Ultrasound GUIDANCE – the new CLINICAL & LEGAL standard for Facial COSMETIC injections

Flying Blind

In almost every aspect of modern medical practice, clinical procedures are made safer and more effective through the use of routine imaging. 

Whether it be digital or conventional film; MRI or CT; the use of some reliable method of imaging is considered best practice for all manner of medical treatments and, indeed, the failure of a health practitioner to properly utilize available imaging to aid in everything from patient screening and diagnosis; to actively guiding treatment delivery; and conducting appropriate post-operative evaluation and complication management, would be considered a substantial departure from accepted standards, exposing them to regulatory action and litigation.

Essentially, it would be irresponsible and inappropriate to “fly blind” in mainstream medicine and indefensible if you did. Yet, until recently, a blind approach to treatment provision was the only option practitioners had when performing skin rejuvenation therapies; like Botox, Dermal Filler, Fat-dissolving injections and facial Thread Lifting; across the head and neck region and it had become the accepted norm. 

So, while health practitioners would never dream of blindly placing various implants into complex anatomy without the aid of imaging; running the risk of not only a poor result but serious complication if inadvertently encroaching on adjacent nervous or vascular structures; those placing Botox, dermal filler, and the like, simply had no other option. This is in large part due to the nature of the tissues being treated.  Facial soft tissues have been much harder to image directly by treating clinicians with technologies like MRI and CT having only been developed over a much shorter period which, despite significant advances, are still expensive, cumbersome, and inconvenient.

Yet, a critical aspect to many facial rejuvenation procedures, is correct anatomical placement. Whether it is depositing dermal filler into a strategic tissue space; aligning thread lifts within specific tissue planes; injecting Botox into individual muscle layers; placing fat-dissolving solution into designated fat compartments; or even achieving the correct depth of micro-needling penetration into the dermis; a failure to achieve correct anatomical orientation will reduce the effectiveness of treatment. More importantly, poorly planned, imprecise, and ill-conceived procedures, when working within the complex and closely related anatomy of the face, have the potential to cause serious complication, ranging from aesthetic asymmetries and irregularities; functional defects, if Botox impacts unintended muscles; through to skin necrosis and blindness if dermal filler inadvertently encroaches on vascular supply.

Above: Portable, wireless, hand-held, point-of-use Ultrasound technology, has set a new standard for patient care and practitioner education in dento-facial procedures.

While practitioners tried to mitigate these risks by ensuring they had a comprehensive anatomical knowledge and deployed “safer” materials and techniques, differences in individual patient anatomy and practitioner ability meant that this was far from fool-proof. Ultimately it had to be accepted that flying blind was the norm when performing facial procedures and that even when practitioners were trying to do everything right, complications and poor outcomes could readily occur. 
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This has been particularly difficult for those just starting out and trying to learn these procedures, as it required a substantial amount of blind faith, a steep learning curve and an inherent nervousness without the benefit and reassurance brought about by the kinds of accurate imaging and pre-screening they were accustomed to in traditional medicine. Thankfully, this has recently changed with developments in Ultrasound (US) technology setting the new standard for care.

How is Ultrasound used?

Portable, point-of-use US technology utilises the same technology as all other ultrasound devices, with the advantage that it is low-cost, wireless, hand-held and can deliver real-time, high-quality diagnostic images direct to a tablet or smartphone, both quickly and painlessly, at chairside. 

The US device emits a high-frequency sound wave which can penetrate several centimetres below the surface of the skin, where it is reflected differently by the various tissues being examined. This produces a live image of different densities on a grey-scale – bone appears different to muscle, which looks different to fat, which is distinguishable from the dermis and so on. Additionally, special settings allow for the colourful visualisation of not only the location of blood vessels, but also their size and velocity of flow.

Above: Hand-held, chairside Ultrasound allows practitioners to visualise vital structures in real-time, improving treatment safety and efficacy.

Clinical research has demonstrated repeatedly that these unique imaging features allow practitioners to set new standards for safety and efficacy in three key ways:

• Pre-screening & Diagnosis
  

US can be used in consultations to visualise individual anatomy, plan appropriate treatment, and identify areas of risk. US allows us to develop a clear understanding of the face we are working with, mapping out key structures in advance, to plan treatment delivery in a manner which achieves the best results while actively preventing adverse events. The position, orientation, size, and depth of features can all be noted in advance, allowing a plan to be developed to target specific tissue layers with the likes of threads; avoid critical blood vessels with dermal filler; inject only certain muscles strategically with Botox; and even measure exact skin thickness so micro-needles penetrate precisely into the desired level of the dermis for optimum collagen stimulation. 

• Guided Treatment Delivery

US enables the clinician to perform guided injections for treatments involving Botox, Dermal Filler, fat-dissolving injections, and even facial thread lifts. In real-time practitioners can visualise their needle penetrating through the different layers of tissue until the desired treatment area and depth is reached. They can watch as the treatment is administered deep within the face, all of which previously would have to be done blindly, by feel, while hoping for the best.

• Identification & Management of Complications

US enables practitioners to closely examine areas treated previously that may have experienced complications, diagnose them properly and deliver the appropriate treatment. Prime examples of this are complications arising from the injection of dermal filler. 

US examination will quickly and easily reveal exactly where filler has been placed in the past and it is even possible to tell what type of product has been used from its unique echo signature. It would be possible to see if the filler is blocking a blood vessel and precisely where that blockage has occurred, which without active and accurate treatment, may lead to skin necrosis.

Thankfully, the best modern day dermal filler products consist of a Hyaluronic Acid gel and are therefore dissolvable with hyaluronidase enzymes. This allows the emergency treatment of dermal filler complications by dissolving the gel deposit and can be applied to resolve areas of lumpiness, irregularity or overfill, or importantly, to dissolve areas of filler that are causing a blockage of blood flow to the skin. However, the reversal agent is not without its problems, as it does not discriminate between natural hyaluronic acid in the skin (which forms a vital component adding hydration, elasticity, and integrity), and the filler product injected by the practitioner. 

The problem is that previously, flying blind, practitioners had no way of knowing exactly where a blood vessel was blocked or precisely where an irregularity was positioned within the tissues. This meant that, in order to dissolve dermal filler to treat a complication, the only option was to “flood” a wide area of skin with the hyaluronidase, in the hope that it would reach the site required, wherever that may have been. Commonly, while emergency complications may have been addressed using this saturation approach, the skin is left in a compromised state - dry, flaky and irritated - requiring further intervention to restore health and aesthetics.

With the use of US, in the same way as injections of dermal filler can be guided in the first instance, so too can injections of hyaluronidase, such that only small droplets of the drug are needed, precisely placed in the exact area of vascular blockage or excess filler placement, avoiding collateral damage to adjacent skin and structures.

Adopt the new standard
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A substantial body of research has shown that the ability to now use US chairside has set a new standard for clinical care in Facial Cosmetic rejuvenation, improving results and increasing safety. 

With the availability of this imaging technology, facial procedures have now been brought into line with the long-standing norms of traditional medicine. 

Above: Ultrasound can be used in real-time to guide injections and manage complications.

This may mean that should a practitioner fail to adopt this new standard of care, continuing instead to fly blind, they may very well be exposed to regulatory action and litigation in the event of sub-optimal outcomes or complications.

In a world where patients are increasingly moving away from practitioners who focus on an out-dated approach of basic “Cosmetic Injecting” in favour of responsible practitioners focused on proper healthcare delivery, they are now willing to pay a premium to ensure they receive a higher level of care. The use of US guided treatment gives practitioners a powerful and marketable point of difference.

Cosmetic Injectors should now move swiftly to build US protocols in their practice, with AquLift now offering a ground-breaking training program designed to keep your practice at the forefront of modern aesthetic medicine.