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.
MFU-V allows for visualization to a depth of 8 mm and heats the skin without heating superficial skin structures.9 With these high temperatures, collagen is denatured, with its triple helix shortened, resulting in collagen contraction and the spurring of neocollagenesis.10,11Combining MFU-V with pre- and post-procedure skin care aimed at stimulating fibroblasts to produce more collagen should improve efficacy.
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
Vitamin C is unique among antioxidants because of its ability to augment collagen production. In fact, collagen formation requires the presence of ascorbic acid. Vitamin C also is useful in decreasing inflammation from procedures because of its capacity to interfere with the generation of reactive oxygen species by reacting with the superoxide anion or the hydroxyl radicals. It has been shown to lessen the erythema that occurs from UVB exposure.21-23 I recommend to my patients that they use topical vitamin C at least once a day (preferably in the morning) and take a 500-mg vitamin C supplement twice daily. Vitamin C has antioxidant and tyrosinase blocking activity. It is a great choice for use in preparation for skin procedures to speed healing and reduce postprocedure dyspigmentation and inflammation.
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.
Conclusion
Microfocused ultrasound and many other skin tightening treatments have become very popular. While no studies have yet looked at the effects of combining the use of nutraceuticals and cosmeceuticals before or after an MFUS procedure, anecdotal reports suggest positive outcomes, to which these agents have been thought to have contributed. In addition to seeing research on the various ways microfocused ultrasound may be used in combination with other minimally invasive procedures, I hope that we will soon be presented with data on the effects of combining cosmeceuticals with microfocused ultrasound and other minimally invasive procedures to treat skin laxity. Always remember to give patients printed pre- and postprocedure instructions to improve compliance.
Please email me at DrB@skintypesolutions.com if you have any comments, suggestions, or anecdotal reports to share on using cosmeceuticals and nutraceuticals before and after procedures. I will share your responses on my LinkedIn account.
Dr. Baumann is a private practice dermatologist, researcher, author, and entrepreneur who practices in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann wrote two textbooks, “Cosmetic Dermatology: Principles and Practice” (New York: McGraw-Hill, 2002) and “Cosmeceuticals and Cosmetic Ingredients” (New York: McGraw-Hill, 2014); she also wrote a New York Times Best Sellers book for consumers, “The Skin Type Solution” (New York: Bantam Dell, 2006). Dr. Baumann has received funding for advisory boards and/or clinical research trials from Allergan, Evolus, Galderma, and Revance. She is the founder and CEO of Skin Type Solutions Franchise Systems.
References
1. Clin Cosmet Investig Dermatol. 2017 Oct 30;10:423-9.
2. J Am Acad Dermatol. 2013 Dec;69(6):965-71.
3. Dermatol Surg. 2015 Mar;41(3):327-35.
4. J Cosmet Dermatol Sci Appl. 2012;2(2A):108-16.
5. Dermatol Surg. 2015 Jul;41(7):821-6.
6. J Cosmet Laser Ther. 2014 Oct;16(5):225-9.
7. Dermatol Surg. 2012 May;38(5):754-9.
8. Dermatol Surg. 2014 Oct;40(10):1113-7.
9. Clin Cosmet Investig Dermatol. 2015; 8: 47-52.
10. Dermatol Surg. 2017 Sep 8. doi: 10.1097/DSS.0000000000001216. [Epub ahead of print]
11. Arch Dermatol. 2004 Feb;140(2):204-9.
12. Aesthetic Plast Surg. 1995 May-Jun;19(3):243-6.
13. Plast Reconstr Surg. 2011 Mar;127(3):1343-5.
14. J Am Acad Dermatol. 1998 Aug;39(2 Pt 3):S79-81.
15. Popp C et al. Br J Dermatol. 1995 Jan;132(1):46-53.
16. J Am Acad Dermatol. 2004 Dec;51(6):940-6.
17. J Korean Med Sci. 1996 Aug;11(4):335-41.
18. Eur J Dermatol. 2002 Mar-Apr;12(2):145-8.
19. Proc Natl Acad Sci U S A. 1981 May; 78(5): 2879-82.
20. Exp Dermatol. 2003;12 Suppl 2:57-63.
21. Dermatol Surg. 2001 Feb;27(2):137-42.
22. Br J Dermatol. 1992 Sep;127(3):247-53.
23. J Invest Dermatol. 1991;96:587.
24. Ophthal Plast Reconstr Surg. 2017 Jan/Feb;33(1):47-52.
