By Jane Kollmer

Although most people associate ultrasound with monitoring a fetus in utero, it has also become a reliable and revolutionary tool for plastic surgeons because of its ability to directly visualize the tissue beneath the skin’s surface. The technology has many applications for both existing and new procedures, and its usefulness extends from before a procedure for better planning and after a procedure for tracking results. It is also used in real-time, so the images can guide the procedure itself. Many of the plastic surgeons who use ultrasound routinely say it has made their techniques safer and more precise, allowing them to achieve better results with greater confidence.

Not your grandmother’s ultrasound

One of the benefits of point-of-care ultrasound in plastic surgery is its accessibility. And it’s a safe imaging modality for patients because there is no exposure to radiation or any harmful substances.

“Most of my patients are young mothers, and they have a positive association with ultrasound,” said Pat Pazmiño, MD, FACS, who uses ultrasound at his plastic surgery practice, Miami Aesthetic. He also likes that there are no disposables with ultrasound, making it more affordable than other technologies with pricy disposable fees. The latest models of this technology are wireless, so besides gel, nothing else is needed to use it.

In addition, advancements in microchip-based technology have allowed the devices to get smaller and more portable—some of them, like the Clarius portable pocket handheld ultrasound device, are about the size of an iPhone and are easily grasped in the hand—unlike the clunky, cart-based systems found in hospitals and doctors’ offices. These small, but powerful devices are a fraction of what cart-based systems cost, ranging between $2,000 and $5,000.

“For plastic surgeons, that’s a non-number,” said Marc Salzman, MD, FACS, of Salzman Cosmetic Surgery and Spa in Louisville, Kentucky. “We don’t have any $3,000 devices—our devices are usually $100,000-plus.”

Another perk is that using the technology doesn’t require surgeons to take extensive courses in sonography. All the surgeon does is click on the desired anatomical feature of interest, such as breast, abdomen, and musculoskeletal, within the application’s preconfigured settings. The software also eliminates the need for multiple types of probes, as well.

“It allows doctors to focus on what they’re looking at rather than focusing on fiddling with the knobs on the machine,” said Pazmiño.

Ultrasound for facial aesthetics

Three years ago, Steven F. Weiner, MD, became a proponent of ultrasound in cosmetic surgery after attending a complications clinic in Amsterdam under the instruction of phlebologist Leonie Schelke, MD.  Weiner was impressed by the way ultrasound helped resolve vascular occlusions with one or two vials of filler dissolver. Typically, this procedure would take hours and up to 50 vials of filler dissolver.

“Ultrasound is like a smart bomb,” said Weiner. “You can get very precise imaging of the area that’s occluded and inject and resolve the problem expeditiously.”

At the Aesthetic Clinique in Santa Rosa Beach, Florida, Weiner uses ultrasound regularly to evaluate, diagnose, and treat patients. For patients who have had previous facial fillers who are having problems with swelling, nodules, or a poor cosmetic result, he uses ultrasound to tell what kind of filler was used and its location.

“That can help you diagnose the problem and help the patient, whether it needs to be dissolved or massaged or just followed,” he said.

He uses ultrasound to map the vascularity in instances when he’s injecting filler in areas such as the temples, the nose, the chin, and the glabella area, all areas that carry additional risk of vascular injuries or blindness or occlusions. Knowing where the nerves and vessels are prior to injecting allows the surgeon to alter their technique to avoid them.

“Ultrasound allows us to see through the skin where previously we made educated guesses or used commonalities found on other studies,” he said. “But again, vascularity is very highly variable and it’s nice to know where it is in the patient sitting in front of you.”

In procedures involving radiofrequency microneedling, Weiner uses ultrasound to measure the skin’s thickness so that he can determine how deep into the dermis he can go safely to access the collagen and elastin but not the fat. After treatment, ultrasound can be used again to get an objective rather than subjective measurement of success in improving skin thickness.

Ultrasound for breast evaluation

The FDA until recently had recommended surveillance for women with silicone and gel breast implants with MRI after 3, 5, and 7 years. However, the cost and inconvenience of MRI made this guidance impractical. For this reason, Salzman first started using ultrasound technology 12 years ago to evaluate breast implants in patients who needed surveillance or had issues.

“If a woman comes in and she’s 10 years out and there’s probably an 8% to 15% chance the implants are broken, instead of sending her for an MRI, we are looking in our own office with an ultrasound device,” he said. “And as the devices got smaller and less expensive, it became obvious to me that this was going to be the state of the art.”

With ultrasound, Salzman said he can find broken implants, as well as see fluid around a breast implant, a seroma, which could indicate the development of anaplastic large cell lymphoma (ALCL), a rare lymphoma associated with heavily textured breast implants. Rather than sending the patient to an expensive radiologist that costs time and money, Salzman does the aspiration himself and sends it off to pathology to determine if the patient needs a capsulectomy.

He said patients with concerns about their breast implants are happy to undergo a quick, 5-minute exam with ultrasound to get a definitive answer about the status of their implants and whether or not they need to be replaced.

“It gives the patients a real sense of security because you can tell them everything is fine,” Salzman said.

Ultrasound for pain blocks in plastic surgery procedures

“With ultrasound, we also have made some of the more uncomfortable plastic surgery procedures more comfortable by doing blocks, something an anesthesiologist would normally do,” Salzman said.

For breast surgeries, he uses ultrasound to place a pectoral nerve block, which keeps the muscle from spasming for 8 to 12 hours. He said this allows the implant to “drop and fluff” in a day or two instead of 4 to 6 weeks. His patients spend 15 minutes in the recovery room and go home.

Likewise, the TAP block, which stands for the transversus abdominis plane, numbs the abdominal muscles and skin, revolutionizing how patients feel after a tummy tuck procedure. This block can numb the whole front part of the abdomen for 3 days, making an incredible difference in recovery.

Ultrasound has also obviated the need for drains, according to Salzman. He uses it to diagnose if there are any signs of a seroma or hematoma and can drain them in 5 minutes. However, he said he hasn’t had to use a drain in years because the suture and glue techniques work so effectively.

“Patients are happy to be able to shower the next day after a mommy makeover and not have drains hanging out of their breasts or belly,” he said. “It takes away a lot of the inconvenience.”

Ultrasound for Brazilian butt lifts

Pazmiño has been using ultrasound in his practice for the past 9 years for many different surgeries, but especially for the extremely popular gluteal fat grafting procedure known as Brazilian butt lift (BBL). Ultrasound is helping this previously dangerous procedure become safer.

“What we have learned over the many years is that doctors should be injecting fat only above the muscle, underneath the skin and above the muscle within that subcutaneous compartment,” he said. “What would happen is because the doctors couldn’t see where the instruments were, sometimes by accident they would place the instrument inside the muscle and if they inject into the muscle, that fat could travel to the heart and lungs, cause a fat embolism, and kill the patient instantly.”

During the Brazilian butt lift procedure, he places the ultrasound probe on the patient’s skin so he can see where the cannula is at all times. That way he knows for certain he is placing fat above the muscle safely and precisely.

Before ultrasound, doctors would commonly inject as much fat as possible during a BBL and get inconsistent results. Pazmiño takes a different approach. First, he uses ultrasound to measure the space and lets the patient know how much volume they have room for. If the patient is hoping for a dramatic change, the information gained by ultrasound can help plan ahead of time that there will be multiple fat grafting procedures to achieve the desired result.

After the surgery, he uses ultrasound again to measure exactly how much fat has melted away and how much has stayed.

“I can, with millimeter accuracy, pinpoint where every drop of fat is going to go to maximize the amount that will survive,” he said. “And I think the most important advancement with ultrasound is that it can make a previously blind procedure accurate, reproducible, and safe.”

The learning curve for ultrasound technology in plastic surgery

The plastic surgeons who have adopted ultrasound technology have found that it is an affordable technology useful for nearly all procedures on every part of the body. For those worried about the time it takes to learn how to use it, their advice is to not be intimidated by the learning curve.

“As plastic surgeons, we have the advantage of knowing what the anatomy looks like from our time in the OR, so the learning curve is a little shorter,” said Salzman. “It’s a matter of making that transition to seeing a bunch of grayscale dots on a screen and with time, you’ll be able to understand what’s black and what’s white.”

Of course, having supervised instruction helps. Weiner created Sonosthetics, a 1- or 2-day course. “By the time you’re done with my course, I feel you’ll be able to use the ultrasound, but you won’t be proficient until about 3 or 4 months of using it,” he said. Refresher courses are also available.

“Ultrasound is the stethoscope of the 21st century,” Pazmiño said. “Place it on every patient that comes in because the more you do it, the better you’ll understand the structures and anatomy, and the easier it’ll become for you. It’ll make you not just a better surgeon but a safer one as well.” PSP

Jane Kollmer is a contributing writer for Plastic Surgery Practice.