New contouring options for face and body emerge

Key Points

Las Vegas - Thanks to ongoing refinements with radiofrequency (RF) and ultrasound-based contouring modalities, these treatments are becoming more versatile and patient-friendly, according to physicians who spoke at the Cosmetic Surgery Forum that took place in Las Vegas in December.

In the ultrasound category, the Ulthera device delivers a treatment called Ultherapy and is the first and only device cleared by the Food and Drug Administration (FDA) for noninvasive brow lifting, says Curt Samlaska, M.D., assistant professor of medicine (dermatology), University of Nevada School of Medicine. It uses focused ultrasound waves working at a frequency between 4 mHz to 7 mHz to deposit very precise thermal coagulation points at depths measuring 3 mm to 4.5 mm below the skin's surface (White WM, Makin IRS, Barthe PG, et al. Lasers Surg Med. 2008;40(2):67-75. Laubach HJ, Makin IR, Barthe PG, et al. Dermatol Surg. 2008;34(5):727-734).

"Ninety-five percent of the energy is focused within a very small area. Only 2.5 percent of the energy is transmitted above the treatment zone, and 2.5 percent is transmitted below. The unfocused sound-wave energy is so minimal that there's no risk to the epidermis or deeper structures," he says. "You can treat the darkest skin without worrying about postinflammatory hyperpigmentation."

"Radiofrequency (RF) heating is more diffuse, so it impacts a larger area and is less well-controlled. And RF treats only the dermal layer. Ulthera is the only device that can target deeper regions such as the superficial aponeurotic layer, which is what plastic surgeons tighten in a traditional facelift," he says. "Now, for the first time, we can treat that layer without cutting into the tissues and undermining beneath it."

Treatment parameters

Regarding treatment times, Dr. Samlaska says a full-facial Ultherapy treatment including the forehead, cheeks and upper and lower neck takes him one to one-and-a-half hours. His personal protocol is to use facial nerve blocks.

To ensure the most comfortable patient experience, "I apply anesthesia over the mental nerves in the mandible, the infraorbital nerve on the cheeks and the supratrochlear and supraorbital nerve above the eyebrows," Dr. Samlaska says. "I then run a layer of anesthesia (2 percent lidocaine with epinephrine) along the entire jawline and chin. I then apply a layer of anesthesia above the eyebrows and track it along the lateral and inferior orbital rims. With that, the patient is completely numb, and we can do very aggressive treatments without discomfort. It takes me about 10 minutes to do the anesthesia."

During the procedure, he says, "We treat to tone, palpating the skin until we achieve the desired tone. So we end up putting down more lines" of ultrasound pulses than the device's manufacturer typically recommends when treating patients with higher degrees of skin laxity.

When triggered by the physician, the device's transducer delivers a line consisting of approximately 20 tiny thermal coagulation points of sound energy spaced 1.0 mm apart for the 3 mm depth transducer (which treats the dermis) and 1.5 mm apart for the 4.5 mm depth transducer (which treats the superficial aponeurotic layer).

"It is important to note that this is dual-plane treatment of the dermis and the superficial aponeurotic layer. To treat the forehead, face and upper portion of the neck, the company's recommended guidelines call for approximately 400 lines," Dr. Samlaska says.

After treatment, "Patients can see results immediately. No other device can do that. Then delayed secondary changes, including remodeling and thickening of connective tissue, occur," a process that can take four to six months, he says. "Because Ultherapy induces connective tissue remodeling, I believe the treatment effects last about two years." He says, however, that patients can undergo yearly treatments to perhaps achieve a cumulative effect.