Microfocused Ultrasound

By Dr Galyna Selezneva / 07 Apr 2016

Dr Galyna Selezneva details how she uses microfocused ultrasound with visualisation to treat skin laxity in patients

Microfocused ultrasound waves (MFU) aim to stimulate the body’s natural healing and cell regeneration process, which in turn boosts collagen and influences an uplifted effect. This happens without disturbing the skin’s surface, and a non-invasive MFU device can be used to lift, tone and tighten facial and neck skin, as well as improve the appearance of the décolleté.1 Although there are different MFU systems to choose from, the one that I prefer to use, which has been recognised in clinical trials to be safe and effective, is Ultherapy.2 This device combines MFU with high-resolution ultrasound imaging (MFU-V), which allows the practitioner to identify the individual layers of the skin, anatomical features such as blood vessels and bones, and landmarks such as cysts, in order to focus treatment to a patient’s individual concerns. I feel I can bring a unique perspective to this technique, both as a practitioner and former patient who has benefited from it. The clinic I am based at has considerable experience in the aesthetic use of focused energy devices and of radiofrequency for skin tightening. As the latest generation of devices has embraced ultrasound, our clinic has moved seamlessly into this field. It is beneficial to ensure that you offer the latest and safest devices at your clinic, as we do, and have been properly trained by a skilled practitioner. I have been trained by my clinic lead, Dr Rita Rakus, and have been taught both US and European protocols.

Treatment principles

There are two types of ultrasound used in medicine: high-intensity focused ultrasound (HIFU), which is used mainly for medical applications, and MFU, which uses lower levels of energy (0.4-1.2 J/mm2 at a frequency of 4-10 MHz) to treat superficial layers of the skin.3 An MFU beam can pass harmlessly through the skin to target subcutaneous tissue at a focal point.4 This ultrasound energy causes cellular friction, raising the heat in the targeted area.5 This heat in turn acts on the fibroblasts that synthesise collagen. The device I use precisely heats the tissue containing fibroblasts to 60-70°C, the point at which collagen fibrils break apart and contract in small (less than 1mm3 thermal coagulation points (TCPs) to a depth of up to 5mm, while sparing adjacent tissues.6,7,8,9 Denaturing collagen fibres impairs their function and the body responds through natural wound healing by creating new collagen (neocollagenesis).10 Two phases of tightening occur; an initial post-treatment phase takes place immediately due to the contraction and denaturation of collagen at the TCPs;11 a second stage of lifting then occurs as the body initiates an inflammatory response, stimulating the synthesis of new collagen with improved viscoelastic properties.12 Macrophages engulf and break down ‘injured’ tissue and attract fibroblasts to promote repair.5,7,13

The procedure

The procedure begins with a medical assessment in which the practitioner agrees a treatment plan with the patient. The practitioner needs to identify target areas and decide how to apply the treatment and how much energy to use, according to the characteristics of each patient. Target areas are identified by lax skin that results in weakness of the jawline or ‘jowls’, nasolabial folds, or heavy eyelids, and the consequent need for a brow lift. The number of passes of the handheld ultrasound applicator that will be required in a targeted area will be based on the recommended device protocols and clinical experience. These areas will be photographed for before and after comparisons. A coupling gel is then applied to the skin and the practitioner deploys the applicator in a treatment lasting one hour. While only one session is usually necessary, practitioners follow their own protocols and our clinic uses its discretion to determine whether another is required. An experienced practitioner can use MFU to contour the face by tightening the jawline, enhancing the cheekbones or lifting the eyebrows. The treatment has also been used at our clinic to achieve facial symmetry in patients who have suffered a stroke or paralysis. Ultrasound can be combined with other forms of treatment such as injectables, radiofrequency and lasers, to achieve optimal results. Although most patients can undergo this process, a small group of people may be unsuitable, such as those who are pregnant and breastfeeding, or those who have an auto-immune condition, skin cancer, active cancer, certain collagen vascular disorders, open wounds, uncontrolled diabetes or are recovering from chemotherapy.14,15 Age, skin type, alcohol intake or certain serious illnesses do not tend to affect the level of clinical improvement.16

Patient experience

During treatment patients report sensations that can be uncomfortable, some patients describe a ‘pricking’ sensation, as if little hot needles are pricking them. This is most likely because the deep focal points undergo a temperature elevation to 64°C.17 US practitioners tend to manage pain through multiple medications, including benzodiazepines to reduce anxiety. The use of benzodiazepines to treat pain in patients is not uncommon in the US,18 although there has been longstanding debate regarding whether benzodiazepines possess analgesic properties, and at least one literature review reveals insufficient evidence to support the contention that they have meaningful analgesic properties in most clinical circumstances.19 At my clinic, we follow protocols that aim to enable patients to feel more comfortable; prior to the treatment I provide a step-by-step in depth explanation of what will 

happen in which I share my own personal experiences of it; and during treatment I employ what I call ‘talkanaesthesia’ – a distraction technique using conversation if a patient appears anxious – as well as oral painkillers that take into account recommended protocols and depend on a patient’s individual medical history, if necessary. For up to an hour or so following treatment a small proportion of patients may experience redness, swelling, tingling or tenderness to the touch in treated areas, but these side effects are mild and temporary. 3,20 When complications arise, they are invariably practitioner-dependent rather than treatment-dependent, and I believe if a practitioner manages this process well, the patient will not experience problems or require downtime. While there is some tightening of the skin immediately after treatment, the wound-healing response stimulates tissue remodelling over 90-180 days.21 The results are most visible after about three months, and beneficial effects are durable and generally reported to last between six and 18 months.22

Research and safety

Pre-clinical studies demonstrate the ability of MFU to reach the subcutaneous fat, facial superficial musculoaponeurotic system (SMAS), the fan-shaped area where the facial muscles connect with the dermis, to cause tissue contraction.5,6,9 It has been indicated in a study by Alam et al that the Ulthera device can tighten the brow by treating the full face and neck.3 One study, by Oni et al, indicated overall improvement in skin laxity in 63.6% of evaluated patients when using the device on the lower face/neck and at day 90, 65.6% of patients had perceived improvement in the skin laxity.23 In another study, by Fabi et al, which evaluated the safety and efficiency of MFU-V for treating the face and neck for skin laxity 180 days after treatment, it was suggested that 77.7% of women treated achieved noticeable improvement.16

The Food and Drug Administration cleared the Ulthera MFU-V device in 2009 for eyebrow lift following full-face treatment; in 2012 it gained approval for lifting the tissue beneath the chin and neck; and in 2014 for treating the chest to improve the décolleté.24 A number of studies, of which some are mentioned in this article, have indicated that the use of focused ultrasound is safe and effective for tightening and lifting skin in the neck, but also in other anatomical regions such as the upper arms, thighs, and knees.25 An evaluation of MFU-V for the treatment of décolletage laxity and rhytids has suggested this is also safe.26,27 While discomfort is commonly reported, one study suggested that this pain was not significantly different to that endured during other forms of skin-tightening.3,19, 28

Conclusion

To gain valuable tips and guidance I have recently spent a week at one of the leading MFU clinics based in the US and have learnt that, as both a practitioner and a patient, the treatment can be enhanced in several ways. I would recommend fellow practitioners also take part in continued training to develop their knowledge and understanding of MFU treatments. My experience has taught me that, first, the practitioner should manage the patient’s expectations with candour – someone who requires a more invasive approach, such as a facelift, should be advised accordingly. Secondly, during treatment, a practitioner should observe a patient’s body language to respond to signs of tension. Finally, it is important for the practitioner to maintain an ongoing relationship with the patient following treatment in order to reassure them, as the results will take time to manifest and side effects may occur. In my opinion, MFU is an effective and safe non-invasive form of treatment to lift and tighten skin, which gives patients a fresher, natural look with minimal discomfort and no downtime. Please note that, as with all aesthetic procedures, its effectiveness depends on the skill and technique of the practitioner, which should be continually developed and improved upon through comprehensive training.

References
  1. MacGregor, J & Tanzi, E, (2013) Microfocused Ultrasound for Skin Tightening, Unionderm, <https://www.unionderm.com/documents/SCMS_Vol_32_No_1_Microfocused_Ultrasound.pdf> 
  2. Fabi S.G, (2015a) Noninvasive skin tightening: focus on new ultrasound techniques, Clinical, Cosmetic and Investigational Dermatology, 8 pp. 47–52
  3. Alam M, White L.E, Martin, N et al, (2010) Ultrasound tightening of facial and neck skin: a rater-blinded prospective cohort study, Journal of the American Academy of Dermatology, 62 pp. 262–69
  4. Dubinsky T.J, Cuevas C, Dighe M.K, Kolokythas O, Hwang J.H, (2008), High-intensity focused ultrasound: current potential and oncologic applications, AJR. American Journal of Roentgenology, 190 pp. 191–99
  5. White W.M, Makin I.R, Barthe P.G, Slayton M.H, Gliklich R.E, (2007), Selective creation of thermal injury zones in the superficial musculoaponeurotic system using intense ultrasound therapy: a new target for noninvasive facial rejuvenation, Archives of Facial Plastic Surgery, 9 (1) pp. 22-29.
  6. Laubach H.J, Makin I.R, Barthe P.G, Slayton M.H, Manstein D, (2008), Intense focused ultrasound: evaluation of a new treatment modality for precise microcoagulation within the skin, Dermatologic Surgery, 34, pp. 727–34
  7. White et al (2007) Clinical pilot study of intense ultrasound therapy to deep dermal facial skin and subcutaneous tissues, Archives of Facial Plastic Surgery, 9 pp. 88–95
  8. Bozec L, Odlyha M, (2011) Thermal denaturation studies of collagen by microthermal analysis and atomic force microscopy, Biophysical Journal, 101 (1) pp. 228–36
  9. White W.M, Makin I.R, Slayton M.H, Barthe P.G, Gliklich R, (2008), Selective transcutaneous delivery of energy to porcine soft tissues using Intense Ultrasound (IUS), Lasers in Surgery and Medicine, 40 (2) pp. 67–75
  10. Ferraro G.A, De Francesco F, Nicoletti G, Rossano F, D’Andrea F, (2008), Histologic effects of external ultrasound-assisted lipectomy on adipose tissue, Aesthetic Plastic Surgery, 32 pp. 111–15
  11. Ulthera, Ultherapy: Mechanism of Action (MOA), White Paper, n/d, Mesa, AZ: Ulthera Inc, <www. ultherapy.com/uploads/document/professional/MOA%20Whitepaper%20-%201002845B.pdf>
  12. Christiansen D.L, Huang E.K, Silver F.H, (2000) Assembly of type I collagen: fusion of fibril subunits and the influence of fibril diameter on mechanical properties, Matrix Biology, 19 pp. 409–20
  13. Mosser D.M, Edwards J.P, (2008), Exploring the full spectrum of macrophage activation, Nature Reviews Immunology, 8 (12) pp. 958–69
  14. Rosenberg C.S, (1990), Wound healing in the patient with diabetes mellitus, Nursing Clinics of North America, 25 (1) pp. 247–61
  15. Greenhalgh D.G, (2003), Wound healing and diabetes mellitus, Clinics in Plastic Surgery, 30 (1) pp. 37–45
  16. Fabi S.G, Goldman M.P, (2014), Retrospective evaluation of micro-focused ultrasound for lifting and tightening the face and neck, Dermatologic Surgery, 40 (5) pp. 569–75
  17. Dahan, S & Pusel, B, (2014) Microfocused ultrasound, Facial Rejuvenation: Lasers, lights and energy based devices, John Libbey; Paris
  18. Tennant F, (2014) Benzodiazepines in Pain Practice: necessary but troubling, Editor’s Memo, PPM Practical Pain Management, <http://www.practicalpainmanagement.com/treatments/pharmacological/ non-opioids/benzodiazepines-pain-practice-necessary-troubling>
  19. Reddy S, Pat, R.B, (1994) The benzodiazepines as adjuvant analgesics, Journal of Pain and Symptom Management, 9 (8), pp. 510–14
  20. Lee et al (2012) Suh D.H, A intense-focused ultrasound tightening for the treatment of infraorbital laxity, Journal of Cosmetic and Laser Therapy, 14 pp. 290–95
  21. Ulthera Inc, (2016) How does ultherapy work? Lasers in Surgery and Medicine, 37 (5), pp. 343–49 <http://uk.ultherapy.com/Physicians/Science-Of-How-Ultrasound-Skin-Lift-Works [accessed February 2016]. See also Meshkinpour A, Ghasri P, Pope K, et al (2005) Treatment of hypertrophic scars and keloids with a radiofrequency device: a study of collagen effects>
  22. Fabi S.G, (2015); Fabi S.G, (2015b) Micro-focused ultrasound skin tightening, PRIME: International Journal of Aesthetic and Anti-ageing Medicine, May 14, <https://www.prime-journal.com/micro-focused-ultrasound-skin-tightening>
  23. Oni G, Hoxworth R, Teotia S, Brown S, Kenkel J.M, (2014), Evaluation of a microfocused ultrasound system for improving skin laxity and tightening in the lower face, Aesthetic Surgery Journal, 34 (7) pp. 1099–110
  24. Dayan S.H, Fabi S.G, Goldman M.P, Kilmer S.L, Gold M.H, Prospective, multi-center, pivotal trial evaluating the safety and effectiveness of micro-focused ultrasound with visualization (MFU-V) for improvement in lines and wrinkles of the décolletage, Plastic and Reconstructive Surgery, 134 (4, s1) (2014), pp. 123–24
  25. Alster T.S, Tanzi E.L, (2012) Noninvasive lifting of arm, thigh, and knee skin with transcutaneous intense focused ultrasound, Dermatologic Surgery, 38 pp. 754–59
  26. Fabi S.G, Massaki A, Eimpunth S, Pogoda J, Goldman M.P, (2013), Evaluation of microfocused ultrasound with visualization for lifting, tightening, and wrinkle reduction of the décolletage, Journal of the American Academy of Dermatology, 69 pp. 965–71
  27. Fabi S, Bolton J, Goldman M.P, Guiha I, (2012), The Fabi-Bolton chest wrinkle scale: a pilot validation study’, Journal of Cosmetic Dermatology 11 (3) pp. 229–34
  28. Kakar R, Ibrahim O, Disphanurat W, et al, (2014), Pain in naïve and non-naïve subjects undergoing nonablative skin tightening dermatologic procedures: a nested randomized control trial, Dermatologic Surgery, 40 (4) pp. 398–404 

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