Solving the Mysteries of the Face with Ultrasound

Join us for Dani’s presentation, “Ultrasound in Aesthetics,” at Modern Beauty Con, on May 7, 2023, at the Boston Park Plaza.

 

Within Dani Sher’s Instagram feed—among the tutorials and before-and-after photos—there’s an image of what she describes as a “big manatee humping [a] little manatee.” Soon, however, the manatees dissolve to reveal an ultrasound image of the DAO (depressor anguli oris) and DLI (depressor labii inferioris), muscles in the face that affect the angle of the mouth, the latter of which can cause an asymmetric smile if injected during a neurotoxin treatment. 

 

At once, what seemed like a joke post turned out to be a compelling demonstration of how ultrasound can provide guidance that prevents adverse results. Lori Robertson responded, “This picture will never leave my mind.” The account for a well-respected med spa wrote, “Ultrasound will never be the same.” 

 

This is just one of many examples, both online and in real life, of how Dani combines her extensive experience in the E.R. and aesthetics with a down-to-earth playfulness to teach other providers how they can run safer practices. 

 

So it was a pleasure to sit down with her to discuss what inspired her to begin studying ultrasound, the signs of its growing popularity, and how it can help injectors get taken more seriously as medical providers.

 

In your workshops you describe ultrasound as a “powerful modality that can help minimize complications.” But you’ve also demonstrated how it helps you treat people with complications from previous treatments. How much does the tool assist you throughout your entire practice?

D.S: That’s a really common question. With almost every filler patient, I’m pulling my ultrasound out. I have four different ultrasounds. So I usually have one in any given area of the room, and I’m kinda like, “Oh, let me just check this real quick.” So for most filler patients, and even some Botox treatments. I’ll check the DAO, for example, which is one area that can cause a crooked smile. I’ll check that spot and get really precise with where I put my Botox. 

 

You mentioned having four ultrasounds. Are they all the same model? Or are they like clubs in a golf bag, where some are better in certain situations than others?

D.S: Yeah, exactly. Some are just better in certain situations. I have a bit of an ultrasound problem, where I’ll learn about one and be like, “Oh, wow. I gotta have that one.” Also, because I work in the E.R., I like to have a handheld ultrasound that works in there, too.

 

An ultrasound is a big investment—both in terms of the cost and the ongoing study of it. How do you recommend getting started? Should people learn about it and practice before they invest in the equipment?  

D.S: A lot of people aren’t sure which device to get, so they’ll ask, “Should I get a training first or should I buy the device and get used to it a little bit and then come to you?” In my courses, I like to let everybody see all of my ultrasounds and play around with them. So much of ultrasound is subjective, so it depends on how the picture looks and feels to you. I can show somebody the same area of the face with two different ultrasounds, and they’ll say, “This quality is really better for me than this one.” So I tell people, “Come and take my course. You’ll see all the different devices, you’ll get the idea of what it’s like to use different ones. And then after you buy it, you’ll keep learning, because it’s not like you take a course and you’re an expert. You have to keep practicing and keep learning.”

 

Since it requires ongoing study, how do you recommend balancing the time it takes to improve with ultrasound with the time it takes to run a practice? 

D.S: For me it’s a little different because I’ve been doing ultrasound for 12 years. But I tell people the best thing they can do as a new ultrasound injector is add five minutes onto every single appointment—whether it’s a Botox appointment or a filler appointment—and ask the patient if you can do a little scanning of their face. I send everyone home with what I call the “Ultrasound Scavenger Hunt.” It’s a list of things to find in the face, and I tell them, “Add five minutes to every appointment and find one of these things.” That’s a great way to make it part of your everyday routine. 

 

That’s cool because it also creates that curiosity mind-set. One thing that really comes across in your social-media presence is this ongoing enthusiasm about learning new things. You have the “Mysteries of the Face” content and the “Phone a Smarter Friend” series. What kind of advice would you give to younger people starting out who are trying to build a network of people to turn to?

D.S.: If you’re naturally curious and you’re naturally pushing yourself to learn, then you’ll find other people and keep having conversations. My injector Grace, for example, who works at my spa, she’s incredibly curious and constantly challenging herself to learn. She has a Facebook group of other injectors, and she jumps on there to ask questions and share information. A lot of people on Instagram have things like that. I’m glad you mentioned the “Mysteries of the Face,” because I’m always looking for new ways to explore questions, and I love to think that might help other people stay curious.

 

You’ve mentioned that it was the lack of consensus about injection—the lack of certainty—that was a big inspiration for getting interested in ultrasound. How else has your time in the E.R. informed your practice, and are there ways the two continue to nurture each other?

D.S: Oh yeah, they both still continue to nurture each other. You see the worst of everything in the E.R.—there’s not much I haven’t seen in a Level One trauma center—so when I started injecting, I was like, “I just can’t imagine having to deal with blindness, like someone coming in to get ready for their daughter’s wedding or something, and then you blind them.” That was not an OK risk for me. That was a very E.R. mind-set. 

 

The lack of consensus sent me down a rabbit hole that led me to ultrasound. I flew Lori Robertson out to Oak Park and took a training with her. I said, “I’m gonna train with Lori all day and try to learn as much as I can from the safest person I can think of.” I trained with everybody that seemed to be at the forefront, but there was still no agreement among a lot of these leaders, and it was driving me nuts. I actually bought three different ultrasounds and kept returning them because they weren’t good enough. Then I found the Clarius L20, which was mostly used for regional anesthesia at the time.

 

Is that your go-to now?

D.S.: It’s one of them. I use the Clarius and the Mindray most heavily. And I use the G.E. Vscan a lot in the E.R. So I have two Clarius and a VScan.

 

In your workshops, you talk about Safe Mapping, which I think is a trademarked term. Just to confirm, is that a Dani Sher original?

D.S.: Yes, that’s my trademarked original.

 

Could you explain how you came about developing it, and why it’s so important to you and your teaching?

D.S.: I came up with the concept of Safe Mapping because everybody kept talking about vascular mapping. And the more and more I taught, the more the term annoyed me because they would say something like, “Oh, well, let’s map out where this infraorbital artery goes.” And people started feeling this sense of pressure to find every artery in the face and where it maps. It gave me this sense that people were losing track of the task at hand, which was putting filler in the face. So then it was like telling people, “You don’t need to go off-roading. You don’t need to create this treasure map of vessels in the face. All you need to do is query a certain area that you want to put filler and find out if it’s safe. So I started to push for a different lingo. I wanted to get the message in people’s heads that they don’t need to put pressure on themselves to create this involved map of every vessel, which is a huge task. Whereas Safe Mapping is easy and you can put it into your practice and just keep focused on what you’re doing. 

 

So it prevents things from getting too academic by keeping them focused on the next step as opposed to every possible step? 

D.S.: Exactly. It’s like, “Let’s just focus on what we’re doing right now in this little area. You don’t need to get a script of the whole face. You don’t need to create a three-act play. We’re just doing a little scene here.”

 

In one of your Instagram posts, you talked about how patients might not understand ultrasound, but they understand the comfort it creates. You discuss ultrasound a lot on social media, but it has less of a presence on your med spa’s website. Is there a reason for that? 

D.S.: It should be more on my site, frankly. But I also feel like so much of my aesthetic clientele comes from Instagram rather than websites. I talk about it with everybody who comes in, and a lot of people say, “Oh yeah, I came to you because I see you do ultrasound.” I even had somebody the other day…I was gonna do some filler where I didn’t really think she needed ultrasound. It was straightforward, and she was like, “Don’t you think you should do the ultrasound on me?”

 

Where do you think ultrasound is in terms of its growth? Its popularity is growing, but there are still only a few ultrasound trainers around? Do you think it’s going to grow significantly or will it remain an elevated niche within the industry?

D.S.: It’s definitely on the upswing. I think more and more providers will start using ultrasound, and that it will become a lot more of the norm. I don’t know if we’re gonna have people who are comfortable enough to teach it, because it takes a lot of time to feel comfortable teaching it. I use the emergency room—the arc of ultrasound in the emergency room—as my template to answer this question because I remember when ultrasound was becoming a cool thing in the emergency room but was not the norm. I was an early adopter of ultrasound in the E.R. and saw it grow in popularity. I didn’t invent techniques, but I was watching them and trying to figure out how to do them because nobody could show them to me. Then it really started becoming more and more popular, and now there’s this standard of care for doing those E.R. procedures with ultrasound. I have a course that’s accredited, and the only reason I built that course was because I had a hospital asking me if I could train their nurses and providers on ultrasound-based procedures in the E.R. 

 

Your Modern Beauty Con presentation is going to be shorter than the workshops you give. What will you focus on and what are you hoping your audience will walk away with in terms of their understanding of ultrasound?

D.S.: With shorter talks, I like to answer the questions “Why is ultrasound important?” and “Why should you bring it into your practice?” I try to speak to that percentage of people who are either on the fence or not sold. I try to get them to pay attention. The ones who are interested are going to take courses. But I’m trying to get these other guys to discover what’s so exciting about it. I talk about what has happened in the emergency room, and how ultrasound has flipped E.R. procedures upside down. I’ve watched that happen, so I’m trying to tell people that it’s coming to aesthetics.

 

So there’s still a section of the industry that isn’t convinced about its effectiveness? 

D.S.: Some people pooh-pooh ultrasound as if it’s fear-mongering or an over-the-top concern. There’s been a few major influencers who say we don’t need ultrasound. Things like, “It’s silly. I’ve been practicing for 20 years and never had complications.” But by the same token, a lot of people want to be taken seriously as providers of aesthetic medicine rather than being seen as a beautician. There’s a difference between a nurse or a P.A. and an aesthetician doing Botox injections. But then there’s this sort of disdain for these extra modalities. To me, I think if you want to be taken seriously as a medical provider, why not use medical modalities, like ultrasound?

 

Join us for Dani’s presentation, “Ultrasound in Aesthetics,” at Modern Beauty Con, on May 7, 2023, at the Boston Park Plaza.