Non-invasive facial rejuvenation and skin tightening can be achieved with non-ablative lasers, radio frequency and ultrasound technologies. How does ultrasound work? How long do results last? What are the potential risks and complications? Read on.

Ultrasound skin tightening is yet another option for those who want facial and body rejuvenation without downtime and surgical scars. But what is ultrasound, and how does it produce results in facial rejuvenation?

Ultrasound makes use of acoustic or sound waves with frequencies above what humans can hear – hence its name, “ultra”-sound. Ultrasound has been used in medical applications since the 1940’s.  It has found uses in vascular and radiological studies, wound healing and physical therapy to name a few. Ultrasound is used in breast exams and for examining the fetus during pregnancy.

The same qualities that make it valuable in other medical applications, the ability to see through tissue, have been tested and developed for non-surgical skin tightening. These rejuvenation systems use intense-focused ultrasound. Ongoing research into ultrasound and its capabilities is opening up new frontiers that go far beyond skin rejuvenation.

How does ultrasound work?

Ultrasound brings about short-term, immediate changes as well as much longer lasting results. It does so in a number of ways. The heat and vibrations from ultrasound can be designed to produce thermal effects at various depths of skin and deeper tissues. The heat produced by ultrasound waves increase blood flow providing the fibroblasts, the most common cells in the skin, in assisting the skin to rejuvenate itself and increase collagen production. Ultrasound waves are also capable of selectively injuring the skin to trigger a natural healing response. These combined thermal effects cause the skin lifting, tightening and firming that can be experienced after ultrasound therapy. The improvements are due to growth of new collagen and straightening of elastin fiber in the skin.

Ultrasound energy used in this way also improves the superficial skin layer, exfoliating and smoothing it, and leading to what appears as an improvement in skin colour and complexion. Some patients have reported that their skin also becomes less oily.

Researchers have found that ultrasound energy can temporarily change the structure of the outer skin layer, making it easier for topical applications to reach inner tissue layers. Rapid oscillations caused by ultrasound energy alter the permeability of the cell membranes and increases fibroblast activity and collagen formation.

Sonophoresis is the ability of ultrasound to improve how topical applications pass through the skin barrier. Cavitation, the phenomenon that generates small gas bubbles that grow in size with each additional exposure to ultrasound, causes structural disorder in the skin, leading to enhanced permeability. In particular, it has been established that low frequency ultrasound in the range of 20 kHz is ideal for enhancing skin permeability. Such permeability can last up to 12 hours after ultrasound treatments. These findings open up new possibilities for combining ultrasound with topical skin rejuvenation agents.

Reasons for choosing to have an ultrasound treatment

The best candidates for ultrasound skin tightening are those between the ages of 35 and 65 who have some level of skin looseness in the face and body, and wish to postpone or avoid cosmetic surgery and invasive procedures.

People who smoke or have excessively sun-damaged skin are not good candidates for ultrasound face and body rejuvenation, because the ability of their skin to create new collagen may be compromised.

Ultrasound treatments should not be given to people with active infections, open wounds or acne at treatment sites. Ultrasound skin tightening is not suitable for pregnant women or people with pacemakers and other electrical medical devices. People with medical conditions that impair wound healing and those on medications that alter or impair healing might also not see great results with this treatment. Often, people who are unsuitable for ultrasound treatments aren’t suitable for any other form of laser treatment either.

For most people, the key reasons for choosing ultrasound are convenience, safety and its non-invasive skin tightening abilities. Unlike laser and radio frequency treatments, ultrasound skin tightening focuses on the same deeper tissue layers that are addressed during a standard facelift. Although ultrasound cannot reproduce results similar to or even close to a facelift, it allows the user to buy time before surgery. It is also ideal for those who cannot undergo cosmetic surgery or are considered unsuitable for more invasive skin rejuvenation procedures.

The fact that ultrasound can bring about changes in the deep tissue layers of the face and body without damaging the outer skin makes these treatments attractive to consumers seeking non-invasive facial and body rejuvenation.

Many studies have shown that intense-focused ultrasound is capable of penetrating the superficial layers of the skin to create thermal and non-thermal effects in deeper tissue layers containing fiber and muscle. It is the same layer, the superficial musculoaponeurotic system, better known as the SMAS, which a facial surgeon works on when performing a standard facelift. Besides surgery, few options offer such penetrating capacity to treat deep tissue. This is what makes ultrasound technology an exciting area of research in anti-ageing rejuvenation treatments.

Ultrasound therapy has been proven safe and effective in tightening the skin on face and neck. Research studies show that the forehead, eyelids, cheeks, chin and jaw areas can benefit from the treatment with ultrasound. ^[1],[2] Ultrasound therapy has also been proven safe and effective in improving the texture and contour of the upper arms, knees and mid-thighs.^[3]

The most widely known ultrasound skin tightening system is the Ulthera System. Originating in the US, the Ulthera System has received approval of the US Food and Drug Administration (FDA). It has also received TGA approval in Australia.

What to expect

How many treatment sessions are needed depend on the specific system being used. The Ultherapy system usually requires just one session to produce results.

Ultrasound treatments can be painful, but are not usually unbearable. It all depends on your pain threshold. Because ultrasound travels far below the skins surface, topical anaesthetics are not effective. You will typically be given pain medications as well as drugs to make you relaxed and comfortable. If needed, IV sedation can be given under the supervision of a qualified anaesthetist. New research has recently been released showing that reduced energy can be used while still providing the desired results.

The handheld applicator is passed across each area to ensure all areas that need treatment are covered. With Ultherapy the first pass is set to go very deep and the second set to reach tissue layers closer to the skin. It takes about an hour to treat the face, neck and eyebrows. The neck and lower face can be treated within 30 – 45 minutes. Treatment for any single area takes between 15 and 30 minutes.

There is no downtime. You can return to your normal routines immediately.

There is no age limit for ultrasound skin tightening treatments. However, because the results are dependent on new collagen production in the skin, younger and healthier people are likely to get a better result. Patients in their 70s and 80s who have undergone one neck or facelift procedure but are still bothered by skin laxity, find ultrasound therapy attractive. They do not want another surgical operation with the hassle of anaesthesia, downtime and recovery.

Some doctors have observed that some men over sixty do not respond to treatment as well as other patients. People who do not respond well to Ultherapy the first time around often have better results with touch-up treatments.

Although results vary, most people notice changes in their skin laxity within two to three months. The results are likely to be subtle rather than dramatic and immediate. Just as there is no one answer to how fast anyone ages, it is difficult to predict how long it will take your skin and tissues to produce results. Most people respond to ultrasound therapy well. A few do not.

The collagen renewal process will continue for three or four months after treatment, so the reductions in skin laxity are likely to be gradual rather than immediate. You may, however, notice an improvement in skin texture and quality. Wrinkles will become less prominent in that time and loose skin on the face will tighten. The platismal bands in front of the neck will tighten, firming up the neck area. The brow lifting that occurs following an ultrasound treatment will reduce excess skin on the eyelids and refresh the eye area.

Before and after

Ultrasound therapy has been known to work synergistically with some facial injectables and topical applications, while causing other injectables to breakdown sooner. It is best to consult your dermatologist or cosmetic doctor if you are planning combination treatments. Some cosmetic doctors claim that Sculptra and Radiesse work well with Ultherapy. Other injectables like Restylane, and Juvederm are suspected to break down sooner if exposed to ultrasound. Because there hasn’t been extensive research on how ultrasound works with different injectables, most of what is known is anecdotal. The usual practice is to treat patients with Ultherapy first and then follow up with fillers, but some doctors claim good results with simultaneous use. Anecdotally, Botox and Dysport are known to work well with Ultherapy, provided they are strategically placed prior to the ultrasound treatment.

Immediately after treatment your skin will feel flushed and puffy. Sometimes the skin will turn red, but the redness will subside in a few hours. Expect treated areas to be tender and occasionally feel numb. You may feel twinges of pain here and there for some time afterwards.

Results of ultrasound therapy for facial skin tightening can last at least one to two years and usually much longer. The ageing process still continues after the first treatment, but to maintain results achieved from this treatment you may want to consider a second treatment every two years or so. Regardless of having further treatments there will still be some benefit from the improvements of the first treatment for quite a few years compared to not having had any treatments in the first place.

Possible risks and complications

Every treatment method comes with its own unique pros and cons, including potential risks and complications. If you are seeking an ultrasound treatment, make sure that the person performing the procedure is a properly trained technician, as this reduces the risks and complications significantly. If the machine is set up or used wrongly, significant tissue damage can result. A special conductive gel needs to be applied when passing the wand over the skin.

After treatment the ultrasound gel will be removed and a moisturiser will be applied to the treated skin. You should take care of your skin as you do normally.

The risks and complications of ultrasound treatments are insignificant when compared with more invasive treatments or with cosmetic surgery.

Here are possible side effects, risks and complications that could arise after ultrasound skin tightening treatments:

• Redness – Most people experience redness and a flushed face after a treatment session. The colour will go away in a few hours or days. In most people the redness disappears by the next day.
• Skin tenderness – Most people experience mild to moderate skin tenderness after treatment. This should go away within a month.
• Swelling – Not everyone experiences swelling after treatment, and the degree varies significantly. The swelling can last for as long as four weeks. Cold compresses applied to the treated skin will minimise the swelling.
• Purpura or skin bleeding under the epidermis can occur in places, but will be resolved within one to two weeks.
• Grooves or scratch-like marks—lines or geometrical patterns—may appear on treated skin. They are treated with topical corticosteroids and do not leave permanent effects. These typically occur with superficial transducers. Your technician, ensuring there is proper coupling with a corresponding ultrasound image before each pulse is delivered, can prevent them.

More rare but serious complications that may occur include the following:

• Palpable nodules that develop in the skin below the epidermis – These can be prevented by appropriate treatment density and technique using the ultrasound image on monitor.
• Slight or partial paralysis (paresis) of motor nerves – Numbness may occur in the brow or in areas around the eyes, usually within one to 12 hours after treatment. It is most likely related to inflammation of the nerves. It can take two to six weeks for normal sensations to return without any intervention. Nerve paralysis and numbness can be prevented to a large degree by making sure to avoid key nerves that are close to the skin during treatment delivery.If you experience twitching of facial muscles during treatment, inform your doctor immediately. Applying ice immediately to ‘danger zone’ areas and treating with anti-inflammatory treatments to red or inflamed areas can help avert this situation.

Significant risks and complications from ultrasound treatments can be avoided or prevented to a large degree by working with a qualified and experienced doctor or well trained and experienced technicians.

Rough costs involved

Prices for ultrasound skin tightening treatments depend on the area(s) treated and the specific device/system chosen by your cosmetic surgeon or dermatologist. Depending on the treatment area or areas, Ulthera System treatment may cost between $ $950 (AUD) to $3,300 (AUD). Different doctors may have varying rates for the same treatment.

This information is correct as of 2019.

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_{[1] Alam M, White LE, Martin N, Witherspoon J, Yoo S, West DP. Ultrasound tightening of facial and neck skin: a rater-blinded prospective cohort study. J Am Acad Dermatol. 2010 Feb;62(2):262-9. doi: 10.1016/j.jaad.2009.06.039. Accessed on 4 May 2013.
[2] Suh DH, Oh YJ, Lee SJ, Rho JH, Song KY, Kim NI, Shin MK. A intense-focused ultrasound tightening for the treatment of infraorbital laxity. J Cosmet Laser Ther. 2012 Dec;14(6):290-5. doi: 10.3109/14764172.2012.738912. Accessed on 4 May 2013.
[3] Alster TS, Tanzi EL. Noninvasive lifting of arm, thigh, and knee skin with transcutaneous intense focused ultrasound. Dermatol Surg. 2012 May;38(5):754-9. doi: 10.1111/j.1524-4725.2012.02338.x. Epub 2012 Jan 23. Accessed on 4 May 2013.}