Ultrasound and the Breast Implant Patient—A Conversation with Dr. Marc Salzman

Alison Werner:
Hello, and welcome to the Plastic Surgery Practice Podcast, a part of the MEDQOR Podcast Network. My name is Alison Warner and I am the Co-Chief Editor of Plastic Surgery Practice. In this episode, sponsored by Clarius, we are going to be talking about the use of ultrasound in the plastic surgery practice, with a specific look at how it can be used with breast plastic surgery patients. And joining me to talk about this is Dr. Mark Salzman. Dr. Salzman is a Plastic Surgeon in private practice in Louisville, Kentucky. He completed his General Surgery Residency in New York at Mount Sinai Medical School, and his Plastic Surgery Fellowship at Duke University. He is an Assistant Clinical Professor of Plastic Surgery at the University of Louisville. Dr. Salzman is a key opinion leader for several plastic surgery companies, including our sponsor today Clarius. Dr. Salzman, thank you so much for joining me today.

Dr. Marc Salzman:
Thank you, Alison.

Alison Werner:
Well, let’s get started. Can you tell me a little bit about your plastic surgery practice in Louisville?

Dr. Marc Salzman:
Well, I’ve been in practice since ’92 and probably since ’94. So almost 28 years. It’s been exclusively cosmetic surgery, aesthetic plastic surgery.

Alison Werner:
Mm-hmm.

Dr. Marc Salzman:
So I do breast, body, face, nose, eyes, 10 or 12 different operations, but all aesthetic. No real reconstructive since ’93, really.

Alison Werner:
Mm. Okay. So when did you first start using ultrasound in your practice?

Dr. Marc Salzman:
Well, I bought a VASER from a company that was then going to make a ultrasound device that they had OAM’d by a company that really made ultrasound devices, and they took a MacBook Pro and they put the inner workings of an ultrasound machine below the MacBook Pro. But all of the little knobs and buttons and things were all in a tray. So if you didn’t want to use it, you could just use MacBook Pro Apple type commands, and they kind of dumbed it down. But there really wasn’t anybody in the country doing ultrasound. So I’m not sure why they thought it was necessary, but they had someone design a probe that they thought would be better used by a plastic surgeon.

Dr. Marc Salzman:
It was still a linear probe, which is the kind that we use for ultrasound for plastics, but they made it so it would fit in your hand and you could run it over the breast like you were doing a breast exam. So rather than a T-shaped probe that an ultrasound tech would use, this was an L-shaped probe. So it was kind of different. And they had no idea what the implications or what the applications would be of this thing. So I just started using it and experimenting with it. And there was a couple of us in the country that had it and at a meeting we all talked about, well, what do you do with this thing? How do you use it? So it kind of expanded from there.

Alison Werner:
So since your experience goes back so far, I was going to ask, when you got started with ultrasound, what types of applications were you using it with? But I think maybe the more pertinent question is what types of applications are you using it for now?

Dr. Marc Salzman:
Well, when I first started out, I looked at everything because I didn’t know what the hell I was looking at.

Alison Werner:
Yeah.

Dr. Marc Salzman:
And the nice thing about plastic surgeons in difference to a radiologist or to radiology tech is, we know what it really looks like underneath. So we are kind of our own AI. So when we start looking at breasts, we know we’re looking through breast parenchyma, we know that there’s a capsule. We know what the implant looks like. We know that there’s fluid around it. So it’s not a quantum leap to be able to interpret these gray bitmap images that you’re seeing on a screen, and put it in your brain to making a 3D image of what actually exists. So I first started looking at breasts because that seemed to be the simple thing. And there was some literature back then that showed that in proper hands, ultrasound could be used as a first source thing to try and look at signs and symptoms of a broken implant.

Dr. Marc Salzman:
Could you see the implant? Could you see fluid around the implant? Could you see if the implant was intact? Could you tell a textured implant from a smooth implant? So I was mainly just looking to kind of see what was there. And from there it kind of expanded to a bunch of different things. So we do everything today with it. So we’ll look at, in the face, we’ll see is there a filler that has a nodule? What is the filler? Is it a filler that’s a hyaluronic acid filler? Is it calcium based filler? Is it located in a place where we can get a needle into it and maybe break it up because it’s calcium, or is it just something that we need to put a directed triamcinolone or steroid injection in? And you can do that under ultrasound.

Dr. Marc Salzman:
You can make an assessment of where do you want to put the fillers? Where are the blood vessels? What layer do you want to put the filler? So it really helps in the face. And then we started playing around with it to do blocks, because here was some good literature out of Spain that one of the Spanish anesthesiologists had started doing these pectoralis blocks. And I thought it’d be a neat idea to try and alleviate some of the negative thoughts of patients, well, the submuscular implants going to hurt more than the subglandular implant. And the spasm of the muscle was going to cause the implant to be more high riding. And the more I read about the blocks I was intrigued. So I started doing them and then I came up with a better way of doing them, because anesthesiologists are standing at the head of the bed and while they’re messing around with the tube or putting the LMA and I’m thinking, “I don’t want to be up there trying to do a block and I didn’t want the needle heading towards the pleura, towards the lung where I could drop a lung.”

Dr. Marc Salzman:
I wanted to be more parallel to the chest wall. So I started doing them from the side and we have a series of over 600 pectoralis blocks now. And then we started with the abdomen. We said, all right, what else? There’s a tap block, and so we read about, and my anesthesiologist actually went to a course in Chicago on how to do a tap block. And we started doing tap blocks six or seven years ago. And that really alleviated a lot of the pain that patients were having. Then they came out with a long lasting pain medicine that lasts three days, and we’re thinking, oh my God, this is great. So we’ve looked at a whole bunch of things from there.

Alison Werner:
Yeah. Well, I’d like to move on to discussing your area of expertise, which is breast surgeries and post-surgery maintenance, a little bit of what you talked about. You recently spearheaded a study that screened 584 asymptomatic women with implants for silent ruptures. Can you explain why you initiated the study and share some of the results?

Dr. Marc Salzman:
I think there was not any good literature at the time to know how many people are really walking around with a silent rupture. And I had scanned, I don’t know, 1,000’s of women by then who were totally asymptomatic. And every once in a while, you’d find someone who everything looked good, everything felt good and yet the implants were 10 years old and you go, there’s going to be a fair percentage that they’re ruptured. And low and behold, they were ruptured.

Alison Werner:
Mm.

Dr. Marc Salzman:
And the FDA had recommended that we tell our patients. And the patients can read it online themselves. That they have an MRI at years three, five, and seven, but at a cost of $1500 to $2,500. The surgery’s only back then $7,000. No one’s doing a $1,500, $3,000 MRI every couple of years to look at a $5,000 procedure.

Dr. Marc Salzman:
So an ultrasound seemed like a better way to go. And then I noticed also in the literature that really no one ever asked patients and did any kind of a study or presented any kind of statistics to how women felt about the fact that these implants could break. And there was all this non-information on the internet. If you ask a woman, how long do implants last? They’ll tell you, you’re supposed to have them replaced every 10 years. And that’s not true. The warranty lasts 10 years, but the implant can last well longer than 10 years, so.

Alison Werner:
Okay.

Dr. Marc Salzman:
We wanted to see what do women really feel about the fact that there maybe is a ticking time bomb that this thing at some point is going to break. A saline implant, it breaks it’s a bag of water, it goes flat. Gel implant. You may not know it. Implant can break and yet the breast remains soft and it doesn’t look distorted and everybody thinks it’s fine.

Alison Werner:
Hmm. Okay. Well, MRI and my mammography have long been considered the gold standard for screening breast implants. So could you describe the comparative benefits of high resolution ultrasound for screening? I know you just kind of touched on that a little bit there.

Dr. Marc Salzman:
Well mammography is really only good for extracapsular rupture, meaning that the gel has extravasated from not only the shell, but has left the scar tissue or the capsule around, and it’s very sensitive to finding that. Unfortunately, the vast majority of ruptures are intracapsular and it’s very, very poor, mammography is, in seeing an intracapsular rupture. The gold standard for intracapsular rupture is an MRI, because it’s sensitivity is in the high ’90’s, and in some studies the specificity is as high as 100%. So it’s very sensitive and very specific. The problem is cost, and it’s not done at your plastic surgeon’s office. I mean, you’re going to a special place, a women’s diagnostic center, a hospital, an outpatient center. You have to go park and put the name band on and it’s an expense and a hassle.

Dr. Marc Salzman:
So nobody does it for surveillance. So ultrasound has always been kind of a second line of defense. When someone has a suspicious mammogram, they look at parenchymal changes in the breast with ultrasound to really hone down on, is this something that is worrisome and needs to be looked at as a cancer or is it more benign?

Dr. Marc Salzman:
But it really has never been a first-use diagnostic modality for looking at broken implants, because everybody just sent people for MRI. So it’s only been in the last couple of years from all the data from the ultrasound literature that in the right hands, you’re not going to miss very many broken implants. It hasn’t happened to me yet that I get a surprise in the OR that I thought the lady had two intact implants and low and behold one’s broken. I haven’t seen that.

Alison Werner:
Mm.

Dr. Marc Salzman:
I’ve had some false positives, but that’s a different story because almost every time I’ve ever had a false positive, the lady was going to have surgery anyway. She had such bad capsule contracture that we were taking the implants out regardless if they’re broken or not. They’re 12 years old and she’s got grade four capsules.

Alison Werner:
Yeah. Well, you talked there about how it’s advantageous to the patient. So do you think using ultrasound makes you a better plastic surgeon?

Dr. Marc Salzman:
Yeah, I really do. I think it’s the 21st century stethoscope, being able to see inside the woman’s breast makes all of the diagnostic workups shorter. We don’t have to send the patient to a radiologist. Let’s say someone presents with an expanded breast. It’s suddenly bigger. We know it’s fluid, usually have a seroma. And in today’s world we’re worried about ALCL, which is a rare lymphoma that you can get with longstanding, heavily textured implants. And we want to know if that’s the case, because in that scenario you’d want to take not only the implant out, but do a capsulectomy. And if you don’t have ultrasound, first you have to say, well, is it a seroma? I don’t know. We have to send the patient for an ultrasound. If it is a seroma, then from the diagnostic ultrasound, there’d be another sent to a radiologist who knows how to do an aspiration, and wait for that to come back.

Dr. Marc Salzman:
Is the implant broken or not broken? That would have to be discerned with one of the two ultrasounds. We can tell all that in five minutes in the office with a little handheld Clarius device and the whole conversation and the workup is pretty much done and we can move on to planning for the surgery. A lot of times it helps just knowing what type of implant we’re dealing with. I mean, sometimes the patients don’t remember. I don’t know if it’s saline or gel. Is the texture smooth? I can tell if it’s saline or gel, and I can tell if it’s textured or smooth. So it really helps in shortening the diagnosis of what needs to be done and makes the planning of what needs to be done so much better. It also helps in not having surprises in the operating room. Because in my game, when you’re in aesthetic plastic surgery, once you give the patient the bill, there’s no adding on to the bill for, oh whoops, we found something that we spent three more hours doing. We didn’t think that we were going to do, oh whoops.

Dr. Marc Salzman:
We went in and your implant was broken. We thought we’re going to keep your seven year old implants. But low and behold, they were both broken. And now you owe us $3,000 more, and the lady goes, whoa. You’re going to eat that cost. So there’s no surprises. You know what you’re going to find. You know how much time to schedule that patient for. It’s not an hour long out and in of implants, that’s a different operation at a different cost than a three hour bilateral capsulectomy and new implant placement.

Alison Werner:
Okay. So you have a reputation for reducing post-surgery recovery time for your patients. What’s your secret?

Dr. Marc Salzman:
Well, I learned a long time ago from a buddy of mine down in Texas that the less tearing of tissues, the less blunt dissection that you do, the quicker the recovery. And having absolutely no blood in the pocket, the quicker the recovery. So John Tebetts who recently passed away in March was my mentor on this. And I’ve used since talking with him a handswitching electrocautery forcep. So there is no blunt dissection. There’s no finger of pushing and tearing any tissues. Everything is coagulated and cauterized before any bleeding takes place. So there’s absolutely no blood in the pocket.

Alison Werner:
Mm.

Dr. Marc Salzman:
And then I think it’s a bad idea to put sizers in. I do a breast augmentation in 22 minutes and with no blood loss and I never use a sizer. I think stuffing sizers in and out runs the risk of more bacterial infiltration into and around the pocket, higher rates of capsular contracture.

Dr. Marc Salzman:
And you’re setting up a stretching of the tissues, which hurts. And I think you’re setting up as the implant goes in and out a pulling apart of a vessel that you’ve not coagulated, and having a late hematoma that you’re not able to account for because it was the implant, but it really wasn’t the cutting that did it, it was the putting in and out of implants. So we do all of our sizing on a computer. We have a 3D image and we can show the patient exactly different implant sizes, different implant shapes, different implant projection ratios. If you want to get crazy and do different brands, one on one side one or the other, you can do all that on a computer without stuffing it in and out of the lady while she’s asleep. I think all those things help. And then there’s the isolation of the no touch technique and changing your gloves and irrigation with different antibiotics and dilute Betadine, all those things help.

Alison Werner:
Mm-hmm. Okay. So back to ultrasound a little bit. Ultrasound is also useful for post-surgery patient management, including the identification and aspiration of seromas. Can you tell me more about how ultrasound improves postoperative care there?

Dr. Marc Salzman:
Oh, it’s so important when you see a tummy tuck patient and she’s swollen. Could be a man, but he or she is swollen. And you’re thinking, is that edema or swelling or is it a succinct amount of fluid that would we be better off aspirating? Is it a hematoma versus a seroma? And with ultrasound, I can look at it the next day if I wanted to before it’s purple and I can see it’s blood because blood absorbs some of the ultrasound. It looks a little bit darker like there’s stuff in there with a little bit of light-colored stuff in between. Whereas a seroma is just totally black. It’s just water. It just transmits the ultrasound waves, nothing bounces back and you can see that it’s fluid. And edema just looks like a cloudy day. I mean, so they look totally different.

Dr. Marc Salzman:
So you’re able with great clarity to be able to say, this is swelling, Mrs. Smith, you’re going to be fine. It’s going to go away. And you can actually measure the amount of swelling. You can measure the size of the seroma and show the lady that it was four millimeters this week, this next week it’s one millimeter and show her, even though it looks big on the screen. When you tell them that’s a one centimeter screen, your seroma is only two millimeters big, the needle’s one millimeter big. If you go try and put a needle in it, even for me it’s going to be hard. So to watch the resolution of the seroma it’s unbelievably better to be able to tell a patient I don’t use drains. I do a drainless tummy tuck and operate the dead space with a progressive tension, continuous suture with using a V-Loc.

Dr. Marc Salzman:
And I haven’t drained a seroma in years. There was a study that we did using a biologic cyanoacrylic glue. I think every single patient had a seroma. And I’m happy that at that point in time, I did have ultrasound. I’ll never forget a lady standing up who was one of the 10 people on the study. And I was one of them and she got up on the podium in a national meeting and said, “well, none of her patients had seromas.” And I really wanted to raise my hand and said, “I’ll bet you $1 million dollars they all had seromas. You didn’t look did you?” If you don’t look, you don’t see it. But every single patient with this glue had seromas.

Alison Werner:
Mm.

Dr. Marc Salzman:
It just didn’t work as well as people thought it did.

Alison Werner:
Right. Okay. Well, I want to get your thoughts on the Florida Board of Medicine’s recent implementation of an emergency order mandating ultrasound guidance for safer Brazilian Butt Lifts or BBL procedures. How do you feel about this regulation?

Dr. Marc Salzman:
I think it’s great. I think it takes an operation that had the highest death rate and makes it nearly, not totally impossible, but nearly impossible. You’re going to place the fat below the deep gluteal fascia, and I’ve done it that way for six or seven years. Even before I had a Clarius device. We used a long condom on a regular linear probe. It was much more onerous than the Clarius device. It’s so simple to see that big fat cannula as a big white line between the deep and superficial gluteal fascias. And then you don’t have to do the whole thing under ultrasound. It’s fun to do, but then as you pull back, you’re not going any deeper. And, to see that the fat is in the proper place is rewarding. It’s also great to see where their opportunities put more fat.

Dr. Marc Salzman:
You can not only see it visually that you need a little bit more of say right here, but you can visualize and say, the superficial fascia is not pushed out quite as much right here. I know I can get my cannula in there and put some more fat in. And there’s also another component that people haven’t started talking about, because I’m doing it, but not many people in the country are yet.

Alison Werner:
Yeah.

Dr. Marc Salzman:
Is you can see that the superficial septa that go from the superficial fascia to the dermis and when you’re all finished, where they have little dimpling, you can take an 18 gauge needle under ultrasound and just cut that little septa. I know they make some fancy devices that cost a bunch of money with lights on and all that. You don’t need it. You just take a 18 gauge needle ultrasound and find the little vertical septa and then put a little fat where that septa was and that’ll push the skin back out and get rid of the dimples that you see in the superficial part of the buttock. So I think it’s a good idea. I know people are mad because they don’t want to learn ultrasound, but I think it’s a good idea.

Alison Werner:
So do you think there should be a national mandate?

Dr. Marc Salzman:
Well, I think it’s up to plastic surgeons. I mean, I think it’s going to be, the lawyers will probably force us into this once they see that Florida has this and then that it’s a safety issue. I don’t know if it would be mandated or it’ll just be the standard of care that if you don’t do it, you’re going to get sued if you kill somebody. If you don’t kill somebody, nobody knows.

Alison Werner:
Yeah.

Dr. Marc Salzman:
But I think it’s a good idea. And I think the people that are against it are afraid for the wrong reasons. If they would just buy the thing. And anybody at our skill level who’s done as much as we have as plastic surgeons, can certainly see two white lines and some striated muscle underneath and follow a big, big rod between these two white lines and then put the fat in. It’s just not that hard. And looking at our plastic surgery forums people have already said, “yeah, I started doing it. I don’t know what you guys are afraid of. It’s easy. It’s not hard. My fellows do it.” The very first time we show them how to do it they go, this is nothing, this is child’s play.

Alison Werner:
Okay. So what about in terms of training? What kind of training do you need to use something like the Clarius?

Dr. Marc Salzman:
Well, we’ve had some training courses in my office, private training courses, and then we’ve done somewhere around the country and people like that. I run a course at the American Society of Plastic Surgery Meeting, which is the biggest plastic surgery meeting in the world. And we probably have 200 people at those. We’ve done sometimes two of them, so it’ll be 400 people. But there’s not enough, frankly.; There needs to be more training. Clarius has been great about doing webinars and supporting some of our training efforts in bringing the machines and bringing us some techs that can support and help people how to do it, show people how to do it.

Alison Werner:
Mm-hmm.

Dr. Marc Salzman:
And every time that we have one of these, people come up to me and go, man, this is great. I’m so excited to get back and do this because it’s the only new thing we’ve had in plastic surgery that’s really different. Everything in the last 10 years has been a variation on the theme, new RF device, a new RF needling device. There really hasn’t been anything new. This is really totally new and something that people my age in general surgery never use. I never read an ultrasound or sent somebody. It just didn’t exist. So to have it and be able to take something out of your pocket that hooks to your iPhone or iPad it’s pretty cool.

Alison Werner:
Okay. So let’s talk about integrating ultrasound into the practice. Is it costly to add ultrasound to your practice?

Dr. Marc Salzman:
I mean, everything’s relative to people in my line or my level. There’s nothing that’s under $100,000 dollars to buy. There’s no machine.

Alison Werner:
Right.

Dr. Marc Salzman:
Hell, a good Bovie’s $100,000 dollars he says. So to buy, even when the thing was $5,000, to me that’s a non-number. It’s a number that doesn’t even matter. So, I look at it as an iPhone. I get a new iPhone every year just because I can. And I know I don’t have to, but probably every three years the technology changes and becomes better. I’ve had every iteration of the Clarius devices that they’ve had from the really big one to the one that was a little bit smaller of the two. And now this one’s wonderful and I’m sure the four will be better than the three. They’ll think of something. Make it cooler, doesn’t over heat, those kind of things. But they keep changing the software even behind the scenes.

Dr. Marc Salzman:
And just firmware updates when the app updates, and I have to read and see what’s different. But I would say the hardware, if I had to guess, is probably going to last two to three years, maybe longer before they’re going to say, well, the new firmware or the new stuff we have, we can’t support it on this old platform. But as far as I know, I don’t know that my original L-seven does not work. Honestly, I haven’t tried it in a while. I know that the second version still does work. But I remember one of the people at one of the booths telling me, there’s a point in time where the software gets so far advanced, just like Apple computer that we just stop supporting the legacy devices and that’s understandable.

Alison Werner:
Mm-hmm. So is there a return on your investment?

Dr. Marc Salzman:
Well, I’ve not charged for it yet, so I can’t say there’s an ROI. But I think that if you calculated what you’re able to do, and just the cases that you don’t have to not bill the patient for stuff you should have known, it’s an absolute no brainer.

Alison Werner:
Right.

Dr. Marc Salzman:
And for the patient that doesn’t leave your office because you’ve diagnosed the broken implant and come up with the operative plan and handed them the quote and they know they have a broken implant, they’re not going all over the city looking for somebody else to do their case, because if they do, they’re going to say, I don’t believe Salzman, that ultrasound thing. You’re going for an MRI. Really? He told me he showed me the picture. The damn thing’s broken. You want me to spend $2,500? I’m going, I think I’ve ordered two MRIs in the last 10 years.

Alison Werner:
Oh okay.

Dr. Marc Salzman:
There’s just very few scenarios that it’s ever necessary when you have this device.

Alison Werner:
Mm. Okay. Let’s see. Do you have an equipment recommendation for plastic surgeons considering adding an ultrasound to their practice?

Dr. Marc Salzman:
I’ve looked at all of them. I don’t know if I’m allowed to say this, but I think the Clarius is the best one. I really do. I’ve tried them all. I think the GE is okay. Last I looked at it I’m a Mac guy, I like a Mac computer. All of our software in the office runs on Windows. But you had to have a Windows server to store the anonymized images or it had to go on a DICOM server. And for us as plastic surgeons in private practice, there’s no hospital DICOM server that this thing goes on. And you couldn’t annotate the image on the GE. And I’m sure that’s going to be changed. That was last fall that we looked at it. I looked at the Korean SONON device. It was terrible. I think the butterfly image is sometimes okay, sometimes not okay.

Dr. Marc Salzman:
It’s hard to use intraoperatively because it’s a corded device. So you got to have whatever you’re looking at close enough. And if you’re doing a BBL, you’re moving the thing all around. The Clarius device just sits in a little baggie and it’s just always, hey, pull it up, stick it on, put it back down. It’s just easier to use intraoperatively. We have the butterfly as well in the office because the anesthesia department has it. My anesthesiologists use it. And the clarity is just not great. And I don’t understand why. I know it only goes to 10 megahertz and that may be why, but it’s just a fuzzier image. It just doesn’t look as good. So I’m kind of spoiled. I’ve been driving a Ferrari and yeah, so Porsche is okay, but the Ferrari just looks better and turns better. It’s just a better car.

Dr. Marc Salzman:
And I think it’s the same thing.

Alison Werner:
Yeah.

Dr. Marc Salzman:
I think Clarius is just really on top of it as far as the software being very easy to use. I mean, anybody my age and certainly younger who can use an iPhone can use this thing. You don’t have to learn anything about ultrasound. You really don’t. You don’t have to understand how it works or what you’re looking at. Just up and down and sideways and all the presets are there. The butterfly only has one preset that’s applicable and it can’t work for every single thing. It just doesn’t make sense. And they may get better. But I think they’re limited by that technology of ultrasound on a chip rather than using a piece of electric crystal.

Alison Werner:
Are there specific features that you would advise people who are looking at ultrasound to look for?

Dr. Marc Salzman:
I get asked this question all the time. So that’s a very good question.

Alison Werner:
Mm.

Dr. Marc Salzman:
I mean, because they make three of them essentially, a seven, a 20 and a 15. And it all depends on what your sweet spot is. In Louisville, Kentucky, we got a lot of what we call Kentucky mediums and that’s a euphemism for a larger lady with a high BMI. And so the sweet spot for the L=7, it’s a little deeper where you’re going to be able to see seven centimeters down with some degree of acuity, whereas the L-15 it’ll see it at that depth, it’s just not as good of an image. And I’d rather see better at seven centimeters down in a big thick breast or a big abdomen, than see a little better at two centimeters down.

Dr. Marc Salzman:
Because I haven’t seen that the L-7, which is the one I have, doesn’t work for me for face. I see what I need to see. I tried the L-15. Is it a little better? It’s a little better, but it’s not markedly better. And so I think for us as plastic surgeons, I tell the people by the L-7, because I think it works well enough for the face, and the face is going to be 10% of your use. If you’re a facial plastic surgeon and you’re never going to look at anything other than the face that’s a centimeter and a half, two centimeters thick, then you get the L-20, because you’re going to look more superficially you want that acuity. And if you’re two people using and one’s a facial ENT guy and one’s a board certified general plastic surgeon like I am that does face and body, get the L-15 it’s in between. But for most people I think the L-7 is the better choice.

Alison Werner:
Okay. Well, Dr. Salzman, thank you so much for taking the time to speak to me and our audience today. I think you provided some really great insight into the role of ultrasound and how it can play a part in the clinical workflow. So thank you so much.

Dr. Marc Salzman:
You’re welcome, Alison. Take care.

Alison Werner:
Well, thank you. And to our listeners, thank you for joining us for this episode. Be sure to subscribe to the MEDQOR Podcast Network to keep up with the latest Plastic Surgery Practice Podcast episodes. And be sure to check out plasticsurgerypractice.com for the latest plastic surgery news. Until next time, take care.