The use of microfocused ultrasound (MFUS) emerged in dermatology in 2009 as a minimally invasive approach to treating mild to moderate facial and neck laxity. Microfocused ultrasound with visualization (MFU-V), as represented by the device Ultherapy, adds high-resolution ultrasound imaging so that the user can see the targets for MFUS energy. Visualization also allows the user to choose the appropriate treatment depth and transducer.1 Since its introduction, Ultherapy has been investigated for efficacy and safety in tightening, lifting, and wrinkle reduction beyond the face and neck, specifically including the décolletage, abdomen, arms/elbows, knees, medial thighs, and buttocks.1-8 This column will focus on using cosmeceuticals to improve the skin-tightening outcomes of microfocused ultrasound.
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Arnica Montana flower
Two weeks before the procedure
Ingredients that should be used prior to MFU-V include retinoids, such as tretinoin and retinol. Various studies have demonstrated that pretreatment with tretinoin increases collagen production and speeds wound healing.12-14 Kligman et al. assessed wound healing after punch biopsy and found that arm wounds pretreated with tretinoin cream 0.05%-0.1% were significantly smaller by 35%-37% on days 1 and 4 and by 47%-50% on days 6, 8, and 11 than were wounds on the untreated arms.15 The majority of studies on the subject recommend a 2- to 4-week tretinoin pretreatment regimen because peak epidermal hypertrophy occurs after 7 days of tretinoin application and normalizes after 14 days of continued treatment.16,17 This time frame allows for the skin to recover from any retinoid dermatitis prior to the procedure. Adapalene should be started 5-6 weeks prior to procedures because it has a longer half-life and requires an earlier initiation period.18 Although studies have not been performed evaluating the efficacy of topical ascorbic acid and hydroxy acids, pretreating skin with them also may accelerate collagen production after procedures such as MFU-V.19,20
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Rhododendron tomentosum
Postprocedure skin care
Because no incision or ablation occurs with MFUS, the use of ascorbic acid, hydroxy acids, and retinoids can and should be continued after the procedure in addition to before the procedure. The combination of topical Arnica montana and Rhododendron tomentosum in a gel pad has been shown to mitigate postoperative ecchymosis and edema after oculofacial surgery.24 Topical curcumin has been shown to facilitate wound healing in animals, but its smell and color make it difficult to use topically. I recommend adding turmeric to food pre- and postprocedure.25
Adverse events
Late in 2017, Friedmann et al. offered a report on the nature of the rare complications from MFUS, which have included mild and fleeting ecchymosis, edema, erythema, and nerve paralysis. In this retrospective multicenter case series of five patients seen in the authors’ practice who experienced serious adverse reactions to Ultherapy, the authors reported that single sessions of MFUS yielded blistering, erosion/ulceration, or cutaneous or subcutaneous tissue edema with resulting atrophy and/or cutaneous necrosis. The authors concluded that while serious adverse events following MFUS are rare, such reactions might be underreported and should be prepared for with early management to diminish inflammation.26 Other adverse events, which are transient and rare, may include discomfort and mild bruising.
Educating patients on pre- and postprocedure instructions can help minimize adverse events. Avoiding foods that decrease platelet function, like ginger, green tea, alcohol (red wine), salmon, and flax seeds, can reduce the risk of bruising. Use of topical and oral antioxidants before and after treatments also may help reduce inflammation and edema.