Chapters Transcript Ultrasound Therapy in Cosmetic Dermatology Course: 44th Annual Advances in Dermatology Hello everyone, and good afternoon. My name is Lisa Acantillo. I'm one of the newest dermatologists here at NYU. I'm also a cosmetic dermatologic surgeon and I'm excited to talk to you today about ultrasound therapy and cosmetic dermatology. In a world of inescapable social media, nonstop Zoom calls and WebEx calls, I might add, and society's constant pursuit of youth, not to mention the rising popularity of obesity medications and their effect on the body and face like Ozempic face that we've all heard about, we have patients coming to see us in droves looking for skin tightening and skin lifting. They want to look more refreshed but still look like themselves without going under the night of plastic surgery. Additionally, body contouring is a huge part of the cosmetic market. It's estimated to be worth $11 billion by 2030. Thankfully, in dermatology, we have the tool of ultrasound at our disposal to help our patients achieve their goals in a minimally invasive way. As an outline, I'll start with talking about the basic principles of ultrasound and energy-based devices in general, and then I'll delve into specific applications of ultrasound in cosmetic dermatology and then end with some final thoughts. OK, so what is ultrasound? To answer that, we have to take a step back and think about what energy-based devices are. So these are laser and non laser technologies used for a wide array of aesthetic indications like skin resurfacing, skin tightening, and body contouring, and we'll focus on the latter two today. So with energy-based devices, the basic principle is that collagen contracts and remodels when heat is applied or trauma occurs. That leads to an increase in collagen, elastin, and hyaluronic acid, which then leads to skin contraction, which is our goal. So now getting into ultrasound, ultrasound is high frequency sound waves or acoustic energy created by mechanical vibration of molecules. And to put it in perspective, human hearing is in the range of 20 Hz to 20,000 Hz, with 1 Hz being one cycle per second. Ultrasound is thought to be greater than 20,000 Hz, and therapeutic ultrasound is on the range of 1 to 3 mz, with that 1 mz being 1 million cycles per second. With ultrasounds, a coupling medium like ultrasound gel that we're all familiar with is required to enhance visibility. This helps minimize absorption, distortion, and disturbance of that acoustic energy. So with diagnostic ultrasound, we're all pretty familiar with this. We're able to create images of internal organs and tissues, and it's a point of care diagnostic technology for the organs listed here. Therapeutic ultrasound then uses that same heat and energy from that mechanical molecular vibration to heat and break down tissue through coagulation. Indications include chronic pain, kidney stones, solid tumors, physical therapy, and aesthetics, which is where we come in. So now moving into specific applications of ultrasound in cosmetic dermatology. So ultrasound and dermatology has several different names and it's because of the technological advancements that have been made over time. So you might have heard of high intensity focus ultrasound, microfocus ultrasound, and then the newest kid on the block, synchronous ultrasound parallel beam array, and we'll talk about most of these. So in dermatology, ultrasound energy penetrates into the skin, creating these isolated microthermal injury zones that are about 1 millimeter in sizes, and this is in the dermis. This leads to an inflammatory wound healing response where you have cytokines released, macrophages recruited, and stimulation of fibroblasts. This leads to regeneration of new tissue with collagen, elaccid, and hyaluronic acid like I said before, leading to skin tightening and wrinkle reduction. Optimal treatment parameters require heating those thermal injury zones in the dermis to temperatures of 60 to 70 °C. That's about 140 to 160 °F at a depth of 1 to 4.5 millimeters, and that optimal treatment involves no epidermal damage, which is amazing because that means this procedure is color blind. It's safe to use in all skin types. So with ultrasound for skin tightening and lifting, you can selectively target collagen rich facial anatomic structures like the mass, the platismo fascia, and the deepreticular dermis. Indications for ultrasound and cosmetic dermatology include skin tightening, but for mild to moderate laxity of the lower face, neck, submentum, and chest. As it notes, severe laxity is not well treated with this procedure, although you could try. And then it can also be used for brow lifts, acne scarring, cellulite, and body contouring. I put this image here just to show us the role of ultrasound in comparison to other cosmetic tools we have in our arsenal, from skincare to peels, neurotoxin, laser, filler, radio frequency, and even a surgical face lift, which is definitely the most aggressive option. So now I'm gonna talk about specific ultrasound uh devices in our field of cosmetic dermatology. So there's two main ones on the market. I'm gonna describe both of them. There's all therapy by MERS and then Softwave by Softwave Medical, and we'll start with the first one, all therapy. So the technical term for this is microfocused ultrasound with visualization, and it was FDA cleared in 2014, so 10 years ago, to lift skin on the neck, brow, and submentum. It can also improve lines and wrinkles on the chest. I put this image here just to show you guys how this device works. You're basically able to generate that thermal effect that I mentioned before to different depths of the skin. So with our therapy, the provider is able to visually identify the depth of those collagen rich tissue planes, and they can use a transducer to deliver lines of energy to either the dermis, the deep dermis, or the subdermal fibrous tissues. There is an advantage of treating multiple deaths with this device. Number 1, clinical studies have shown superior results with treating more than just one depth. And then number 2, you can actually personalize your treatment based on your individual patient's anatomy. Among individual patients, the depth, thickness, and distribution of tissue layers can vary greatly. So with this, you can confirm visually with ultrasound that you're at the precise depth. So this is a representative image, or actually 2 from the device where I show you here that you can see actually where those collagen rich tissue planes are, that kind of reflects white at you at the screen and you can see, OK, this tissue plan is at this depth, so I should use this transducer to induce the desired effect. So with this device, the epidermis is unaffected, like I said, there's no downtime, no visual visible signs of injury at the surface. Treatment sessions can range from 30 to 90 minutes depending on how many treatment areas you're focusing on, and it's recommended that patients get one session every 1 to 2 years. So now moving to the competitor, Softwave by Softwave Medical, which we actually have two here at NYU which is exciting. So this is called synchronous ultrasound Parallel beam array and it was FDA cleared quite recently in 2021. So this is showing you how this device works. So with uh this device with the superb technology, we have integrated contact cooling and a real-time skin temperature monitoring mechanism for epidermal protection and to make sure you're accurately targeting that thermal effect. There is parallel delivery of the ultrasound beams and a large contact area to allow for repeatable and controllable energy deposition in the skin. The depth of this device is fixed, so unlike all therapy, you cannot change or tailor the treatment depth based on your patient's anatomy. It has a long list of things that it has been FDA cleared for, so you can use it for improving facial lines and wrinkles, lifting the eyebrow, the submentum, and the neck. You can uh create short term improvement in the appearance of cellulite, treat acne scars, and also improve the appearance of skin laxity of the upper arms. So more information about this device, it has a unique thermal injury. It's controlled, it's fractional like a lot of energy-based devices are. That depth is centered at 1.5 millimeters under the skin. That thermal dose of 60 to 70 °C is provided for 4 to 5 seconds of exposure, and you cover a good amount of tissue. The thermal coagulation is directional. It's parallel to the skin surface. You induce that collagen, elastin and hyaluronic acid that we're looking for, and there's no epidermal or dermal epidermal junction injury. So, like all therapy, the epidermis is unaffected, there's no visual signs of injury, no downtime patients can go right back to work. Treatment sessions are shorter than all therapy, about 30 to 45 minutes, but still a lengthy procedure compared to other things we do in cosmetics. And then it's recommended that patients get two sessions spaced about 8 weeks apart initially and then get a treatment once a year after that. Do remember, both for you as a provider and then for your patients that you don't see the results until about 3 months after you get the treatment done, so you have to be patient. It's building up that new collagen. OK, so a little bit about pre and post care for this procedure. So most patients do just fine. Free treating is optional, but if you have these in your office, it's nice to offer them to your patients. NSAIDs can be helpful for mitigating the pain. It is a mild to moderately painful procedure. Benzodiazepines can be given for anxiety. Definitely use Valtrex or some other antiviral if there's a history of herpes simplex. Nitrous oxide is amazing. It can really make patients more comfortable. And then anesthesia, so your topical lidocaine, your forced cold air, and then vibratory anesthesia as well can be really helpful. And then post-treatment, it's normal, gentle skin care, nothing fancy. OK, so potential side effects I described before that it's mildly to moderately painful. There's transient purpura or edema that can happen, um, and urticaria can happen as well. And then there is a risk of temporary motor nerve paresis, so that marginal mandibular nerve we know of course is very superficially over the mandible and due to the inflammation of this procedure, you may temporarily immobilize that nerve, but not to worry if it does happen, it usually goes away in 2 to 6 weeks. So now other applications of ultrasound in cosmetic dermatology. It has become quite popular in cosmetic dermatology offices as an injunctive tool for soft tissue filler therapy. So believe it or not, you can see filler under uh on ultrasound as different kinds of nodules. They can reflect different colors. Definitely the easiest is hyaluronic acid, where you can see anechoic nodules. But in general, ultrasound can be really helpful when you're doing filler or looking for precisely where filler is located to facilitate filller dissolution, filler duration, filler migration, and injection. You can have vascular mapping as well with Dopplers, so you can see, OK, there's a vessel here. I want to avoid that while I'm injecting my filler. And you can also, depending on what device you have, watch yourself inject the filler to make sure it's in the correct tissue plane. So it's amazing. It's more dynamic anatomy that can really make us successful in treating our patients. So I'll put this image here just to show you what hyaluronic acid looks like on ultrasound. It's these big kind of black blobs, um, anechoic homogeneous nodules, and then oftentimes they have posterior acoustic enhancement, that whitening of the um uh the nodules in the back. Other avenues of clinical and research utility, I don't have time to get into now, but it has been studied for skin aging, for uh uh analyzing efficacy of lasers, and then acne scarring like I mentioned before too. So some before and after. So I put this here for the pathologist in the audience, just to show you some skin biopsy specimens before and after ultrasound. So the top images are before and the bottom is after, and you can see that after ultrasound, the collagen fibers are more parallel and straight after the treatment. The same goes for elastin fibers. So this is an elastin stain, and you can see after ultrasound therapy, that those fibers are more parallel and straighter in the dermis. OK, I also have a few images here from the companies themselves. Please keep in mind these are from the company, so it's definitely their best, you know, results, but it is impressive what uh treatment of ultrasound can do, especially for tightening the lower face. I think it's a slam dunk in this area. So here's some more. These are all from the company of Therapy by MERS, and then I have some, uh, from publications and from the company themselves that were studying that superb technology by Softwood Medical. So you can see here it's, it's quite impressive and then for cellulite as well. OK, so some final thoughts. Ultrasound is definitely a rising star in the realm of minimally invasive aesthetics and the cosmetic dermatology. It can be used for a multitude of indications. It feels like the list of indications gets longer by the day, and it's definitely an attractive option in cosmetics because it is safe in all skin types. I'm sure in the coming couple of years we'll see even more ways we can harness the power of ultrasound to help our patients look and feel the very best. So, ultrasound has expanding therapeutic indications in cosmetic dermatology. It has rising diagnostic utility and cosmetic dermatology. It's well tolerated, well received, and well utilized, which makes it a win in my book. Thank you very much. Published June 6, 2024 Created by Related Presenters Lisa Akintilo, MD View full profile
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