Although not everyone experiences pigmentation or acne throughout their lives, sagging skin is an inevitability. Since it can happen to everyone, it is useful to understand more about facial sagging even if it does not bother you at the moment. The increasing demand to tighten and lift sagging skin has caused many devices and many different technologies to surface.
My experience as an aesthetic doctor says that many devices are based more on hype and myth rather than reality. I have written this guide to help you find the best HIFU treatment in Singapore.
I have included the different brands of HIFU treatments, benefits, side effects, up to the cost for each HIFU treatments. I hope this article can help you decide which treatment suits you!
What is HIFU?
HIFU stands for high-intensity focused ultrasound and is an advanced medical technology that uses focused sound waves to treat medical and cosmetic problems in tissues.
It is special because it can be directed at deep layers of tissue without harming the surface, hence it does not require a cut in the skin, and it is a completely non-invasive treatment.
The first HIFU treatments were developed to treat tumour growths in the body (benign and cancerous). Today, HIFU is a popular medical aesthetic treatment for its ability to tighten different skin layers non-invasively. 
What are the different brands of HIFU in Singapore?
HIFU further splits into micro and macro focused technology. 
- Macro-focused HIFU is usually used for the removal of unwanted fat tissue.
- Micro-focused only damages or removes very small columns of skin tissues, with the main purpose of contracting the target layers and stimulating collagen.
However, some brands only have either technology, hence limiting its application.
Type of HIFU
Both micro and macro-focused
Body slimming and tightening
Body slimming and tightening
What are the benefits of a HIFU treatment?
HIFU aesthetic treatments can tighten skin at different layers without harming the surface skin.
This can be very useful for treating facial sagging, which can occur at MANY layers from the deep retaining ligaments to the retinacular fibres within fat compartments and skin.
Sagging is more than just skin deep and this diagram shows the different layers where the loss of collagen and sagging can occur.
Additionally, the renewal of multiple tissue layers can lead to a rejuvenating effect on the skin. This is a result of the stimulation of growth factors in the deeper skin layers, resulting in collagen growth and overall skin rejuvenation. Patients often comment that their complexion improves and pigmentation appears clearer (even though this is not the main intended effect). 
How does a HIFU treatment work?
Special ultrasound transducers direct the ultrasound energy to a small focal point where high temperatures causes tissue coagulation. Similar to medical imaging, the focused beam of ultrasound energy can be made to pass harmlessly through the skin. This allows the focal point to target deeper tissues, such as the fat or muscle layers, where protein around the focal point will reach over 65°C and lose their structure (be denatured) almost instantly. By targeting highly focused ultrasound energy in different depths within dermal and subdermal tissues, HIFU causes discrete thermal coagulation points while sparing adjacent non-target tissues. The tightening of different depths allows the stiffening of different saggy tissues, from saggy ligaments to pendulous fat areas, all the way up to skin laxity and wrinkles. 
This video illustrates how it works.
How is HIFU different from other non-surgical skin tightening procedures?
With HIFU, your doctor can tighten your skin at specific depths, regardless of skin type or colour.
Let’s take radiofrequency and laser skin tightening for comparisons with HIFU. Unlike HIFU, radiofrequency skin tightening is very dependent on each individual’s skin impedance (which varies greatly), while laser skin tightening is dependent on the skin type or colour of the individual, depending on the laser used. 
Even though HIFU aesthetic treatments have seemed mild immediately after treatment, the long term results are visibly noticeable when used appropriately.
How long does it take to see results from treatment?
There are mild results right away after a treatment (mostly from immediate mild swelling and tightening). The full effect can be seen after 2 to 3 months due to the time the collagen fibres take to mature. 
Some long term results that are noticeable include:
- Firmer skin and less sagginess
- Smoother face contours
- Lesser wrinkles and pores
- Brighter skin
How long do the results of HIFU last?
The results from a properly done HIFU treatment can last for years, but not indefinitely.
Gravity and the aging process will ultimately reverse the benefits of HIFU, but the collagen synthesised from your own body persists for years even after a single treatment. Moreover, patients who usually go for yearly treatment can upkeep and further improve results.
Is HIFU safe?
HIFU aesthetic devices are considered medical equipment and should only be used at licensed medical centres. There is a broad and inexhaustible range of brands due to the wide interest generated around HIFU treatments, so not all HIFU treatments offer the same safety or efficacy. In general, inappropriate use and poor techniques account for most of the side effects. The cases I witnessed in my career with severe side effects after HIFU treatment come from top branded equipment.
What are the side effects of HIFU?
Even though it is considered a safe treatment due to the precise placement of energy, there can be 2 types of side effects, expected or unexpected:
- Expected risks include:
- Mild discomfort during and after the treatment (most common).
- Mild swelling, especially after aggressive treatment.
- Rarely, mild bruising can occur.
- Mild skin irritation and redness right after treatment may occur, especially when using more surface transducers (1.5mm or 2mm). This usually disappears after a few hours.
- Unexpected risks and rare side effects can happen from poor technique or placement:
- Striated patterned “embossing” or swelling on the skin surface from poor contact of the transducer on the skin and poor technique.
- Muscle weakness and skin numbness with major nerve damage from a poor understanding of proper anatomy and placement of transducers.
- Fat loss and facial sunkenness, usually from excessive treatment at the wrong depth.
How much does it cost for a HIFU treatment in Singapore?
Cost mostly depends on three factors
- Brand. For example, Ultherapy charges more than 10x the price of consumables from other branded HIFU treatments - this cost is passed on to consumers.
- Treatment time, larger areas require more time and are more expensive.
- Expertise and experience of the doctor.
HIFU for smaller areas can start from less than SGD 500 (usually what you see on advertising promos), all the way up to SGD >6000 for larger areas.
Beware of “mini-HIFUs” that either try to upsell you with cross services or persuade you to repeat a small HIFU treatment regularly. “Mini-HIFUs” rarely reach the baseline intensity needed for an effective treatment.
How many HIFU sessions do I need?
It depends on which HIFU machine your doctor uses. Generally, treatments require you to come in only once every 6-12 months. If your doctor says you need to come in for treatment more frequently, ask them why and what machine they use so that you can research the equipment yourself.
Where can I go for HIFU treatments?
You can go for HIFU treatments from doctors, who uphold the gold standard for such treatments. You may have heard of certain spas providing ‘HIFU’ too.  These spas are not medically trained and there is no guarantee that your beautician will understand safety procedures nor techniques. These spas may also ask you to come in for treatment once every month or every fortnight. HIFU is a strong treatment and you should only go for treatment generally once every 6-12 months.
Am I suitable for HIFU?
A good selection is extremely important for the best results because not everyone is suitable for HIFU. HIFU is usually suitable for almost everyone with facial sagging, but it is less suitable for those with either:
- A lot of volume loss. Fillers or other collagen stimulators are more useful.
- Too much sagging or individuals with extremely damaged skin. The repair process is slow or insufficient to make much of a difference. 
How do I get the best results from HIFU?
It is very important to get a detailed clinical consultant to determine your problem and the various treatment options. A clinic that has various treatment options is more likely to give you an unbiased opinion of how HIFU can work for you. Therefore, you have to make sure:
- You find a doctor who is patient and knowledgeable in explaining the various options and who knows how to say NO to you when it’s unsafe or unnecessary.
- To look for someone experienced with many patients under his/her belt and with credible before and after case studies to show you.
- Be open to other treatment options if they are necessary to manage your particular concern. For example, some medical problems only require 1 type of medicine, whereas different diseases may require more than 1 type of medication or even other medical interventions. You probably won’t reject another medication type if your doctor told you it was necessary for your treatment, so be open to different treatment options if you’re looking for a proper medical solution!
When can I see results and how long do they last?
You will generally see results from your HIFU treatment after 2-3 months. As HIFU stimulates collagen production, how long the results last depends on your body.
Dr. Chua Cheng Yu teaching at a regional Ultraformer 3 training session
There are multiple methods for facelifting, both surgical and non-surgical. HIFU remains an extremely useful tool in non-surgical facelifts and has stood the test of time, holding ground despite rapid medical advancements.
However, take note that many other treatments offer a different dimension of the non-invasive face lifting with new exciting options such as:
- LDM-Med which uses another type of ultrasound (HFUS) to provide cell massage and a completely regenerative way of generating collagen.
- Ultra-long pulse lasers such as the Fotona PIANO which can reach as far as bone deep on the face (who says lasers can only be used on the skin surface for texture and complexion??).
- Mucosal lasers can tighten and plump up the skin. Mucosal lasers are used inside the mouth or the eyelids, uniquely developed by Fotona (SMOOTH).
These options can be complementary depending on the individual's skin type and the biggest concern.
Injectable collagen stimulators are also a frequent complement with HIFU treatments (since HIFU treatments cannot replace lost volume) - studies have shown that these injectables are especially synergistic with HIFU since they target different aspects of a facelift treatment, so be open to injectables if you want optimal results! They are not a must, but they can be very helpful in some cases. 
If you are still unsure of which treatments to choose, I would suggest you consult your trusted doctor.
Dr. Chua Cheng Yu (Veritas Medical Aesthetics) is a frequent trainer at medical seminars. He often shares his knowledge on multiple aesthetic technologies, including the Ultraformer HIFU and Teosyal fillers. Besides that, his clinic mirrors his philosophy of functional aesthetics: holistic health and beauty. Also, in his spare time, he plays the piano, dabbles with amateur photography, and maintains a personal blog.