In-Depth Read-Up: HI, Focused Ultrasound

The search words “HIFU” and “Ulthera” are often used when looking for a non-invasive or non-surgical facelift. A quick Google search finds a plethora of aesthetic clinics offering either of these treatments, and a stroll past a row of beauty salons might also show some offering HIFU treatments, too.

So, what really is HIFU? How does it work? And how does it differ from Ulthera? What are the differences of HIFU treatments offered by aesthetic clinics and beauty salons?

This article has been written to help you make an informed decision on taking up either HIFU or Ulthera by understanding that they are both medical procedures using devices that are required to be operated by a trained, experienced medical doctor.

I may not address the commonly asked questions such as numbers of sessions required, side effects, etc - you can read about it on my easier-to-read article on HIFU (click on link).

What is HIFU?

HIFU stands for High Intensity Focused Ultrasound. The principle of how it works is pretty much the same as Ulthera, the original device using micro-focused ultrasound for non-invasive and non-surgical facelift.

HIFU refers to South Korean-made focused ultrasound devices and Ulthera, American made.

Graphic: Classys, Inc.

They both are treatments using ultrasound energy focused to produce a small but concentrated thermal heat zone, resulting in controlled damage to the treated areas such as the dermis & SMAS (Superficial Muscular Aponeurotic System, or tissue glue).

Initially, areas of the face – cheeks, submentum (underchin), infra-orbits (undereye), brow and forehead – were the areas treated. Subsequently, the neck, décolleté (female upper chest) and even certain parts of the body were approved for treatment.

Graphics: Google

It may surprise you to find out that focused ultrasound has been around since the 1950s. Focused ultrasound energies were postulated by Frank and William Fry to generate localised “trackless” tissue damage.

Unfortunately, back then, the limitations of available technologies to monitor and manipulate this energy resulted in HIFU being put into the backrooms of ideas. Its resurgence in the early 1990s in fields such as gynaecology, hepatology, urology spelled renewed interest in focused ultrasound.

Which one is better - Ulthera® or Korean HIFU?

Graphics: Classys, Inc. & Merz Aesthetics.

In 2008, Ulthera was commercially launched for aesthetic indications, receiving US FDA approvals for non-invasive brow lift (2009), non-invasive neck & submentum (underchin) lift (2012) and non-invasive treatment of lines and wrinkles of the décolleté (female upper chest; 2014).

Initially, HIFU devices were deemed poorly made copy-cat devices with poorly focused ultrasound energies. Subsequent iterations of Korean HIFU devices made good their deficiencies and weaknesses, resulting in much improved versions with claimed efficacies equal, if not similar, to that of Ulthera.

In a study by Harker-Martinez (2016), 22 female patients aged between 45 and 55 years were equally split into a two-arm study that pitted Ulthera against a leading South Korean HIFU manufacturer. Pre- and post-procedure photographs were evaluated by two independent plastic surgeons unaware of which part of the face was treated, hence, unable to determine which device was used for treatment.

According to that article, 85 per cent of patients were highly satisfied with the treatment. Additionally, most patients reported no appreciable differences between each half of their face. Only 13 per cent of patients reported moderate improvement and were taken to complimentary follow-up treatment. Treatment outcomes were highly satisfying for both patients and physicians who found no significant difference in treatment outcomes between the Ulthera and HIFU.

Why should I still be treated with Ulthera instead of HIFU?

I have used both Ulthera and a medical-grade Korean HIFU device – both devices could dish out very similar outcomes.

So, why do I still recommend to my patients to get treated with Ulthera instead of its Korean doppelgänger?

The answer is simple – quality assurance.

Ulthera is an FDA-approved device for non-invasive and non-surgical facelift. Ultherapy is owned by Merz Aesthetics, the largest dedicated medical aesthetics business globally.

Comparisons of different modalities of facelifts. Microfocused ultrasound refers to Ulthera and HIFU, and Radio Frequency with Thermage, as an example. (Graphics: Merz Aesthetics)

The physical appearance of the Ulthera device has barely changed since 2008. Its treatment handpiece was updated in mid-2012 for treatment efficiency and most importantly, the treatment protocols were updated. The initial protocols started out with 500 shot-count treatments. Then in 2016, updated protocols were boosted to a minimum of 800 shots – this is the Amplify 2 Protocol. The clincher for good treatment outcome is the shot-count – the doctor will need to assess you and then decide on what you best need.

Merz guarantees that its Ulthera hardware is stable and the focused ultrasound points underneath the skin are always at the depths indicated, that is, 4.5mm, 3.0mm and 1.5mm. Ulthera remains the only device today with the DeepSEE visualisation technology that can scan and visualise the area underneath the skin before the doctor applies the energy – this is crucial for an effective treatment as the Micro-Focused Ultrasound must be applied to the correct plane of the skin.

Is the treatment painful?

The comfort level varies from one individual to another and the areas being treated. In any case, the discomfort during the treatment is mitigated by a combination of topical numbing cream and oral painkillers.

In the post-treatment period, patient may feel a dull discomfort and/or mild swelling over the treatment areas. This is due to swelling caused by repair mechanisms at work underneath these areas that will resolve in 10-14 days.

Ulthera treatments (known as Ultherapy) are often misconceived as being painful and its competitors have used this to sway their prospective clients.

From my personal experience, Ultherapy, when performed with the correct technique and when adequately effective analgesia is given, is mostly comfortable with moderate discomfort only in certain areas of the face and submentum.

Beauty salons offer HIFU treatments, too. So, what about these?

It can be simultaneously confusing, for consumers, and confounding, for aesthetic doctors, to see HIFU being offered in both clinics and beauty salonsIt can be simultaneously confusing (for consumers) and confounding (for aesthetic doctors) to see HIFU being offered in both clinics and beauty salons.

Graphics: Screenshot from webpage of National Environmental Agency (NEA), Singapore.

The National Environment Agency (NEA) requires the N2 licence for clinics to use any non-ionising apparatus, such as lasers and ultrasound-based devices (including HIFU devices). Those offering claimed medical grade HIFU devices in a non-clinical setting are doing so at their own legal risk.

YouTube videos showing treatments using focused ultrasound devices appear seemingly too easy to perform. Untrained personnel may not know about the subtleties of the procedure and the required knowledge of anatomy, for example, depth of skin to be treated; areas to avoid preventing complications (nerve damage); and contraindications of treatment. The outcome of HIFU treatment of the body can be potentially catastrophic – particularly the abdomen – in patients with recent abdominal surgery or undiagnosed abdominal hernia.

There are also spa-grade HIFU treatments that claim to be painless. Many beauty spas and some medi-spas offer monthly treatments with these painless HIFU devices – the efficacies and longevity of results have yet to be proven. The long-term outcome of frequent (that is, excessive) HIFU treatments has yet to be elucidated.

While the recommended treatment intervals for any medical-grade focused ultrasound treatment is 1 to 1.5 years – in practice, many patients request for a follow-up treatment between the ninth and 12th month from their last treatment.

These are the answers to questions that you would probably not find in any articles and I hope that the reader has become more informed of HIFU. This is also an evolving article and I will add more material to it as per comments received from my readers.

Disclaimer: The opinions expressed here are solely my own. It does not replace a consultation with your doctor.

This article has also appeared on Business Times, Weekend Edition in the Health Section on 10th October 2020.