By Daebbang
“People around me often say they have had Ultherapy. But I don’t really understand how ultrasound can lift a face. Does it hurt?”
Ultherapy is one of the HIFU (high-intensity focused ultrasound) lifting devices. It focuses ultrasound on a single point inside the skin, much like a magnifying glass, to create a tiny heat point, and the tissue tightens as that spot heals. The key idea is that heat is created inside the skin while the skin surface is left untouched [1, 2]. In a study of a single treatment, the eyebrows rose by just under 2mm on average [3]. In one study the change was most noticeable at about 3 months and in some cases lasted up to 1 year, but other studies found that the results returned to the pre-treatment level by 6 months or by 1 year [4, 5, 6, 7].
HIFU is a treatment that makes a mildly to moderately sagging face a little firmer, and it does not lift sagging skin dramatically the way surgery does. In this article I will explain step by step, starting with what ultrasound does inside the skin, for readers who have never had the treatment.
Are Ultherapy and HIFU the Same Thing?
HIFU stands for “high-intensity focused ultrasound,” which means that ultrasound is strongly concentrated in one place. Ultherapy is the name of a lifting device that uses this principle, and several devices use the same principle (for example, Shurink). In research, HIFU used for facial lifting is also called microfocused ultrasound [4]. In this article I will focus on the principle of HIFU rather than on device names.
How Is Ultrasound Focused on a Single Point Inside the Skin?
You may have tried burning paper with sunlight through a magnifying glass as a child. Sunlight passing through the lens is only warm, but once it is gathered into a single point it becomes hot enough to burn the paper. HIFU works in a similar way. Ultrasound is a high-pitched sound that human ears cannot hear, and it is the same kind of wave used in hospital ultrasound scans. HIFU gathers this ultrasound into a single point at a set depth inside the skin.
The point where the ultrasound converges is heated to about 60~70°C, and the collagen at that spot is denatured by the heat [4]. In an experiment on skin tissue obtained from deceased donors, the depth and size of the heat injury were determined by the power, the exposure time and the focal depth, and the injury formed in a narrow area shaped like an upside-down cone [1]. In the experiments the skin surface that the ultrasound passed through was not damaged, and only small heat points formed underneath [2, 8].
At What Depth in the Skin Are the Heat Points Made?
With a HIFU device, the depth at which heat points form depends on the part attached to the tip. On the face, depths of 1.5mm, 3mm and 4.5mm below the skin are mainly used. Usually 1.5mm targets the dermis, 3mm the layer just beneath the dermis, and 4.5mm the layer called the SMAS. Because higher-frequency ultrasound penetrates less deeply, different frequencies are used for different depths [4].
The SMAS is a thin membrane that wraps the facial muscles. In an experiment using facial tissue from human cadavers, ultrasound could create heat injuries of a consistent size in the SMAS layer alone while sparing the skin surface and the surrounding tissue. The higher the energy and the more densely the heat points were placed, the more the tissue shrank [8].
Ultherapy, Shurink and Other Korean-Made HIFU Devices: What Is the Difference?
Ultherapy and Shurink are both HIFU devices that gather ultrasound into a single point inside the skin to create heat points. The principle is the same and the difference lies in how each device is configured.
A distinctive feature of Ultherapy is that the inside of the skin can be viewed as an ultrasound image during treatment. According to a 510(k) clearance summary from the U.S. Food and Drug Administration (FDA), Ultherapy uses a component called DeepSEE to display ultrasound images down to a depth of 8mm below the skin. This imaging is cleared for checking that the device is in proper contact with the skin and for confirming an appropriate treatment depth, for example to avoid bone. The cleared uses in the same summary are lifting the eyebrow, lifting lax tissue under the chin and on the neck, and improving lines and wrinkles of the décolleté [9].
Shurink Universe is a HIFU device made by a Korean company. According to the company’s materials, there are 4 depth-specific cartridges exclusive to the ULTRA F handpiece (1.5mm, 2.0mm, 3.0mm, 4.5mm) and 3 pen-shaped cartridges (1.5mm, 3.0mm, 4.5mm). In the illustrations in the materials, the normal mode is drawn with heat points placed apart like dots and the MP mode is drawn with them joined like a line. The materials state that they are intended for investors and that details should follow the approval granted by Korea’s Ministry of Food and Drug Safety [10].
How deep and how densely the heat points are made matters more than the device name. Few studies have compared devices such as Ultherapy and Shurink directly under the same conditions, so it is hard to say that one device is better than another. Other Korean HIFU devices work on the same principle, so when choosing a device, check which cartridge depths are used and how experienced the treating doctor is.
What Happens in the Skin After the Heat Points Form?
Two things happen once heat points form. First, the heated collagen contracts on the spot. Then, as the skin heals these small injuries, it makes new collagen over several months [8, 11]. That is why in one study the effect of HIFU was clearer several months later than on the day of treatment [5].
In a Korean study in which 22 people received a single treatment, skin samples from 11 of them were taken before treatment and 2 months later and compared. After treatment the collagen in the dermis had increased, the dermis had thickened and the elastic fibers had straightened [2]. In a study that followed 28 women for 1 year, the face swelled slightly right after treatment and then gradually tightened, with the greatest reduction in volume at 3 months. The skin collagen signal measured by ultrasound was highest at 9 months and was still higher than before treatment at 12 months [5].
When Do the Results Appear and How Long Do They Last?
In a study of 35 people who received a single treatment from the forehead to the neck, doctors comparing photos taken 90 days after treatment judged that the eyebrows had risen in 30 of the 35 people (86%). Eyebrow height measured on the photos rose by 1.7mm on average [3]. A systematic review of 16 studies of a single treatment also found that the eyebrows rose by 0.47~1.7mm. In doctors’ assessments 92% had improved at 90 days and the effect lasted up to 1 year. However, the improvement patients rated themselves was mild, and there were no data beyond 1 year [4].
There are also opposite results. In a study that measured 25 Asian people with 3D photos, the eyebrows rose by 0.47mm on average at 90 days, but by 180 days there was no difference from before treatment. Submental sagging had also improved at 90 days, but at 180 days there was no clear difference [6]. In a review of 11 studies, about half were rated as much improved at 30 and 90 days, but by 360 days most had returned to the pre-treatment level [7]. In an analysis that pooled 17 studies (477 people), HIFU produced a moderate improvement in the face and neck [12].
How long the effect lasts differs from person to person, and the effect of HIFU is closer to “the jawline and eyebrows look a little neater when photos are placed side by side” than to “I look completely different in the mirror.” Rather than judging the result within 1~2 weeks after treatment, it is better to compare photos at about 3 months. The interval between treatments is covered in detail in Shurink Every Month, Ultherapy Every Year? Why Are the Treatment Intervals Different?
Does It Hurt? Are There Side Effects?
There is pain. In an analysis that pooled several studies, the average pain score was 4.85 on a 0~10 scale, which is moderate, but it varied widely between studies [13]. In a study that assessed 93 people, the area under the chin (6.09) and below the lower jaw (6.53) hurt more than the cheeks (5.68) [14]. In a study of 20 people who received a single treatment, 90% felt muscle-ache-like pain after treatment, which went away after a median of 6 days [15].
Common side effects were redness, swelling, bruising and tenderness when pressed, and most were mild to moderate [13]. Rare serious side effects such as altered sensation or nerve injury have also been reported [4, 16], so it is best to have the treatment after a thorough consultation with an experienced doctor. When treatment is done close to the eyes, also check in advance how the eyes will be protected.
Who Is It Best Suited For?
The people in whom an effect was confirmed in studies were mainly women with mild to moderately sagging faces. Very loose skin or a body mass index over 30 was noted as reducing the effect, making these cases in which treatment should be considered carefully [4, 14]. A review also states that surgery remains the main treatment for moderate or more severe sagging [11].
HIFU is a treatment suited to people who want a little more firmness when sagging is just beginning. If sagging has already progressed considerably, it is better to first discuss whether another treatment is needed rather than having HIFU many times. Before treatment, tell your doctor about any recent procedures, current illnesses and medications you are taking.
So What Should I Do?
| Situation | What to do | Reason |
|---|---|---|
| When sagging feels like it has just started | HIFU is worth discussing. Check the change with photos after 3 months | Studies were done in mild to moderate sagging, and in one study the change was most noticeable at about 3 months [4, 5] |
| When sagging has progressed considerably | Rather than adding more sessions, first discuss whether another treatment is needed | The effect was smaller with severe sagging, and a review states that surgery is the main treatment for moderate or more severe sagging [4, 11] |
| When you are on the heavier side | Keep expectations modest when you discuss it | With a body mass index over 30, more than half showed no change [14] |
| When you are worried about pain | Ask in advance how pain will be managed | The average pain was about 5 out of 10 [13] |
| When altered sensation or a sunken area appears after treatment | See a doctor before the next session | Altered sensation and fat loss appear in adverse event reports [16] |
In the next article I will explain in simple terms how radiofrequency lifting works; it also uses “heat,” but with electrical energy instead of ultrasound. If you are curious about radiofrequency treatment intervals, you may want to read Can Frequent Thermage or RF Skin Tightening Make Your Skin Thinner? first.
Take-home messages
- Ultherapy is one of the HIFU (high-intensity focused ultrasound) lifting devices. It works on the same principle as other HIFU devices such as Shurink, and differs in configuration, such as the imaging function, the cartridges and the way energy is delivered.
- HIFU focuses ultrasound, like a magnifying glass, on a single point inside the skin rather than on the surface, creating tiny heat points of about 60~70°C.
- The heat points are made at set depths such as the dermis, just beneath the dermis and the membrane that wraps the facial muscles (SMAS).
- Heated collagen contracts and new collagen forms over several months, and in one study the effect was most noticeable at about 3 months. How long it lasts varied from 6 months to 1 year across studies, and data beyond 1 year are still lacking.
- The effect is moderate and varies greatly from person to person. It is smaller when sagging is severe or the body mass index is high.
- There is moderate pain, and redness, swelling and bruising are common. Rare serious side effects such as nerve injury have also been reported, so it is best to have the treatment after consulting an experienced doctor.
References
[1] Laubach HJ, Makin IR, Barthe PG, et al. Intense focused ultrasound: evaluation of a new treatment modality for precise microcoagulation within the skin. Dermatologic Surgery. 2008;34(5):727–734. DOI: 10.1111/j.1524-4725.2008.34196.x (used a prototype from the device developer)
[2] Suh DH, Shin MK, Lee SJ, et al. Intense focused ultrasound tightening in Asian skin: clinical and pathologic results. Dermatologic Surgery. 2011;37(11):1595–1602. DOI: 10.1111/j.1524-4725.2011.02094.x
[3] Alam M, White LE, Martin N, et al. Ultrasound tightening of facial and neck skin: a rater-blinded prospective cohort study. Journal of the American Academy of Dermatology. 2010;62(2):262–269. DOI: 10.1016/j.jaad.2009.06.039
[4] Contini M, Hollander MHJ, Vissink A, et al. A Systematic Review of the Efficacy of Microfocused Ultrasound for Facial Skin Tightening. International Journal of Environmental Research and Public Health. 2023;20(2):1522. DOI: 10.3390/ijerph20021522
[5] Li X, Xie G, Yang Z, et al. Evaluating the Long-term Effects of Microfocused Ultrasound on Facial Tightening Using Quantitative Instruments: Efficacy and Safety. Aesthetic Plastic Surgery. 2026;50(2):692–706. DOI: 10.1007/s00266-025-05205-z
[6] Lu PH, Yang CH, Chang YC. Quantitative Analysis of Face and Neck Skin Tightening by Microfocused Ultrasound With Visualization in Asians. Dermatologic Surgery. 2017;43(11):1332–1338. DOI: 10.1097/DSS.0000000000001181
[7] Al-Omair A, Bukhari A. Patient satisfaction of microfocused ultrasound treatments on the face and neck laxity: A narrative review. Journal of Cosmetic Dermatology. 2023;22(10):2671–2676. DOI: 10.1111/jocd.15766
[8] White WM, Makin IR, Barthe PG, et al. Selective creation of thermal injury zones in the superficial musculoaponeurotic system using intense ultrasound therapy: a new target for noninvasive facial rejuvenation. Archives of Facial Plastic Surgery. 2007;9(1):22–29. DOI: 10.1001/archfaci.9.1.22
[9] U.S. Food and Drug Administration. 510(k) Summary K233996: Ulthera System (UC-1 Control Unit PRIME). 2024. https://www.accessdata.fda.gov/cdrh_docs/pdf23/K233996.pdf Accessed 2026-11-06. (clearance summary submitted by the manufacturer)
[10] Classys Inc. IR Book: The Investor Relations of Classys 2024. IR Book 1Q24. 2024. p. 7, 12. https://classys.com/wp-content/uploads/sites/2/2024/06/IR-Book_Classys_1Q24_eng_vF.pdf Accessed 2026-11-06. (manufacturer’s investor relations material)
[11] MacGregor JL, Tanzi EL. Microfocused ultrasound for skin tightening. Seminars in Cutaneous Medicine and Surgery. 2013;32(1):18–25. PMID: 24049925
[12] Ayatollahi A, Gholami J, Saberi M, et al. Systematic review and meta-analysis of safety and efficacy of high-intensity focused ultrasound (HIFU) for face and neck rejuvenation. Lasers in Medical Science. 2020;35(5):1007–1024. DOI: 10.1007/s10103-020-02957-9
[13] Amiri M, Ajasllari G, Llane A, et al. Microfocused Ultrasound With Visualization (MFU-V) Effectiveness and Safety: A Systematic Review and Meta-Analysis. Aesthetic Surgery Journal. 2025;45(3):NP86–NP94. DOI: 10.1093/asj/sjae228 (research funding from the device manufacturer; some authors advised the manufacturer)
[14] Oni G, Hoxworth R, Teotia S, et al. Evaluation of a microfocused ultrasound system for improving skin laxity and tightening in the lower face. Aesthetic Surgery Journal. 2014;34(7):1099–1110. DOI: 10.1177/1090820X14541956
[15] Lou Y, Hsieh I, Cai S. Efficacy and safety of micro-focused ultrasound for middle and lower face rejuvenation: A prospective study. Lasers in Medical Science. 2026;41(1):74. DOI: 10.1007/s10103-026-04831-6
[16] Humphrey VS, Rambhia PH, Gmyrek R, et al. Microfocused Ultrasound With Visualization: A Systematic Review of Adverse Events and Risk of Subsequent Facelift Compromise. Dermatologic Surgery. 2025;51(4):424–429. DOI: 10.1097/DSS.0000000000004510
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