How are HIFU and Pelleve different?

Question

Dear Expert Doctors Can you please explain to me in basic terms the difference between HIFU and Pelleve? What advantages or disadvantages does one have over the other? Do they both help in giving a non-surgical facelift? How long do the results last?

Amiya Prasad, MD · Answer

Thank you for your question. You didn’t submit a photo, but ask about the difference between high intensity focused ultrasound (HIFU) versus Pelleve, and if they both lift the face.
I can help you understand this confusion, which is very common. A little background: I’m a Board-certified cosmetic surgeon and Fellowship-trained oculofacial plastic and reconstructive surgeon. I have been in practice in Manhattan and Long Island for over 20 years. I have integrated into my practice many non-surgical modalities to help my patients look their best, beginning with the first CO2 lasers in the mid-90s, to the more modern non-invasive methods including laser-assisted and radiofrequency thermal tightening. I can give you an idea of the principles, and how to distinguish the outcomes most people are looking for.
One of the challenges in our profession with the proliferation of devices and other modalities to help people improve their appearance is that the strategy of device manufacturers is very similar to that of pharmaceutical companies. They are marketing directly to patients, trying to create demand for their product before doctors (not the doctors who do the studies), and clinicians get a sense of whether these devices work as proposed, or it’s a lot of hot air behind them. 
The flavor of the past couple of years was high intensity focused ultrasound (HIFU) and one particular product created so much buzz, and was featured in multiple media outlets. Almost as quickly as it came into the scene within the past couple of years, as what I initially predicted, the results were challenged and disappointing. Even though the manufacturers often don’t claim to provide results that are the same as surgery and facelifts, there’s no shortage of insinuations and implications of a non-surgical facelift.
Before you decide that one particular device is better than another for your needs, it’s very important to understand facial aging. Generally speaking, these devices and brands are sought after by people who are seeing their facial aging process, but want to avoid surgery. Facial aging is two things: volume loss, meaning bone loss, muscle, fat, and soft tissue; then sagging, soft tissue descent, weakening of the tissue, and the connections of the underlying tissue. 
The idea is if you heat up the skin to a certain temperature, you are inducing a collagen remodeling response. Although there can be some tightening effect, there isn’t really a predictable, consistent lifting effect. In no way does any radiofrequency or heating technology from high intensity focused ultrasound, long pulse width laser devices, actually lift - it’s about shrinking and remodeling. You can get improvement in skin tone and skin quality, but you don’t necessarily get vertical lifting. 
One of the things I present in this discussion with my patients who have asked similar questions is I will take their photos, place them on screen, and view three quarter view, side views, and show them what they want often is to pull upward. They do mirror lift, a very common thing people do at home to see how much better they would look. At a certain stage, often in the 40s and 50s, and even later 30s, and as late as the early 60s, volume loss is the dominant issue. The structure underneath has shrunk, and people believe the skin has sagged. 
An alternative to these devices is a procedure we perform in our practice called Structural Volumizing. Structural Volumizing is placing long acting fillers such as Juvederm Ultra Plus and Juvederm Voluma at the bone level to restoring volume in a way that creates the effect of a lift. When you restore volume in the cheeks, jaw angle, jawline, and chin, you’re creating a re-inflation of lost volume that often looks like you had a facelift. 
A strategy could be to combine Structural Volumizing with some skin and  soft tissue remodeling using a thermal energy device. I think it’s important to ask critical questions about this. The principle behind every device from Pelleve, to high intense focused ultrasound is about heating the skin to a critical temperature, and having the skin respond with remodeling of the skin. These are similar outcomes, even though they’re different styles of delivery. 
It’s important to have a consultation by an unbiased doctor who can do pretty much everything, and may or may not have these devices in their practice. What I find is when people get convinced to get a very expensive device in their practice, they end up having to use them. Often, the hype pushes the sale or lease of the device, but when the hype dies away, they’re stuck with the device, so you have to take things with a grain of salt. Be specific about what kind of outcome you want to see. 
I would predict as an experienced practitioner with 20 years of practice, that once someone lifts vertically like this and improves their neck and jawline, it’s not going to happen with a thermal energy device as it just doesn’t work that way. When the face is lifted in surgery, we are lifting not just skin, but  also repositioning soft tissue, and muscle-related tissue, so there’s a lot of work to move, and remove excess skin. Even the most conservative facelift has a fair amount of skin that ends up being redundant. You’re not going to get those kinds of results with a thermal energy device. 
When we do surgery, we do it under local anesthesia with LITE™ sedation. That is a big step in helping people overcome their hesitation about having face lifting surgery. When you do these procedures under local anesthesia with LITE™ sedation, you avoid general anesthesia. Even if you choose never to have a facelift, you have to decide what really matters most for your appearance, and understand there’s always room to achieve a certain goal that meets a desired range of expectations. You can’t get surgical results with non-surgical solutions, but in the modern world where we have opportunities to improve volume and  improve skin quality, we can do a lot of things that are non-surgical and can’t be done with surgery. There really is a potential opportunity for synergy when you put the right modalities together. I hope that was helpful, I wish you the best of luck, and thank you for your question.

David U. Lipsitz, MD, FACS · Answer

HIFU uses ultrasound to create heat energy under the skin to improve skin tightening. Pelleve uses radio-frequency energy to tighten the skin and improve collegen. It is all about realistic expectations of a non-surgical face lift. Many of my patients are trying to avoid plastic surgeons because of a fear of being "talked-into" and unwanted facelift. Many have already had face surgery and did not get the desired outcome. I tend to favor radio-frequency because it has been around much longer, is more accurate to control, and lower cost

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