High-frequency ultrasound in the 21st century.

The beginnings of skin ultrasound date back to about 50 years ago. However, the dynamic progress of skin ultrasound took place in the last twenty years, when the unprecedented development of computer technologies occurred, which resulted in the popularization of and easier access to modern ultrasound equipment. Skin tests can be performed with both classic scanners equipped with broadband transducers with a minimum frequency of 15 MHz, and specially dedicated skin systems with high-frequency scanners, which are equipped with mechanical transducers with a frequency of 20 MHz to up to 100 MHz. Owing to technologically advanced machines, ultrasonography has proved to be useful in many areas. The aim of this study was to present the current knowledge and possibilities of skin imaging using high-frequency ultrasonography. Te paper discusses technical aspects, types of devices available on the market, as well as methods for the analysis of ultrasound skin images and parameters useful in their interpretation. We also present current applications of skin ultrasound, with particular emphasis on dermatology and aesthetic medicine. In the field of dermatology, we discussed imaging of focal lesions as well as an assessment of pathologically changed skin and treatment monitoring. We also focused on the use of high-frequency ultrasonography in aesthetic medicine and cosmetology. The popularity of this method is constantly growing in these fields, and ultrasound is now used in everyday practice to assess the skin, plan and monitor procedures, as well as to treat potential complications. High-frequency ultrasonography is a highly effective method for skin evaluation, although still underappreciated in may fields. Further research is needed to standardize this modality, as well as to implement training for operators, and to popularize this imaging technique.

The use of high-frequency ultrasonography for the diagnosis of palpable nodules after the administration of dermal fillers.

INTRODUCTION: Esthetic medicine is a buoyant field of medicine. As the number of performed procedures - mainly injections of botulin toxin and dermal fillers - is increasing, the number of complications is rising as well. The most popular dermal filler is hyaluronic acid. Injection of hyaluronic acid dermal fillers is considered a minimally invasive procedure, but complications in the form of skin nodules and lumps are being encountered more and frequently. Esthetic medicine does not currently offer its own diagnostic methods that would allow one to diagnose complications. In these circumstances, the implementation of objective diagnostic methods from other fields of medicine becomes significant. High-frequency ultrasound is one of such methods. AIM OF THE STUDY: The aim of this study was to implement high-frequency ultrasound for the diagnosis of palpable nodules after the administration of dermal fillers. MATERIAL AND METHOD: The study group included 15 women who developed palpable nodules in the region of hyaluronic acid injection. The study includes both early and late complications. An EPIQ 5 (Philips, Bothell, USA) ultrasound machine and a L5-18 transducer were used to examine the nodules. Ultrasound images were evaluated qualitatively by 2 independent investigators. RESULTS: Ultrasound enabled the diagnosis of hyaluronic acid deposition in 9 women, granulomas in 3 women, fibrosis in 2 women and a deposition with inflammation in 1 case. Each of the diagnosed structures presented a typical ultrasound appearance. CONCLUSIONS: High-frequency ultrasound is a useful diagnostic method that has a chance to become a widespread tool to diagnose and treat complications. Because of a low number of study reports in this area, continued research is warranted.

Usefulness of high-frequency ultrasound to assess the healing progress of shin ulcers.

INTRODUCTION: As the average lifespan becomes longer, the number of cases of chronic shin ulcers is rising, which is slowly becoming a societal problem. Currently, there no methods for objective evaluation of ulcer healing process. AIM OF THE STUDY: The aim of the study was to assess the use of high-frequency ultrasound to monitor the healing of shin ulcers subjected to laser biostimulation. MATERIAL AND METHODS: The study included 8 patients (4 men and 4 women) aged from 46 to 81 years with 9 shin ulcers in whom the healing process did not progress within 8 weeks despite effective causal treatment. The ulcers were subjected to laser biostimulation. The induced changes were monitored using high-frequency ultrasound and photographic records. Ultrasound examination was used to assess the depth of ulceration and the thickness of granulation tissue, migrating epidermis, subepidermal low-echogenic band (SLEB) and epidermis in the immediate vicinity. The wound severity index and ulcer vascularity were also assessed. RESULTS: As a result of laser therapy, in 7 out of 9 cases the ulcers healed completely and in the remaining 2 cases ulcer size was reduced. During the ulcer healing process induced by laser therapy, ultrasound examination revealed decreasing ulcer depth, wound severity index and SLEB thickness. Granulation tissue increased in thickness and there was an epidermal formation effect (newly formed epidermis was much thicker than the one surrounding the wound and became thicker as a result of laser therapy sessions). During the healing of ulcers induced by laser therapy no significant changes were observed in ulcer vascularity and thickness of the surrounding epidermis. CONCLUSIONS: High-frequency ultrasound is a useful technique for the imaging of leg ulcers. It allows one to monitor their healing process induced by laser biostimulation. Further research on the subject needs to be pursued.

Ultrasound image of healthy skin in newborns in the first 24 hours of life.

INTRODUCTION: Ultrasound imaging is a safe, repeatable and easily available imaging procedure. Based on these qualities, it may become a useful tool for skin assessment in newborns. Aims: The aim of the study was to evaluate the usefulness of high-frequency ultrasound imaging for neonatal skin assessment. Another aim was to identify differences in ultrasound features of the skin in newborns depending on the examination site, sex, age, birth weight, and arterial blood gas results. MATERIAL AND METHOD: A total of 72 newborns in the first 24 hours of life, without any skin lesions, were included in the study. All newborns underwent ultrasound skin examinations in three body sites (forearm, abdomen and thigh) during the first 24 hours of life. DermaMed Ultrasound Scanner with a 48 MHz probe was used for imaging. A total of three structures were identified in the ultrasound images: epidermal echo, dermis, and subcutaneous tissue. The study assessed the thickness of the epidermis and dermis, and the echogenicity of the dermis and subcutaneous tissue. Data were analysed to determine possible links with sex, post-conceptional age, body weight, birth route, and results of umbilical cord blood gas analysis. RESULTS: Depending on the body site examined, the mean epidermal thickness was 0.081 to 0.083 mm, while the mean thickness of the dermis ranged between 0.679 and 0.722 mm. The newborns with higher birth weights were shown to have a thicker epidermis regardless of the examined site [R (correlation coefficient) for the forearm: 0.47 (p <0.001), abdomen: 0.53 (p <0.001), thigh: 0.48 (p <0.001)]. A positive correlation was found between epidermal and dermal thickness (R = 0.34; p = 0.004), but a comparison of the three examined sites revealed no significant differences in the thickness of the two structures. The sex of the newborn had no significant effect on the ultrasound features of the skin. None of the ultrasound parameters under study was found to correlate with the pH level in umbilical cord blood gas analysis. Subcutaneous oedema was detected in the examined sites in all the newborns studied. CONCLUSIONS: High-frequency ultrasound imaging may become a useful method for neonatal skin assessment, complementing existing diagnostic techniques for monitoring pathologically altered skin.

The efficacy of high-frequency ultrasound-guided injection lipolysis in reducing fat deposits located on the inside of the knees.

INTRODUCTION: Many women consider local fat deposits unacceptable for aesthetic reasons as they have negative impact on appearance and thus, contribute to reduced self-esteem. Injection lipolysis (intralipotherapy) may be an alternative for conventional liposuction in reducing fat deposits. AIM: The aim of this paper was to assess the efficacy of high-frequency ultrasound-guided injection of deoxycholic acid (intralipotherapy) to remove fat deposits on the inner side of knees. MATERIALS AND METHODS: The procedure was performed in 7 women (14 inner sides of knees). The formulation was administered under high-frequency ultrasound guidance. The procedure was performed twice at 4-week intervals in each patient. High-frequency ultrasound guidance was used to monitor such parameters as the thickness of the dermis (DermaMed, Draminski S.A.) or the subcutaneous tissue (Philips Epiq 5, USA). Ultrasound was performed both before and after treatment. Additionally, anthropometric measurements were taken, a questionnaire was performed, and a photographic documentation was recorded. RESULTS: Reduction in knee circumference and subcutaneous tissue occurred in 71.42% of patients. CONCLUSIONS: Intralipolysis with deoxycholic acid formulation is an effective method for reducing fat deposits on the inner part of the knees. Ultrasonography proved to be a useful method to monitor the procedure (correct administration of the preparation) and to assess treatment outcomes. A small sample size was a limitation of our study; therefore further studies are needed.

Usefulness of high-frequency ultrasound in the monitoring of laser treatment of acne scars.

INTRODUCTION: Acne scarring is considered one of the complications of acne vulgaris. Scarring is an important aesthetic problem for patients; therefore, effective methods for scar removal are sought. In recent years, laser methods for the treatment of acne scarring have become popular as a result of technological development. Monitoring and objective assessment of treatment outcomes are important elements of laser treatment. High-frequency ultrasonography is a diagnostic modality likely to become a common tool used for this purpose. AIM: The aim of this study was to assess the usefulness of high-frequency ultrasonography for the monitoring of laser treatment of acne scarring. MATERIALS AND METHODS: The study group included 7 patients (6 women and 1 man) aged 29-43 years with evident facial acne scarring. Each patient underwent laser treatment with Alma Harmony Er:Yag laser. Ultrasound examinations were performed with high-frequency DermaMed scanner. The following parameters were assessed on ultrasound images: the thickness of epidermis and dermis, the depth and width of scars. We additionally collected photographic documentation and assessed patient satisfaction with treatment outcomes. RESULTS: The analysis of our findings showed statistically significant changes in the thickness of the epidermis and the depth of scars. No statistically significant results were obtained for the thickness of the dermis and the extent (width) of scars. The patients rated treatment outcomes as good. CONCLUSIONS: High-frequency ultrasonography is a useful method for the monitoring of laser treatment of acne scarring.

High frequency ultrasound assessment of labial glands simulating small nodules or granulomas after lip augmentation.

AIM OF THE STUDY: The aim of this study is to evaluate the utility of high-frequency ultrasound in the assessment of the nature and differentiation of lumps occurring in the labial mucosa after lip filling procedures. MATERIAL AND METHODS: The study sample included 5 women aged from 28 to 43 years (mean age: 37.4 years) who previously underwent a lip augmentation or rejuvenation procedure. Photographic documentation was taken and high-frequency ultrasound assessment was performed in all the patients. The presence of deposits, foreign body granulomas, fibrosis and labial glands was mainly investigated taking into account the shape of the abnormalities, their margins, surface area, location and echogenicity. In order to confirm the diagnosis, histopathological examination was performed. RESULTS: The examinations performed made it possible to differentiate between granulomas and persistent deposit nodules and to demonstrate the presence of massive fibrosis and of labial glands pushed out by these abnormalities with the glands presenting as hypoechoic oval areas. Histopathological examination confirmed the morphology of labial glands reported by the patients as uncomfortable lumps felt from the side of the mucosa, which clinically simulate persistent deposit nodules or granulomas. CONCLUSIONS: High-frequency ultrasound is a method that is essential for the correct differentiation between complications of tissue filler procedures. This, in turn, makes it possible to apply the right treatment. In this study, it was demonstrated for the first time that the lumps reported by patients who have had a lip filling procedure may be the result of labial glands being pushed out by deposits, granulomas or massive fibrosis, which are complications of such procedures.

Usefulness of Doppler sonography in aesthetic medicine.

INTRODUCTION: In recent years, ultrasonography has been used in an increasing number of fields, such as dermatology, aesthetic medicine and cosmetology. For skin imaging, research has shown the usefulness of both classic scanners equipped with linear transducers, and high-frequency scanners with mechanical transducers. An increasing number of reports indicating high usefulness of Doppler sonography have been published recently. The aim of this study was to assess the usefulness of high-frequency Doppler imaging in the diagnosis of vascular complications after aesthetic procedures using tissue fillers. MATERIALS AND METHODS: A total of 12 women aged 19-48 years (mean age 36.08 years) who had undergone hyaluronic acid treatment were included in the study group. Ultrasound scans were performed using standard ultrasound scanners, i.e. Philips Epiq 5 with a linear transducer and Samsung RS85 with linear transducers and Doppler Microflow Imaging option. Ultrasound scans were performed to assess the presence of blood flow using Color Power Doppler (CPA). Pulsed-Wave Doppler was used only for arteries. If no blood flow was recorded with Color Power Doppler, Microflow Imaging was used. RESULTS: Doppler ultrasound showed normal blood flow despite reported symptoms in 3 cases. Vascular stenosis was found in 2 patients. In the other 7 patients, Doppler ultrasound showed no blood flow at the sites where complications developed. CONCLUSIONS: Skin ultrasound with Doppler options is a useful tool in the diagnosis of aesthetic medicine complications.

Gallbladder-duodenal fistula detected by ultrasound - a case report.

Gallbladder-duodenal (cholecystoduodenal) fistula is an uncommon bilioenteric fistula between the gallbladder and the duodenum. It usually occurs following a chronic case of cholecystitis upon which the gallbladder adheres to the adjacent duodenum, and a stone penetrates through the wall. The case presented herein is that of a gallbladder-duodenal fistula detected primarily with the use of ultrasound imaging, and subsequently confirmed by computed tomography. The patient is a 54-year-old woman who was admitted with upper abdominal pain. The fistula was caused by chronic cholecystitis, however no gallstones were present in the duodenum. Surgical management was undertaken for the patient, and the recovery was uneventful.

Sex and body mass index implications on gluteofemoral subcutaneous tissue morphology visualized by ultrasonography - preliminary study.

Introduction: Since the protective value of gluteofemoral subcutaneous adipose tissue against cardiovascular risk factors has already been described in scientific reports, it is important to pay more attention to its evaluation. Aim of the study: The purpose of this study was to evaluate sex and body mass index implications on gluteofemoral subcutaneous tissue morphology visualized by ultrasonography. Material and method: A population of 40 participants between 20-50 years of age was examined. All individuals underwent the ultrasound examination of subcutaneous adipose tissue in three locations: anterior, posterior and lateral side of a thigh in the 1/3 distal part. All examinations were collected, and the following parameters were evaluated: thickness of subcutaneous adipose tissue in general, thickness of superficial and deep subcutaneous adipose tissue. Results: The study revealed significant differences in the architecture of subcutaneous adipose tissue between male and female subgroups. In the group of males, a significantly thinner layer of not only subcutaneous adipose tissue in general (0.65 vs. 1.67 cm, p <0.0001), but also in its main compartments was observed. Moreover, we observed strong positive correlation between body mass index and all subcutaneous adipose tissue layers in the female subgroup. Interestingly, there was no relation between the thickness of the subcutaneous adipose tissue layers between subgroups with a decreased and normal body mass index and an increased body mass index. Conclusions: The presented data indicates that sex is an important factor in the determination of subcutaneous adipose tissue architecture of a thigh. The ultrasound examination of this structure can be a useful prognostic tool in the assessment of cardiovascular risk.Introduction: Since the protective value of gluteofemoral subcutaneous adipose tissue against cardiovascular risk factors has already been described in scientific reports, it is important to pay more attention to its evaluation. Aim of the study: The purpose of this study was to evaluate sex and body mass index implications on gluteofemoral subcutaneous tissue morphology visualized by ultrasonography. Material and method: A population of 40 participants between 20­50 years of age was examined. All individuals underwent the ultrasound examination of subcutaneous adipose tissue in three locations: anterior, posterior and lateral side of a thigh in the 1/3 distal part. All examinations were collected, and the following parameters were evaluated: thickness of subcutaneous adipose tissue in general, thickness of superficial and deep subcutaneous adipose tissue. Results: The study revealed significant differences in the architecture of subcutaneous adipose tissue between male and female subgroups. In the group of males, a significantly thinner layer of not only subcutaneous adipose tissue in general (0.65 vs. 1.67 cm, p <0.0001), but also in its main compartments was observed. Moreover, we observed strong positive correlation between body mass index and all subcutaneous adipose tissue layers in the female subgroup. Interestingly, there was no relation between the thickness of the subcutaneous adipose tissue layers between subgroups with a decreased and normal body mass index and an increased body mass index. Conclusions: The presented data indicates that sex is an important factor in the determination of subcutaneous adipose tissue architecture of a thigh. The ultrasound examination of this structure can be a useful prognostic tool in the assessment of cardiovascular risk.

The use of high-frequency ultrasonography in the assessment of selected female reproductive structures: the vulva, vagina and cervix.

INTRODUCTION: High-frequency ultrasonography enables visualization the layered structure of the skin and shows the epidermis, dermis, subcutaneous tissue and skin appendages: hair follicles, sebaceous glands, sweat glands and blood vessels. The aim of this study was to apply high-frequency ultrasonography to evaluate the structure of the vulva, vagina and cervix, and to describe their anatomy in ultrasound. MATERIAL AND METHOD: The examinations were conducted with the use of high-frequency probes: DermaView 48 MHz and Episcan 50 MHz, by three operators experienced in performing classical ultrasound scans (with 30-, 10- and 9-year experience). The study involved 50 women aged 20-80 years who reported for a periodical gynecological check-up and presented no symptoms within the reproductive system. RESULTS: In this study, the individual layers of the skin in the area of the mons pubis, labia majora (together with hair follicles and sweat glands) and labia minora were successfully visualized in all the patients. The subepidermal low-echogenicity band was seen in the area of the mons pubic and labia majora in 40 cases. This concerned 100% of women who underwent cosmetic skin treatments. In all the patients, HFUS demonstrated the layered structure of the anterior and posterior vaginal walls, the walls of the urinary bladder and rectum, layers of the vaginal portion of the cervix and the external opening of the cervix. CONCLUSIONS: High-frequency ultrasonography offers new quality of vulvar, vaginal and cervical imaging. It can be used for evaluation of the vulva and vagina, and confirms their layered structure. It also enables accurate measurements of the thickness of the vulvar epidermis and dermis as well as the thickness of the vaginal walls.

The utility of high-frequency ultrasonography in preoperative assessment of vulvar Paget's disease - a case report.

Paget's disease of the vulva is a rare skin cancer accounting for less than 1% of all vulvar neoplasias. Surgery is the first treatment of choice. Unfortunately, it is insufficient in many cases, which require further treatment, and the risk of recurrence is high. We present a case of an 85-year-old woman who underwent surgery due to Paget's disease of the vulva. A preoperative skin imaging using a high-frequency 48 MHz mechanical probe was used to assess the lesion margins. Typical high-frequency ultrasonographic features of vulvar Paget's disease were identified and analyzed. This is the first report of high-frequency ultrasonography imaging of vulvar Paget's disease.

Thrombin obliteration of subclavian artery aneurysm with intravascular balloon protection.

A rare case of a 56-year-old man with posttraumatic false aneurysm of the right subclavian artery is presented. He was admitted to hospital due to pain in the shoulder. The diagnosis was made upon ultrasonography and computed tomography (CT) results. With ultrasound guidance, the aneurysm was punctured and injected with bovine thrombin (Biotrombina 400u, Biomed). During the injection, the aneurysm neck was occluded by an endovascular balloon placed in the subclavian artery. Complete aneurysm embolisation was confirmed by ultrasound and CT studies. The postoperative course was complicated by Horner's syndrome which resolved completely within 3 weeks. The procedure technique is described in detail.

Application of high-frequency ultrasonography in closing small blood vessels.

One of the most common treatments performed in phlebological and aesthetic medicine clinics is closing small blood vessels in the lower extremities, so-called telangiectasias and reticular vessels. Currently, there are several methods that allow for closing the dilated vessels and obtaining desirable effects, both therapeutic and aesthetic. Unfortunately, despite applying various methods and instruments, the effects of treatments are frequently not satisfactory. The factor that largely contributes to decreasing the efficacy of such procedures is complicated anatomy of the venous system and the lack of a method to precisely specify the vessel's course, its diameter, location in the skin etc. High-frequency ultrasonography is a method enabling accurate determination of the vessels' course as well as the measurement of their basic parameters, such as diameter, depth in the skin and presence or absence of perfusion. Thanks to ultrasound imaging with the use of high-frequency transducers, an adequate treatment method and procedure parameters may be selected, which entails enhancing the efficacy of the procedure itself. Ultrasonography may be also used for monitoring the performed procedures.

Ultrasound image of the skin, apparatus and imaging basics.

Ultrasound imaging of the skin is becoming more and more popular. Skin ultrasound examinations are used both in order to assess healthy skin and to evaluate pathological lesions. They are mainly performed in dermatology as well as in broadly understood aesthetic medicine and cosmetology. At present, skin imaging is enabled by high-frequency equipment and high-quality conventional devices. The introduction of high-frequency electronic transducers which are supported by conventional scanners may be a turning point in skin ultrasound equipment. Irrespective of the ultrasound scanner, three layers may be distinguished in the image of the healthy skin: epidermal echo, dermis and subcutaneous tissue. High-frequency equipment allows for detailed imaging of the epidermal echo, dermis and upper part of the subcutaneous tissue. It is also possible to visualize the skin appendages (hair with follicles and nails) as well as slight vessels that run in the dermis and upper subcutaneous tissue. Contrary to high-frequency equipment, conventional scanners do not allow for a detailed assessment of the epidermal and dermal echoes. Instead, they enable the visualization of the entire subcutaneous tissue. The following parameters are used for the assessment of skin ultrasound images: thickness of individual skin layers, caliber of blood vessels, echogenicity of the dermis or its individual layers, echogenicity of the subcutaneous tissue as well as the presence or absence of flow in slight venous vessels. Currently, the studies on the usage of sonoelastography for skin assessment are in progress. Considering the dynamic development of skin imaging equipment and its diagnostic possibilities, one might suspect that high-frequency examinations will become more common and will be fundamental for the evaluation of both healthy and pathologically altered skin. This paper is an introduction to a series of articles on the clinical application of high-frequency ultrasound. The next articles will be published in the subsequent issues.

Imaging of the skin and subcutaneous tissue using classical and high-frequency ultrasonographies in anti-cellulite therapy.

BACKGROUND: The development of ultrasonography allowed for skin imaging used in dermatology and esthetic medicine. By means of classic and high-frequency ultrasonographies, changes within the dermis and subcutaneous tissue can be presented. OBJECTIVE: The aim of this study was to show the possibilities of applying classic and high-frequency ultrasonographies in esthetic dermatology based on monitoring various types of anti-cellulite therapies. METHODS: Sixty-one women with cellulite were assigned to two smaller groups. One group was using anti-cellulite cream and the second group was a placebo group. The ultrasound examination was carried out before the initiation and after the completion of the treatment and evaluated epidermal echoes, the thickness of the subcutaneous tissue and the dermis, dermis echogenicity, the length and surface area of the subcutaneous tissue fascicles growing into the dermis, and the presence or absence of edemas. RESULTS: After the completion of the treatment, a statistically significant difference was observed. The most useful parameters were as follows: the thickness of the subcutaneous tissue, echogenicity, the surface area and length of the subcutaneous tissue, as well as the presence of edemas. The discussed changes were not observed in the placebo group. CONCLUSION: Classic and high-frequency ultrasonographies are useful methods for monitoring anti-cellulite therapies.