Nariaki Miyata, M.D.
Director of Miyata Plastic Surgery and Skin Clinic
＜Introduction＞
In recent years, low-invasive treatment for facelifts using medical devices has attracted considerable attention as an alternative to conventional surgery. Among such treatment devices, ULTRAcel Q+ (Jeisys Medical Inc.) is the latest model with improved features including an increased irradiation rate, reduced pain during irradiation, and maximized ease of use based on the technology used in conventional devices for high-intensity focused ultrasound (HIFU). In 2019, an additional new cartridge, LinearFirm, available for the ULTRAcel Q+, was introduced, allowing clinicians to perform procedures more quickly and efficiently than ever before due to the increased thermal diffusivity per pulse.
In this article, I will explain the functional differences between the cartridges and how to select the most appropriate cartridge depending on the purpose of the procedure and the benefits being sought, as well as the protocol for the actual procedure.
<Background>
Age-related facial wrinkles and sagging are mainly caused by skeletal and soft tissue atrophy as well as distortion of the superficial facial layer, known as the superficial muscular-facial system (SMAS), which lies between the subcutaneous tissue and the aponeurotic muscles. Since this SMAS, along with the platysma muscle and other associated muscles, causes sagging of the entire face, conventional surgical procedures for facelift have been performed to remodel fascia-centered layers to the SMAS. However, surgical procedures are associated with issues including concerns about invasiveness, downtime, and pain so that a non-surgical procedure using medical devices has become more mainstream in recent years.
Given this background, HIFU has attracted considerable attention as a non-surgical method using medical devices that focus thermal energy to stimulate thermal degeneration-induced remodeling in the SMAS, which is a key tissue for facelift therapy. HIFU is a technique that uses focused ultrasound to generate heat locally at any target under the skin and is characterized by heating only the target tissue and inducing thermal denaturation of proteins without affecting areas outside the focal area or the superficial layers of the skin. In addition to this technique, radiofrequency (RF) energy can be used for lifting and tightening the face with medical devices. However, RF irradiation is limited to superficial areas from the epidermis to the dermis, precluding a therapeutic approach to the deep SMAS. On the other hand, HIFU can select the focal depth by using different cartridges, allowing a wide range of depth-based approaches to dermal tissues, including 1.5 mm for the subcutaneous subjacent area, 3.0 mm for subcutaneous tissue, and 4.5 mm for deep SMAS.
<Technologies>
• Differences between ULTRAcel Q+ and conventional HIFU devices
The ULTRAcelQ+ from Jeisys is the latest HIFU device based on modified conventional HIFU devices. While conventional HIFU can cause severe pain during the procedure, ULTRAcelQ+ can achieve significant pain reduction by shortening the exposure time and lowering the focal temperature of the thermal energy. The instantaneous increased temperature at the focal point for ULTRAcel Q+ can be set between 60 and 65 °C, while for conventional HIFU devices it is around 67 °C, a temperature at which collagen is completely destroyed. It is well known that proteins such as collagen begin to unfold and denature their triple-helical structure when the temperature reaches 60 °C, and are completely destroyed above 65 to 67 °C. Thus, conventional HIFU devices promote remodeling by completely destroying collagen in the SMAS with heat, whereas ULTRAcelQ+ promotes collagen renewal through moderate thermal denaturation without completely destroying the collagen. This means that there is a significant difference in the mechanism of action between conventional devices and ULTRAcelQ+.
In addition, the ULTRAcel Q+ cartridges have a compact skin contact area for improved visibility and are designed to reliably irradiate complex anatomical sites including the nasal rim, periorbital and submandibular region, a distinct advantage compared to conventional HIFU devices.
• Features of the ULTRAcel Q+ LinearFirm Cartridges
In 2019, the new LinearFirm series of cartridges that can be mounted on ULTRAcel Q+ has been added to the product portfolio. The introduction of the Linear cartridges represents a new system in which the focus of thermal energy develops in a linear fashion, resulting in improved heat transfer efficiency and the ability to heat a larger area in a single pulse. This heat diffusion over a wide area allows clinicians to achieve a fat melting effect and tissue volume reduction, compared to the dot heat source with dot cartridges.
When using the linear cartridge, the irradiation time can be further reduced from an approximately 1.5 sec/pulse with the dot cartridge to a 0.7 sec/pulse. Pain during the procedure can also be reduced and patient discomfort can be minimized.
The following two types of linear cartridges for facial use can be selected according to the application: 2.0 mm for brightening and 4.5 mm for tightening a double chin and other forms of sagging skin.
<Selecting Cartridges for Different Purposes>
In this section, I will explain my treatment protocols using ULTRAcel Q+ with linear cartridges based on my clinical practice. The first protocol described is for irradiation using the ULTRAcel Q+ as a facelift procedure for sagging of the entire cheeks.
In this protocol, ULTRAcel Q+ with the 4.5 mm dot cartridge is used to target the SMAS and broad cervical muscles to treat sagging of the entire cheek skin. The retaining ligament including the zygomatic ligament is irradiated with consideration given to these structures, followed by irradiation of the area surrounding them. Then, the entire face is irradiated using ULTRAcel Q+ with the 3.0 mm dot-shaped cartridge, followed by irradiation of malaris muscle with a pattern having continuity with the group comprising the orbicularis oculi and zygomatic muscles while taking into account the anatomical locations. In my clinical practice, I regard the malaris muscle group as a very important area for achieving a total facelift. In this case, I used a 2.0 mm dot cartridge for safety when irradiating the periocular and upper eyelids, demonstrating that ULTRAcel Q+ is effective in raising the eyelid when used in accordance with this protocol. In addition, ULTRAcel Q+ has an excellent skin-forming effect, which is one of the features not available in conventional HIFU devices.
Next, the protocol using the ULTRAcel Q+ with linear cartridges is described. In my clinic, ULTRAcel Q+ with the 4.5 mm linear cartridge is mainly used for reducing a double chin. As shown in Figure 3, I have found that a significant facelift effect can be achieved by applying deep irradiation three times to the central area of the double chin. Based on my experience in clinical practice to date, the ULTRAcel Q+ linear cartridge has demonstrated a sufficient facelift effect in patients with a double chin in their 40s and 50s, suggesting that this device not only has a fat-reducing effect but also a tightening effect on the platysma muscle.
＜Discussion and Summary>
In this article, I introduced the features of the new ULTRAcel Q+ HIFU device from Jeisys and the latest dedicated LinearFirm cartridge, as well as the practical treatment protocols for using these devices. My clinical practice has shown that the ULTRAcel Q+ and the ULTRAcel Q+ with the LinearFirm cartridge are highly effective for achieving a facelift. In particular, when the linear cartridges are mounted on the ULTRAcel Q+, the thermal energy can be converged in a linear fashion, allowing a wide and continuous heat zone to be developed for the target layer. Moreover, much higher total energy can be delivered because the adjacent heat sources overlap due to continuous irradiation.
In the case where the 4.5 mm linear cartridge is used under the chin, the ULTRAcel Q+ can have a powerful tightening effect on the adipose tissue and the SMAS, as well as on the fascia of the platysma muscle located at a deeper level.
In actual clinical settings, I believe that the ULTRAcel Q+ linear cartridge has a stronger tightening effect than that of the dot cartridge because it can tighten the target layer over the entire surface.
The ULTRAcel Q+ and linear cartridges have advantages in terms of effectiveness not matched by conventional HIFU devices. Other than the excellent treatment results described above, the HIFU device also has the following advantages.
First, the shorter procedure time and improved operability and visibility during treatment allow for easy handling and finely tuned treatment.
Second, pain in patients during the procedure can be significantly reduced compared to conventional HIFU devices. The HIFU device dot cartridge reduces pain by controlling its irradiation rate and focal temperature, while the ULTRAcel Q+ linear cartridge can provide additional pain relief by setting focal temperature at a lower value.
Third, both ULTRAcel Q+ dot and linear cartridges can provide a facelift effect as well as a so-called skin firming effect through an improvement in skin texture and tension.
With the 2.0 mm linear cartridge targeting the dermal layer, the ULTRAcel Q+ also has a brightening effect on this layer.
The ULTRAcel Q+ with linear cartridges with the features described above is expected to be a new treatment option for the following: those who do not want to undergo surgery due to downtime issues; those who cannot be treated with HIFU or RF due to pain or other reasons, or those who want to achieve tightness, weight loss and improved skin texture along with a facelift.
However, unlike the surgical procedure, the subcutaneous depth that the HIFU device can access is limited to approximately 5 mm (up to the superficial fascia). For this reason, the device cannot be used in all cases of sagging skin including those with skeletal and soft tissue atrophy. For such cases, the combined use of thread lift and dermal filler for adding volume should be considered, if needed. The ULTRAcel Q+ is less tissue-invasive and can be used in combination with threads and fillers. Therefore, this new device will give clinicians the ability to handle a wide range of cases by combining its use with other treatment programs.
(References)
1. Nariaki Miyata, A Real Key Point of Aesthetic Dermatology, Kokuseido Co., Ltd., 2020.
2. Nariaki Miyata, Basic Theory and Practice of Cosmetic Medical Devices, All Japan Hospital Press, 2013.
3. Nariaki Miyata, Laser, radiofrequency, and ultrasound therapy for sagging skin, Extra Volume: Tips for Laser Skin Aesthetic Treatment, Japan Society of Plastic and Reconstructive Surgery, 56: S60-66, 2013.
4. Nariaki Miyata, Facial sagging treatment by high-density focused ultrasound, Japanese Journal of Aesthetic Plastic Surgery 32(2): 64-69, 2010.