Dr Kim Booysen explains why you might want to introduce ultrasound into your aesthetic practice and shares her approach for implementation
Facial ultrasound seems to be the latest thing in facial aesthetics. Every time I read new journal articles, it seems to be about ultrasound-guided treatments or investigations. I had seen a few articles about ultrasound in the past but had not really considered its use in clinic.1,2 After dealing with a vascular complication, I became convinced that ultrasound-guided treatments and vascular mapping would make a big difference to my patients’ downtime, and provide an added layer of safety when performing injectable treatments.1 Here, I share my journey of discovery into the use of ultrasound in my clinic.
I initially became interested in facial ultrasound after dealing with a tricky vascular occlusion. Anyone who has dealt with an occlusion is aware that resolution is not instant and often requires repeat injections and daily reviews of the patient.3 I successfully reversed the occlusion and the patient healed uneventfully, but I was convinced the treatment could have been faster and less painful for the patient. If I had been able to doppler and identify the affected vessel by detecting the area of abnormal blood flow using the ultrasound doppler mode,1,4,5 I could then have injected hyaluronidase into the affected vessel under direct visualisation. This would have likely made the resolution and recovery time much quicker. So, I began researching affordable ultrasounds that could be used in a facial aesthetic clinic setting.
There are, of course, other advantages to ultrasound use which I will discuss later in this article, but my primary objective was to help minimise the risk of occlusion and hasten recovery in case of a complication by utilising vascular mapping on my patients. I would aim to scan patients prior to injection to identify and map the location of the large vessels and rescan patients after injection to check the blood flow, and in doing so try to minimise the risk of vascular occlusions by identifying and treating them as soon as possible.
Having worked in A&E, ultrasound was not new to me. I had performed many nerve blocks, central line placements and cannulations under ultrasound guidance. I had also attended several emergency ultrasound courses to be able to perform extended focused assessment with sonography for trauma (eFAST) scans. Offering Ultherapy, an ultrasound-guided lifting and tightening procedure, similarly allowed me to become familiar with superficial facial anatomy ultrasound. So, taking the leap to scanning and vascularly mapping all my new patients did not seem as daunting, and I was quite excited to get started.
For practitioners who have never used ultrasound, the journey will be more difficult. You will need to learn the basics of how an ultrasound works, the types of images you will see, how to interpret the different images, learn to identify different tissues using ultrasound and learn how to optimise the images you see on your screen to best interpret the anatomy you are looking at. You will also need to become acquainted with the doppler function on the ultrasound so that you can identify normal and abnormal blood vessel flow in a vessel. However, I believe ultrasound is a skill that can be learnt by most medical practitioners.4,6
There are several ultrasounds on the market and your choice will depend on your budget, ultrasound skills and how you plan to utilise ultrasound in your practice, so it’s important to do your research before investing. I wanted something lightweight and portable as I work in two locations and provide teaching around the UK and Ireland, so I needed something easy to pack up and go. I also had to consider the battery life as I needed there to be good amount of time before recharging. How the images are transferred and stored is also a factor; the ultrasound device I went with is visualised on an iPad or mobile device and images are stored to the cloud which integrated with my current devices in clinic and made saving images for the clinic records easier and faster. I also purchased a desktop charger, so the machine is always close by and ready to scan. Other machines need the battery to be unclipped and placed in a charger which can make scanning longer and take up more of the appointment time.
In my experience, you don’t need the most expensive machine, but you do want a minimum 4-5cm visualisation depth and a scanning frequency of around 20MHz as this will allow you to visualise all the necessary facial structures. The higher the frequency the smaller the depth of penetration and the bigger spatial resolution. Facial structures are rarely deep and therefore a higher frequency will get clearer images of these shallower facial structures.4 In time, you may want to upgrade to a more expensive machine with higher resolution and therefore better image quality, but as a starter machine I have found my handheld scanner more than adequate.
Depending on the device you go with, there will likely be several add-ons you can choose from when purchasing your machine, such as needle visualisation assistance. Needle visualisation helps you accurately see the needle when injecting under ultrasound guidance. Some companies offer a one-week trial of any add-ons such as needle visualisation assistance. I would advise that you first get accustomed to basic visualising of facial structures and using your machine well before you trial any of these other features, as using advanced features will not be your top priority and this will be a wasted opportunity if trialled too soon.3
Being good at ultrasound takes a lot of practice. I started by scanning myself and my husband – a lot. Lockdown gave me a lot of time to just scan each of the major vessels, identify all the facial muscles, use the different ultrasound functions, and basically play with the buttons on the scanner, until I could identify the major vessels and their tributaries using the colour doppler. Watching the flow of blood vessels is also important to get a sense of what is normal flow in the tissues in a particular area. I then started scanning patients before every dermal filler treatment and identifying the large vessels that should be present in the proposed injection area. I would also look at tissue depths and identify the area I would ideally like to place my filler. Once the treatment was complete, I would rescan the patients to assess my placement and check blood flow to the vessels in the area.
I also scanned patients who reported previous filler or threads to see if the treatments were evident and if the patient was suitable for treatment. Interestingly, I’ve had a patient with a permanent implant request fillers, and after scanning the area I was able to better advise which areas we could augment as fillers are not advised over permanent implants.
It should be noted that visualising old fillers is very complex and requires years of practice and skill. Fillers and treatments are also constantly evolving, and this influences your ability to see these changes in the tissues.7 I would not expect practitioners to be able to accurately identify older filler in the first few months of using facial ultrasound, but with more practice and hours of visualisation, I believe this is a skill that can be learnt over time. There are several ultrasound textbooks and online resources that can help you identify the structures you see when performing ultrasound.4 In-person training is also available, although as this is such a developing field there are limited training providers available in the UK.
Being able to identify filler placement immediately after injection has made me more aware of the need for small, linear thread placement in the deep fat of the mid-face, as this gives better integration in the tissue when viewed on ultrasound. I have also improved my accuracy of placement of periosteal boluses by being able to confirm with visualisation what I had only perceived with tactile sensation when injecting.8 Identifying blood vessels by vascularly mapping a patient has also led to me adapting my injection depths to the individual patient’s vascular bed. This is particularly helpful with lip fillers, as identifying the position of the labial artery in, above or below the orbicularis oris muscle in various areas of the lip, helps with safer placement of the filler (Figure 2).7,9 Other areas that are helpful to scan prior to injection are the chin, jawline, temple and glabellar area as you can identify any large vessels in the area and aim to place the filler away from the vessels you have identified (Figure 3). Often the difference of a few millimetres can make your placement safer and improve results.6,7,9 Patients are also very interested in the ultrasound, and I use it as an educational tool in clinic to talk about safety, correct filler placement, anatomy knowledge and how these can benefit the patient during their aesthetic treatments and any possible complications. As vascular occlusions are rare, I have not had to use the ultrasound during a complication as yet; but I believe I will feel more confident in managing any occlusions.3,6
Ultrasound training and practice will take many, many hours of your time and this can be disheartening in the beginning. You will also need to invest in a machine and attend courses and scan patients until you are able to accurately visualise facial anatomy. Ultrasound will also make your consultations and treatment times longer and it is not cheap. However, ultrasound visualisation is becoming the new standard for injectable treatments as it can improve accuracy, improve anatomy knowledge, help select patients for treatment and assist in diagnosing complications when they arise.6,7 If you are an advanced injector, then I would encourage you to explore introducing ultrasound into your clinic.
Upgrade to become a Full Member to read all of this article.