Ulthera device beings to make waves for facial rejuvenation

Omaha, Neb. - Ongoing refinements of the Ultherapy (Ulthera) device and how it’s used are making it a go-to treatment for rejuvenating the face and neck, an expert says.

Since the device debuted in 2009, says Joel Schlessinger, M.D., it has progressed with the addition of new treatment heads designed to address different tissue layers of the face and neck for optimal results.

“Just as most energy-based devices become more efficient and effective as time goes on and patterns of success are delineated, the same has happened with Ultherapy,” says Dr. Schlessinger, a board-certified dermatologist and cosmetic surgeon based in Omaha, Neb. “This is contributing to its overall success as a new modality.

Dr. Schlessinger

“One of the initial criticisms of the (treatment) was discomfort. As with any new treatment, there was a give-and-take” until physicians could determine what type or types of anesthesia worked best with the device.

In this regard, Dr. Schlessinger gives patients 800 mg ibuprofen, 1 mg to 2 mg Ativan (lorazepam, Pfizer) and one to two Vicodin (hydrocodone bitartrate/acetaminophen, Abbott) tablets preprocedure. Additionally, patients can apply a handheld massager -  and an air cooler (Zimmer) -  to their skin during treatment to distract them from any discomfort.

Dr. Schlessinger doesn’t sugarcoat the need for anesthesia, however. Recently, a physician about to undergo Ultherapy for her face and neck wanted to forgo it.

“I insisted that she have the pain medications,” he says, and the patient was grateful that she did. For similar reasons, he recommends avoiding treating directly over nerves such as the marginal mandibular nerve, or in the supratrochlear area.

Additionally, he says, “We’ve discovered that higher energy levels don’t always correlate with more success. Yet they clearly create more discomfort. Therefore, many of the treatment parameters have backed off from the initial higher energy settings.”

A 50-year-old female patient before (far left, second from right) and four months after one Ultherapy session. (Photos: Joel Schlessinger, M.D.)

Examining energy settings

In an ongoing prospective, blinded, randomized study, researchers found that reducing the device’s energy setting from level 4 (the highest setting) to either level 1 or 3 improved patient comfort by 18 and 38 percent, respectively (data on file, Ulthera). Level 4 corresponds with 0.45 J to 1.2 J, the device’s original default setting, depending on the transducer used; level 3 is 0.35 J to 1.0 J, and level 1 is 0.25 J to 0.75 J. These reduced energy settings moreover did not affect results 90 days post treatment. Accordingly, Ulthera has changed the device’s default setting to level 2 (0.30 J to 0.90 J).

Meanwhile, Dr. Schlessinger says, “The number of repetitions done with the machine has increased.” In this regard, each push of the device’s activator button delivers a “line” of approximately 20 short bursts of ultrasound energy.

Originally, Ulthera recommended using 300 to 325 such lines total per treatment session. “But now, we’re seeing up to 700 or 800 lines being delivered during a treatment session including the face and neck.” This figure includes approximately 300 superficial and 500 deep passes, he adds. Such a treatment typically takes one to one-and-a-half hours, says Dr. Schlessinger, who has treated 65 patients -  including eight men -  with the device.

“The main difference between this device and all other energy devices is the fact that Ultherapy delivers the energy to the exact area we want to tighten - the superficial muscular aponeurotic system (SMAS),” through a transducer designed to deliver ultrasound energy 4.5 mm deep, into the subdermal tissue. Other available transducers target the dermis (1.5 mm) and deep dermis/subcutaneous tissue (3.0 mm).

Competing laser or energy-based devices generally heat the subcutaneous tissues and the area surrounding the SMAS, which can create downtime and adverse effects such as fat necrosis, Dr. Schlessinger says. Plastic surgeons’ practice of cutting and “tacking up” the SMAS during a facelift also can create pain, downtime and a risk of infection, he adds.

A 53-year-old female patient before (left) and five months after one Ultherapy treatment. (Photos: Joel Schlessinger, M.D.)

A 55-year-old female patient before (left) and four months after one Ultherapy session. (Photos: Joel Schlessinger, M.D.)

Addressing the SMAS

Conversely, he says, “Ultherapy hones in exactly on the SMAS in a noninvasive manner. Therefore, it is able to contract the area of tissue that provides dramatic results in the neck and periorbital areas” without causing collateral damage.

Additionally, Dr. Schlessinger says, “Newer treatment areas such as the décolleté are responding quite nicely.” Similarly, he says that a new treatment head for the upper lip enables the device to treat most -  if not all -  of the problem areas for a typical 40- to 50-year-old patient. As a result, Dr. Schlessinger says he is particularly pleased by the amount of interest his patients are showing in Ultherapy – and their post-treatment satisfaction levels.

“I had treated patients for years with various lasers ranging from fractionated to fully ablative CO₂ lasers.” However, he says the downtime these treatments required dampened patients’ overall satisfaction.

Conversely, with Ultherapy, “I’ve seen virtually no downtime, except for the hour or two right after the procedure,” during which patients experience mild erythema and, very rarely, bruising. “The side effects are extraordinarily limited” and don’t require patients to alter their schedules -  or take analgesics -  after treatment.

As a practical consideration, “I try to do Ultherapy treatments along with fillers and neurotoxins because I believe that improves results. Generally we do the fillers and neurotoxins after Ultherapy,” because it could shorten the duration of these products. As for Ultherapy, “I tell patients the results should last between 18 and 24 months,” though Dr. Schlessinger says he’s seen no long-term data yet. Patients see some results immediately after treatment, he adds, although longer-term collagen remodeling can take up to six months.

Proper patient selection

Regarding patient selection, he says, “Ultherapy is outstanding for somebody who has mild-to-moderate wrinkles, and those who have moderate neck laxity. But this isn’t a shortcut for a necklift or facelift.”

The treatment area that responds best to Ultherapy can vary from patient to patient. “Some patients get dramatic results in the periorbital area and modest results around the neck,” and vice versa. Regarding patient expectations, Dr. Schlessinger says, “Some people have more collagen stimulation ability than others.” He and his staff inform patients of this possibility, and the possibility that they may need a second session. To date, he says, this has happened in only six of his patients.

Thanks to the high success rate and lack of downtime associated with Ultherapy, he says, “We’ve been very pleasantly surprised with the results and patient acceptance of the treatment.” DT

Disclosures: Dr. Schlessinger reports no relevant financial interests.