Facial Skin Tightening With Microfocused Ultrasound and Dermal Fillers: Considerations for Patient Selection and Outcomes

November 2019 | Volume 18 | Issue 11 | Original Article | 1075 | Copyright © November 2019

Gabriela Casabona MD and Kai Kaye PhD

Ocean Clinic, Marbella, Spain 

process involves more than just collagen and elastin restoration. We must understand that there are different needs in terms of stimulation. Therefore, patient assessment becomes a key point in understanding whether just one treatment such as MFU-V is enough to induce collagen formation, or if other procedures that up-regulate mediators and cell migration23 are also needed during the first phases of healing started by MFU. These include calcium hydroxylapatite (CaHa) or poly-L-lactic acid (PLLA), as shown in a recent study where the histology of the skin after combining both procedures on the same day resulted in larger collagen and elastin formation by increasing stimulation during the first phases of the healing cascade.24

The Devices
Most HIFU devices have more than one transducer depth and size focus (Table 1). Macrofocused transducers are used for fat reduction, and are not safe for collagen stimulation because the TCPs are too large and the pulse duration is usually longer. Microfocused transducers have different frequencies. A MFU-V transducer with a frequency of 4 MHz has a depth of 4.5mm and creates a TCP of 1mm4, while a transducer with a frequency of 7 MHz has a 3mm depth and creates a TCP of 0.3mm4, and a transducer with a frequency of 10 MHz has a 1.5mm depth and creates a TCP of 0.18mm4 (Figure 1).6 All devices work with one handpiece, and the transducers are interchangeable and should be used over a thin layer of gel to guarantee good contact with the skin (See video http://jddonline.com).10

How to Achieve the Best Results
Patient assessment is far more complex than just observing the complaints of the patients who arrive at our office. Sometimes it is hard to estimate the number of lines or which procedures should be combined to provide a natural and satisfactory result. For didactic reasons and to try to facilitate a certain procedure on why and when to use a certain number of MFU-V treatment lines and depths, as well as when to combine other treatments, the authors have divided patient assessment into five steps:
1) Assess – expectations, features
2) Decide – which depth to customize
3) Select – choose a number of lines to achieve the objective
4) Plan – combination, if needed
5) Treat – documentation, safety, and comfort

1. Assess
In this step, there are two main goals:

A. Expectations
Identify patient expectations based on the MFU procedure alone. A retrospective study24 showed discordance between physician and patient regarding satisfaction with results. Sometimes, even though the physician graded the result as only mild improvement, the patients were happy and satisfied, but the opposite can also occur. Sobanko et al26 showed how important psychological aspects are in improving appearance and how patient motivations for the treatment can differ. Also, patient