HOLLYWOOD, FLA. – Many physicians use microfocused ultrasound (MFU-V) or other energy devices along with neurotoxins and injectable fillers, but how these therapies should be sequenced, and how closely they can be grouped, remains an open question. One physician’s look at his own and colleagues’ data found a surprising answer: it doesn’t seem to matter.
“We have had this ongoing debate for years and years on when you should use an energy device, on when you should inject a toxin, on when you should inject a filler – and maybe more importantly, on when you shouldn’t use a toxin or a filler in proximity to the energy device,” said Dr. Phillip Werschler, a cosmetic surgeon in private practice in Spokane, Wash.
There are theoretical concerns that applying heat energy to recently placed fillers or neurotoxins may alter the protein structure of the injected material, and also about injecting skin recently treated by ultrasound or other energy-based therapies, Dr. Werschler said at the annual meeting of the American Academy of Cosmetic Surgery.
Citing a paucity of evidence for best practices, Dr. Werschler and his colleagues conducted a small retrospective study – a multicenter chart review – to examine whether microfocused ultrasound (MFU-V) is safe when used within 6 months of the administration of neurotoxins and/or dermal fillers.
The study’s primary outcome measure was the incidence of adverse events in patients who were treated with both MFU-V and toxins or fillers within 6 months’ proximity. Dr. Werschler and his colleagues examined the charts of 101 patients who had received MFU-V and either a neurotoxin or a dermal filler in the previous 2 years, and for whom the injectable therapy was administered within 6 months of the energy-based treatment. “One subject did not provide gender data. 101 subjects were enrolled. 4 males, 96 females, & 1 without gender provided.”
Men and women aged 25-70 years were included in the review. Mean age was 55.3 years (range, 32-72); 4 males, and 96 females were enrolled (gender information was not provided for one patient).
All 101 patients received MFU-V treatments, with transducer depth during treatment at 1.5 mm (n = 69 treatments), 3.0 mm (n = 99), or 4.5 mm (n = 84). Some patients received treatments in more than one area, so 48 subjects received a full-face treatment, 58 received neck treatment, 45 received partial facial or other area treatment, and 7 received décolleté treatment.
Filler treatment was administered to 83 subjects, with 57 of those (69%) receiving hyaluronic acid, and 26 (31%) receiving calcium hydroxylapatite. Depth of injection varied: 59 areas had intradermal injections, 56 had subdermal injections, and 11 injections targeted the periosteal layer.
Of the 83 patients receiving fillers, 16 received MFU-V on the same treatment day, and one patient had neurotoxin.
Twenty patients received neurotoxin treatment at the muscle (48 areas) and intradermal (10 areas) layers. Of these, four also received MFU-V on the same day.
The majority of patients treated with multiple modalities received toxin or filler within 90 days before or after the MFU-V treatment (n = 48 for filler + MFU-V and n = 12 for filler + toxin).
Of the 101 enrollees, seven patients each had one adverse event. Four of these events resolved without sequelae, while the outcomes for the other three are unknown. Most of the adverse events were mild bruising, purpura, or swelling; one patient had a herpes simplex virus outbreak, one patient had paresthesias, and one patient reported moderate bruising and swelling.
“What we didn’t see is … for example, granuloma formation in those patients that were treated previously with a filler, either a particulate or a natural filler, and then heat energy was applied over it in the form of microfocused ultrasound. We didn’t see melting of the fillers.”
The retrospective chart review supports the safety of combination treatments, said Dr. Werschler. “So what does all this mean to your practice? It’s another piece of evidence – a small piece – that it’s OK to put energy over toxins and fillers,” said Dr. Werschler.
Dr. Werschler disclosed that he is a consultant, investigator and speaker for Ulthera, a division of Merz Aesthetics. He did not receive compensation for this study.
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