Ultrasound for Facial Aesthetics: Skin Evaluation and Biostimulation Assessment

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[00:00:01][music] >> Hello and welcome. I'm Geniece [music] Smith, sonographer at Clarius. We're excited to have so many of you join us here today [music] for the live webinar titled ultrasound for facial aesthetics, skin evaluation and biostimulation assessment. We're excited to welcome aesthetic physician and ultrasound expert Dr. Gina Murray to provide some great practical ultrasound tips that will help you objectively measure skin aging and prove to your patients that the treatments are effective.

[00:00:35]You're among just under 1,400 keen aesthetic practitioners who registered for today's popular event. Thanks for joining us from all corners of the world.

[00:00:45]More and more we're seeing new and exciting uses for ultrasound in the area of facial aesthetics. Evaluating the skin is one of these areas.

[00:00:54]Biostimulation treatments, for example, are among the fastest growing segments of aesthetic medicine. Yet, outcomes have long relied on subjective assessment and patient reported satisfaction.

[00:01:06]Dr. Gina will show us how high-frequency ultrasound reveals what we can't see with our eyes. We'll see how we can assess the skin, particularly the slab, to better assess the skin more objectively.

[00:01:20]Shelly is also here to do some live scanning with the Clarius L20 HD3, including a demonstration of T-mode following Dr. Gina's presentation.

[00:01:30]A quick housekeeping note. Please use the Q&A box on your screens at any time during today's webinar. We'll have a live Q&A session with Dr. Gina following her presentation.

[00:01:42]I have the pleasure of hosting the webinar today, and just before we start, I'd like to share a couple of relevant papers on today's topic.

[00:01:54]This article presents an innovative use of point-of-care ultrasound devices to help diagnose and manage complications or challenges associated with LNA's treatment. A type of dermal filler. The author presents a case series of six patients to illustrate how POCUS can guide clinical decisions.

[00:02:14]The core argument of the paper is that POCUS adds meaningful precision to LNA's management both before treatment for safety and after for troubleshooting complications.

[00:02:27]By giving practitioners real-time objective imaging data to guide decisions rather than solely on clinical observations.

[00:02:37]The next paper here Harmony CA is a hybrid filler combining hyaluronic acid for immediate volumizing and calcium hydroxyapatite micro microspheres for longer-term collagen biostimulation.

[00:02:54]This paper examines whether high-frequency ultrasound can objectively track the behavior of this product in facial tissue over time both immediately after injection and at 4 months.

[00:03:07]Although the author only studies one patient, they found that high-frequency ultrasound proved effective at visualizing and tracking Harmony CA over time confirming both its placement and its tissue effects including dermal thickness.

[00:03:23]They argue that ultrasound should become a standard auxiliary tool for OFH practitioners not only for treatment, safety, and precision, but also as objective documentation of results.

[00:03:35]They stress, however, that for ultrasound to be useful as a legal or clinical proof of results tool, examinations must be highly standardized. Same radiologist, same equipment, same technique, and consistent timing.

[00:03:52]And now I'd like to get to know a little bit more about you.

[00:03:57]Here's a quick poll um that we'd like you to to apply. Um we'd like to know how often do you use ultrasound for skin assessments in your practice today? So go ahead and choose any of those options.

[00:04:13]Do you use it daily, occasionally, rarely, you're just learning today, or I don't use ultrasound at all.

[00:04:22]I'll give you a few more seconds here to put your answers in.

[00:04:31]All right, we'll close the poll.

[00:04:35]So it looks like there's a lot of different skill levels here. Some are most are um occasionally using it, so that's nice.

[00:04:44]So we'll try to change that today and get everybody using it daily.

[00:04:49]All right. Close that poll.

[00:04:52]All right, I'd like to introduce our guest speaker for today. Dr. Gina Murray was born in Brazil and graduated medical university in Brazil at FESOU University in 2008. She is a board-certified physician, expert in the advanced use of dermal fillers, botulinum toxin, and spider web technique, specializing in minimally minimally invasive holistic aesthetic and regenerative medicine.

[00:05:18]She has pursued her training in aesthetic medicine with some of the world's expert in the in the field. Dr. Murray has successfully completed many medical education extension programs in France, Italy, Brazil, Singapore, and Turkey. Dr. Murray is a master trainer for Evore, LG fillers, infinite threads, and is the head trainer and educational director of the B Academy. She is also the first and only doctor in South America to be legally accredited in the Republic of Turkey.

[00:05:52]Because Dr. Murray is a firm believer in education, she has successfully obtained international accreditation as medical trainer and education supervisor in the United Kingdom.

[00:06:04]Welcome, Dr. Gina.

[00:06:06]Hi. Hello. Good evening, everyone. Uh thank you for being here.

[00:06:12]Thank you, Janelle. Thank you, the Clarius team. And thank you all for uh coming here to listen to us at this uh hour, and I'm very very excited. So, let's start.

[00:06:26]So, ultrasound for facial aesthetics, the skin evaluation and biostimulation assessment.

[00:06:33]Yes, there you go.

[00:06:35]So, I have a question for all of you.

[00:06:38]We all can see improvement after a procedure, okay? But can we measure it?

[00:06:43]What if you could objectively prove your results?

[00:06:47]That's what we are going to talk today, and that's the importance of uh the scanning the skin before and uh after the procedures. You're going to get to a stage that you are going to be able to prove to standardize and to quantify your results to the patient. It's going to be very objective.

[00:07:07]Uh we are making our days biological claims based on visual impressions. The current uh evaluation methods are photography, which lightening and angle bias can change even makeup. And you have palpation, of course, it's subjective, and it's also dependent on who is making it. And of course, patient perception, which can change with emotion. It's not very consistent.

[00:07:36]So, when aesthetic medicine is evolving, we are seeing now a visual approach going away from that and becoming a more measurable approach, a more objective approach. And the high frequency ultrasound give us that. It has several characteristics, several gains, and in my opinion one of the biggest one is it is real time. And with the L20 and artificial intelligence, the T mode, you can actually not only see yourself uh you can learn it much faster because uh the the artificial intelligence is going to show you all of the tissues that are there in color, so you can see the ultrasound there next to it.

[00:08:23]Uh Shelley will uh beautifully uh show you that later in the live scan session.

[00:08:30]And so it's real time and the patient seeing it makes them really happy and understand what's going on underneath the skin. So that's one big big big plus. It's non-invasive, it's reproducible, it gives tissue level insight, it's quantifiable, and it gives us an objective biomarker, several actually, and we are going to talk about that about all of them today.

[00:08:55]Let's start with the basics cuz uh when Janaya did the poll I said that I think it was 28% if I'm not mistaken. Some of you said that you are learning today, so let me get to the basics and bring you a little bit um of an idea of what the ultrasound is because before we interpret the change, we must understand the normal the normality. So I think you can see my my rotor, can't you? Can you, Janaya?

[00:09:27]Yeah, okay. Yes, I can see it.

[00:09:30]Thank you.

[00:09:31]So here is uh the very hyperechoic thin line, it's the epidermis.

[00:09:38]A little bit underneath, well, actually right underneath, you have a more heterogeneous, echogenic structure here. This is the dermis, and underneath, you have the division between the dermis and the hypodermis, and here you have the hypodermis, where you're going to find the fat lobules, which are going to have this look. They are dark, hypoechoic structures with a little line of fibrotic tissue around the fat.

[00:10:08]And this makes us come to this little scan picture here, where you have the ultrasound showing the the structures I just said, but inside the tissue section, the histologic tissue section, where you can see the keratin layer, which right here it's on top, you show the epidermis, then you have the dermis with the collagen, and you have a more hypoechoic area with the fat lobules and the little uh fibrotic tissue around the fat. It's uh the hypodermis. And here, in this other picture, you have the same structure, but showed in divided in colorful areas. So, you have right here the pink one, the epidermis, the blue one, the dermis, and then you have the subcutaneous fat tissue. This might sound a little bit uh too much now if you don't have any um experience with ultrasound, but I can assure you the learning curve with Clarius and the artificial intelligence is extremely fast, because while you are scanning, you are seeing next to it all the structure shown in color by uh the AI, and that makes learning very fast.

[00:11:33]Uh So, I wanted to talk to you before everything about this lab. Because when we analyze these layers, we look at their thickness, at their homogeneity, their structure, but we also analyze something called this lab. And that's one of our main uh subjects today.

[00:11:56]What is this lab?

[00:11:58]This lab is the subepidermal low echogenic band. It is a hypoechoic band beneath the epidermis.

[00:12:09]I will show you right here.

[00:12:12]In this uh scan, you can see the epidermis.

[00:12:16]And then right under, you have this lab.

[00:12:21]Uh this lab is a marker of photoaging, is a marker of collagen degradation, and collagen disorganization.

[00:12:33]Also, some glycosaminoglycan accumulation. And all of that process, as we know, comes mostly from chronic UV exposure or uh oxidation damage, uh external cellular matrix breakdown, water retention changes that comes with inflammation, and structural dermal disorganization.

[00:12:57]I will show you now a slide where you can see this dark band under the epidermis, okay, which is this lab. Here's the epidermis, and here's the dark band. This dark band variable, which is this lab, the subepidermal low echogenic band. It variable. It is very variable in thickness, okay, and we are going to talk about that later.

[00:13:20]Uh why is it variable? And also, it is irregular. It can it have one little part here, then nothing, then it comes back on again. So, it has a irregular distribution, especially when we are talking in advantage advanced aging or advanced um elastosis process like UV damage.

[00:13:48]In this slide, I am showing for you a little video that shows the formation of the subepidermal low echogenic band here. have the collagen fibers getting less and let me start it again so you can see getting less and less organized.

[00:14:03]You have the fibroblast cells decreasing and then this little space forming right underneath the epidermis.

[00:14:12]The core structural changes that you are going to see are the collagen breakdown, the glycosaminoglycan accumulation, increased water retention from the low-grade inflammation. But, in this slide specifically, I wanted to talk to you about the elastosis, which is elastin disorganization or more known aka solar elastosis. I'm sure you heard about it. So, it refers as the pathological accumulation and the degeneration of the elastin fibers within the dermis.

[00:14:47]They are, of course, like we just talked about before, most commonly a result of chronic UV exposure.

[00:14:55]But, histologically, it is characterized by a replacement of the normal well-organized collagen elastin architecture with an amorphous more dense basophilic elastotic material that is composed from abnormal elastin fibrin fibers and of course degraded extracellular matrix components.

[00:15:20]And this is a very important part of the process of formation of this lab.

[00:15:27]From the pathophysiologic standpoint, the fibroblasts from the UV radiation, the fibroblasts, they they get this function. And if that upper regulatory upper regulates the matrix of the MMPs.

[00:15:43]And that disrupts the balance between the synthesis and the degradation of the dermal proteins, which leads to collagen breakdown and all of the things that we talked.

[00:15:54]Uh in this is light, there is also something that is very important. We have something called dermal remodeling. And the dermal remodeling is exactly one of our biggest areas that we are going to work with the procedures in medical aesthetics that we can remodel and rejuvenate that skin.

[00:16:20]Let's continue.

[00:16:23]So, let's talk a little bit about the clinical interpretation of this lab.

[00:16:29]Why do we do we use this lab? Because it reflects a structural and a biochemical change within the dermis.

[00:16:37]It can provide us a visible ultrasound marker of dermal alteration, which is super useful for us. And it can help us objectify skin changes beyond just our clinical observation, beyond just a dermatoscopy or the feeling of improvement of a patient or a before and after picture. We can quantify, just like I I like to use this analogy, just like blood test, okay? You can analyze before, right after, and during the some periods that we'll talk about later. And that will give you quantification and assurance to your patient that the treatment work or that it didn't, maybe, and you have to increase your your treatment um strength.

[00:17:23]So, why is lab is also there are some special things about slab? Why it cannot be analyzed by itself? The absolute slab thickness can vary between patients, and it depends on anatomy, on skin thickness, and on site. It shouldn't be interpreted in isolation. So, let me explain that. Imagine you have a 0.2 mm slab on a patient, which may be very insignificant size in a thick dermis. But, if the same 0.2 mm in a more thin degraded dermis represents a much bigger space, uh and it will show a much more severe structural alteration of the dermis.

[00:18:10]That's why by itself the analyzation the analysis, sorry, of the thickness of the slab is not enough. We need to create a proportion with the thickness of the dermis to give us an understanding of how much of the dermis that process of elastosis, of disorganization is taking space, which will of course give us a conclusion about how that skin is, how that aging process is, how the velocity of aging, and the amount of um oxidation and UV radiation damage that it got.

[00:18:48]So, in other words, the slab does not damage sorry, measure damage. It reflects how much of the dermis has been structure structurally altered.

[00:19:00]Let me show you now what is um how we use the slab thickness.

[00:19:08]We use it in a ratio. So, we call it the slab ratio.

[00:19:12]We get the slab thickness, which I will show you how to um I will I will have a video of how to measure the slab a little later, and also Shelly will uh make a beautiful um scanning to show you live how to measure it and how easy it is. So, we get the slab thickness and then we divide by the dermal thickness, okay?

[00:19:36]Something very important here. When we measure the slab thickness and then we measure the dermal thickness, the dermal thickness should exclude the epidermis.

[00:19:47]So, you're going to measure right under that. We'll show it in detail later. So, you multiply that by 100 and you have a percentage.

[00:19:55]This ratio shows relative occupation within the dermis, like we said. It measures how much of the dermis is altered. It represents dermal structure imbalance and it will allow us to compare uh independent of the size, creating, of course, a more standardized parameter, which is our goal in the end.

[00:20:16]So, a higher ratio is greater dermal change.

[00:20:21]To make that um a little bit easier to understand, we are going to show you now a video and the video has no sound. I am going to talk over the video to uh help you understand.

[00:20:34]Let me start it.

[00:20:36]The first thing uh that we have to check is some standardized parameters that we have to use. First of all, you have to use always the same place. So, if you measure in one time before in one place specific place before the procedure, you have to measure in that same place after. You have to keep the same gain and the same parameters in the uh ultrasound, the L20, which, by the way, is very easy because it has a specific parameters already ready for you. So, you don't have to worry about changing the gain, doing that. Shelly will explain that to you very clearly. You need to have a very small, very minimal probe measure pressure, sorry. So, that's why I use this hand gesture. I hold the probe like this and I leave these two fingers, three fingers free for me to support on the patient face and the whole probe weight is only on these fingers here.

[00:21:35]So, that also helps a lot. Also, you have to use a lot of gel, okay? Once you found the a good visibility, which is the epidermis and seeing right here the uh slab, you just pause the the the the scanning, okay? In this specific video, I use a voice control, which is a a um a thing that I love in in the the Clarius L20.

[00:22:07]Then, you go to measurements, just like it's showing here in the screen.

[00:22:12]And you are going to measure, I'm going to show you now how to measure the only the slab.

[00:22:19]So, you go right underneath the epidermis and until the end of that little dark hypoechoic line, okay? So, that's the measurement of the slab and it shows right here the amount it's showing. I think it's 0.344.

[00:22:40]Now, I'm going to uh measure the dermis without excluding the epidermis. So, you go right under the epidermis and go to the higher uh limit of the hypodermis. There you go. I'm doing that just there. It's very simple to do this with the ultrasound.

[00:23:03]I actually got to tell you uh when I first got it, my L20, I used it as a toy. I scanned my dog, I scanned my kids because it's so much fun.

[00:23:14]Me, too. So, you do, right?

[00:23:18]I mean, you can carry with you and it's it's it's amazing. I love to see everything in it under the ultrasound.

[00:23:24]And that's how you measure it.

[00:23:26]Uh the continuation of the video, I'm talking a little bit about analyzing the the ISL ratio, okay? So, you're going to use the ISL thickness that you wrote it out right there, here, and the ISL uh the dermal thickness, you're going to divide the the ISL and through the dermal thickness multiply by 100 and have the percentage, okay?

[00:23:48]So, I'm going to show you now what Let me pass the slide. Yes.

[00:23:56]I'm going to show in this um First, what I did is that I made for you guys to make it easier to visualize a chart, okay? So, in this chart, you have the horizontal uh axis.

[00:24:11]It represents the total dermal thickness. And the vertical axis axis represents the ISL thickness. So, the colored zones that you see here, you have the blue, the yellow, the green, and the red, they represent the proportion of the degener- degeneration inside the dermis.

[00:24:30]So, as the patient moves upwards, from down to upwards, into the higher ratio zones, the ISL occupies a larger percentage of the dermis, which means, of course, that the healthy collagen compartment is progressively being replaced by edema, elastosis, UV radiation damage, all the things that we talked about that create the ISL.

[00:24:54]So, when we have two patients, they can actually look similar. But, their dermal biology can be different and you can only see that with the ultrasound and analyzing this lab this lab ratio.

[00:25:06]Um right here, when you have the blue area, you have a lower proportion of degradation of the skin. The yellow area, you have a moderate structural alteration. The green area, you're going to have a significant more dermal compromise and the red is more advanced degeneration. So, this this chart was more for you guys to visualize it to make it a little bit simpler. Now, we are going to analyze it through the limits of percentage. So, let's move to the next slide.

[00:25:39]I have my notes here uh for me not forget anything and give you the best uh sharing uh experience that I can. So, from 0% to 10%, we have optimal skin.

[00:25:54]You have a minimal or absent slab. A bright homogeneous dermis. And what you need treatment-wise, you need maintenance only. What we advise, mesotherapy, skin boosters, and preventive care. You don't have to do many many many sessions.

[00:26:11]Maybe one or two cycles per year.

[00:26:14]When we are talking about a patient between the 10% and the 20%, you have some early changes. Actually, the patient in the video that we talked he had around 17%. He was right in this specific um part is specific um cut limit. So, between 10% and 20%. What you see, you see a thin slab, okay? You see good echogenicity uh because of the amount of collagen.

[00:26:45]So, the collagen it uh increases the brighter uh reflects of the ultrasound. so it's hyperechogenic. So, you have a good echogenicity. So, you have also in treatment-wise for this category, early intervention. You need to treat that, okay? And maybe don't allow it to continue the process of degradation. So, what we advise would be PRP would be a great option for a patient in this uh category. PDRN, which sometimes it's called uh salmon DNA or salmon uh salmon sperm.

[00:27:26]And you have biostimulation with other mesotherapy products.

[00:27:32]Uh between 20 to 30, this category is a little bit more complicated. We have already some moderate aging. Slightly thicker slab, early dermal heterogeneity, and reduced brightness.

[00:27:46]You need for this type of patients more active biostimulation is required. So, we are going to use more polynucleotides.

[00:27:55]You are going to make more sessions of also again what we talked before, mesotherapy, PRP, PDRN, what you have available for you. I love to use for this category exosomes. I think they really help to make it come back in time, let's say it like that. And I use of course a combination mesotherapy. I love to use DMAE for these types of patients for something tightening.

[00:28:21]Now, let's talk about the patients with more advanced skin aging, the ones that are in the category between 30 to 40%.

[00:28:31]They have a much thicker slab. They have dark dermis without the collagen brightening it up. You have more structural disorganization, and a much stronger intervention is needed for this type of patients. So, here we are going to use our guns, calcium hydroxylapatite for collagen stimulation, poly-L-lactic acid, but now we have even a improved version is the poly-D-L-lactic acid, which I love because it can give less complications, and is stem cell therapy if you have that available in your country.

[00:29:06]When we are talking about patients with more than 40% we are talking about a severe photodamage.

[00:29:13]And when we are talking about severe photodamage, you're going to see a very thick slab, you're going to see poor dermal dermal definition, a thin dermis, a marked hypoechogenicity, and you need multimodal combinational therapy. Now you're going to use the extra big guns. Uh you're going to use everything we talked before plus a highfu, biostimulators like we talked calcium and PDLLA or PLLA, and regenerative therapy. Within this regenerative therapy world, you have the the PRP, you have the exosomes, you even have the stem cells.

[00:29:51]Uh but the follow-up loop is very, very important. You have to reassess, so you are going to do the scanning before, like I showed in the video, but you are going to reassess that patient in 1 month, in 3 months, and in 6 months after the procedure. And that is what is going to give them the trust and the feeling that, "Okay, I see the results.

[00:30:12]I literally see underneath my skin the results." And the goal there when you're scanning it's to see a much smaller uh slab ratio, a lower slab ratio, a higher dermal thickness, and a higher echogenicity.

[00:30:29]This is just a uh a chart like a table that I did uh making it a little bit again more didactic and visual the different categories. You can maybe um take a screenshot of it and it's just repeating what we talked before. I have a question just regarding the this lab measurement measurement ratio. Is there any contraindications with like medications that might affect the slab measurement that a patient might be taking or does it just remain the same? Yeah. No, there are but they are all anecdotal because a slab is something that still we are doing many papers and writing about it. But personally, I have seen a little bit difference when they are taking isotretinoin.

[00:31:25]But that is again anecdotal. It's just my personal experience drug-wise, okay? But of course, if the patient has an extremely elevated slab ratio, okay?

[00:31:40]Let's say that means that the healthy dermis is disappearing. That is a severe dermal structure compromise. It's more like a disease. So, within that within those conditions, we have connective tissue disorders. One very special question something about what you asked is chronic corticosteroid use because that will give a skin atrophy. So, decreasing the size of the the dermis, you are going to have a higher proportion of the slab, of course. So, scleroderma is there into cutaneous lupus is there and psoriasis is there. So, there are other diseases, especially the ones that are creating a lot of inflammation and degradation of the ECM and the fibers of the skin that will create a different approach. So, anything that you see that it's much over like 45% or 50% you should first of all re re re-measure. Maybe it's a mistake there.

[00:32:45]Or you should evaluate evaluate this patient for how do you say clinical dermatology it probably has a skin disease a skin condition.

[00:32:58]Thank you.

[00:33:00]So thank you for the question.

[00:33:01][laughter] Uh now Uh this lab is not only thing we we we see. We check also other parameters and they are pretty I think in my opinion easy to understand. The first one is the echogenicity. So echogenicity is uh the color that you see. So when we say hyper echogenic and hypo echogenic we are talking about the brightness or the darkness of uh the the is scanning the the reflect of the the the ultrasound waves. Okay, back to the probe and giving that black and white and gray scale image for us. So collagen reflects.

[00:33:44]So it gives bright. So the more brighten the more increase the more improved the structure. The darker it means that okay, you have less collagen but also means liquid. Okay, so when you are when you are seeing maybe a vessel or a fat lobule it we are talking about there a cell that has a lot of water or a vessel or a structure that is inflamed which in our case here is the case of this lab.

[00:34:12]It has less collagen it has inflammation it has edema. So again it's hypoechoic it's darker.

[00:34:20]Dermal thickness and for us to help a little bit visualizing the dermal thickness I made this facial dermal thickness heat map and here you can see so again thick dermis is more structured.

[00:34:33]It and the the thickness of the dermis it indicates volume as well as the integrity of the external cellular matrix of the skin.

[00:34:44]So you can see around the eyes and the temples you have the thinnest skin when where you have the blue. When it goes getting close to green, yellow and the red is the thicker. So you have the thicker here on the on top of the upper lip.

[00:35:02]And this chart is for a normal skin and you're going to see that the measurements that you're going to take in different skin >> [clears throat] >> thickness even though they are different when you do the ratio that's not going to matter but by looking at the dermal thickness itself it's also a parameter for us that gives the the the the understanding of the structure of the dermis. So thicker dermis is better.

[00:35:32]For example, I'm going to give an example. The neck when when we come patients mostly after 50 they complain about the thickness of the skin of their neck or the under eye and you can really see if you compare to this heat map that it got much much thinner than what it should be.

[00:35:53]So that is one of a good parameter that we use. The other parameter that I like to use is tissue homogeneity. So it's just checking uniformity, okay? And uh uniformity of the dermal architecture. So you have an uniform dermis or a fragmented dermis. That comes a little bit with uh experience but it's something that you can see very easily because it's pattern based and our brains are >> [laughter] >> love patterns. So it's very easy to see something that it's homogeneous and uniform and something that is broken and fragmented.

[00:36:30]Um let me show you now a little bit about how to use these markers when we are evaluating a patient.

[00:36:41]So, biostimulation and ultrasound from the subjective to the objective. What we should access, okay, before we do any treatment and even before we plan the treatment for the patient because these will help us plan the treatment and understand why we need maybe some biostimulation, some uh collagen um um increase stimulation and depending on that you're going to decide and you're going to be much more precise, much more target uh with your with your um treatment decisions. So, first thing, dermal thickness like we talked before, slab ratio, dermal echogenicity, homogeneity, and disorganization of uh the the the skin, subcutaneous tissue quality, the presence of pillars, fibrosis, nodules, and edema, and of course, our vascular anatomy.

[00:37:38]Let's talk a little bit about each one of those, okay?

[00:37:42]Uh so, ultrasound they change uh how aggressively and how deeply and safely and even whether we should stimulate the tissue or not. That's why it's so important. When we are now analyzing the dermal thickness, a thin dermis means a fragile tissue with limited collagen support. So, you need more gentle protocols. You need more a lower inflammation burden. You don't want to do many things, for example, maybe a radio frequency ultrasound ultrasounding that skin uh using uh too too strong radio frequency levels there because you don't want that inflammation. It has difficulty with uh that part taking it out. So, you need more sessions and less intensity. When you have a thicker dermis, you have a better structural reserve, so you can do stronger stimulation treatments. You can do some more combination therapy. It's easier to do that. When we are talking about the slab ratio, when it's mild, you need prevention focus.

[00:38:43]Uh prevention focus treatments. When it's moderate, you need more active regeneration, like we talked before. And more severe, you have to go slow on regenerative The skin has slow regenerative capacity. So, sometimes, when you have a severe slab ratio, it doesn't specifically means that you need a stronger treatment. It can sometimes means that uh the skin biology that uh skin is more fragile. You need to be careful, okay?

[00:39:17]Now, when you are talking about dermal echogenicity, when you have low echogenicity, you have uh to focus on regeneration, collagen induction, and tissue quality restoration. When it's a good echogenicity, maintains protocols. So, all of these parameters, they talk to each other and they help each other. And they're more or less saying the same thing, right? They take you to the same uh conclusions.

[00:39:44]Now, when we are talking about homogeneity and or disorganization, a more homogeneous uh skin, a more homogeneous dermis, it's going to give you a more predictable response. So, you can tell the patient in a more predictable way what's going to happen. But, when you have disorganization, you have more fibrosis, so you have more irregular healing and chronic damage. So, you have to plan your sessions accordingly. A more disorganized skin might need more sessions to reach that same level of um uh result that you want.

[00:40:20]The subcutaneous tissue quality, we evaluate the septae, the fat integrity, the edema, atrophy, and fibrosis. So, how does it affect our treatment plan?

[00:40:32]So, the amount of product that we're going to use, the profile risk of the patient, product choice, and of of course, injection plane.

[00:40:41]When we have uh old fillers, again, it's going to uh it's going to impact all of those things as well because sometimes you need to melt, and you have to check if it's uh HA filler or if it's um uh a non-biodegradable filler because if in that case, you cannot go there. So, there are several things that you need to evaluate, also the plane. You need to evaluate fibrosis, presence of nodules, and edema, and of course, the last parameter that we are going to talk in this slide is the anatomical results, the vascular zones, the vascular areas that you have to look before doing a procedure. I actually last week, I had two patients coming in for me after a complication with biostimulators intravascular.

[00:41:32]So, it is not such a big deal because in the end, it's easier to to treat, but it can it can be problematic.

[00:41:44]So, let's move on for our next slide, which is talking about what we look after the treatment, after the biostimulation. We are going to be looking at an increased dermal density and echogenicity.

[00:41:58]You are going to be looking at improved dermal homogeneity. Those are the goals.

[00:42:03]Reduction or at least a stabilization of this lab ratio, increasing dermal thickness, and that will decrease this lab ratio, better definition of tissue planes and absence of complications of course, nodules, granulomas, edema, fibrosis.

[00:42:20]So, if the ultrasound guides the treatment decision before biostimulation, it will also allow us to objectively objectively evaluate whether regeneration actually happened. So, it's very good and you can live show the patient that, not only by giving the numbers, they quantifiable numbers, results, you can say uh show it live to the patient.

[00:42:44]So, let's now focus a little bit more precisely on the uh specific biostimulation treatments. The first one that I want to talk to you about is the calcium hydroxylapatite or the CaHA.

[00:42:59]So, immediately you are going to have visible hyperechoic particles deposits.

[00:43:06]Look, guys, this is this uh webinar is not about recognizing different uh biostimulators or fillers in the in the skin.

[00:43:17]For that, you can go to our library in the Clarius uh classroom, and you are going to have many visi- videos of amazing uh experts telling you how to analyze and to see if this is calcium hydroxylapatite, if this is PD- PDLLA, if this is hyaluronic acid, but here I will go give you a more generic brush on top of it because our focus here is the effects on the dermis after the the the the the procedure, okay? So, in these black stars here, you are going to see a 1 year after a treatment. So, you're going to see hyperechoic band still present, okay? You're going to look after the procedure for a collagen response, tissue integration, and of course no nodules.

[00:44:07]Here, in this one, you have the old calcium hydroxylapatite, and you have a just made right now, in that moment, right after the retreatment with calcium hydroxylapatite, with these blue uh stars, okay? And here, you have the uh the older older, and then 2 months after the retreatment, you can see the difference of the image uh between the two different times of the apply where they applied the calcium hydroxylapatite. What we see here is a new thick hyperechoic band observed right there, and that's what we want to see after a calcium hydroxylapatite um um procedure. You want to see more brightness, you want to see more collagen, because that's the whole goal.

[00:44:59]It's a collagen stimulator.

[00:45:01]The baseline for Oh, sorry. The best timing for re-scanning is 1 month, 3 months, and 6 months after treatment.

[00:45:09]That is also a great reason to bring the patient back to your uh consultation room.

[00:45:16]So, here, we have uh the PDLLA or PLLA type biostimulation, also a type of collagen stimulation. So, here, you have the normal uh scan, okay? The normal uh dermis without anything of the face. This is a uh a scan of the face. So, you have the dermis, the hypodermis, and the epidermis here. Right after the procedure, you have the accumulation here of the product, the PLLA, okay?

[00:45:47]Uh the deposit outline with posterior This is a very important thing. Look, this is a posterior acoustic shadow.

[00:45:55]This is a telltale of uh PDLLA. So, when you see this, it's you can be sure it's PDLLA.

[00:46:04]And uh after 1 month, a more subtle um accumulation deposit of the product and a more organized dermis, as you can see.

[00:46:15]So, the follow-up you are going to check for progressive dermal and subdermal echogenic change, and you look for uniform distribution, no papules, no nodules. When I my my personal experience is when I'm using PDLLA, I have a much lower chance of nodules and granuloma. So, it allows me to use it in a more thin skin, like the neck, for example.

[00:46:42]Of course, we have to be very careful and choose our patients well on the account of decreasing risk of complications.

[00:46:51]Here, it's one of my favorite treatments.

[00:46:54]Uh of course, if the patient doesn't have volume loss because HIFU or focused ultrasound can melt fat. You have to be careful with that, but I I really like this uh procedure.

[00:47:07]So, what we normally see I don't know if you guys have experience, but for those 28% that don't, uh this is the cheek, okay? You really have the bone, and here these lines, hyperechoic lines, which are easier to see in this scan because the patient had a HIFU treatment. I think this was 2 months after the HIFU treatment.

[00:47:36]This fibrotic tissue here, this thick collagen bands, they are called the SMAS.

[00:47:44]And I think all of us know what the SMAS is and how important it is for uh the process of aging in our skin, and again, the process of anti-aging procedure. So, when the thermal tiny little points that the HIFU gives with the focused ultrasound into the SMAS, you are going to have this hyperechoic, much, much more bright than you would in a normal in a patient without this treatment. And you can see these points of extra hyperechogenicity, which were the points where the HIFU dots, the thermal dots went there.

[00:48:25]So, you are going to see after the tissue the treatment, tissue remodeling, increased echogenicity, collagen response much, much better, and you are going to look for the correct target layer, if it's in the right layer that you want it, if there is no fat injury, like I said before, HIFU can melt fat, and no focal fibrosis. The best timeline, again, to reevaluate this patient is between it's after the first month after the treatment, and then the third month.

[00:48:57]I think you have a question for me, Janaea.

[00:49:00]Oh, no, sorry. I was just Okay. If you do, I love your question.

[00:49:06]>> [laughter] >> So, some treatment is specifics.

[00:49:11]Uh, again, we are going to talk about two other um treatment um treatments that we use in our daily practice. They are the exosomes and the PRP. Those two treatments, they have something in common.

[00:49:25]They are um you can see the result on the dermis when you are scanning, but you cannot see, like the other procedures, you saw the the calcium hydroxyapatite, you saw the implant of the the the the polylactic acid. This you don't see. You don't see the exosomes, you don't see the PRP. You just see the liquid there while you are doing it, but that's it.

[00:49:47]It would be the same with any liquid, even if you inject ASF. Okay? But, what you do see is uh after the procedure, you're going to look for indirect tissue response for both. You want a dermal echogenicity improvement, you want a slab ratio improvement, you want the thickness of the dermis and edema reduction.

[00:50:11]The more or less the same goes for the PRP.

[00:50:15]Uh you are going to see a little bit more improvement in the dermal thickness and the echogenicity, uh especially if you use the Doppler. Sorry.

[00:50:28]It slipped my mind the word. The color Doppler, because you're going to see a lot of um new vascularity, which is great for your skin health, uh of course, if they are not capillary or or spider veins. But, uh in this case, no, PRP doesn't do that. And the best time for baseline treatment after those two is again, 1 month, 3 months, and if you continue the treatment, if you do several uh sessions, 6 months later.

[00:50:58]Now, we are getting to the end of our um of our presentation here.

[00:51:06]And I made this slide just to make things easier in your mind. I know this is a lot of information, and I know this can be a little bit scary, but please understand that ultrasound with especially the artificial intelligence and the way you can use it, because you can carry it everywhere. You can use it, you can try it everywhere, just like a toy, just like an iPhone, you know? You are going to get used to it. It's going to give you even something like I like to say, ultrasound muscle memory, you know? You just get used to it. So, don't be scared, but I made this slide to make everything organized in your head. So, first, we are going to scan.

[00:51:46]Then, we are going to analyze. Then, we're going to treat according to the analyzation. Then we're going to monitor and communicate. Communicate is very important here.

[00:51:55]So, this is how I think ultrasound can change your practice.

[00:51:59]First, you are going to scan, understand the anatomy before injection. That will help you also identifying the responders, detect severe dermal damage, assess tissue quality, and improve patient selection. That is your side.

[00:52:15]And you can communicate that to the patient as well.

[00:52:18]Uh then you are going to analyze.

[00:52:21]You are going to determine tissue quality and the regenerative potential of that specific patient. You are going to plan the treatment. You are going to choose the treatment more intelligent, match the modality to the tissue condition, combine therapies more strategically, and of course, in my opinion, one of the most effective things to make your patient happier would be here, the personalization of the biostimulation protocol. They are going to feel that this is made for me, for my skin, and only for me.

[00:52:59]And that is something that I can tell you has no price.

[00:53:03]So, the third step, sorry, the fourth step is monitor. So, you're going to do the follow-up protocol. You're going to monitor the structural changes, track the dermal remodeling, compare objective measurements that you already took and standardize your follow-up.

[00:53:18]Standardization here is the main word.

[00:53:22]So, the fourth, sorry, 1 2 3 4, the fifth.

[00:53:25]>> [laughter] >> The fifth block here, here is a block, but it's the fifth thing that you're going to do is patient communication.

[00:53:32]You are going to through this whole process make the patient understand that this is something that it's not abstract, that we can measure. It shows the the patient the visible biological change, not only subjective aesthetic outcomes. And for that, you are going to enhance and with that, you are going to enhance patient trust. You are going to give him a visual proof and increase its your credibility. And you can do that live with them and they kind of love that.

[00:54:05]Oh, I see this is Oh, I I I get it. This is how I look underneath. It's It's actually super fun. And it improves treatment compliance a lot. You have no idea, especially when we have several sessions of PRP or mesotherapy and biostimulation is like that. It's a long process. And elevates perceived value of care. And that means for us, of course, a much improved uh price and um how do you say price structure with you and the patient?

[00:54:39]Um So, I want to leave you now with this sentence that I love. So, the future of aesthetic medicine is not about performing treatments. Yes, it's not, in my opinion. It is about understanding the tissue, measuring the change, and providing natural results. High frequency ultrasound allows to move from perception to precision. We are not blind anymore. Thank you so much. And this is my Instagram.

[00:55:08]Awesome. Thank you so much, Dr. Gina.

[00:55:11]Um that was great. Before we um hand it over to Shelley for the live demo, um I'd love to help everyone continue in their ultrasound journey and bringing ultrasound into their aesthetic practices. So, please complete this poll if you'd like any additional information.

[00:55:29]So, we'll leave that up there for a few seconds.

[00:55:33]Oh, sorry.

[00:55:34]All right.

[00:55:36]Are you guys ready for me?

[00:55:38]>> [laughter] >> You know, can you see my iPad screen all right? Yes. All right, excellent. Okay, good. So, I have the L20 um high frequency scanner that Dr. Gina was talking about.

[00:55:50]And uh I'm just going to um I I would really like to demo the um the T mode that she she talked about for for the educational ultrasound. So, um so, here is my scanner here. I've got a whole bunch of gel on the probe right now. Um and we're going to just kind of use that as a bit of a stand-off pattern. As Dr. Gina said, I'm using my pinky to anchor the um uh my scanner on the skin. And what we're getting here is a nice layer of gel so that we can actually look at the the epidermis here, which is really important. And underneath the epidermis is where I'm seeing the sled layer right here. So, when I pick my preset, my auto gain is on, and those are the consistent settings that we want to do from from patient to patient or um following a patient along every time we see them.

[00:56:45]So, I'm just going to quickly show you um the T mode here. So, I'm using the cheek preset. So, um the algorithm has been trained to recognize the cheek anatomy, and right away we get a nice side-by-side representation of tissue layers, nice graphic graphical overlays.

[00:57:03]We can see the SMAS here, which corresponds to this layer here. I can also um adjust the T mode opacity here just by sliding right to left, and that puts a slight tint over the ultrasound image, the grayscale image, and just is really helpful um when you're learning how to how to do this.

[00:57:22]So, that's the cheek. Now, this also works for the lips, and and I can just quickly show you the temple. And so, what I would do is just go back and pick the temple preset so that the um the AI knows how to recognize the the temple anatomy here. So, you know, I know that this is the temporal bone here and muscle tissue here, but when I activate the T mode we can actually see the live labels of the tissue layers, which is just so helpful for for learning.

[00:57:56]Yeah, it makes it very visual for the visual learners.

[00:57:58]>> Yeah.

[00:58:00]And And one more thing I'll do here.

[00:58:02]I'll go to the dermatology preset cuz that's what Dr. Gina was using here. We'll go back to the cheek here. And honestly, I didn't know what the slab was. I, you know, I think it's new. All the this aesthetic medicine anatomy has been a real learning experience for both Gina and myself. And so, you know, learning how to image the slab was was one of the another one on the on the books for us.

[00:58:27]So, yeah, I I confirmed with Dr. Gina before we started here that I'm just going to put a little bit more gel here so I can get that gel layer in here that this skinny little layer, this dark layer here is the slab. And so, I can actually zoom that image a little bit more to make it easier to measure.

[00:58:46]And then if we freeze I can go into my measurement and just do a quick distance of the slab here which Dr. Gina, you can tell me if I'm if I'm in the right area.

[00:59:01]>> [laughter] >> That is that is perfect. That's exactly how it should be.

[00:59:06]>> [laughter] >> And then And then the dermis level is here.

[00:59:10]>> Yes. Is that right? Yeah.

[00:59:12]>> You are You are excluding the epidermis, so that's is great. Okay, but I'm including the slab in that measurement. Is that correct?

[00:59:21]>> Yes. Yes. Yes. And then >> that's what I wasn't sure about.

[00:59:24]Upper level of the hypodermis.

[00:59:28]Okay, which is So, am I in the in the area there?

[00:59:36]It's great. That's perfect.

[00:59:37]>> Okay, great.

[00:59:38]Great.

[00:59:40]Good. So, we So, you all too can be experts at imaging the slab. It's not that difficult once you know that uh what what you're looking for. So, >> [laughter] >> great. So, I will stop there um and Janette can just talk a little bit more about the um the um uh L20 and Clarius, and then we'll open the floor for questions if we have any.

[01:00:02]>> say one thing before that? Yeah. What do you do remember the the the the the screen that had the both of the the measurements, the slab and the the dermis? So, you're going to get that, the slab, the that number, and divide it by the epidermis, multiply uh sorry, by the dermis, multiply by 100, and that's the percentage. That's the slab ratio, okay?

[01:00:29]Perfect. Yeah. Awesome.

[01:00:32]Thank you so much, Shelly. Um we'd like to invite you to register for our next aesthetics webinar with Dr. Ahmed. The webinar is titled um thread applications and complication measurement, and will be happening sometime in August. And I'll give you a moment to respond um so that we can save your seat.

[01:00:51]All right.

[01:00:53]And we'd love to help everyone continue their journey in bringing an ultrasound in their aesthetic prac- practices. So, please complete this poll if you'd like more information um before we start um before we start our live Q&A session, I'd like to take a minute to tell you a little bit more about the Clarius L20 HD3, the world's only high-frequency ultrasound in a 20 MHz wireless scanner.

[01:01:18]Now 30% smaller and lighter with an integrated battery and it's available in several countries worldwide. And with membership or the one-time license, you'll have access to educational team mode and other advanced features.

[01:01:33]Now, we all know that the traditional ultrasound systems are costly and difficult to learn and use. Clarius ultrasound has changed the game, particularly in facial aesthetics.

[01:01:43]Miniaturization and innovation with handheld units means high-definition imaging is now easy and affordable with image quality that rivals traditional ultrasound systems, but at a fraction of the cost. The Clarius L20 h3 is the only handheld ultrasound with a high frequency up to 20 MHz for exceptional superficial imaging, which makes it ideal for facial aesthetics.

[01:02:07]With high-definition imaging of the skin, muscles, special vessels, and fascia, you'll be more confident with your needle placement, easily characterize and evaluate fillers, and accurately treat complications, improving patient safety with consistent treatment outcomes.

[01:02:24]As you saw during the web the webinar and live demo demo, Clarius is wireless, freeing up space with zero footprint.

[01:02:31]It's also fully immersible and so much faster to clean and disinfect, as well.

[01:02:36]Only Clarius delivers linear wireless scanners with an ecosystem that includes a free app for your iOS or Android devices with free updates. Clarius Cloud is available to capture and manage your exams from anywhere.

[01:02:50]We also offer Clarius classroom videos with experts in onboarding Clarius clinicians to build your ultrasound scanning skills.

[01:02:59]Now, um if you didn't get a chance to ask for more information, you can do so in the closing survey.

[01:03:07]All right, so um we'll head over for a few questions. Um we don't have much time, um but we'll answer a couple here. So, So have one, um how do you get the T mode? I got my Clarisonic today. That's great.

[01:03:21]Oh, that's great. I think that's Shelly.

[01:03:25]T mode comes uh with the purchase of a membership or one-time license. So wherever you got your your scanner from, talk to the salesperson or distribution manager or whoever that might be and they can get you set up with that.

[01:03:40]And if you have any questions, you can just um email go to the website and uh and email us for that. We can get you more information on that.

[01:03:51]Your videos in the classroom are also amazing Shelly and they teach you even how to hold the ultrasound, how to do game changes. I think, you know, it's like the classroom of the website is very very uh strong and you can get most of your information there. Uh and I think uh the one that talks about T mode, you gave it, right? You did it.

[01:04:16]You recorded it.

[01:04:19]Do we have time for one more question, do you think? Yeah. Okay, um this one's for Dr. Murray. Have you seen any changes to the dermis associated with GLP-1 treatments or do these uh treatments only affect the fat pads?

[01:04:34]Uh I've seen some um at the most the yes, it's the fat pads and I see some loosening on the isthmus.

[01:04:44]So you can see more thinner isthmus, but uh specifically on the dermis, it's still anecdotal. We are still trying to do some uh research about it, getting a lot of cases because it's a little bit difficult to do this since you cannot uh just prepare the patients and give them the GLP and then uh do the analysis in a more standardized way. So, you just have to have the patients that by chance they did the treatment and then you can analyze. And that gives different timelines. So, it's very hard to make a very well-accepted paper about it. But, yes, anecdotal anecdotally, I've seen changes not only on the fat tissue tissue, but in specific this mass and the fibrotic tissue of the fascia.

[01:05:35]What about, uh, you, Jeanine and Shelly?

[01:05:42]I haven't had I don't have much experience with, um, patients with GL1.

[01:05:47]>> Um, I so Unfortunately, I can't weigh in on that.

[01:05:51]>> [laughter] >> Um, all right. Uh, we've now reached the top of the Oh, sorry.

[01:05:57]>> One question here. Sorry, sorry. Just one question here. I think it was very interesting if they ask if the the findings of the fat measurements are consistent throughout the face or they differ from different areas. They do differ from different areas. That is why you have to standardize the areas that you're going to check. I normally check the zygomaticus arch area. You can check the temples. I check the, uh, the jawline, the under eye, and the mouth. And of course, if the patient complains about, uh, the neck, also the neck.

[01:06:29]Sorry.

[01:06:31]Okay. Um, [music] we now reached the top of the hour. If we didn't get to your questions, we will follow up with you by email in the coming [music] week.

[01:06:39]Um, please complete our closing survey to provide your feedback so that we can continue [music] to bring you more educational webinars like today's. I'd like to thank you, Dr. Jeanine, for your insights and your expert [music] ultrasound skill. And a very big thank you to you all for joining us today.

[01:06:55]Have a wonderful day and remember that practice makes perfect. Thank you.

[01:07:00]Thanks, everyone.

[01:07:02]Thanks, everyone. [music] Thank you so much. Bye-bye.