INTRODUCTION
Amicrofocused ultrasound (MFU) device was developed to meet the patient demand for a noninvasive but effective means to achieve lifting and tightening of lax skin (Ultherapy®; Merz Aesthetics, Raleigh, NC).1 MFU focuses ultrasound energy in subcutaneous tissue. There, most of the delivered ultrasound energy is converted to heat, raising the temperature at the focal point to ~60° C. This temperature is optimal for denaturing collagen, producing small (<1 mm3) thermal coagulation zones at a depth of up to 5 mm in the mid-to-deep reticular layer of the dermis and subdermis. The net effect is immediate collagen contraction and stimulating neocollagenesis.2 Treatment is achieved by creating parallel rows of coagulation zones. Using different transducers, the energy and focal depth of emitted ultrasound is customized to address the unique characteristics of each patient to achieve specific treatment goals. Combining MFU with ultrasound imaging allows the user to visualize the planned treatment area and avoid non-target tissues, such a bone (DeepSEE® Technology; Merz Pharmaceuticals GmbH, Frankfurt am Main, Germany) (MFU-V). Originally intended to non-invasively lift eyebrow, neck and submental tissues, numerous clinical studies have demonstrated the value of MFU-V for improving the appearance of lax skin on the chest, knees, elbows, upper arms, and buttocks.3-7
Another firmly established aesthetic treatment8 is a calcium hydroxylapatite (CaHA) dermal filler developed for correcting moderate-to-severe facial lines and wrinkles and soft tissue augmentation (Radiesse®; Merz North America, Inc., Raleigh, NC).9 CaHA is an effective and long-lasting biostimulatory filler that can improve global facial appearance10; however, its use has expanded to include other anatomical areas for rejuvenating the chest, hands, abdomen, thighs, and upper arms.11-13 It has been recently demonstrated that injections of dilute (1:1) and hyperdilute (≥1:2) CaHA also stimulate neocollagenesis and improve laxity and skin quality in the mid- and lower face, neck, décolletage, upper arms, abdomen, upper legs, knees, and buttocks.14,15 Consensus guidelines for dilute and hyperdilute CaHA have been developed regarding insertion points, dosages, and volumes for needle and cannula injections and the number of treatment sessions and intervals.16
Although treatment with MFU-V and the CaHA filler are each effective for achieving aesthetic improvements in numerous anatomical areas, there is growing interest in combining these treatments. Several studies have demonstrated the benefit of combining MFU-V and CaHA for treating the lower face,17 lifting the neck and décolleté,18 outer thighs,19 and striae distensae.20
Our clinic has previously demonstrated that combining MFU-V with CaHA and diluted CaHA is effective for treating atrophic facial acne scars,21 improving skin laxity and the appearance of cellulite on the buttocks and upper thighs,22 and the appearance of lines in the neck and décolletage.23 Based on published literature reports, most patients with severe (Grade 3) skin laxity achieve only modest or no improvement with fewer than three treatment sessions.
Another firmly established aesthetic treatment8 is a calcium hydroxylapatite (CaHA) dermal filler developed for correcting moderate-to-severe facial lines and wrinkles and soft tissue augmentation (Radiesse®; Merz North America, Inc., Raleigh, NC).9 CaHA is an effective and long-lasting biostimulatory filler that can improve global facial appearance10; however, its use has expanded to include other anatomical areas for rejuvenating the chest, hands, abdomen, thighs, and upper arms.11-13 It has been recently demonstrated that injections of dilute (1:1) and hyperdilute (≥1:2) CaHA also stimulate neocollagenesis and improve laxity and skin quality in the mid- and lower face, neck, décolletage, upper arms, abdomen, upper legs, knees, and buttocks.14,15 Consensus guidelines for dilute and hyperdilute CaHA have been developed regarding insertion points, dosages, and volumes for needle and cannula injections and the number of treatment sessions and intervals.16
Although treatment with MFU-V and the CaHA filler are each effective for achieving aesthetic improvements in numerous anatomical areas, there is growing interest in combining these treatments. Several studies have demonstrated the benefit of combining MFU-V and CaHA for treating the lower face,17 lifting the neck and décolleté,18 outer thighs,19 and striae distensae.20
Our clinic has previously demonstrated that combining MFU-V with CaHA and diluted CaHA is effective for treating atrophic facial acne scars,21 improving skin laxity and the appearance of cellulite on the buttocks and upper thighs,22 and the appearance of lines in the neck and décolletage.23 Based on published literature reports, most patients with severe (Grade 3) skin laxity achieve only modest or no improvement with fewer than three treatment sessions.
