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<p>Medical Lasers122</p><p>Glabellar wrinkle improvement after forehead and</p><p>periorbital micro-focused ultrasound treatment in</p><p>Republic of Korea: a case report</p><p>Do Hyung Kim, Chong Hyun Won, Joon Min Jung, Myoung Eun Choi</p><p>Department of Dermatology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea</p><p>Microfocused ultrasound (MFU) is a non-invasive treatment modality for skin tightening that induces multiple</p><p>tiny thermal injury zones at focused areas resulting in neocollagenesis and skin lifting. This paper presents a</p><p>38-year-old female treated with MFU in the forehead and periorbital area, showing significant improvement in</p><p>glabellar wrinkles, eyebrow lift, and skin regeneration. The pain during the MFU treatment was minimal, and</p><p>the effects of the improvement in glabellar lines were maintained for eight weeks. The results suggest that</p><p>MFU could be an effective treatment option for glabellar lines.</p><p>Key words: High-intensity focused ultrasound therapy; Rejuvenation; Skin agining; Skin wrinkling</p><p>Case report</p><p>Med Lasers 2023;12(2):122-125</p><p>https://doi.org/10.25289/ML.23.019</p><p>pISSN 2287-8300ㆍeISSN 2288-0224</p><p>INTRODUCTION</p><p>High-intensity focused ultrasound (HIFU) is a thera-</p><p>peutic modality that uses ultrasonic waves as an energy</p><p>source [1]. It conveys high-energy pulses to a spatially</p><p>coordinated manner, resulting in the increased tempera-</p><p>ture of the focused target in a non-invasive manner while</p><p>minimizing damage to surrounding tissue [2]. Initially de-</p><p>veloped and used for the treatment of brain cancer, pros-</p><p>tate cancer, etc., HIFU has widened the application range</p><p>across dermatologic field for skin lifting due to its non-</p><p>invasive and targeting nature [1,3]. The HIFU used for skin</p><p>lifting is technically known as microfocused ultrasound</p><p>(MFU). MFU uses lower ultrasonic energy compared to</p><p>typical HIFU and produces heat over 60ºC at the focal</p><p>point [3,4]. This leads to thermal coagulation points (TCP),</p><p>which in turn induces neocollagenesis and skin lifting</p><p>[5,6].</p><p>MFU has been proven to be effective in skin lifting and</p><p>eyebrow lifting [3,5,7]. A study on the skin tightening effect</p><p>of MFU revealed a mean eyebrow lift ranging from 0.47</p><p>to 1.7 mm at 90 days [8-10]. However, the effectiveness of</p><p>MFU on glabellar wrinkles has not yet been clearly dem-</p><p>onstrated. This case demonstrates the effect of MFU on</p><p>glabellar wrinkles.</p><p>A written informed consent was obtained from the pa-</p><p>tient for the publication of this case report.</p><p>CASE REPORT</p><p>A 38-year-old female referred to the Department of</p><p>Dermatology for eyebrow lifting and skin rejuvenation.</p><p>She was concerning about skin aging around forehead</p><p>and periorbital area. On physical examination, the patient</p><p>showed grade 3 of maximum frown on Glabellar Line</p><p>Scale (GLS) assessed by dermatologist and superficial</p><p>Received June 5, 2023, Accepted June 21, 2023</p><p>Correspondence</p><p>Myoung Eun Choi</p><p>E-mail: mechoi316@naver.com</p><p>ORCID: https://orcid.org/0000-0001-7514-7873</p><p>C Korean Society for Laser Medicine and Surgery</p><p>CC This is an open access article distributed under the terms of the</p><p>Creative Commons Attribution Non-Commercial License (http://</p><p>creativecommons.org/licenses/by-nc/4.0) which permits unrestricted</p><p>non-commercial use, distribution, and reproduction in any medium,</p><p>provided the original work is properly cited.</p><p>https://orcid.org/0000-0001-7514-7873</p><p>Micro-focused ultrasound for wrinkle improvement</p><p>Do Hyung Kim, et al.</p><p>https://doi.org/10.25289/ML.23.019 123</p><p>C</p><p>ase report</p><p>forehead lines (Fig. 1A). When we measured eyebrow</p><p>height from inner canthus at an interval of 5 mm using</p><p>3D Vectra H1-270 camera and Vectra Analysis Module</p><p>software (Canfield Scientific, Inc.), five vertical lines (in-</p><p>ner side 1, inner side 2, middle, outer side 1, outer side</p><p>2) could be assessed (Fig. 2A, D). She received MFU</p><p>(LinearFirm [ULTRAcel Q+]; Jeisys Medical Co., Ltd.)</p><p>treatment on forehead and periorbital area. At first,</p><p>Fig. 1. Front view of the patient with maximum frown of glabella lines before treatment (A), 4 weeks after treatment (B), and 8 weeks after</p><p>treatment (C).</p><p>A B C</p><p>Fig. 2. Front view of the patient before treatment (A, D), 4 weeks after treatment (B, E), and 8 weeks after treatment (C, F). The standard</p><p>photographs of the patient before treatment (A), 4 weeks after treatment (B), and 8 weeks after treatment (C). The photographs taken from 3D</p><p>Vectra H1-270 camera and analysis was performed using Vectra Analysis Module software (Canfield Scientific, Inc.) before treatment (D), 4</p><p>weeks after treatment (E), and 8 weeks after treatment (F).</p><p>20.3620.36 30.4430.44 29.0129.01 27.2027.20 23.7823.78 26.4826.48 29.0129.01 30.2730.27 21.8021.80</p><p>24.2924.29 32.7932.79 30.8430.84 29.2429.24 26.0626.06 27.1327.13 30.1330.13 32.9632.96 23.7523.75 24.7224.72 32.9732.97 30.7630.76 28.5628.56 25.2925.29 26.7526.75 29.8629.86 24.5424.5431.1631.16</p><p>31.9031.90 31.6831.68 32.6032.60</p><p>A B C</p><p>D E F</p><p>Fig. 3. Treatment protocol of the patient. (A) The patient received 372 lines of microfocused ultrasonography (MFU) (LinearFirm [ULTRAcel</p><p>Q+], Jeisys Medical Co., Ltd.) laser on forehead at the energy setting of 0.5 J with 3.0-mm hand piece. (B) Then, the patient received 66 lines of</p><p>MFU laser on both temples and 157 lines on both cheeks under the eyes at the energy setting of 0.35 J with 2.0-mm hand piece. (C) Lastly, the</p><p>patient received 383 lines of MFU laser on forehead at the energy setting of 0.35 J with 2.0-mm hand piece.</p><p>21</p><p>lines</p><p>21</p><p>lines</p><p>40</p><p>lines</p><p>40</p><p>lines</p><p>70</p><p>lines</p><p>70</p><p>lines</p><p>110</p><p>lines</p><p>110</p><p>lines 70</p><p>lines</p><p>70</p><p>lines</p><p>40</p><p>lines</p><p>40</p><p>lines 21</p><p>lines</p><p>21</p><p>lines</p><p>33</p><p>lines</p><p>33</p><p>lines</p><p>79</p><p>lines</p><p>79</p><p>lines</p><p>78</p><p>lines</p><p>78</p><p>lines</p><p>33</p><p>lines</p><p>33</p><p>lines</p><p>20</p><p>lines</p><p>20</p><p>lines</p><p>40</p><p>lines</p><p>40</p><p>lines</p><p>70</p><p>lines</p><p>70</p><p>lines</p><p>70</p><p>lines</p><p>70</p><p>lines</p><p>40</p><p>lines</p><p>40</p><p>lines 20</p><p>lines</p><p>20</p><p>lines</p><p>123</p><p>lines</p><p>123</p><p>lines</p><p>A B C</p><p>Medical Lasers124</p><p>372 lines at the energy setting of 0.5 J with 3.0-mm hand</p><p>piece were applied to her forehead (Fig. 3A). Addition-</p><p>ally, 383 lines and 223 lines were applied to her forehead</p><p>and periorbital area, respectively at the energy setting of</p><p>0.35 J with 2.0-mm hand piece (Fig. 3B, C). The pain was</p><p>tolerable (visual analog scale of 2) without anesthesia and</p><p>she did not experience any side effects after treatment</p><p>except for mild erythema which lasted for only several</p><p>hours.</p><p>At 4 weeks follow-up, the patient showed grade 1 of</p><p>maximum frown on GLS assessed (Fig. 1B). The average</p><p>eyebrow height of the five lines increased 2.49 and 1.43</p><p>mm on right side and left side, respectively compared</p><p>with baseline. The maximum eyebrow height was 2.35</p><p>and 1.80 mm on right side and left side, respectively</p><p>compared with baseline (Fig. 2B, E).</p><p>At 8 weeks follow-up, the GLS scale of maximum frown</p><p>remained 1 (Fig. 1C). The average increase of eyebrow</p><p>height was 2.30 and 1.34 mm on right side and left side,</p><p>respectively compared with baseline. The increase of</p><p>maximum eyebrow height was 2.53 and 1.44 mm on right</p><p>side and left side, respectively compared with baseline</p><p>(Fig. 2C, F). The patient was satisfied with the eyebrow</p><p>lifting and very satisfied with glabella line improvement.</p><p>The patient did not report any adverse effects during the</p><p>follow-up period.</p><p>DISCUSSION</p><p>Face wrinkles are the most obvious sign of aging, and</p><p>therefore a wide range of cosmetic modalities have been</p><p>developed to treat facial rhytides. Among these, glabellar</p><p>lines are perceived as obvious sign of aging and individu-</p><p>als with glabellar lines often seek treatment because</p><p>these wrinkles can deliver erroneous impression of be-</p><p>ing annoyed or angry [11]. Currently, there are various</p><p>methods used to treat these wrinkles, including surgery,</p><p>botulinum toxin A (BXTA), and implants [11,12]. Accumu-</p><p>lating evidence based on clinical trials has indicated that</p><p>BXTA is an effective and safe aesthetic treatment method</p><p>for glabellar lines [11,13]. However, BXTA injection on gla-</p><p>bellar lines could result in several</p><p>side effects such as</p><p>ecchymosis, infection, transient headache, allergic reac-</p><p>tion, blepharoptosis, and periorbital edema [14]. Repeated</p><p>BXTA treatments can lead to permanent muscle atrophy,</p><p>and in rare cases, treatment resistance may occur due to</p><p>antibody formation [15].</p><p>On the other hand, MFU offers advantages over these</p><p>treatment methods as it is relatively less invasive. Fur-</p><p>thermore, MFU does not lead to antibody formation be-</p><p>cause it forms TCP and induces neocollagenesis by tar-</p><p>geting the deep dermis, subcutaneous fat, and superficial</p><p>musculoaponeurotic system layer [6,9]. We observed</p><p>that standard treatment of forehead and periorbital area</p><p>using MFU could lead to the significant improvement</p><p>of glabellar lines in addition to eyebrow lift and general</p><p>skin-regenerating effect. Moreover, the pain during laser</p><p>treatment was minimal even without anesthesia and the</p><p>improvement in GLS score of glabellar lines lasted for 8</p><p>weeks. Therefore, MFU can be considered as an alterna-</p><p>tive treatment option for glabellar wrinkles.</p><p>ORCID</p><p>Do Hyung Kim, https://orcid.org/0009-0007-0015-5132</p><p>Chong Hyun Won, https://orcid.org/0000-0003-1997-2240</p><p>Joon Min Jung, https://orcid.org/0000-0003-3432-8306</p><p>Myoung Eun Choi, https://orcid.org/0000-0001-7514-7873</p><p>AUTHOR CONTRIBUTIONS</p><p>Conceptualization: MEC. Data curation: DHK, CHW.</p><p>Formal analysis: MEC. Investigation: JMJ. Methodology:</p><p>CHW. Project administration: CHW. Software: DHK. Vali-</p><p>dation: CHW. Visualization: MEC. Writing–original draft:</p><p>DHK, MEC. Writing–review & editing: all authors.</p><p>CONFLICT OF INTEREST</p><p>No potential conflict of interest relevant to this article</p><p>was reported.</p><p>FUNDING</p><p>None.</p><p>DATA AVAILABILITY</p><p>None.</p><p>ACKNOWLEDGMENTS</p><p>None.</p><p>SUPPLEMENTARY MATERIALS</p><p>None.</p><p>https://orcid.org/0009-0007-0015-5132</p><p>https://orcid.org/0000-0003-1997-2240</p><p>https://orcid.org/0000-0003-3432-8306</p><p>https://orcid.org/0000-0001-7514-7873</p><p>Micro-focused ultrasound for wrinkle improvement</p><p>Do Hyung Kim, et al.</p><p>https://doi.org/10.25289/ML.23.019 125</p><p>C</p><p>ase report</p><p>REFERENCES</p><p>1. Bachu VS, Kedda J, Suk I, Green JJ, Tyler B. High-intensity</p><p>focused ultrasound: a review of mechanisms and clinical ap-</p><p>plications. Ann Biomed Eng 2021;49:1975-91.</p><p>2. Izadifar Z, Izadifar Z, Chapman D, Babyn P. 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