by Kate Dee, MD
Dermal Fillers have become incredibly popular, with over 2.6 million people having received them in 2018 (the number is very likely much higher today). With that has come the inevitable rise in vascular occlusions caused by intravascular injection. Most aesthetic injections are performed with hyaluronic acid (HA) fillers, which are reversible with hyaluronidase. Accordingly, there has been a surge of interest in and use of ultrasound for the diagnosis and treatment of vascular occlusions, as well as for vascular mapping prior to injection. As a radiologist turned aesthetic injector, I have been following this trend very closely. My background: I am board-certified with 16 years experience in diagnostic ultrasound and ultrasound-guided procedures. After 7 years in aesthetics, I am finally able to apply some of my imaging expertise to my current practice.
There are currently 4 portable hand-held ultrasound systems available on the market at a relatively low cost ($2500 to $6900) considering the historical cost of standard units in the past (a GE or Philips system when I was a resident in the 90’s could run well over $300K). In this review I’ll explain the main features, advantages and drawbacks of the following devices:
The main criteria for this review are critical features needed to diagnose and treat vascular occlusion caused by hyaluronic acid filler in addition to vascular assessment prior to and during dermal filler injections. The use of these devices for other purposes is mentioned but is not the priority of my recommendations.
Critical features for ultrasound use in aesthetics: (I consider the following features a must-have)
The first hand-held device I evaluated was the Clarius. Clarius offers two US probes at this time-- either of which could be used in aesthetics. The L-HD15 (up to 15 MHz) had a standard footprint and the HD L-20 (higher resolution up to 20MHz) has a slim footprint (similar to a hockey-stick). The first thing that stood out about the Clarius is that it feels like holding a brick. This thing is BIG and HEAVY. If you were operating this device for any length of time your hand and arm would fatigue quickly. The device itself is very large for an US probe. Though the L-20 has a slim footprint, the probe itself is the same huge size as the HD-15. Why is that odd? The slim footprint that the high-res hockey sticks are designed with have a very small handpiece so as to not get in the way of needle procedures or the patient’s anatomy. They are great for getting into small areas where things are in the way-- say the nasolabial fold near the nose. The Clarius handpiece is missing this important feature.
Image quality of both devices is excellent. Do you need the higher resolution of the 20MHz? In my opinion no. There is no added diagnostic value. Unless you are specifically looking for that smaller footprint, there would be no advantage. And having done more US-guided procedures than I could possibly count, the larger issue is that enormous handpiece. As with all 4 of these devices, the Clarius offers high-quality color doppler for evaluating flow. For an extra $1000 you can also get power doppler-- but this really provides no benefit over standard color doppler and in my opinion is not necessary for aesthetics.
Battery life with the Clarius is about 60 minutes with 90 minutes to recharge. Importantly-- the battery is detachable (this is actually part of the reason the probe is so bulky and heavy). This is critical if you have to scan for any length of time-- especially for occlusions. With the Clarius, you can have a backup battery ready for when your probe conks out. Since lysing an occlusion can take hours-- and there have been reports of cases lasting over 24 hours, albeit without ultrasound assistance-- one vital feature is having a probe that will go the distance. With a recharge time of 150% of the battery life, you might run out of battery anyway if you only have 1 back up. But you can always have 2!
The software design for the Clarius is intuitive and simple to use. The device is wireless, and communicates via bluetooth to any phone or tablet. The handpiece itself is limited by its bulk and weight-- twice the weight of a standard ultrasound probe like the GE and 4 times the weight of the Philips Lumify. Unless you’re a football player, this will be a major limiting factor for any physician actively using this in practice.
There is a lot to love about the GE Vscan Air. It has a unique design, built with a Linear transducer at one end and a curved array at the other end, all within a single cordless device that weighs the same as any regular ultrasound probe. This makes it ideal to use for many practices with a wide range of diagnostic ability for almost any body part. For an aesthetics-only practice, however, the curved array is completely unnecessary. For a radiologist like me, it is almost irresistible! I scanned my whole abdomen, just for fun! But really-- you won’t use that feature for aesthetics.
At 12 MHz, the resolution is slightly lower than the Clarius. To my eye, the images were slightly fuzzier, but the diagnostic quality was excellent. Color Doppler on the GE is excellent as well. There is no power doppler, pulsed wave or even M mode at this time, but again, these are features not needed for aesthetics.
According to GE, the Vscan Air battery lasts 50 minutes-- but in my hands this was closer to 40 minutes. Recharging is wireless and recharge time is 60 minutes. The battery is built-in, so you can’t have a back-up battery. This is where the GE falls short for aesthetics: for treating occlusions, you must have a method of imaging over longer periods of time than 40-50 minutes. So, unless you have a second probe, you’re out of luck.
The GE has a huge leg up on the Clarius for ease of scanning. The probe feels great in the hand and at half the weight, it shouldn’t tire you out (if only the battery could last that long). The software for the GE is the least intuitive of the bunch, but it is adequate. It can be used with any phone or tablet, so it is very versatile. However, I had to pair the device every time I used it, even on the same tablet. I’m not sure why this would be necessary, and I found it to be annoying and introduced a delay each time I used it. So, as much as it was absolutely delightful to scan with the GE, they have some work to do on the interface to make it more seamless.
Philips makes 3 Lumify probes for different uses. I evaluated the L 12-4 which goes up to 12MHz, like the GE. They also make separate curved array and linear phased array for other applications, each probe for the same price. The Lumify has a very different design-- it is corded and runs off the power of the device it is attached to. Thus it has no battery. At first I thought that this would be a drawback but it turned out to be an advantage.
The Lumify is amazingly lightweight (since it has no battery)-- at less than a quarter pound it is half the weight of the GE and feels comfortable and nimble in the hand. It is also a slightly smaller footprint than the GE or Clarius L HD-15 making it very easy to use on the face. Though it does have a cord, I found it not to be a problem while scanning. Perhaps this is because I am used to having a cord that is present on all of the major systems I’ve ever used. Regardless, I don’t think this is a detriment to scanning.
The Philips has excellent image quality. Despite having a frequency identical to the GE, I found the images to be crisper-- not significantly different from the Clarius. The color doppler was excellent and easy to adjust. It happens that a patient walked in my office with a full-on occlusion (from filler placed elsewhere!) and we were able to evaluate her blood flow with ease with the Lumify. It was this experience that cemented my belief that the higher frequency of the Clarius does not help diagnosis or treatment of vascular occlusions.
The Lumify is powered by the device to which it is attached. Philips recommends a Samsung tablet, which puts out plenty of power and will last over 6 hours on a single charge with continuous use. This is a tremendous advantage over the rechargeable probes. You can always plug the Lumify into a different tablet if you actually needed to use it that long. The disadvantage is that the longevity will depend on what device you’re using. Android tablets are all different and Philips does not supply data on how long each different device would last. And apple devices do not put out enough power to run it at all. The Lumify will work with an iOs device-- but you’ll need a battery pack to go along with it-- which itself has its own battery life. The Lumify battery pack for the apple devices lasts 2 ½ hours and has a recharge time of 3 hours, and of course you can have a backup battery as well. Either way, the Lumify is the winner hands-down as far as battery life.
The Lumify was by far the easiest of the handhelds to use. The app launches automatically and is completely intuitive. The demo didn’t come with any instructions, but none were needed. I was up and running in seconds. With the lightweight maneuverable handpiece and easy interface, the Lumify felt like a natural extension of my hand.
The Butterfly is all over social media marketing directly to the consumer. This device is a completely different technology that uses an array of sensors on a chip rather than true piezoelectric crystals that traditional ultrasound devices use to produce the images. With one handpiece, they are able to reproduce the equivalent of the linear and curved array probes. The result is a very versatile device with relatively low-resolution images. I’m including it in this discussion because of its ubiquitous presence and its availability as a portable low-cost ultrasound imaging system. However, I find the images lack the diagnostic quality one needs for superficial, soft tissue and vascular imaging. Its size and weight are comparable to the GE. It is corded, but unlike the Lumify, it runs off of an internal battery, like the GE. The battery life is 120 minutes with a 300 minute recharge time. So it will scan for longer, but there is no backup battery.
Butterfly does not require a membership to function, but many features including image storage are turned off without one. The membership currently ranges from $200 to $1200 per year, so this cost offsets the cheaper price of $2500.
Because the images are moderate to poor, the Butterfly is not well-suited to aesthetics applications. However, it can easily be used in a pinch if one is available. And if all you want is to invest the least amount of money to have an ultrasound only for emergency occlusions, you could consider it. But if you use it and learn about ultrasound imaging at all, over time you’ll wish you had bought a better device.
I highly recommend the Philips Lumify for use in aesthetics. For ease of use, high-quality images and the ability to scan for hours, this light elegantly-designed hand piece is the ideal solution for imaging in the aesthetic setting. Because of the heavy bulky design, the Clarius is not recommended, but otherwise is a reasonable solution for image quality and a replaceable battery. The GE is beautifully designed, but its low battery life and no energy back-up option makes it unsuited to treat vascular occlusions. The Butterfly will do in a pinch if the family practice down the hall has one to spare, but it is not recommended for aesthetics.