[Doctor's Column] Ultherapy Prime: How to Get It Without Cheek Hollows? Why Are Design and the Practitioner's Experience Important? 🤔

With the weather suddenly getting hotter these days, there has been a significant increase in talk about skin elasticity in the clinic. 🤔

 

 

So these days, nine out of ten people who come for consultations ask about lifting equipment. 😄

 

 

Among them, Ultherapy Prime is what we have been asking about particularly often recently. Perhaps because the name itself is so famous, the number of people coming in after seeing reviews on social media or online communities has increased significantly.

 

However, when I do counseling, there is something that everyone has in common.

Teacher, the question is: "What should I do if my cheeks are sunken?" 😥

In fact, there are people who come for consultations out of concern after searching for photos of sunken cheeks on the internet, and others who come after hearing stories from friends and family about how their cheeks became slimmer after getting Ultherapy.

 

I completely understand your concern. Since it is a procedure done on the face, it is only natural to get scared if you hear even the slightest bit about side effects.

Today, I will explain this topic in detail and as simply as possible. I will go through it step-by-step, covering exactly what Ultherapy Prime is, why cheek hollowing occurs, and what you need to check to avoid it.

 

1. What is Ultherapy Prime?

Everyone has probably heard the name Ulthera at least once. It is a device that has been around for so long that it can be considered practically the original among lifting procedures. After receiving approval in the U.S. in 2009, it was introduced to Korea a long time ago and is a representative lifting device that many people have experienced.

 

 

UltheraPy Prime is a new successor model released by Merz, the same company that created Ulthera. Since it is a relatively recent version introduced to the domestic market in 2025, many people who have already experienced the original Ulthera ask about the differences out of curiosity.

 

The principle itself is the same as the existing Ulthera. It delivers high-intensity focused ultrasound (HIFU) precisely deep into the skin, specifically to the SMAS layer, to provide thermal stimulation to that area. To use an analogy, it is easy to understand if you think of it as a method where ultrasound energy is concentrated at a single point to generate heat only at that depth, much like using a magnifying glass to focus sunlight onto a single point to burn paper.

 

 

Then, the tissue in that area slightly coagulates and naturally contracts, simultaneously inducing the regeneration of collagen and elastin. While you may feel a firming sensation immediately after the procedure, the true lifting effect often appears gradually over the following weeks to months as collagen regenerates.

 

 

There is an interesting misconception here: many people think of Ulthera as a laser. Even during consultations, quite a few people mention that they thought it was a type of laser. However, Ulthera is actually a device that uses ultrasound, not light (laser).

 

 

Even though they are both lifting procedures, the energy itself is completely different from the radio frequency (RF) methods used at our clinic, such as Densert or Oligio. The difference lies in the fact that RF generates heat within the tissue itself using electrical energy, whereas the Ulthera series utilizes sound waves—that is, sound energy—to focus on specific depths. 😮

 

 

2. How is Prime different from the existing Ulthera?

 

The biggest difference is the precision of the images that can be checked during the procedure.

 

The existing Ulthera could only visualize up to a depth of 4.5mm using 2D imaging, but UltheraPi Prime enables observation up to 8mm using real-time 3D ultrasound imaging.

 

 

To put it simply, if in the past you could only guess which layer the energy was reaching by looking at a single black-and-white ultrasound image, you can understand Prime as performing the procedure while continuously monitoring a much wider and deeper range on a real-time 3D screen. It is similar to the feeling of driving while looking at real-time navigation, whereas in the past you used to find your way with just a map.

 

Thanks to this imaging technology, the practitioner can now determine with much greater precision whether the energy is currently in the fat layer or has accurately reached the fascia layer. The importance of this is directly connected to the next story.

 

3. Why do cheek hollows occur?

 

The most frequently mentioned side effect of Ultherapy-type procedures is cheek hollowing. This is the biggest concern for those coming for consultations, and since it is often mentioned in online reviews and communities, you have likely heard about it at least once.

 

The cause is generally clear. Ultrasound energy, which should be directed at the fascia layer, is excessively delivered to the subcutaneous fat layer above it, causing fat cells to atrophy or disappear. To use an analogy, it is similar to trying to hit the center of a target, but instead, energy keeps accumulating slightly ahead or at a shallow point, causing the fat in that area to gradually decrease.

 

Cheek hollows are also generally divided into two types.

One type is hollowing that occurs on the side of the cheek, which develops as the space above the masseter muscle (the Prima Setter Space) widens. In particular, for those who have repeatedly received masseter Botox injections to improve a square jaw, this space often already has widened; therefore, there is analysis suggesting that the risk of cheek hollowing increases slightly during Ultherapy treatment.

In fact, during consultations, there are some patients who have received masseter muscle Botox multiple times and ask about this in advance. In such cases, we ask about their Botox treatment history and go through a process of examining the fat layer and muscle condition in the side cheeks more thoroughly.

 

Another type is the hollowing that occurs as deep fat decreases in the front of the cheeks and below the cheekbones. Since this is an area where fat naturally diminishes with age, it is a part that requires relatively more attention for those who already have less deep fat.

 

Since the underlying mechanisms of these two areas are fundamentally different, it is crucial to identify which structure is more vulnerable before the procedure. This is precisely why results vary even when receiving the same Ultherapy treatment, as each person has different facial structures and fat distributions. 🤔

 

 

4. To receive a shot without cheek hollowing - Design and experience are key.

 

There is something I always emphasize during consultations. Even with the same equipment, the results can vary completely depending on where, at what intensity, and how many shots you take. While the performance of the equipment itself is certainly important, I believe that how you use it determines the outcome much more.

 

To avoid cheek hollowing, three main factors must work together.

 

The first step is to check the individual's fat distribution and skin thickness. Since the areas of fat distribution vary from person to person, ignoring this and simply following a fixed pattern can result in excessive injections for those with thinner fat. For instance, individuals who typically have less cheek fat and a slender face are more likely to have a thinner fat layer, so the intensity and number of shots often need to be adjusted more cautiously than standard guidelines.

 

The second step is to use real-time video to accurately reach the fascia layer while avoiding the fat layer. This is where the 3D imaging feature I mentioned earlier truly shines; you must be able to continuously monitor whether the energy is currently in the fat or fascia layer during the procedure. If you proceed relying solely on intuition without verifying the layers on the screen, risks will inevitably remain, no matter how advanced the equipment is.

 

The third factor is ultimately the operator's experience. Even when looking at the same ultrasound image, the eye for interpreting and judging it inevitably varies depending on the operator's experience. Applying a shallower touch to one area or a bit more caution to another—such subtle adjustments can affect the outcome. In particular, since almost no one has a perfectly symmetrical face, there are many cases where the know-how for fine adjustments is required rather than proceeding with identical settings on both sides.

 

Of course, even if you take all these factors into account, the effects and reactions may vary depending on the individual. Temporary reactions such as swelling, bruising, redness, and pain are common, and it is also advised that rare reactions such as white streaks may occur.

 

Even if cheek hollowing occurs, mild cases usually recover gradually over 6 months to a year, while severe cases may require supplementary procedures such as fillers or fat grafting. However, I would like to emphasize once again that it is much more important to plan carefully from the beginning to avoid the need for such corrective treatments.

 

 

5. Make sure to ask these things during the consultation.

 

If you are considering Ultherapy Prime, I recommend asking these questions during your consultation.

• Is the fat layer on the thinner or thicker side of my cheeks?

• Am I at risk of cheek hollowing on the side of my cheek or the front?

• Will you proceed while monitoring via real-time video?

• I have had masseter muscle Botox injections; will you take this into account when designing?

If you ask these kinds of questions and see if the answers are specific, you will get a sense of how personalized the treatment plan is ✨ If the answers to your questions are vague or you feel like the same settings are being applied to everyone, it is a good idea to think about it a little more carefully.

 

Among those considering a lifting procedure, many also consider Softwave, which delivers ultrasound energy to the mid-dermis layer, or Dencerty, our clinic's flagship monopolar radiofrequency device, in addition to Ulthera. Dencerty is a needle-free monopolar radiofrequency device that stimulates collagen with heat to help improve elasticity and pores. Since its energy delivery method and depth differ from the ultrasound-based Ulthera, the choice may vary depending on your skin condition and desired results.

 

Even within the same lifting procedure, the energy methods and depths differ, so it is much more helpful to consult with a specialist to determine the method best suited to your skin condition. Rather than assuming that one piece of equipment is unconditionally better than another, it is best to view this as a process of finding the equipment and settings that fit your facial structure and concerns.

 

I’ve explained this a bit at length today, but the core point is simple. While using good equipment is important, how you design with it and how you handle it plays a much larger role in reducing concerns like cheek hollowing. 🥹

 

The face is a body part where there is no single right answer, especially since left-right asymmetry and fat distribution vary from person to person. That is why I believe it is truly important to have a thorough conversation during the consultation and work together to create a plan tailored to your specific face.

 

If you have any questions, please feel free to contact us for a consultation. 😊

 

※ This article is intended to provide general information about the procedure and does not replace diagnosis or treatment.

※ This post was written directly by a practicing physician for the purpose of providing medical information in compliance with Article 56, Paragraph 1 of the Medical Service Act.

※ Since the effects and side effects after the procedure may vary depending on the individual, we recommend consulting thoroughly with medical staff.