# 📖 **Nerve Blocks in Ultherapy** --- ## 1. Rationale - Ultherapy targets **deep dermis and SMAS**, where nociceptive fibers are rich. - Pain is most intense when ultrasound energy is delivered over **bony prominences** (orbit, zygoma, mandible). - **Topical anesthesia** has little effect at these depths. - **Nerve blocks** can anesthetize large facial territories without tissue distortion, unlike local infiltration. --- ## 2. Key Nerves for Ultherapy Blocks ### (1) **Supraorbital Nerve Block** - **Anatomy**: - Branch of ophthalmic division (V1, trigeminal nerve). - Emerges from **supraorbital notch/foramen**, ~2.5–3.0 cm lateral to midline of forehead, just above orbital rim. - **Technique**: - Palpate supraorbital notch. - Insert 27–30G needle just superior to orbital rim. - Inject 1–2 mL of 1% lidocaine (± epinephrine). - **Anesthetized area**: - Forehead, scalp up to vertex, upper eyelid. - **Use in Ultherapy**: - Reduces pain for periorbital and upper forehead treatments. --- ### (2) **Infraorbital Nerve Block** - **Anatomy**: - Branch of maxillary division (V2). - Exits through **infraorbital foramen**, located ~1 cm below infraorbital rim, in line with mid-pupillary line. - **Technique**: - Palpate infraorbital foramen by gentle pressure below orbital rim. - Insert needle at mucobuccal fold above maxillary canine → advance toward foramen (intraoral approach). - Alternatively, percutaneous approach directly over foramen. - Inject 1–2 mL of 1% lidocaine. - **Anesthetized area**: - Lower eyelid, side of nose, upper lip, midface. - **Use in Ultherapy**: - Reduces discomfort during **malar and midface treatment**. --- ### (3) **Mental Nerve Block** - **Anatomy**: - Terminal branch of mandibular division (V3). - Exits via **mental foramen**, located below second premolar, mid-pupillary line. - **Technique**: - Palpate mental foramen (slight depression in mandible). - Insert needle at mucobuccal fold near premolars → advance toward foramen. - Inject 1–2 mL of 1% lidocaine. - **Anesthetized area**: - Lower lip, chin, anterior mandibular skin. - **Use in Ultherapy**: - Reduces pain during **jawline and chin tightening**. --- ## 3. General Considerations - **Dosage**: - Lidocaine 1–2% without epinephrine typically sufficient. - Total dose must remain within safe limits (≤4.5 mg/kg plain lidocaine, ≤7 mg/kg with epinephrine). - **Needle**: 27–30G, short length (0.5–1 inch). - **Onset**: 2–5 minutes. - **Duration**: 45–90 minutes (lidocaine), extended with epinephrine. - **Advantages**: - Profound analgesia of large treatment zones. - No swelling or tissue distortion → ultrasound imaging unaffected. - **Risks**: - Hematoma, intravascular injection, nerve injury, transient paresthesia. - Aspiration before injection is mandatory. --- ## 4. Clinical Pearls - Combine with **oral analgesics** (e.g., ibuprofen + tramadol) for multimodal pain control. - Consider nerve block especially for **thin patients** and **jawline/periorbital zones**. - Inform patient of temporary numbness in lip/chin/forehead → reassure that it resolves within hours. --- Excellent. Let’s now go into **Chapter 3.2 Thermage: mechanism, indications, protocols**. As agreed, this section will be **Academic Knowledge in English** only. --- # **Chapter 3.2 Thermage: Mechanism, Indications, Protocols** --- ## 1. Mechanism of Thermage ### **Principle** - Thermage is a **monopolar radiofrequency (RF) device**. - Current flows from an active tip on the skin → through dermis/subcutis → to a grounding pad. - This configuration allows **deep, uniform tissue heating** (up to ~4–6 mm). ### **Physics** - RF energy generates **Joule heating** in tissue. - Dermal temperatures reach ~55–65 °C → collagen denaturation & fibril contraction. - Simultaneous **cryogen spray cooling** protects epidermis (keeps surface ≤ 40 °C). ### **Biological Response** 1. **Immediate**: - Collagen fibrils shrink ~1/3 of original length. - Dermis contracts → subtle tightening effect. 2. **Delayed**: - Heat Shock Protein (HSP) induction (HSP47, HSP70). - Fibroblast proliferation, neocollagenesis, elastogenesis, angiogenesis. - Peak effect 3–6 months after treatment. 3. **Long-term**: - Remodeling continues for up to 12–18 months. --- ## 2. Indications of Thermage ### **Facial** - Mild-to-moderate skin laxity (jawline, nasolabial folds, marionette lines). - Eyelid skin tightening (Thermage Eyes tip, FDA-approved). - Non-surgical brow lift. - Periorbital wrinkles, crow’s feet. ### **Neck** - Submental laxity, platysmal band softening. - Early “turkey neck” appearance. ### **Body** - Abdomen (postpartum skin laxity). - Upper arms (bat wings). - Thighs, buttocks (skin texture & cellulite improvement). - Knees (lax, crepey skin). --- ## 3. Patient Selection - Best suited for **ages 30–55** with mild-to-moderate laxity. - Works well in patients with **thin-to-medium skin thickness**. - Less effective in severe laxity or heavy subcutaneous fat → surgical lift may be needed. - Safe across **all Fitzpatrick skin types** (color-blind technology). --- ## 4. Treatment Protocols ### **Preparation** - Pre-procedure photography and consent. - Skin cleansing, marking treatment zones. - Grounding pad placement (thigh or back). - Coupling gel + return electrode check. ### **Energy Delivery** - **Tips**: - CPT (Comfort Pulse Technology) tips (e.g., 3.0 cm² face tip, 0.25 cm² eye tip). - Single-use disposable tips with limited pulses (e.g., 600–1200 shots). - **Settings**: - Typical energy range: 120–200 Joules per pulse (depends on region). - Pulse duration: ~1–2 sec with cooling spray before and after. - **Technique**: - Overlapping stamping technique (no linear dragging). - Multiple passes (2–4 passes common). - Higher density in laxity-prone areas (jawline, periorbital). ### **Pain Control** - Moderate discomfort → oral NSAIDs, anxiolytics, or topical anesthetic. - Some clinics use nerve blocks (supraorbital/infraorbital/mental). ### **Duration** - Face: 45–90 minutes. - Body: 60–120 minutes depending on area size. --- ## 5. Post-Treatment Care - Minimal downtime: mild erythema/edema resolving in hours. - Avoid excessive sun exposure for several days. - Moisturizers and sunscreen recommended. - Results develop gradually → patient counseling essential to set expectations. --- ## 6. Clinical Efficacy - Studies show significant tightening lasting **1–2 years**. - Improvement rate: 70–90% patient satisfaction in well-selected cases. - Best outcomes: jawline definition, periorbital tightening, forehead lifting. - Less dramatic for heavy jowls or advanced laxity. --- ## 7. Safety Profile - **Common transient effects**: erythema, edema, tingling. - **Rare complications**: - Subcutaneous fat atrophy (usually from overtreatment). - Surface burns (if poor coupling or improper technique). - Neuropathic pain (very rare). - Overall considered **very safe** when performed properly. ---