Emerging trends in neck rejuvenation include the incorporation of nonsurgical treatment modalities as an offering to those patients desiring minimal downtime and accepting of mild results. Intense focused ultrasound is a promising technology for treatment of the neck. It is rapidly growing in clinical use and undergoing further investigation to determine optimum treatment parameters and make its outcomes more predictable.
Key points
- •
Intense focused ultrasound is a noninvasive treatment option that can provide clinical results.
- •
Assessment of patient candidacy is critical but does not guarantee a treatment response.
- •
Current high-density treatment protocols have not markedly increased reproducibility or objective results in the authors’ experience.
- •
Satisfaction may be related to minimal expectations from a no-downtime treatment modality.
- •
Patient selection and counseling are paramount, because patients with expectations on par with surgical treatment modalities are disappointed.
A video of Ulthera treatment accompanies this article at http://www.facialplastic.theclinics.com/
Introduction
With the ever-growing social acceptance of cosmetic interventions to help patients look and feel their best, facial and neck treatments for the effects of aging and obesity are expanding. The desired areas of improvement are submental lipoptosis, skin laxity, platysmal banding, and jowling. Currently, the gold standard for improvement remains a surgical solution. Submental liposuction, corset submentoplasty, an isolated neck lift, or neck lift in concert with a facelift all provide an immediate, substantial improvement. These surgical treatments, tailored to the individual needs of patients, can offer long-term results at a lower final cost to patients. For many reasons, however, not every patient desires a surgical modality. Finding time in a busy schedule, general operative anxiety, and financial limitations are the authors’ patients’ most common reasons given for seeking treatment alternatives.
The alternative, nonsurgical device options are similar in their goals to achieving an improved neckline. Different from the surgical treatment by direct tissue excision and repositioning, the nonsurgical technologies depend on thermal tissue disruption and the healing response to obtain the desired result. In current clinical use, this disruption can be accomplished through a variety of methods, including intense pulsed light, nonablative lasers, and radiofrequency bulk heating. These modalities attempt to preserve the epidermis while creating enough heat in the target tissues. Although protein denaturation begins at approximately 45°C, the goal is to reach greater than 60°C to break the collagen heat-sensitive bonds and 65°C for denaturation of collagen and contraction. Most of these treatment modalities are unable to heat tissue adequately to achieve a collagen response, and ablative laser treatment modalities can only do so with superficial vaporization of the epidermis. Additionally, the ideal depth of surgical treatment of facial skin tightening and rejuvenation is the superficial muscular aponeurotic system (SMAS) or platysma. It is assumed that this depth is also ideal for nonsurgical methods. Each of the noninvasive treatment modalities discussed previously is limited in its ability to accomplishing both these goals.
Introduction
With the ever-growing social acceptance of cosmetic interventions to help patients look and feel their best, facial and neck treatments for the effects of aging and obesity are expanding. The desired areas of improvement are submental lipoptosis, skin laxity, platysmal banding, and jowling. Currently, the gold standard for improvement remains a surgical solution. Submental liposuction, corset submentoplasty, an isolated neck lift, or neck lift in concert with a facelift all provide an immediate, substantial improvement. These surgical treatments, tailored to the individual needs of patients, can offer long-term results at a lower final cost to patients. For many reasons, however, not every patient desires a surgical modality. Finding time in a busy schedule, general operative anxiety, and financial limitations are the authors’ patients’ most common reasons given for seeking treatment alternatives.
The alternative, nonsurgical device options are similar in their goals to achieving an improved neckline. Different from the surgical treatment by direct tissue excision and repositioning, the nonsurgical technologies depend on thermal tissue disruption and the healing response to obtain the desired result. In current clinical use, this disruption can be accomplished through a variety of methods, including intense pulsed light, nonablative lasers, and radiofrequency bulk heating. These modalities attempt to preserve the epidermis while creating enough heat in the target tissues. Although protein denaturation begins at approximately 45°C, the goal is to reach greater than 60°C to break the collagen heat-sensitive bonds and 65°C for denaturation of collagen and contraction. Most of these treatment modalities are unable to heat tissue adequately to achieve a collagen response, and ablative laser treatment modalities can only do so with superficial vaporization of the epidermis. Additionally, the ideal depth of surgical treatment of facial skin tightening and rejuvenation is the superficial muscular aponeurotic system (SMAS) or platysma. It is assumed that this depth is also ideal for nonsurgical methods. Each of the noninvasive treatment modalities discussed previously is limited in its ability to accomplishing both these goals.
Intense focused ultrasound
Ultrasound use as a therapeutic modality has grown from its early investigations for neurologic applications in the 1950s. In recent decades, high-frequency ultrasound use for the treatment of both benign and malignant solid tumors has expanded. In this form, ultrasound creates thermal injury as well as a cavitation. Trials are under way for the use in benign prostate hypertrophy and approval has already been given for an MRI-guided focused ultrasound for uterine fibroid treatment. The use for breast, liver, prostate, and brain cancers is also being studied. A nonablative application of ultrasound for targeted drug delivery also shows promise as a future application.
Alternatively, the application for facial rejuvenation utilizes thermal injury alone through intense focused ultrasound. This is accomplished by a shorter pulse duration of 50 to 200 ms, a higher frequency of 4 to 7 MHz, and a decreased energy quantity of 0.5 to 10 J. This technology was commercialized as the Ulthera System (Ulthera, Mesa, Arizona) in 2004 and several preclinical and clinical studies refined the device and supported its ability to create thermal coagulation points (TCPs) at specific tissue depths ( Figs. 1 and 2 ). Subsequently, a study by Alam and colleagues led to Food and Drug Administration (FDA) approval for a brow lift indication in 2009. Most recently, Kenkel demonstrated improvement in the neck, giving the device an FDA-approved neck lift indication.
Treatment goals and planned outcomes
The goals of neck rejuvenation with the Ulthera device are to achieve some improvement in the neckline and skin tightness through thoughtful patient selection and increased energy delivery. An ideal patient is usually a younger patient with a robust wound healing response, mild lipoptosis, and good elasticity. An older patient with extensive photoaging, severe skin laxity, marked platysmal banding, and a very heavy neck is not a good candidate. Between these 2 extremes, it becomes even more difficult to predict who will respond; thus, managing expectations becomes paramount. Through a multilayered approach, the authors attempt to see outcomes in good candidates and obtain a response in those who are intermediate candidates through increased TCPs per unit area.
Preprocedure planning and preparation
With the initial treatment protocols, pain management required the most attention during preprocedure planning. Despite studies reporting minimal or mild pain only (average 3–4 on a 10-point visual analog scale) with topical anesthetic use, the authors’ personal findings of patient discomfort were much higher. Treatment over osseous structures and repetitive treatment passes elicited the strongest responses, leading to the need of a combination of antiinflammatories, anxiolytics, narcotics, and distraction techniques. Facial field blocks were also offered at patient discretion. Although patient comfort was increased, this led to issues with transportation and the effects of postprocedure facial numbness.
The challenge to achieve desired effects and promote patient comfort led to several Ulthera-sponsored pain control studies, which have been presented, but are, as of yet, unpublished. In these studies, narcotics did not demonstrate any benefit over ibuprofen alone and topical lidocaine did little for analgesia with the 4.5 and 3.0 transducers. Most importantly, the company found that lowering the amount of energy transmitted markedly decreased pain levels. Differences in TCP size and split face outcomes could not be identified with the lower transducer settings. Therefore, the newly recommended protocol includes pretreatment with ibuprofen (800 mg) alone and reduced energy settings for each transducer to maximize patient tolerance.
The authors’ experience with the new protocol is that, despite lowered energy settings, it remains uncomfortable but bearable for resilient patients. The authors still frequently depend on facial blocks, in addition to ibuprofen and the new settings, for patients to be comfortable during the procedure. Other users have also seen the benefit of facial blocks and local infiltration. This lessens the immediate intensity in most areas with persistent mild to moderate sensitivity noted over the osseous structures. The elimination of narcotics and anxiolytics has made treatment logistics much easier. Overall, additional published studies closely investigating the ideal balance between energy delivery, comfort, and efficacy are necessary.
Procedural approach
An Ulthera treatment of the neck is performed alone or in continuity with a full face treatment ( [CR] ). Standardized preprocedure digital photographs are obtained after adequately cleaning the face. The patient is then placed in the supine position and the neck is then divided into the desired treatment areas ( Fig. 3 ). The thyroid cartilage, inferior mandibular border, clavicles, and preauricular line are marked as landmarks for creation of the treatment areas. Next, each region is marked with a planning card to determine the number of treatment columns necessary to cover the area with minimal overlap ( Fig. 4 ). Usually, 5 to 7 columns are possible in the submental/submandibular area and 6 columns are possible below the level of the superior thyroid cartilage. Then, within each column, the measured density is calculated to quantify the number of lines of treatment ( Fig. 5 ). These markings then serve as a guide during the procedure.
With the introduction of software updates, use of the device now requires even less decision making and easier calculation of lines. Treatment areas and densities are now automatically recorded in a patient’s history. Instead of the default maximum settings, energy density is selected at 1 of 4 preset levels. In the authors’ practice, treatment is usually initiated at the second-lowest setting and the energy levels modified based on patient tolerance. Treatment begins at the upper neck region and continues downward as each region is completed in a deep to superficial manner. Ultrasound gel is applied and the handpiece is placed perpendicular to the skin ( Fig. 6 ). Correct transducer coupling and verification of depth is confirmed by scanning using the ultrasound images on the monitor. Adjustments should be made prior to treatment to avoid skin striping, incorrect treatment depth, and treatment of inappropriate tissue (major vessels, thyroid tissue, and osseous or cartilaginous structures). Typically, treatments are performed at a minimum of 2 depths with 1 pass of a 4- to 4.5-mm (0.9 J/TCP) transducer and then retreating the area with a superficial 7- to 3.0-mm (0.30 J/TCP) transducer. This is in line with current recommended treatment protocols. More commonly, the authors follow the first 2 depths with an advanced treatment protocol using the 10- to 1.5-mm (0.18 J/TCP) transducer for dermal skin tightening ( Fig. 7 ). These treatments can be combined with full face treatments or performed in isolation. This multiple-depth treatment protocol is based on previous studies where dual-depth treatments improved subjective outcomes on the upper and midface. The ideal neck treatment protocol is still evolving.
