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    Guided ultrasound for noninvasive skin tightening may be wave of future

    Skin-rejuvenation modalities such as lasers and radiofrequency (RF) are commonly used for noninvasive skin tightening. However, significant cosmetic results are still lacking.

    Although it’s in its early stages of development, a new technique using “guided” ultrasound shows much promise as a future noninvasive skin-tightening approach.

    “Ultrasound technology used for skin tightening is still in its fledgling stages and there is still significant room for improvement and development of the technology for this indication. However, there are intrinsic elements of ultrasound technology that render it particularly appropriate for skin tightening, and therefore, this treatment modality could eventually pan out to be very effective here,” says Murad Alam, M.D., associate professor of dermatology, otolaryngology and surgery and chief of cutaneous and aesthetic surgery, Feinberg School of Medicine, Northwestern University, Chicago.

    Ultrasound can be delivered arbitrarily deep into the skin and subcutaneous tissue and can reach target areas without causing any significant injury to the surface of the skin, unlike other forms of energy used in dermatology. These include lasers, particularly infrared devices ranging from 1,100 nm to 1,800 nm, as well as mono-, bi- and unipolar RF devices.

    With further evolution and development of ultrasound technology, “guided” ultrasound treatments could better differentiate and more precisely target specific structures in the dermis and subcutaneous tissue, resulting in more consistent treatments with more predictable cosmetic outcomes.

    U/S study

    The Ulthera System (Ulthera) is a noninvasive ultrasound device designed for full-face and neck skin-tightening treatments and is currently the only device of its kind approved by the FDA for a lift indication. Recently, Dr. Alam conducted a study evaluating the efficacy of the Ulthera device for brow lifting in the context of a procedure treating the full face and neck.

    The study assessment included 35 patients who received a single Ulthera treatment to the forehead, temples, cheeks, submental region and side of the neck using varying ultrasound probes at different depths.

    Results showed that 30 of 35 patients (86 percent) demonstrated a clinically significant brow lift three months after treatment. Compared to baseline, 83 percent of patients could achieve an average brow height elevation ranging from 1.7 mm to 1.9 mm lasting three month post-treatment.

    Adverse events following the treatment were minimal and included slight erythema and edema which resolved in 78 percent of patients by day-two follow-up visit and in all patients by day-seven post-treatment.

    “Focused ultrasound has been shown to cause some tightening of the facial skin such as the jowls, lower face as well as brow elevation. Theoretically, as the technology is optimized and as deeper and more sophisticated probes are developed, the focused ultrasound should be able to extend those results further without causing associated adverse events of current treatment modalities,” Dr. Alam says.

    Skin tightening is believed to be associated with contraction of the fibrous septae that engulf the fat cells in the deep subcutaneous tissue. When performing a facelift, the SMAS, which lies below the level of the fibrous septae and the subcutaneous tissue, is plicated, resulting in a lifting effect of the sagging facial skin. Thermal energy in the form of ultrasound delivered to the SMAS could potentially also effect a contraction of these tissues.

    “Heat delivered to the SMAS might cause some thermal contraction analogous to the kind of plicating achieved in a traditional facelift, which may result in a corresponding improvement in the facial contour. Focused ultrasound has a realistic potential to accomplish this task,” Dr. Alam explains.

    Reliability, predictability

    According to Dr. Alam, the problem and frustration seen with current skin-tightening techniques is that they are not always reliable, and predictable and reproducible cosmetic outcomes remain elusive. Moreover and for reasons that are still unclear, tightening is not equally effective in every patient or at every targeted site, resulting in variable outcomes.

    “The Ulthera device has not solved these problems just yet, however, if the technology can be precisely tuned and approximate a noninvasive facelift, then the results might be more consistent as they are in a facelift,” Dr. Alam says.

    One major advantage of the Ulthera device used for skin tightening is that it is not only therapeutic, but also a diagnostic ultrasound device. Unlike with most lasers and RF devices, the physician can visualize the layers of the skin and the target tissues with ultrasound before firing the device, making it a guided ultrasound.

    Key developments that this novel technology would have to undergo could include the development of various probes of different depths and sizes and varying energies. These more sophisticated probes would allow physicians to apply ultrasound energy at different levels in the skin and subcutis and achieve more reliable and consistent cosmetic results.

    According to Dr. Alam, skin tightening is difficult to do, substantiate and reproduce, moreso than any other dermatologic cosmetic intervention, and innovative tools like the Ulthera device may help dermatologists improve current cosmetic outcomes in skin tightening.

    “Skin tightening is much desired by cosmetic patients, and guided ultrasound treatments may potentially be a major contribution of dermatology to the realm of aesthetics. Moreover, should the evolving technology result in a high level of efficacy and in a consistent manner across patients, we would also greatly enhance patient safety by not requiring as many invasive procedures which could potentially put them at risk,” Dr. Alam says.

    Disclosures: Dr. Alam was the principal investigator for this Ulthera study, the funds for which were given to Northwestern University.