Optimizing Patient Outcomes by Customizing Treatment With Microfocused Ultrasound With Visualization: Gold Standard Consensus Guidelines from an Expert Panel

May 2019 | Volume 18 | Issue 5 | Original Article | 426 | Copyright © May 2019

Sabrina G. Fabi MD,a John Joseph MD,b Julia Sevi MD,c Jeremy B. Green MD,d Jennifer Deaver Peterson MDe

aGoldman Fitzpatrick Butterwick Groff & Fabi, San Diego, CA bClinical Testing Center of Beverly Hills, Beverly Hills, CA cAesthetic Health, Leeds, UK dSkin Associates of South Florida, Coral Gables, FL eThe Pearl Dermatology, Houston, TX

tervals between 14 and 45 days with safe and effective results. There was some discussion regarding whether this shortinterval approach is optimal for maximizing collagen, as full remodeling and maturation requires 6-12 months; however, no consensus was reached due to lack of evidence. Additional studies are needed to investigate the histologic effects and aesthetic outcomes using shorter intervals between treatments.

Restoration vs Prevention

All participants agreed that the total number of MFU-V treatment lines would not vary if the patient was seeking significant tissue lift or preventative treatment (restoration vs rejuvenation). In either case, the best possible treatment should be offered to maximize results and ensure patient satisfaction.The group was divided regarding the distribution of treatment lines for older patients seeking restoration vs younger patients seeking rejuvenation. One-half of the group indicated they may place more lines superficially in younger patients to stimulate collagen in those layers of the skin. The other half indicated they would treat both patient groups the same, suggesting that targeting the deeper layers of the SMAS is key for all age groups.

Maintenance

All participants agreed that 12- to 18-month treatment intervals are generally effective for MFU-V treatment maintenance withsome possible adjustments for patient age. Younger patients ~30 to 45 years old and those seeking early intervention/ rejuvenation may only require retreatment on the higher end of that range, possibly up to every 24 months. Older patients more than 50 years old should be retreated closer to every 12 months.For long-term planning that involves multiple retreatments, it is important to manage “perception drift”.36 Patients need to be reminded about their original pre-treatment baseline so that they can appreciate their ongoing progress because MFU-V treatments after the initial treatment are not likely to result in a change of the same magnitude. It is important to counsel these patients that these are maintenance treatments to sustain the original result over time as much as possible.There was some discussion about terminology and whether “maintenance” is really the best description of this process. It was noted that several other terms may resonate better with patients, including “preservation,” “continuation,” “regeneration,” and possibly “preservation of regeneration.”

Pre- and Post-Treatment Patient Imaging

It was agreed that high-quality standardized digital imaging is essential, particularly for revealing subtle changes in laxity or lifting. Quantitative analysis systems, such as those offered by Canfield, Inc., were highly recommended. Pretreatment imaging is critical from a medico-legal standpoint and for documenting any possible aesthetic issues and asymmetries.It was also agreed that photos can be an effective patient retention tool although the group was split on the importance of reviewing pre- and post-treatment photos for establishing patient satisfaction. Some felt strongly that it is in everyone’s interest to recommend that patients return after 6 months for follow-up photos. If they have an opportunity to retrospectively review and understand how they have improved, it may enhance patient satisfaction and possibly spread a positive message for the provider. Asking patients to return for post-treatment photos also allows the provider to reassess patient needs for other aesthetic concerns and provide advice regarding other potential treatments, such as fillers, toxin, or topical skincare. Integrating multiple treatment modalities can also enhance patient perception of MFU-V effectiveness and improve overall satisfaction.

Safety Recommendations

Participants were all in agreement with the following safety recommendations:• Avoid treating the auricular area, particularly adjacent to the earlobe as facial nerves are more superficial in these areas and could be inadvertently affected at MFU-V treatment depths.• Avoid excessive stacking of lines at one depth which can cause serious injury.• Avoid buccal nerve injury.• Never use lidocaine infiltration or a tumescent anesthetic prior to MFU-V because ultrasound energy is absorbed byliquids and excessive heating of liquid anesthetic boluses in the skin increases the potential for adverse events.• MFU-V should not be performed on skin that is compromised due to disease, injury, or medical procedure because transducers are intended for multiple uses.• For same-day combination treatments, MFU-V should be performed prior to filler or toxin injections according to published consensus recommendations for combination treatment.34

Comfort Management

All participants use different combinations of pretreatment medications and techniques for comfort management, but two common treatments were the use of a topical anesthetic and distraction techniques, such as cool air, a stress ball, massage, or music. One participant noted that after implementing a 100% customized treatment approach, overall patient-reported pain scores decreased and were less heterogeneous. This was likely due to more carefully targeting tissues and avoiding placing energy in potentially painful areas.