The Expanding Role of Diagnostic Ultrasound in Plastic Surgery

Eric Swanson, MD


Plast Reconstr Surg Glob Open. 2018;6(9):e1911 

In This Article

Abstract and Introduction


Background: Ultrasound in plastic surgery is quickly finding new applications. Ultrasound surveillance may replace ineffective individual risk stratification and chemoprophylaxis for deep venous thromboses. Abdominal penetration can be a catastrophic complication of liposuction. Preoperative screening for fascial defects may reduce risk. Limiting buttock fat injections to the subcutaneous plane is critical for patient safety, but it is difficult to know one's injection plane.

Methods: The author's use of diagnostic ultrasound was evaluated from May 2017 to May 2018. Ultrasound scans were used routinely to detect deep venous thromboses. Patients undergoing abdominal liposuction and/or abdominoplasty were scanned for possible hernias. Other common applications included the evaluation of breast implants, breast masses, and seroma management. The device was used in surgery in 3 patients to assess the plane of buttock fat injection.

Results: One thousand ultrasound scans were performed during the 1-year study period. A distal deep venous thrombosis was detected in 2 patients. In both cases, the thrombosis resolved within 1 month, confirmed by follow-up ultrasound scans. A lateral (tangential) fat injection method was shown to safely deposit fat above the gluteus maximus fascia.

Conclusions: Ultrasound scans are highly accurate, noninvasive, and well-tolerated by patients. Some of these applications are likely to improve patient safety. Early detection of deep venous thromboses is possible. Unnecessary anticoagulation may be avoided. Subclinical abdominal defects may be detected. Ultrasound may be used in the office to evaluate breast implants, masses, and seromas. In surgery, this device confirms the level of buttock fat injection.


Ultrasound may be broadly classified into diagnostic and therapeutic applications. Therapeutically, ultrasound has long been used for liposuction assistance in an effort to reduce tissue trauma and improve skin contraction.[1,2]

Diagnostically, ultrasound imaging has proven to be useful in reconstructive surgery for identification of perforators for a variety of flaps,[3–10] including the anterolateral thigh flap,[3–5] and the deep inferior epigastric perforator flap.[6,7] Visconti et al.[11] routinely use color Doppler ultrasound when planning lymphaticovenular anastomoses.

Ultrasound has been used to study the integrity and rotation of breast implants.[12–20] Ultrasound is an important tool in the management of Breast Implant-Associated Anaplastic Large-Cell Lymphoma.[21] This device is essential for the evaluation of breast masses, including those that occur after autologous fat grafting.[22]

Ultrasound has been used to quantitate changes in fat volume after fat injection of the breasts and buttocks.[23,24] This device has also been used to measure decreases in thickness after nonsurgical fat reduction including cryolipolysis.[25–27] Other novel applications include evaluation of facial hyaluronic acid injection and subcutaneous thickness after botulinum toxin injection.[28–30]

This tool has been used to screen patients for abdominal wall defects before liposuction or abdominoplasty.[31,32] It has been used to evaluate repairs of the rectus abdominis diastasis, and for seroma management.[33–37] Hand surgeons have found numerous applications, such as visualizing tendons and foreign bodies of the upper extremities and guiding injections.[36]

Intraoperative ultrasound imaging assists surgeons who perform thoracic wall, paravertebral, and transversus abdominis plane nerve blocks.[38–44] Ultrasound guidance may be used to avoid the implant at the time of breast fat grafting,[36] to guide iliohypogastric nerve resection in patients with chronic pain,[45] assist in cephalic vein transposition,[46] and to identify digital artery perforators.[47]

Two recent reviews include many of these applications.[5,48] However, an important office application has not been widely recognized—diagnostic ultrasound for deep venous thrombosis (DVT) surveillance.[35] The safety of buttock fat injection is a major concern because of the risk of fat embolism.[49–51] This device may be used to evaluate the level of fat injection.[24,52]