Aesthetic Ultrasound: Seeing Beneath the Surface

What if your injector could actually see what’s happening beneath your skin before placing a needle?

In this episode of Cowboy & the Queen, we’re diving into one of the most exciting advancements in aesthetic medicine: ultrasound.

We break down how ultrasound is changing the way experienced injectors approach facial anatomy, filler placement, complications, and dissolving unwanted or migrated filler. We’ll talk about why knowing anatomy is essential—but being able to visualize anatomy in real time can add another layer of information when treating patients.

From locating blood vessels and identifying existing filler to evaluating what may actually be causing that lump, bump, or swelling, ultrasound is giving aesthetic providers a whole new view beneath the surface.

Is ultrasound the future of safer, more precise injecting? We think it’s going to play a very important role.

Transcript

SPEAKER_00 0:05

Miss, how you doing, darling? I'm doing good. How are you? I'm doing pretty darn well. Just up here in uh good old Charlotte, North Carolina. Chuck, truck, truck, trucking along, as always. So the rambling man.

SPEAKER_01 0:19

Well, we are in Houston. We are in Houston getting pounded by rain. So hopefully April showers bring Mayflowers and probably lots of mosquitoes. But I'm so tired of the cold weather. I'm ready to be hot and sweat.

SPEAKER_00 0:33

So yeah, I know. Let's go. I know. I'm fixing to make a trip out there to see y'all in Houston or y'all coming to the south. So uh it's been long overdue for sure, sis.

SPEAKER_01 0:45

Long overdue, my friend. Let's do it.

SPEAKER_00 0:47

We'll make it, we'll make it up. So, well, y'all, let's get into it. So, today we're gonna be talking about the hidden game changer. You know, why ultrasound is becoming non-negotiable in aesthetic injecting. So, whether it be safety, precision, uh, liability, um, because today's an aesthetic landscape. Choosing not to use the ultrasound isn't just a preference. It can become a risk. Uh, correct, miss?

SPEAKER_01 1:18

Yes. I mean, today we're talking about something that I feel very strongly about. And honestly, it's something that's going to change the entire standard of care and aesthetics, in my opinion, for sure.

SPEAKER_00 1:29

What's crazy about it, it's that it's, you know, it's already here. It's just not widely uh adopted yet, you know.

SPEAKER_01 1:38

Exactly. We're talking about ultrasound, and it's not in a fluffy surface, you know, foo-foo kind of way, but we're talking about what matters in safety, precision, and and honestly, a really big liability in aesthetics.

SPEAKER_00 1:53

Yeah, because I mean, this isn't just about, you know, getting pretty results. Um, this is about protecting your patients and protecting yourself truly as a provider.

SPEAKER_01 2:07

Absolutely. And and for those that are listening to this, this episode might completely change the way that you look for an injector, quite honestly. So, you know, let's start out simple. Um, ultrasound and aesthetics allows us to see um underneath the skin in real time things that we cannot see with the naked eye. And so it helps us visualize blood vessels, filler placement, um, tissue planes, and honestly identify complications, whether they're, you know, certain things like occlusions, nodules, migration. I mean, the list goes really on and on why it.

SPEAKER_00 2:43

Yeah, because it's like literally, you know, turning the, you know, turning the lights on, because without it, we're, you know, we're in still many ways, you're you're you're y'all are you're working blind pretty much.

SPEAKER_01 2:55

No, absolutely. And and this is where ultrasound changes everything. Injecting from, you know, goes from educated guessing to really precision medicine. So, you know, without ultrasound, you know, we're relying on anatomical landmarks. And having been a trainer for many, many years in the aesthetic space, you know, anatomy is just a template. And so although everyone has, you know, the same anatomy, sometimes the placement of that anatomy varies. And so I think this is what ultrasound is necessary because without it we're relying on anatomical landmarks and well, we're relying on what we're feeling with our hands and what we're seeing with our eyes, but we're assuming depth and we're assuming placement when we're not using ultrasound. So with ultrasound, we can confirm you know, exact depth, um, be extremely precise with placement, um, and we can see that product placement or removal in real time. And it can allow us to avoid those critical structures, which we quite frankly don't want to run into when we're using um injectables, uh, biologics, anything like that for sure.

SPEAKER_00 4:16

Well, no, and I'm and I'm sure like, you know, we can elaborate on this more too. I'm sure you see this all the time, but like the the the second you actually see it in real time, you realize how much guesswork there still, you know, is without it, correct?

SPEAKER_01 4:32

No, absolutely. I mean, let's be honest, patients are paying for precision and not probability. And so what that means is is, you know, I without being precise, I might need six syringes. But if I'm very precise with my procedure, I might need three syringes, right? So what that does for the patient, it is allows them to get really good results without overcorrection and miss, you know, guessing where we're placing the product. And, you know, what that does for patients over time is it keeps them looking refreshed and normal. But what really the bigger message here is precision is is so key in making these procedures safe. So, you know, let's talk about what really matters, right?

SPEAKER_00 5:19

And I and I just wanted to ask you a question too, real quick on this, too, and not to sidetrack, but like, you know, you talk about do you have patients coming in, maybe say just need one CC or I just think I need two CCs or whatever like that. This is probably where this really comes into effect, too, to help them to where they like they just think they need that one CC, but then they might come back in a month and they're like, I'm not happy with my results.

SPEAKER_01 5:43

Uh just absolutely. You know, and I try to talk to patients in my in my office in kind of real terms, right? And so one syringe of a dermal filler is the equivalent of a blueberry, the size of a blueberry, or a fifth of a teaspoon. So just even with using ultrasound, precision is super important because the amount that, you know, myself as a provider or the artist painting this canvas, you know, if I have an unlimited amount of paint, it doesn't necessarily mean it's going to turn out as if I have just the appropriate amount of paint, but I know exactly where to put it on the canvas, right? And so precision makes it less expensive in the short term and the long term for the patient. But as a provider, it helps me get exactly the results that I've promised my patients, you know, and spend a hell of a lot less money when we know exactly where we're where we're putting it. So ultrasound improves safety by identifying those vessels before we inject, avoiding high-risk areas in real time, confirming safe planes of injection, and detecting early complications if there were to be one. So that real-world impact means we reduce the um the risk of intravascular occlusion. Uh, we can identify more quickly complications, and this builds better patient trust. And having a true plan before you poke approach is super important. And so, for example, in my practice, patients come in all the time for under-eye filler. And about one in 50 of those patients is actually a good candidate. And so, before we ever touch a patient and put anything under the eyes, we use our ultrasound to see what we're seeing. So, because if it's fluid buildup or lymphatics, we would never use a dermal filler under the eye because it's going to exacerbate that problem and actually make it worse. And sometimes the only reversal is to have it surgically removed. But if we do an ultrasound, which takes about a minute and 30 seconds, we can very quickly identify if it's fat, if it's fluid, um, if it's bone, or if it's ill-placed filler, right? And so just by using that simple tool, you know, we really understand what we're seeing. And it makes us safer injectors to know exactly what we're seeing instead of guessing.

unknown 8:08

Yeah.

SPEAKER_00 8:08

So and those are all things you just spoke about. Like you said, you're with the with Ultron, you you're, you know, you're confirming the depth, you are seeing the product placement in that real time. You are, like you said, avoiding those critical structures. And so this is like, you know, the difference between like throwing a throwing a between the throwing a dart in the dark, right? Or versus turning on a spotlight, right?

SPEAKER_01 8:34

100%. That's exactly right. So um, you know, that's what makes ultrasound super important. And I hope that in the future it becomes kind of the gold standard in this industry. We really don't need to, you know, give someone, you know, you don't give someone a driver's license, put them in the car, and let them go be on the freeway without having a seatbelt on. It just doesn't make a lot of sense. So to be safe, injectors, I think, you know, we have to have an ultrasound, but you're gonna think I'm crazy with what I'm about to say. If you can have an ultrasound device and not know how to use it, right? And it looks pretty in the corner and occasionally you dust it off, when it should be one of the first things that you're doing when a patient comes in for a filler consultation, especially if they said they've had filler in the past. I like to just know what I'm looking at. And I am, you know, consider myself a damn good injector, but you're only as good as what you can see. And so we tend to use, you know, the ultrasound on almost every patient because it's just super important to be precise and just to get it right the first time. And honestly, because we are get this one of the uh few offices in Houston, which is the fourth largest city in the United States. So we have a huge aesthetic market here. Um, most practices do not have ultrasound. And so we get a ton of referrals on a group text with a bunch of injectors all over Houston. I'm not really even sure how many thousands of people are in that network. Um, but when there is a complication with dermal filler, we are one of the first people that are referred, you know, to our practice because we have an ultrasound, number one, and number two, we actually know how to use it. So um, you know, when when physicians and nurses and nurse practitioners get in a bind, we typically will do, you know, the professional courtesy of getting them out of a bind by helping, you know, with their adverse events that they're they're they're hopefully that they're seeing but not seeing in their practices, if that makes sense. Sorry, I I digress.

SPEAKER_00 10:45

No, I mean that definitely does make sense. That kind of along the lines of what I said kind of before like folks are having to come back in and um kind of recorrect maybe things that have have happened in the past. And you know, once you understand what's at stake, it's hard to justify not using it.

SPEAKER_01 11:06

1000%, Wyatt. This is one of the most overlooked benefits of ultrasound, is is using it to dissolve filler. So I always say, you know, having ultrasound is your insurance policy. And we all know that we have to have malpractice insurance and insurance on our buildings, but we should have to have some sort of insurance on our craft. And so this just really is the the, you know, what makes injectors way more safe is when they are using and utilizing an ultrasound with every patient. So um, you know.

SPEAKER_00 11:42

You know, like without ultrasound, without ultrasound, then you know, like what? Like, you know, without ultrasound.

SPEAKER_01 11:50

Well, I think, you know, I see patients that have had multiple sessions of hyaluronidase to dissolve filler unsuccessfully because there's no precision there, they're guessing. And your tissue is divided into many planes and subplanes. So, you know, you can't just put a needle in and guess where the filler might be. I guess that's what's really intriguing to me is to try to guess, you know, to hit the target. And we know that when you don't use ultrasound when dissolving filler, that you can over-dissolve, and sometimes that's not the goal. And it takes multiple sessions. And hyaluronidase is expensive. I mean, you know, for I think it's two CCs, it's 400 bucks. It's not a cheap product. And you have to stock, you know, many. I think we have probably 20 vials of Hylian X on hand at all times because we do so much injecting. And so, you know, you just want to make sure that you can um you're not having to have those multiple sessions by doing blind injections. And patients, unfortunately, by the time I see patients to get filler dissolved, they're one word, and that is frustrated.

SPEAKER_00 13:06

Yep, I I completely agree. And like, you know, like if if you if you you know you it can feel like you're chasing something uh that you really can't see, right? But then when we're using ultrasound, right?

SPEAKER_01 13:21

We like absolutely you have to locate exact filler pockets. Um, you have to be able to differentiate filler versus tissue and target only what needs to be dissolved. And so when I do trainings with other um practitioners, you I always take a poll of how many people in in the room have an ultrasound. At my last training that I did, um there were 32 injectors present for the training, and eight of them had ultrasound, and six of them had never even used it because they didn't have training on how to use it. And that's that's devastating, quite frankly. So that's you know, that's just um and I was asking it too.

SPEAKER_00 14:11

I mean, were they aware of that too?

SPEAKER_01 14:13

I mean, that just turns dissolving Yeah. This just turns dissolving filler into precision medicine instead of trial and error. And so, you know, if you have an ultrasound and you're a master at your craft using the ultrasound, you get faster correction, less product needed, better outcomes, increased patient confidence. And, you know, by using the tools in your practice, it decreases your liability as a provider to know that you've done all the things. And and now here's the part that honestly shocks most people. Get this white. If you don't have a tequila, you should probably get one. All right, ready?

SPEAKER_00 14:57

So I'm ready.

SPEAKER_01 14:58

Less than less than 15, less than 10 to 15 percent of med spas use ultrasound on a regular basis. And drum roll, even fewer use it for complication management and dissolving filler.

SPEAKER_00 15:15

That is like so you're telling me that you're telling me the majority of injectors are still pretty much injecting blonde.

SPEAKER_01 15:30

And patients assume that that is the standard of care, and it absolutely should not be. I mean, let's talk about liability, right? Um, because this is where things get very real very quickly. So the shift that is happening in aesthetics medicine is that number one, patients are becoming more educated, which is awesome, in my opinion. And now, because we have access to, you know, Facebook, Instagram, TikTok, all these outlets, right? Some are real, some are fake. However, um, complications are more visible. I mean, with social media, and you can see every litigation, you can see people talking about their bad outcomes. Um, people expect more. And so I think the standard of care is evolving, but we're just not not there yet.

SPEAKER_00 16:26

You know, the risk with ultrasound or without, I should say, without ultrasound, you know, is you know, higher chance of complications, right? So we have that. We have harder to defend the the outcomes, um, you know, increased legal exposure, of course. And then, you know, now going the risk without using or with using, I should say, with using ultrasound, you know, you now you have documented visualization, you have evidence of precaution, and you have a higher standard of care, which is all huge, I believe.

SPEAKER_01 17:03

Absolutely. And this just this isn't about just being a better injector. This is about protecting your license, your practice, your reputation. And quite frankly, having to deal and live with the fact if you cause something to happen and you haven't used every tool that you have in your tool shed is just devastating. And so, you know, I I think people consider some barriers to having um ultrasound as cost. And I always say this if you cannot afford an ultrasound, whether it's $3,000 or $20,000, you shouldn't be in injecting carrying. In my opinion, that should be the first device that you that you purchase as a new provider. You have your injectables and then you have an ultrasound. From there, you can bring on whatever you want, but your insurance policy is going to be your ultrasound device. And unfortunately, having been in this space for so long, this is actually something that A is never purchased, B is only purchased after a catastrophic event, or C, they purchase it to say they own it and they have no idea how to use it. It's just mind-blowing, really. And so, yeah.

SPEAKER_00 18:22

Yeah, so it's a yeah, it's a you know, lack like you were saying, lack of awareness. But here the the real question is though, like, what's what's the cost of not having it?

SPEAKER_01 18:33

Absolutely. Why one complication can cost way more money than the device itself. And so my hope is that ultrasound will hopefully become the standard of care in aesthetic medicine when dealing with injectables, but even energy-based devices as well. Patients will start asking for it. So they will come in when they're interviewing their potential injector to ask those questions like do you have an ultrasound? How often do you use it? Do you use it pre-procedure or do you just use it in an instance that you have a complication? And so patients will be asking for it. And quite frankly, practices without it will fall behind because patients will realize that this isn't something, it's like going to a tire shop to get your tire fixed. They don't have any tires. So confusing, right? Um, but but so practices without it will absolutely fall behind.

SPEAKER_00 19:30

Yeah, and it's honestly like this it's like this is like pre-GPS medicine, you know, versus GPS medicine, right?

SPEAKER_01 19:39

It will get you, it will get you near the right spot or the right spot every single time. No, absolutely. And once you have it, you can't go back. If you're a patient, ask your injector if they use ultrasound, if they're certified at ultrasound, and how often that they use it.

SPEAKER_00 19:57

Yeah, and it and if you if y'all are a provider, I mean, you know, start start learning it now. Start learning about it.

SPEAKER_01 20:05

Because the future of aesthetics isn't just about artistry anymore, it's about being precise, safe, and also patients need to be holding their providers very accountable.

SPEAKER_00 20:16

No, and I and I I think you made a ton of valid, really good points today. Just, you know, yes, I know it's the cost and so forth, but what you end up paying for is for patients that are, you know, like said, you're working on something you can't see, they might have a negative result, or like we always say too, is like you have might have that, you know, that one patient that has a negative experience. Okay, so what do they do? They tell the world. You have that one patient has a great experience, and they'll tell three to four of their patients as well. And I think, like you said, we're providing this and the awareness of ultrasound and having this access, I think it's a huge, huge impact to helping not just with filler, but other procedures that you're obviously or other officers are providing for their patients.

SPEAKER_01 21:06

That's right. And this concludes this episode of Cowboy and the Queen of Aesthetics because we are here to bring you what is on the forefront of aesthetic medicine and make sure when you're choosing a provider that you choose someone that is all about precision, safety, and accountability. We appreciate you guys joining us today on Cowboy and the Queen of Aesthetics.

SPEAKER_00 21:28

And I thank y'all very much. And we cannot wait to hear the feedback, what y'all have to say. Please, like I said, comment, send us messages. We love the feedback. We're loving the feedback we're getting, and we are so excited to continue to do this as we are Cowboy and the Queen of Aesthetics.

SPEAKER_01 21:45

Thanks for joining us, and we'll see you next time on a Cowboy in the Queen of Aesthetics.

SPEAKER_00 21:50

Thank y'all.