Identification and Complications of Cosmetic Fillers: Sonography First

Ultrasound in Aesthetics: Filler and Non-Filler Applications

Ultrasound in aesthetics presents multiple applications in several areas, including diagnosing fillers and non-fillers complications, the performance of ultrasound-guided injections in real-time, and identifying the most common types of cosmetic fillers. Furthermore, this application of ultrasound in aesthetics has become a must for managing aesthetic patients because, to date, this modality is the one that provides the higher resolution among imaging techniques, detailed anatomical information, and blood flow detection, besides showing worldwide availability. This paper aims to review the current applications of ultrasound in aesthetics based on publications from scientific literature and the authors' experience.

Objective Noninvasive Measurement of the Volumizing Effect of a Dermal Filler: An In Vivo Study

BACKGROUND

Information about the volumizing effects of dermal fillers is critical for physicians' understanding of product features and prudent decision-making in clinical practice. It is important for material engineers to develop and optimize new dermal fillers, especially when comparing the physiochemical properties of a new product with those of existing fillers that are used worldwide.

OBJECTIVE

This study aimed to establish a reliable, noninvasive method for in vivo quantitative evaluation of the filling effect in order to predict possible effectiveness after filler injection and to evaluate the degradation trend over time.

METHODS

A rabbit model of ear injection with dermal fillers was established. Hyaluronic acid (HA) filler was injected into the subcutaneous layer of rabbit ears, resulting in a stable skin bulge. Ultrasonography was used to noninvasively measure the skin bulge for volume calculation; the volume change was analyzed periodically until 38 weeks. Pathological examination, the gold standard, was performed to confirm degradation.

RESULTS

The immediate volumizing effect of HA filler injection was macroscopically observed as a local skin bulge. Ultrasound was able to precisely detect the shape of the filler and calculate the length, width, and height of the skin bulge at each time point. The degree of uplift and amount of residual samples in the pathological evaluation were consistent with the results of morphological observation using ultrasound.

CONCLUSION

Evaluation of the volume impact of dermal filler through the rabbit ear injection model evaluation enables material science evaluation in the early stage of material development, and has certain clinical reference value.

LEVEL OF EVIDENCE I

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

ULTRASONOGRAPHIC FEATURES OF NON-VASCULAR COMPLICATIONS OF HYALURONIC ACID FILLERS: A RETROSPECTIVE STUDY AT A REFERENCE CENTER FOR DERMATOLOGIC ULTRASONOGRAPHY

Hyaluronic acid (H.A.) filler injections have been associated with early, temporary, and delayed-onset onset complications. High-resolution ultrasound (HRUS) with Doppler analysis has been increasingly used to detect and identify such complications. We describe comprehensively the most common ultrasonographic findings of non-vascular complications associated with H.A. filler injections. This retrospective, cross-sectional observational study was conducted at a reference center for dermatologic ultrasound in Bogotá, Colombia. Ultrasound reports documented the ultrasonographic findings of non-vascular complications of H.A. filler injections. Fifty-two complications were documented in a cohort of 50 patients (women, 88%). The infraorbital region was the most common site affected (23%), followed by the nasolabial (22%). The Tyndall effect was the most common complication (25% of all), followed by changes in rheology (21%) and pseudo-sarcoidal (foreign body granuloma) reaction (15%). The Tyndall effect stood out for its distinctive ultrasonographic characteristics. We discuss the ultrasonographic findings and pathogenesis of other complications, including filler migration, early hypersensitivity, aseptic abscess, overcorrection, and filler material interaction. The clinical presentation of H.A. filler complications can be confusing, delaying timely diagnosis and treatment. HRUS with Doppler analysis is a valuable tool for avoiding unnecessary treatments and ensuring timely diagnosis and treatment.

Complications of collagen biostimulators in Brazil: Description of products, treatments, and evolution of 55 cases

BACKGROUND

Complications of temporary and permanent fillers have been extensively studied. However, there is a lack of comparative data regarding poly-L-lactic acid (PLLA), calcium hydroxyapatite (CaHA), and polycaprolactone (PCL) known as collagen biostimulators.

AIMS

This study addressed the complications of collagen biostimulators concerning their diagnosis, type of product, treatment, and monitoring.

PATIENTS/METHODS

An electronic questionnaire was sent to Brazilian dermatologic ultrasound experts to identify complications related to biostimulators. The type of biostimulator, location of application, number of vials injected, application plan, time between injection treatment and complication, injector profile, treatment, and prognosis were assessed.

RESULTS

Fifty-five cases were identified, of which 49.1% were caused by PLLA-Elleva®, 23.6% by CaHA (alone or combined with hyaluronic acid), 20.0% by PLLA-Sculptra®, and 7.3% by PCL. The most affected area was the face (72.7%), with nodules being the most common clinical form (89.1%), generally occurring late (60.0%) (>1 month). Only one case was injected at an incorrect depth (musculoaponeurotic system-SMAS). Despite several treatments, including saline (45.5%), hyaluronidase (25.5%), diluted corticosteroids (23.6%), and energy-based devices (10.9%), only five cases showed complete resolution. Hyaluronidase was beneficial in complications related to fillers when there was an association of calcium hydroxyapatite with hyaluronic acid (p < 0.01).

CONCLUSIONS

Complications from collagen biostimulators were more common on the face, typically manifesting about 1 month after treatment. These issues seemed to be related more to the properties of the products rather than inadequate technique. Furthermore, hyaluronidase demonstrated efficacy only in cases where there was an association with HA.

Ultrasound-guided Treatment of Polycaprolactone Granuloma

Foreign body granulomas associated with polycaprolactone (PCL) filler injections are rare, yet challenging to manage. Multiple management modalities have been described. Here, we present a literature review and describe a case of histologically confirmed PCL-related granuloma, treated using ultrasound-guided injections of triamcinolone, hyaluronidase, and 5-fluorouracil combined with oral prednisolone and doxycycline.

Personalization of Minimally-Invasive Aesthetic Procedures with the Use of Ultrasound Compared to Alternative Imaging Modalities

Ultrasonography is a well-tolerated procedure that aids in the targeted esthetic therapies of special cutaneous regions, as well as in the prevention (vascular mapping, identification of previous filler, and others) and management of potential complications (vascular occlusion, external vascular compression, product misplacement or migration, inflammatory reactions, and others). It has lately been promoted as the first-line imaging tool to address injectables. In this article, we aim to review the evolving role of ultrasonography in cosmetic filler procedures, from the fundamental ultrasound characterization of cosmetic fillers to the ultrasound-enhanced detection and management of cosmetic filler complications, including ultrasound's role in hyaluronidase-guided injections for cosmetic filler dissolution. Furthermore, the paper explores the integral role played by ultrasound in enhancing the precision, efficacy, and safety of additional minimally invasive aesthetic techniques such as mesotherapy, radiofrequency, cryolipolysis, and polydioxanone procedures.

Effect of pdo facelift threads on facial skin tissues: An ultrasonographic analysis

BACKGROUND

Recent studies demonstrate that PDO threads, after being introduced into the facial skin, provide benefits due to collagen formation around the thread and improved vascularization.

AIMS

This work aims to report the ultrasound and photographic follow-up after the execution of the facelift thread technique, thus evaluating the anti-aging treatment that PDO threads will provide for human facial skin.

METHODS

The facelift will be performed using PDO thread 18G cannulated Sculpt i- Thread FML 100 × 185 mm, and 29G PDO thread Needled Flat i-Thread 38 × 50 mm. A total of 10 patients were selected for the study; all of them had medium-grade facial ptosis and aged 40-50 years old. In order to control tissue changes after thread, insertion ultrasound measurements will be made with Philips ultrasound 12 MHz linear probe at maximum resolution, initial evaluations and control of 30, 60, 90, and 120 days, measuring the skin layers: epidermis\dermis and hypodermis. Photographic control was performed before and after 120 days of intrusion of the PDO threads.

RESULTS

The formation of collagen around the PDO thread was evidenced through ultrasound images in all patients in this study, as well as improvement in the appearance of the skin and sagging, evaluated by photographic control.

CONCLUSIONS

We can define that the PDO threads used for the facelift are effective in the formation of collagen around the thread (observed through the increase in the dermal layer), and improvement of the condition of the anti-aging factor through sagging skin, vascularization and thinning of the superficial fat layer (observed through the reduction of the subcutaneous or hypodermis layer).

Ultrasonographic Patterns of Calcium Hydroxyapatite According to Dilution and Mix With Hyaluronic Acid

OBJECTIVES

To assess the ultrasonographic patterns of different calcium hydroxyapatite (CaHA) formulations, including the undiluted, diluted, and mixed with hyaluronic acid (HA) compounds.

METHODS

To review the ultrasonographic images of patients ≥18 years with confirmed injections of CaHA clinically and ultrasonographically, and without different concomitant types of fillers in the same region or other systemic or localized cutaneous diseases.

RESULTS

Twenty-one patients met the criteria (90% female; 10% male; mean age: 52 years ± 12.8). Of these, 33.3% have been injected with an undiluted formulation, 33.3% with diluted, and 33.3% with a mixed formulation. All cases were studied with devices presenting frequencies that ranged from 18 to 24 MHz. Twelve cases (57%) were also studied with the 70 MHz. The ultrasonographic patterns of CaHA presented differences in the presence and intensity of PAS and the degree of inflammation according to the dilution and mix with HA. Diluted formulations show a milder intensity posterior acoustic shadowing (PAS) artifact than undiluted at 18-24 MHz. In mixed formulations, 57% showed mild PAS, and 43% demonstrated no PAS artifact at 18-24 MHz, besides fewer inflammatory changes in the periphery of the deposits.

CONCLUSIONS

The ultrasonographic patterns of CaHA show differences in the presence and intensity of PAS and the degree of inflammation according to the dilution and mix with HA. Awareness of these ultrasonographic variations can support better discrimination of CaHA.

Complications of fillers in the lips and perioral area: Prevention, assessment, and management focusing on ultrasound guidance

An ever-increasing interest in perioral rejuvenation with dermal fillers reflects the esthetic importance of this region. However, filler injections in the lips and perioral area have been associated with various complications. Such complications are classified according to severity (mild, moderate, severe) or by the time of onset: immediate (within 24 h after injection), early (24 h to 4 weeks post-procedure), and late or delayed (>4 weeks after injection). While most complications are mild and manageable, vascular compromise, infections, and the development of delayed-onset nodules may significantly undermine the ultimate esthetic outcome and cause substantial morbidity. These more serious complications often require more invasive treatment modalities. This article details the prevention and management of such adverse events and discusses safe filler injection principles, including safety recommendations for the lips. Lastly, we highlight the use of ultrasound guidance in complication prevention (vascular mapping, filler identification, location, and extent), assessment (identification of intravascular embolus or external vascular compression by the filler implant), and management (real-time imaging of hyaluronidase or other drug injection in the affected area). Esthetic practitioners should be versed in injection anatomy, and the prevention, recognition, and management of filler complications in the perioral area.

Dermatoporosis in Upper Limbs Treated With Polymethylmethacrylate Microspheres Using the BioSculpt® Technique

Dermatoporosis is a syndrome of fragility or chronic cutaneous insufficiency. It presents with localized violaceous spots on the extensor face of the upper limbs of older people, with signs such as senile purpura, actinic purpura, or Bateman purpura, in addition to atrophy of the skin and subcutaneous tissue. These lesions can be painful and a source of morbidity. We report a case of an 80-year-old patient presented for the treatment of dermatoporosis in the upper limbs with polymethylmethacrylate (PMMA) using the BioSculpt®technique. The photographic and ultrasonographic clinical responses of the soft tissue were evaluated before and after nine months of treatment.

Key Points to Select a Device for Dermatologic Ultrasound

What points to consider when selecting a device for practicing dermatologic ultrasound is an excellent question. After we met the requisites published in the guidelines for practicing dermatologic ultrasound, it is necessary to consider the main objective of the use because it is not the same to be focused mostly on the avoidance of the puncture of important facial vessels such as the case of injectors of cosmetic fillers in comparison to the use of operators that need to deal with the diagnosis and monitoring of a wide range of dermatologic pathologies. Currently, a broad variety of ultrasound devices meets the minimum requirements for practicing these examinations in the market. Thus, small, portable, and high-end devices may present advantages and limitations that must be balanced according to the primary purposes and the budget. Moreover, the shape and footprint of the probes can make difficult or facilitate a dermatologic procedure. Other points to consider are the type of storage and the need for technical service. In summary, there are key points that we need to consider when we select a dermatologic ultrasound device in dermatology or aesthetics.

The growing importance of ultrasonography in cosmetic dermatology: An update after the 23rd IMCAS Annual World Congress (2022)

BACKGROUND

Ultrasound (US) has been used for many years in the field of medicine. Many specialties have embraced US as a quick, painless, and relatively inexpensive tool to assist the clinician in determining anatomy, pathology, and aid in diagnostic or therapeutic procedures. US allows for precise mapping of cutaneous and subcutaneous structures in the face, in particular vascular structures. The use of US leads to reduced chances of complications and clinical failures, rendering more safety and high quality.

METHODS

US is considered the first-imaging technique for dealing with fillers and managing their potential complications. US can be deployed for vascular mapping, safe placement of fillers, and directed low-dose hyaluronidase reversal of vascular adverse events. It is a noninvasive imaging modality that provides a good definition for studying the skin, deeper layers, and blood flow in real time. In other words, we go from static to dynamic anatomy. In addition, US can guide with the application of botulinum toxin, in order to define the muscular planes. US may contribute to a more personalized procedure, better cosmetic results, and help to avoid complications. In general, physicians tend to use it for prevention. Last, for research purposes, US examination provides valuable information on the behavior, longevity, and interaction of the filler within the tissues.

CONCLUSION

This new approach for US-guided treatments is a very practical and an effective method in cosmetic dermatology. As doctors, we owe it to our patients to do our best to prevent any harm. We feel that in near future, US will be an essential diagnostic tool in any dermatology or cosmetic doctor's office to both ensure safety and provide legal protection for the professional.

Dynamic ultrasound evaluation of body fillers and biostimulators in the buttocks of fresh-frozen specimen

BACKGROUND

Ultrasound imaging is a useful tool to study the injection of fillers and biostimulators in the body.

OBJECTIVE

Sonographically evaluate real-time injections of fillers and biostimulators and describe their behavior in the subcutaneous tissue of the buttocks of fresh-frozen specimen.

METHODS

injection of two brands of high-density hyaluronic acid (HA), one brand of calcium hydroxyapatite (CaHA), one brand of hybrid injectable (CaHa + HA), one brand of polycaprolactone (PCL) and three brands of poly-l-lactic acid (PLLA) were performed in the subcutaneous tissue of the gluteal region under ultrasonography visualization on a fresh-frozen specimen. Videos during injection and static images immediately after injection were obtained. The sonographic aspects of the substances and their dispersion and interaction with the surrounding tissues were described.

RESULTS

Real-time ultrasound showed different dispersion patterns of the two brands of HA, CaHA, hybrid injectable (CaHa + HA) and the three brands of PLLA. The sonographic aspects among the brands of PLLA were also different.

CONCLUSIONS

The dynamic ultrasound evaluation of the injection of HA, CaHA, hybrid injectable (CaHa + HA), PCL and PLLA in a fresh-frozen specimen shed some light on their aspects and dispersion pattern in the buttock. If these patterns are confirmed in further studies in vivo, there will be a positive impact on the selection and development of safer and more effective techniques to enhance buttock contour.

Complications Following Facial Injection of Growth Factor Solution

OBJECTIVE

Topical injection of growth factor (GF) for facial rejuvenation is unauthorized, but it is commonly performed in China, leading to emerging and challenging complications. The purpose of this study is to investigate the clinical, imaging, and histopathologic characteristics of complications caused by facial GF injection, as well as their treatments and outcomes.

METHODS

We performed a retrospective single-centered case series study on consecutive patients who were treated for complications following facial injection of GF. The primary outcome was the recurrence over follow-up period. The secondary outcomes were the subjective evaluations of the facial aesthetic, symptomatic, and psychological improvements using the Global Aesthetic Improvement Scale (GAIS) and a patient-reported outcome measurement (PROM). Kaplan-Meier analysis and log-rank test were performed to investigate the recurrence.

RESULTS

A total of 32 females with an average age of 42.6 ± 9.4 years were included. Most patients received GF injections in non-medical institutes such as beauty spas and presented with uncontrollable soft tissue hyperplasia, diffuse subcutaneous swelling, and skin redness. Ultrasonography showed heterogeneous hypoechoic or echogenic areas in a thickened and disorganized subcutaneous tissue hierarchy. MRI showed flaky isointensive or hypointensive signals on T1WI and hyperintensive signals on T2WI. 37.5% patient underwent triamcinolone acetonide injection, whereas 62.5% patients underwent surgical interventions. Lipoma-like hyperplastic tissue was found during surgery. HE staining confirmed intramuscular lipoma and fibrolipomatous tissue hyperplasia. Recurrence was found in 37.5% patients over a median follow-up of 6 months. KM curves and log-rank test demonstrated no significant difference in the recurrence between patients who underwent nonsurgical or surgical interventions (p = 0.77). GAIS and PROM scores indicated substantial aesthetic, symptomatic, and psychological improvements in 70%, 91.7%, and 75% patients, respectively.

CONCLUSIONS

Both surgical and nonsurgical interventions are feasible and effective treatment options for GF-induced complications. Although recurrence rate was relatively high, aesthetic, symptomatic, and psychological improvements were achieved in most patients. We developed a workflow that might help diagnose and treat complications following unknown dermal filler injections.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Static and dynamic high-resolution ultrasound analysis of tissue distribution of poly-L-lactic acid particles during subdermal application in two different presentations

Background

All the changes the skin goes through, peaking at flaccidity, occur in the dermis and hypodermis, leading to loss of support and a lower capacity to totally accommodate displacements or any loss of subjacent volume, bringing about the onset of furrows and sagging. Improvements in facial sagging may be obtained with the administrations of substances like poly-L-lactic acid (PLLA), which triggers a tissue response through a controlled inflammatory reaction.

Objectives

Compare the tissue distribution of the particles of PLLA of both products available in Brazil (Sculptra® and Rennova Elleva®) during and immediately after their subdermal administrations, with 22G cannulas, through high-resolution ultrasound imaging.

Methods

A total of four patients aged between 18 and 64 years had the inner part of the upper arms divided into eight quadrants and treated with 16 ml of each product, reconstituted to correspond to 9.5 mg/ml. The sites where PLLA was injected were analyzed through the high-resolution ultrasound during (dynamic imaging) and immediately after the procedures (static imaging).

Results

During Sculptra® injection, high-resolution ultrasound revealed that its distribution did not follow the trajectory of the cannula homogeneously. It was characterized by a more hyperechogenic central portion and an anechogenic peripheral portion, forming discrete posterior acoustic shadowing at times. Regarding Rennova ELLEVA® injection, the high-resolution ultrasound analysis showed a homogeneous distribution of the product across the subcutaneous tissue following the trajectory of the cannula without formation of significant interface with the surrounding tissue, maintaining the sonographic aspect of thinly granulated hyperechogenic deposits, with strong posterior acoustic shadowing during and immediately after its administration.

Conclusion

Static and dynamic high-resolution ultrasound imaging show a more homogenous distribution of PLLA particles with the use of Rennova ELLEVA® when compared with Sculptra®, which may induce the formation of capsules and a subsequent more dispersed fibroplasia, with larger area of action and a possible better therapeutic result. The interest of this article lies in its originality, highlighting the differences in the tissue distribution of two different brands of PLLA particles, which can impact the clinical response to the two products - which we are researching and seems to interfere with the increase in dermal thickness.

Emerging High-Frequency Ultrasound Imaging in Medical Cosmetology

Cosmetic skin diseases are a part of many dermatological concerns brought up by patients, which negatively affect mental health and quality of life. Imaging technology has an established role in the diagnosis of cosmetic skin diseases by recognizing information on deep skin lesions. Due to the complex physiological and pathological nature of cosmetic skin diseases, the diagnostic imaging performance varies greatly. Developing noninvasive technology models with wide applicability, particularly high-frequency ultrasound (HFUS), which is able to achieve high-resolution imaging of the skin from the stratum corneum down to the deep fascia, is of great significance to medical cosmetology. To explore the great potential of HFUS in cosmetic skin diseases, a narrative review of literature from PubMed and Web of Science published between 1985 and 2022 was conducted. This narrative review focuses on the progression of HFUS imaging in medical cosmetology, especially on its promising application in the quantitative evaluation and differential diagnosis of cutaneous pathological scar, port wine stain (PWS), acne, skin aging, and other cosmetic applications.

Clinical Management of Complications Following Filler Injection

AIM

Dermal fillers have been progressively used for cosmetic procedures. Concurrently, the rates of filler complications have also increased. The aim of this study is to describe the clinical management and treatment we performed in patients with complications occurred after filler injection.

METHODS

From March 2000 to February 2020, 197 patients have been evaluated for complications due to filler injection. For each patient type of material, symptoms and signs were recorded. Ultrasound evaluation was used to obtain information about the type, amount and location of the injected material. Magnetic Resonance Imaging was performed in those patients who were candidate for surgery. Based on the clinical manifestations, we performed a targeted therapy.

RESULTS

The local and systemic medical therapy allowed us a complete remission of the clinical signs and symptoms in all patients presented with edema and erythema. We obtained optimal results with surgery, where a complete removal of the injected material was possible. In all the cases in which the complete removal of the infiltrated area could have led to functional impairments, we performed partial removal with poor outcomes.

CONCLUSION

We observed complex clinical manifestations in the patients subjected to permanent fillers. An accurate knowledge upon the effects of the materials on tissues, a specific instrumental evaluation and a targeted therapy are crucial. We suggest the use of absorbable fillers. Patient should be subjected to filler implant in authorized structures by an expert specialist with experience in filler injection and with a thorough knowledge of the anatomical structures.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

A New Target for Temple Volumization? An Anatomical and Ultrasound-Guided Study of the Intermediate Temporal Fat Pad

BACKGROUND

Current techniques for temple volumization primarily focus on deep or superficial targets. Further anatomical exploration of intermediate injection targets is warranted.

OBJECTIVES

The purpose of this study was to examine the anatomy of the intermediate temporal fat pad (ITFP) as it relates to filler injection procedures and to explore the utilization of ultrasound technology for clinical localization.

METHODS

Ultrasound technology was utilized to identify and inject red dyed hyaluronic acid filler into the ITFP in 20 hemifacial fresh cadavers. Cross-sectional dissection was performed to confirm injection accuracy and document pertinent anatomical relationships. The same technique was performed in a single clinical patient case employing ultrasound guidance and injectable saline.

RESULTS

The ITFP is a quadrangular structure located in the anterior-inferior bony trough. The ITFP is supplied by a middle temporal artery branch and encased between the superficial and deep layers of deep temporal fascia. In 18 of 20 (90%) injections performed under ultrasound guidance, the injected product was accurately delivered to the substance of the ITFP, and in 2 of 20 (10%), the product was found immediately below the deep layer of deep temporal fascia within the temporalis muscle. In the single clinical case, saline was successfully injected in the ITFP under ultrasound guidance.

CONCLUSIONS

The ITFP is a consistent anatomical structure in the anterior-inferior trough of the temporal fossa. Ultrasound technology can be utilized to identify and inject the fat pad. Further clinical evaluation will determine the role of this fat pad as a potential intermediate injection target for temple volumization procedures.

Ultrasonographic Subclinical Signs of Inflammation of the Lacrimal, Parotid, and Submandibular Glands in Users of Cosmetic Fillers

OBJECTIVES

To detect ultrasonographic inflammatory signs in the lacrimal, parotid, and submandibular glands in cosmetic fillers (CFs) users.

METHODS

A prospective and cross-sectional ultrasound study of the glands in cases with CFs was performed. The sample included users of hyaluronic acid, silicone oil, polymethylmethacrylate, polycaprolactone, calcium hydroxyapatite, and polyacrylamide. Abnormalities of the parenchyma and hypervascularity signs of the glands were compared with a control group (n = 10), evaluated by 2 observers, and correlated with the type, number, and location of the facial CFs. Cohen's kappa test and logistic regression models with odds ratios (OR) adjusted by age with 95% CI were performed.

RESULTS

Sixty-three patients with CFs met the criteria. Parotid and submandibular glands had the highest percentage of parenchymal involvement: 87.3 and 88.9%, respectively (p <.01). Abnormalities of the echostructure of the parenchyma and hypervascularity of the glands were detected with all kinds of fillers without significant differences per type. A significant substantial interrater kappa (0.61) with an agreement of 90% for all glands among observers was found.

CONCLUSION

Users of common types of CFs frequently present subclinical ultrasonographic signs of inflammation of the lacrimal, parotid, and submandibular glands. Further research on the topic seems necessary.

A Guide to Doppler Ultrasound Analysis of the Face in Cosmetic Medicine. Part 2: Vascular Mapping

Duplex mode ultrasound imaging can detect the course of the main vascular structures in the face, which are known to be subject to variation. Once duplex mapping has been performed, measures can be taken to prevent injection into an artery, thereby avoiding skin necrosis or, worse, vision loss. For this reason, in particular, we predict that in the coming years sonography will become standard equipment in the offices of cosmetic doctors. We discuss the basics of vascular imaging by Doppler ultrasound, both in normal and pathologic situations. Starting from the 7 basic positions for the ultrasound probe, all facial arteries relevant in cosmetic medicine can be found.

A Guide to Doppler Ultrasound Analysis of the Face in Cosmetic Medicine. Part 1: Standard Positions

Interest in Doppler ultrasound (DUS) analysis of the face has grown in cosmetic medicine, in particular for injectable fillers. When dealing with complications, DUS has the advantage of easily visualizing the filler and identifying the problem in relation to the patient's anatomy. When working with hyaluronic acid filler, ultrasound-guided injections with hyaluronidase can precisely target the problem. In addition, DUS can be used to study the anatomy of a patient, specifically to prevent intravascular injections. We predict that in a few years' time DUS will become standard equipment in the offices of cosmetic doctors. We discuss the basics of ultrasound imaging of different tissues with the concomitant terminology. With the use of 7 basic DUS probe positions, key anatomic reference points can be easily found. From these, all relevant anatomic structures in the face can be observed and analyzed. With some practice, physicians will ultimately be able to acquire a complete 3-dimensional mental image of a patient's face.

Laser Doppler Imaging for Treating Vascular Complications from Procedures Involving Dermal Fillers: Case Series and Literature Review

Vascular occlusion is a rare but severe complication of dermal filler injections. Early treatment of this complication produces better outcomes. Current diagnostic methods for vascular occlusion in the skin are subjective and imprecise; these include capillary refill time, skin color, and reports of pain. This study aimed to assess the use of laser Doppler imaging (LDI) in the evaluation and treatment of vascular complications caused by dermal filler injections. This retrospective study used laser Doppler imaging (LDI) in 13 patients who developed vascular occlusion after facial dermal filler injections, with subsequent follow-up. The precise areas of perfusion observed on LDI were compared with the findings of clinical and photographic evaluation. The results showed that LDI accurately identified areas of vascular occlusion and improved treatment precision among these thirteen patients. The procedure was more precise than visual inspection or photographic evidence. Satisfactory outcomes were achieved for all patients, and no procedure-related complications were reported. Collectively, LDI provides fast, noninvasive, and accurate delineation of areas of vascular occlusion caused by complications of dermal filler injections and avoids several subjective shortcomings of visual and photographic evaluations. Thus, LDI effectively tracks treatment outcomes. However, large-scale studies are required to confirm the present findings.

The perils of penile enhancement: case report of a fulminant penile infection

BACKGROUND

Penile enhancement with injectable agents is a rising trend and yet has received little scientific attention despite the potential for serious complications. These include cosmetic, functional and systemic complications that may require complex penile reconstructive surgery. We report a case of delayed severe infection following penile filler insertion leading to multi-organ failure and intensive care support.

CASE PRESENTATION

A 31-year-old man presented with fevers and progressive pain and swelling of the penile shaft, 3 days after unprotected sexual intercourse. The patient received subcutaneous hyaluronic filler injections at a cosmetic clinic for penile enlargement two months prior to presentation. Relevant social history include polysubstance abuse and multiple sexual partners. Physical examination revealed gross penile oedema and erythema, with a ventral curvature of the penile shaft and a superficial abrasion on the distal ventral penile shaft. Within 24 h the patient developed septic shock with anuria, hypotension and fevers to 40 °C, requiring transfer to the Intensive Care Unit (ICU) for vasopressor and inotropic support. Intraoperative penile exploration revealed multiple pus stained fillers which were drained and grew Streptococcus Pyogenes on cultures. There was no abscess or evidence of necrotising fasciitis intraoperatively. The patient improved with intravenous antibiotics and was stepped down from the ICU after four days and discharged on day eight. One month post admission there was significant superficial skin loss to both ventral and lateral aspect of the penis, with healthy granulation tissue at the base. The patient opted for conservative management with regular dressings. He reported normal sexual and urinary function three months post admission.

CONCLUSION

This is the first published case of sepsis from a penile infection in the context of hyaluronic acid penile fillers. In an era of escalating demand for penile cosmetic procedures, there is an increasing need for early recognition and appropriate management of penile filler infections. We report an unusual case of a localised penile infection rapidly progressing to sepsis with multi-organ failure requiring intensive care support. The case demonstrates early surgical intervention with targeted antimicrobials can result in successful eradication of infection, with satisfactory cosmetic and functional outcomes for patients.

Ultrasound to Improve the Safety and Efficacy of Lipofilling of the Temples

BACKGROUND

Autologous fat is known for a reliable and natural safety profile, but complications do occur-even serious vascular adverse events.

OBJECTIVES

The authors sought to examine doppler-ultrasound (DUS) imaging for the harvesting and subsequent facial implantation of autologous fat tissue.

METHODS

All patients underwent lipofilling treatment of the temporal fosse of the face. DUS examination was performed for preprocedural vascular mapping and imaging of previously injected (permanent) fillers. In addition, the injection of autologous fat was performed DUS-guided.

RESULTS

Twenty patients (all female; mean age, 57.9 years; range, 35-64 years). DUS examination showed that 16 of the 20 patients (80%) had been injected with resorbable or nonresorbable fillers elsewhere in the past. The temporal artery could be visualized and avoided in all cases. An average of 1.1 cc of autologous fat was injected in the temporal fossa per side. One case of edema and nodules was described, but no other adverse events were reported.

CONCLUSIONS

The utilization of DUS can add valuable information to a lipofilling procedure and should be considered an integral part of a safe lipofilling treatment.

LEVEL OF EVIDENCE: 4

European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) Position Statement on Dermatologic Ultrasound

Dermatologic ultrasound is a recent application of ultrasound for the evaluation of healthy skin and appendages and their diseases. Although the scientific literature regarding this application is still not sufficient for evidence-based guidelines, general recommendations issued by scientific societies are necessary. The EFSUMB (European Federation of Societies for Ultrasound in Medicine and Biology) steering committee for dermatologic ultrasound has developed a series of consensus position statements regarding the main fields of dermatologic ultrasound (technical requirement, normal skin and appendages, inflammatory skin diseases, tumoral skin diseases, aesthetic dermatology and practice-training requirements). This document is the foundation for future evidence-based recommendations and guidelines for dermatologic ultrasound practice.

Spreading Pattern and Tissue Response to Hyaluronic Acid Gel Injections in the Subcutis: Ultrasound Videos, Ultrasound Measurements, and Histology

Background

Despite the popularity of hyaluronic acid (HA) filler treatments, few publications focus on their effects on adipose tissue.

Objectives

The authors assessed the deposition pattern in the subcutis of injected HA, the tissue response at short and intermediate term, and the effects of remodeling the filler by strong finger pressure immediately after the treatment.

Methods

Two brands, specifically developed by the industry for deep injection, were compared. The gels were injected subcutaneously in 5 candidates for abdominoplasty or breast reduction, in the area of excision, 6 to 98 days before surgery. Ultrasound measurements and films were compared with postoperative histological findings. Tissue response was scored semi-quantitatively.

Results

Real-time ultrasound showed a slightly different deposition pattern of the 2 brands. Histologically, both were present in large pools of the same magnitude and looked the same. Linear retrograde injection sometimes resulted in a globular deposit due to elastic recoil of septae. After remodeling and over time, HA deposits became difficult to detect by ultrasound. Firm remodeling of the tissue immediately after injection or time had no significant effect on filler spread or tissue response. Except for 1 zone of granuloma formation, tolerance for both fillers was good.

Conclusions

HA deposition in adipose tissue occurs in much larger pools than in the dermis. Ultrasound examination is useful during and immediately after the injection but less reliable after filler remodeling or over time. Filler deposition can be less precise, and reshaping by finger pressure can have less effect than expected.

Level of Evidence: 4

Ultrasonography for long-term evaluation of hyaluronic acid filler in the face: A technical report of 180 days of follow-up

Purpose

In this study, we used ultrasonography to monitor the use of hyaluronic acid (HA) as a filler in the face for esthetic reasons. We monitored changes in the filler shape, distribution, and relationship with adjacent anatomical structures over a 180-day period.

Materials and Methods

Two patients each received an ultrasound-guided injection of HA, with different products and application sites for each patient. In 1 patient, the injection was administered in the angle of the mandible, while in the other, it was administered in the zygomatic region. The injection sites were monitored via ultrasonography at 24 hours, 30 days, and 180 days, at which times the imaging characteristics of the filler were observed. All injections were performed by the same professional, as were the ultrasound exams, which were conducted using the same equipment.

Results

In both cases, the HA fillers were visualized using ultrasound at all time points. Some differences were observed between the cases in the images and the distribution of the pockets of filler. In 1 case, the filler appeared as a dark hypoechoic region with well-defined contours, and the material was observed to have moved posteriorly by the 180-day mark. In the other case, the material appeared hyperechoic relative to the previous case and presented no noticeable changes in its anteroposterior distribution over time.

Conclusion

Based on these 2 cases, ultrasonography can be a complementary tool used to monitor facial fillers over the long term, allowing for the dynamic observation of different fillers.

Polycaprolactone: How a Well-Known and Futuristic Polymer Has Become an Innovative Collagen-Stimulator in Esthetics

Compared to other domains, tissue engineering and esthetics have dramatically expanded in recent years, leading to both major biomedical advances and futuristic perspectives. The two share a common approach based on biomaterials, especially polymers. This paper illustrates this with the example of polycaprolactone (PCL), a polymer synthesized in the early 1930s, and one of its most recent applications, a PCL-based collagen stimulator, a filler used in esthetics. PCL is biocompatible and biodegradable. Its specific physicochemical and mechanical properties, viscoelasticity and ease of shaping led to the production of PCL-based products with various shapes and durations dependent on its biodegradation kinetics. PCL has been safely used in the biomedical field for more than 70 years, from sutures to tissue and organ replacement by 3D printing. The PCL-based collagen stimulator is composed of PCL microspheres suspended in a carboxymethyl-cellulose gel carrier providing immediate and sustained volumizing effects when injected; the morphology, the biocompatibility of the PCL microspheres embedded with the collagen fibers produced all contribute to the creation of a unique 3D scaffold for a sustained effect. Its safety has been investigated in clinical studies and vigilance surveys. Recently published experts' recommendations on injection modalities and techniques should help further optimize treatment outcome and safety. This paper also integrates reviews and recommendations on the prevention and management of adverse events related to dermal and subdermal fillers including the PCL-based collagen stimulator. In addition, in terms of efficacy and safety, this product benefits from its daily clinical use in esthetics worldwide and continuous extensive fundamental and clinical research, both on it and the PCL polymer. Forthcoming data from further investigations will reinforce knowledge of the product and procedures in the field.

External vascular compression by hyaluronic acid filler documented with high-frequency ultrasound

We present a case report of a hyaluronic acid filler-induced complication documented using high-frequency ultrasound. We regard the scientific value of the case as indicating the benefit that ultrasound provides for the management and documentation of this complication. This technology has been becoming increasingly widespread in the care of patients who experience unwanted effects of hyaluronic acid filler because it can be used for the high-resolution visualization of skin layers as well as the differentiation of filler types and their relationships with adjacent tissues (via gray scale or B-mode ultrasound) and blood vessels (via color Doppler ultrasound). In addition, it was possible to conclude that external vascular compression causes clinical repercussions, a fact that is often questioned by some dermatologists. This questioning is based on the vast vascularization and anastomosis of arteries of the face, which should permit compensation for vascular compression. However, in this case, there was no doubt that compression caused a region of low output with the clinical manifestation of peri-oral pallor. Ultrasound was used to document the compression of a vessel by the filler; after application of hyaluronidase, increased vessel lumen and clinical reversal of hypoperfusion in the affected area were observed.

Nomenclature proposal for the sonographic description and reporting of soft tissue fillers

BACKGROUND

There is a steady increase in publications about the use of ultrasound and filler treatments, written by physicians from different specialties. The terminology used to describe the ultrasound images of fillers is not uniform, making the different articles difficult to compare. Standardization of the descriptions based on their basic sonographic parameters is recommendable.

AIMS

The purpose of this study is to propose a nomenclature for the sonographic description and reporting of cosmetic fillers.

METHODS

An assessment of articles indexed for MEDLINE/PubMed and Embed electronic database was conducted; in total of 39 articles could be included.

RESULTS

All articles were investigated for their sonographic descriptions of soft tissue fillers. Ten parameters used for describing and monitoring soft tissue fillers were distinguished.

CONCLUSION

The proposed sonographic descriptions for cosmetic fillers may contribute to a better standardization and understanding fillers ultrasound images in the reports or literature.

A case report on dermal filler-related periorbital granuloma formation

We report a case of a 49-year old East-Asian female who presented with delayed onset granuloma formation at the right medial lower eyelid area. The clinical and radiologic presentation with pathologic correlation following synthetic hyaluronic acid filler injection and its management are described along with a review of literature following dermal-filler injections types. Dermal-filler-related granuloma formation should be included in the differential diagnoses of periorbital inflammatory and mass lesions. It is recommended that clinicians who perform this procedure should discuss these risks and possible late complications with patients and provide them with the relevant product information of the injected filler for appropriate management should such early or late complications occur.

Clinical value of high-resolution (5-17 MHz) echo-color Doppler (ECD) for identifying filling materials and assessment of damage or complications in aesthetic medicine/surgery

PURPOSE

The purpose of this retrospective study is to evaluate the role of echo-color-Doppler (ECD) imaging in identifying a series of characteristics pursuant to aesthetic filling material such as their degree of absorbability and their potential complications which include their propensity to stimulate the formation of encapsulated foreign-body granulomas. In the latter case, ECD can be of aid by giving indication for surgical therapy.

MATERIALS AND METHODS

Over a 4-year period, we studied 180 patients (60 ♂) who underwent an aesthetic medical/surgical treatment. We used ECD to evaluate the implant material, its thickness, the injection site, the integrity of dermal layers and the presence of any associated complications.

RESULTS

In 97% (174/180) of our patients, we were able to identify the type of material used; furthermore, 57% of patients had a hyaluronic acid implant, 14% a lipofilling and 29% a non-absorbable filler (with 10% of silicone). In 6/180 (3%), we could not recognize the material used; 89% (161/180) of our patients presented post-injection complications; moreover, 67% showed peri-implant dermal-hypodermal thickening areas with adjacent lymphostasis, 6% displayed an abnormal implant site, and 17% showed inflammation with encapsulated foreign-body granulomas that required subsequent surgical excision. Biopsy samples were obtained from 37/180 patients (21%); among these, 31 patients had an ECD evidence of granuloma and on 6 patients we were not able to define the injected material. Histopathological examination identified 29 granulomas, 5 sterile abscesses and 3 chronic inflammations in the absence of granuloma. ECD showed an overall 78% diagnostic accuracy, with 90% sensitivity and 37% specificity in detecting filler granulomas.

CONCLUSION

ECD is a low-cost technique that allows to identify filling materials and to assess the complications of an esthetic medical/surgical treatment.

High frequency ultrasound imaging as a "potential" way of evaluation modality in side effects of lip augmentation - case report

Lip augmentation is a popular procedure performed by esthetic medicine doctors, however, it is associated with a significant number of side effects. High frequency ultrasound imaging helps with diagnosis of side effects.The patient was 43-year-old healthy female, 8 months after lip augmentation.The examination showed a variety of delayed side effects of lip augemntation. Ultrasound imaging revealed an increased echogenicity of lip soft tissue, too deep filler injection, occlusion of the inferior labial artery.

A novel animal model for residence time evaluation of injectable hyaluronic acid-based fillers using high-frequency ultrasound-based approach

BACKGROUND

Hyaluronic acid (HA)-based devices are among the most popular filler agents for skin rejuvenation. One of the principal goals is the improvement in residence time of HA-based products, to increase their performance and reduce frequency of the treatment. So, understanding fillers, behavior after subcutaneous injection is a fundamental aspect for discovery and optimization of new products. Current in vivo approaches to detect/quantify injected HA fillers are not always well optimized or easy to apply.

OBJECTIVE

To develop more efficacious and noninvasive diagnostic tools to make a quantitative evaluation of the degradation of fillers in a small animal model.

MATERIALS AND METHODS

We evaluated the residence time of different HA-based fillers, fluorescein-labeled and not, injected subcutaneously in mice. Volumes of fillers were monitored through high-frequency ultrasound (HF-US) method while fluorescence intensity through the well-established fluorescence living imaging method. To confirm the effectiveness of HF-US, obtained volumetric measurements were compared with fluorescence intensity values.

RESULTS

Both the presented methods revealed the same degradation kinetics for the tested products.

CONCLUSION

The two used methods are fully comparable and quantitatively accurate. The presented approach has been proved to be noninvasive, sensitive, and reproducible.

Ultrasound Morphology of Polycaprolactone Filler

Nowadays, cosmetic fillers are widely used and the reports of complications are rising. Therefore, the possibility to detect and identify noninvasively new fillers can provide a potent tool for managing complications. The objective of this study was to assess the ultrasound morphology of polycaprolactone. First, polycaprolactone was injected into porcine skin and this sonographic morphology was prospectively compared with the one observed in patients injected with this filler. On sonography, polycaprolactone shows as hypoechoic deposits that present multiple bright hyperechoic spots with mini-comet-tail artifact. This morphology differs from the ultrasound appearance of other common fillers.

Sonography of Dermatologic Emergencies

Dermatologic conditions may be the subjects of potential emergency consultations, and the knowledge of their sonographic appearance can facilitate an early diagnosis and management. In this pictorial essay, the sonographic dermatologic anatomy, technique, and conditions that can be supported by a prompt sonographic diagnosis are reviewed. The sonographic signs that may help diagnose these entities are discussed with a practical approach.

Clinical and color Doppler ultrasound evaluation of polyacrylamide injection in HIV patients with severe facial lipoatrophy secondary to antiretroviral therapy

BACKGROUND/PURPOSE

Facial lipoatrophy in HIV patients, secondary to antiretroviral therapy (ART) with thymidine analogs, has been related to important psychosocial alterations and poor adherence to treatment. Polyacrylamide gel (PAAG) is a filler that has been used for treating facial lipoatrophy in HIV patients. The aim was to assess the clinical and sonographic anatomical changes after injection of PAAG in HIV patients with facial lipoatrophy secondary to ART.

METHODS

HIV patients receiving ART and suffering from severe facial lipoatrophy were recruited and underwent clinical and color Doppler ultrasound evaluation prior to PAAG application (AQUAMID^® ) and sonographically monitored at 18 months and clinically followed up for 36 months after the procedure. Adverse effects were recorded based on occurrence and complexity.

RESULTS

A total of 33 patients were evaluated, 30 men (91%) and 3 women (9%) with an average age of 49.6 years (±8.4). Clinical improvement assessed by a dermatologist had an average score of 5.9 (±0.7) on a scale of 1-7. On color Doppler ultrasound there was a significant increase of the thickness of the subcutaneous tissue (SCT) in both nasofold lines when comparing before and after PAAG injection (P < 0.01) and no signs of inflammation (hypervascularity). User satisfaction was qualified as excellent or good in all cases. Only two patients experienced adverse effects (hematoma and puncture site infection), which was successfully managed without consequences.

CONCLUSION

Treatment of facial lipoatrophy with PAAG seems to be effective in HIV patients and no signs of complications were observed in the monitoring at 36 months after injection. Color Doppler ultrasound can identify the filler deposits and the anatomical changes of the SCT non-invasively.