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

Tissue Targeting

Participants indicated that they often target the subcutaneous fat layer, particularly if they are trying to achieve a sculpting effect. For example, if a patient has prominent jowls, targeting the fat may reduce the volume slightly, thus improving the overall appearance of the lift. Another anecdotal observation was that MFU-V may also help to thicken the fibrous septae in the fat layer, contributing to the lifting effects. Moreover, there are small connective tissue fibers connecting the skin to the superficial fascia (SMAS/platysma), therefore energy delivered superficial to the fascia could potentially induce lifting and tightening.Subcutaneous fat may also be targeted if a patient has a particularly deep SMAS secondary to high BMI. If the fat layer is targeted during the initial treatment, it may thin the fat layer making the deep SMAS accessible to the 4.5 mm transducer during a follow-up treatment. One participant noted that most of their patients who request MFU-V require improvement primarily in the jawline and neck areas. Therefore, they concentrate delivery of lines in this area, noting “lines of energy are a precious commodity, so I focus it where it is needed most,” typically delivering 1000 lines to this area (omitting the brow/ upper face areas) with excellent outcomes.Regarding the question of whether the fascia is the best target for treatment, or perhaps that the contributions of more superficial layers of the skin are underappreciated, it was agreed that the relative contribution of skin tightening, and fascia tightening may vary according to certain patient factors and merits further investigation.

Positioning MFU-V in Clinical Practice

One participant almost never discusses the lifting ability of MFU-V, preferring to approach discussions from the biostimulationperspective, ie, stimulating collagen formation. MFU-V is used as monotherapy in only 5-10% of patients and that proportion is declining. Most patients are receiving MFU-V as an adjunct to toxins, fillers, or laser treatments. MFU-V can also be positionedas a valuable method for maintaining results of face lifts. The most satisfied patients are those with little overall cost barrier who can invest in a comprehensive treatment plan with multiple modalities. All agreed that the provider needs to educate their patients to the best of their ability, and if patients are looking for something dramatic, they should provide other options.

CONCLUSION

Supported by a large body of clinical literature, a well-characterized mechanism of action, and high reported patient satisfaction,MFU-V is considered by the expert panel of physicians to be a key foundation for aesthetic treatment and the gold standard for nonsurgical lifting and skin tightening. The consensus guidelines presented here extend the available clinical data to provide a framework for physicians to fully customize their approach to treating patients with MFU-V, leading to excellent outcomes that are integral to a patient’s overall aesthetic treatment plan. These guidelines are summarized in Table 2.

DISCLOSURES

All authors are consultants for Merz North America.

ACKNOWLEDGMENTS

The authors would like to acknowledge the case studies that Dr. Gabriela Casabona presented during the panel discussion andthe valuable content that she provided. The authors acknowledge the editorial assistance of Dr. Carl S. Hornfeldt, Apothekon, Inc., with financial support from Merz North America, Inc. This activity was sponsored by Merz North America, Inc., Raleigh, NC.

REFERENCES

1. White WM, Makin IR, Barthe PG, et al. Selective creation of thermal injury zones in the superficial musculoaponeurotic system using intense ultrasound therapy: a new target for noninvasive facial rejuvenation. Arch Facial Plast Surg. 2007;9:22–29.2. Fabi SG. Microfocused ultrasound with visualization for skin tightening and lifting: my experience and a review of the literature. Dermatol Surg. 2014;40:S164-7.3. Alam M, White LE, Martin N, et al. Ultrasound tightening of facial and neck skin: a rater-blinded prospective cohort study. J Am Acad Dermatol. 2010;62:262–69.4. Casabona G. Combined use of microfocused ultrasound and a calcium hydroxylapatite dermal filler for treating atrophic acne scars: A pilot study. J Cosmet Laser Ther. 2018;Feb 5 [Epub ahead of print].5. Casabona G, Nogueira Teixeira D. Microfocused ultrasound in combination with diluted calcium hydroxylapatite for improving skin laxity and the appearance of lines in the neck and décolletage. J Cosmet Dermatol. 2017;Dec 29 [Epub ahead of print].6. Doh EJ, Kim J, Lee DH, et al. Neck rejuvenation using a multimodal approach in Asians. J Dermatolog Treat. 2018;29:400-04.7. Fabi SG, Goldman MP, Mills DC, et al. Combining microfocused ultrasound with botulinum toxin and temporary and semi-permanent dermal fillers: safety and current use. Dermatol Surg. 2016;42:S168-76.8. Har-Shai Y, Bodner SR, Egozy-Golan D, et al. Mechanical properties and microstructure of the superficial musculoaponeurotic system. Plast Reconstr Surg. 1996;98:59-70.9. Ghassemi A, Prescher A, Riediger D, et al. Anatomy of the SMAS revisited. Aesthetic Plast Surg. 2003;27:258-64.10. Cilento BW. Superficial Musculoaponeurotic System (SMAS). In (Kountakis SE, ed): Encyclopedia of Otolaryngology, Head and Neck Surgery; Springer, Philadelphia, 2013.11. Branchet MC, Boisnic S, Frances C, et al. Skin thickness changes in normal aging skin. Gerontology. 1990;36:28-35.12. Psillakis JM, Rumley TO, Camargos A. Subperiosteal approach as an improved concept for correction of the aging face. Plast Reconstr Surg. 1988;82:383-94.13. Kikkawa DO, Lemke BN, Dortzbach RK. Relations of the superficial musculoaponeurotic system to the orbit and characterization of the orbitomalar ligament. Ophthal Plast Reconstr Surg. 1996;12:77-88.14. Laubach HJ, Makin IR, Barthe PG, et al. Intense focused ultrasound: evaluation of a new treatment modality for precise microcoagulation within the skin. Dermatol Surg. 2008;34:727-34.15. Casabona G, Michalany N. Microfocused ultrasound with visualization and fillers for increased neocollagenesis: clinical and histological evaluation. Dermatol Surg. 2014;40:S194-8.16. Sasaki GH, Tevez A. Clinical efficacy and safety of focused-image ultrasonography: a 2-year experience. Aesthet Surg J. 2012;32:601-12.17. Fabi SG, Massaki A, Eimpunth S, et al. Evaluation of microfocused ultrasound with visualization for lifting, tightening, and wrinkle reduction of the décolletage. J Am Acad Dermatol. 2013;69:965-71.18. Brobst RW, Ferguson M, Perkins SW. Ulthera: initial and six month results. Facial Plast Surg Clin North Am. 2012;20:163-76. 19. Baumann L, Zelickson B. Evaluation of micro-focused ultrasound for lifting and tightening neck laxity. J Drugs Dermatol. 2016;15:607-14.20. Fabi SG, Goldman MP, Dayan SH, et al. A prospective multicenter pilot study of the safety and efficacy of microfocused ultrasound with visualization for improving lines and wrinkles of the décolleté. Dermatol Surg. 2015;41:327-35.21. Gold MH, Sensing W, Biron J. Use of micro-focused ultrasound with visualization to lift and tighten lax knee skin. J Cosmet Laser Ther. 2014;16:225-9.22. Alster TS, Tanzi EL. Noninvasive lifting of arm, thigh, and knee skin with transcutaneous intense focused ultrasound. Dermatol Surg. 2012;38:754-9.23. Goldberg DJ, Hornfeldt CS. Safety and efficacy of microfocused ultrasound to lift, tighten, and smooth the buttocks. Dermatol Sur. 2014;40:1113-7.24. Rokhsar C, Schnebelen W, West A, et al. Safety and efficacy of microfocused ultrasound in tightening of lax elbow skin. Dermatol Surg. 2015;41:821-6.25. Pak CS, Lee YK, Jeong JH, et al. Safety and efficacy of ulthera in the rejuvenation of aging lower eyelids: a pivotal clinical trial. Aesthetic Plast Surg. 2014;38:861-8.26. Casabona G, Marchese P. Calcium hydroxylapatite dermal filler combined with microneedling and topical ascorbic acid: a novel and effective methodof treating stretch marks. Plast Reconstr Surg Glob Open. 2017;5:e1474.27. Casabona G, Pereira G. Combination treatment using microfocused ultrasound with visualization and calcium hydroxylapatite to improve skin laxity and the appearance of cellulite on buttocks and thighs. Plast Reconstr Surg Glob Open. 2017;5:e1388.28. DeepSEE®. Ulthera Inc., Mesa, AZ.29. Hitchcock TM, Dobke MK. Review of the safety profile for microfocused ultrasound with visualization. J Cosmet Dermatol. 2014;13:329-35.30. Harris MO, Sundaram HA. Safety of microfocused ultrasound with visualization in patients with Fitzpatrick skin phototypes III to VI. JAMA Facial Plast Surg. 2015;17:355-7.31. Marr K, Carruthers JDA, Humphrey S. Transient nerve damage after microfocused ultrasound with visualization. Dermatol Surg. 2017;43:894-96.32. Friedmann DP, Bourgeois GP, Chan HHL, et al. Complications from microfocused transcutaneous ultrasound: case series and review of the literature. Lasers Surg Med. 2018;50:13-19.33. Hart DR, Fabi SG, White WM, et al. Current concepts in the use of PLLA: clinical synergy noted with combined use of microfocused ultrasound and poly-L-lactic acid on the face, neck, and décolletage. Plast Reconstr Surg. 2015;136:180-87S.34. Carruthers J, Burgess C, Day D, et al. Consensus recommendations for combined aesthetic interventions in the face using botulinum toxin, fillers, and energy-based devices. Dermatol Surg. 2016;42:586-97.35. Fabi SG, Goldman MP. Retrospective evaluation of micro-focused ultrasound for lifting and tightening the face and neck. Dermatol Surg. 2014;40:569-75.36. Sola C, Fabi SG. Perception shift. Derm Surg. 2018;In press.

AUTHOR CORRESPONDENCE

Sabrina G. Fabi MD SFabi@gbkderm.com