Microfocused Ultrasound for Skin Tightening

Use of a fractional 1570-nm diode laser scanner for non-ablative face and neck rejuvenation

BACKGROUND

The use of non-ablative fractionated lasers for skin rejuvenation has been proven to be effective in improving skin texture, and has become popular due to minimal wounding, significantly shorter recovery times and decreased adverse effects.

OBJECTIVE

To retrospectively analyze improvement in skin texture in healthy women aged over 18 years with Fitzpatrick skin types II-IV.

METHODS

Participants received three facial and/or neck treatments with the 1570-nm fractional scanning diode laser at 1-month intervals. Three months after the last treatment session two blinded evaluators assessed skin improvement using before and after photos. Pain and patient satisfaction were recorded.

RESULTS

Sixteen women with a mean age of 45.4 ± 4.1 years (range 35-50 years) and skin type II-IV were included in the analysis. All 16 participants received facial treatments and seven (43.8%) also received neck treatments. Three months follow-up evaluation showed that the majority of participants had a visible change in the treated areas. Mean pain score was low and decreased with each treatment session.

CONCLUSION

Skin treatment using fractional scanning 1570-nm diode laser improves skin laxity in women with skin types II-IV. Larger studies are warranted to further clarify the efficacy and safety of this modality.

Safety and Efficacy of High-Intensity Focused Ultrasound and Monopolar Radiofrequency Combination Therapy for Skin Tightening: A Retrospective Study in Malaysia

Background

High-intensity focused ultrasound (HIFU) and monopolar radiofrequency (MRF) are common treatment modalities that have shown significant results in skin tightening. Nevertheless, the novel combination of these two treatments is new to the Malaysian landscape. Thus, this study aims to investigate the safety and efficacy of this novel combination treatment for the Malaysian population.

Methods

This retrospective study included data on HIFU and MRF combination therapy for skin tightening collected from an aesthetic clinic in Johor Bahru, Malaysia from June 2018 to May 2021. Efficacy was assessed using the Global Aesthetic Improvement Scale (GAIS) and Glogau classification, while the safety of the treatment was analysed using pain scores and adverse events (AEs).

Results

A total of 56 patients with a mean age of 47.7 years old (SD 10.00) were included in this study. The majority of the patients had Fitzpatrick skin types III and IV. Most of the patients were Chinese, followed by Malay, Indian and others. Most patients (96.4%) showed clinically significant improvement in skin tightening after treatment, with 15 patients scoring 1 (very much improved) and 39 scoring 2 (improved). All patients reported transient mild erythema, with no serious AEs, such as burn, swelling, numbness or muscle weakness. Among the patients, 80% reported a pain score of 5, while 10% reported pain scores of 4 and 6.

Conclusion

Combining HIFU with MRF therapy improved GAIS scores by 96.4%, indicating a secure and efficient skin-tightening method. Transient erythema was shown to be the most common side effect of this combination.

Handheld microfocused ultrasound device for facial lifting: A preliminary study of ULTIGHT

OBJECTIVE

Although focused ultrasound modalities have achieved positive clinical results in noninvasive skin rejuvenation, they presented various side effects and particularly severe pain during treatment. This study introduces a microfocused ultrasound (MFU) device, ULTIGHT, to overcome the severe pain issue, providing quasi-facial lifting.

MATERIALS AND METHODS

Transducer surface was imaged with a scanning electron microscope. The energies of four treatment cartridges were measured using an ultrasound power meter. In vitro experiments were performed to quantitatively evaluate the MFU thermal zones (MFUTZs) and treatment line (TL) of 10 MFUTZs. Ex vivo experiments were performed to evaluate the MFUTZs and temperature rise in tissue. Clinical trials using eight volunteers were performed to qualitatively evaluate facial lifting.

RESULTS

The MFU transducer clearly showed a smooth and no air gap surface. ULTIGHT produced 10 discrete MFUTZs in a TL of length 10 mm. In ex vivo tissue, discrete linear MFUTZs were clearly observed at lower number of TLs; however, they started to aggregate at higher number of TLs. The temperature rise was linearly increased as a function of the number of treatments. A single MFUTZ resulted in a temperature rise of 3°C-10°C that could cause hyperthermia for body temperature. In the clinical trials, the volunteers showed quasi-facial lifting right after treatment on the lower facial region.

CONCLUSIONS

ULTIGHT provides relatively low energy, which may be advantageous or disadvantageous depending on clinical applications. Additionally, it has the advantage of being pain-free even without anesthetic during treatment, providing quasi-facial lifting right after treatment.

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.

Association of PDO threads and technologies-Facial treatment protocols

BACKGROUND

Aging is part of the immutable characteristics of the human being, and the search for treatments to alleviate the undesirable effects of aging is frequent in the dermatological office.

AIMS

This work proposes the technique of association of PDO threads with technologies and the description of the facial treatment protocols.

METHODS

For contextualization, two case studies of two patients subjected to the procedure are analyzed.

CONCLUSIONS

In recent years, there have been marked changes in facial rejuvenation techniques using PDO threads and these have shown satisfactory results for collagen biostimulation. Having technologies in dermatological clinics is a frequent reality, and sometimes, some doctors are in doubt about when to use them associated with PDO wires and in which sequence it should be done, ensuring patient safety and maintaining the integrity of the wires. This article aims to bring clarity about how to use technology and when is the right time. It is also intended to clarify that the PDO wire can be used in conjunction with the microfocused ultrasound technology, since the melting point of the PDO polymer is between 110° and 115°C.

The efficacy and safety of the high-intensity parallel beam ultrasound device at the depth of 1.5 mm for skin tightening

BACKGROUND

High-intensity parallel beam ultrasound (US) is a novel device equipped with Synchronous Ultrasound Parallel Beam (SUPERB) technology applied in anti-aging treatment. The system is aimed at pathways stimulating neocollagenesis and neoelastinogenesis in the dermis leading to skin tightening and rejuvenation.

AIMS

Evaluate the efficacy and safety of the high-intensity parallel beam US device at the depth of 1.5 mm for skin tightening treatment.

METHODS

Thirty-six participants were enrolled in the study. Digital photographs and Antera 3D photographs were taken at baseline, 1 and 3 months post-treatment. The depression volume of nasolabial folds (NLFs) and marionette lines (MLs) in each visit was evaluated using Antera 3D imaging program. Pain was evaluated by pain measurement scales immediately after treatment. Any procedure related side effects were documented and examined.

RESULTS

Post-treatment results were compared to the baseline; statistically significant mean depression volume (MDV) change of NLFs and MLs were found at 1 and 3 months post-treatment. No significant MDV change from 1 to 3 months post-treatment could be demonstrated. The mean pain score was 6.64 on a 0-10 scale. No adverse events were reported.

CONCLUSIONS

Our study demonstrates that the novel high-intensity parallel beam US device is clinically safe and effective for skin tightening in the lower face area. We noticed a reduction in NLFs and MLs in more than 60% of our participants already as early as 1 month post-treatment.

A Systematic Review of the Efficacy of Microfocused Ultrasound for Facial Skin Tightening

Objective: to systematically review the efficacy of microfocused ultrasound (MFU) for facial skin tightening. Methods: A systematic search was performed (Pubmed, Embase) to assess the efficacy of single MFU treatments for facial skin tightening. Eligible studies included randomised controlled trials, controlled trials, cohort studies and case series (n ≥ 10). Objective and subjective outcomes were assessed. Results: A total of 693 studies were identified of which 16 studies were eligible. All the studies involved female patients. MFU is capable of tightening the skin, as observed in studies measuring the results of brow lifts (0.47−1.7 mm) and submental lifts (measured as a 26−45 mm2 reduction in the submental area on lateral photographs). Data from the Global Aesthetic Improvement Scale (GAIS) were pooled, and the day 90 pooled subjective investigator reported scores (IGAIS) (n = 337) showed that 92% of the patients demonstrated an improvement in skin tightening and/or in wrinkle reduction which continued up to one year. Longer-term follow-up data are not available. The patient-reported pooled scores (SGAIS) (n = 81) showed that the skin improvements were mild and continued to increase from 42% (90 days) to 53% (360 days) post-treatment. The MFU treatment was moderately painful and caused transient erythema with or without oedema. Other adverse effects were rare (2%), including dysesthesia (numbness or hypersensitivity), bruising and stinging, mandibular burns, striations and contact dermatitis. Various device settings, treatment protocols and energies were applied. Excessive skin laxity and a BMI > 30 were posed as relative contraindications for MFU treatment because positive results declined with an increase in laxity and BMI. Conclusions: MFU treatment is effective in tightening female patients’ mildly to moderately lax facial skin. Future studies should focus on objective treatment outcomes, optimising treatment regimens and male patients.

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.

Ultrasound for Aesthetic Applications: A Review of Biophysical Mechanisms and Safety

Aesthetic ultrasound is used for fat reduction and to improve skin appearance. In this review, the fundamental mechanisms by which ultrasound can alter tissue are outlined. The technologies that are commercially available or under development are discussed. Finally, recommendations are made for safe and effective use of aesthetic ultrasound.

Aging of the Neck Decoded: New Insights for Minimally Invasive Treatments

BACKGROUND

Many signs of aging manifest in the neck region, including platysmal bands, excess skin, horizontal neck lines and decreasing contour of the neck. While the clinical signs of an aged neck are well-known, data determining the underlying aging process are limited.

OBJECTIVE

To decode aging of the neck.

MATERIALS AND METHODS

This prospective study investigated elasticity and firmness of skin, muscle activity and skin displacement upon muscular contraction in the neck in 77 young-, middle- and old-age individuals. Objective outcome measures, including 3-dimensional imaging, cutometry and surface electromyography, were utilized for all assessments.

RESULTS

Mean firmness of skin decreased significantly from young to old individuals (0.37 ± 0.13 mm, 0.30 ± 0.12 mm and 0.26 ± 0.12 mm in young, middle and old subjects, respectively; p < 0.001). Gross elasticity decreased significantly from 75.1 ± 13.0% in young subjects, to 64.53 ± 15.7% in middle-aged subjects and 55.79 ± 13.0% in old subjects (p < 0.001). The mean y-axis skin displacement increased from 2.48 ± 4.33 mm in young subjects, to 3.11 ± 4.49 mm in middle-aged subjects and 3.61 ± 5.38 mm in old subjects (p = 0.006). The mean signal-to-noise ratio decreased significantly from 16.74 ± 5.77 µV in young subjects, to 14.41 ± 4.86 µV in middle-aged subjects and to 12.23 ± 5.99 µV in old subjects (p < 0.001).

CONCLUSION

This study provides insights into the interplay between skin elasticity, muscular activity and the reflected movement of the skin of the neck. Appreciation of these age-related changes lays the fundament for aesthetic treatments in this delicate region.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

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.

Optimizing skin tightening in aesthetics in men

The field of cosmetic dermatology has recently witnessed unbridled growth in the past several years. Part of this has been due to the increasing popularity of aesthetic treatments in men, who represent a growing patient population. Men tend to have higher levels of collagen density and greater skin thickness, but these begin to decrease earlier on. They can also more frequently have severe photodamage. Their clinical presentations can affect the selection of treatments. Physicians should be familiar with the subtle differences between treating men and women. Early studies and literature are beginning to shed more light on these important distinctions. We review the notable differences in facial aging, pathophysiology, and patient selection and discuss available treatment options with these factors in mind.

Sonogenetic Modulation of Cellular Activities in Mammalian Cells

Ultrasound is acoustic waves that can penetrate deeply into tissue in a focused manner with limited adverse effects on cells. As such, ultrasound has been widely used for clinical diagnosis for several decades. Ultrasound induces bioeffects in tissues, providing potential value in therapeutic applications. However, the intrinsic millimeter scale of the ultrasound focal zone represents a challenge with respect to minimizing the illuminated regions to perturb target cells in a precise manner. To control a specific cell population or even single cells, sonogenetic tools that combine ultrasound and genetic methods have been recently developed. With these approaches, several ultrasound-responsive proteins are heterologously introduced into target cells, which enhances the cells' ability to respond to ultrasound stimulation. With optimization of the ultrasound parameters, these tools can specifically manipulate activities in genetically defined cells but not in unmodified cells present in the ultrasound-illuminated regions. These approaches provide new strategies for noninvasive modulation of target cells in various therapeutic applications.

Non-invasive evaluation of elasticity of skin with the processing of ultrasound images during ultraviolet radiation: An animal photoaging model

OBJECTIVE

The aim of this study was to provide a non-invasive imaging method to evaluate the physical and mechanical parameters as a novelty method during skin photoaging.

METHODS

In order to evaluate the process of skin damage, 25 mice (C57BL6) were exposed to UVB radiation (0.03 mW/cm² ), 5 times a week for 5 weeks. The thickness of the epidermal and dermal layers was measured weekly from the ultrasound images (40 MHz). The elastic parameters of the skin were estimated from the processing of the sequential ultrasound images with the motion detection algorithm during the injury generation process.

RESULTS

The thickening, Young modulus, and shear modulus of the dermal and epidermal layers during the UVB damage process significantly increased during the 5-week study period (P < .05). In addition, the percentage of changes in the thickness of the epidermal layer (0.22 ± 0.01 mm in day 0 to 0.37 ± 0.02 mm in day 35) and dermal layer (0.57 ± 0.05 mm in day 0 to 0.90 ± 0.08 mm in day 35) increased by 68% and 57%, respectively. Furthermore, Young modulus (154.41 ± 8.8 kPa) was 11 times more than that of non-irradiated skin (14.90 ± 2.2 kPa) and the shear modulus (2.33 ± 0.04 kPa) was 2.2 times more than non-irradiated skin (1.06 ± 0.04 kPa).

CONCLUSION

With processing the sequential ultrasound images and extracting the thickening, the elasticity of the skin layers can detect skin lesions by UVB radiation.

Improvement of wrinkles and skin tightening using TriPollar® radiofrequency with Dynamic Muscle Activation (DMA™)

BACKGROUND

Radiofrequency (RF) energy promotes skin renewal by inducing tissue remodeling through dermal heating and neocollagenesis.

AIM

To evaluate the safety and effectiveness of a medical esthetic system that combines simultaneously TriPollar® RF energy with Dynamic Muscle Activation (DMA™) for improving facial skin tightness and wrinkles.

METHODS

A prospective, open-label study. Eleven subjects (mean age, 43 years; Fitzpatrick skin type II-IV) with Fitzpatrick Elastosis Scale (FES) score 3-6 were treated. The participants underwent six weekly treatments. Effectiveness of the treatments was evaluated at 1 and 3 months follow-ups after the last treatment, using the FES and evaluator- and subject-rated Global Aesthetic Improvement Scale (GAIS). Treatment safety and tolerance were evaluated as well. Pain was evaluated on a visual analog scale (VAS) of 0-10.

RESULTS

Treatment was safe, with minimal pain (VAS score less than 1), no adverse events, and no downtime. At 1 and 3 months follow-up evaluation, mean physician-rated FES statistically significantly improved from baseline (4.63 ± 0.88) by 2.27 ± 0.45 for both time points (P < .0001). According to investigator GAI scale at 3 months follow-up evaluations, 81.8% of patients were improved and 18.2% were much improved in fine lines, wrinkles and skin tightness.

CONCLUSIONS

Treatment with RF TriPollar® combined with DMA™ is effective and well-tolerated treatment for improving skin tightness and reducing wrinkles.

Nerve Blocks Prior to Microfocused Ultrasound Treatment are Safe and Reduce Patient Discomfort

BACKGROUND

Microfocused ultrasound with visualization has become one of the more popular nonsurgical facial rejuvenation therapies available. Although the treatment has gained wide acceptance, providing adequate pain relief during the procedure can be challenging.

OBJECTIVES

The aim of this study was to test our hypothesis that nerve blocks prior to treatment would be well tolerated and significantly reduce patient discomfort.

METHODS

Subjects undergoing microfocused ultrasound were offered the choice of participating in a split face nerve block, bilateral block, or a control group. Nerves targeted included infraorbital, supratrochlear, supraorbital, zygomaticofrontal, mental, great auricular, and cervical plexus. Pain assessment was based on a 10-point Wong-Backer FACES Pain score.

RESULTS

A total of 65 patients were included in the study: 28 in the split face group, 19 in the bilateral block group, and 18 without a block. The mean [standard deviation] pain score of the bilateral block cohort was 3.9 [1.2], and that of the control group was 5.1 [1.7] (P = 0.001). Patients in the split face cohort reported a higher pain score on the unblocked side of the face (7.5 [1.3]) than on the blocked side (2.9 [1.0]) (P < 0.001). The mean pain score for local anesthetic injection was 2.7 and 1.4 for the split face and the bilateral groups, respectively. There were no adverse events.

CONCLUSIONS

Nerve blocks are well tolerated and significantly improve patient comfort during microfocused ultrasound treatment without compromising outcomes or increasing adverse events.

LEVEL OF EVIDENCE: 2

Effect of fullerene nanoemulsion on the repair of wrinkles induced by UVB radiation: A c57bl6 mice model

INTRODUCTION

The effect of fullerene nanoemulsion on skin wrinkle repair in an animal model was evaluated using ultrasonic images processing.

METHODS

Wrinkles were created in C57BL6 mice during 35 days of UVB radiation. Then, to investigate the therapeutic effect of fullerene nanoemulsions, mice were divided into three groups of control, UVB radiation, and treatment with fullerene nanoemulsion. Stable fullerene nanoemulsions were prepared using shear equalization. The therapeutic effect of fullerene nanoemulsion was investigated by extracting the skin thickness and mechanical parameters. Histology studies were performed to confirm the reliability of the treatment.

RESULTS

A significant decrease was observed in the thickness of the epidermis and dermis layers (43% and 36%), Young modulus (27%), and the shear modulus (20%) of the skin on day 28 of the fullerene nanoemulsion treatment. Skin stiffness obtained by tensiometry on day 28 of the treatment showed a 48% reduction in the treatment group compared with the control group. Histological results confirmed the effect of fullerene nanoemulsions on wrinkle repair.

CONCLUSION

The healing effect of fullerene nanoemulsion in wrinkle repair was confirmed. To study the skin repair, parameters including Young modulus, the shear modulus, and skin layer thickness can be calculated using ultrasonic images processing.

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.

Non-invasive high-intensity focused ultrasound for UV-induced hyperpigmentation in Fitzpatrick skin types III and IV: a prospective, randomized, controlled, evaluator-blinded trial

Skin hyperpigmentation is a frequently encountered problem, particularly in darker skin types. Unfortunately, standard treatments for this condition have shown disappointing results. High-intensity focused ultrasound (HIFU) is commonly indicated for skin laxity, but recently was used to treat UV-induced hyperpigmentation in animal models. This study is aimed to evaluate the efficacy and safety of high-intensity focused ultrasound for UVB-induced hyperpigmentation in human subjects. A randomized, evaluator-blinded pilot study was conducted on 20 subjects. Each subject was induced three hyperpigmentary spots by local broadband UVB. After 2 weeks, each spot was randomly allocated to control, low-energy, and high-energy HIFU. Subjects were instructed to follow up weekly for a duration of 1 month. Lightness index measurements, mean improvement scores, subjects' satisfaction, pain scores, and side effects were evaluated. All 20 subjects completed the study. Fourteen subjects had Fitzpatrick (FPT) skin type III and six subjects had FPT skin type IV. Twelve subjects showed greater improvement at control sites while eight subjects showed greater improvement at HIFU-treated sites. In FPT skin type III, HIFU appeared to be inferior to control in both lightness index and mean improvement scores, but in FPT skin type IV, HIFU had greater lightness index improvement and higher improvement scores than control. Side effects were more frequent in high-energy-treated areas. Focused ultrasound may be offered in some patients with hyperpigmentary conditions. More research is needed to determine proper energy settings for optimal outcome.