High-Intensity Focused Ultrasound (HIFU) has become a gold standard in non-invasive skin lifting and tightening. For beauty clinics, dermatologists, and medical spas, understanding and implementing the correct treatment protocol is critical not only for client satisfaction but also for safety and long-term results. This blog dives into the comprehensive HIFU treatment protocol—from indications to parameters and aftercare—so professionals can confidently deliver effective and safe procedures.
Indications: Who is the Ideal Candidate?
HIFU is most suitable for individuals experiencing:
- Mild to moderate facial and neck skin laxity
- Fine lines and early-stage wrinkles
- Subtle jawline or facial contour loss
- Those who wish to delay surgical interventions
Absolute and Relative Contraindications
Absolute Contraindications
- Patients with active herpes virus infection in the treatment area.
- Patients with highly sensitive facial skin.
- Patients with active dermatological conditions exhibiting Koebner phenomenon.
- Patients with unhealed local wounds or active systemic diseases or localized infectious skin conditions that may interfere with healing.
- Pregnant or breastfeeding women.
- Patients with psychiatric disorders or unrealistic expectations of treatment results.
- Patients with severe systemic diseases.
- Other contraindications as determined by the physician.
Relative Contraindications
- Metal implants in the treatment area.
- Severe or cystic acne in the treatment area.
- Severe obesity or significant body weight fluctuations (BMI over 30 kg/m²) in patients seeking treatment.
- Excessively loose facial skin with severe wrinkles and folds.
- Severe photoaging.
- Patients with severe elastosis or facial paralysis.
- Patients prone to keloids or with a keloid constitution.
- Continuous use of systemic corticosteroids or undergoing immunotherapy.
- Use of psychiatric medications, warfarin, or heparin in the past 2 weeks.
- Patients with implanted pacemakers or defibrillators should be treated with caution.
Treatment Area Markings
- Begin 1.5 cm above the lip tip, following the outer brow, orbital rim, and infraorbital bone as the inner boundary line (area inside is prohibited).
- Forehead and periorbital area: Draw arcs from the outer canthus along the hairline and 1 cm outward from the mouth corner; mark vertical lines at 2.5 cm intervals within the area.
- Mark 1.5 cm outside the mouth corners and in front of the ears; draw lines connecting the nasal ala to the highest point below the ear, passing through the previously marked points.
- Submandibular area: Draw a line from the mandibular margin to 1.5 cm in front of the ear; draw vertical lines from the midpoint of the chin to the ear, and from the upper edge of the thyroid cartilage to the submandibular region—this area is designated for treatment.
Treatment Line Drawing Zones
- Includes the bony orbit area, including the upper eyelid and periorbital region.
- Mid-temporal area down to below the cricoid cartilage and above the sternal notch, within the lateral edges of the trachea (avoid the Adam’s apple, vocal cords, and thyroid).
- Regions with dense nerve branches, such as the infraorbital foramen, supraorbital foramen/notch, great auricular nerve area, and facial nerve zone.
- 1.5 cm anterior to the ear and 1.5 cm inward from the mouth corners.
- Depressed facial areas, like the cheeks and temples.
- Bony areas along the mandibular margin.
Treatment Line Marking and Recommendations
- Treatment Head Usage:
- 4.5mm: Not suitable for periorbital area, forehead, neck below the thyroid cartilage, or sunken temple areas.
- 1.5mm & 2.0mm: Commonly used on the entire forehead, face, and neck (excluding the nose).
- 3.0mm: Used based on individual tissue thickness and fat levels.
- Upper third of the face (forehead, upper face, outer canthus, infraorbital area): Each side typically gets 7 shots, totaling around 30–50; distribute accordingly. Slight overexpansion is acceptable.
- Mid to lower face (cheeks): Use 1.5–4.5mm heads; avoid 5mm and 7mm.
- Submandibular area: Use same heads and energy levels as cheeks or slightly lower.
- Neck: Typically use 1.5–2.0mm heads. Avoid 3.0mm or above.
Pro Tip: Always avoid bony prominences, nerve-rich areas (e.g., supraorbital foramen, facial nerve path), and the central throat region.
Reference Treatment Parameters
- Mid to lower face: Use 1.5–4.5mm heads (5mm and 7mm prohibited).
- Submandibular area: Use cheek-equivalent heads and energies or lower.
- Neck: Use 1.5–2.0mm; 3.0mm and above not recommended.
Choosing the Right Cartridge: Depth and Energy Parameters
| Region | Cartridge Depth | Notes |
|---|---|---|
| Forehead / Temples | 1.5mm / 2.0mm | Thin skin, avoid high energy |
| Cheeks | 3.0mm / 4.5mm | Treat deeper for lifting |
| Jawline / Chin | 3.0mm / 4.5mm | Use light pressure |
| Neck | 1.5mm / 2.0mm | Avoid 3.0mm+ heads |
Guideline Tips:
- Start from deeper to superficial, bottom to top, and inside to outside.
- 1.5mm and 2.0mm: For epidermal firming and pore refining
- 3.0mm: For dermal tightening
- 4.5mm: For SMAS lifting
Key Operating Techniques & Peri-Treatment Management
Consistency Principles
- Avoid treating upper eyelids, vocal cords, and thyroid area.
- Avoid high-energy use of 3.0mm+ heads near nerve clusters (e.g., infraorbital foramen, supraorbital foramen/notch, auriculotemporal/facial nerve areas).
- Avoid using 3.0mm+ heads in sunken lip areas.
- Combine “knife heads” and “shot heads.”
Treatment Depth Recommendations
- Thick subcutaneous fat: Start with 4.5mm, followed by 3.0mm, then 2.0mm/1.5mm.
- Loose skin without much fat: Use 3.0mm, 2.0mm, 1.5mm.
- Thin-skinned areas (e.g., eyes, cheeks, neck, depressed zones): Use 2.0mm and 1.5mm.
- Avoid using 3.0mm+ heads in these areas.
General Technique
- Standard order: Deep to superficial, bottom to top, inside to outside. Start with “knife heads,” end with “shot heads.”
- Ensure probe fully contacts the skin, maintain even spacing.
- Do not lift probe off skin until each point is completed.
- For knife heads: Use “fixed height, variable direction,” slow to fast after heating. Keep steady movement.
- When using 4.5mm: Apply light pressure—do not press hard.
- For 1.5mm/2.0mm: Use lower energy and ensure tight skin contact to avoid burns.
Peri-Treatment Management Plan
- Apply sufficient coupling gel to treatment area.
- Avoid treating directly on bony prominences; stop if patients report numbness or pain.
- Inform patients of possible swelling or tingling beforehand.
- Offer oral pain relief 30 minutes before treatment for pain-sensitive individuals.
- Assessment: Take standard before-and-after photos (front/side/45° angle under consistent lighting); consider f-tap or ultrasound.
- Use lower energy with 3.0mm/4.5mm heads; avoid overtreatment.
- Standard anti-aging treatments: Every 12 months.
- Lower-energy or fewer-line treatments: Every 4–6 months.
- 1.5mm/2.0mm-focused treatments: Every 2–3 months.
- Maintenance or pore/skin texture improvement: Every 4–5 weeks.
- Use medical cooling masks for hydration and repair, and ensure proper sun protection.
- Avoid high-temperature environments (sauna, hot baths, etc.) for 48 hours.
- Avoid products with retinoic acid or AHAs.
During Treatment: Application Technique
- Apply coupling gel liberally to ensure effective ultrasound transmission.
- Maintain constant skin contact; probe should not lift mid-shot.
- Use light pressure with 4.5mm heads, stronger pressure for superficial depths.
- Space lines evenly with 2.5 cm intervals, aligned with skin anatomy.
- Avoid excessive shots in one area to prevent thermal damage.
Reminder: If the patient reports excessive pain or numbness, pause immediately and assess.
Post-Treatment Care and Patient Management
To minimize side effects and optimize results:
- Apply cold compresses post-treatment to reduce redness/swelling.
- Advise patients to avoid saunas, hot baths, and sunlight for 48 hours.
- Recommend hydrating masks and physical sunblock for a week.
- Discourage the use of retinoids, AHAs, or harsh exfoliants post-procedure.
Common and Rare Side Effects
Common (Transient):
- Redness, swelling, tightness, dryness (2–7 days)
- Mild jaw soreness or tingling (2–3 days)
Rare (Severe):
- Blisters, pigmentation, nerve irritation (usually resolves in 1–2 weeks)
- Scarring or burns (due to improper energy/depth use)
- Vision risks (extremely rare; avoid eye areas unless properly shielded)
Control treatment depth and energy to avoid burns and atrophic scars.
Have ice packs ready pre-treatment and monitor throughout. If papules or streaky skin elevation occurs, stop immediately, apply cold compress (avoid overextending the ice area), and use corticosteroid ointments or burn creams. If blistering appears, treat cautiously to avoid sunken scars.
Prevent nerve injury by energy control and standardized operation. If it occurs, treat with vitamin B12, steroids, and neurotrophic agents. Most recover within a month.
Eye injury is extremely rare, but improper protection during eyelid treatment may cause acute cataracts. Strict protocol adherence is essential. If it occurs, initiate aggressive treatment.
If nerve-related symptoms occur, recommend Vitamin B12, corticosteroids, or neurotrophic agents.
Treatment Frequency Guidelines
| Goal | Interval |
|---|---|
| Anti-aging lift (standard) | Every 12 months |
| Light maintenance (low energy) | Every 4–6 months |
| Surface rejuvenation (1.5/2.0mm) | Every 2–3 months |
| Skin texture/pore refining | Every 4–5 weeks |
Avoid over-treatment. More is not always better in HIFU.
Mastering the HIFU machine treatment protocol ensures safe, effective, and science-backed results for your clients. By following a structured and evidence-based approach, beauty professionals can confidently integrate this cutting-edge technology into their service offerings. Whether you’re a dermatologist, spa owner, or distributor, understanding these protocols strengthens your credibility and elevates client outcomes.
