worsened compared with the Scoring charts are presented in Tables 1–4.
original condition
Group 1: fractional laser skin
change from baseline score at 0, 6 and 12 weeks. A total resurfacing
global score was recorded in each patient based on the
addition of points obtained from six photodamage Phase 1
variables. The degree of perceived improvement in Dysport® treatment to three areas: glabellar, frontalis and
overall aesthetic effect reflecting chronological age was periorbital.
assessed separately by patients and physicians using the
Wrinkle Severity Rating Scale (WSRS) and the Global Phase 2 (Week 2)
Aesthetic Improvement Scale (GAIS). The WSRS is Lumenis ActiveFX with settings (energy) 125 mJ (rate)
recognised as a valid and reliable instrument for 1 9w CPG 3/9/4
quantitative assessment of facial skin folds, with good In the pre-laser procedure, the author typically
inter- and intra-observer consistency5. Wrinkle severity is prescribes Valium (Diazepam 5–10 mg orally) for anxiety,
measured using a wrinkle severity rating scale with 1 administered 45 minutes before the procedure.
being absent and 5 being extreme. By allowing objective For infection prophylaxis, Famvir (famciclovir) 750 mg
grading of data, these proved useful clinical tools for daily or Valtrex (valcyclovir) 500 mg twice per day for 7
assessing the effectiveness of facial volumisation with days, was prescribed for every patient starting 3 days
PRP and microneedling–633. before procedure. If the patient had a strong history of
acne, By-Mycin (doxycycline 100 mg daily) or Keflex
Interventions (cephalexin 500 mg twice per day) was prescribed for
The following treatment protocols were used for this 7 days, beginning on the day of surgery. Diflucan
study: Lumenis ActiveFX CO2 laser, Traylife PRP, Omnilux (fluconazole 150 mg) was not routinely prescribed in any
633 nm red light, Dermaroller®, and Dysport®. All patient.
participants received selective regional anaesthesia The patients were treated under topical and regional
blocks with 2% lignocaine plus adrenaline, a topical anaesthesia. Topical anaesthesia comprised benzocaine
combination anaesthetic of 23% lignocaine, and 20%, Lidocaine Base 6%, and tetracaine 4%. Regional
prophylactic Valtrex 500 mg twice daily for 8 days. anaesthesia was three-fold:
Valium 5–10 mg stat was given as a pre-medication to ■■ Supraorbital and supratrochlear nerve block. The
some patients. A post-procedural advice sheet and supraorbital foramen was located and 1 cc of 1–2%
Nurofen or codeine with paracetamol — as required — was Lidocaine injected just above the bone laterally, with
also given to patients. the needle directed medially, parallel to the brow and
The ActiveFX is a protocol of settings applied in toward the nose
conjunction with an improved computer pattern ■■ Infraorbital nerve block. 1 cc of 1–2% Lidocaine injected
generator to the ultrapulsed CO2 laser (UltraPulse into the buccal cavity with the needle directed



towards the infraorbital foramen
■■ Mental nerve block. 1 cc of 1–2% Lidocaine injected into A B
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. C

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

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 rRate)
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
neocollogenesis 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 Figure 4 xxxxxxx



Figure 5 xxxxxx presence of collagen fibres were observed. The thickness
of the dermal layer was calculated by measuring five
A different sites from each section, and the mean value of
the thickness of the dermal layer for each group was
used for the comparison.

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
B 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
C thermal coagulation of the epidermis and superficial
dermis in a depth ranging from 85 to 113 µ. The zone of
residual thermal (coagulative) damage was less in the
Group 2 patients, in whom less laser energy was used.
The best neocollogenesis 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,
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.
The two methods appeared to produce different
D clinical improvement of lesions and rhytides. The GAIS
for 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



B
A

was superior in 62% and 55.2% of patients respectively,
while fractional laser skin resurfacing was superior in C
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
Figure 6 xxxxx
laser skin resurfacing. Investigator-based GAIS
assessment of this region at 3 months after baseline
indicated that fractional resurfacing was superior in 93% resurfacing treatment, which was 3.4. The author noted
of patients, while the DUBLiN Lift was superior in 6.8% of that most patients did not feel much pain at all with the
patients (P = 0.0025). ActiveFX until the energy level crosses 100 mJ. No patient
Re-epithelialisation occurred in all laser-treated areas experienced any adverse reaction to laser skin
of both groups by day 7, and this appeared to be clinically resurfacing, except one case of herpetic infection in each
similar for both procedures. Mean duration of erythema group (Group 1 6.6%; Group 2 3.4%). Both treatments were
was 6.9 days after resurfacing (range 4–10 days) in Group 1 well tolerated. Clumping of platelets occurred in 10% of
and 4.2 days in Group 2 (range 3–7 days). This appeared to patients treated with PRP and the author felt that this was
be in keeping with previous studies37. All patients a result of the concentration of solution used. In fact,
reported having no ‘crusting’ effect remaining on their anecdotal evidence suggests that most cosmetic
face after 6 days. Residual erythema remained in one physicians are using PPP (platelet-poor plasma) in most
patient in Group 1 for a period of 14 days, but this was areas of the face, rather than the higher concentrations
minimal. Post-operative erythema was most intense in used by orthopaedic surgeons.
the areas treated with the ActiveFX at an energy level
above 125 mJ. Conclusions
The mean pain sensation (Table 2) felt during the Facial ageing is a consequence of many interacting
DUBLiN lift was 2.2 compared to conventional fractional 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.

Declaration of interest none

Patient images ©Patrick Treacy

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Further reading
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laser surgery. In: Alster TS. Manual of wrinkle severity rating scale: a validation profilometric, histologic, ultrastructural, and
Cutaneous Laser Techniques. Philadelphia: study. Am J Clin Dermatol 2004; 5(1): 49–52 biochemical evaluations and comparison of
Lippinco, 2000 Doddaballapur S. Microneedling with three different treatment settings. J
Avram MM, Tope WD, Yu T, Szachowicz E, dermaroller. J Cutan Aesthet Surg 2009; 2(2): Photochem Photobiol B 2007; 88(1): 51–67
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facial rhytides. Dermatol Surg 1995; 21(12):


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