We have all seen the recent wave of aesthetic clinics implementing ultrasound into their daily clinical practice. But, Dr Kim Booysen questions is it something you should be considering?
Ultrasound is utilised in most fields of
clinical medicine. Ultrasound allows us to
visualise the anatomical layers of the face,
helps improve practitioners’ anatomical
knowledge and can help in identifying the
correct layers for augmentation.1
Ultrasound
has been shown to make placement of
filler safer and improve results.2,3 Ultrasound
use also improves the identification of filler
complications, allowing practitioners to
accurately and swiftly treat the diagnosed
concern.2,3
Personally, I feel ultrasound use
has increased my anatomical knowledge
and improved my injection technique. My
knowledge of complications and comfort with
addressing these has also increased.
Why did I initially introduce
ultrasound into my
clinical practice?
Ultrasound had been something I had been
thinking about for a while. I had used a lot
of ultrasound when I was working in the
emergency department and I had also
made use of ultrasound with my Ultherapy device. Ultherapy, is an ultrasound guided
lifting and tightening machine, used to
stimulate collagen and elastin production,
through heat stimulation.
Ultherapy uses ultrasound to both
visualise target collagen and deliver
treatment to exact tissue depths.4 So, I
had been visualising superficial tissue
depth for a period of time before actually
purchasing a device. It was after treating
a filler complication, that I bought a
handheld ultrasound device to use in clinic.
I was convinced it would have made the
resolution of the complication quicker and
made the experience less traumatic for
my patient. Although filler complications
are not that common, some calculations
place the incidence at 1:6800, so most
practitioners, especially if they work in busy
clinics, will see filler complications at one
point or another. Ultrasound use can help
identify these complications and aid with
speedier resolution.5
How do I use the machine in
clinic now?
I haven’t used the device for management
of an occlusion as yet, I have however
treated other filler complications. I
have found encapsulated filler nodules
in patients who have had treatment
elsewhere and I have used the device to
look for old filler in all my new patients.
As part of my initial consultation, I now look
for the large blood vessels and vascularly
map these patients. I basically look for big
deviations in recognised vascular patterns
in the face, I look at the quality of the blood
flow before and after treatment and I look
for any previous filler or other treatments
such as threads to see if they are causing
any concerns that need addressing.
Identifying the vascular pattern of a facial
vessel has shown to help injectors take
measures to avoid vessels and in so
avoiding serious complications such as
tissue necrosis or permanent vision loss.6
The ultrasound can be used to visualise
vessels in the temporal fossa, lips, piriform
space, mid-face, nose and locate the facial
artery course.1
Ultrasound is therefore
useful to plan where to place filler. If I can
locate the deep temporal artery or follow
the labial arteries this knowledge then
guides me in how I will place the filler to
get the best result for the patient while
respecting the vascular anatomy and not
putting undue pressure on the vessel.
Ultrasound has also improved my filler
placement in that I am able to identify the
anatomy of the treatment area before
injecting, select a safe area for treatment
and then review if I have placed the filler
in the correct area, such as a fat pad or
periosteal region. In the past we have
relied on tactile feedback to decide if we
are placing filler periosteally or intrafascially,
and on occasion we are not in the correct
place, ultrasound use reinforces the feel
of correct placement and allows early
correction, before complications arise, if the
filler is incorrectly placed.7
How did I train myself in
ultrasound use?
I was lucky in that I had used ultrasound for
eFast scans, placing central and peripheral
lines and looking for cardiac functionality
in an arrest situation, so the fundamentals
and ‘knobology’ of ultrasound was familiar
to me. But facial anatomy was not. I spent
most of lockdown scanning my own and my
husband’s face trying to identify and follow
vessels, looking for muscles and trying to
marry that with the 2D images I had seen
in anatomy text books. I spent a lot of time
looking up what different muscles and vessels
looked like on ultrasound. As with everything
repetition is key. Initially it took me ages to
find the vessels, now with a lot of practice it is
quicker and I can scan and find vessels in a
short time and my treatment times are not that
much longer using the ultrasound.7
Once lockdown finally lifted I was able
to attend training with Dr Leonie Schelke
and Dr Peter Velthius, who are considered
the pioneers of aesthetic ultrasound and
complications management. Merz Aesthetics
UK, also arranged for further training for
the Merz Innovation Partners (MIPs) with
these two thought leaders. The MIPs spent
two days training in facial muscle and
structure recognition and also ultrasound
guided injection. Each MIP now uses a
handheld ultrasound in their clinic to help
with training and treating of patients.8
Lastly
I was privileged to attend Dr Schelke and
Velthuis’ complications clinic at the Erasmus
University in the Netherlands courtesy of Merz
Aesthetics UK. This clinic has been running
since 2011 and received referrals from all over
the Netherlands.5
I was able to observe the
clinic over two days and saw how patients
with hyaluronic acid filler were treated with
ultrasound. I also saw some patients with
permanent fillers. These were identified
with ultrasound and then treated, as much is
possible with a permanent filler. Attending this
clinic, further reinforced the need for accurate
injections technique and for improving filler
safety with ultrasound use.
How did I choose an ultrasound to get started?
I luckily have been able to use two different types of ultrasound devices. Deciding on the one you want to purchase can be difficult as there are advantages and disadvantages to each device. Most handheld devices are light weight, can be charged in a handy desktop charger or charging pad and the images can be viewed on a mobile or iPad. Images are saved to a cloud and can be retrieved on a laptop at a later date. In my clinic I have a separate stand for my iPad and this is set up next to the treatment couch so it is ready to go with each treatment.7
You don’t need to purchase the most expensive machine when you get started. At a minimum you need 4-5cm visualisation depth and a scanning frequency of around 20MHz. This will allow you to visualise all the necessary facial structures. Higher frequencies and shallower depths of penetration are ideal for facial ultrasound as facial structures are rarely deep and therefore a higher frequency will get clearer images of these shallower facial structures.7 Other the years, you may decide to upgrade to a more advanced device, but as an initial device, I have found my handheld scanner perfectly adequate for my needs.7
