Ultherapy side effects, risks & complications- safe or not?

Oligio RF is a non-invasive, monopolar radiofrequency device used for skin tightening and lifting of the face, neck and eyelids. Oligio RF works by bulk heating the epidermis and dermis- causing existing collagen to contract and tighten and stimulating the development of new collagen.

How does Ultherapy work?

Ultherapy is a non-invasive treatment that utilises micro-focused ultrasound energy. This energy is delivered to the deep layers of the skin, specifically targeting the SMAS (superficial musculoaponeurotic system) layer, creating tiny areas of injury known as Thermal Coagulation Points (TCPs). These TCPs cause existing collagen to contract and stimulate the production of new collagen, resulting in a natural and gradual lifting and tightening effect. In comparison, skin tightening devices such as Oligio RF utilise monopolar Radiofrequency (RF) to bulk heat and tighten the superficial layer of skin.

Ultherapy side effects, risks and complications

The risk of developing adverse effects after Ultherapy is low, estimated at less than 1-2%. The majority of Ultherapy treatments are safe and uneventful. However, side effects, risks and complications may occasionally develop, due to patient or provider factors. The majority of Ultherapy adverse effects are temporary and resolve with time.

1. Burns, Blisters, and Welts

Thermal injury from ultrasound energy can result in epidermal and dermal burns, leading to blisters and welts. Such injuries often stem from improper technique, including excessive energy delivery, incorrect transducer angling, or inadequate coupling gel application.​Patient discomfort and patient movement during treatment may also play a role. Welts are milder, develop more often, and typically resolve completely without any long-term issues. Welts often develop when using the 1.5mm Ultherapy transducer (superficial delivery of energy) and in areas where the skin is thin, such as the neck. Burns and blisters are rare, but they take 1-2 weeks to heal and often leave post-inflammatory hyperpigmentation and scarring.

Treatment of welts:

Cooling the affected area, and topical steroids to subside the inflammation

Treatment of burns and blisters:

Wound care, antibiotics to prevent secondary infections, laser treatment of hyperpigmentation and scarring

2. Hyperpigmentation

Post-inflammatory hyperpigmentation (PIH) can occur following thermal injury, particularly in individuals with higher Fitzpatrick skin types. The inflammatory response to skin injury stimulates melanocyte activity, leading to increased melanin production.​Treatment:  Topical agents such as hydroquinone and retinoids can be used to lighten hyperpigmented areas. PicoSure laser can effectively target melanin and lighten the pigmentation.

3. Fat Atrophy and loss

Excessive and poorly targeted ultrasound energy may inadvertently target subcutaneous adipose tissue, leading to fat atrophy and volume loss. This complication is more likely to occur in individuals with a low baseline facial fat volume or when the ultrasound transducer is improperly positioned or applied at an inappropriate depth.

Prevention:

Patient selection: Patients with a moderate to high amount of facial fat are generally better candidates for Ultherapy. Those with low facial fat may be at higher risk of a gaunt appearance post-treatment.

• Depth Control and Visualisation: Careful ultrasound visualisation to ensure energy is delivered precisely to the SMAS or deep dermis, and not to the subcutaneous fat layer.
• Anatomic Areas to Avoid or Treat Conservatively:
  • Malar and submalar regions (cheekbones and hollow of the cheeks)
  • Temporal region: already a fat-deficient area
  • Periorbital area and lower eyelids: very thin subcutaneous tissue, high risk of fat pad reduction

Treatment:

Once fat loss has occurred, options to restore volume include hyaluronic acid fillers and biostimulatory fillers such as Ellanse.

4. Blood Vessel Injury and Bruising

Ultrasound energy can damage superficial blood vessels, resulting in bruising or hematomas.

Prevention- Understanding the anatomy of key vessels and avoiding these high-risk areas:

• Facial Artery and Vein
  • Location: Curves around the inferior border of the mandible and becomes superficial anterior to the masseter muscle
  • Avoid: Stay superficial or lateral to the artery path
• Angular Artery
  • Location: Terminal branch of facial artery, runs alongside the nose
  • Avoid: Avoid deep passes near the nasolabial fold and medial canthus
• Superficial Temporal Artery (STA)
  • Location: Emerges anterior to the ear, ascends across the temporal region
  • Avoid: Avoid energy lines along the temporal hairline and temple

Treatment: Cold compresses can alleviate bruising. Most cases resolve spontaneously within a few weeks.​ BBL HERO can help expedite the resolution of the bruise

5. Nerve Injury

Thermal effects from Ultherapy can affect superficial nerves, leading to temporary nerve injury that results in neuropathic pain (shooting, electricity-like pain in the distribution of the nerve) or  facial muscle weakness

Nerves at risk:

• Frontal Branch of the Facial Nerve:
  • Anatomy: Traverses the superficial fascia over the zygomatic arch, innervating the frontalis muscle.​
  • Risk: Injury can result in forehead muscle weakness, affecting the raising of the eyebrows
• Marginal Mandibular Nerve:
  • Anatomy: Travels along the inferior border of the mandible, supplying muscles of the lower lip.​
  • Risk: Damage may lead to asymmetry of the mouth
  • Avoid delivering ultrasound energy directly over the mandibular margin.​
• Supratrochlear and Supraorbital Nerves:
  • Anatomy: Emerges from the supraorbital notch, providing sensation to the forehead and scalp.​
  • Risk: Injury can cause numbness and tingling in the forehead and hairline region.​
• Treatment: Most nerve injuries are transient, resolving within a few weeks with no permanent effects. Nerves are too small to visualise on ultrasound, and a good understanding of anatomy is required to avoid nerve injuries. 

Ultherapy at Bay Aesthetics Clinic and Medical Spa

Having performed hundreds of Ultherapy cases with almost 20 years of combined experience, Medical Directors Dr Hoe Ying Min and Dr Bernard Tan have significant experience with Ultherapy, having been trained by international experts in the finer points of Ultherapy.

Thankfully, at Bay Aesthetics Clinic, the only adverse effects from Ultherapy ever encountered (so far) were welts on the skin that resolved after a week. We occasionally get patients who come to us for treatment of Ultherapy complications that developed after treatment elsewhere. Hence, we are well aware of the potential risks from Ultherapy and are able to treat complications should they arise. Avoiding side effects and complications became easier with Ultherapy Prime, which features high definition real-time ultrasound imaging, faster treatment speeds and reduced pain, making Ultherapy treatments safer for patients.