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Unmasking Plastic Surgery With POCUS

Florida plastic surgeons are using point-of-care ultrasound (POCUS) to help remedy death caused by cosmetic surgery. According to NBC 6 Investigators, since 2017, 19 women in the state have lost their lives after a Brazilian butt-lift (BBL) procedure, making it one of the deadliest plastic surgeries conducted. In response, the Florida Board of Medicine put into effect an emergency order on June 3, 2022, requiring surgeons to use ultrasound imaging to help make the procedure safer, and many Florida plastic surgeons are turning to POCUS to comply.

The leading cause of death resulting from the procedure is untreated pulmonary embolisms. Because embolisms are more likely to occur when fat enters deep muscle tissue, the board mandated in 2019 that Florida surgeons may no longer inject fat into muscle. The board’s new order incentivizes surgeons to use preoperative and intraoperative imaging to see where the muscle is and inject instead into the subcutaneous plane. As a result of this order, set to last 90 days, Florida has seen a sharp rise in POCUS usage.

The hand-held nature of bedside ultrasounds saves space in the operating room and allows for flexibility of use during the procedure. So while BBL is the most lethal plastic surgery procedure, it isn’t the only one that benefits from imaging. Before and during aesthetic procedures, performing an ultrasound allows surgeons to see how much room a patient has for grafting and where to make injections for best results. Seeing where to transfer fat not only helps avoid life-threatening complications but also ensures that the grafted fat survives and that the effects of the procedure are satisfying and long-lasting. Performing an ultrasound during the consultation period can even advise surgeons on how many rounds of operations a patient may need to achieve their desired results.

POCUS has also enabled surgeons to perform other types of injections such as botox and fillers more accurately. With facial injections, knowing where the masseter muscle is could mean the difference between a successful operation and a botched botulinum toxin procedure. Injecting botox into the risorius muscle instead of the masseter affects a patient’s ability to smile. Because the risorius draws back the lips, paralyzing that muscle with botox will result in a drooping of the mouth that lasts about three to four months. Imaging allows surgeons to locate correct muscles to prevent impacting unintended parts of the anatomy that may not be visible via the skin’s surface. POCUS helps to guide injections and avoid unwanted outcomes.

Surgeons use liposuction in many fat-grafting procedures and to remove fat from areas of a patient’s body that may not have responded to diet or exercise. The popularity of these body contouring procedures makes liposuction the most common type of aesthetic surgery in the United States. Ultrasound is a popular tool to use in these procedures because it increases the precision of liposuction by helping to avoid trauma to tissue cells and improving skin contraction.

Ultrasound imaging is useful for scanning breast implants for ruptures or signs of silicone leakage. It may also be used to assess Breast Implant-Associated Anaplastic Large-Cell Lymphoma, a cancer of the immune system often seen in patients with textured implants. While annual clinical breast exams are recommended for people with breast implants and without, patients may be referred to a plastic surgeon for monitoring if something about the implant seems unusual.

The use cases for ultrasound in plastic surgery are considerable, ranging from BBLs to hair follicle imaging and more. While POCUS has been gaining popularity in the broader world of medicine for its ease and diversity of use, it is also becoming widely known in the discipline of plastic surgery. It allows for more personalized procedures, as surgeons can, with a few taps of a screen, locate muscles, salivary glands, and other biological structures that vary in their precise location depending on each patient’s body structure. POCUS takes the guesswork out of an otherwise masked procedure and provides information that supports surgeons with making educated decisions before, during, and after an operation.

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