Ultrasound has been a topic commonly discussed at international congresses and described in the literature for more than 12 years.1-8 Yet, despite its clear potential in enhancing dermal filler safety, it still hasn’t become a mainstream tool in aesthetic practice. Here, we explore the benefits and limitations of ultrasound and where its future lies in clinical practice.
Using ultrasound in practice
A simple literature search reveals dozens of papers on ultrasound and dermal fillers;3 many highlight its potential as a non-invasive tool for reducing dermal filler complications,4 monitoring the behaviour of filler implants,4,5 detecting dermal filler sites, quantity, and the nature of the filler injected,2 as well as identifying and managing dermal filler complications.6,7,8
So with rising reports of complications, why hasn’t ultrasound become a common tool in every aesthetic practice?
Phlebologist Dr Leonie Schelke and dermatologist Dr Peter Velthuis practice in the Netherlands and are co-founders of one of the world’s few aesthetic ultrasound training providers – Cutaneous. They have been using ultrasound to aid in complication management and guide their injectable treatments for the past 10 years. The pair suggest that the main reason ultrasound isn’t commonplace in many aesthetic clinics is because historically, device prices have been too high, costing around the same as a large laser. UK-based aesthetic practitioner Dr Alexander Parys, who previously worked in the NHS as a radiologist, believes that the newer, cheaper, hand-held alternatives have increased momentum for the use of ultrasound in aesthetics. While Dr Schelke, Dr Velthuis and Dr Parys all say these smaller devices can have a number of benefits for clinics, they also note that there are limitations and considerations for their use.
Ultrasound-assisted injections and complication prevention
Due to his prior experience in clinical and interventional radiology, Dr Parys purchased a hand-held ultrasound device to assist in injecting platelet-rich plasma into the elbow of his patients to improve conditions such as tennis elbow. “I later expanded to the face as I realised it could be hugely beneficial for complication prevention, particularly vascular occlusion,” he says, explaining, “Although you may know your anatomy and employ safe injection techniques, with variations amongst individuals and higher risk areas, the danger is still there. I’ve found that ultrasound can be a useful tool to identify vessel location and depth and allow you to adapt your injection technique to make sure the filler is being deposited into the correct, lower-risk location.” Dr Parys notes that although he finds it very useful, at the moment he only uses it for higher-risk areas and is not something he routinely does for every patient as he says it can be time-consuming and doesn’t replace good technique, anatomical knowledge, and complication recognition.
Dr Velthuis and Dr Schelke on the other hand, use it routinely. “I use ultrasound to assist my dermal filler injections for every patient and, after a lot of practice, it now only takes me two to three minutes prior to injection. I think it’s a much safer method of injecting and although I still employ other complication prevention practices, if I don’t do my ultrasound examination I do feel a bit worried,” Dr Schelke says, adding, “I will check to see if there is any other filler already injected, try to identify the filler type and, importantly, assess whether there is variation in the vascular anatomy.”
Complication management
All practitioners note the large scope for complication management. In fact, Dr Schelke and Dr Velthuis first began using ultrasound purely to treat complications.
“When I began I was using it once every six weeks to help treat complications. Now, at our complication management centre, we have two full days every week with a waiting list of a couple of months and always use ultrasound,” notes Dr Schelke.
Ultrasound allows for very targeted hyaluronidase injections, Dr Velthuis and Dr Schelke explain, which can be of huge benefit to the patient. “Ultrasound allows you to see exactly where the problem is – such as an obstructed vessel – and this means that you can treat it very precisely and even see the restoration of the blood flow. Instead of injecting the area with 1500 units every hour for example, I would inject once or twice using only 70-100 units. This allows for your patient to require less hyaluronidase because you don’t have to guess where the issue is, and the patient can ultimately go home earlier and recover quicker,” Dr Schelke explains.
Dr Velthuis adds, “Many patients come to us after their practitioners have tried to resolve their complication and have already been injected with hyaluronidase, but just not in the precise location.”
Dr Parys highlights that the uses of ultrasound doesn’t just stop at occlusions. “You can identify an abscess, nodule, oedema and various other types of complications, which can lead to quicker diagnosis. Identifying vascular occlusion is particularly helpful. You can potentially trace the blood supply to/from the area and the blood flow. Even if you had a patient with a clear bruise and you just wanted to double-check it wasn’t something more concerning, you can use ultrasound as an adjunct to check for adequate perfusion,” he explains.
Other uses in aesthetic settings
Ultrasound is also commonly used in clinical studies to monitor treatment outcomes and effectiveness. Dr Schelke says she is currently using it to explore how HA integrates into the tissue over time. However, she notes that this requires larger devices with higher frequencies.
Dr Parys explains that he uses ultrasound for other procedures in his clinic, such as body contouring and fat-dissolving injections. “I have an EMsculpt machine – which aims to build muscle whilst simultaneously burning fat – and I like to use ultrasound to monitor the results on the abdomen,” he says. Dr Parys will scan the patient pre-treatment and measure the fat and muscle, then repeat after the end of the treatment plan.
He notes, “It’s nice to be able to explain patients’ improvement to them in a quantifiable way. I especially like using it with patients with diastasis recti after childbirth as I am able to tell them exactly how much they have improved. It doesn’t change safety or protocol but, from a patient point of view, it’s a really nice addition to their treatment. And, as a practitioner, it helps you scientifically validate that your treatments are working!”
Dr Parys adds, “I also use it for fat dissolving assessment for gynaecomastia. It’s important to be 100% sure that it’s the fat, rather than glandular tissue, which is causing the issue and I know I can check this with ultrasound and safely treat.” He also likes to use ultrasound on patients who have previously had implants or metal work to ensure he avoids the area to prevent biofilms.
Enhancing anatomy knowledge through ultrasound
There is a vast array of educational opportunities when it comes to ultrasound, the practitioners note. Dr Velthuis explains that much like cadaver training, ultrasound can give practitioners a whole new appreciation for 3D anatomy. “Textbook anatomy is so different to real-life anatomy, and once you start using ultrasound a lot you are able to form a 3D image of the anatomy in your mind, which is extremely helpful for complication prevention and achieving optimum results. It really made me recognise the anatomy and what’s going on underneath the skin in real time, allowing you to know where you are injecting, exactly what plane you are in and how the filler is responding to this area. What’s amazing is often you are so sure you are in a particular plane, but then you check with ultrasound and realise you aren’t in the layer you thought!”
Dr Parys adds that he has also finds ultrasound extremely useful for continued learning. “Personally, I think training is where the real future lies rather than day-to-day practice. Depending on one’s medical background, the facial anatomy isn’t often something learnt in-depth and, like cadaver training, which can be hard to come by, ultrasound really helps you to visualise all the layers. You also grasp what an injection feels like and can associate it with what it looks like under the skin after looking at it through ultrasound.”
Dr Velthuis says it’s particularly good to understand how tissues react to dermal fillers through movement. He also notes that the apps provided with many hand-held ultrasound devices allow for easy collaboration with others, explaining, “You could be in the mountains injecting someone and be able to show your ultrasound images in real-time to a colleague miles away! The potential for collaborative work is huge and it’s ideal for training, webinars and teaching virtually.”
Limitations
Despite its progression to become more user-friendly, affordable and available, ultrasound still has limitations, according to the practitioners interviewed. Of course, without appropriate training, you can’t simply purchase a device and start using it. “You really have to be trained in how to use the ultrasound and interpret the images for the particular areas you will treat,” Dr Schelke says, adding, “You have to invest time and money to do this.”
A lot of practice is also required, all practitioners note. “You need to practice a lot; it’s like driving a car. Once you have been trained it really does take a couple of weeks to get used to – scanning friends and family is a good approach before integrating it into practice,” Dr Velthuis emphasises.
Although all practitioners say that purchasing a hand-held device is ‘affordable’, they come in lower frequencies compared to larger machines so there are restrictions to the resolution and visible layers. Dr Parys adds that the probes currently available are a technical limitation. He says, “The image quality for the small hand-held devices are actually surprisingly good, but you don’t have the option of different probe sizes and that’s definitely missing at the moment. For larger areas it’s ok, but scanning the tear trough, for example, is very difficult at the moment and we would really benefit from different adapters.”
Alongside this, it can be difficult injecting and holding an ultrasound device at the same time. Dr Parys says, “I like to use it for assessing more challenging and high-risk areas like the forehead/glabella or temple, but personally I find it a bit impractical for day-to-day use for every single filler treatment.”
Dr Parys notes that as ultrasound is very operator dependent, things could be missed, giving practitioners a false sense of security when using it for injections. “Very fine vessels could be missed due to the resolution, and practitioners could also misinterpret the image, so it can’t be your only method of complication prevention and you can’t rely solely on this,” he emphasises.
How will ultrasound progress in aesthetics?
Despite the positives of incorporating ultrasound into clinical practice, it’s still not commonly used in aesthetic clinics. However, Dr Schelke, Dr Velthuis and Dr Parys all believe there is future.
Dr Parys says, “For me personally, I think training is where ultrasound in aesthetics will really excel. It can make a real difference to one’s knowledge of the anatomy which will increase treatment outcomes and reduce complications. I don’t see it becoming mainstream until cheaper, more dedicated devices with better adapters come onto the market, as well as more dermal filler-specific training becomes available.”
Dr Schelke and Dr Velthuis do believe that the future of aesthetics will involve ultrasound. “I think it will become much more mainstream with further device developments featuring higher frequencies and better probes. We are also starting to see many company key opinion leaders train with us, so I think this could have a ripple effect and encourage more to seek training. You can see what you are doing in real time, so the safety and quality of treatments can improve,” says Dr Schelke says, highlighting, “Our patients also like the fact that we use ultrasound! We have patients come to us especially because we use it as they want an ultrasound-guided treatment due to enhanced safety, so that’s something that might influence the market.”
References:
1. Young SR & Bolton PA, Use of high-frequency ultrasound in the assessment of injectable dermal fillers, Skin Res Technol, 2008 Aug;14(3):320-3.
2. Gripped FR & Mattei M, The Utility of High-Frequency Ultrasound in Dermal Filler Evaluation, Annals of plastic surgery, February 2011, 67(5):469-73
3. Pubmed, ‘Ultrasound and Dermal Filler’ Nov 2020, <https:// pubmed.ncbi.nlm.nih.gov/?term=ultrasound%20and%20dermal%20filler&sort=pubdate&page=14>
4. Phumyoo T et al., Anatomical and Ultrasonography-Based Investigation to Localize the Arteries on the Central Forehead Region During the Glabellar Augmentation Procedure, Clin Anat, 2020 Apr;33(3):370-382. <https://pubmed.ncbi.nlm.nih. gov/31688989/>
5. Carvalho Rocha LP et al., Ultrasonography for long-term evaluation of hyaluronic acid filler in the face: A technical report of 180 days of follow-up, Imaging Sci Dent, 2020 Jun;50(2):175-180. <https://pubmed.ncbi.nlm.nih.gov/32601593/>
6. RK Mlosek, et al., High-frequency ultrasound-based differentiation between nodular dermal filler deposits and foreign body granulomas, Skin Res Technol, 2018 Aug;24(3):417-422. <https:// pubmed.ncbi.nlm.nih.gov/29363178/>
7. Schelke LW, Decates, TS & Velthuis PJ, Ultrasound to improve the safety of hyaluronic acid filler treatments, J Cosmet Dermatol. 2018 Dec;17(6):1019-1024. <https://pubmed.ncbi.nlm.nih. gov/30084182/>
8. de Freitas Lima, VG, et al., External vascular compression by hyaluronic acid filler documented with high-frequency ultrasound, J Cosmet Dermatol, 2019 Dec;18(6):1629-1631. <https://pubmed. ncbi.nlm.nih.gov/30838729/>
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10. Philips Lumify 2020. <https://www.philips.co.uk/healthcare/sites/ lumify/transducers>
