Safety study of transcutaneous focused ultrasound for non-invasive skin tightening in Asians

Ultrasound Therapy for the Skin

Ultrasound energy is delivered to the dermal and subdermal tissue to induce thermal injury, leading to collagen remodeling and resulting in lifting and tightening of the skin. Ulthera and Sofwave are two Food and Drug Administration-approved systems that have demonstrated clinically significant results in providing eyebrow, submental, and neck lift and minimizing facial fine lines and wrinkles. Patient selection and management of expectations are important components to a successful treatment process. Both devices boast high patient satisfaction rates, minimal recovery time, and excellent safety profile. Ultrasound technology is an effective, nonsurgical option for facial rejuvenation.

[High intensity focussed ultrasound for skin tightening]

High intensity microfocussed ultrasound (HIFU) is currently used for skin tightening and recently also for fat reduction. The HIFU uses bundled ultrasound waves that are focussed by a type of concave mirror to bundle thermal energy. The indications for HIFU include, in particular, sagging skin that does not need a plastic surgical operation for tightening. In most cases only one or two treatment sessions are needed. More expensive HIFU treatment can be further optimized by maintenance therapy with radiofrequency (RF). The greatest disadvantage of HIFU is that the treatment is very painful.

The role of topical capsaicin gel in pain management during microfocused ultrasound treatment for neck laxity

BACKGROUND

The transient receptor potential vanilloid 1 (TRPV1) provides a heat and pain sensation (nociception). Capsaicin, a TRPV1 agonist, has been shown to induce a refractory period in the nerve terminal expressing TRPV1 and create long-term nerve terminal defunctionalization.

OBJECTIVE

To evaluate the efficacy of capsaicin for pain reduction during microfocused ultrasound with visualization (MFU-V) treatment.

METHODS AND MATERIALS

A randomized, split-side study including 24 subjects was conducted. A combined 0.025% capsaicin gel and topical anesthetic were randomly applied on one side of the neck, and a topical anesthetic monotherapy was applied on the contralateral side for 30 min before MFU-V treatment. Pain score (visual analog scale, 0-10) was evaluated at T1 (before MFU-V), T2a (after the 4.5-mm transducer treatment), T2b (after the 3.0-mm transducer treatment), and T3 (after the entire treatment). Side effects were recorded.

RESULTS

Mean pain scores at T2a for combined and single regimens were 5.19 (±2.26) and 6.91 (±1.72), respectively (p < 0.001). The capsaicin-treated side had a lower pain score at T2b and T3 (p < 0.001). Redness was longer on the capsaicin-treated side (112.67 vs. 10.68 min, p < 0.001). No other adverse events including contact dermatitis were reported.

CONCLUSION

A single application of a combined 0.025% capsaicin gel with topical anesthesia produces a significantly lesser pain score during the MFU-V treatment. Defunctionalization of TRPV1 may explain the alleviation of painful sensations caused by heat from MFU-V.

Micro-Focused Ultrasound Therapy in Patients with Urogenital Atrophy and Vaginal Laxity

Vaginal laxity (VL) and genitourinary syndromes of menopause (GSM) create physical, psychological, and functional problem for women and their partners. We aimed to evaluate the efficacy and safety of micro-focused ultrasound (MFU) therapy performed twice in the vaginal canal in a patients with VL and GSM. A total of 20 women with GSM and VL were treated with MFU Ultravera by Hironic. The treatment course consisted of two vaginal applications of MFU at an interval of 6 weeks. The clinical effects of the protocol were evaluated using the Vaginal Laxity Questionnaire (VLQ), the Vaginal Health Index (VHI), and the Female Sexual Function Index (FSFI). The overall values of the vaginal laxity evaluation for the total subject population showed a statistically significant improvement between the baseline and the findings at 3 and 6 months after treatment. The effect of therapy was consistent across all domains of FSFI. It peaked at the 6 week follow-up visit (from 26.5 to 32) and plateaued at 12 weeks and 6 months. There was a significant VHI improvement over time, with the greatest and most significant change between the study entry and 21 days after treatment; the VHI score leveled off up to 3 months after the procedures. MFU therapy, performed twice in the vaginal canal, showed promising efficacy and safety profiles, meriting further investigation.

Clinical efficacy and safety of a focused-radiofrequency device on middle and lower face rejuvenation: a retrospective clinical study

The aim of the present study was to evaluate the efficacy and safety of a unipolar focused-RF device used to rejuvenate the middle and lower face and to create an assessment system. This retrospective study comprised 52 patients with mild-to-moderate skin laxity and wrinkles who received 1-3 treatments 1 month apart and were followed up for 1-7 months. At baseline and post-treatment, three blinded observers measured facial contour and lines, analyzed VISIA scores, and assessed the results using Alexiades Comprehensive Grading Scale (ACGS) and Global Aesthetic Improvement Scale (GAIS). Significant improvements were observed (P < .05) in facial width (left 5.95%, right 5.66%), nasolabial folds (left 18.98%, right 20.56%), marionette lines (left 18.88%, right 25.80%), and cheek lines (left 3.35%, right 3.05%) and in the scores of wrinkles (15.37%), texture (13.67%), pores (6.48%), and red areas (6.57%) using VISIA. There was an obvious reduction in wrinkles, laxity, erythema/telangiectasia based on ACGS, and 75% improved and 5.8% much improved using GAIS. There was no severe side effect. We suggest that the unipolar focused-RF device is an effective and safe technique for middle and lower face rejuvenation and provides a series of comprehensive assessment methods based on standardized photos using VISIA.

A Systematic Review of the Clinical Efficacy of Micro-Focused Ultrasound Treatment for Skin Rejuvenation and Tightening

The demand for non-invasive skin-tightening techniques is continuously on the rise, as now numerous patients seek safe and effective alternative body, neck, and facial aesthetic surgical procedures. Micro-focused ultrasound (MFU) has been recently introduced as a novel energy modality for skin rejuvenation to produce a more significant wound healing response at various levels, including strong collagen remodeling and long-lasting clinical response. This literature study was intended to find the role and efficiency of using micro-focused ultrasound therapy in male and female patients aged 35-65. A total of 139 articles were extracted from the PubMed and Science Direct electronic databases. After a thorough evaluation and following the exclusion and inclusion criteria, 10 full-text articles were relevant to the study. The goal was to analyze and examine the effects and benefits of MFU treatment to improve the skin. In addition, all of the patients were evaluated to report the harms and risks associated with MFU treatment. The literature study results revealed that significant improvements in the overall aesthetics of sagging of the mid and lower face could be accomplished by using a micro-focused ultrasonic treatment plan. Patients report no considerable side effects, and the results were also long-lasting. MFU treatment can activate deeper tissues without causing injury to the epidermis, which sets it apart from all other skin tightening methods. Better improvements rates have been reported by both patients' self-assessment and clinical investigators' evaluation.

The effect of lyophilized platelet rich-plasma on skin aging: a non-randomized, controlled, pilot trial

Platelet-rich plasma (PRP) showed positive results in the improvement of skin aging. Lyophilized PRP can be interesting in clinical practice due to the facility to obtain many samples in a single blood collection and can be used in multiple injections. To evaluate the effect of lyophilized PRP in the treatment of skin aging, through a Phase II pilot study. Nineteen women (54 years ± 7 years) with Glogau photoaging II and III types were select for this non-randomized, split-face controlled study. They received monthly intradermal injections of lyophilized PRP and saline solution (as control) into the facial skin, during a period of 2 months. The evaluation was performed by imaging method, histological techniques, and multiphoton microscopy. Although lyophilized PRP presented 10 times the platelet baseline value (P < .0001) and growth factors in adequate levels, only saline solution showed an increase of dermis thickness (p = .0009). Collagen pre and post-application remained the same for both types of treatments. The use of lyophilized PRP by mesotherapy showed no improvement on skin aging. TRIAL REGISTRATION APPROVAL: RBR-3n9wxw, UTN U1111-1226-6093-retrospectively registered.

Facial Tightening Effects, Following Focused and Radial Acoustic Wave Therapy Assessment, Using a Three-Dimensional Digital Imaging

Background and Objectives

Acoustic wave therapy is a novel facial tightening technique that involves nonthermal penetration of the skin and subcutaneous tissue, affecting cells and their metabolism, and resulting in an increased release of unwanted fat and activation of blood and lymphatic flow in tissues. The objective of this study was to investigate the effectiveness of acoustic wave therapy.

Study Design/Materials and Methods

A total of 333 patients underwent multiple facial tightening treatment sessions using focused and radial acoustic waves. Each patient received 2,000–3,000 pulses of focused acoustic waves at a power of 0.45–0.88 mJ/mm² with a pulse frequency of 3–5 Hz and 4,000 pulses of radial acoustic waves at 4‐bar power at a frequency of 21 Hz. These sessions were performed more than three times, and treatments were repeated at 1‐month intervals. Digital photographs superimposed three‐dimensional volumetric assessments, and three‐dimensional skin surface displacement calculations using vectors were used to evaluate the results 12 months after the last treatment. Patients also evaluated the results using a 5‐point Likert scale.

Results

Improvements in skin texture, clarity, and laxity were observed in digital photographs. Superimposed three‐dimensional color images showed marked volumetric reduction and/or formative modification for even contour toward the lower mid‐face. Most vectors showed three‐dimensional skin surface displacement at the lateral sides of the temples, cheeks, and chin, in an upward direction. These results were obtained and sustained for up to 12 months without edematous reactions. Almost all patients reported improvement, with 79% reporting “good” or “excellent” improvement. Complications were minor and transitory. Persistent side effects were not observed.

Conclusion

Acoustic wave therapy could be used as a standard facial tightening treatment, with skin rejuvenation effects shown on digital photographs and three‐dimensional quantification assessments. This noninvasive acoustic wave approach was found to be a safe, long‐lasting, and effective method for facial tightening. Lasers Surg. Med. 00:00–00, 2020. © 2020 Wiley Periodicals LLC

Prospective Study on Clinical Efficacy and Safety of a Single Session of Microfocused Ultrasound With Visualization for Collagen Regeneration

BACKGROUND

Recent studies have shown that transcutaneous microfocused ultrasound with visualization is beneficial for noninvasive skin tightening, collagen regeneration, and lower face contour improvement.

OBJECTIVES

The primary study endpoint was the improvement of the laxity and ptosis face skin; the secondary endpoint was the improvement of wrinkles, texture, and hemoglobin content; and the third endpoint was the patient's responses to a patient satisfaction questionnaire.

METHODS

Patients with soft to moderate skin laxity and ptosis of the face and neck were enrolled and their sex, ethnicity, age, Fitzpatrick skin type, and smoking habit recorded. Patient assessment was made by digital macro-photographs, Vectra H2, and Antera 3D, and strict exclusion criteria were set up.

RESULTS

From November 2017 to November 2018, 47 women and 3 men with a mean age of 52.8 ± 7.43 years and Araco's Ptosis Scale System 2.7 ± 0.46, which fit the inclusion criteria, were enrolled in the study. All patients signed a consent form and received 1200 spot-lines (400 lines from each transducer) of microfocused ultrasound with visualization. No major side effects were reported during the study and all patients completed the follow-up after 6 months. Wrinkles, texture, Surgeon Assessment Scoring System scores, and patient satisfaction questionnaire scores improved significantly. Patients found the treatment tolerable according to the patient pain scale rate. No statistically significative differences were found among homogenous groups of smokers and nonsmokers.

CONCLUSIONS

The study proves that microfocused ultrasound with visualization in a single session of treatment in monotherapy is safe and effective for the treatment of face laxity and ptosis when a proper number of energy spot-lines is delivered in the correct tissue layer.

LEVEL OF EVIDENCE: 4

Evaluation of microfocused ultrasound for improving skin laxity in the lower face: A retrospective study

To evaluate the efficacy and safety of a newer microfocused ultrasound (MFU) device on the lower face laxity. Subjects who underwent MFU therapy for skin tightening were enrolled in the study. The primary outcome measure was overall improvement in skin laxity of the lower face that was evaluated by improvement on jawline irregularities, marionette line, and submental laxity. Assessments were obtained from two blinded dermatologists paired pre- and post-treatment photographs with Investigator-Global-Aesthetic-Improvement-Scale (IGAIS) and from subjects with Subject-GAIS (SGAIS). A total of 24 subjects were evaluated on a median of 4.3 months after 1 session MFU application. According to IGAIS, 5 subjects (20.9%) demonstrated improvement and 15 subjects (62.5%) had no change. Four subjects (16.7%) were scored as worsening. According to SGAIS, 11 subjects (45.9%) reported an improvement whereas 9 subjects (37.5%) reported no change. There was a statistically significant difference between the improvement rate assessed by the investigators and the subjects, where investigators scored lower (P = .006). No serious adverse effects were observed. The relatively high improvement rate observed by the subjects' self assessments compared to investigators evaluation from the photographs suggested that we need to find new evaluation methods other than photography which may reflect what subjects feel but we cannot see.

Accuracy of a high-intensity focused ultrasound device with and without real-time visualization system in face and neck treatment of skin laxity

BACKGROUND

Microfocused ultrasound (MFU) is a nonsurgical treatment for the improvement of skin laxity. Multiple MFU devices with and without a visualization system are commercially available.

AIMS

This study aims to compare the accuracy rates of MFU on target treatment areas with and without a visualization system.

PATIENTS/METHODS

A cross-sectional study was conducted using 52 dermatologists as study subjects. Each subject was asked to treat one simulated volunteer on the face and upper neck with MFU for 2 sessions using the training mode. Participants were allowed to see the ultrasound monitoring screen in one session (visualized session) and were not allowed to see the monitoring screen in the other session (nonvisualized session). One investigator evaluated the accuracy rate by monitoring real-time whether an appropriate contact between the transducer and the skin is shown on the visualization system when the energy release button is pressed.

RESULTS

Higher accuracy rates were observed in the visualized session than the nonvisualized session in all treatment areas including brow, lateral orbit, infraorbital, cheek, and upper neck. The greatest difference in accuracy rates was observed when performing the treatment on the upper neck. Participants with more experiences had higher accuracy rates while performing visualization session when compared to those who had less experiences. Visualized sessions required a significantly longer treatment time.

CONCLUSIONS

The utilization of MFU with visualization system increases the likelihood of proper skin contact. This in turn may give a more favorable treatment outcome and decrease the rates of complications from MFU treatment.

Use of Micro-focused Ultrasound for Skin Tightening of Mid and Lower Face

The changes in the mid face and lower face are among the most prominent features of the aging process. Intense focused ultrasound, known as the Ulthera System (Ulthera Inc., Mesa, AZ, USA), was designed to correct this process. It employs micro-focused ultrasound to cause discrete focal heating of the dermis and stimulates neocollagenesis and elastin remodeling.

Skin physiology and safety of microfocused ultrasound with visualization for improving skin laxity

Purpose

The efficacy of microfocused ultrasound with visualization (MFU-V; Ultherapy^®) has been demonstrated in clinical studies and daily practice. However, data addressing skin physiology after MFU-V treatment are lacking. This observational evaluation was aimed to assess skin physiology before and after MFU-V treatment using noninvasive biophysical measurements.

Patients and methods

Twenty-two female patients with moderate-to-severe skin sagging at the jawline and submental region on the Merz Aesthetics Scale obtained a single MFU-V treatment according to protocol. Skin function measurements focused on short-term effects up to 3 days and long-term effects up to 24 weeks after treatment. Skin temperature, transepidermal water loss, skin hydration, erythema, elasticity, and skin thickness and density were evaluated under standardized conditions. Pain was assessed using a validated numeric visual analog scale.

Results

Skin temperature remained in a physiologic range and no significant increase was noted at day 3 after MFU-V treatment. Transepidermal water loss, hydration, and erythema values were fairly stable and showed no significant differences at short- and long-term measurements vs baseline. At week 4 after a single MFU-V treatment, gross and net elasticity values were significantly decreased (P=0.003 and P=0.0001, respectively), followed by significantly increased values at week 12 (P=0.015, P=0.046) and week 24 (P=0.001, P=0.049). Edema due to MFU-V treatment resolved without sequelae. For all patients, pain diminished shortly after treatment. No adverse events occurred during the 24-week follow-up period.

Conclusions

MFU-V treatment is well tolerated and it does not alter the epidermal barrier function or physiology of skin. Significant increase in the elasticity of skin was observed at 12 and 24 weeks after a single treatment, which reflects improvement in dermal tissue function. These short- and long-term effects are congruous with the mode of action of MFU-V due to a proven intrinsic tissue remodeling process.

A Split Face Study to Determine the Significance of Adding Increased Energy and Treatment Levels at the Marionette Folds

BACKGROUND

Microfocused ultrasound with visualization (MFU-V) has become a safe and effective means to tighten skin and subdermal structures by optimizing the amount of joule energy and treatment tissue planes for improved customization for the individual patient. To date, there have been an absence of split treatments to verify algorithms.

OBJECTIVES

The aims of this institutional review board-approved investigation and clinical experience were to clarify the safety and efficacy of current treatment guidelines.

METHODS

This split-face investigation quantified tissue displacement at the marionette folds after single treatments of 2 different treatment densities or number of lines and 2 vs 3 planes of treatment with matched-orientation photography, elasticity measurements, subjective assessments by patient (SGAIS), and blinded-investigator global investigation (IGIAS) analyses at baseline, 180 days post treatment (D180), and 360 days post treatment (D360). Clinical studies, utilizing these algorithms to treat regional areas of the forehead, periorbitum, face, neck, and décolleté, were analyzed by (IGIAS) assessment, pain scoring, and incidence of complications and side effects at D180 and D360.

RESULTS

Post hoc analyses at D180 and D360 in pilot studies 1 and 2 demonstrated greater tissue displacements, elasticity measurement, and pain scores, supported by SGAIS and IGAIS assessment with the use of higher amounts of joule energy and treatment planes than those used on the contralateral reference marionette folds at D180 and D360. Pain scores after use of each transducer or at the end of the procedure showed variability at different regional areas with more discomfort noted with treatments at the deepest and most superficial tissue planes. There were no major adverse reactions and minimal short-termed side effects in the entire study.

CONCLUSIONS

Optimization, customization, and safety were observed with the use of current MFU-V algorithms as clarified by the findings in this investigation. Further investigations with multiple sessions will be required to advance this unique noninvasive technology for tissue lifting.

LEVEL OF EVIDENCE

3.

High-intensity focused ultrasound treatment for skin: ex vivo evaluation

BACKGROUND/PURPOSE

High-intensity focused ultrasound (HIFU) has been used for skin tightening. However, there is a rising concern of irreversible adverse effects. Our aim was to evaluate the depth of thermal injury zone after HIFU energy passes through different condition.

MATERIALS AND METHODS

To analyze the consistency of the HIFU device, phantom tests were performed. Simulations were performed on ex vivo porcine tissues to estimate the area of the thermal coagulation point (TCP) according to the applied energy and skin condition. The experiment was designed in three orientations: normal direction (from epidermis to fascia), reverse direction (from fascia to epidermis), and normal direction without epidermis.

RESULTS

The TCP was larger and wider depending on the applied fluence and handpieces (HPs). When we measured TCP in different directions, the measured area in the normal direction was more superficially located than that in the reverse direction. The depth of the TCP in the porcine skin without epidermis was detected at 130% deeper than in skin with an intact epidermis.

CONCLUSION

The affected area by HIFU is dependent on the skin condition and the characteristics of the HP and applied fluence. Considerations of these factors may be the key to minimize the unwanted adverse effects.

Synergistic effect of high-intensity focused ultrasound and low-fluence Q-switched Nd:YAG laser in the treatment of the aging neck and décolletage

High-intensity focused ultrasound (HIFU) is regarded as an effective skin-lifting device; however, literature regarding treatment of the aging neck and décolletage with HIFU is scarce. Our study aimed to evaluate the efficacy of combination with HIFU and low-fluence Q-switched Nd:YAG (LQSNY) laser on the aging neck and décolletage. Nineteen women were assessed. HIFU at two visits and LQSNY laser at six visits were used to irradiate the neck and chest. At week 16, improvements were rated using the Dedo classification, Fabi/Bolton Chest Wrinkle Scale (FBCWS), and Global Aesthetic Improvement Scales (GAIS). Erythema and melanin indices (EMIs) and cervicomental angle were measured. Subject GAIS and satisfaction were evaluated at follow-up visits. At week 16, neck sagging and chest rhytides were improved on Dedo classification and FBCWS, respectively. Pigmentation and rhytides of the neck and chest were rated as improved in 30 % or more of the subjects by physician GAIS and in approximately 80 % of the subjects by subject GAIS. The above differences seemed to be attributable to the initial expectation level and mild severity pertaining to dress custom in Korea. Eighty-four percent of subjects were satisfied with treatment outcomes. EMIs were decreased on the chest. The combination of HIFU and LQSNY is an effective treatment option to mitigate rhytides and pigmentation of the neck and décolletage.

Intense focused ultrasound (IFUS) with a modified parameter on facial tightening: A study on its safety and efficacy

BACKGROUND

Intense focused ultrasound (IFUS) is a novel treatment modality for skin laxity. The delivery of thermal energy to the deeper tissue layers effectively tightens the skin but can also cause significant fat atrophy, limiting its use in patients with a lean face.

OBJECTIVES

We sought to evaluate the safety and efficacy of modified IFUS on facial rejuvenation.

PATIENTS AND METHODS

This was a retrospective, single-center study of 28 subjects with age-related facial laxity who underwent 3 sessions of IFUS (Ultraskin^TM, WONTECH Co., Daejeon, Korea) at an interval of four weeks, and then followed up for three months. IFUS was first applied using a 4-MHZ, 4.5-mm transducer followed by a 7-MHZ, 3-mm transducer. Approximately 200-300 treatment lines were applied to the face during each session. Standardized photographs were taken at baseline and follow-ups and were assessed by two independent dermatologists. A questionnaire was used to evaluate patient satisfaction and the incidence of adverse reactions.

RESULTS

Twenty-eight subjects with mild-to-moderate age-related facial laxity were included in the study. The mean age of the subjects was 48 (range 29-74) years. About 32.1% of the subjects showed significant improvement and 57.1% showed improvement of facial laxity in their follow-up photographs. All of them (100%) replied that they were either greatly satisfied or satisfied with the results at three-month follow-up. None of the subjects experienced any serious adverse events including fat atrophy after the procedure.

CONCLUSION

Modified IFUS (three sessions, four weeks apart, 200-300 treatment lines per session) can be safely performed with good clinical results.

Safety of Microfocused Ultrasound With Visualization in Patients With Fitzpatrick Skin Phototypes III to VI

IMPORTANCE

A microfocused ultrasound (MFU) system is a safe and effective aesthetic treatment for tightening and lifting skin in the facial and neck areas. This open-label, nonrandomized trial was performed to further demonstrate the safety of MFU for improving laxity of the skin of the face and neck in 52 adults with Fitzpatrick skin types III to VI.

OBSERVATIONS

Before treatment with MFU, the skin tissue of each participant was assessed and ultrasound imaging was performed on the treatment area to ensure appropriate acoustic transducer coupling. Treatment was performed from March 23, 2011, to July 20, 2011. Following treatment, there were 3 reported adverse events described as raised areas of mild edema or welts (2 events) and moderately severe prolonged erythema with mild scabbing (1 event). All events resolved after 90 days without sequelae. Analysis was conducted from Janaury 18, 2012, to March 13, 2013.

CONCLUSIONS AND RELEVANCE

The adverse events that occurred in this trial were temporary and associated with treatment technique. When performed by trained physicians, MFU is safe in patients with Fitzpatrick skin types III to VI.

LEVEL OF EVIDENCE

4.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01368965.

High-Intensity Focused Ultrasound for the Treatment of Wrinkles and Skin Laxity in Seven Different Facial Areas

BACKGROUND

High-intensity focused ultrasound (HIFU) treatment has recently emerged in response to the increasing demand for noninvasive procedures for skin lifting and tightening.

OBJECTIVE

This study was aimed at evaluating the clinical efficacy of and patient satisfaction with HIFU treatment for wrinkles and laxity in seven different areas of the face in Asian skin.

METHODS

Twenty Korean patients with facial wrinkle and laxity were analyzed after a single session of HIFU treatment. Two independent, blinded clinicians evaluated the clinical improvement in seven areas of the face by comparison of standardized photographs obtained before, and at 3 and 6 months after treatment. Assessment of subjective satisfaction and adverse effects of treatment were done by using questionnaires.

RESULTS

The physicians' evaluation and patients' satisfaction with the clinical effects of HIFU in each area were similar regardless of the number of treatment shots. The jawline, cheek, and perioral areas were the sites where HIFU was most effective, in decreasing order. The adverse effects included erythema and swelling in six cases, and purpura and bruising in two cases. However, the adverse effects were mild and transient.

CONCLUSION

HIFU could be a safe, effective, and noninvasive procedure that can be used to improve facial wrinkles and skin laxity in Asian skin. It is particularly effective for clinical improvement in the jawline, cheek, and perioral areas.

Review of the safety profile for microfocused ultrasound with visualization

The Safety of Microfocused Ultrasound with Visualization (MFU-V) has been well established in both controlled clinical studies and in clinical use, showing only mild and transient anticipated side effects and only rare unanticipated adverse events (AEs). This publication discusses the safety profile of MFU-V based on data from a variety of sources. Reports of side effects and AEs were obtained from published peer-reviewed medical literature, clinical studies, in-market use reports (AEs reported to the manufacturer), and retrospective chart reviews of patient treatments. Events that were typical included tenderness, redness, and slight edema. Rare events included bruising, welting, and nerve-related effects (paresthesia and paresis). Rare incidence of surface thermal effects was seen in some cases where improper technique was used. In all cases where the device was uses properly, the safety events reported tended to be transient, mild in nature, and resolved without sequelae. In general, unexpected and rare AEs could be attributed to incorrect treatment technique or classified as unrelated to MFU-V treatment. Side effects that do occur are generally mild and transient in nature. MFU-V consistently allows for safe treatment when correct treatment technique is used.

A prospective multicenter pilot study of the safety and efficacy of microfocused ultrasound with visualization for improving lines and wrinkles of the décolleté

BACKGROUND

A previous pilot study demonstrated microfocused ultrasound with visualization (MFU-V) to lift and tighten the décolleté produced significant and durable aesthetic improvements.

OBJECTIVE

To further evaluate the safety and effectiveness of MFU-V for improving lines and wrinkles of the décolleté in a larger patient population.

MATERIALS AND METHODS

Healthy women with moderate-to-severe décolleté skin lines and wrinkles were enrolled. After obtaining digital images, MFU-V was administered using 3 transducers emitting ultrasound at frequencies of 4 MHz and a focal depth of 4.5 mm, 7 MHz/3.0 mm, and 10 MHz/1.5 mm. During the procedure, 280 lines of discrete thermal coagulative points 25 mm long and 2 to 3 mm apart were applied to the treatment area. Additional imaging for masked assessments and live assessments were completed at 90 and 180 days.

RESULTS

Among the evaluable subjects, 77 (66.4%) demonstrated aesthetic improvement at 180 days based on blinded assessments. Approximately, 75% and 65% of treated subjects demonstrated some degree of improvement at 90 and 180 days, respectively, and most were satisfied with treatment outcomes. Adverse events were generally mild.

CONCLUSION

A single MFU-V treatment provided significant aesthetic improvement for moderate-to-severe décolleté lines and wrinkles for at least the 180-day duration of the study.

Objective assessment of facial skin aging and the associated environmental factors in Japanese monozygotic twins

Twin studies, especially those involving monozygotic (MZ) twins, facilitate the analysis of factors affecting skin aging while controlling for age, gender, and genetic susceptibility. The purpose of this study was to objectively assess various features of facial skin and analyze the effects of environmental factors on these features in MZ twins. At the Osaka Twin Research Center, 67 pairs of MZ twins underwent medical interviews and photographic assessments, using the VISIA(®) Complexion Analysis System. First, the average scores of the right and left cheek skin spots, wrinkles, pores, texture, and erythema were calculated; the differences between the scores were then compared in each pair of twins. Next, using the results of medical interviews and VISIA data, we investigated the effects of environmental factors on skin aging. The data were analyzed using Pearson's correlation coefficient test and the Wilcoxon signed-rank test. The intrapair differences in facial texture scores significantly increased as the age of the twins increased (P = 0.03). Among the twin pairs who provided answers to the questions regarding history differences in medical interviews, the twins who smoked or did not use skin protection showed significantly higher facial texture or wrinkle scores compared with the twins not exposed to cigarettes or protectants (P = 0.04 and 0.03, respectively). The study demonstrated that skin aging among Japanese MZ twins, especially in terms of facial texture, was significantly influenced by environmental factors. In addition, smoking and skin protectant use were important environmental factors influencing skin aging.

Noninvasive skin tightening: focus on new ultrasound techniques

Microfocused ultrasound (MFU) has been recently developed to meet the ever-growing public demand for achieving significant, noninvasive skin lifting and tightening. MFU can be focused on subcutaneous tissue where the temperature briefly reaches greater than 60°C, producing small (<1 mm³) thermal coagulation points to a depth of up to 5 mm within the mid-to-deep reticular layer of the dermis and subdermis. The intervening papillary dermal and epidermal layers of skin remain unaffected. The application of heat at these discrete thermal coagulation points causes collagen fibers in the facial planes such as the superficial musculoaponeurotic system and platysma, as well as the deep reticular dermis, to become denatured, contracting and stimulating de novo collagen. A commercially available device combines MFU with high-resolution ultrasound imaging (MFU-V), which enables visualization of tissue planes to a depth of 8 mm and allows the user to see where the MFU energy will be applied (Ultherapy^®; Ulthera Inc., Mesa, AZ, USA). Using different transducers, MFU-V treatment can be customized to meet the unique physical characteristics of each patient by adjusting energy and focal depth of the emitted ultrasound. By targeting the facial superficial musculoaponeurotic system, noninvasive tightening and lifting of sagging facial and neck skin and improvements in the appearance of wrinkles can be achieved. MFU-V can also improve lines and wrinkles of the décolleté. Treatment protocols for the use of MFU-V continue to be refined, and its use in combination with other rejuvenation techniques has been demonstrated. Brief discomfort that often occurs during treatment can be minimized with oral nonsteroidal anti-inflammatory drugs. Other treatment-related adverse events include transient erythema, edema, and occasional bruising. MFU-V is best suited for patients with mild-to-moderate skin and soft tissue laxity. For older patients with severe skin laxity and marked platysmal banding, surgical treatment should be considered.

Safety and efficacy of ulthera in the rejuvenation of aging lower eyelids: a pivotal clinical trial

BACKGROUND

The changes in the periorbital region are among the most prominent features of the aging process in the lower eyelids. Intense focused ultrasound (IFUS), known as the Ulthera System, was designed to correct this process. The current study assessed the safety and efficacy of the Ulthera System.

METHODS

This study enrolled seven adult patients who presented from March 2011 to May 2012 for correction of lower eyelid aging by Ulthera. The subjects were treated using Ulthera 1.5 and 3.0 mm probes. The 1.5 mm probe is used to tighten of loose eyelid skin and the deep dermis, whereas the 3.0 mm probe is used to tighten the orbicularis oculi muscle and the orbital septum. The patients were evaluated for allergic reactions and other side effects. The subjects' satisfaction with clinical photographs and the degree of pain were evaluated. Moreover, orbital computed tomography (CT) and ophthalmologic examinations were performed. The study used CT both as a research tool and as a clinical score system for evaluating aging lower eyelids and performed statistical analysis.

RESULTS

Based on the CT images, the difference between the pre- and postoperative distances from the baseline (line between the most inferior point of the supraorbital rim and the most superior point of the infraorbital rim) to the most protruding point of the orbital septum was 0.51 ± 0.23 for the right eye (p < 0.001) and 0.54 ± 0.17 for the left eye (p < 0.001). The subjective score for patient satisfaction was 3.85 ± 0.69. The objective satisfaction scores reported by two blinded researchers were respectively 3.45 ± 1.69 and 3.25 ± 1.43. During the study period, no adverse events and no suspected serious adverse reactions were noted.

CONCLUSIONS

Tightening of infraorbital laxity and skin can be achieved using the Ulthera System. Patients showed a minimal pain level during treatment, and topical analgesic cream was able to manage pain during the procedure.

Evaluation of a microfocused ultrasound system for improving skin laxity and tightening in the lower face

BACKGROUND

The Ulthera System (Ulthera, Inc, Mesa, Arizona) employs microfocused ultrasound to cause discrete focal heating of the dermis and stimulate neocollagenesis and elastin remodeling.

OBJECTIVES

The authors investigated tightening and lifting of cheek tissue, improvement in jawline definition, and reduction in submental skin laxity in patients treated with the Ulthera System.

METHODS

A total of 103 adults were enrolled in this prospective nonrandomized clinical trial. Three-dimensional photographs obtained at baseline and 3 months posttreatment were assessed qualitatively by 3 blinded reviewers and quantitatively with AutoCAD software (Informer Technologies, Redwood City, California). The relationship between outcomes and body mass index (BMI) was examined as well. Patients rated pain during the procedure and provided subjective assessment of their outcome at 90 days. Adverse events were documented.

RESULTS

Ninety-three patients were evaluated. Blinded reviewers observed improvement in skin laxity in 58.1% of patients. During quantitative assessments, overall improvement in skin laxity was noted in 63.6% of evaluated patients. No change was detected in 54.5% of patients whose BMI exceeded 30 kg/m2 or in 12.2% of patients whose BMI was ≤30 kg/m2. At day 90, 65.6% of patients perceived improvement in the skin laxity of the lower half of their face/neck. The average procedural pain scores for the cheek, submental, and submandibular regions were 5.68, 6.09, and 6.53, respectively. Wheals, which resolved without intervention or long-term sequelae, were reported for 3 patients.

CONCLUSIONS

To the authors' knowledge, this is the largest clinical study of the effectiveness of the Ulthera System for rejuvenation of the lower face. At day 90, improvements were reported by two-thirds of patients and by nearly 60% of blinded reviewers. Outcomes were better in patients with BMI≤30 kg/m2.

LEVEL OF EVIDENCE

2.