INTRODUCTION
Request for a youthful look is rising worldwide.
The available techniques to the plastic surgeon
range from non-invasive techniques to invasive
techniques. Throughout the aging process, the skin
criteria changes, with loss of elasticity due to the
decrease in the number of fibroblast on the skin
and the decreased synthesis of collagen and functions
associated with decreased count of the skin
111
appendages. The neck often ages more noticeably
than the face [1].
The criteria of youngish look for the neck is
the acute cervicomental angle and a firm, welldefined
jawline with smooth healthy skin free of
any neck lines; no platysmal bands; no visible
submandibular glands; small, non-hypertrophic
masseter muscles; and skin that is bright and even
in color, with negligible melanin or vascular lesions.
The aging process involves those multiple layers
of the skin and soft tissue, to include the subcutaneous
fat, muscle and related bony structures. The
dermis thins with altered collagen and elastin
functions. The ligaments and fascia that support
the skin became weakened, with atrophy of subcutaneous
fat and the muscles [2].
The plastic surgeon should be able to diagnose
subcutaneous fat, which is preplatysmal, from
subplatysmal fat, which will also compromise the
acute cervicomental angle, but is more difficult to
reach for management with no incisional or excisional
surgery. With aging and muscle flaccidity
and atrophy, the platysma bands can contribute to
cervical laxity, creating a loose, adynamic, and
obtuse neck [3].
The presence of excess submental fat causes a
look known as a “double chin” which affects the
aesthetic look of the face and neck and is a common
concern among cosmetic surgery patients, regardless
of sex or age. Focal accumulation of fat leading
to submental convexity which is attributed to
several factors mainly obesity, age-related tissue
changes and genetics, which explains why younger
adults and normal-weight individuals may develop
a double chin [4]. The aesthetic physician needs to
be able to diagnose the submental fat compartment
“double chin”, either by clinical examination or
ultrasound techniques, when the submental fat is
due to preplatysmal or subplatysmal pathology [5].
Suctioning of the submental and jowl regions
is a low risk outpatient procedure that gives a
profound aesthetic result requires a small incision
in the skin for the cannula in the subcutaneous
plane, or open subplatysma lipectomy. Since the
late 1960s, the techniques have progressed towards
a minimally invasive procedure, often combining
laser-assisted therapy for enhanced skin tightening
through collagen neogenesis to obtain optimal
results [6].
Another procedure used for neck tightening is
the ultrasound waves via inducing molecular vibration
deep within the tissue, by targeting facial
Superficial Muscular Aponeurotic System (SMAS)
and platysmal, resulting in tissue heating deep in
the dermis bypassing the epidermal layer. There
are two subtypes; High Intensity Focused Ultrasound
(HIFU); used in medicine and surgery, for
non-surgical ablation of tumors and subcutaneous
lipolysis, and Micro Focused Ultrasound (MFU)
used for cosmetic purposes like skin tightening
[7].
White et al., reported the first dermatologic,
aesthetic use of HIFU [8], and it was approved by
the Food and Drug Administration (FDA) in 2009
for use in brow lifting [9].
Right now, it is being utilized for facial rejuvenation,
tightening and body contouring, which are
investigated as a modern treatment for skin tightening
and rejuvenation [9,10], as one of the recent
advances in non-invasive skin tightening where it
yields small, micro-thermal lesions at precise depths
in the dermis up to the fibromuscular layer, causing
thermally induced contraction of collagen and
tissue coagulation with subsequent collagenesis,
whereas saving the epidermis [11,12].
Non-Ablative Rejuvenation (NAR) devices
induce thermal injury within the dermis without
epidermal damage [13] whereas, laser energy can
be diffracted, absorbed, or scattered, resulting in
suboptimal energy penetration [14].
Given that very few studies have been done
HIFU method for neck tightening and submental
fat contouring, we have conducted this study to
compare HIFU versus LAL for neck tightening
and correction of the double chin among young
females, as regards the degree of clinical improvement,
the patient's satisfaction, the adverse effects
of treatment and the pain following the procedures.
112 Vol. 44, No. 1 / Comparative Study of HIFU versus Laser Assisted Liposuction
PATIENTS AND METHODS
This cross sectional comparative study was
conducted over a six months' period starting from
January 2018 till July 2018, on 30 female patients,
divided equally into two groups, aged between 20
and 45 years old, with BMI <35, non-pregnant,
non-lactating. Cases complaining of redundant
submental fat and moderate skin laxity of the neck
and jowls were included in the study (type 1 and
type 2 patients according to Baker classification
[15]) where type 1 patients are those with slight
cervical skin laxity with submental fat and early
jowls, and type 2 patients are those with moderate
cervical skin laxity, moderate jowls, and submental
fat. Patients with local infections, genetic disorders
of connective tissue were excluded. The study was
approved by the Institutional Review Board (IRB)
of the Mansoura Faculty of Medicine (R.19.02.424).
Informed consent was obtained from all patients.
All patients were classified into two groups,
each group contains 15 patients, where; group I:
Subjected to Laser Assisted Liposuction (LAL)
and group II: Subjected to High-Intensity Focused
Ultrasound (HIFU). The neck was divided into 3
areas, two laterals and one medial.
Procedures:
LAL was done using a 1444nm pulsed Nd:YAG
lasers (Accusculpt Nd:YAG, Lutronic, Korea) using
a 600mm optical fiber inserted interstitially into
the fatty tissue of the target region through a 16G
needle as the cannula to ensure correct placement
of the fiber and lower the abrasive damage to the
tissue at the entry point Fig. (1).
The LAL technique involved the following
steps: Marking the entry points and the skin target
areas, sterilization of the field of work using Chlorhexidine
digluconate 0.5% in alcohol 70%, Injection
of local anaesthesia (Xylocaine® 1% with
adrenaline (epinephrine 1:200,000)) at the submental
and mandibular angle entry points, Ensure
protection of the eye for the participating subject
and the surgeon. Then a small incision is made
and dilated to a diameter of 3mm to create the
entry point using a 16G needle. The procedure was
performed through 3 stab incisions; one submental
and one in each of the lower part of each ear lobe.
A 2.5mm cannula is used to infiltrate 200-300ml
of tumescent solution (1000ml NaCl 0.9%: 1mg
adrenaline, 12ml NaHCO3 8.4%, 1000mg lidocaine)
across the digastric and submental regions.
Use the labiomental folds for LAL at the jawline,
and then make a lateral mark on the antero-lateral
cervical zones of the neck on both sides. Place the
needle in the subcutaneous layer and insert the
Egypt, J. Plast. Reconstr. Surg., January 2020 113
fiber through the needle. The red beam will be
visible through the skin. Move the needle and fiber
forwards and backwards in the tissue in a fan-like
maneuver, with the entry point as the base of the
fan, and about 0.5cm between each end point in
the fan periphery. When the fiber reaches the
periphery of the marked zone, the needle and fiber
should be withdrawn for each stroke in the fan.
The laser energy is emitted in a square wave
(switched continuous wave) with an output power
of 6W, pulse rate of 30Hz and pulse energy of
200MJ. A total of 60J/cm2 per treated zone should
be delivered. The fiber should be moved at the
constant rate of 0.3-0.5cm/sec, be sure to keep the
needle and fiber moving constantly, never remaining
in the one spot for any length of time Fig. (1).
A total of 1500J at a setting of 6W was applied
across the whole treatment area. The entry holes
were closed with a single suture (non-absorbable
Prolene® 6-0) [6].
For group II, all patients were prohibited for 3
days from ingestion of drugs such as corticosteroids,
heparin, NSAIDS. A HIFU lifting device (Doublo
from Hironiccompany made by South Korea) was
applied to the target regions (neck and chin). A
probe of 3mm, 4mm, 6mm, 9mm and 13mm were
used, power is in the range of 0.8 to 1.5MHz Fig.
(2). Pitch was considered 2-mm in all patients.
Post-operative care:
Group I: A neck compression garment is worn
vertically and horizontally across the head is applied
five days to prevent swelling and is intended to
keep the soft tissue and skin in place. The average
neck tite operative time was 45 minutes (25 minutes
to 60 minutes). The average total aspirated fat
volume was 30mL (20-150mL). The average time
for double chin contouring was 45 minutes. Group
II: No specific maneuvers needed. The procedure
took 30 minutes.
Clinical evaluation and follow-up:
All patients were evaluated via three independent,
blinded plastic surgeons and three nurses for
the clinical improvement of the skin laxity in the
areas of the neck and chin by comparison of photos
obtained before, and at 3 months after the procedures
using a digital camera to take three views;
anteroposterior and two lateral view by using the
following scale: 0, none; 1, mild; 2, mild/moderate;
3, moderate; and 4, excellent clinical improvement.
The overall clinical improvement was also assessed
Figs. (3-5).
Also, the participants were asked to complete
a Patient Satisfaction Questionnaires (PSQ) to
measure the patient satisfaction and adverse effects
after three months of either procedure. The questionnaire
assessed the patients' satisfaction after
either the HIFU or LAL techniques, their assessment
of adverse effects and their opinions about
whether they would like to undergo the same technique
again or whether they would recommend the
same experience to others. Each point of the questionnaire
score were graded from 0-5, where: 1,
not satisfied; 2, somewhat satisfied; 3, satisfied;
4, very satisfied; and 5, extremely satisfied.
Patients also were asked to express their assessment
of adverse effects, and their opinions about
whether they would like to undergo further HIFU
treatment or whether they would recommend LAL
or HIFU to others, and their responses were recorded
via YES or NO answers.
The pain following the procedures was evaluated
by Visual Analogue Scale (VAS), which is a
simple and reproducible tool for the assessment of
pain severity consisting of 11 levels (0-10 points),
and was done immediately after the application of
HIFU or LAL (week 0) and 3 months after.
Fig. (1): Parameter of laser machine. Fig. (2): Parameter of HIFU.
Statistical analysis:
The data were analyzed using Statistical Package
of Social Science (SPSS). Responses of the
participants who did not supply sufficient data
114 Vol. 44, No. 1 / Comparative Study of HIFU versus Laser Assisted Liposuction
because of not completing the questionnaires were
excluded. The results were presented in the form
of number and percentages. Significance was considered
at p<0.05.
Fig. (3): (A,B) Pre-operative photos of a case with double chin deformity. (C,D) Post-operative photos
after laser assissted liposuction.
Fig. (4): (A,B) Pre-operative photos of a case with double chin deformity. (C,D) Post-operative photos after HIFU.
(A) ((BB))
(C) (D)
(A) (B)
(C) (D)
Egypt, J. Plast. Reconstr. Surg., January 2020 115
RESULTS
The age in group I (40±5.168) and group II
(39.53±5.3966), with BMI<35, 73.3% of group I
and 86.666% of group II were obese, most participants
were of higher education in both groups
(66.66% in group I and 86.66% of group II) and
the majority of our study sample were working
females (86.66% in group I and 66.66% of group
II) (Table 1). 66.66% of the participants were
complaining of redundant submental fat and moderate
skin laxity of the neck and jowls of type 2
according to Baker classification in group I versus
80.00% of group II.
The clinical improvement of the skin laxity in
the areas of the neck and chin by comparison of
standardized photographs obtained before, and at
3 months after the procedures using a digital camera,
showed nearly similar results (Table 2) with
excellent improvement via HIFU (60.00%) as
compared to LAL cases (66.66%). The degree of
the participants' satisfaction was satisfactory and
nearly close among cases of both groups.
The participant's assessment of adverse effects,
showed higher percentage of side effects with LAL
rather than HIFU (53.333% versus 13.333% respectively)
and their opinions about whether they
would like to undergo further HIFU treatment was
satisfactory 80% as compared to LAL who showed
only 40% who would reuse the same procedure.
46.666% of group I confirmed that they would
recommend LAL to others; 93.333% of the participant
of group II would recommend HIFU to others
(Tables 3,4).
Immediately after the application of LAL, the
mean VAS score was 6.333±0.8997, and improved
after 3 months was 4.4±0.91. However immediately
after the application of HIFU the mean VAS score
was 2.13±0.915, but no pain was reported after 3
months.
Table (1): Demographic characters of the participants.
Group I (LAL)
Variables
Age (20-45):
• 20-30
• 31-35
• 35-40
• 40-45
BMI (<35):
• Normal (18-24.9)
• Overweight (25-29.9)
• Obese (30-35)
Participant's level of
education:
• Primary education
• Intermediate education
• High school education
• University education
Participant's Job:
• House wife
• Working
Degree of redundant
submental fat and skin
laxity of the neck and
jowls according to Baker
classification:
• Type 1
• Type 2
Number
1
3
4
7
1
3
11
1
1
3
10
2
13
5
10
Group II (HIFU)
Percentage
6.666%
20.00%
26.666%
46.666%
6.666%
20.00%
73.3%
6.666%
6.666%
20.00%
66.666%
13.333%
86.666%
33.333%
66.666%
Number
1
1
4
9
1
1
13
0
1
1
13
5
10
3
12
Percentage
6.666%
6.666%
26.666%
60.00%
6.666%
6.666%
86.666%
0.0%
6.666%
6.666%
86.666%
33.333%
66.666%
20.00%
80.00%
Table (2): Clinical improvement of the skin laxity in the areas
of the neck and chin.
Group I (LAL)
No improvement
Mild
Moderate
Excellent
Number
0
2
3
10
Group II (HIFU)
Percentage
0.00%
13.333%
20.00%
66.666%
Number
0
1
5
9
Percentage
0.00%
6.666%
33.333%
60.00%
Fig. (5B): Post-operative photos after laser assissted liposuction.
Fig. (5A): Pre-operative photos of a case with double chin
deformity.
DISCUSSION
There is paucity of the clinical trials directed
towards options for treating the aging neck. In
term of skin laxity particularly, the gold standard
of treatment remains rhytidectomy or facelift. In
any case, there has been a sensational move towards
non-surgical methods, as the patients look for to
attain skin tightening with no or negligible downtime
[3]. Liposuction is considered the gold standard
for surgical removal of fat to manage the double
chin and up to 25% of liposuction procedures target
the submental region [16].
Few studies have confirmed the use of HIFU
for skin tightening particularly in the area of the
neck and its use for submental fat that causes the
appearance of the “double chin”. Therefore, this
study was carried to compare between the use of
the invasive technique LAL in group I versus the
use of non-invasive procedure HIFU in group II,
in neck lift and contouring of the double chin. The
age in group I (40±5.168) and group II (39.53±
5.3966), reflecting that the willingness of the
aesthetic procedures increases with increase age,
particularly in late thirties and the fourth decade
of age.
The neck undergoes extrinsic and intrinsic aging
changes in all anatomic layers for the specialist,
116 Vol. 44, No. 1 / Comparative Study of HIFU versus Laser Assisted Liposuction
being talented in nonsurgical cervical rejuvenation
is critical, as many patients may need for nonexcisional
cervical enhancements, alone, or in
combination with other facial restorative surgical
strategies.
Several studies confirmed the same results as
the current study, increasing the BMI leads to a
relative broadening of the midface and lower face
and that individuals with lower body fat proportion
have a more angular face with moderately narrower
cheeks and a pointed chin [17-19].
In our study, the clinical improvement showed
excellent improvement of the skin laxity in the
areas of the neck and chin after three months for
both procedures, with nearly similar results via
HIFU (60.00%) as well as LAL cases (66.66%).
Evidence based studies confirmed the efficacy of
HIFU skin-tightening devices [20].
Suh et al., in their studies reported that HIFU
was a safe and effective modality for skin tightening
of the [12]. Park et al., unlike all previous studies,
evaluated each part of face after HIFU treatment,
they detailed that the clinical effects of HIFU were
similar in all areas, where improvement was prominent
after 3 months and showed a gradual decrease
with time [20]. Studies reported that HIFU showed
the highest level of neocollagenesis and neoelastogenesis
in the reticular dermis [21].
Laser lipolysis and ultrasound-assisted liposuction
treat fat in a manner different from conventional
liposuction; where fat is removed via cavitation,
via the implosion of adipose cells followed
by lysis and emulsification [22]. It helps remove
those areas of redundant and prolapsed fat whereas
countering skin laxity, and address both jowl formation
and submental flaccidity via stimulation
of neocollagenesis in the dermal layer overlying
the fatty layer being treated through secondary
photothermal effect, enhancing the elasticity of
the skin and facilitating the skin contraction in the
operative region, yet with mild trauma [23]. This
goes with the excellency of our results in group
one who used LAL.
Jianu et al., in their results showed a significant
improvement in the fat distribution, the skin condition
and the contour correction in all the patients
treated with LAL, which was noticeable at 10 days'
post-treatment [23].
LAL with liposuction has a statistically significant
effect on skin shrinkage and tightening of
the skin in the abdominal area when compared to
liposuction alone [24]. Therefore, all evidence based
Table (4): Participants' opinions following either procedures.
Group I (LAL)
Participant assessment of the
adverse effects:
Yes
No
Whether they would like to
undergo further treatment
using the same procedure:
Yes
No
Whether they would
recommend the same
procedure to others:
Yes
No
N
8
7
6
9
7
8
Group II (HIFU)
Percentage
53.333%
46.666%
40.00%
60.00%
46.666%
53.333%
N
2
13
12
3
14
1
Percentage
13.333%
86.666%
80.00%
20.00%
93.333%
6.666%
Table (3): Patient satisfaction after three months via Patient
Satisfaction Questionnaires (PSQ) score.
Group I (LAL)
1 (Not satisfied)
2 (Somewhat satisfied)
3 (Satisfied)
4 (Very satisfied)
5 (Extremely satisfied)
Number
1
3
2
6
3
Group II (HIFU)
Percentage
6.666%
20.00%
13.333%
40.00%
20.00%
Number
0
2
6
5
2
Percentage
0.00%
13.333%
40.00%
33.333%
13.333%
Egypt, J. Plast. Reconstr. Surg., January 2020 117
studies confirmed the role of laser lipolysis to
liquefy the adipose tissue and stimulate neocollagensis,
yet more results are needed to assure its
role in neck tightening and double chin.
The degree of the participants' satisfaction after
three months was satisfactory and nearly close
among cases of both groups (13.33-40.00%) in
group I and II were of variable degree of satisfaction,
only 6.66% were not satisfied with the results
in group I. Senra reported high satisfaction with
laser lipolysis (93.2%) [22].
The participant's assessment of adverse effects,
showed higher percentage of side effects with LAL
rather than HIFU (53.33% versus 13.33% respectively)
and their opinions about whether they would
like to undergo further HIFU treatment was satisfactory
80% as compared to LAL who showed
only 40% who would reuse the same procedure.
Only 46.66% of group I confirmed that they would
recommend LAL to others as compared to 93.33%
of the participant of group II would recommend
HIFU to others.
The results obtained with laser lipolysis when
used as an adjuvant to conventional liposuction,
has proved to improve the patient recovery, particularly
for contouring the irregularities after liposuction
treatment [22].
Ko et al., evaluated the viability and safety of
HIFU in skin lifting and demonstrated that the
unfavorable impacts were restricted to transient
pain in most patients and occasional erythema or
ecchymosis in some patients. Also, Nayak in his
study to evaluate the efficacy of HIFU for neck
lifting detailed no pain at 4 and 12 weeks posttreatment
and no serious side effects during the
follow-up [25].
One of the limitation of our study, is the small
sample size, and the relatively short follow-up
period of less than 6-months with inclusion of only
young female patients which hinders the generalization
of our results and in evaluating the degree
of satisfaction from the procedure we only applied
it to the patient not to the aesthetic surgeon too.
One of the main strengths of this study, is that
it is the first study, to best of our knowledge, to
assess both LAL and HIFU in the skin tightening
in that region (the neck) and eliminating fat in the
submental region with either a minimally invasive
surgical procedure (LAL) or (HIFU), a totally noninvasive
procedure and compare both techniques
and assess the satisfaction with the results posttreatment.
Based on our results, we recommend a Handson-
training preceptorship then beginning with
larger body cases and to start working in the neck
and face with conservative parameters and further
studies to generalize the use of HIFU in neck lifting
and chin contouring.
Conclusions:
Finally, we conclude that LAL though a very
promising treatment for these areas and a good
alternative to open, excisional surgery, with longlasting
results in selected patients. Whereas, HIFU
is considered safer, more rapid, effective, and
noninvasive procedure for neck tightening, to
improve the skin laxity and is particularly effective
in improving the skin tone, facial contour and
lesser incidence of subjective symptoms such as
tightness or tension on the skin, and no postoperative
edema, bruises or need to wear corset.
Conflict of interest:
The author declared no conflict of interest.
